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20,793
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43888+43889
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Discharge summary
|
report+report
|
Admission Date: [**2111-9-4**] Discharge Date: [**2111-9-22**]
Date of Birth: [**2038-3-10**] Sex: M
Service: SURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 73-year-old
male with a history of several months of fatigue and a 50
pound weight loss over six months. He had an
esophagogastroduodenoscopy in [**Country 25091**] that demonstrated a
gastric ulcer which, upon biopsy, was positive for
adenocarcinoma. On the morning of [**2111-9-4**], the
patient awoke and complained of left neck pain, at which time
he took one sublingual nitroglycerin, which gave him some
resolution of the pain. He presented to his primary care
physician and then the emergency department at [**Hospital1 346**].
PAST MEDICAL HISTORY:
1. Coronary artery disease with two vessel disease and a 45%
ejection fraction.
2. Status post aortobifemoral bypass.
3. Status post right femoral-popliteal bypass in [**2105**].
4. Chronic renal insufficiency.
5. Diabetes mellitus type 2.
6. Hypertension.
7. Gastric adenocarcinoma.
8. Renal artery stenosis.
9. Congestive heart failure.
MEDICATIONS ON ADMISSION:
Lopressor 12.5 mg p.o. q.d.
Captopril 50 mg p.o. t.i.d.
Isosorbide 20 mg p.o. t.i.d.
Sublingual nitroglycerin.
ALLERGIES: The patient had no known drug allergies.
HOSPITAL COURSE: After admission, the patient was ruled out
by enzymes and electrocardiogram. His cardiac medication
regimen was optimized and the patient underwent an
esophagogastroduodenoscopy on [**2111-9-8**]. The
esophagogastroduodenoscopy demonstrated an ulcerated,
infiltrated, nonbleeding, 6 to 8 cm mass of malignant
appearance, which was biopsied. The mass was also
significant because it demonstrated near obstruction of the
pylorus.
A cardiology consultation was obtained after a Persantine
MIBI demonstrated a mild reversible inferior wall perfusion
defect. The patient was evaluated to be at intermediate risk
for gastric cancer resection. However, prior to the planned
surgery, the patient had an episode of neck pain again and
cardiac enzymes revealed a troponin of 65.
On [**2111-9-15**], after the patient's cardiac issues had
been addressed, the patient underwent subtotal gastrectomy
and placement of a feeding jejunostomy and a cholangiogram.
The operation was uneventful and the specimen was sent to
pathology. The patient was sent to the post anesthesia care
unit in stable condition.
The patient was then transferred to the surgical intensive
care unit, where his course was notable for episodes of sinus
block and bradycardia. However, these episodes resolved and
the patient was transferred to the floor without any
complications.
On the floor, the patient continued his jejunostomy tube
feedings, but they began cycling at night. He began
tolerating a soft post gastrojejunostomy diet and he was pain
free with stable vital signs.
DISPOSITION: The patient will be discharged home with
[**Hospital6 407**] services for jejunostomy tube
feeding management.
FOLLOW UP: The patient also will have outpatient follow up
with his private hematologist oncologist, Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **], at phone number [**Telephone/Fax (1) 94221**]. The patient will
also be followed up by Dr. [**Last Name (STitle) **] in the clinic within a
week.
DISCHARGE MEDICATIONS: The patient will be discharged with
prescriptions for Percocet one to two tablets p.o. every four
to six hours p.r.n. for pain and jejunostomy tube feeds for
ten days.
[**Name6 (MD) 843**] [**Name8 (MD) 844**], M.D. [**MD Number(1) 845**]
Dictated By:[**Name8 (MD) 522**]
MEDQUIST36
D: [**2111-9-23**] 11:50
T: [**2111-9-25**] 11:36
JOB#: [**Job Number 94222**]
Admission Date: [**2111-9-25**] Discharge Date: [**2111-9-25**]
Date of Birth: [**2038-3-10**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 1071**] is a 73 year-old male
who has a past medical history of several months of fatigue
and 50 pound weight loss over six months,
esophagogastroduodenoscopy in [**Country 25091**] with biopsy demonstrated
a gastric ulcer positive for adenocarcinoma. His main reason
for presentation to the [**Hospital1 **] Emergency
Department was chest pain and neck pressure.
PAST MEDICAL HISTORY: 1. Coronary artery disease, two
vessel disease with 45% ejection fraction. 2. Status post
aortobifemoral. 3. Right femoral popliteal bypass in [**2105**].
4. Chronic renal insufficiency. 5. Diabetes mellitus type
2. 6. Hypertension. 7. Renal artery stenosis.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: 1. Lopressor 12.5 mg q.d. 2.
Captopril 50 mg t.i.d. 3. Isosorbide 20 mg t.i.d.
HOSPITAL COURSE: Mr. [**Known lastname 1071**] was admitted to the Medical
Service after his presentation to the Emergency Department
and he ruled out for myocardial infarction. Later during his
hospital course he [**Known lastname 1834**] esophagogastroduodenoscopy,
which demonstrated an ulcerated and infiltrative nonbleeding
6 to 8 cm malignant mass at the prepyloric region causing
complete obstruction. At this point a surgical consult was
acquired and cardiology staff evaluated the patient for
surgical risk grading him as intermediate. Prior to his
surgery Mr. [**Known lastname 1071**] [**Last Name (Titles) 1834**] several episodes of neck tightness
and his blood pressures were very labile. These episodes
were controlled with beta blockade and IV nitroglycerin
drips. On the [**9-15**], the patient [**Month (only) 1834**] a
subtotal gastrectomy, a feeding jejunostomy tube was placed
and cholangiogram was performed by Dr. [**Last Name (STitle) **] and assisted
by Dr. [**First Name (STitle) 1586**] [**Name (STitle) **]. The procedure was uncomplicated and the
patient was admitted to the Surgical Intensive Care Unit
afterwards. His course in the SICU was relatively
uncomplicated and only notable for one episode of
questionable sinus block and bradycardia, which a
electrophysiology consult was obtained, which the consulting
fellows recommended observing.
The patient was begun on tube feeds to supplement his lack of
per oral intake and these were well tolerated. His medical
regimen was optimized to control his hypertension and the
patient was transferred to the floor. On the floor his
course was without complications. He began tolerating a
regular diet with tube feeds cycled in the evening with
notable elevations in his blood sugar, which were covered by
a sliding scale. Otherwise the patient remained afebrile and
had stable vital signs. He tolerated the advancement of his
diet well. He is tolerating a post gastrectomy diet and he
was seen by physical therapy and performed adequately.
DISPOSITION: The patient will be discharged to a rehab or a
skilled nursing facility.
MEDICATIONS ON DISCHARGE: 1. Lopressor 100 mg t.i.d. 2.
Captopril 100 mg t.i.d. 3. NPH 5 units b.i.d. while on tube
feeds and sliding scale regular insulin.
The patient should continue on tube feeds cycled in the
evening, Promote with fiber at 60 cc an hour from 6:00 p.m.
to 10:00 a.m. These tube feeds should be discontinued when
the patient takes adequate oral intake. The patient is being
followed by his primary care physician, [**Name10 (NameIs) **]
hematologist/oncologist Dr. [**Last Name (STitle) **], phone number
[**Telephone/Fax (1) 94221**] and Dr. [**First Name (STitle) **] [**Name (STitle) **].
[**Name6 (MD) 843**] [**Name8 (MD) 844**], M.D. [**MD Number(1) 845**]
Dictated By:[**Name8 (MD) 522**]
MEDQUIST36
D: [**2111-9-25**] 13:10
T: [**2111-9-25**] 13:49
JOB#: [**Job Number 47275**]
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,907
| 100,989
|
36903
|
Discharge summary
|
report
|
Admission Date: [**2146-11-3**] Discharge Date: [**2146-11-10**]
Date of Birth: [**2079-1-5**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
endotracheal intubation
History of Present Illness:
Patient is a 67 year old female with a history of Type II DM,
HTN, stage III CKD, and 2 vessel CAD admitted on [**2146-11-3**] with
hyperglycemia. The patient was hospitalized two months ago with
dysphagia and provided history suggestive of CHF. Subsequent
evaluation showed severely depressed LVEF, 20-25%, with elevated
right- and left-sided filling pressures. A diagnostic left- and
right-heart cath was performed, and attempted PCI to mid-LAD was
unsuccessful. The patient was evaluated by CT surgery, and was
determined to be a poor surgical candidate. The patient was
discharged with a plan to optimize medical management of
presumed ischemic heart disease (there had been a question of
possible tachycardia-induced cardiomyopathy, alcoholic
cardiomyopathy). Iron studies did not show evidence of
hemachromatosis. The patient had scheduled Cardiology follow up
on [**2146-11-2**] which she unfortunately did not keep. The following
day, the patient was found to be hyperglycemic, with home FSBGs
in the 500s. Since admission, management of hypervolemia from
CHF has been limited by hypotension. We are asked to provide
recommendation for management of patient's CHF.
On further history, patient notes progressive DOE over the past
summer. She denies any inciting event. Her exercise capacity and
level of activity have been limited over the past few months due
to progressive DOE.
On cardiac review of symptoms, patient denies any current or
prior chest pain/pressure/angina. Denies palpitations,
presyncope, and syncope. Patient does have [**1-19**] pillow orthopnea
with occasional PND. Lower leg swelling has not changed over
prior two months.
Currently, the patient notes fatigue and mild shortness of
breath at rest during the interview. She denies chest
pain/pressure, lightheadedness, and is otherwise asymptomatic.
Past Medical History:
DM A1c 7.9% [**2146-9-27**]
2VD s/p unsuccessful PCI mid-LAD [**2146-9-13**]
Ischemic CMP EF 20-25% by TTE [**2146-9-11**]
CKD stage III b/l Cr ~1.4
HTN
Hyperlipidemia
s/p bilat cataract surgeries
Cardiac Risk Factors include diabetes, dyslipidemia,
hypertension, and family history of CAD
Social History:
Patient is retired since [**2139**] from Met Life. She has been
divorced for many years. Currently not sexually active.
Admits to drinking alcohol rarely and has a 10 pack-year smoking
history (she quit 25 years ago). Denies illicit drug use. Says
she enjoys walking but has been limited by DOE more recently.
One son, 43yo, in good health, with 6 children, lives in [**Location (un) 5426**].
Family History:
Mother passed away from MI at age 85. Siblings with asthma and
diabetes. ? CAD in brother. 1 sister with breast cancer.
Physical Exam:
Vitals: T: 97.9 BP: 98-100/68-74 P: 101-110 R: 20-24 O2: 100 on
RA-2L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP elevated to jawline, no LAD
Lungs: decreased breath sounds at bases, crackles bilat L > R
CV: Tachy rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, obese non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: no rashes, lesions
Pertinent Results:
[**2146-11-3**] 10:00AM URINE OSMOLAL-347
[**2146-11-3**] 10:00AM URINE HOURS-RANDOM UREA N-376 CREAT-45
SODIUM-26
[**2146-11-3**] 12:00PM PLT SMR-NORMAL PLT COUNT-285
[**2146-11-3**] 12:00PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL
[**2146-11-3**] 12:00PM NEUTS-78.4* BANDS-0 LYMPHS-14.1* MONOS-6.3
EOS-0.8 BASOS-0.4
[**2146-11-3**] 12:00PM CALCIUM-9.2 PHOSPHATE-2.9 MAGNESIUM-2.3
[**2146-11-3**] 12:00PM CALCIUM-9.2 PHOSPHATE-2.9 MAGNESIUM-2.3
[**2146-11-3**] 12:00PM GLUCOSE-479* UREA N-39* CREAT-1.8*
SODIUM-121* POTASSIUM-7.2* CHLORIDE-85* TOTAL CO2-23 ANION
GAP-20
[**2146-11-3**] 12:00PM GLUCOSE-479* UREA N-39* CREAT-1.8*
SODIUM-121* POTASSIUM-7.2* CHLORIDE-85* TOTAL CO2-23 ANION
GAP-20
CXR: [**2146-11-3**]
A moderate right pleural effusion is largely unchanged. Linear
opacity adjacent to the effusion is most consistent with
atelectasis. There is improved aeration of the left lung base.
Upper lung zones are well aerated without new consolidation.
There is no pneumothorax. Pulmonary vascularity is normal. There
is no hilar enlargement. The cardiomediastinal silhouette is
grossly stable.
IMPRESSION:
Persistent moderate-to-large right pleural effusion and small
left pleural
effusion, with atelectasis. No edema
ECHO: [**2146-11-7**]
The left atrium is elongated. The estimated right atrial
pressure is 10-20mmHg. Left ventricular wall thicknesses and
cavity size are normal. There is severe global left ventricular
hypokinesis (LVEF = 20 %). No masses or thrombi are seen in the
left ventricle (fibrotic apical trabeculations are seen). The
right ventricular cavity is moderately dilated with severe
global free wall hypokinesis. [Intrinsic right ventricular
systolic function is likely more depressed given the severity of
tricuspid regurgitation.] The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild to
moderate ([**11-19**]+) mitral regurgitation is seen. The left
ventricular inflow pattern suggests a restrictive filling
abnormality, with elevated left atrial pressure. The tricuspid
valve leaflets are mildly thickened. The tricuspid valve
leaflets fail to fully coapt. Moderate to severe [3+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. Significant pulmonic regurgitation is
seen. The end-diastolic pulmonic regurgitation velocity is
increased suggesting pulmonary artery diastolic hypertension.
There is an anterior space which most likely represents a fat
pad.
Compared with the prior study (images reviewed) of [**2146-9-11**],
the right ventricular cavity is slightly larger with more severe
free wall hypokinesis. The other findings are similar.
Brief Hospital Course:
67 F with DM, 2 vessel CAD, CKD, and ischemic cardiomyopathy (EF
(20-25%) initially admitted with hyperglycemia after missing
insulin for several days.
With administration of home doses of insulin, hyperglycemia
corrected. There was no evidence for an infection. Hospital
course was then complicated by the development of hypotension
from decompensated CHF. Although patient ruled out for an acute
ischemic event, echo showed progression of cardiac dysfunction
with an EF of 20%, 3+ tricuspid regurgitation and severe RV
dysfunction with free wall hypokinesis. Transferred to the CCU
for further management and started on lasix and milironone drip
to optimize cardiac output. CCU course complicated by the
development of PEA requiring cardiac resuscitation with
intubation and 4 pressor support.
Given the patient's end stage heart failure and prognosis, the
family decided to withdraw care. A morphine drip was initiated
and pressors and mechanical ventilation was discontinued. Time
of death was 4:30am on [**2146-11-10**]. Her son (next of [**Doctor First Name **]) and
niece [**Name (NI) 382**], declined an autopsy.
Medications on Admission:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
5. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day.
6. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
7. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
8. Insulin
Glargine Insulin 4 units each morning (up titrate as needed)
Humalog sliding scale. QACHS. At FS 150 start at 2 units and
increase by 2 unit for every additional 50 point rise in blood
glucose. If > 400 contact supervising physician. [**Name10 (NameIs) **] evening
dosing do not start additional insulin unless > 200.
.
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary Diagnosis:
end stage systolic congestive heart failure
hyperglycemia
Discharge Condition:
deceased
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
[
"428.23",
"414.8",
"250.02",
"585.3",
"403.90",
"041.86",
"427.5",
"276.1",
"458.9",
"414.01",
"V15.81",
"530.81",
"428.0",
"V66.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
8637, 8646
|
6541, 7674
|
327, 352
|
8766, 8776
|
3667, 6518
|
8828, 8834
|
2956, 3079
|
8609, 8614
|
8667, 8667
|
7700, 8586
|
8800, 8805
|
3094, 3648
|
276, 289
|
380, 2213
|
8686, 8745
|
2235, 2528
|
2544, 2940
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,194
| 149,903
|
3148
|
Discharge summary
|
report
|
Admission Date: [**2168-1-3**] Discharge Date: [**2168-1-13**]
Date of Birth: [**2096-4-28**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
altered mental status, renal failure and hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
71yo morbidly obese F with multiple medical problems including
recurrent [**Name (NI) 14870**] and urosepsis presented to ICU with altered
mental status, renal failure and hypotension
Past Medical History:
MRSA
Right Femur Fx S/P ORIF ([**10/2165**]: Tripped Over Commode)
HTN
Hyperlipidemia
DMII
Peripheral Neuropathy
CKD with baseline creat 1.5
Obesity
Anemia if chronic disease, bl 30
IBS (Chronic Constipation, Abdominal Pain and Intermittent
Diarrhea) Chronic LBP/Sciatica (Osteoporisis, DJD/OA, Spinal
Stenosis) Depression/Anxiety
Panic Disorder
Parotid Gland Tumor S/P Resection
S/P Multiple Falls
H/O Herpes Zoster
S/P CCY
B/L Cataract Removal.
Social History:
She lives with her daughter, who is very involved with her care.
She had 11 children, and one passed away. She was a homemaker.
She quit smoking 20 years ago and had between [**4-28**] py. She uses
ETOH rarely (<1x/month).
Family History:
Her mother had DM. She knows nothing of her father. [**Name (NI) **] sister
died of [**Name (NI) **] at 60.
Physical Exam:
PHYSICAL EXAM:
Vitals: T 98.4, BP 68/52 HR 92 RR 12 100% on 100% NRB
Gen: Lethargic but arousable and will answer questions,
recognizes daughter but otherwise not oriented
[**Name (NI) 4459**]: dry MMM, unable to assess JVP
CV: RR, nl S1, S2, No m/g/r
Chest: CTA b/l anteriorly, has apneic episodes when sleeping
Abd: Obese, NABS, soft, NT/ND
Ext: 2+ edema to knees, left knee non-erythematous, non-tender
Skin: area of erythema over left shin, not warm or painful(old)
Neuro: movea all 4 extremities, cannot follow commands
Pertinent Results:
[**2168-1-5**] 05:24AM BLOOD WBC-8.4 RBC-3.17* Hgb-9.4* Hct-29.0*
MCV-91 MCH-29.5 MCHC-32.3 RDW-16.1* Plt Ct-338
[**2168-1-3**] 06:00PM BLOOD WBC-8.3 RBC-3.15* Hgb-9.6* Hct-28.8*
MCV-91 MCH-30.4 MCHC-33.3 RDW-16.2* Plt Ct-282
[**2168-1-3**] 07:40PM BLOOD PT-14.5* PTT-29.8 INR(PT)-1.3*
[**2168-1-5**] 05:24AM BLOOD Glucose-206* UreaN-20 Creat-2.3* Na-144
K-4.5 Cl-107 HCO3-27 AnGap-15
[**2168-1-3**] 07:40PM BLOOD UreaN-26* Creat-3.3*#
[**2168-1-3**] 07:40PM BLOOD ALT-12 AST-20 AlkPhos-106 Amylase-31
TotBili-0.3
[**2168-1-5**] 05:24AM BLOOD Calcium-7.6* Phos-4.8* Mg-2.4
[**2168-1-3**] 07:40PM BLOOD TotProt-6.0* Albumin-2.6* Globuln-3.4
Calcium-6.4* Phos-6.6*# Mg-1.0*
[**2168-1-5**] 12:15AM BLOOD Cortsol-39.5*
[**2168-1-4**] 08:39PM BLOOD Cortsol-15.4
[**2168-1-3**] 07:40PM BLOOD Cortsol-18.0
[**2168-1-5**] 08:37AM BLOOD Type-ART Temp-36.3 FiO2-26 pO2-65*
pCO2-74* pH-7.20* calTCO2-30 Base XS-0 Intubat-NOT INTUBA
[**2168-1-4**] 02:14AM BLOOD Type-MIX Temp-37.1 O2 Flow-15 pO2-49*
pCO2-68* pH-7.17* calTCO2-26 Base XS--4 Intubat-NOT INTUBA
[**2168-1-5**] 08:37AM BLOOD Glucose-204* Lactate-1.0 Na-144 K-4.5
Cl-108 calHCO3-30
[**2168-1-5**] 08:37AM BLOOD freeCa-1.08*
[**2168-1-3**] 06:12PM BLOOD freeCa-0.83*
[**2168-1-3**] 05:58PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.008
[**2168-1-3**] 05:58PM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2168-1-3**] 05:58PM URINE RBC-0-2 WBC-[**5-29**]* Bacteri-FEW Yeast-MANY
Epi-0-2
[**2168-1-4**] 02:10AM URINE Hours-RANDOM UreaN-157 Creat-154 Na-75
[**2168-1-4**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL INPATIENT
[**2168-1-4**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL INPATIENT
[**2168-1-3**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL INPATIENT
[**2168-1-3**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL EMERGENCY [**Hospital1 **]
[**2168-1-3**] URINE URINE CULTURE-FINAL {YEAST} EMERGENCY [**Hospital1 **]
BILATERAL LOWER EXTREMITY DOPPLER ULTRASOUND: This evaluation is
limited secondary to patient body habitus. The right and left
common femoral and proximal superficial femoral veins are patent
and demonstrate normal compressibility, color flow, waveforms,
and augmentation. The popliteal veins demonstrate normal color
flow, waveforms, and augmentation. The mid and distal
superficial femoral veins are not well visualized.
IMPRESSION: Extremely limited study secondary to patient body
habitus. No evidence of deep vein thrombosis within the
visualized vasculature (proximal common femoral to proximal
superficial femoral vein and the popliteal veins).
CT HEAD WITHOUT CONTRAST: No high-density material is seen to
suggest the presence of acute intracranial hemorrhage. There is
no mass effect or shift of normally midline structures. Size of
ventricles and sulci is stable since prior study. Small
hypoattenuating focus along the falx is stable and may represent
a small lipoma. Osseous structures are unremarkable. Visualized
paranasal sinuses and mastoid air cells are clear. A
fat-containing lesion is seen inferior to the expected location
of the parotid gland and may be consistent with lipoma. This
area had not been included on prior head CTs.
IMPRESSION: No evidence of acute intracranial hemorrhage or mass
effect.
Brief Hospital Course:
# Altered mental status: It seems that her mental status has
been waxing and [**Doctor Last Name 688**] since discharge. It is possible that she
becasme more delerious with her recent increase in pain meds,
had decreased Po intake which lead to pre-renal ARF and
worsening renal function lead to worsening mental status and
volume overload given decreased UOP in the setting of being
intravascularly dry. This in conjunction with possible UTI may
have lead to her worsening mental status. CT head negative. No
focal neurologic deficits on exam.
- Treated for UTI with meropenum given h/o of klebsiella
sensitive to only zosyn and meropenum with addition of
vancomycin
.
# Hypotension: Difficult to get blood pressure given body
habitus. Had dificulty getting A lines in past. Anesthesia
placed aline [**2167-1-4**]
.
# UTI: UA appears positive but not much differnt from UA on [**12-22**]
after treatment which grew yeast.
- treated empirically for klebsiella with meropenum awaiting
culture data with addition of vancomycin after hypotensive
episode [**2167-1-4**]
.
#left knee pain
-xray neg for fracture or dislocation
.
# ARF: Likely pre-renal in the setting of dehydration. Baseline
Cr 1.0.
.
# Hypoxia: Likely [**1-22**] atelectasis and L pleural effusion.
Unclear why she was put on 100% NRB as it does not seem that she
needs this. Will wean O2 to keep O2 sats 90-95%. She does not
tolerated Bipap but has know sleep apnea
.
# Sacral ulcers:
- Wound care
.
# CODE STATUS: DNR/DNI
The patient was made CMO in the ICU after communication wit
family given the advanced morbidity and poor prognosis. The
patient died peacefully and was surrounded by supprotive family.
Palliative care team as well as Dr [**Name (NI) **], pt's PCP followed
the patient in house.
.
# Communication: daughter [**Name (NI) **] [**Name (NI) **]. (granddaughter [**Name (NI) **]
[**Telephone/Fax (1) 14871**] (cell) [**Telephone/Fax (1) 14872**] (home).
Medications on Admission:
1. Oxycodone 60 mg Tablet Sustained Release Q12H (increased on
[**1-1**])
2. Oxycodone 30 mg Q4H PRN (increased on [**1-1**])
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H: PRN
4. Gabapentin 300 mg PO BID
5. Trazodone 50 mg PO HS:PRN
6. Calcium Acetate 667 mg Two Capsules PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
7. Docusate Sodium 100 mg PO BID
8. Olanzapine 10 mg PO HS
9. Glipizide 5 mg PO BID
10. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical TID (3
times a day) as needed.
11. Nystatin-Triamcinolone 100,000-0.1 unit/g-% Cream Sig: One
(1) Appl Topical [**Hospital1 **] (2 times a day) as needed.
12. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for antifungal.
13. Double Guard Cream One (1) appl Topical twice a day.
14. Aloe Vesta 2-n-1 Antifungal 2 % Ointment Sig: One (1) appl
Topical twice a day
15. ASA 325 mg PO QD
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Death due to :
Sepsis
Hypotension
Acute renal failure
Sleep apnea
Morbid obesity
Discharge Condition:
Patient died
Discharge Instructions:
Patient died
Followup Instructions:
Patient died
|
[
"250.00",
"355.9",
"511.9",
"599.0",
"428.0",
"518.0",
"578.1",
"278.01",
"584.9",
"995.91",
"038.8",
"707.03",
"272.4",
"401.9",
"458.29",
"428.30",
"780.57"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8266, 8275
|
5345, 5355
|
367, 374
|
8400, 8415
|
1984, 5322
|
8476, 8492
|
1315, 1424
|
8237, 8243
|
8296, 8379
|
7308, 8214
|
8439, 8453
|
1454, 1965
|
275, 329
|
402, 587
|
5370, 7282
|
609, 1058
|
1074, 1299
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,544
| 150,409
|
42096
|
Discharge summary
|
report
|
Admission Date: [**2181-2-22**] Discharge Date: [**2181-3-22**]
Date of Birth: [**2121-2-4**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Cipro / vancomycin
Attending:[**First Name3 (LF) 38277**]
Chief Complaint:
syncope, hypoxia
Major Surgical or Invasive Procedure:
right central venous line placement for dialysis
History of Present Illness:
60F with a h/o IDDM, CAD s/p CABG [**2172**] (LIMA -> LAD, SVG to
[**Year (4 digits) 11641**]), s/p STEMI ([**2174**]) w/ occlusion of vein graft, s/p stents
to LAD and [**Year (4 digits) 11641**] ([**2174**]), sCHF (EF ~35% 2/12), s/p AICD, PVD s/p
R toe amputations and L BKA p/w syncope. Rehab uses a [**Doctor Last Name **] lift
to move her and she feels like she can't breathe every time they
use it. While she was being moved in [**Doctor Last Name **] today, she passed
out, was given O2 and felt better but was sent in to ED.
.
Labs were wnl, AICD not interrogated as no shock delivered. CXR
showed anasarca and fluid. Pt was recently hospitalized for an
episode of unresponsiveness, work up essentially negative at
that time, thought to be possibly due to sedating medications
and discharged with increased dose of torsemide for her CHF.
However, [**First Name8 (NamePattern2) **] [**Hospital1 **] note from [**2-20**], pt has not responded to
40 mg of torsemide, so increased to 40 AM/20 PM torsemide and
did receive 1 dose of metolazone on [**2-16**]. Wt on [**2-20**] was 273#,
pt states her [**Month/Year (2) 5348**] wt is 230# back in late [**Month (only) 1096**].
Lisinopril was started and then stopped due to increase in
creatinine. [**Hospital1 **] called hospitalist here as they feel that
the patient requires higher level of care and IV diuresis and
the initial plan had been for admission to floor and discharged
to advanced care.
.
While in [**Name (NI) **], pt refused treatment and became more hypoxic. Her
initial vitals in ED showed her satting 96 on 4L NC but
eventually came down to 88% on 4L and pt refused to take IV
diuretics till coming upstairs. Floor refusing to take her bc of
hypoxia. Pt also refusing foley but did finally receive IV
torsemide in ED. Transfer vitals were: 72 130/77 16 95% on 7L
venti mask.
.
On arrival to the ICU, patient appears comfortable, satting high
90s on 4L NC. Pt states that her shortness of breath is stable,
endorses orthopnea and interval improvement in her swelling,
denies chest pain, PND, cough, fever/chills or abdominal pain.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies cough/wheezing.
Denies chest pain, palpitations. nausea, vomiting, diarrhea,
constipation, abdominal pain. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
Past Medical History (per record):
Cardiovascular Risk Factors:
+ HTN + HL + DM
# CAD: STEMI in [**2174**] with occlusion of vein graft
INTERVENTIONS:
CABG: [**2172**] with LIMA -> LAD and vein graft to [**Last Name (LF) 11641**], [**First Name3 (LF) **] 25 %
at the time
PERCUTANEOUS CORONARY INTERVENTIONS:
- [**2174**] stents in left anterior descending and [**Year (4 digits) 11641**]
# Systolic CHF - ischemic cardiomyopathy, severely reduced LV
function. ECHO in [**4-2**] with EF 25 - 30%
# PACING/ICD: Right-sided AICD in place ([**2178**]) for primary
prevention given EF
# IDDM, eye and renal manifestations, last HbA1c 9.3% ([**2180-4-23**])
# asthma
# PVD
# s/p left BKA [**2176**]
# s/p right 1st toe amputation [**2176**]
# h/o left intraductal breast cancer - s/p left mastectomy in
[**Month (only) 116**]/[**2173**], now question of right-sided breast cancer, which is
just being followed
# s/p cholecytectomy
Social History:
Hospitalized at [**Hospital1 18**] and/or rehab since [**2180-11-23**].
Otherwise lives in [**Hospital3 **], having left her own home in
[**Hospital1 189**] 6 mos ago. Wheelchair-bound. Son [**Name (NI) **] is HCP, daughter
[**Name (NI) **] also involved; a third son [**Name (NI) **] lives in [**Name (NI) 86**].
-Tobacco history: none
-ETOH: rarely
-Illicit drugs: denies, but used marijuana in the past
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION EXAM
General: Alert, no acute distress, NC in place.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP difficult to appreciate given body habitus
Lungs: Clear to auscultation in upper lung fields, +scattered
wheezes, crackles at the bases up to mid lung bilaterally
CV: Faint heart sounds, RRR, normal S1/S2, no murmurs, rubs,
gallops
Abdomen: Obese abdomen, soft, non-tender, bowel sounds present,
no rebound tenderness or guarding. Pitting dependent edema up to
mid axillary line.
GU: no foley
Ext: s/p R great toe amputation and L BKA. DP palpable on R foot
(marked). Right foot with black eschar on medial and lateral
aspect of his right foot, also has debrided area on right side,
clean red base with some white-ish fibrous material along the
edges. Pitting edema in dependent area all the up to
sacrum/back.
.
[**Hospital1 **] CARDIOLOGY SERVICE ADMISSION EXAM (TRANSFERRED FROM
MEDICINE [**2181-3-9**])
VS: 97.6 144/78 67 18 95/4L (88/RA) Wt 125.3 kg
GEN: somnolent, minimally-verbal, nods occasionally in response
to questions, grossly volume overloaded
HEENT: MMM, oropharynx clear, EOMI, PERRL
NECK: supple, JVP to ear
CV: RRR nl S1 S2 +2/6 SEM
LUNGS: breathing unlabored, poor air movement, no rales no
wheeze
ABD: obese, tense edema but non-tender, +distant BS
EXT
3+ pitting edema of legs/thighs,
2+ pitting arms, equal bilaterally
L BKA
R foot kerlix-wrapped + amputation 2nd digit (well-healing), no
cyanosis
Neuro: AOX2, somnolent, minimally verbal, able to move
extremities on command, gait not assessed [**1-25**] body habitus (&
uses wheelchair at [**Month/Day (2) 5348**])
.
DISCHARGE EXAM:
VS Tmax 98.6, BP 100-110s/50-70s, HR 70-80s, Sats > 94% on RA
exam unchanged except:
mental status is appropriate response to questions and awake
JVP 10 cm (mid-neck)
.
Pertinent Results:
ADMISSION LABS:
[**2181-2-22**] 05:15PM BLOOD WBC-7.9 RBC-3.72* Hgb-9.5* Hct-30.5*
MCV-82 MCH-25.4* MCHC-31.0 RDW-21.8* Plt Ct-265
[**2181-2-22**] 05:15PM BLOOD Neuts-78.7* Lymphs-13.8* Monos-5.4
Eos-1.2 Baso-0.9
[**2181-2-22**] 05:15PM BLOOD PT-16.1* PTT-39.5* INR(PT)-1.5*
[**2181-2-22**] 05:15PM BLOOD Glucose-193* UreaN-86* Creat-1.4* Na-136
K-6.4* Cl-99 HCO3-27 AnGap-16
[**2181-2-23**] 01:14AM BLOOD ALT-35 AST-34 LD(LDH)-233 CK(CPK)-113
AlkPhos-133* TotBili-0.9
[**2181-2-23**] 01:14AM BLOOD CK-MB-5 cTropnT-0.25*
[**2181-2-23**] 01:14AM BLOOD Albumin-2.6* Calcium-8.4 Phos-3.8 Mg-2.1
[**2181-2-22**] 05:34PM BLOOD Lactate-2.4* K-4.7
.
DISCHARGE LABS:
[**2181-3-22**] 06:29AM BLOOD WBC-7.9 RBC-3.37* Hgb-8.4* Hct-28.9*
MCV-86 MCH-25.0* MCHC-29.1* RDW-21.2* Plt Ct-268
[**2181-3-22**] 06:29AM BLOOD Glucose-93 UreaN-62* Creat-2.0* Na-137
K-3.2* Cl-91* HCO3-35* AnGap-14
[**2181-3-22**] 06:29AM BLOOD Calcium-9.2 Phos-4.7* Mg-2.1
.
MICRO
BLOOD CULTURES ([**2-22**], [**3-9**], [**3-11**]) - NEGATIVE
URINE CULTURES ([**3-9**], [**3-11**]) - NEGATIVE
.
STUDIES
.
[**2181-3-16**] TTE
Conclusions
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size. There is
moderate global left ventricular hypokinesis (LVEF = 30-35%).
The right ventricular cavity is mildly dilated with mild global
free wall hypokinesis. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. There are filamentous strands
on the aortic leaflets consistent with Lambl's excresences
(normal variant). Moderate (2+) mitral regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
moderate global systolic dysfunction. Mild functional mitral
regurgitation. Moderate pulmonary hypertension.
Compared with the prior study (images reviewed) of [**2181-2-6**],
the findings are similar.
.
[**2181-3-15**] NON-INVASIVE DUPLEX VENOUS STUDY OF THE RIGHT UPPER
EXTREMITY
CLINICAL INDICATION: Morbid obesity and congestive heart failure
with
persistent right upper extremity edema.
Pulse Doppler waveform analysis shows symmetric flow in the
right and left
subclavian veins. The right internal jugular vein is markedly
dilated,
measuring up to 1.6 cm in diameter and showing some effects of
slow blood flow with swirling and somewhat sludgy flow. However,
the IJ is patent and is fully compressible.
The axillary vein and both brachial veins are easily
compressible and show
normal wall-to-wall flow on color flow imaging. The cephalic and
basilic
veins are also compressible and fully patent, and PICC line is
seen within the basilic vein.
CONCLUSION: No evidence of DVT in the right upper extremity.
Note is made of a dilated and slow flowing internal jugular vein
on the right side, possibly related to the patient's underlying
congestive heart failure.
.
[**2181-3-2**] RENAL ULTRASOUND
FINDINGS: Note is made that this is an extremely limited
ultrasound due to
the patient's body habitus. The right kidney is identified and
measures 12.0 cm in length. No hydronephrosis is seen in the
right kidney. A small
shadowing non-obstructing stone is seen within the right renal
collecting
system measuring 5 mm.
Despite diligent effort, the left kidney could not be identified
in the left flank or in the pelvis. Ascites is seen in the
pelvis.
DOPPLER EXAMINATION: The Doppler examination is entirely
non-diagnostic.
Flow cannot be detected in the right kidney due to the technical
limitations.
The left kidney cannot be visualized.
IMPRESSION:
1. No hydronephrosis in the right kidney. Small non-obstructing
right renal stone.
2. No Doppler examination could be performed as the
visualization is
extremely limited due to the patient's body habitus.
3. Despite diligent effort, the left kidney could not be
identified.
4. Small amount of ascites seen in the pelvis
.
[**2181-3-3**] CXR
SINGLE FRONTAL VIEW OF THE CHEST
REASON FOR EXAM: CHF, improved oxygen requirement after
aggressive diuresis. Morbid obesity.
Comparison is made with prior study [**2-26**].
Moderate cardiomegaly is unchanged. Pacer leads are in unchanged
position,
one in the right atrium, the second is probably in the right
ventricle, though is in an unusual location more medial than
expected. There is mild vascular congestion. Bibasilar
atelectases are larger on the left side. There is a small left
pleural effusion. There is no pneumothorax. Sternal wires are
aligned. Patient is status post CABG. Right PICC tip is in the
lower SVC.
Brief Hospital Course:
Ms. [**Known lastname 91333**] is a 60 year old female w/ history of severe
systolic heart failure s/p CABG ([**2172**]), STEMI (vein graft
occlusion, LAD/[**Year (4 digits) 11641**] stenting [**2174**]) stents to LAD and [**Year (4 digits) 11641**]
([**2174**]), AICD placement, presents after hypoxic
minimally-responsive episode at rehab, found to be grossly
volume overloaded due to underdiuresis, improved after
aggressive diuresis with lasix drip augmented with hemodialysis.
.
# HX SYNCOPE AT REHAB
When pt was initially evaluated in the ED and ICU, there was
question about whether there was true syncope, especially since
she was hypoxic. Additionally, she was at [**Year (4 digits) 5348**] level of
somnolence/confusion, and the episode occurred in the setting of
being moved via [**Doctor Last Name **]. Noted recent admission for the same
concern, during which time a work-up for arrhythmia, seizures,
medication effect was without clear findings. AICD was
interrogated w/o evidence of arrythmia.
.
# HYPOXIA ON ADMISSION
Patient found to be hypoxic in ED to 88% on 4L NC. Hypoxia
thought to be due to ongoing volume overload and unresolved
pulmonary edema, especially given her anarsarca, with some
additional contribution from obesity hypoventilation and OSA.
No evidence of pneumonia on CXR. For CHF management, see below.
Regarding etiology of likely worsening failure, concern was
raised for chronic thromboembolic disease (SVC syndrome given
syncopal episode and upper extremity edema, or chronic PE
burden). Troponins were stably elevated and peaked at 0.28,
thought to be due to renal failure. IV heparin started
empirically when initial doppler US of extremities were
difficult to definitely read as negative; patient subsequently
had doppler US of all 4 extremities, reviewed carefully with
radiology & read as negative--heparin discontinued. No V/Q scan
pursued given high likelihood false positive due to body
habitus, CTA not possible due to underlying renal disease. Pt
successfully weaned from oxygen after 15-20 kg volume removed by
HD.
.
# ACUTE ON CHRONIC SYSTOLIC HEART FAILURE
Most recent echocardiogram 2 weeks prior to admission showed
stable systolic function (LVEF 35%). Pt had been discharged on
increased dose of torsemide & continued on digoxin and
carvedilol. Nonetheless, she was grossly volume overload on
arrival to the cardiology service, after minimal response to
torsemide in the ICU and on medicine. Transitioned to lasix
drip, which successfully promoted diuresis of ~10 kg. HD started
when worsening renal function and decreased UOP limited further
diuresis. HD effectively removed >15 kg additional body weight.
Pt felt better, was able to be weaned to RA. Transitioned to
torsemide at 200 mg QD with metolazone 5 mg [**Hospital1 **] and
spironolactone 25 mg daily. TTE performed after completion of
HD, demonstrated unchanged, poor systolic function w/LVEF 35%.
Family meeting held w/patient and son on [**3-16**] to review pt's
poor prognosis from a heart failure/renal failure perspective.
She was seen by palliative care who felt that she would be able
to get home hospice set up after PT/[**Hospital **] rehab if she can rehab
enough to not need 24 hour care. She was discharged on the
following medications for heart failure: torsemide at 100 mg [**Hospital1 **]
with metolazone 5 mg [**Hospital1 **] and spironolactone 25 mg daily,
carvediolol 3.125 mg [**Hospital1 **], aspirin 325 mg daily, clopidogrel 75
mg daily, atorvastatin 80 mg daily, digoxin 0.0625 mg daily. She
will need to start an ACEi when her creatinine stablizes. While
she is on aggressive diuresis, please check chemistry panel
daily starting on [**2181-3-23**] and dose her potassium chloride daily
to maintain a potassium greater than 3.5. When she appears
euvolemic by exam and by her laboratory values (creatinine =
2.3, BUN = 50, or bicarbonate = 40) then please decrease her
torsemide to 100 mg once daily.
.
# ACUTE-ON-CHRONIC KIDNEY DISEASE
Creatinine 1.4 on transfer, 2.0 on d/c date. Only 1 kidney
visualized on renal ultrasound, no hx nephrectomy so likely
congenital. Worsening creatinine likely secondary to diuresis,
but this was necessary given overwhelming volume overload.
Ultimately patient required temporary HD as recommended by renal
consult when her lasix diuresis waned & she developed
somnolence/confusion/decreased appetite (considered possible
symptomatic uremia vs med effect, see above). RIJ temporary HD
line placed by HD. Dialysis discontinued after [**3-17**] when volume
status and renal function improved. She was briefly treated
with acetazolamide for low bicarbonate but this improved with
improved creatinine clearance and she no longer needed the
acetazolamide. She was continued on calcium acetate tablets 667
TID.
.
# INTERMITTENT SOMNOLENCE & CONFUSION: TOXIC MEDICATION EFFECT
Waxing/[**Doctor Last Name 688**] MS [**First Name (Titles) 767**] [**Last Name (Titles) 5348**] AOX2 (name, hospital, not date)
and increased somnolence from [**Date range (1) 86279**]. No e/o infection (blood
cultures, urine cultures and CXR all clear). Some suspicion for
symptomatic uremia but BUN not particularly elevated. Therefore,
clearing w/HD sessions attributed to toxic med effect. Thus, her
venlafaxine was decreased to 112.5 mg daily and buproprion to
100 mg daily.
.
# PERIPHERAL VASCULAR DISEASE (PVD), STABLE FOOT ULCERS
Pt with chronic PVD s/p L BKA and R toe amputations and diabetic
ulcers on R foot. Patient had arterial non-invasive imaging
during last hospitalization which demonstrated patent popliteal
and PT arteries on the right with known moderate RLE occlusive
disease. Ulcers appear stable and noninfected on exam. Wound
consult followed closely, requested vascular surgery evaluation
- they felt ulcers were stable, not-infected-appearing. Will
need ongoing dressing changes/wound care per nursing
recommendations (see page 1). She was discharged on aspirin 325
mg daily and clopidogrel 75 mg daily.
# CHRONIC LOW BACK PAIN
Patient takes qHS GABAPENTIN chronically. This was discontinued
in the setting of altered mental status (transitioned to
tylenol). No complaints of back pain thereafter. Gabapentin was
not restarted at discharge.
.
# HX DEPRESSION, ANXIETY, COPING DIFFICULTY
Patient has been through long, difficult hospital -> rehab ->
hospital course over the past 3 months. Tearful, frustrated, and
occasionally verbally abusive to nursing staff at time of
transfer from medicine to cardiology. These symptoms resolved as
a therapeutic relationship evolved. Pt appeared to benefit from
ongoing counseling by social work consult; refused psych
evaluation. Initially continued home medications (buproprion,
Venlafaxine XR) plus PRN qHS ativan, which helped her mood by
helping her sleep. These were dose-reduced when she later
developed altered mental status. We note that the patient
previously had a therapist at home in [**Hospital1 189**] but has not seen
anyone since first hospital admission in [**Month (only) 1096**].
.
# DIABETES MELLITUS, TYPE 2
Poorly controlled with complications, last A1c 7.6 (1/[**2180**]). BS
maintained w/lantus + humalog SS.
.
TRANSITIONAL ISSUES
- needs follow-up appointment w/breast center, also for
mammography and/or R breast ultrasound
- needs psych/therapist after she gets to rehab
- needs follow-up labs on [**2181-3-23**] and daily to check her
potassium given multiple diuretics. Also should check the
creatinine given her acute on Chronic heart failure.
- needs close follow-up for diuresis, rehab shouldn't let her
gain more than 3 lbs without calling cardiologist
- may need to adjust doses of venlafaxine and buproprion once
renal function improves, but recommend keeping gabapentin off
given 2 admissions for "unresponsiveness"
- still has PICC for blood draws given ongoing diuresis with 3
agents. She should have this removed when her outpatient
doctors think she [**Name5 (PTitle) **] not need frequent blood draws anymore or
if it becomes painful or infected
- she was not started on an ACE-inhibitor because her creatinine
was still elevated on discharge to 2, this should be added in
the future with nephrology input
- Please check chemistry panel daily starting on [**2181-3-23**] and
dose her potassium chloride daily to maintain a potassium
greater than 3.5.
- When she appears euvolemic by exam and by her laboratory
values then please decrease her torsemide to 100 mg once daily.
Medications on Admission:
1. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
Daily PRN as needed for Constipation.
2. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
Units Injection TID (3 times a day).
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation Q6H (every 6
hours) as needed for SOB.
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
7. atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
8. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
9. digoxin 125 mcg Tablet Sig: One half Tablet PO DAILY
10. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day): Hold for SBP < 100 or HR < 50.
11. bupropion HCl 100 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO BID
12. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: Four
(4)Capsule, Ext Release 24 hr PO DAILY
13. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO TID (3 times a day) as needed for abd pain,
bloating.
14. gabapentin 300 mg Capsule Sig: One (1) Capsule PO QHS
15. torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO 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/wheezing.
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain (do not give for fever before alert
HO).
5. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
6. bupropion HCl 100 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO QAM (once a day (in the morning)).
7. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
10. digoxin 125 mcg Tablet Sig: [**12-25**] Tablet PO DAILY (Daily).
11. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO BID
(2 times a day).
12. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
13. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO TID (3 times a day) as needed for bloating/abdominal
pain.
14. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
15. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
16. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. torsemide 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
18. venlafaxine 37.5 mg Capsule, Ext Release 24 hr Sig: Three
(3) Capsule, Ext Release 24 hr PO DAILY (Daily).
19. insulin glargine 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous at bedtime.
20. insulin aspart 100 unit/mL Solution Sig: as directed units
Subcutaneous three times a day: FBS:
71-150=0, 151-200=2, 201-250=4, 251-300=6, 301-350=8,
351-400=10, >400=[**Name8 (MD) 138**] MD.
21. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
Two (2) Tablet, ER Particles/Crystals PO once a day.
22. metolazone 5 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] [**Location (un) 686**]
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Acute on chronic systolic heart failure
acute kidney injury
.
SECONDARY DIAGNOSIS
coronary artery disease
peripheral vascular disease
type 2 diabetes mellitus
depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms. [**Known lastname 91333**],
.
You were admitted to the hospital because you were having
difficulty breathing. This is because you were having an
exacerbation of your heart failure. You were treated with
diuretics and your weight went down significantly because you
had a lot of extra fluid on your body. Also, your mental status
was very sleepy so we adjusted the doses of your anti-depressant
medications so that your mentation improved.
.
The following changes were made to your medications:
DECREASE your digoxin to 0.0625 mg daily for heart failure
INCREASE your torsemide to 100 mg twice a day for heart failure
DECREASE your venlafaxine XR (Effexor) to 112.5 mg daily for
depression
DECREASE your buproproin (Wellbutrin) to 100 mg daily for
depression
START calcium acetate 667 mg three times a day for your kidney
disease
START metolazone 5 mg by mouth twice a day for heart failure
START spironolactone 25 mg daily for heart failure
STOP taking your gabapentin, this can make you somnolent
.
It is also very important that you weigh yourself every morning,
[**Name8 (MD) 138**] MD if weight goes up more than 3 lbs.
.
You should keep all of the follow-up appointments listed below
and bring all your medications to each appointment so that your
doctors [**Name5 (PTitle) **] [**Name5 (PTitle) 4169**] to make sure they are the proper dosages.
.
It was a pleasure taking care of you in the hospital!
Followup Instructions:
Cardiology Wednesday [**2181-4-25**] at 10:30 am
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Location (un) 2274**] [**Location (un) **]-Cardiology
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2258**]
Name: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2262**]
Location: [**Location (un) 2274**] [**Location (un) **]-Nephrology
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2263**]
Appt: [**4-13**] at 8:20am
Name: Dr [**First Name8 (NamePattern2) **] [**Name (STitle) **]
Location: [**Location (un) 2274**] [**Location (un) **]-Vascular Surgery
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2284**]
Appt: [**4-17**] at 9am
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50,691
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6243
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Discharge summary
|
report
|
Admission Date: [**2182-10-15**] Discharge Date: [**2182-10-19**]
Date of Birth: [**2112-9-22**] Sex: M
Service: SURGERY
Allergies:
Morphine
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
abdominal pain and preliminary findings of hemoperitoneum
Major Surgical or Invasive Procedure:
Arteriogram [**2182-10-16**]
History of Present Illness:
HPI: 70 year-old male presents as transfer from [**Hospital1 **] for
abdominal pain and preliminary findings of hemoperitoneum.
Patient had sudden onset of lower abdominal pain that began at
12
noon today. Patient denies any trauma. He has never had pain
like this before. Pain was [**5-26**] and now has progressed to [**8-26**].
It is nonradiating, localized to mid lower abdomen. No F/C. No
vomiting. + nausea, no appetite. Last BM was this AM -
nonbloody. Patient first seen at [**Hospital **] Hospital. He became
bradycardic at one point and lost his blood pressure - came back
with atropine. He has been hemodynamically stable since then.
CT
from OSH shows hemoperitoneum likely from a mesenteric bleed.
Patient received one unit of blood at OSH when HCT dropped from
39 to 30. He also received 2 units of FFP and 5 mg of Vitamin K
at OSH for INR 2.6.
Past Medical History:
CAD s/p stenting, A Fib, renal cysts, hyperlipidemia, spinal
stenosis,
gallstones
Social History:
SH: drinks 50 ml of ETOH (wine or cognac per night), smokes 5
cigarettes per night
Family History:
FH: Noncontributory
Physical Exam:
VS: T 98.5, HR 77, BP 111/75, RR 16, 100% on 2L
GEN: NAD, A&O x 3 (Russian speaking)
HEENT: No scleral icterus
LUNGS: Clear
CV: irregularly irregular, nl S1 and S2
ABD: Soft, TTP across lower abdomen, + guarding, no rebound,
slightly distended, no hernias
RECTAL: no gross blood
EXT: palpable femoral pulses and DP pulses B/L
Pertinent Results:
[**2182-10-15**] 08:30PM BLOOD WBC-9.1 RBC-3.58* Hgb-10.9* Hct-32.1*
MCV-90 MCH-30.6 MCHC-34.1 RDW-14.1 Plt Ct-130*
[**2182-10-16**] 07:41PM BLOOD Hct-26.5*
[**2182-10-18**] 10:50AM BLOOD Hct-28.0*
[**2182-10-15**] 08:30PM BLOOD Plt Ct-130*
[**2182-10-16**] 01:47AM BLOOD PT-17.0* PTT-28.0 INR(PT)-1.5*
[**2182-10-18**] 04:10AM BLOOD Plt Ct-111*
[**2182-10-17**] 01:15AM BLOOD Glucose-86 UreaN-13 Creat-1.0 Na-142
K-3.3 Cl-109* HCO3-27 AnGap-9
[**2182-10-15**] 08:30PM BLOOD ALT-29 AST-16 CK(CPK)-81 AlkPhos-57
TotBili-2.2*
[**2182-10-15**] 08:30PM BLOOD Calcium-8.0* Phos-3.2 Mg-1.6
[**2182-10-15**] CT scan of abdomen
IMPRESSION:
1. Hemoperitoneum. A focus of high density on contrast-enhanced
images in
the anterior pelvis concerning for active extravasation.
Post-contrast images
were obtained only in venous phase, but the source of
extravasation is likely arterial.
[**2182-10-16**] Bleeding study
IMPRESSION: Findings consistent with active bleeding into the
peritoneal cavity
in the pelvis.
[**2182-10-16**] Messenteric aortogram
No evidence of active contrast extravasation seen on the
abdominal and pelvic aortograms.
Brief Hospital Course:
Patient transferred from outside hospital with known mesenteric
bleed. Patient first seen at [**Hospital **] Hospital. He became
bradycardic at one point and lost his blood pressure - came back
with atropine. He has been hemodynamically stable since then.
CT from OSH shows hemoperitoneum likely from a mesenteric bleed.
Patient received one unit of blood at OSH when HCT dropped from
39 to 30. He also received 2 units of FFP and 5 mg of Vitamin K
at OSH for INR 2.6.
On arrival to [**Hospital1 18**] patient was admitted to the icu for close
monitoring. He also underwent another CT scan that confirmed
bleeding into his peritoneum. His INR was reversed and he was
transfused and given FFP. Serial hcts were followed and he went
for a bleeding study that also showed active bleeding. The last
study he had was an aortagram that confirmed that bleeding has
stopped. Since then patient has been stable with hematocrits
around 28.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions to hold plavix and coumadin until follow
up with Dr. [**Last Name (STitle) 1159**]. Patient with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
[**Last Name (un) 1724**]: Tramadol 50 mg [**Last Name (un) 24018**], Gabapentin 300 mg [**Last Name (un) 24018**], Nifedical 30
mg [**Last Name (un) 24018**], Lisinopril 40 mg [**Last Name (un) 24018**], HCTZ 25 mg [**Last Name (un) 24018**], Coumadin 5 mg
[**Last Name (un) 24018**], Alprazolam 0.5 mg prn (pt does not use), Plavix 75 mg
[**Last Name (LF) 24018**], [**First Name3 (LF) **] 325 mg [**First Name3 (LF) 24018**],
Lipitor 80 mg [**First Name3 (LF) 24018**]
Discharge Medications:
1. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. Tramadol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Discharge Disposition:
Home
Discharge Diagnosis:
Mesenteric bleed
Discharge Condition:
Stable
Discharge Instructions:
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please hold Plavix and Coumadin until following up with Dr.
[**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 1159**].
Followup Instructions:
Please follow up with your primary care provider within one
week. Please call immediately to make an appointment.
[**First Name8 (NamePattern2) 1158**] [**First Name8 (NamePattern2) 3613**] [**Last Name (NamePattern1) 1159**], MD
Practice Name: [**Location (un) **] Family Practice Inc
Address: [**Street Address(2) **] [**Location (un) **], [**Numeric Identifier 20591**]
Phone Number: [**Telephone/Fax (1) 20587**]
|
[
"427.31",
"V64.3",
"574.20",
"272.4",
"568.81",
"V45.82",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.47",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
5342, 5348
|
3014, 4380
|
327, 358
|
5409, 5418
|
1859, 2991
|
6309, 6731
|
1475, 1497
|
4904, 5319
|
5369, 5388
|
4407, 4881
|
5443, 6286
|
1512, 1840
|
230, 289
|
386, 1252
|
1274, 1358
|
1374, 1459
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,828
| 135,603
|
50870
|
Discharge summary
|
report
|
Admission Date: [**2109-5-6**] Discharge Date: [**2109-5-10**]
Date of Birth: [**2063-5-8**] Sex: F
Service:
CHIEF COMPLAINT: Shortness of breath.
HISTORY OF PRESENT ILLNESS: This is a 45-year-old woman with
a past medical history of back pain with pain medication
addictions, who presented from an assisted-living facility
with shortness of breath. Patient was in her usual state of
health until approximately three days prior to admission,
when she noted onset productive of green sputum. She denied
any fever or chills. This persisted over the next three days
and was eventually accompanied by shortness of breath.
Over the last 12 hours prior to the presentation at [**Hospital1 1444**], she became progressively
more shortness of breath, requiring an Emergency Room visit.
In the Emergency Room, she was noted to be hypoxic and
tachycardic, with initial room air sats in the high 70's.
Initial arterial blood gas on 8 liters nonrebreather was
7.42/34/48. This improved to 7.39/42/372 with BiPAP. Chest
x-ray showed diffuse pulmonary edema/ARDS.
Cardiology was consulted, and a bedside echocardiogram was
performed, and it was reportedly normal. When the patient
remained persistently hypoxic and had increasing work of
breathing, she was intubated. She was also pancultured, and
given doses of levofloxacin and erythromycin. Patient was
admitted to the MICU for hypoxic respiratory failure.
PAST MEDICAL HISTORY:
1. Back pain.
2. Torticollis.
3. Depression/bipolar disorder.
4. Alcohol use.
5. Posttraumatic stress disorder.
6. Gastroesophageal reflux disease.
7. Substance use.
8. History of overdoses on medications.
MEDICATIONS PRIOR TO ADMISSION:
1. Prempro.
2. Tramadol 100 mg po qid.
3. Klonopin 0.25 mg po bid.
4. Fluoxetine 20 mg po q day.
5. Benztropine 0.5 mg po bid.
6. Protonix.
ALLERGIES: Penicillin and tricyclics - unknown reaction.
SOCIAL HISTORY: Patient lives in assisted-living facility,
The [**Hospital1 **] at [**Hospital1 1426**]. Smokes 1-2 packs per day of
tobacco times last 20 years. No known history of IV drug
use, cocaine use. History of overdoses to Tylenol, Benadryl,
Xanax in the past. Of note, the day prior to admission was
the 18th anniversary of the patient's daughter's death.
PHYSICAL EXAMINATION: Vitals: Temperature 98.3, pulse 96,
blood pressure 121/83, 98% on FIO2 100%. General appearance:
Patient was intubated, sedated. HEENT: Pupils are equal,
round, and reactive, and accommodated to light. Sclerae are
anicteric. Extraocular eye movements intact. Mucous
membranes moist. No oral lesions noted. Neck: Supple.
Positive jugular venous distention. No bruits. No
lymphadenopathy. Lungs: Crackles at both lung fields.
Heart: Regular, rate, and rhythm, S1, S2 auscultated, no
murmurs, rubs, or gallops. Abdomen: Soft, nontender,
nondistended. Normoactive bowel sounds. Extremities: No
clubbing or cyanosis, trace pretibial edema.
PERTINENT LABORATORIES, X-RAYS, ELECTROCARDIOGRAM, AND OTHER
TESTS: Laboratory data on admission showed a white blood
cell count of 14.3 with 88.8% neutrophils, 9% lymphocytes,
hemoglobin 10.7 with MCV of 97, hematocrit 31.4, platelets
254. Serum electrolytes on admission were a sodium of 134,
potassium of 4.1, chloride 97, bicarb 20, BUN 21, creatinine
0.9, glucose 159. Coagulation profile showed a PT of 12.4,
PTT 25.3, INR 1.0. Urinalysis showed [**1-16**] red blood cells,
[**1-16**] white blood cells, moderate bacteria, no yeast, [**4-23**]
epithelial cells.
Initial arterial blood gas: 7.4/34/48. This improved to
7.39/42/372 on 100% nonrebreather.
Chest x-ray upon admission showed bilateral air space
opacities affecting the mid and lower lung zones.
CT scan of the chest ([**2109-5-6**]): Demonstrated diffuse
alveolar process with ground-glass opacification and
scattered areas of more confluent opacification, as well as
thickened septal lines, particularly in the right lower lobe.
Differential diagnosis for this appearance is broad and
included pulmonary edema, infection, and pulmonary
hemorrhage. Given the normal size of the heart, causes of
noncardiogenic pulmonary edema should be considered,
emphysema.
Electrocardiogram ([**2109-5-6**]): Sinus tachycardia, rate 117.
Otherwise, normal tracing with no acute ST-T changes.
Chest x-ray ([**2109-5-7**]): Interval decrease in the extent of
diffuse opacities over lung fields suggestive of improved
pulmonary edema. There are no pulmonary effusions. Soft
tissue osseous structures unremarkable. Lines and tubes in
appropriate position.
Sputum culture: Rare OP flora. Sputum Gram stain:
Gram-negative rods. Blood cultures: Negative x2. Urine
culture: Negative with no growth. Urine Legionella antigen
negative.
Serum toxicology screen: Positive for acetaminophen. Urine
toxicology screen: Positive opiates, status post intubation.
HOSPITAL COURSE:
1. Hypoxic respiratory failure, diffuse pulmonary edema:
Patient presented with an ARDS-like picture. Etiology
included infectious versus toxic ingestion related. She was
started on the ARDS-NET ventilation strategy. Permissive
hypercapnia was allowed for. FIO2 was weaned as tolerated.
In light of the concerns for an infectious etiology, she was
started on Levaquin and azithromycin. After results of her
sputum culture returned showing gram-negative rods, she was
switched to Levaquin and gentamicin.
By [**2109-5-7**], the patient was awake and moving. Her FIO2 and
PEEP were weaned down throughout the course of the day, she
tolerated this well.
By [**2109-5-8**], the patient was in clinically improved via
stable oxygenation status and improving chest x-ray. On the
morning of [**2109-5-8**], she was extubated without incident.
After extubation, the patient was transferred to General
Medicine Floor. Initially, she was started on O2 via nasal
cannula. Her O2 was weaned down as tolerated by her
saturation levels. At the time of discharge, she was stable
on room air.
Additionally, she was continued on Levaquin for the course of
her stay in order to cover for an infectious etiology for her
diffuse pulmonary edema, although her cultures returned
negative.
2. Hypotension: On [**2109-5-6**], the patient had an episode of
hypotension to blood pressure of 70/40. A right radial
arterial line and left subclavian central line were placed in
the MICU. The patient required dopamine for this episode of
decreased blood pressure. Initially she was started on
hydrocortisone 100 mg IV q8h. Her blood pressure stabilized,
and [**2109-5-7**] dopamine was weaned.
3. Psychiatric: A possible etiology of the patient's diffuse
pulmonary edema included toxic ingestions. As patient had
history of overdoses, serum urine and toxicology screens were
sent with results as above. She was started on Ativan and
Fentanyl to cover for benzodiazepine or narcotic withdrawal.
Initially her outpatient psychiatric medications were held
with the exception of her fluoxetine.
A psychiatric consultation was obtained. Impression was that
the patient likely had impaired judgement and poor impulse
control. She may well have taken excess medications without
suicidal intent.
Recommendations from Psychiatry included continuation of
standing Klonopin doses ordered, and monitoring for possible
alcohol withdrawal with treatment of benzodiazepines per CIWA
protocol if clear symptoms of withdrawal.
The patient initially expressed interest in discharge to a
HRI Mental Health Program. She was screened by Social Work
and a psychiatric nurse case manager. However, ultimately,
patient decided that she would like to be discharged to home
with additional mental health nursing services.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: Home with services.
DISCHARGE DIAGNOSES:
1. Pulmonary edema.
2. Depression/bipolar disorder.
3. Anxiety.
4. Past history of overdose.
DISCHARGE MEDICATIONS:
1. Levofloxacin 500 mg one tablet po q day x7 days.
2. Tramadol 50 mg two tablets po qid.
3. Fluoxetine 20 mg one tablet po q day.
4. Benztropine 0.5 mg one tablet po bid.
5. Ferrous sulfate 325 mg one tablet po bid, do not take at
the same time as levofloxacin.
6. Clonazepam 0.5 mg one tablet po tid.
FOLLOW-UP PLANS:
1. Patient was instructed to make an appointment with her
primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 20670**] within the next two
weeks. She was instructed to have her hematocrit checked at
Dr.[**Name (NI) 105765**] office as her last hemoglobin was 9.
2. Additionally, she had an appointment with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] at the [**Hospital 23**] Clinic Center, Department of Neurology
on [**2109-6-4**] at 1:15 pm.
POST-DISCHARGE SERVICES: Tender Loving Care Mental Health
Services, nursing.
Will provide outpatient home psychiatric services, home
safety evaluation, and mental health nursing service as
needed.
[**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**]
Dictated By:[**Last Name (NamePattern1) 257**]
MEDQUIST36
D: [**2109-5-15**] 18:01
T: [**2109-5-20**] 06:58
JOB#: [**Job Number 105766**]
cc:[**Last Name (NamePattern4) 105767**]
|
[
"486",
"311",
"514",
"518.81",
"280.0",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.04",
"96.72",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
7777, 7871
|
7894, 8198
|
4885, 7684
|
1687, 1887
|
2282, 4868
|
8215, 9203
|
143, 165
|
194, 1426
|
1448, 1655
|
1904, 2259
|
7709, 7756
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,382
| 129,952
|
27061
|
Discharge summary
|
report
|
Admission Date: [**2107-3-11**] Discharge Date: [**2107-3-21**]
Date of Birth: [**2028-7-17**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
abdominal pain and diarrhea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
78 year-old gentleman discharged from [**Hospital1 18**] on [**2107-3-10**] after
admission for hyperextension injury to c5/c6 resulting from
fall. He also was experiencing increased wheezing and low
grade fevers.
Past Medical History:
Hypertension
see HPI
Social History:
He lives with his wife. [**Name (NI) **] does drink
extensive amounts of alcohol. He stopped smoking 20 years
ago.
Physical Exam:
He moves all extremities to pain and his neuro exam is unchanged
from baseline.
Tacheostomy in place.
Diffuse wheezes bilaterally.
Heart is regular.
Abdomen is distended, but nontender. A PEG is in place and is
clean and dry. There is evidence of recent diarrhea.
Pertinent Results:
[**2107-3-10**] 02:49AM PLT COUNT-335
[**2107-3-10**] 02:49AM WBC-10.3 RBC-2.87* HGB-9.6* HCT-28.6*
MCV-100* MCH-33.6* MCHC-33.6 RDW-13.2
[**2107-3-10**] 02:49AM CALCIUM-8.3* PHOSPHATE-4.7* MAGNESIUM-2.6
[**2107-3-10**] 02:49AM GLUCOSE-130* UREA N-59* CREAT-1.7* SODIUM-138
POTASSIUM-4.3 CHLORIDE-106 TOTAL CO2-25 ANION GAP-11
[**2107-3-10**] 03:12AM TYPE-ART RATES-/22 TIDAL VOL-500 PEEP-5 O2-40
PO2-123* PCO2-42 PH-7.37 TOTAL CO2-25 BASE XS-0
INTUBATED-INTUBATED VENT-SPONTANEOU
[**2107-3-11**] 04:20PM WBC-17.5*# RBC-3.40* HGB-11.3* HCT-33.8*
MCV-99* MCH-33.2* MCHC-33.4 RDW-13.2
[**2107-3-11**] 04:20PM NEUTS-89.5* LYMPHS-6.6* MONOS-2.8 EOS-0.8
BASOS-0.3
Brief Hospital Course:
Mr. [**Known lastname 66473**] was admitted to the [**Hospital1 18**] Trauma ICU. Blood,
sputum, uring, and stool cultures were sent, and emperic
treatment was started for pneumonia. Cultures were only
positive for 2+ GPC which grew from sputum. These were never
speciated.
During his hospitalization he had several episodes of SVT and
atrial fibrillation with rapid ventriccular response. He was
always hemodynamically stable and no episode persisted for more
than 24 hours. He was stabilized on a regiment of propafenone
and verapamil.
Mr. [**Known lastname 66473**] required significant amounts of IV hydration
during his first days of this hospitalization. He was diuresed
with a lasix drip and is now stable on 40 mg IV TID.
At the time of discharge he is tolerating trach mask trials, his
WBC has normalized, and tolerating tube feeds at goal. He
should do well at rehabiliation.
Medications on Admission:
detrol, alprazolam, verapamil
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
3. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QMON (every Monday).
4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Six
(6) Puff Inhalation Q4H (every 4 hours) as needed.
5. Propafenone 150 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
6. Albuterol 90 mcg/Actuation Aerosol Sig: 8-10 Puffs Inhalation
Q4H (every 4 hours) as needed.
7. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO DAILY (Daily).
8. Verapamil 40 mg Tablet Sig: 1.5 Tablets PO Q8H (every 8
hours).
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Nystatin 100,000 unit/g Ointment Sig: One (1) Appl Topical
QID (4 times a day) as needed.
12. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
13. Zinc Oxide-Cod Liver Oil 40 % Ointment Sig: One (1) Appl
Topical PRN (as needed).
14. Lidocaine HCl 5 % Ointment Sig: One (1) Appl Topical PRN
(as needed).
15. Metolazone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
16. Ascorbic Acid 90 mg/mL Drops Sig: One (1) PO DAILY (Daily).
17. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO DAILY
(Daily).
18. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
19. Lasix 80 mg Tablet Sig: One (1) Tablet PO three times a day.
Disp:*90 Tablet(s)* Refills:*2*
20. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO four times a
day. Tablet(s)
21. Levofloxacin 250 mg/10 mL Solution Sig: One (1) PO once a
day for 4 days.
22. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection four times a day: PLease use the previously described
sliding scale to keep FSBS 75-110.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Pneumoinia
SVT
HTN
cervical spine injury
Discharge Condition:
Stable
Discharge Instructions:
Tracheostomy care per protocol.
Please perform tracheostomy mask trials during the day.
Patient will require C-spine collar.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] as needed. Reversal of
tracheostomy will be discussed in the office when stable on
trach mask and no longer requires mechanical ventillation.
|
[
"802.0",
"428.0",
"507.0",
"518.81",
"401.9",
"599.0",
"291.0",
"482.41",
"V09.0",
"427.5",
"E888.9",
"303.01",
"V46.9",
"805.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"43.11",
"96.6",
"96.72",
"31.1",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
4655, 4734
|
1768, 2666
|
342, 349
|
4819, 4828
|
1071, 1745
|
5001, 5192
|
2746, 4632
|
4755, 4798
|
2692, 2723
|
4852, 4978
|
785, 1052
|
275, 304
|
377, 594
|
616, 638
|
654, 770
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
83,171
| 183,439
|
34907
|
Discharge summary
|
report
|
Admission Date: [**2164-12-12**] Discharge Date: [**2164-12-24**]
Date of Birth: [**2088-5-23**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
shortness of breath, chest discomfort
Major Surgical or Invasive Procedure:
coronary artery bypass graft x 1 (SVG->PDA)
aortic valve replacement (21mm [**Company 1543**] Mosaic Porcine)
History of Present Illness:
76 year old white female who presented to the emergency
department with complaints of one day history of burning
sensation i the chest and epigastrium as well as shortness of
breath.
Past Medical History:
aortic stenosis
coronary artery disease
hypertension
asthma
titanium chip right breast
s/p hysterectomy
s/p cesarian section x2
Social History:
retired
quit smoking 40 yrs ago
lives alone
denies alcohol use
Family History:
unremarkable
Physical Exam:
VS: 97.6, 107/52, 68SR, 18, 98% 2L
Gen: NAD, overweight white female
Lungs: crackles b/l bases, otherwise clear
CV: distant heart tones, RRR, no murmur or rub
Abd: obese, soft, non-tender, non-distended, NABS
Ext: 2+ edema bilaterally, RUE- warmth/erythema/tenderness @
former amiodarone IV site
sternal incision: c/d/i, no erythema or drainage
Pertinent Results:
[**2164-12-24**] 06:59AM BLOOD WBC-10.8 RBC-3.41* Hgb-10.1* Hct-29.4*
MCV-86 MCH-29.5 MCHC-34.2 RDW-15.5 Plt Ct-331#
[**2164-12-24**] 06:59AM BLOOD UreaN-21* Creat-0.7 Na-139 K-4.1
[**2164-12-24**] 06:59AM BLOOD Mg-2.1
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 79880**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 79881**] (Complete)
Done [**2164-12-18**] at 11:54:02 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: [**2088-5-23**]
Age (years): 76 F Hgt (in): 62
BP (mm Hg): 145/78 Wgt (lb): 215
HR (bpm): 67 BSA (m2): 1.97 m2
Indication: Intraoperative TEE for CABG AVR. Aortic valve
disease. Coronary artery disease. Hypertension. Left ventricular
function. Preoperative assessment.
ICD-9 Codes: 402.90, 786.05, 786.51, 440.0, 424.1, 424.0
Test Information
Date/Time: [**2164-12-18**] at 11:54 Interpret MD: [**Name6 (MD) 1509**] [**Name8 (MD) 1510**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1510**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW4-: Machine: [**Doctor Last Name **]
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.7 cm 0.6 - 1.1 cm
Left Ventricle - Ejection Fraction: 55% >= 55%
Aorta - Annulus: 1.9 cm <= 3.0 cm
Aorta - Ascending: 2.8 cm <= 3.4 cm
Aortic Valve - Peak Velocity: *3.2 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *43 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 28 mm Hg
Aortic Valve - Valve Area: *0.7 cm2 >= 3.0 cm2
Mitral Valve - Mean Gradient: 3 mm Hg
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. Bidirectional shunt
across the interatrial septum at rest. Small secundum ASD.
LEFT VENTRICLE: Moderate symmetric LVH. Normal regional LV
systolic function. Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Normal descending aorta diameter.
Simple atheroma in descending aorta.
AORTIC VALVE: Severely thickened/deformed aortic valve leaflets.
Severe AS (AoVA <0.8cm2). Mild (1+) AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets.
Moderate mitral annular calcification. Moderate (2+) MR.
TRICUSPID VALVE: Mild [1+] TR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
Conclusions
Prebypass
1. No atrial septal defect is seen by 2D or color Doppler.
2. There is moderate symmetric left ventricular hypertrophy.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%).
3. Right ventricular chamber size and free wall motion are
normal.
4. There are simple atheroma in the descending thoracic aorta.
5. The aortic valve leaflets are severely thickened/deformed.
There is severe aortic valve stenosis (area <0.8cm2). Mild (1+)
aortic regurgitation is seen.
6. The mitral valve leaflets are moderately thickened. Moderate
(2+) mitral regurgitation is seen.
7. Small secundum ASD with bidirectional flow is seen.
8. Dr. [**Last Name (STitle) **] was notified in person of the results on
[**2164-12-18**] at 1030 am.
Post bypass
1. Patient in sinus rhythm.
2. LV systolic function was normal for 30 minutes after
separation from CPB. There was sudden onset of severe
hypotension with elevated PA pressures. At this time the
anterior wall, septum and anterior septum were extremely
hypokinetic. After resuscitation with epinephrine wall motion
improved. Now LV function is normal.
3. Aorta intact post decannulation.
4. Mild mitral regurgitation persists.
5. There is still bidirectional flow across the interatrial
septum.
6. Bioprosthetic valve seen in the aortic position. Valve
appears well seated and the leaflets move well. No aortic
insufficiency seen.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2164-12-19**] 11:46
?????? [**2159**] CareGroup IS. All rights reserved.
Brief Hospital Course:
The patient is a 76 year old female who presented to the ED with
chest discomfort and shortness of breath. Workup revealed
aortic stenosis and coronary artery disease. Upon evaluation
for surgery, the patient was found to require dental
extractions. This was performed on [**2164-12-16**]. The patient
recovered well from this and on [**2164-12-18**] she was brought to the
operating room where she underwent aortic valve replacement and
coronary artery bypass graft x 1. Please see operative note for
further details. Overall, the patient tolerated the procedure
well and postoperatively was transferred to the CVICU in good
condition for observation and recovery. At this time she was on
levophed and epinephrine drips. On POD 1, the patient was
extubated, alert and oriented and breathing comfortably. She
remained on epinephrine for hypotension. Chest tubes and pacing
wires were discontinued without complication. The patient was
transferred to the step down unit on POD 2. She did develop
atrial fibrillation. Amiodarone was started as well as
anticoagulation with coumadin. The patient converted to sinus
rhythm. Beta blocker was titrated as tolerated. Oral
amiodarone was continued, and coumadin was discontinued.
Remainder of hospital course was uneventful. The patient was
discharged to rehab on POD 6.
Medications on Admission:
verapamil 180', advair 250/500', asa 81', calcium
Discharge Medications:
1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as
needed.
3. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
9. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
10. Metoprolol Tartrate 25 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
11. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg 2x/day for 4 days, then 200mg 2x/day for 7 days,
then 200mg daily until further instructed by Dr. [**Last Name (STitle) 656**].
12. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 1 weeks.
14. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
15. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) as needed for RUE phlebitis for 7 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 15644**] Long Term Health - [**Location (un) 47**]
Discharge Diagnosis:
aortic stenosis
coronary artery disease
hypertension
asthma
Discharge Condition:
good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for
appointment
Dr. [**Last Name (STitle) 656**] in 2 weeks () please call for appointment
Dr. [**First Name8 (NamePattern2) 27302**] [**Last Name (NamePattern1) **] in [**3-11**] weeks () please call for appointment
Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse
([**Telephone/Fax (1) 3071**])
Completed by:[**2164-12-24**]
|
[
"522.4",
"416.8",
"997.2",
"493.90",
"458.29",
"451.82",
"427.31",
"511.9",
"414.01",
"424.1",
"E878.2",
"278.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"23.19",
"36.11",
"35.21",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
9179, 9269
|
6131, 7462
|
361, 473
|
9373, 9380
|
1328, 6108
|
9892, 10333
|
933, 948
|
7562, 9156
|
9290, 9352
|
7488, 7539
|
9404, 9869
|
963, 1309
|
284, 323
|
501, 685
|
707, 837
|
853, 917
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,810
| 195,354
|
12989+56416
|
Discharge summary
|
report+addendum
|
Admission Date: [**2194-9-28**] Discharge Date: [**2194-10-8**]
Date of Birth: [**2122-2-3**] Sex: M
Service:
In brief, this is a 72-year-old white male with aortic
stenosis, hypertension, obesity, diabetes mellitus, chronic
renal insufficiency, high cholesterol and Parkinson's who
noticed had been walking 100 feet when his legs gave out. No
chest pain for two years and positive for orthopnea, no
paroxysmal nocturnal dyspnea, angina, diaphoresis,
palpitations. Positive leg swelling for the past month and
question of dyspnea who had been taking medications. He came
to the hospital for evaluation at that time.
PAST MEDICAL HISTORY: Significant for aortic stenosis,
obesity, hypertension, high cholesterol, diabetes mellitus
Type 2, chronic renal insufficiency, Parkinson's, congestive
heart failure with three hospitalizations in the past two
years, back pain, gout, psoriasis, colonic polyps.
MEDICATIONS ON ADMISSION:
1. Insulin NPH 76 units of Regular, 20 units in the morning
and NPH 66 units in the evening.
2. Humilog 18 units.
3. KCL 20 mEq p.o. q day and 10 mEq p.o. q PM.
4. Lasix 80 mg p.o. b.i.d.
5. Salicylate 750 mg p.o. b.i.d.
6. Monopril 10 mg p.o. b.i.d.
7. Adalat 30 mg p.o. q day.
8. Atenolol 50 mg p.o. q day.
9. Cangrow 100 mg p.o. b.i.d.
10. Colchicine 0.6 mg p.o. b.i.d.
11. Xanax 0.5 mg p.o. b.i.d.
No known drug allergies.
PAST SURGICAL HISTORY: As above.
PHYSICAL EXAMINATION: He is afebrile, vital signs were
stable. He is an obese male in no apparent distress. Head,
eyes, ears, nose and throat is normocephalic, atraumatic.
Pupils are equal, round, and reactive to light and
accommodation. Extraocular movements intact. Neck supple
with no bruits. His cardiac exam is regular rate and rhythm.
3/6 systolic ejection murmur at the base. Pulmonary: Lungs
clear to auscultation. Abdomen is obese, nondistended,
nontender. Bowel sounds present. Extremities: He had
bilateral lower extremity edema, 2+ and scattered throughout
his extremities. His distal pulses were 2+. Neurological
exam was nonfocal.
On admission his electrocardiogram showed increased ST
segment in V1 through V4 that were old. Flipped T's in 1 to
V6, left ventricular hypertrophy was unchanged.
He was admitted to the medical service, question of
congestive heart failure and was taken for cardiac
catheterization. He was found to have significant congestive
heart failure with aortic stenosis. Coronaries were found to
be normal on catheterization.
He was taken to the operating room for an aortic valve
replacement on [**2194-9-30**]. He had an AVR [**17**] mm pericardial
valve and did well. He was transferred to the PSRU
postoperatively where he was extubated and he continued to
improve.
Physical therapy was consulted for ambulation and for
mobility. Felt he might be able to be discharged home,
first there is a question of being discharged rehabilitation.
If he were to be discharged home he would require home
physical therapy. Postoperatively his Foley was removed. He
was transferred to the floor. While on the floor he
developed a delirium where he became agitated and he pulled
his chest tube and wires at that time. He was started on
Haldol. He also pulled out his Foley which required
replacement due to blood and lack of ability to urinate. His
venous access was poor postoperatively and he developed rapid
atrial fibrillation at the time he had venous access
therefore, he was started on Lopressor intravenous as well as
Amiodarone load and he resolved, his rate control was better
and over time he was switched to sinus rhythm. He was
started on Heparin on [**2194-10-3**] with the goal PTT of 50 to 70.
However his loss of intravenous access and conversion to
sinus rhythm, his Heparin was discontinued. He was continued
on Coumadin. [**Female First Name (un) 3408**] Diabetes Center was consulted for
control of his diabetes and blood sugars continued to improve
and continued to stay that way. He was continued on
Lopressor 25 mg p.o. q day and Amiodarone 400 mg p.o. three
times a day and restarted on all his home medications.
He has a tremor which question possibly increasing so at the
time he was being considered to increase his
Carbidopa/Methidopa dose to one tab p.o. three times a day.
The patient is discharged to a rehabilitation facility on:
1. Lasix 40 mg p.o. b.i.d.
2. KCL 20 mEq p.o. b.i.d.
3. Aspirin 325 mg p.o. q day.
4. Colchicine 0.6 mg p.o. b.i.d.
5. Metoprazole 40 mg p.o. b.i.d.
6. Carbidopa, Levodopa 25/100 one tab p.o. b.i.d.
7. Lopressor 25 mg p.o. b.i.d.
8. Amiodarone 400 mg p.o. q day.
Daily electrocardiograms were done while the patient was
Amiodarone loaded which showed no prolongation of QT
intervals.
The patient is discharged to rehabilitation in stable
condition. Instructed to follow-up in four to six weeks with
CT surgery service, one to two weeks with primary care
physician, [**Name10 (NameIs) **] to four weeks with Cardiologist. The patient
is discharged to rehabilitation.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern4) 23403**]
MEDQUIST36
D: [**2194-10-6**] 16:37
T: [**2194-10-6**] 16:02
JOB#: [**Job Number 39808**]
Name: [**Known lastname 7167**], [**Known firstname **] Unit No: [**Numeric Identifier 7168**]
Admission Date: [**2194-9-28**] Discharge Date: [**2194-10-8**]
Date of Birth: [**2122-2-3**] Sex: M
Service:
Patient is discharged on [**2194-10-8**].
MEDICATIONS: Lasix 40 mg po bid, [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 3112**] 20 mEq po bid,
EC-ASA 325 po q day, colchicine 0.6 mg po bid, Protonix 40 mg
po bid, Carbidopa and Levodopa 25/100 one tablet po tid,
Lopressor 25 po bid, amiodarone 400 mg po q day, Coumadin 5
mg po q day, INR goal of [**2-23**].
DISCHARGE DIAGNOSES: Aortic stenosis, status post aortic
valve replacement, obesity, hypertension, high cholesterol,
diabetes, chronic renal insufficiency, Parkinson's,
congestive heart failure, back pain, gout, psoriasis, and
colon polyps.
The patient is discharged to a rehabilitation facility on
this day in stable condition. Instructed to followup in [**1-22**]
weeks with a primary care physician. [**Name10 (NameIs) **] up with
Cardiology in [**2-24**] weeks and follow up with Dr. [**Last Name (STitle) 71**] in
four weeks.
Patient is discharged in stable condition.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 2728**]
Dictated By:[**First Name (STitle) 1589**]
MEDQUIST36
D: [**2194-10-8**] 09:59
T: [**2194-10-8**] 10:22
JOB#: [**Job Number 7169**]
|
[
"428.0",
"424.1",
"293.0",
"788.29",
"250.02",
"416.0",
"593.9",
"272.0",
"332.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"88.53",
"37.23",
"88.56",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
5982, 6841
|
950, 1392
|
1416, 1427
|
1450, 5960
|
661, 924
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,583
| 133,495
|
19314
|
Discharge summary
|
report
|
Admission Date: [**2136-10-9**] Discharge Date: [**2136-10-19**]
Date of Birth: [**2073-6-11**] Sex: F
Service: NEUROLOGY
Allergies:
Vicodin / Sulfa (Sulfonamide Antibiotics) / Prednisone / Iodine
/ morphine
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
aphasia and R-sided weakness
Major Surgical or Invasive Procedure:
s/p tPA at OSH
intubation
History of Present Illness:
Ms. [**Known lastname 52592**] is a 63yo woman with a complex PMHx
including recently diagnosed metastatic lung adenocarnioma,
takotsubo cardiomyopathy complicated by MI x3, DM, HTN, COPD,
and
HL who presents today with acute onset aphasia and and right
sided weakness s/p tPa. She had been in her USOH until two days
ago, when her husband reports that she has been increasingly
sleepy, noting that she awakes to eat and take her pain
medications, but otherwise has been more somnolent than usual.
However, she was appropriate and moving all four extremities
well, with no change in speech. No apparent complaints about
HA.
Of note, she was recently started on palliative chemotherapy
with
carboplatin and pemetrexed for her metastatic lung cancer with
mets to her left femur, which she has been medicating with
around
the clock oxycontin and oxycodone. She was just at an
orthopedics f/u appointment on the day prior to presentation,
during which she was noted to be very fatigued-appearing.
On the day of admission, she was tired but otherwise at her
baseline per her husband. [**Name (NI) **] gave her oxycontin/oxycodone at
1:30pm and she took a nap. She awoke at 3pm and her husband
helped her to the bathroom. At that time, she was noted to have
normal gait and was speaking normally. She then went back to
sleep. At approximately 4:30pm, her husband noted that she woke
up and was unable to speak. She sates that it looked as though
her mouth was "stuck closed". He believes that her face was
drooping, but wasn't sure. Noted that she had weakness on her
right side, but was looking around with apparent full EOM.
However, concerned about a stroke, he carried her to his car and
drove him to the local OSH for urgent evaluation (drove because
he lives minutes away from the hospital).
There, the ED was concerned about a stroke given her
symptoms. Her NIHSS was scored at approximately 22. A NCHCT
revealed that she had a ?clot in the L MCA. She was given tPa
approximately 4hrs and 20 minutes after her last seen well time
(~7:20pm). Her husband states that while she wasn't talking or
following commands in the ED, he states that her children
thought
that she was doing better and that she was looking at them.
Prior to transport, she fell asleep. She was then brought to
the
[**Hospital1 18**] ED for consideration of urgent neurointervention. With
that in mind, a code stroke was called and neurology was
urgently
invited to consult.
Past Medical History:
-- metastatic lung adenocarcinoma -- diagnosed in [**7-/2136**] after
she had left thigh pain and suspicious lytic lesions of her left
femur were found. CT torso revealed nodules. bx of femur
lesions in [**8-/2136**] confirmed diagnosis. She recently started
chemo (carboplatin and pemetrexed) five days prior to
presentation. Left femur s/p ORIF in [**7-/2136**] [**12-28**] concern for
impending fracture. Repeat imaging of femur on [**10-8**] showed no
fracture or any acute changes of femur
-- Takotsubo cardiomyopathy and s/p MI x3 -- recently (first at
age 58, clean cath at [**Hospital3 417**] Hospital; second on [**2136-5-21**]
and third on [**2136-5-23**], again admitted to [**Hospital3 417**],
ultimately diagnosed with "broken heart syndrome", f/b
Dr. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 1557**] at [**Hospital1 1474**] Cardiology and Dr. [**Last Name (STitle) **] at [**Hospital1 1774**]).
No ECHOs in our system.
-- Asthma/COPD
-- DM2 -- no HbA1c in our system
-- HTN
-- Dyslipidemia
-- Hypothyroidism
-- h/o chronic pancreatitis
-- Diverticulitis s/p sigmoidectomy
-- Spinal fusion surgery at age 24
-- T11 compression fracture in [**2133**] s/p vertebroplasty
-- Ectopic pregnancy s/p bilateral ovarian resection
-- Peripheral neuropathy
-- Fe deficiency anemia
Social History:
She is married and lives with her husband. rare social EtOH. no
h/o IVDU.She has smoked 1ppd for roughly 40yrs and continues to
actively smoke
Family History:
Significant family history of CAD and DM. No known family
history of lung cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Physical Examination: done just prior to RSI
VS: 96.8 80 118/71 16 98% 10L
Genl: sleepy, but arousable with noxious stim. No acute
distress
HEENT: Sclerae anicteric, no conjunctival injection, oropharynx
clear
Ext: No lower extremity edema bilaterally
Neurologic examination:
Mental status: eyes closed and opened only to painful stim. did
not follow any commands or attend at all to examiner. Did not
react to any stimulation on right side. Non-verbal.
Cranial Nerves: Pupils equally round and reactive to light, 2 to
1 mm bilaterally. +gaze deviation to the left side and unable to
get her to cross midline (did not perform oculocephalic
manuever). Did not blink to threat. +right sided NLF
flattening.
Motor: Moved LUE and LLE antigravity and spontaneously with
apparent full strength. RUE and RLE plegic.
Sensation: responded to light stimulation on LUE and LLE, but
did
not respond to noxious stimulation on right side
Reflexes: 2+ and symmetric on bilateral LE (unable to test RUE
[**12-28**] IV placement). Toes upgoing bilaterally.
Coordination/Gait: unable to assess
DISCHARGE PHYSICAL EXAM:
GEN: elderly-appearing woman lying in bed, not moving
HEENT: pupils fixed and dilated
CV: No heartbeat auscultated at chest, no heartbeat palpated at
radial artery
PULM: No breath sounds auscultated, no breaths felt at mouth
EXT: cool, pulseless, no movement
Pertinent Results:
ADMISSION LABS:
[**2136-10-9**] 09:37PM BLOOD WBC-6.4# RBC-3.40* Hgb-10.1* Hct-30.0*
MCV-88 MCH-29.8 MCHC-33.7 RDW-12.6 Plt Ct-315
[**2136-10-9**] 09:37PM BLOOD Neuts-87.3* Lymphs-9.2* Monos-0.8*
Eos-2.5 Baso-0.3
[**2136-10-9**] 09:37PM BLOOD PT-10.7 PTT-23.2 INR(PT)-0.9
[**2136-10-10**] 03:19AM BLOOD Glucose-97 UreaN-10 Creat-0.5 Na-133
K-5.0 Cl-99 HCO3-26 AnGap-13
[**2136-10-10**] 03:19AM BLOOD ALT-8 AST-41* AlkPhos-107* Amylase-36
TotBili-0.3
[**2136-10-9**] 09:37PM BLOOD CK-MB-4 cTropnT-0.03*
[**2136-10-10**] 05:14AM BLOOD CK-MB-5 cTropnT-0.08*
[**2136-10-10**] 12:58PM BLOOD CK-MB-3 cTropnT-0.10*
[**2136-10-10**] 10:07PM BLOOD CK-MB-2 cTropnT-0.06*
[**2136-10-11**] 05:54AM BLOOD CK-MB-1 cTropnT-0.04*
[**2136-10-9**] 09:37PM BLOOD Calcium-8.1* Phos-3.4 Mg-1.9
[**2136-10-10**] 03:19AM BLOOD %HbA1c-5.9 eAG-123
[**2136-10-10**] 12:58PM BLOOD Triglyc-225* HDL-35 CHOL/HD-5.8
LDLcalc-122
[**2136-10-9**] 09:37PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2136-10-10**] 12:12AM BLOOD Type-ART Rates-18/ Tidal V-400 PEEP-5
FiO2-50 pO2-192* pCO2-41 pH-7.44 calTCO2-29 Base XS-4
-ASSIST/CON Intubat-INTUBATED
DISCHARGE LABS:
None, as patient CMO
IMAGING:
CT HEAD [**2136-10-9**]: IMPRESSION:
1. No intracranial hemorrhage.
2. No acute large territorial infarction. Recommend MRI for
increased
sensitivity for detection.
ECHO [**2136-10-10**]:
Conclusions
Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF>55%). Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. The aortic valve leaflets are mildly thickened
(?#). No masses or vegetations are seen on the aortic valve, but
cannot be fully excluded due to suboptimal image quality. There
is no aortic valve stenosis. The mitral valve leaflets are
mildly thickened. No masses or vegetations are seen on the
mitral valve, but cannot be fully excluded due to suboptimal
image quality. Physiologic mitral regurgitation is seen (within
normal limits). The estimated pulmonary artery systolic pressure
is normal. There is no pericardial effusion. There is an
anterior space which most likely represents a prominent fat pad.
IMPRESSION: Suboptimal image quality. No echocardiographic
evidence of endocarditis. Left ventricular systolic function is
probably normal, a focal wall motion abnormality cannot be
excluded. The right ventricle is not well seen. If clinically
indicated, a transesophageal echocardiogram may better assess
for valvular vegetations.
CT HEAD [**2136-10-10**]:
IMPRESSION:
1. Evolution of left MCA acute infarction with interval
development of
hypodense areas, with 4-mm rightward shift, but no evidence of
hemorrhagic
transformation. Assessment for any neoplastic lesions is
limited. Consider MR if not CI.
2. Chronic involutional changes.
Brief Hospital Course:
63yo woman with a complex PMHx including recently diagnosed
metastatic lung adenocarnioma, takotsubo cardiomyopathy
complicated by MI x3, DM, HTN, COPD, and HL who presented on
[**10-9**] with acute onset aphasia and and right sided weakness s/p
tPa at OSH. Patient was intubated in the ED and transferred to
the ICU [**10-9**].
# NEURO: On examination, the patient had a dense right
hemiparesis and left gaze deviation and was initially somnolent.
Initial CT-head at [**Hospital1 18**] showed no obvious infarct. Repeat
CT-head [**10-10**] showed a large L MCA infarct with 4mm of midline
shift. On [**10-11**], the patient was more alert on vent 11/17 and
opened her eyes. Palliative care was consulted and heme-oncology
informed. Family meeting [**10-11**] and the outcome was for CMO
status after extubation
# CARDS: Patient had episodes of rapid AF on [**10-10**] and was
started on IV metoprolol and briefly (2 hours) required pressor
support with neosynephrine although the lowest recorded SBP was
90. Repeat CT-head [**10-10**] showed a large L MCA infarct with 4mm o
midline shift.
# PULM: Patient was intubated in the ED on [**10-9**], and sent to
the ICU. She was extubated on [**10-12**] and started on a fentanyl
patch in addition to a fentanyl drip and all unnecessary
medications were stopped. Patient was transferred to the floor
on [**10-13**].
# PALLIATIVE CARE: Palliative care was consulted and determined
that patient should remain in the hospital on hospice benefit.
Patient's medications were adjusted to acheive maximal comfort.
She expired peacefull on [**10-19**] at 4am.
Medications on Admission:
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - (Prescribed by Other
Provider) - Dosage uncertain
FOLIC ACID - 1 mg Tablet - 1 Tablet(s) by mouth daily
FUROSEMIDE - (Prescribed by Other Provider) - 80 mg Tablet - 1
Tablet(s) by mouth qday
INSULIN ASPART [NOVOLOG FLEXPEN] - (Prescribed by Other
Provider) - Dosage uncertain
INSULIN GLARGINE [LANTUS SOLOSTAR] - (Prescribed by Other
Provider) - Dosage uncertain
LORAZEPAM - (Prescribed by Other Provider) - 1 mg Tablet - 1
Tablet(s) by mouth three times a day as needed for anxiety
METOPROLOL SUCCINATE - (Prescribed by Other Provider) - 25 mg
Tablet Extended Release 24 hr - 1 Tablet(s) by mouth qday
OMEPRAZOLE - (Prescribed by Other Provider) - 40 mg Capsule,
Delayed Release(E.C.) - 1 Capsule(s) by mouth every twelve (12)
hours
ONDANSETRON - 4 mg Tablet, Rapid Dissolve - [**11-27**] Tablet(s) by
mouth every 8 hours
OXYCODONE - 5 mg Tablet - 1 Tablet(s) by mouth every 4 hours as
needed for pain
OXYCODONE [OXYCONTIN] - 20 mg Tablet Extended Release 12 hr - 1
Tablet(s) by mouth three times a day
POTASSIUM CHLORIDE [KLOR-CON] - (Prescribed by Other Provider)
-
8 mEq Tablet Extended Release - 6 Tablet(s) by mouth qday
PROCHLORPERAZINE MALEATE - 5 mg Tablet - [**11-27**] Tablet(s) by mouth
every 8 hours as needed for nausea
PROCHLORPERAZINE MALEATE - (Prescribed by Other Provider) - 10
mg Tablet - 1 Tablet(s) by mouth every six (6) hours as needed
for nausea
TEMAZEPAM - (Prescribed by Other Provider) - 22.5 mg Capsule -
1
Capsule(s) by mouth at bedtime as needed for sleeplessness
Medications - OTC
BISACODYL [DULCOLAX] - (Prescribed by Other Provider) - Dosage
uncertain
DIPHENHYDRAMINE HCL [BENADRYL] - (Prescribed by Other Provider)
- Dosage uncertain
Discharge Medications:
N/A pt expired.
Discharge Disposition:
Expired
Discharge Diagnosis:
Metastatic lung adenocarcinoma
left MCA infarct
Discharge Condition:
Exam at time of Death:
pale, cold skin, pupils fixed and dilated, no heart beat
auscultated, no respirations auscultated
Discharge Instructions:
Ms. [**Known lastname 52592**] was seen in the hospital after she had a
large L MCA stroke. It was determined that she should be CMO
after a family meeting. She was put on hospice care while an
inpatient at [**Hospital1 18**]. She died on [**10-19**] at 4am peacefully.
Followup Instructions:
N/A patient expired
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
[
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"412",
"434.01",
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"V49.86",
"342.90",
"V45.88",
"162.9",
"784.3",
"305.1",
"429.83",
"198.5",
"V66.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
12206, 12215
|
8787, 10392
|
365, 392
|
12307, 12430
|
5923, 5923
|
12750, 12865
|
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12166, 12183
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12236, 12286
|
10418, 12143
|
12454, 12727
|
7090, 8764
|
4534, 4534
|
4556, 4788
|
297, 327
|
420, 2894
|
5009, 5619
|
5940, 7074
|
4827, 4993
|
4812, 4812
|
2916, 4232
|
4248, 4393
|
5644, 5904
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,498
| 168,615
|
50884
|
Discharge summary
|
report
|
Admission Date: [**2171-5-29**] Discharge Date: [**2171-6-10**]
Date of Birth: [**2109-11-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
[**2171-6-5**] Re-do Sternotomy CABG x 4 (LIMA to LAD, SVG to DIAG, SVG
to PDA, sequential to PLV)
History of Present Illness:
61 yo M with history of CAD s/p PCI [**2154**] who was recently
admitted with chest pain, found to have stress test and was
medically managed. Returned to [**Location **] 2 days later with recurrent
chest pain.
Past Medical History:
CAD s/p RCA POBA [**2154**] at [**Hospital 3278**] med ctr
Hypertension
[**2142**] - Stab wound to chest with laceration of diaphragm,
ventricle, s/p ex lap and laceration repair
Social History:
Former police officer, injured on the field from stab wound.
Married, works as a contractor, denies any current cigarrete use
but reports 30 pack year history. Sexually active with his wife,
no alcohol use or illicit drug use
Family History:
Father died of lung cancer, mother died from complications of
alzheimer's
Physical Exam:
VS:T 97.9, P 59, BP 168/92, R 16, O2 sat 96% RA
260lbs Ht 5'[**73**]
GEN: Obese, well appearing male in no distress
HEENT: EOMI, PERRL, anicteric sclera, pharynx non injected
CV: Regular rate, distant heart sounds, no murmurs, rubs or
gallops
LUNGS: Clear to ascultation bilaterally, no rales, rhonchi or
wheezes
ABDOMEN: Obese, non tender, non distended, normoactive bowel
sounds
EXT: No clubbing, cyanosis, edema, strong 2+ pulses bilaterally
NEURO: CN II-XII intact, full strength in upper and lower
extremities, 2+ reflexes and symmetrical.
guaic negative
Pertinent Results:
[**2171-6-9**] 08:50AM BLOOD WBC-5.2 RBC-3.58* Hgb-10.1* Hct-30.0*
MCV-84 MCH-28.2 MCHC-33.6 RDW-14.7 Plt Ct-243
[**2171-6-6**] 02:47AM BLOOD PT-15.2* PTT-34.6 INR(PT)-1.3*
[**2171-6-9**] 08:50AM BLOOD Glucose-156* UreaN-13 Creat-0.9 Na-137
K-4.4 Cl-104 HCO3-20* AnGap-17
CHEST (PA & LAT) [**2171-6-9**] 11:41 AM
CHEST (PA & LAT)
Reason: infiltrate
[**Hospital 93**] MEDICAL CONDITION:
61 year old man s/p cardiac surgery with fever
REASON FOR THIS EXAMINATION:
infiltrate
PA AND LATERAL CHEST ON [**2171-6-9**], 11:56.
INDICATION: Cardiac surgery with fever.
COMPARISON: [**2171-6-8**].
FINDINGS:
Compared to the prior study, there continues to be some density
in the left lower lobe but this does not appear to be
progressive. It in fact takes on more of an atelectatic
appearance on the current study. The upper lungs remain clear.
Small posterior effusions are again evident.
IMPRESSION: Little change versus prior without clear evidence of
evolution of left lower lobe airspace process (atelectasis
versus pneumonia).
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 105795**], [**Known firstname 1730**] [**Hospital1 18**] [**Numeric Identifier 105796**] (Complete)
Done [**2171-6-5**] at 11:01:10 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**]
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2109-11-17**]
Age (years): 61 M Hgt (in): 70
BP (mm Hg): 120/55 Wgt (lb): 260
HR (bpm): 50 BSA (m2): 2.34 m2
Indication: Intraop cabg evaluate wall motion, ventricular
function, aortic contours
ICD-9 Codes: 440.0, 424.0
Test Information
Date/Time: [**2171-6-5**] at 11:01 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW1-: Machine: aw 5
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.7 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 3.6 cm <= 5.2 cm
Right Atrium - Four Chamber Length: 4.3 cm <= 5.0 cm
Left Ventricle - Inferolateral Thickness: *1.7 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 3.6 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.0 cm
Left Ventricle - Fractional Shortening: *0.17 >= 0.29
Left Ventricle - Ejection Fraction: 50% to 55% >= 55%
Left Ventricle - Stroke Volume: 80 ml/beat
Left Ventricle - Cardiac Output: 3.98 L/min
Left Ventricle - Cardiac Index: *1.70 >= 2.0 L/min/M2
Left Ventricle - Septal Peak E': *0.05 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 12 < 15
Aorta - Annulus: 2.3 cm <= 3.0 cm
Aorta - Sinus Level: *3.9 cm <= 3.6 cm
Aorta - Sinotubular Ridge: *3.3 cm <= 3.0 cm
Aorta - Ascending: *3.5 cm <= 3.4 cm
Aorta - Arch: 2.9 cm <= 3.0 cm
Aorta - Descending Thoracic: *2.6 cm <= 2.5 cm
Aortic Valve - Peak Velocity: 1.5 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: 9 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 4 mm Hg
Aortic Valve - LVOT pk vel: 0.98 m/sec
Aortic Valve - LVOT VTI: 23
Aortic Valve - LVOT diam: 2.1 cm
Aortic Valve - Valve Area: *2.5 cm2 >= 3.0 cm2
Mitral Valve - Peak Velocity: 0.6 m/sec
Mitral Valve - Mean Gradient: 0 mm Hg
Mitral Valve - Pressure Half Time: 65 ms
Mitral Valve - MVA (P [**1-9**] T): 3.4 cm2
Mitral Valve - E Wave: 0.6 m/sec
Mitral Valve - A Wave: 0.5 m/sec
Mitral Valve - E/A ratio: 1.20
Mitral Valve - E Wave deceleration time: 162 ms 140-250 ms
Findings
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Severe symmetric LVH. Normal LV cavity size.
Mild regional LV systolic dysfunction. Low normal LVEF.
LV WALL MOTION: Regional left ventricular wall motion findings
as shown below; remaining LV segments contract normally.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Mildly dilated
ascending aorta. Focal calcifications in ascending aorta. Normal
aortic arch diameter. Complex (>4mm) atheroma in the aortic
arch. Mildly dilated descending aorta. Complex (>4mm) atheroma
in the descending thoracic aorta.
AORTIC VALVE: Three aortic valve leaflets. Mildly thickened
aortic valve leaflets. No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MS.
Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications.
Conclusions
Pre Bypass: The left atrium is mildly dilated. There is severe
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. There is mild regional left ventricular
systolic dysfunction with mild inferobasal hypokinesis. Overall
left ventricular systolic function is low normal (LVEF 50-55%).
The ascending aorta is mildly dilated. There are complex (>4mm)
atheroma in the aortic arch. The descending thoracic aorta is
mildly dilated. There are complex (>4mm) atheroma in the
descending thoracic aorta. There are three aortic valve
leaflets. The aortic valve leaflets are mildly thickened. There
is no aortic valve stenosis. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen.
Post Bypass: Preserved/mildly impoved biventricular function.
LVEF 55%. MR is trace. Aortic contours are intact. Remaining
exam is unchanged. All findings discussed with surgeons at the
time of the exam.
Brief Hospital Course:
Cardiac catheterization showed left main and 3VD. He ruled out
for MI. he was maintained on IV heparin awaiting plavix washout
prior to being taken to the operating room on [**6-5**] where he
underwent a redo sternotomy and CABG x 4.
Transferred to the CVICU in stable condition. Extubated that
night and transferred to the floor on POD #1 to begin increasing
his activity level. Chest tubes removed on POD #1. Pacing wires
removed on POD #3. ACE inhibitor and beta blockade titrated.
Gently diuresed toward his preop weight. Cleared for discharge
to home/hotel on POD #5.
Medications on Admission:
1. Lisinopril 5 mg po daily
2. Pravastatin 40 mg Tablet po daily
3. Aspirin 81 mg EC po daily
4. Nitroglycerin 0.3 mg SL PRN
5. Metoprolol Tartrate 25 mg po BID
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Coronary Artery Disease s/p Angioplasty [**2154**], s/p cabg x4
Hypertension/Hyperlipidemia
PSH: stab wound chest [**2142**]
Discharge Condition:
Stable
Discharge Instructions:
Call Dr.[**Name (NI) 9379**] office [**Telephone/Fax (1) 170**] if experience Fever > 101
or chills, increased shortness of breath, cough, chest pain or
if Sternal Incision develops redness or drainage or increased
pain.
Shower daily washing incision, pat dry: no tub bathing or
swimming
Report any weight gain greater than 2 pounds in 24 hours or 5
pounds in 1 week
No creams, powder or lotion on incisions
No driving for 1 month
No lifting > 10 pounds for 10 weeks
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) 914**] in 4 weeks
Follow-up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4972**] in 2 weeks
Follow-up with Dr. [**Last Name (STitle) **] in [**2-10**] weeks
Wound check appointment on [**Hospital Ward Name 121**] 6 as instructed [**Telephone/Fax (1) 3071**]
Completed by:[**2171-6-10**]
|
[
"414.01",
"414.8",
"E878.2",
"401.9",
"272.4",
"518.0",
"411.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"88.52",
"88.55",
"36.13",
"37.22",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
8590, 8639
|
7804, 8378
|
332, 433
|
8808, 8817
|
1807, 2161
|
9333, 9687
|
1135, 1210
|
2198, 2245
|
8660, 8787
|
8404, 8567
|
8841, 9310
|
1225, 1788
|
282, 294
|
2274, 7781
|
461, 673
|
695, 875
|
891, 1119
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,065
| 130,750
|
29769
|
Discharge summary
|
report
|
Admission Date: [**2180-2-5**] Discharge Date: [**2180-2-25**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
sepsis, aspiration, altered mental status
Major Surgical or Invasive Procedure:
Intubation-Mechanical Ventilation
Internal Jugular Central Venous Line.
PICC.
History of Present Illness:
Patient is an 82 year old portugese speaking male with recent L
MCA CVA 2 weeks ago (d/c to [**Hospital1 **] on [**2180-1-25**]), PNA (treated
with Unasyn/Zosyn last 2 days), hip fracture, osteomyelitis of
left hip, delerium, aphasia who was vomiting x 2 days,
shivering, depressed MS, hypoxic to 65, and he was transferred
to [**Hospital 8**] Hospital. On arrival to [**Hospital1 8**] vitals were
103.2, 148, 85/41 (all subsequent ones demonstrated HTN), 42,
83% - placed on nonrebreather with little improvement and was
found to be tachypneic with labored breathing and was intubated
(received versed, lidocaine, rocuronium). Also received cipro
400 mg IV x 1, Vanc 1 g IV x 1, cefepime 2g IV x 1, 2L NS.
Noted to have facial movement and with history of left MCA
infarct 2 weeks prior patient had CT head which showed
hemorrhagic conversion of left MCA infarct. No neurosurgery on
call at [**Hospital1 8**] and was therefore transferred for further
management.
.
Upon arrival to [**Hospital1 18**] vitals were 102.3, 129, 129/54, 22, 97% on
Ac 500/16/1%/5. Lactate elevated at 6 and code sepsis called.
Right IJ sepsis line placed, 3L NS administered, and ativan 1mg
given. Transferred to ICU for further management. Patient
intubated and unresponsive, unable to obtain further history
upon arrival.
Past Medical History:
# CVA - Presented on [**1-19**] with 2wks MS changes, slurred speech
- found to have CVA in left temporal region by CT on [**1-21**] (no
TPA).
- no paralysis, able to move arms and legs, unable to feed
himself, working on getting him up at [**Hospital1 **], follows commands
- memory loss/aphagia
- nml carotid U/S in [**12-28**]
- improved motor to [**5-27**] in UE
- intermittent fevers, LP pending with VDRL, HSV, AFB, fungal cx
pending at time of transfer to [**Hospital1 **]
# Seizures - Developed after recent CVA, controlled with valium
and phenytoin
# HTN - was on Atenolol, Lisinopril, HCTZ prior to CVA, on hold
since
# PNA
# Sepsis
# L hip fracture s/p open reduction/internal fixation in [**2143**]
with ongoing drainage - wound + for staph aureus and staph epi
in past
# Osteomyelitis of left hip [**4-/2179**] (had continuous drainage
from hip since [**2143**]'s)
# stress MIBI was neg in [**2174**]
Social History:
Patient was previously fully independent prior to CVA. No ETOH,
no tobacco. 2 sons, 2 daughters (one in [**Name (NI) 6257**]).
Family History:
Mother died of CVA suddenly
Physical Exam:
Vitals: 101.4, 122, 112/52, 40, 98%
Vent: AC 500/16/0.7/5, PIP 20, ABG 7.31/35/268 (on FiO2 100%)
HEENT: PERRL, left ovaloid, unable to assess EOM, anicteric
sclera, OP clear
Neck: supple, no LAD, no JVD
Cardiac: tachy, regular, NL S1 and S2, no MRGs
Lungs: CTAB anteriorly with course upper airway sounds
Abd: soft, NTND, NABS, no HSM, no rebound or guarding
Skin: Erythema overlying left hip, dimples, one of which is
draining
Ext: warm, 1+ right DP pulse, 2+ left PT pulse, no C/C/E
Neuro: sedated, toes equivaqual, not moving
.
By discharge, patient was extubated, alert, moving all four
extremiteis well, speaking occasional words, following commands
Pertinent Results:
EKG [**2180-2-4**] OSH: RBBB, tachcardia, LAD, ST changes opposite
major deflection.
.
EKG [**2180-2-5**]: Sinus tachy, RBBB, nml axis
.
Radiology:
Head CT OSH [**2180-2-4**]: Acute to subacute infarct L temporal lobe
with interval development of parenchymal hemorrhage.
.
Head CT [**2180-2-5**]: Large left MCA ?fusiform? aneurysm without
definite evidence of rupture. Large left MCA territory subacute
infarction.
Overread: Agree. MRI/MRA has been recommended to confirm that
the lesion is aneurysm and not other pathology such as mass or
unusual bleed CTA may also be helpful.
.
CXR at OSH [**2180-2-4**]: Bilobar PNA
.
CXR [**2180-2-5**]: Bilateral lower lobe opacities, R>L (right middle
and lower, left lower), with vascular redistribution, deep
sulcus sign and hyperlucency in RUL
.
CT HEAD [**2180-2-10**]:
1. No significant change in the appearance of the left MCA
territory subacute infarction with an 18 x 11 mm hyperdense
focus medially within the temporal lobe consistent with
hemorrhagic infarction.
2. No evidence for midline shift or herniation.
.
EEG [**2180-2-11**]:
This is an abnormal EEG due to the frequent spike and wave
discharges, primarily from the left frontal region with spread
to the
left and right hemispheres independently. These discharges
suggest a
left frontal region of cortical irritability. The second
abnormality
suggests diffuse encephalopathy, which may be seen with
infections,
toxic metabolic abnormalities, medications and ischemia.
.
MRI/MRA [**2180-2-11**]:
1. There are confluent areas of abnormal signal consistent with
the history of herpes encephalitis. There is involvement of the
medial and lateral aspect of the left temporal lobe, the left
gyrus rectus, the left hippocampus, and both cingulate gyri.
2. There is a stable nearly 2 cm hemorrhage at the anteromedial
aspect of left temporal lobe near the MCA and there is a stable
small amount of intraventricular hemorrhage.
3. There is good flow in the distal internal carotid arteries,
the distal vertebral arteries, and the basilar artery. There is
mild distal asymmetry of the PCAs, which is commonly seen.
There is probably slight elevation of the left MCA by the
hemorrhage but no stenosis of it is seen. IMPRESSION: There is
no significant stenosis of the left MCA from the adjacent
hemorrhage.
.
CXR [**2180-2-20**]: Worsening left lower two foci of consolidation
which might represent worsening infection or aspiration, with
otherwise unchanged appearance of the lungs.
.
Brief Hospital Course:
Mr. [**Known lastname **] is an 82 year old male who was transferred from an
outside hospital for hypoxic respiratory failure.
.
# Pneumonia and sepsis: the patient likely experienced an
aspiration event resulting in either aspiration pneumonia or
chemical pneumonitis and hypoxia. Upon transfer, the patient was
admitted to the [**Hospital1 18**] MICU. A CXR showed evidence of CHF
(iatrogenic due to fluid resuscitation) and possible PNA. An
EKG showed RBBB and no concordant ST changes. Cardiac enzymes
were negative for MI. He was intubated on the day of admission
and started on Vancomycin and Zosyn. Mr. [**Known lastname **] qualified for
the sepsis protocol and was treated as such with mixed venous O2
monitoring, maintaining MAP > 65 (pressors), CVP 10-12 (fluids),
following UOP and high-dose steroids.
.
His MICU course was complicated by development of pansensitive
Klebsiella pneumonia that was treated with
Meropenem/Vancomycin/Flagyl. The patient's family decided that
they wanted the patient to be extubated despite RISB > 100. He
was subsequently transferred to the floor and oxygen requirement
weaned. The patient is being converted to oral antibiotic
coverage upon discharge with levofloxacin and will require 2
more days of treatment.
.
# Altered mental status: the patient had a recent history of
hemorrhagic stroke and HSV encephalitis. The patient was
continued on Acyclovir for HSV encephalitis for 21 day course
total. The patient's SBPs were maintained between 100-140 in
setting of possible intracranial bleed. Aspirin was held. An
MRI was performed which showed similar findings to the previous
MRI. Neuro recommended an additional month of Dilantin after
discharge and after a repeat EEG.
.
# Seizure history: the patient had a known history of seizures
during his last hospital admission, and he was maintained on
dilantin. His target therapeutic range is 15-20 as per
Neurology recommendations. The patient showed no evidence of
seizure activity during this hospitalization.
.
# Thrombocytosis: the patient's platelet count reached 1100
during this admission and it was thought to be related to an
acute inflammatory reaction. ESR, CRP, ferritin, fibrinogen were
also significantly elevated. The patient's platelet count was
decreasing at the time of discharge.
.
# Hyperglycemia: the patient developed elevated blood sugars in
the setting of high dose steroid administration. Although, high
dose steroids were stopped, he continued to have some isolated
elevations. The patient's blood sugars should be monitored and
covered with sliding scale insulin until further work-up or
resolution.
.
# Sacral decubitus ulcer: the patient was noted to have a Stage
II sacral decubitus ulcer during this hospitalization. It did
not appear to be infected. Wound care was consulted. It was
treated with duoderm dressing, air mattress, frequent position
changes and physical therapy.
.
# Osteomyelitis: the patient has a chronically infected hip for
approximately 40 years, per his family. This was unlikely to be
the predominant infectious source given it's appearance on this
admission. Wound care was consulted to provide recommendations.
.
# Nutrition: Given the patient's altered mental status and
concern for aspiration, a speech and swallow examination was
performed. The patient was cleared for nectar thick liquids and
regular solids.
Medications on Admission:
Aspirin 325 QD
Dilantin 300 PO QD
Pravastatin 20 QD
Bacitracin oint
Dalteparin/Fragmin 5000 units SQ QD
Colace
Fluoxetine 20 QD
MVI
Pantoprazole 40 QD
Acet prn, Bisacodyl prn, Zofran prn, Compazine prn
Discharge Medications:
1. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
2. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO BID (2 times a day) as needed for agitation.
3. Phenytoin 100 mg/4 mL Suspension Sig: Eight (8) mL PO TID (3
times a day).
4. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
5. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day) as needed for constipation.
7. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation every 4-6 hours as needed for shortness of breath or
wheezing.
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. Insulin Regular Human 100 unit/mL Solution Sig: One (1) QID
Injection ASDIR (AS DIRECTED): See attached sliding scale.
10. Levaquin 500 mg Tablet Sig: One (1) Tablet PO once a day for
2 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary:
1. HSV Encephalitis w/ Hemmorhage.
2. Generalize Seizure.
3. Sepsis NOS.
4. Respiratory Failure.
5. Ventilator Associated Pneumonia - Klebsiella.
6. Steroid Induced Diabetes Mellitus.
7. Anemia of Chronic Inflammation.
8. Malnutrition - Moderate Degree.
9. Delirium.
10. Reactive Thrombocytosis.
Secondary:
1. S/P Left Hip ORIF c/b Osteomyelitis [**2143**].
2. Recurrent Osteomyelitis Left Hip, 4/[**2179**].
3. Depression.
4. Hyperlipidemia.
Discharge Condition:
Stable. Afebrile. Tolerating PO.
Discharge Instructions:
You were admitted to the hospital for an infection in your brain
called HSV encephalitis. You received a course of antibiotics.
During your hospitalization, you also developed pneumonia. This
was treated with antibiotics. Please return to the ED or call
your doctor if you have any of the following symptoms: fever >
101.5, severe pain, difficulty breathing, intractable
nausea/vomiting or any other concerning symptoms.
.
Please take all medications as prescribed.
.
Please follow-up with all appointments as scheduled.
Followup Instructions:
1. Check albumin and dilantin level 2 days from discharge.
Adjust dilantin dose as needed, then check weekly when
therapeutic (~15-20).
2. Check phosphate.
3. Check blood sugars and give insulin per sliding scale.
3. Please make an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 42325**] after you
are discharged from the extended care facility. You can call
[**Telephone/Fax (1) 31553**] to make the appointment.
4. The patient will need to follow-up with a Neurologist in in 4
weeks. He can call ([**Telephone/Fax (1) 2528**] to make an appointment with
Dr. [**Last Name (STitle) 2340**]. Alternatively, he can be seen by the Neurologist
at [**Hospital1 **].
5. Repeat EEG in one month.
|
[
"428.0",
"780.39",
"401.9",
"285.29",
"V12.59",
"251.8",
"518.81",
"054.3",
"507.0",
"707.03",
"431",
"255.4",
"995.92",
"730.15",
"263.0",
"038.9",
"482.0",
"E932.0",
"438.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.72",
"96.6",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
10655, 10734
|
6056, 7326
|
301, 381
|
11231, 11266
|
3539, 6033
|
11835, 12563
|
2819, 2848
|
9680, 10632
|
10755, 11210
|
9454, 9657
|
11290, 11812
|
2863, 3520
|
220, 263
|
409, 1720
|
7341, 9428
|
1742, 2657
|
2673, 2803
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,808
| 183,850
|
14208
|
Discharge summary
|
report
|
Admission Date: [**2188-7-17**] Discharge Date: [**2188-7-26**]
Date of Birth: [**2129-9-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Hydrocodone / Keflex
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2188-7-22**] - CABGx4 (LIMA-LAD,SVG-DG,SVG-OM,SVG-PDA)
[**2188-7-17**] left heart catheterization, coronary angiogram and left
ventriculogram
History of Present Illness:
This is a 58-year-old male status post IMI in [**2181**] with
subsequent stenting of his RCA at [**Hospital **] Hospital. He was
also noted to have a 50% mid LAD lesion and a 70% distal LAD
lesion. He underwent repeat cardiac catheterization at [**Hospital1 2025**] in
[**2182**] for recurrent chest discomfort and was found to have
reoccluded his RCA. He was, however, noted to have left to right
collaterals and was medically managed.
He saw Dr. [**Last Name (STitle) 11493**] in cardiology follow up on [**2188-7-15**] where he
reported chest discomfort with exertion and profound fatigue. He
reported chest discomfort with as little as walking on flat
ground. chest burning in the substernal area He reports
associated shortness of breath, lightheadedness, palpitations,
nausea and diaphoresis. He stops his activity and the pain
dissipates. The most he can walk before developing symptoms is
[**Age over 90 **] yards and he develops symptoms with one flight of stairs. He
denies any rest pain, pedal edema ororthopnea.
Past Medical History:
Coronary artery disease
s/p Coronary artery bypass graft x 4
h/o Myocardial infarction
s/p PCI to RCA with restenosis
Hypertension
Hyperlipidemia
Anxiety/Depression
Hemochromatosis
s/p Tonsillectomy
s/p Appendectomy
S/P bilateral carpal tunnel release
S/P left shoulder surgery in [**2149**]
S/P benign cyst removed from neck
Social History:
He is divorced and lives with his girlfriend. [**Name (NI) **] does not smoke
cigarettes but smokes marijuana (1 cigarette per day) and drinks
alcohol on rare occasions. He works as film maker.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; his father died during CABG surgery at
age 64
Physical Exam:
Admission:
VS: 98.2, 107/54, 58, 16, 97%RA
GENERAL: Middle aged male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP not visible
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ DP 1+ PT 1+
Left: Carotid 2+ Femoral 2+ DP 1+ PT 1+
Pertinent Results:
[**7-17**] Cardiac cathterization: 1. Selective coronary angiography
of this right dominant system revealed three vessel coronary
artery disease. The LMCA had no angiographically apparent flow
limiting epicardial coronary artery disease. The LAD had
mid-diffuse disease with up to a 70% stenosis. The LCx had a
large 90% OM1 with slow flow. The RCA had a diffuse proximal 90%
stenosis and the distal stent was patent with 50% restenosis.
The RCA was occluded after the PDA with L > R collaterals from
the LCx. 2. Resting hemodynamics revealed moderately elevated
left sided filling pressures with an LVEDP of 22 mmHg. There was
no evidence of systemic arterial systolic hypertension with an
SBP of 109 mmHg and DBP of 72 mmHg.
[**7-19**] Carotid U/S: Right ICA stenosis 0 %. Left ICA stenosis 0%.
[**7-22**] Echo: PRE-BYPASS: 1. The left atrium is moderately dilated.
No atrial septal defect is seen by 2D or color Doppler. 2. Left
ventricular wall thicknesses and cavity size are normal.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). 3. Right
ventricular chamber size and free wall motion are normal. 4.
There are simple atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta. 5. There are three
aortic valve leaflets. There is no aortic valve stenosis. No
aortic regurgitation is seen. 6. Mild (1+) mitral regurgitation
is seen. 7. There is a trivial/physiologic pericardial effusion.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including phenylephrine and is in
sinus rhythm. 1. Bi ventricular function is preserved 2. Aorta
appears intact post decannulation 3. Other findings are
unchanged
[**2188-7-25**] 05:35AM BLOOD WBC-9.2 RBC-3.19* Hgb-10.1* Hct-29.1*
MCV-91 MCH-31.7 MCHC-34.8 RDW-13.3 Plt Ct-101*
[**2188-7-25**] 05:35AM BLOOD Plt Ct-101*
[**2188-7-24**] 05:50AM BLOOD Glucose-116* UreaN-15 Creat-0.9 Na-137
K-4.9 Cl-104 HCO3-27 AnGap-11
Brief Hospital Course:
Mr. [**Known lastname 42255**] presented to the hospital on [**7-17**] and underwent a
cardiac cath. Catheterization revealed severe three vessel
coronary disease with preserved LV function. Due to the extent
of his disease he was referred for bypass surgery. Therefore he
was admitted post-cath, underwent complete cardiac work-up and
awaited for Plavix to wash-out.
On [**7-22**] he was brought to the Operating Room where he underwent
coronary artery bypass graft x 3. Please see operative report
for surgical details. Following surgery he was transferred to
the CVICU for invasive monitoring in stable condition. Within 24
hours he was weaned from sedation, awoke neurologically intact
and was extubated.
On post-op day one he was transferred to the telemetry floor for
further care. Chest tubes and epicardial pacing wires were
removed per protocol. Physical therapy worked with him for
strength and mobility. Beta blockers were resumed and he was
diuresed towards his preoperative weight.
Discharge instructions and medications were explained, as were
limitations and follow up prior to going home. PA & lateral
CXRs after CT removal were clear. He was nearly at preop weight
and Lasix was discontinued at discharge. Lopressor was
transitioned to Atenolol as he was on this preoperatively.
Pacing wires were removed on POD 3. He was ready for discharge
on POD 4.
Medications on Admission:
Amlodipine 5 mg daily, Atenolol 50mg daily, Lisinopril 2.5 mg
daily, Nitroglycerin 0.4 mg Tablet, Sublingual PRN, Simvastatin
80 mg daily, Venlafaxine 75 mg daily, Sust Rel Osmotic Push
24hr, Aspirin 325 mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
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. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
4. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
5. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO every four
(4) hours as needed for pain for 4 weeks.
Disp:*50 Tablet(s)* Refills:*0*
6. Atenolol 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Disp:*50 Tablet(s)* Refills:*2*
7. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO every [**5-5**]
hours as needed for fever or pain.
8. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
10. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 10
days.
Disp:*10 Tablet(s)* Refills:*2*
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 10
days.
Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Coronary artery disease
s/p Coronary artery bypass graft x 4
h/o Myocardial infarction
s/p PCI to RCA
Hypertension
Hyperlipidemia
Anxiety/Depression
Hemochromatosis
s/p Tonsillectomy
s/p Appendectomy
S/P bilateral carpal tunnel release
S/P left shoulder surgery in [**2149**]
S/P benign cyst removed from neck
Discharge Condition:
good
Discharge Instructions:
Report any redness of , or drainage from incisions.
Report any fever greater then 100.5.
Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1
week.
No lotions, creams or powders to incision until it has healed.
Shower daily. No bathing or swimming for 1 month.
No lifting greater then 10 pounds for 10 weeks from date of
surgery.
No driving for 1 month and while taking narcotics.
Call with any questions or concerns.
Followup Instructions:
Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 16827**]) Date/Time:[**2188-8-15**] 1:00
Dr. [**Last Name (STitle) **] in 1 month ([**Telephone/Fax (1) 170**])
Dr. [**Last Name (STitle) 11493**] in 2 weeks ([**Telephone/Fax (1) 11376**].
Dr. [**Last Name (STitle) **] in 2 weeks ([**Telephone/Fax (1) 11767**])
[**Hospital Ward Name 121**] 6 wound clinic in 2 weeks.
Please call for appointments.
Completed by:[**2188-7-26**]
|
[
"411.1",
"V45.82",
"275.0",
"414.01",
"412",
"272.4",
"401.9",
"305.21",
"300.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"88.72",
"88.53",
"39.61",
"36.13",
"88.56",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
8016, 8022
|
5114, 6492
|
311, 458
|
8376, 8383
|
3095, 5091
|
8863, 9295
|
2090, 2224
|
6755, 7993
|
8043, 8355
|
6518, 6732
|
8407, 8839
|
2239, 3076
|
261, 273
|
486, 1512
|
1534, 1862
|
1878, 2074
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,168
| 116,840
|
38350+58208
|
Discharge summary
|
report+addendum
|
Admission Date: [**2168-7-18**] Discharge Date: [**2168-7-22**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
Bradyarrhythmia, transfer for evaluation of PPM
Major Surgical or Invasive Procedure:
Pacemaker placement on [**2168-7-19**]: [**Company 1543**] Sensia
History of Present Illness:
Mr. [**Known lastname **] is a 89 year old male with PMH significant for chronic
lymphocytic leukemia, IDDM, CAD s/p CABG ([**2141**]) who is
transferred from [**Hospital **] hospital for bradycardia.
.
Patient experienced fatigue and weakness for the past few days.
On [**7-16**] he fell out of a chair onto the floor when adjusting
himself. He states that his head got stuck in the legs of the
desk. He denies losing consciousness but he states that he
"fell asleep." His He denies CP, nausea, diaphoresis, shortness
of breath. His daughter found him on the groud ~4hours later.
In the ED at [**Location (un) **], his VS T 98.3, HR 73, RR 20, BP 141/60, O2
96% RA. Labs were notable for trop 8.58, CK 618, CK-MB 28.3,
hct 24.8, plt 80, Cr 1.6. The patient was given aspirin, but
not started on heparin gtt.
.
ECG showed Wenckebach block with bradycardia. Per OSH records,
he had multiple runs of NSVT, the longest 10-15sec and was given
lidocaine iv. Per nursing report, however, patient was stated
to have 15-20 sec pause. He had persistent bradycardia with HR
of 30s and a temporary pace wire was placed. He was also
transfused 2 pRBC while there (hct improved to 29). An
echocardiogram was done that showed mild MR/TR, biatrial
enlargement, EF 50%, dyssynergic septum with RV temp pacing.
His Trop per nursing report peaked to 10.3.
.
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, chills or rigors.
S/he denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, -Dyslipidemia, -Hypertension
2. CARDIAC HISTORY:
-CABG: s/p CABG [**2141**]
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- Chronic lymphocytic leukemia, on procrit
- DMII, insulin dependent
- CAD, s/p CABG [**2141**]
- BPH
- Bl cataract surgery
- SCC of the scalp
- H/o bradycardia, PPM not recommended
Social History:
Lives independently. Retired broadcast engineer. Has eight
children.
-Tobacco history: None
-ETOH: None
-Illicit drugs: None
Family History:
Mother w/ [**Name2 (NI) 499**] cancer.
Physical Exam:
GENERAL: Elderly male, thin, in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. Dry MMM. No
xanthalesma.
NECK: Supple with flat JVP. Guaze covering area of excised SCC
c/d/i.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
Pt with thyroid nodule this admission which needs f/u
[**2168-7-18**] 09:42PM PT-12.0 PTT-25.2 INR(PT)-1.0
[**2168-7-18**] 09:42PM PLT SMR-LOW PLT COUNT-96*
[**2168-7-18**] 09:42PM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL
POIKILOCY-1+ MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL
OVALOCYT-1+
[**2168-7-18**] 09:42PM NEUTS-25* BANDS-2 LYMPHS-73* MONOS-0 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2168-7-18**] 09:42PM WBC-8.6 RBC-3.28* HGB-11.1* HCT-33.2*
MCV-101* MCH-33.7* MCHC-33.3 RDW-17.3*
[**2168-7-18**] 09:42PM TSH-1.4
[**2168-7-18**] 09:42PM CALCIUM-8.1* PHOSPHATE-2.9 MAGNESIUM-2.1
[**2168-7-18**] 09:42PM CK-MB-4 cTropnT-0.34*
[**2168-7-18**] 09:42PM ALT(SGPT)-19 AST(SGOT)-30 LD(LDH)-241
CK(CPK)-288 ALK PHOS-83 TOT BILI-0.6 DIR BILI-0.2 INDIR BIL-0.4
[**2168-7-18**] 09:42PM estGFR-Using this
[**2168-7-18**] 09:42PM GLUCOSE-311* UREA N-29* CREAT-1.3* SODIUM-138
POTASSIUM-4.1 CHLORIDE-108 TOTAL CO2-24 ANION GAP-10
Brief Hospital Course:
89 year old male with PMH significant for chronic lymphocytic
leukemia, IDDM, CAD s/p CABG ([**2141**]) who is transferred from
[**Hospital **] hospital for PPM for symptomatic bradycardia.
# Symptomatic Bradycardia: Patient's fall was suspected to be
secondary to symptomatic bradyarrhythmia. His ECG from the OSH
showed Wenckebach and CHB. Per report, as an outpatient patient
had sinus pauses on Holter monitor. Patient underwent placement
of PPM and tolerated this procedure well. He was treated with
antibiotics for 48hours. His pacemaker was interrogated and
working well. Patient will follow up in device clinic next
week. Please see page 1 for pacer site care and activity
restrictions.
.
# Non ST Elevation Myocardial Infarction: Patient has a history
of CABG (anatomy unknown). His cardiac markers were elevated at
OSH and at [**Hospital1 18**]. While here he denied any chest pain. Patient
was limited to receiving anti-aggregation therapy (see below).
He was started on lisinopril, metoprolol after PPM was placed,
ASA 325. Lipitor was started at discharge. His lipid panel is
pending at this time. There was a discussion at discharge about
persuing stress testing but given his CLL, it was thought that
medical management was most appropriate at this time.
.
# Acute on Chronic Kidney Disease: Patient's Cr was 1.6 at OSH.
His urine was notable for large blood and there was a concern
for rhabdo. On arrival to [**Hospital1 18**] patient's Cr was 1.4, which
remained stable. He also had protein in his urine which
suggested likely underlying renal insufficiency likely secondary
to diabetes. His metformin and glipizide were held, but
restarted on discharge.
.
# CLL: With likely bone marrow involvement: thrombocytopenia and
anemia. ANC 2150. His counts were monitored and procrit was
held. Platelets decreased to 64 on day of discharge, Hct stable
at 30. No signs of overt bleeding. Given the patient will not be
able to f/u with his home Hematologist (Dr. [**First Name (STitle) 12795**] in [**Location (un) **]
VT) an appt was made wth Dr. [**Last Name (STitle) **] at [**Hospital1 **] [**Location (un) 620**] for further
monitoring. Dr. [**Last Name (STitle) **] will decide when to restart Procrit and
arrange for monitoring of labs. FeSo4 was continued. Please
check labs on Monday [**7-25**].
.
# IDDM: Held metformin and glipizide, but restarted on
discharge. Patient continued on home lantus.
.
# BPH: Continued terazosin
.
# Thyroid nodule: An incidental thyroid nodule was seen on CT
scan, which needs to be followed as an outpatient.
.
# S/P Mohs Surgery for Squamous Cell CA on scalp on [**7-14**]. His
daughter has been changing the dressing daily. Sutures can be
removed on [**7-26**], then a non-occlusive dressing to the site until
there is only pink skin visible.
Medications on Admission:
MEDICATIONS:
Folic acid 1mg daily
metformin 500mg [**Hospital1 **]; 250mg at noon
ecotrin 81mg daily
glipizide 10mg [**Hospital1 **]
terazosin 10mg daily
MVI
iron tab daily
lantus 10U daily
procrit
.
MEDICATIONS ON TRANSFER:
aspirin 325 daily
lipitor 80mg daily
metoprolol 25mg [**Hospital1 **]
MVI
terazosin 10mg qhs
tylenol 650mg Q4prn
SLN prn
ISS
HSC
Discharge Medications:
1. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily): Hold
SBP < 100.
4. Lantus 100 unit/mL Solution Sig: Ten (10) units Subcutaneous
at bedtime.
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
6. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Metformin 500 mg Tablet Sig: 0.5 Tablet PO NOON (At Noon).
8. Glipizide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
9. Clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q6H
(every 6 hours) for 1 days.
10. Terazosin 5 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
11. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): Hold for diarrhea.
15. Outpatient Lab Work
Please check CBC and chem-7 on Monday [**2074-7-23**]. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
17. Multiple Vitamin Tablet Sig: One (1) Tablet PO once a
day.
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **]
Discharge Diagnosis:
Primary Diagnosis:
Acute systolic Dysfunction: EF 30%
Non ST Elevation Myocardial Infarction
Complete Heart Block
Acute on chronic Kidney Disease
.
Secondary Diagnosis:
Chronic lymphocytic leukemia
Diabetes Mellitus on Insulin
Coronary Artery Disease s/p CABG [**2141**]
Benign Prostatic Hypertrophy
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 had a fall at home and was brought to [**Hospital **] Hospital with
a heart attack. You were then transferred here to [**Hospital1 18**] for
treatment. You were also very anemic and had some dangerous
heart rhythms. We placed a pacemaker to fix your heart rhythms
and gave you some blood. You blood count and platelet counts are
still quite low, you should consider seeing a
hematologist/oncologist for this within the next month. You can
return to your doctor [**First Name (Titles) **] [**Last Name (Titles) 3914**] or you can go to a doctor close
to Newbridge:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD
[**Hospital1 **] Hospital - [**Location (un) 620**]
[**Street Address(2) 3001**]
[**Location (un) 620**], [**Numeric Identifier 3002**]
Phone: [**Telephone/Fax (1) 38619**]
Fax: [**Telephone/Fax (1) 85425**]
Date/time: Wednesday [**7-27**] at 1:30pm
.
Medication changes:
1. Increase aspirin to 325 mg to prevent another heart attack
2. Start Lisinopril to help your heart pump better
3. Start Tylenol for pain at the pacer site as needed
4. Start Clindamycin to prevent an infection at the pacer site,
you have one more day left
5. Start Atorvastatin to lower your cholesterol
6. Start Colace and senna to prevent constipation.
.
Weigh yourself every morning, call Dr. [**Last Name (STitle) **] if weight goes
up more than 3 lbs.
Followup Instructions:
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2168-7-26**]
4:00pm
[**Hospital Ward Name 23**] Clinical Center, [**Location (un) 436**]. [**Location (un) **], [**Hospital Ward Name 5074**] [**Hospital1 18**].
.
Primary Care:
Provider: [**Name10 (NameIs) 14218**], [**Name11 (NameIs) **] Phone:([**Telephone/Fax (1) 85426**] Date/Time:
[**2168-7-29**] 8:30am This appt needs to be cancelled if pt is still
in MA
.
Cardiology:
[**8-8**] at 11:20am with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. [**Hospital Ward Name 23**] Clinical
Center, [**Location (un) 436**]. [**Location (un) **], [**Hospital Ward Name 516**] [**Hospital1 18**]
.
Hematology/Oncology:
[**Last Name (LF) **], [**First Name3 (LF) **] H., MD
[**Hospital1 **] Hospital - [**Location (un) 620**]
[**Street Address(2) 3001**]
[**Location (un) **], across from Medical Day care. Please stop at
registration first.
[**Location (un) 620**], [**Numeric Identifier 3002**]
Phone: [**Telephone/Fax (1) 38619**]
Fax: [**Telephone/Fax (1) 85425**]
Date/time: Wednesday [**7-27**] at 1:30pm
Name: [**Known lastname 7998**],[**Known firstname **] Unit No: [**Numeric Identifier 13541**]
Admission Date: [**2168-7-18**] Discharge Date: [**2168-7-22**]
Date of Birth: [**2079-5-30**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1051**]
Addendum:
On [**7-21**] when pt was waiting for ambulance to rehab, he had a
vagal episode while straining with a bowel movement on the
commode. He was noted to be unresponsive for about 1 minute. Put
in bed and woke up spontaneously. BP and HR unchanged. ECG
showed 100% paced rhythm. Pacer interrogated and no sign of
arrhythmias or pacer disfunction. Denied any precipitating
symptoms such as palpitations, chest pain or dizziness. Pt was
given 500cc INF bolus and hct was stable. Orthostatic vital
signs were checked x2 before discharge and were negative. Pt had
no further episodes, constipation has now resolved. Pt should
continue to take colace [**Hospital1 **] and bowel movements should be
monitored to prevent constipation.
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1052**] MD [**MD Number(2) 1053**]
Completed by:[**2168-7-22**]
|
[
"428.0",
"250.00",
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"410.71",
"426.13",
"585.9",
"414.00",
"428.31",
"427.89",
"V45.81",
"V58.67",
"600.00",
"584.9",
"426.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.83",
"37.72"
] |
icd9pcs
|
[
[
[]
]
] |
13486, 13710
|
4722, 7537
|
267, 335
|
9692, 9692
|
3753, 4699
|
11268, 13463
|
2811, 2851
|
7942, 9258
|
9369, 9369
|
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|
9875, 10765
|
2866, 3734
|
2349, 2434
|
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|
180, 229
|
363, 2241
|
9538, 9671
|
9388, 9517
|
9707, 9851
|
2465, 2648
|
7788, 7919
|
2263, 2329
|
2664, 2795
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,706
| 132,316
|
8408
|
Discharge summary
|
report
|
Admission Date: [**2146-2-1**] Discharge Date: [**2146-2-5**]
Date of Birth: [**2081-7-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5755**]
Chief Complaint:
cough and shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient is a 64 yo male with h/o CAD s/p CABG, DM, CHF with EF
20 % p/w cough, lethargy, chills, SOB and right sided
back/scapular pain x 2 days. Mr. [**Known lastname **] noticed that he was more
lethargic over the past 2 days and wanted to sleep more. He also
noticed some right scapular "muscle pain" which he treated with
icy hot and massage. On the evening of admission he developed
cough productive of blood-tinged sputum, SOB and chills and
presented to the ED. He denied CP, PND, orthopnea, recent
increasing DOE, LE edema. He has been taking all of his
medications as directed. Denies sick contacts.
.
In the ED RIJ was placed and patient recieved 5 liters NS and
levaquin 750 mg x1 with SBPs in 70s-80s and dopamine was
started. He subsequently devloped respiratory distress and CP
after fluid resuscitation and was given lasix 40 mg IV x1 and
morphine 2 mg IV x1 and his dopamine was was decreased to 20
cc/hr. He was placed on 100% NRB but remained conversant with
improvement in his breathing after the lasix satting 100%. On
transfer BP 104/52, HR 105, RR 18, O2 sat 100% on 100% NRB 5
liters in and 900 cc UOP over 2 hours.
.
On arrival to the ICU he reported that his breathing was
improved but he was feeling "like I was drowning." Denied CP,
HA, dysuria, hematuria, melena, BRBPR. His right scapular pain
has resolved
.
ROS: Denies weight loss, weakness, diarrhea.
Past Medical History:
CAD c/b MI s/p 3v CABG '[**38**]
PVD s/p left common iliac thrombectomy and patch angioplasty;
left femoral endarterectomy and femoral-femoral bypass graft
AAA s/p repair c/b type I endo leak followed by serial CT
scans
h/o thrombus in left limb of aortic graft
DM II, insulin requiring (recent FS 120s-160s)
CHF, with most recent ECHO from [**2-26**] showing EF 20-25%
PUD and h/o h pylori infection
s/p AICD placement
s/p R knee surgery
s/p bilateral cataract surgery
Recurrent LE DVT on coumadin
Arthritis
Social History:
The patient lives at home with his wife. [**Name (NI) **] is retired since
his CABG in [**2138**] but manages an online radio station from his
home. Smoked [**3-27**] ppd since age 14 but quit in [**2138**] at time of
CABG. Very occasional ETOH. Denies IVDU.
Family History:
Father died of MI in his 60s.
Physical Exam:
Vitals: T 99.9 (ax) HR 83 BP 93/54 (MAP 63) O2Sat 98 % on 100%
NRB
Gen: Obese male, lying flat in bed in mild distress, able to
speak in [**3-27**] word sentences
HEENT: PERRL, EOMI, OP clear, MM dry
Neck: JVP could not be assessed given body habitus and RIJ
placement
CV: regular, distant heart sounds
Lungs: bibasilar crackles and coarse BS on right
Abd: obse, soft, +BS, NT/ND
Back: no spinal or CVA tenderness, no tenderness in right
scapular area
Ext: 2+ pitting edema to shins bilaterally
Neuro: CN II-XII intact, strength in upper an LE [**5-28**] and equal
bilaterally
Skin: no rashes
Pertinent Results:
[**2146-2-1**] 12:40AM WBC-16.9*# RBC-3.53* HGB-12.5* HCT-35.4*
MCV-100* MCH-35.3* MCHC-35.2* RDW-15.0
[**2146-2-1**] 12:40AM NEUTS-77* BANDS-12* LYMPHS-4* MONOS-4 EOS-0
BASOS-0 ATYPS-0 METAS-3* MYELOS-0
[**2146-2-1**] 12:40AM PLT COUNT-182
.
[**2146-2-1**] 11:07AM RET AUT-1.5
[**2146-2-1**] 11:07AM IRON-17*
[**2146-2-1**] 11:07AM calTIBC-248* FERRITIN-123 TRF-191*
FOLATE 12.7, B12 469
.
[**2146-2-1**] 12:40AM PT-36.2* PTT-33.0 INR(PT)-4.0*
.
[**2146-2-1**] 12:40AM CORTISOL-36.3*
[**2146-2-1**] 12:47AM LACTATE-4.5*
.
[**2146-2-1**] 12:40AM GLUCOSE-252* UREA N-26* CREAT-2.0* SODIUM-137
POTASSIUM-4.5 CHLORIDE-98 TOTAL CO2-26 ANION GAP-18
[**2146-2-1**] 12:40AM ALT(SGPT)-20 AST(SGOT)-20 CK(CPK)-138 ALK
PHOS-58 AMYLASE-46 TOT BILI-0.5
[**2146-2-1**] 12:40AM LIPASE-36
[**2146-2-1**] 12:40AM ALBUMIN-4.6 CALCIUM-9.3 PHOSPHATE-2.0*
MAGNESIUM-1.6
.
[**2146-2-1**] 12:40AM CK-MB-3 cTropnT-<0.01
[**2146-2-1**] 11:07AM CK(CPK)-105
[**2146-2-1**] 11:07AM CK-MB-3 cTropnT-0.02*
[**2146-2-1**] 03:51PM CK(CPK)-108
[**2146-2-1**] 03:51PM CK-MB-3 cTropnT-<0.01
.
[**2146-2-1**] 07:15AM DIGOXIN-0.6*
.
[**2146-2-1**] 07:53AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2146-2-1**] 07:53AM URINE RBC-15* WBC-2 BACTERIA-NONE YEAST-NONE
EPI-<1
.
URINE CX [**2146-2-1**]: NO GROWTH
BLOOD CX [**2146-2-1**]: NO GROWTH
.
EKG:
Sinus rhythm
Anterolateral infarct - age undetermined
Probable old inferior infarct
Low QRS voltages
Since previous tracing, the heart rate decreased
.
AP UPRIGHT PORTABLE CHEST X-RAY: A dual lead left chest wall
pacemaker is seen in unchanged position from prior exam. The
cardiac silhouette, mediastinal and hilar contours are normal.
The patient is status post median sternotomy. There is a new
consolidation at the inferior aspect of the right upper lobe.
The left lung is clear. There are no effusions. The surrounding
soft tissues are unremarkable.
IMPRESSION: New consolidation at the inferior aspect of the
right upper lobe concerning for pneumonia.
Brief Hospital Course:
# Sepsis: Patient was hypotensive, tachycardic, febrile with WBC
16.9 with 12 % bands. Initial lactate was 4.5 and improved with
fluid resusciation to 2.0. Given CXR findings, cough, and SOB
most likely source is community acquired PNA. UA and blood
cultures were negative. Patient responded well to goal directed
therapy with some volume overload. He was weaned off levophed
with SBPs in 120s. He will complete a total 10 day course of
levofloxacin for treatment of his pneumonia.
.
# Community acquired pneumonia: Patient improved on levofloxacin
with scheduled nebs and an incentive spirometer. He will
complete a 10 day course of levofloxacin for treatment. He was
weaned off oxygen and stable on room air, including with
ambulation by the time of discharge. He is s/p the influenza
vaccine but was administered the pneumovax prior to discharge.
.
# CHF (EF 25%): Patient became more short of breath with an
increasing O2 requirement after fluid resuscitation in the
emergency room. His subjective symptoms and oxygen saturation
improved considerably with diuresis. He ruled out for acute
coronary syndrome with serial cardiac enzymes. He was continued
on his home dose of lasix and diuresed well. He will have his
creatinine rechecked on Monday to confirm this remains stable in
the setting of his ongoing diuresis. He was restarted on his
home spironolactone at the time of discharge and was continued
on all of his regular antihypertensives while in house. His
blood pressure is under good control and he is euvolemic at the
time of discharge.
.
# Acute renal failure: Resolved with volume repletion.
Patient's creatinine remained stable with diuresis following
volume overload. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] was initially held but was
restarted prior to discharge. His allopurinol has been renally
dosed.
.
# History of recurrent lower extremity DVT: Patient was
initially admitted with an INR of 4.0. His coumadin was held
until his INR improved. He was discharged home on coumadin 7 mg
po qhs with plans for a repeat INR on Monday. His INR on the
day of discharge was 1.2.
.
# CAD: No evidence of active ischemia on EKG and no CP. Cardiac
enzymes were unremarkable. Patient is on a statin, BB, and [**Last Name (un) **].
He has not tolerated ASA in the past, while on coumadin due to
GI bleeding.
.
# Insulin dependent diabetes: Patient was initially started on
an insulin drip, given his high insulin requirements at home.
He was then switched to a sliding scale of humalog but only
required approximately 70-80 units total per day x 2 days (at
home taking 80 units of 70/30 [**Hospital1 **]). Likely this was due to a
strict diabetic diet while in house and possibly decreased
insulin clearance in the setting of his recovering renal
function. Thus, patient was discharged with instructions to
take 30 units of 70/30 [**Hospital1 **] and to follow his blood sugar 4 times
daily. He will contact his PCP to discuss resuming his regular
insulin regimen if his blood sugars are high at home.
.
# Guaiac positive stool: Patient has a history of iron
deficiency anemia with a ferritin of 15 in [**2144-1-25**].
Iron/TIBC was low this admission, consistent with iron
deficiency (despite high MCV). Ferritin was normal but may be
falsely elevated in the setting of his acute inflammatory
reaction. Thus patient instructed to follow-up with his primary
care doctor for follow-up lab work to determine whether or not
he needs to continue his iron supplement. Patient is due for
his follow-up colonoscopy and will see his PCP for referral. He
was continued on his home PPI and had no epigastric discomfort.
His hematocrit remained stable.
.
# Macrocytic Anemia: Folate and B12 were normal. Hematocrit
remained stable. Patient will follow-up with his primary care
doctor for continued monitoring given low retic count.
.
# Access: RIJ, PIVx2
.
# Code: Full
.
# Communication: Patient and his wife
.
# Dispo: Patient was discharged to home
Medications on Admission:
Allopurinol 300 mg PO QD
Omeprazole 20 mg PO daily
carvedilol 12.5 mg twice daily
Lipitor 80 mg PO QD
Declofenac 75 mf PO QD
Cozaar 50 mg once daily
digoxin 0.125 mg per day
spironolactone 25 mg per day
furosemide 80 mg twice daily
Coumadin 7 mg PO QD
70/30 insulin 82-92 units depending on FS
Zetia at 10 mg per day
gemfibrozil 600 mg twice daily
multivitamin
iron tabs
Colace
Zinc 50 mg PO QD
fish oil
Discharge Medications:
1. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*0*
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
3. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Lipitor 80 mg Tablet Sig: One (1) Tablet PO once a day.
5. Cozaar 50 mg Tablet Sig: One (1) Tablet PO once a day.
6. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a
day.
8. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
9. Coumadin 1 mg Tablet Sig: Seven (7) Tablet PO once a day for
3 days: PLEASE HAVE YOUR INR CHECKED BEFORE TUESDAY NIGHT'S DOSE
SO THAT IT CAN BE ADJUSTED AS NEEDED.
Disp:*21 Tablet(s)* Refills:*0*
10. Novolog Mix 70/30
30 units SQ qam and 30 units SQ qpm
11. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Gemfibrozil 600 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. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
15. Outpatient Lab Work
Please check PT/INR, sodium, potassium, chloride, bicarbonate,
BUN, creatinine, and glucose on [**2146-2-7**]. Phone results to Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16258**] ([**Telephone/Fax (1) 29669**]
Discharge Disposition:
Home
Discharge Diagnosis:
sepsis due to community acquired pneumonia
congestive heart failure (EF 20%)
acute renal failure
insulin dependent diabetes, poorly controlled without
complications
macrocytic anemia
history of recurrent lower extremity DVT
Discharge Condition:
good: afebrile, stable on room air including with ambulation,
blood sugar 145-161
Discharge Instructions:
Please call your doctor or go to the emergency room if you
experience temperature > 101, worsening cough, shortness of
breath, decreased urine output, or other concerning symptoms.
You can restart your regular medications with the following
changes:
1. Please only take 30 units 70/30 in the morning and 30 units
70/30 at night. Check your blood sugars 4 times daily and
record these values. Contact your primary care doctor's office
on Monday to discuss resuming your regular home dose of insulin,
based on your blood sugar values.
2. Please stop taking your iron supplement.
3. Please note the dose of your allopurinol has been decreased
to 200 mg per day.
4. Your coumadin dose has been increased.
5. Please continue to avoid taking your diclofenac until you see
your primary care doctor and have your kidney function
rechecked.
Followup Instructions:
Please call to schedule follow-up with Dr. [**Last Name (STitle) 16258**] within 1 week
to follow-up this hospital admission.
Please have labs checked on Monday and discuss the results with
your primary care doctor for further adjustment of your coumadin
and other medications.
|
[
"584.9",
"785.52",
"995.92",
"428.0",
"038.9",
"V45.02",
"250.00",
"V58.67",
"486",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.17"
] |
icd9pcs
|
[
[
[]
]
] |
11290, 11296
|
5356, 9358
|
343, 350
|
11564, 11648
|
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|
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|
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|
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|
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|
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|
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|
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,734
| 194,687
|
7351
|
Discharge summary
|
report
|
Admission Date: [**2164-4-26**] Discharge Date: [**2164-5-12**]
Date of Birth: [**2114-5-11**] Sex: M
Service: MICU
CHIEF COMPLAINT: Cardiac arrest.
HISTORY OF PRESENT ILLNESS: The patient is a 49 year old man
who was admitted to the Medical Intensive Care Unit status
post cardiac arrest. History was obtained per the Emergency
Department report as well as from the patient's family.
Information was very limited regarding the circumstances of
his cardiac arrest. Reportedly, the patient was at a local
restaurant where he was noted to be unresponsive. EMS was
called and reported to arrive on scene within three minutes.
The patient was asystolic but regained a perfusing rhythm
after 2 mg of Epinephrine and 2 mg of Atropine. He was
intubated in the field and brought to the Emergency
Department. He remained unresponsive despite the
administration of Narcan. CT examinations of the head,
chest, abdomen and pelvis were all unremarkable. Initial
chest x-ray showed a left retrocardiac opacity and prominent
interstitium though his lung volumes were low. Subsequent
chest x-ray showed right main stem intubation with left lung
collapse which had corrected with withdrawal of the
endotracheal tube.
The patient was then transferred to the
Medical Intensive Care Unit for induced hypothermia given his
hemodynamic stability, ongoing unresponsiveness and recent
out of hospital cardiac arrest.
PAST MEDICAL HISTORY:
1) Hypertension.
2) Chronic low back pain, s/p lumbar discectomy x 2.
3) Cirrhosis.
4) h/o stab wound complicated by pneumothorax.
5) h/o lower extremity cellulitis.
6) s/p cholecystectomy.
7) Peripheral neuropathy.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: According to his pharmacy, he was
on:
1. OxyContin 40 mg p.o. q12hours.
2. Percocet.
3. Nortriptyline.
4. Neurontin 1800 mg four times a day
SOCIAL HISTORY: The patient is divorced. His son is a
policeman working in [**Name (NI) 8545**]. He drinks greater than one
case of beer per day. He has a history of abuse of Percocet
according to his brother. [**Name (NI) **] is currently homeless. He was
recently arrested for altering a prescription according to
his pharmacy. He had recently filled a prescription for 560
tablets of Percocet as well as 60 tablets of OxyContin early
last month.
FAMILY HISTORY: Negative for any history of sudden death or
coronary artery disease.
PHYSICAL EXAMINATION: On admission, temperature was 96.2,
blood pressure 150/80, heart rate 92, respiratory rate 16.
In general, he was unarousible, intubated, not on any
sedation. Head, eyes, ears, nose and throat - His pupils
were equal and three millimeters. They were minimally
reactive. His sclerae were anicteric. The cardiac
examination was unremarkable without murmurs. The lungs were
clear to auscultation bilaterally. His abdomen had normal
bowel sounds, soft and nontender. Extremities had multiple
bilateral lower extremity excoriations. Neurologic
examination - he was unarousible and without sedation. He had no
spontaneous movements. Flaccid. Extremities - Babinski
reflex was equivocal bilaterally.
LABORATORY DATA: At the time of admission, laboratories were
remarkable for a partial thromboplastin time of 31.7, INR
1.4, potassium 3.2, glucose 182, lactate was initially 6.6.
Urine toxicology screen was negative. Serum toxicology
screen was positive for TCAs. Tylenol level was 15. Alcohol
level was 199. Initial blood gas was 7.31/46/500/77.
HOSPITAL COURSE: Cardiac arrest - His arrest was of unknown
etiology at the time of admission. No further history was
ever gained about his cardiac arrest throughout his
hospitalization. CT angiogram had been negative for
pulmonary embolism. The patient had an echocardiogram on
[**2164-4-27**], which showed a normal ejection fraction and
trivial mitral regurgitation; otherwise no obvious
abnormalities were seen.
Given the patient had an out of hospital arrest, remained
unresponsive despite hemodynamic stability, he was treated
with induced hypothermia and with cold packs and a cooling
blanket were placed with goals of reducing his core body
temperature to 32 degrees Celsius for a period of twelve
hours at which point he would be rewarmed over the subsequent
six hours. This was done, however, as in problem number two
below, we were not successful in any neurologic recovery.
Neurology - The patient remained unresponsive after the
induced hypothermia, the patient was noticed to develop
myoclonic jerks and occasional fluttering of his eyelids.
Electroencephalogram revealed the patient was experiencing
persistent seizure activity. Neurology was consulted and the
patient was treated very aggressively, loaded with multiple
drugs, including Ativan and Propofol drips. The patient
continued to demonstrate seizure activity despite this. He was
loaded with Dilantin and ultimately was treated with a Pentobarb
coma. After multiple attempts of weaning the Pentobarb, the
patient was continually reverting to status epilepticus which was
never able to be suppressed.
Infectious disease - Over the course of his hospital stay,
the patient's white blood cell count rose to a peak of 17.
Multiple cultures were done and the patient was ultimately
found to have methicillin resistant Staphylococcus aureus
bacteremia, pneumonia, and urinary tract infection. For all
these infections, the patient was treated with Vancomycin and
he was also on Levofloxacin and Flagyl for presumed
aspiration pneumonia at the time of his admission. Blood
cultures cleared by [**2164-5-4**]. Sputum culture as late as
[**2164-5-11**], however was still positive for coagulase positive
Staphylococcus which was methicillin resistant Staphylococcus
aureus.
The patient remained gravely ill throughout his
hospital stay and had multiple meetings were held with his
family with his son being his next of [**Doctor First Name **]. Ultimately it was
decided that the patient's wishes would be to not be
maintained in a vegetative state and given his poor prognosis
ultimately the decision was made to pursue comfort measures
only. With these goals of care, the patient expired on
[**2164-5-12**]. The family did consent to a postmortem
examination.
DISCHARGE DIAGNOSES: Cardiac arrest.
Anoxic brain injury
Status epilepticus
Methicillin resistant Staphylococcus aureus pneumonia.
MRSA urinary tract infection.
MRSA Bacteremia.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**MD Number(1) 27108**]
Dictated By:[**Name8 (MD) 27109**]
MEDQUIST36
D: [**2164-12-25**] 13:55:05
T: [**2164-12-25**] 20:47:07
Job#: [**Job Number 27110**]
|
[
"038.11",
"303.90",
"995.92",
"345.3",
"427.5",
"571.2",
"599.0",
"482.41",
"304.70"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"99.81",
"38.93",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
2353, 2423
|
6274, 6715
|
1736, 1879
|
3522, 6252
|
2446, 3504
|
155, 172
|
201, 1426
|
1448, 1709
|
1896, 2336
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,422
| 199,823
|
3022
|
Discharge summary
|
report
|
Admission Date: [**2121-6-28**] Discharge Date: [**2121-7-4**]
Date of Birth: [**2073-2-8**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
abdominal pain, nausea, emesis x 2, anorexia, chills x 2 days
Major Surgical or Invasive Procedure:
ERCP with clot removal and stent placement
Bleed Scan
History of Present Illness:
The patient is a 48 year-old male who underwent image-guided
radiofrequency ablation of known hepatomas on [**2121-6-26**]. On [**2121-6-27**]
in the evening, he began having vague abdominal pain that went
away and returned on [**2121-6-28**] at 4am. The pain was sharp,
non-radiating and midabdominal. He had 2 episodes of
non-bilious, non-bloody emesis. The pain worsened to the point
that his wife
became concerned and brought him to the [**Hospital1 18**] ED.
He denies fever, but did have chills and anorexia.
Past Medical History:
HIV with undetectable viral load and is documented on
[**2120-11-7**]. He is followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital 1263**]
Hospital
Hepatitis C, was previously on interferon but stopped in [**2118**]
due to fatigue
Hypertension
HSV
hepatocellular carconima
Social History:
The patient lives with his wife and children.
He works in maintenance. He drinks 2 40-oz bottles of beer
everyday. He last used heroin 4 months ago. He is currently
receiving methadone from the methadone clinic. He denies any
other drug use. He does not smoke.
Family History:
His mother has hypertension and CAD, but lived
until age [**Age over 90 **]. His father had hypertension and died at age 80
from questionable heart disease. Siblings, he reports having 15
siblings "a few of them have hypertension." He has five
children, 2 girls and 3 boys, all in good health.
Physical Exam:
v/s
Gen: thin male in NAD at present, mild scleral icterus
HEENT: NC/AT, EOMI, PERRL bilat., dry MM without palpable
cervical/supraclavicular LAD
Cor: RRR without m/g/r
Lungs: CTA bilat.
[**Last Name (un) **]: hypoactive BS, soft, mildly distended, tender at
epigastrium, RUQ, R flank, + [**Doctor Last Name **] sign
Ext: warm feet, no edema
Pertinent Results:
[**2121-6-28**] 06:40PM BLOOD WBC-9.6 RBC-3.23* Hgb-10.0* Hct-29.8*
MCV-92 MCH-30.8 MCHC-33.4 RDW-14.4 Plt Ct-111*
[**2121-7-1**] 04:42AM BLOOD WBC-4.9 RBC-2.69* Hgb-8.3* Hct-25.1*
MCV-94 MCH-30.7 MCHC-32.9 RDW-14.6 Plt Ct-111*
[**2121-7-1**] 04:09PM BLOOD Hct-28.9*
[**2121-7-2**] 03:23AM BLOOD WBC-5.0 RBC-2.62* Hgb-8.0* Hct-25.1*
MCV-96 MCH-30.5 MCHC-31.9 RDW-14.7 Plt Ct-105*
[**2121-7-3**] 03:40PM BLOOD WBC-8.3# RBC-3.20* Hgb-9.3* Hct-31.5*
MCV-98 MCH-29.1 MCHC-29.6* RDW-14.6 Plt Ct-127*
[**2121-7-3**] 03:40PM BLOOD Glucose-101 UreaN-17 Creat-1.1 Na-139
K-3.6 Cl-116* HCO3-16* AnGap-11
[**2121-6-29**] 06:40AM BLOOD ALT-55* AST-171* AlkPhos-221* Amylase-29
TotBili-5.7*
[**2121-7-2**] 03:23AM BLOOD ALT-38 AST-85* AlkPhos-193* TotBili-2.6*
[**2121-7-1**] 04:42AM BLOOD Lipase-41
[**2121-7-3**] 03:40PM BLOOD Calcium-7.6* Phos-2.3* Mg-1.9
.
Radiology Report CT PELVIS W/O CONTRAST Study Date of [**2121-6-28**]
6:34 PM
IMPRESSION:
1. Bowel wall thickening along the right hemi-colon with mild
stranding,
compatible with colitis. Potential causes include infectious or
inflammatory.
Given the recent RF ablation, reactive thickening from procedure
may also be
considered.
2. Distended gallbladder with high-attenuation material layering
at the base
of the gallbladder indicating potential gallbladder hematoma.
Consider US or
MR for further evaluation.
3. Hepatic cirrhosis with post-surgical changes in RF ablation
bed in segment
I, and VI of the liver as described above.
4. Slight interval increase in the amount of perihepatic
ascites. Moderate
pelvic free fluid, with a small hematocrit level in the deep
pelvis suggesting
a component of hemoperitoneum.
.
Radiology Report LIVER OR GALLBLADDER US (SINGLE ORGAN) Study
Date of [**2121-6-28**] 10:37 PM
IMPRESSION: No evidence of acute cholecystitis with a moderate
amount of
sludge noted in the gallbladder.
.
Radiology Report GALLBLADDER SCAN Study Date of [**2121-6-29**]
ADDENDUM: Images were obtained the following morning which show
a small amount
of activity in the region of the cecum. The gallbladder is not
visualized.
.
Radiology Report MRCP (MR ABD W&W/OC) Study Date of [**2121-6-29**]
8:52 PM
IMPRESSION:
1. Post-RFA changes in caudate lobe and segment VI/VII.
2. Likely blood within the gallbladder and possibly in distal
common bile
duct.
3. Mild left intrahepatic dilatation.
4. Normal pancreas.
5. Right greater than left pleural effusions and basal
atelectases.
6. Cirrhosis with ascites.
.
ERCP BILIARY ONLY BY GI UNIT Clip # [**Clip Number (Radiology) 14406**]
IMPRESSION: ERCP with cannulation and balloon extraction of
filling defect,
that was reported to be clot within the common bile duct, and
placement of a
common bile duct stent.
.
Radiology Report GI BLEEDING STUDY Study Date of [**2121-7-2**]
IMPRESSION: No evidence of active extravasation.
Brief Hospital Course:
This is a 48 year-old immunocompromised male with RUQ pain,
jaundice, no fever, with free fluid in pelvis and layering fluid
in gall bladder, both consistent with hematoma.
He was admitted and made NPO with IVF.
Biliary Hematoma: After several imaging studies, he went for
ERCP and Blood was seen draining from the major papilla. Small
blood clots in lower third of the CBD. Successful extraction
using a ballon Successful 10FR by 7cm CBD stent placement.
Respiratory: s/p ERCP he was unable to extubate for low O2
stats. He remined in the ICU for respiratory support. He was
weaned successfully the following day.
Blood Loss Anemia: His HCT was watched and he received 2 units
of blood s/p ERCP for a HCT of 25.1 that was trending down. He
responded appropriately and needed no further transfusions.
Due to concerns of further bleeding, a bleed scan was obtained
and showed no active bleeding. He was then transferred out to
the floor in stable condition.
Once on the floor, he did well without complications. His diet
was advanced. his home meds were restarted. He was ambulating
and safe for discharge.
Medications on Admission:
acyclovir 400', diltiazem 300', efavirenz,
emtricitabine-tenofovir, levothyroxine 125 mcg', methadone 30',
ranitidine 150', valsartan
Discharge Medications:
1. Diltiazem HCl 300 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
2. Methadone 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
4. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
5. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1) Tablet
PO DAILY (Daily).
6. Efavirenz 600 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal Pain
Biliary Hematoma - blood clot in lower third of the common bile
duct
Cholestasis
Discharge Condition:
Good
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
* Take all new meds as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* Continue to increase activity daily
* Monitor your incision for signs of infection.
* You may shower and wash, no tub baths or swimming.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] on [**2120-12-1**] at 9:15am. Call
([**Telephone/Fax (1) 1582**] with questions or concerns.
Please follow-up with [**Name6 (MD) **] [**Name8 (MD) **], MD in 8 weeks for stent
removal. Call ([**Telephone/Fax (1) 10532**] with questions or concerns.
Completed by:[**2121-7-4**]
|
[
"799.02",
"568.81",
"V08",
"E878.8",
"576.8",
"305.01",
"571.5",
"789.59",
"155.0",
"576.2",
"998.12",
"304.01",
"070.54",
"401.9",
"285.1",
"E879.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"51.87",
"99.04",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
7086, 7092
|
5156, 6270
|
374, 430
|
7232, 7239
|
2294, 5133
|
8698, 9029
|
1617, 1916
|
6454, 7063
|
7113, 7211
|
6296, 6431
|
7263, 8675
|
1931, 2275
|
272, 336
|
458, 976
|
998, 1317
|
1333, 1601
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,166
| 135,198
|
23361
|
Discharge summary
|
report
|
Admission Date: [**2189-1-9**] Discharge Date: [**2189-2-2**]
Date of Birth: [**2126-2-16**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Aspirin / Motrin
Attending:[**First Name3 (LF) 10593**]
Chief Complaint:
enlarging vegetation on tricuspid valve
Major Surgical or Invasive Procedure:
tricuspid valve vegectomy
History of Present Illness:
62 year old female with history of recurrent prosthetic
tricuspid valve endocarditis with remote repair of tricuspid
valve, tricuspid valve replacement at [**Hospital1 112**] in [**2169**] and most
recently a redo tricuspid valve replacement in [**2169**] [**Male First Name (un) 923**]
tissue valve in [**2184**] for MSSA and Enterococcal prosthetic valve
endocarditis.
.
She was admitted in early [**2188-11-16**] with [**First Name5 (NamePattern1) 564**] [**Last Name (NamePattern1) 29361**]
tricuspid prosthetic valve endocarditis with pulmonary embolic
phenomena. She was initially seen at [**Hospital3 **] [**11-18**], with
respiratory distress and found to have multiple pulmonary septic
emboli on CT scan and tricuspid valve vegetations on ECHO. She
was in shock at the time of transfer. Blood cultures drawn on
[**11-18**] grew GPC and yeast(GPC ultimately found to be CONS
contaminant) and she was started onto echinocandin therapy on
[**2188-11-19**]. She was subsequently transferred to [**Hospital1 **] for ongoing
managment. At the time of transfer, she was on echinocandin
therapy alone as her antifungal [**Doctor Last Name 360**] and was persistently
fungemic. She was transitioned to ambisome on [**11-20**] as monotherapy
and then micafungin was added back on [**11-29**]. Her fungemia
quenched on [**2188-11-29**]. She was on ambisome and micafungin from
[**Date range (1) 59965**] and then was subsequently transitioned to micafungin
monotherapy on [**12-13**] soon after discharge to rehab. During this
admission, she was determined to be a non-operative candidate.
.
Her echo on [**2188-12-4**] revealed a 1.8 x 1.1 cm tricuspid
vegetation with severe tricuspid regurgitation. At rehab, she
had a persistent oxygen requirement prompting chest film. When
abnormalities were noted on that study, she had a CT scan of the
chest done on [**2189-1-7**] which revealed a question of possible
new cavitary lesion related to ? possible new septic emboli when
the CT was compared with the initial CT done at [**Hospital3 3583**]
on [**2188-11-18**].
.
Plan was for patient to have ECHO on day of admission followed
by appointment
in [**Hospital **] clinic. Due to transport issues, patient was unable to
make
it to [**Hospital **] clinic appointment. Given the findings of increased
size
of vegetation(4.9 cm in greatest dimention) on todays ECHO in
the
context of her overall clinical status and findings on chest CT,
decision made to transport to ER from ECHO for admission. At the
time IDs recommendations were:
-mycolytic and routine blood cultures(multiple sets)
-Continue Micafungin 100 mg IV Q 24 hours
-Would add liposomal amphoterocin B at 5 mg/kg/day
-Evaluation by Cardiology and Cardiothoracic surgical services
-Would consult ID for further detail regarding evaluation and
treatment plan
.
In the ED, initial VS were 100 84 98/56 16 100% 6L Nasal Cannula
As per call-in by Dr [**Last Name (STitle) 7443**] (pager [**Numeric Identifier 59966**])Pt was attending outpt
echo from [**Hospital 59967**] rehab hosp, + SOB. 62 year old female with
chief complaint of [**First Name5 (NamePattern1) 564**] [**Last Name (NamePattern1) 29361**] endocarditis, now with
persistent oxygen requirement, worsened chest CT and worsening
tricuspid vegetation on most recent echo on micafungin.Needs
admission to start onto combination salvage antifungal therapy
and reconsideration of cardiothoracic surgical intervention
Past Medical History:
1. s/p TV repair '[**59**], s/p TVR/PFO closure '[**69**], s/p Redo
tricuspid valve replacement with a St. [**Male First Name (un) 1525**] tissue valve and
placement of epicardial permanent pacing leads
([**2185-2-19**])arrest
2. Breast CA s/p left lumpectomy + axial node
dissection/Chemo/XRT '[**78**]
3. sepsis related to Portacath
4. Afib/fibrilation - s/p ablation at [**Hospital1 **]; also h/o SSS -
currently with pacer wires w/o battery.
5. multiple spinal surgeries, stimulator placed [**2174-8-2**] with a
revision [**2175-2-22**].
6. COPD
7. Left ing hernia repair.
8. BCC X3.
9. Cerebrovascular accident ([**2169**]).
right renal hydronephrosis
Social History:
Lives with partner of 30 years ([**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 17926**]) who has not
been in contact during this admission. Talked to patient's
brother [**Name (NI) **] [**Name (NI) 59954**] (home: [**Telephone/Fax (1) 59955**], cell:
[**Telephone/Fax (1) 59956**]), he is patient's HCP and will send paperwork to
that effect. Lives in Fort-[**First Name9 (NamePattern2) 59957**] [**State 108**] and will travel
here within the next few days. There are two more brothers in
the [**Name (NI) 86**] Area who have
been visiting. Patient's daughter lives in area. Has + tobacco -
about [**11-17**] ppd
Family History:
Mother- Diabetes/HTN
Physical Exam:
ADMISSION PHYSICAL EXAM
General: Patient is alert, appears uncomfortable, opens eyes to
command but otherwise not cooperative, intubated, ventilated, on
IV fentanyl + IV levophed
HEENT: Sclera anicteric, MMM, thrush on tongue, Pupils sluggish
and unequal, R 4mm, L 2mm
Neck: supple, JVP at jaw angle, no LAD, left IJ in place with
some hematoma around site.
CV: IRRegular rate and rhythm, minimal systolic murmur [**11-21**] at
LLSB, no rubs, gallops. Wires are palpable in right anterior
chest subcutaneously.
Lungs: bil air entery other Clear to auscultation bilaterally
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Back: bony protrusion at midline @ ~ T10 level, no tenderness or
erythema, surgical scars along spine.
Ext: clubbing of fingers, large subcutaneous hematoma over left
groin and thigh, femoral pulses palpable bilaterally, warm, well
perfused, DP's + radials thready and symetrical, faint, no
cyanosis, bil tibial edema right > left, no calf tenderness.
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Skin: No stigmata of endocarditis seen. Multiple echymosis,
Stage 3 decub ulcer on left elbow.
.
DISCHARGE PHYSICAL EXAM:
98.1 90/34 62 18 94% on 3L
I/O: 1200/2200
General: Patient is alert and oriented x3, cachectic
HEENT: Sclera anicteric, MMM
CV: RRR ,systolic murmur [**12-22**] at LLSB
Lungs: fair air movement, some crackles at bases
Abdomen: soft, non-distended, BS+, mild diffuse tenderness
Ext: warm, well perfused, bilateral edema
Neuro: no gross abnl
Skin: large excavated lesion (covered w/ clean dressing) in
upper lumbar back approx 4cm x 6cm in diameter, with scalloped
interior, heaped up rounded edges, with wound cleaning material
on wound, covered w/ clean, dry dressing.
Pertinent Results:
Radiology:
ECHO ([**1-30**]):
The left atrium is mildly dilated. The coronary sinus is dilated
(diameter >15mm). There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). The right ventricular cavity is moderately
dilated with moderate global free wall hypokinesis. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis or aortic
regurgitation. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion. There is a minimally
increased gradient consistent with minimal aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. A bioprosthetic tricuspid
valve is present with thickened leaflets and increased gradient.
There is a moderate size (7mm) long mobile
echodensity/vegetation on the tricuspid valve. Mild tricuspid
regurgitation is seen. [Due to acoustic shadowing, the severity
of tricuspid regurgitation may be significantly UNDERestimated.]
There is borderline pulmonary artery systolic hypertension. The
main pulmonary artery is dilated. Abnormal flow consistent with
a possible patent ductus arteriosus is seen. There is no
pericardial effusion.
IMPRESSION: Well seated bioprosthetic tricuspid valve with
increased gradient and mobile echodensity c/w vegetation (may
also involve the leaflets). Right ventricular cavity dilation
with free wall hypokinesis. Possible PDA (vs. coronary artery
fistula). Minimal aortic valve stenosis. Mild pulmonary artery
hypertension.
.
Bone Scan ([**1-21**]):
1. Increased uptake in the lumbar spine may be related to
degenerative change, but concurrent infection is not excluded.
Correlation with gallium scan and SPECT-CT should be considered,
if clinically helpful.
2. Pooling of tracer in the right renal collecting system could
be within normal limits, but partial obstruction is also
possible. Clinical correlation advised.
.
KUB ([**1-18**]):
There is no evidence of bowel obstruction. There are a few
air-fluid levels in small bowel loops. There is air in the
colon. There is increase in fecal material throughout the
ascending and descending colon. There is severe scoliosis and
degenerative changes in the lumbar spine. Surgical clips project
in the hips bilaterally. Increased density in the left upper
quadrant suggests splenomegaly. There is no evidence of free
air.
.
CXR ([**1-16**]):
Lung volumes have improved, and mild pulmonary edema is still
present.
Additionally, there are small focal pulmonary abnormalities
attributable to septic emboli. No new large consolidation has
developed. Small bilateral pleural effusions and mild
cardiomegaly persists.
.
CXR ([**1-9**]):
IMPRESSION: Interval development of pulmonary edema. Other
findings of
peripheral opacities previously described as septic emboli and
bilateral small pleural effusions are unchanged.
.
EKG ([**1-9**]): rate of 91. Normal sinus rhythm with occasional
premature atrial contractions. Right axis deviation. Incomplete
right bundle-branch block. T wave inversions in leads V1-V2
suggestive of possible anteroseptal ischemia. Compared to the
previous tracing of [**2188-12-4**] the T wave inversions in leads V1-V2
are new.
.
EKG ([**1-17**]): rate 58. Possible ectopic atrial rhythm versus sinus
rhythm with premature atrial contraction. Short P-R interval
without other signs of pre-excitation. Non-specific
intraventricular conduction delay. Right axis deviation. RSR'
pattern in lead V1 could be a normal variant. Non-specific T
wave changes in leads V1-V2. Compared to the previous tracing of
[**2189-1-14**] premature atrial contractions are less frequent.
.
EKG ([**1-29**]): rate 93. Sinus rhythm with atrial premature
depolarizations. Compared to the previous tracing there is no
diagnostic change.
.
TTE ([**1-9**]): The left atrium is elongated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is top
normal/borderline dilated. Overall left ventricular systolic
function is normal (LVEF>60%). Tissue Doppler imaging suggests
an increased left ventricular filling pressure (PCWP>18mmHg).
The right ventricular cavity is mildly dilated with moderate
global free wall hypokinesis. There is a mass in the right
ventricle. The aortic valve leaflets (3) are mildly thickened.
There is no valvular aortic stenosis (increased transaortic
velocity is likely related to high cardiac output). Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Physiologic mitral
regurgitation is seen (within normal limits). A well-seated
bioprosthetic tricuspid valve is present with a large, highly
mobile vegetation (5.2x1.7 cm in maximum dimension) seen
prolapsing between the right ventricle and right atrium, with
likely significant tricuspid regurgitation [Due to acoustic
shadowing, the severity of tricuspid regurgitation may be
significantly UNDERestimated.] . There appears to be another
smaller (sub-centimeter) highly mobile mass associated with the
moderator band in the right ventricle (clips #57, 60). The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.
IMPRESSION: Large highly mobile vegetation attached to the
prosthetic tricuspid valve, with likely significant tricuspid
regurgitation. Possible small vegetation associated with the
moderator band. Mildly dilated right ventricle with moderate
global free wall hypokinesis.
Compared with the prior study (images reviewed) of [**2188-12-4**],
the vegetation is larger in size (significantly elongated).
.
CT Chest [**2189-1-7**]
1. Wedge compression deformity at thorocalumbar junction with
focal vertebral body sclerosis. Given history of breast cancer
and reported back pain, findings could represent metastases.
Recommend bone scan.
2. New cavitated peribronchial opacities in right middle lobe
likely represent new area of septic emboli. Previously
identified septic emboli have decreased in size.
3. Bilateral moderately sized low density (no hemorrhagic)
pleural effusions, with left effusion decreased in size.
4. Fibrotic changes in lingula with adjacent increased ground
glass opacities likely represent combination of post-radition
fribrosis and pulmonary edema.
5. Increased mediastinal and hilar lymphadenopathy with necrotic
9 cm right paratracheal lymph node.
6. Enlarged incompletley visualized right renal pelvis, may
represent
parapelvic cyst.
7. Foci of calcification in right kidney, possibly
nephrolithiasis or wall calfication of an incompletey
demonstrated renal cyst.
8. Stable moderate cardiomegaly.
.
ADMISSION LABS:
[**2189-1-11**] 04:50AM BLOOD WBC-8.7 RBC-3.07* Hgb-9.0* Hct-27.0*
MCV-88 MCH-29.2 MCHC-33.2 RDW-17.2* Plt Ct-47*
[**2189-1-9**] 05:30PM BLOOD Glucose-86 UreaN-24* Creat-0.9 Na-129*
K-6.6* Cl-98 HCO3-25 AnGap-13
[**2189-1-9**] 05:30PM BLOOD ALT-16 AST-38 AlkPhos-328* TotBili-0.5
[**2189-1-9**] 05:30PM BLOOD Calcium-9.4 Phos-4.4 Mg-1.9
[**2189-1-10**] 04:45AM BLOOD Cortsol-11.2
[**2189-1-11**] 04:32AM BLOOD Type-ART Temp-37.0 O2 Flow-7 pO2-57*
pCO2-42 pH-7.46* calTCO2-31* Base XS-5 Intubat-NOT INTUBA
.
PERTINENT INTERVAL LABS:
[**2189-1-21**] 08:45AM BLOOD WBC-6.4 RBC-3.09* Hgb-8.7* Hct-27.1*
MCV-88 MCH-28.1 MCHC-32.0 RDW-16.6* Plt Ct-77*
[**2189-1-17**] 05:38AM BLOOD Ret Aut-1.3
[**2189-1-11**] 04:50AM BLOOD Glucose-116* UreaN-29* Creat-1.1 Na-130*
K-5.2* Cl-97 HCO3-27 AnGap-11
[**2189-1-11**] 04:15PM BLOOD Glucose-143* UreaN-33* Creat-1.3* Na-131*
K-5.5* Cl-98 HCO3-24 AnGap-15
[**2189-1-18**] 06:14AM BLOOD Glucose-92 UreaN-38* Creat-1.5* Na-135
K-4.2 Cl-103 HCO3-26 AnGap-10
[**2189-1-22**] 10:20AM BLOOD Glucose-116* UreaN-29* Creat-1.1 Na-131*
K-4.4 Cl-101 HCO3-24 AnGap-10
[**2189-1-15**] 06:41AM BLOOD ALT-7 AST-18 AlkPhos-268* TotBili-0.5
[**2189-1-15**] 06:41AM BLOOD Lipase-19
[**2189-1-22**] 10:20AM BLOOD Calcium-8.9 Phos-3.9 Mg-1.8
[**2189-1-17**] 05:38AM BLOOD Hapto-64
[**2189-1-10**] 04:45AM BLOOD Cortsol-11.2
[**2189-1-11**] 04:32AM BLOOD freeCa-1.27
[**2189-1-27**] 05:29AM BLOOD WBC-5.6 RBC-2.92* Hgb-8.2* Hct-25.2*
MCV-86 MCH-28.1 MCHC-32.5 RDW-16.6* Plt Ct-78*
[**2189-1-31**] 06:21AM BLOOD WBC-4.3 RBC-2.73* Hgb-7.5* Hct-24.8*
MCV-91 MCH-27.5 MCHC-30.2* RDW-16.6* Plt Ct-82*
[**2189-1-31**] 06:21AM BLOOD PT-10.9 PTT-30.9 INR(PT)-1.0
[**2189-1-25**] 08:00AM BLOOD Glucose-98 UreaN-31* Creat-1.2* Na-131*
K-4.7 Cl-100 HCO3-30 AnGap-6*
[**2189-1-31**] 06:21AM BLOOD Glucose-110* UreaN-35* Creat-1.3* Na-132*
K-4.6 Cl-99 HCO3-30 AnGap-8
[**2189-1-27**] 05:29AM BLOOD ALT-13 AST-20 LD(LDH)-139 AlkPhos-309*
TotBili-0.4
[**2189-1-31**] 06:21AM BLOOD Calcium-8.4 Phos-4.9* Mg-2.0
.
URINE:
[**2189-1-9**] 06:51PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.009
[**2189-1-9**] 06:51PM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
[**2189-1-9**] 06:51PM URINE RBC-18* WBC-2 Bacteri-NONE Yeast-NONE
Epi-1
[**2189-1-9**] 06:51PM URINE Hours-RANDOM Creat-22 Na-144 K-41 Cl-119
[**2189-1-9**] 06:51PM URINE Osmolal-466
[**2189-1-17**] 12:18AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.011
[**2189-1-17**] 12:18AM URINE Blood-SM Nitrite-POS Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
[**2189-1-17**] 12:18AM URINE RBC-17* WBC->182* Bacteri-MANY Yeast-NONE
Epi-<1 TransE-1
.
MICRO:
Blood cultures ([**1-9**], [**1-9**], [**1-11**], [**1-13**], [**12/2105**], [**1-15**]): no growth
.
[**2189-1-9**] 6:53 pm BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
Source: Venipuncture.
BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
.
Urine culture ([**1-9**]): no growth
.
MICRO:
Superficial Wound Swab:
GRAM STAIN (Final [**2189-1-10**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
.
WOUND CULTURE (Final [**2189-1-12**]):
STAPH AUREUS COAG +. SPARSE GROWTH.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
ANAEROBIC CULTURE (Final [**2189-1-14**]): NO ANAEROBES ISOLATED.
.
Urine Cx ([**1-15**]):
URINE CULTURE (Final [**2189-1-18**]):
ENTEROBACTER AEROGENES. >100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER AEROGENES
| ESCHERICHIA COLI
| |
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- 64 I 32 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S =>16 R
.
[**2189-1-29**] 1:00 pm FOREIGN BODY TV VEGETATION WITH SALINE .
GRAM STAIN (Final [**2189-1-29**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
Brief Hospital Course:
==================
BRIEF PATIENT SUMMARY
==================
Ms. [**Known lastname **] is a 62 yo F w/ hx of A-fib, h/o IVDA, remote
tricuspid valvue replacement/repair x 3 who was admitted to the
medical ICU with marked enlargement of tricuspid valve Candidal
vegetation and borderline blood pressures. The patient has been
deemed to not be a surgical candidate for valve
repair/replacement by [**Hospital1 18**] thoracic surgery and a second
opinion from [**Hospital1 112**] thoracic surgery. The patient has been treated
with ambisome for her fungal endocarditis, but the prognosis is
poor. She also has a significant wound at the level of the
lower back, at the site of a previous spinal stimulator removal,
that has been evaluated by the wound care nurse, ID and
neurosurgery/back. Unfortunately, considering her clinical
status (renal failure and hardware in body), there is not a
reasonable definitive imaging study, and she is not a surgical
candidate currently due to her functional status and nutrition,
to have the spinal hardware removed. During the course of this
hospitalization, she had a percutaneous catheter-based vegectomy
by Dr. [**Last Name (STitle) **] of Interventional Cardiology ([**2189-1-29**]) to debulk
the tricuspid valve vegetation. It was found that she had
thrombus in addition to vegetation, and thus was started on
coumadin for a goal INR 2.
==================
ACTIVE ISSUES
==================
# Fungal Endocarditis with valvular incompetence and complicated
by septic emboli - TTE prior to admission showed significant
enlargement (5.2x1.7cm) of patient's known tricuspid valve
vegetation. Infectious disease team was consulted. Infectious
disease recommended that patient be continued on ambisome. We
appreciated ID input throughout entire hospital course. CT
surgery reiterated that patient is not a surgical candidate.
While in the ICU, a family meeting was held regarding patient's
poor prognosis without surgery, and decided they would like to
proceed with obtaining a second opinion at an OSH. The patient
was called out of the MICU on [**2189-1-12**]. While on the medical
floor, the patient was followed closely by ID. We continued
ambisome, decreasing dose (to 300mg qd) once, secondary to a
decrement in renal function. All blood cultures culture were
negative. Multiple family meetings were held with the patient
and two brothers. Prognosis was explained (very poor). Second
opinion from [**Hospital6 1708**] also deemed the
patient to not be a surgical candidate. The patient's family is
actively pursuing other opinions. The patient was offered a
salvage catheter-based vegectomy, performed by interventional
cardiology on [**1-29**]. The vegetation was significantly debulked
during the procedure, and it was noted that there was a
thrombotic component to the vegatation. Thus, the patient was
iniatiated on warfarin 2mg qd, with a goal INR [**12-19**] (goal closer
to 2). Social work, patient relations and the ethics
consultation service were also consulted in relation to this
patient. The patient will be seen in infectious disease clinic,
and should have CBC, Chem 7 basic metabolic panel and LFTs
trended every week.
.
# Back Wound from spinal stimulator surgeries - Large, 4x6cm
wound located midline in the mid-back region. It is a large,
rounded edged, likely chronic wound, largely unchanged over the
course of the hospital stay. Wound care was consulted and has
been giving us recommendations regarding the wound.
.
Their current wound recommendations are:
Continue pressure relief measures per pressure ulcer guidelines.
Limit sit time to one hour.
Use pressure relief cushion when OOB to chair.
Continue frequent turn and repositioning.
Change wound care treatment to:
Spine: Cleanse with commercial wound spray. Pat tissue dry.
Wipe periwound skin with barrier wipe.
Pack wound with regular Aquacel (Discontinue use of Aquacel AG).
Cover with DSD and ABD. Secure with Medipore tape.
Coccyx: Cleanse with commercial wound spray. Pat dry. Cover
with heart shaped Mepilex. Change q 3 days and prn.
Elbows: Moisturize [**Hospital1 **] with aloe vesta lotion. Frequent turn
and
reposition. Pad bony prominence to reduce pressure. If patient
continues to favor her left elbow would consider applying a
waffle boot to off load pressure.
.
Pain control was achieved with morphine SR 30mg q8hrs and
dilaudid 2mg PO q3hrs PRN for breakthrough pain. Patient's pain
adequately controlled on this regimen. We restricted pressure on
this site by propping up lateral aspects of torso with cushions.
A bone scan was performed [**2189-1-21**] to investigate for
osteomyelitis, and was inconclusive. Neurosurg/back team
evaluated pt on [**1-22**], and they agreed that there were no feasible
options to further image the back to r/o osteo, considering pt's
tenuous renal function (CT w/ contrast) and significant amt of
hardware in body (MRI). There was extensive discussion with
infectious disease team and neurosurgery regarding potential
back wound surgical exploration and closure. Given the
inconclusive bone scan and lack of other data supporting deep
infection as well as the risks involved with this surgery, we
felt the risks of pursuing surgery outweighed the benefits at
patient's current functional status. The patient may benefit
from eventual removal of back hardware, as it may be a source of
infection. If patient's functional and nutritional status
improve, the patient may consider surgical intervention in
future.
.
# Hypotension - The patient has had blood pressures stably in
the 80s-100s throughout entire hospitalization, and has been
asymptomatic. Likely secondary to poor forward flow from
tricuspid valve regurgitation. Patient did not require pressor
support or fluid resuscitation as she continued to mentate
appropriately. Clinic BP was recently 98/54 in medical record.
In setting of relative hypotension we have been holding ACE/BB.
.
# Urinary tract infection: pt w/ mild symptoms and repeat UA w/
e/o UTI on [**1-17**]. Treated complicated (foley) UTI w/ cipro (prior
pathogens sensitive) x 10d. Final day for abx was [**1-26**].
.
# Acute renal failure: Pt's Cr on admission 0.9, peaking at
1.5, and now back down to 1.1. Also, pt had UTI which has now
been treated. We renally dosed meds while she she was here.
.
# Tachycardia: patient with tachycardia early in hospitalization
secondary to atrial tachycardia. the patient received 500cc
fluid bolus and tachycardia resolved. For past two weeks of
hospitalization, HR has been 60s-80s primarily.
.
# Anemia: Stable 24-27 throughout admission. No gross e/o
bleeding. No e/o hemolysis. No e/o bleeding. Most likely
secondary to poor production in setting of severe illness.
Stable today
.
# Thrombocytopenia: stable. platelets have ranged from 70K-90K
.
# Hypoxemia: Likely secondary to poor tricuspid valve, pulmonary
emboli secondary to endocarditis and atelectasis from poor
functional status. O2 has been able to be titrated down to 3L,
with saturations 91-95% on 3L of O2.
.
# Hyponatremia - Likely SIADH from pulmonary disease. Sodium was
131-133 for most of hospitalization, and was 135 at the time of
discharge.
.
# Code status: patient is a full code.
.
# Emergency Contacts:
[**Name (NI) **] (son from Ca) [**Telephone/Fax (1) 59960**]
brother in [**Name (NI) 108**] and HCP [**Name (NI) **] [**Name (NI) 59954**] (home:
[**Telephone/Fax (1) 59955**], cell: [**Telephone/Fax (1) 59956**]),
==========================
TRANSITIONAL ISSUES
==========================
1. continue ambisome for a total course of at least 2 months
(starting [**2189-1-9**]). pt will be followed in [**Hospital **] clinic
2. Patient should have Chem 7, LFTs and CBC w/ differential
drawn once per week. All laboratory results should be faxed to
Infectious disease R.Ns. at ([**Telephone/Fax (1) 1353**].
3. f/u appointments:
Department: INFECTIOUS DISEASE
When: TUESDAY [**2189-2-3**] at 11:15 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 456**], 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: INFECTIOUS DISEASE
When: MONDAY [**2189-2-16**] at 10:00 AM
With: [**Name6 (MD) 14621**] [**Last Name (NamePattern4) 14622**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: CARDIAC SERVICES
When: THURSDAY [**2189-2-12**] at 2:40 PM
With: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**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: NEUROSURGERY
When: TUESDAY [**2189-2-17**] at 1 PM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 9151**], MD [**Telephone/Fax (1) 1669**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Medications on Admission:
1. bisacodyl 5 mg prn
2. senna 8.6 mg [**Hospital1 **] prn.
3. docusate sodium [**Hospital1 **]
4. ascorbic acid 500 mg [**Hospital1 **]
5. zinc sulfate 220 mg daily
6. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler
7. thiamine HCl 100 mg
8. trazodone 25 mg HS
9. lisinopril 2.5 mg Tablet qd
10. metoprolol tartrate 12.5 mg TID
11. acetaminophen 650 mg q6
12. multivitamin
13. heparin (porcine) 5,000 sq TID
14. methocarbamol 750 mg TID
15. oxycodone 20 mg Q12H
16. oxycodone 5 mg Tablet [**11-17**] q6prn
17. furosemide 20 mg qd
18. ipratropium bromide 0.02 % q6
19. benzonatate 100 mg Capsule TID
20. Ambisome 400 mg IV Q24H
21. Ondansetron 4 mg IV Q8H:PRN n/v
22. Micafungin 100 mg IV Q24H
Discharge Medications:
1. senna 8.6 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
2. morphine 30 mg Tablet Extended Release [**Month/Day (2) **]: One (1) Tablet
Extended Release PO Q8H (every 8 hours): hold for sedation, RR <
12.
3. acetaminophen 325 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO Q6H (every
6 hours).
4. docusate sodium 100 mg Capsule [**Month/Day (2) **]: One (1) Capsule PO BID (2
times a day).
5. temazepam 15 mg Capsule [**Month/Day (2) **]: One (1) Capsule PO HS (at
bedtime) as needed for insomnia.
6. sodium chloride 0.65 % Aerosol, Spray [**Month/Day (2) **]: [**11-17**] Sprays Nasal
QID (4 times a day) as needed for dry mucosae.
7. hydromorphone 2 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO Q3H (every 3
hours) as needed for breakthrough pain: hold for sedation, rr <
12.
8. Ondansetron 4-8 mg IV Q8H:PRN nausea
9. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
10. Ambisome 300 mg IV Q24H
Please space by 2 hours from platelet transfusions.
11. Outpatient Lab Work
Patient should have Chem 7, LFTs and CBC w/ differential drawn
once per week. All laboratory results should be faxed to
Infectious disease R.Ns. at ([**Telephone/Fax (1) 1353**]
12. multivitamin Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY
(Daily).
13. warfarin 2 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO Once Daily at 4
PM.
14. alprazolam 0.25 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO TID (3
times a day) as needed for anxiety: hold for sedation, rr < 12.
15. Vital Signs
Note that patient's blood pressures for the past 4 weeks while
in house have been stable in the systolic range of 80-95. Heart
rates have been 70-90s.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
primary diagnoses:
fungal endocarditis
back wound
acute renal failure
urinary tract infection, complicated
hypoxia
anemia
thrombocytopenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname **],
You were admitted to the hospital for an enlargening infectious
mass on your tricuspic heart valve. It is not amenable to
surgery. We are treating you with an IV anti-fungal medication.
You also had a procedure to debulk or make smaller the infection
on your heart valve. You also have a wound on your back that we
have been treating with wound care.
We have made the following changes to the medications you had
previously been on:
STOP:
bisacodyl 5 mg prn
ascorbic acid 500 mg [**Hospital1 **]
zinc sulfate 220 mg daily
albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler
thiamine HCl 100 mg
trazodone 25 mg HS
lisinopril 2.5 mg Tablet qd
metoprolol tartrate 12.5 mg TID
methocarbamol 750 mg TID
oxycodone 20 mg Q12H
oxycodone 5 mg Tablet [**11-17**] q6prn
furosemide 20 mg qd
ipratropium bromide 0.02 % q6
benzonatate 100 mg Capsule TID
Micafungin 100 mg IV Q24H
START:
morphine 30 mg Tablet Extended Release [**Month/Day (2) **]: One (1) Tablet
Extended Release PO Q8H (every 8 hours): hold for sedation, RR <
12.
alprazolam 0.25 mg PO three times per day PRN for anxiety
temazepam 15 mg Capsule [**Month/Day (2) **]: One (1) Capsule PO HS (at
bedtime) as needed for insomnia.
sodium chloride 0.65 % Aerosol, Spray [**Month/Day (2) **]: [**11-17**] Sprays Nasal
QID (4 times a day) as needed for dry mucosae.
hydromorphone 2 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO Q3H (every 3
hours) as needed for breakthrough pain: hold for sedation, rr <
12.
warfarin 2mg PO daily at 4pm. Your LTAC should adjust this dose
based upon your INR. (goal INR around 2).
CHANGE: Ambisome to 300 mg IV Q24H
Otherwise, you should continue to take all of the medications as
you previously had prior to this current hospitalization.
Followup Instructions:
Department: INFECTIOUS DISEASE
When: TUESDAY [**2189-2-3**] at 11:15 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 456**], 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: INFECTIOUS DISEASE
When: MONDAY [**2189-2-16**] at 10:00 AM
With: [**Name6 (MD) 14621**] [**Last Name (NamePattern4) 14622**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: CARDIAC SERVICES
When: THURSDAY [**2189-2-12**] at 2:40 PM
With: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**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: NEUROSURGERY
When: TUESDAY [**2189-2-17**] at 1 PM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 9151**], MD [**Telephone/Fax (1) 1669**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
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icd9cm
|
[
[
[]
]
] |
[
"37.34"
] |
icd9pcs
|
[
[
[]
]
] |
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|
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,072
| 161,136
|
31437
|
Discharge summary
|
report
|
Admission Date: [**2133-2-18**] Discharge Date: [**2133-2-23**]
Date of Birth: [**2077-11-22**] Sex: F
Service: MEDICINE
Allergies:
Crestor
Attending:[**First Name3 (LF) 1674**]
Chief Complaint:
hypertensive urgency
Major Surgical or Invasive Procedure:
none
History of Present Illness:
55 Y F with hx diastolic HF, [**First Name3 (LF) 2091**] with baseline Cr of 2.2, HTN,
CAD (50% stenosis of OM, no stents), DM, presenting with BP
242/124 in the setting of inability to take meds for 3 days [**3-7**]
N+V.
N+V started 4 days ago, last solid meal 3 days ago, and has not
been taking meds for past 3 days. Usually applies clonidine
patch on Sunday but reports that she didn't take a shower on
sunday [**3-7**] NFW and therefore never put on her patch. She doesn't
remember ever taking her old patch off but states that it must
have come off at some point. Mild abd pain, none now. No
diarrhea or constipation, last bm yesterday. Seen today at Heart
Failure clinic, sent here for SBP>200. She denies fever, chills,
URI symptoms, diarrhea, sick contacts.
.
In the ED she had mild chest pressure when she arrived, which
resolved now after treating BP. EKG was negative, trop 0.39 (but
not up from baseline) and CK-MB negative (10). They were unable
to get IV access so an EJ was placed. No HA, dizziness, visual
changes on presentation. Her BP was treated with labetalol 20 mg
IV x2, then a nitro gtt. Her SBP remained in the 190s. Head CT
was obtained due to the isolated nausea/vomiting, no ICH seen.
.
At time of transfer she continues to report nausea and slight
headache, worsened since getting NTG in ED. ROS negative for
fevers, chills, cough, URI ,dysuria, hematuria, melena, BRBPR,
rash.
.
Past Medical History:
CAD (stent in [**May 2131**])
CRI (baseline Cr ~2.0)
diastolic CHF
HTN
Anemia
DM
peripheral neuropathy
.
Social History:
Denies tobbacco, denies alcohol, denies IVDU.
Family History:
Mother with HTN and [**Name (NI) 2091**], denies fh of DM, CAd.
Physical Exam:
Vitals: T97.2 HR 74 BP 207/98 RR 8 100%RA .
GEN: Middle aged female, sleeping, awakens easily, appears
uncomfortable
HEENT: PERRLA, EOMI, sclera anicteric, OP clear, MMM, no LAD, No
JVD, REJ IV in place
CV: regular, nl s1, s2, +syst II/VI murmor at RUSB.
PULM: CTAB anteriorly, no r/r/w.
ABD: soft,obese, nontender, nondistended, BS+
EXT: warm, no pedal edema, DP's 2+ bilaterally
NEURO: alert & oriented x 3, CN II-XII grossly intact
Pertinent Results:
[**2133-2-18**] 12:00PM GLUCOSE-236* UREA N-33* CREAT-2.2* SODIUM-143
POTASSIUM-3.7 CHLORIDE-106 TOTAL CO2-26 ANION GAP-15
[**2133-2-18**] 12:00PM CK-MB-10 cTropnT-0.39*
.
[**2133-2-18**] 12:00PM WBC-10.9 RBC-4.05* HGB-11.0* HCT-34.1* MCV-84
MCH-27.3 MCHC-32.3 RDW-14.5
[**2133-2-18**] 12:00PM NEUTS-85.0* LYMPHS-11.8* MONOS-2.8 EOS-0.4
BASOS-0.1
[**2133-2-18**] 12:00PM PLT COUNT-197
[**2133-2-18**] 12:00PM PT-12.0 PTT-24.6 INR(PT)-1.0
.
.
STUDIES:
R heart Cath [**8-10**]:
1. Resting hemodynamic measurements by right heart
catheterization demonstrated elevated left and right heart
pressures with a mean PCWP of 37mmHg, RVEDP of 24mmHg and RA of
21mmHg. The pulmonary artery systolic pressure was significantly
elevated with a mean of 50mmHg. The calculated Fick C.I. was
preserved at 3.33 L/min/m2.
FINAL DIAGNOSIS:
1. Severe biventricular diastolic dysfunction.
2. Severe primary pulmonary hypertension.
.
TTE [**8-10**]:
The left atrium is moderately dilated. There is moderate
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Regional left ventricular wall motion is
normal. Left ventricular systolic function is hyperdynamic
(EF>75%). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). Transmitral Doppler
and tissue velocity imaging are consistent with Grade II
(moderate) LV diastolic dysfunction. There is no ventricular
septal defect. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. The tricuspid valve leaflets are mildly thickened.
There is moderate pulmonary artery systolic hypertension. There
is a small pericardial effusion. There are no echocardiographic
signs of tamponade.
.
Compared with the prior study (images reviewed) of [**2132-8-14**],
the degree of tricuspid regurgitation (underestimated on prior
study and pulmonary hypertension detected have decreased. These
constellation of diastolic heart failure, LVH, thickened valves,
large atria and pericardial effusion are suggestive (not
diagnostic) of cardiac amyloidosis.
.
CXR [**2-18**]: No radiographic evidence of pneumonia or CHF.
.
Head CT [**2-18**]: No acute intracranial hemorrhage.
.
[**2133-2-18**] EKG 19:56 - NSR at 68bpm, evidence of atrial
enlargement, L axis deviation, minimal criteria for LVH, normal
intervals. '
EKG 11:29 NSR at 88bpm, LAD, atrial enlargement, LVH, strain
pattern with ST elevation in V1 through V3.
Brief Hospital Course:
This is a 55 year old woman with h/o of diastolic CHF, [**Month/Day/Year 2091**], and
diabetes who presented with hypertensive emergency, and was
transferred to ICU on nitroprusside gtt.
.
# Hypertensive Emergency/Urgency: Thought most likely [**3-7**] to
stopping antihypyertensives, including clonidine patch and
inability to take oral pills due to nausea/vomiting. Patient has
severe HTN likely worsened by [**Month/Day (2) 2091**] and is on a 4 drug regimen as
an outpatient. Associated symptoms of headache and chest pain
with strain pattern on EKG were concerning for HTN emergency.
She was admitted to ICU, ruled out for MI, required nitro drip.
On transfer to the floor she was able to tolerate po's and was
restarted on her home regimen with good effect. By discharge
day, the trend had shown that the one time of day when blood
pressure above goal was shortly after waking. Pt was told to
take her carvedilol very soon after awakening rather than
waiting an hour and a half as she had been doing. Pt states she
sleeps until 9am every morning.
# Nausea/Vomiting: Resolved with addition of reglan. Pt was
warned of side effects and discharged on one week supply. Told
to follow up with PCP as she may only require this for one week
if nausea and vomitting were due to virus. If due to developing
gastroparesis, may need indefinitely.
.
# Chronic Diastolic Dysfunction: At dry weight currently (166
lbs) and without evidence of volume overload.
.
#Chronic Kidney disease: Creatinine at baseline by discharge.
.
# Anemia: at baseline of 35, attributed to [**Month/Day (2) 2091**], no evidence of
acute bleed at this time.
Medications on Admission:
diovan 160 mg [**Hospital1 **]
coreg 25 mg [**Hospital1 **]
clonidine 0.3mg/24h patch QSun
amlodipine 10 mg QDay
lasix 100/80 mg [**Hospital1 **]
neurontin 300 PO QDay
zetia 10 mg QDay
vitamin D 1000 U QDay
lantus 16 units QHS
ASA 81 mg QDay
FeSo4 325 mg QDay
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWED (every Wednesday).
3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
5. Valsartan 160 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO TID w/
meals for 1 weeks.
Disp:*20 Tablet(s)* Refills:*0*
7. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
8. Lasix
100 mg in the morning and 80 mg in the eveming
Discharge Disposition:
Home
Discharge Diagnosis:
hypertensive emergency
nausea
Discharge Condition:
stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Please be sure to take the same blood pressure medications you
were taking prior to admission, BUT make a point to take the
carvedilol as soon as you wake up in the morning.
Followup Instructions:
Please follow up with your primary care doctor within one week.
You will be given enough of the anti-nausea medication to last
one week.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**]
Completed by:[**2133-2-24**]
|
[
"414.01",
"250.60",
"536.3",
"585.9",
"428.32",
"403.00",
"285.21",
"357.2",
"428.0",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
7707, 7713
|
5094, 6733
|
290, 296
|
7787, 7796
|
2480, 3296
|
8119, 8409
|
1944, 2009
|
7044, 7684
|
7734, 7766
|
6759, 7021
|
3313, 5071
|
7820, 8096
|
2024, 2461
|
230, 252
|
324, 1736
|
1758, 1865
|
1881, 1928
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,624
| 155,119
|
43928
|
Discharge summary
|
report
|
Admission Date: [**2131-1-19**] Discharge Date: [**2131-1-23**]
Date of Birth: [**2063-10-15**] Sex: M
Service: MEDICINE
Allergies:
Sulfonamides / Penicillins / Tetracyclines / Erythromycin Base
Attending:[**First Name3 (LF) 562**]
Chief Complaint:
Lightheadedness
Major Surgical or Invasive Procedure:
Foley placement
History of Present Illness:
67 year old male with chief complaint of lightheadedness. The
patient reports that he first noticed the LH about 1 week prior
to admission and mentioned it to his VN one day prior to
admission who noted a BP of 70/30. He reports also an episode of
his typical CP for which he has been evaluated in the past with
a negative cardiac workup. He states the CP was lasting about
1hr but was independent of his LH and not associated with other
symptoms. His VN asked him to increase his fluid intake and he
drank a significant amount of fluid and lightheadedness
improved. He did not take his blood pressure medications last
night or on the morning of admission. This morning he went to
see his PCP and was found again to have a BP of 70/30. He was
referred to the ED.
He denies any palpitations, cough, shortness of breath, nausea,
vomiting, diarrhea, melena or hematochezia, f/c or ns. He still
feels weak and lightheaded. He reports a decreased urinary
output over the last week but states that he has had difficulty
initiating urinary stream due to a neurogenic bladder and needed
to straight cath himself in the past. His diabetes is well
controlled. He denies any recent seizure activity. The patient
also reports taking Ibuprofen usually once daily over the last
week. Pt denies any medication changes recently, however he
recently suffered from a PNA.
.
In the ED, the patient was noted to be hypotensive with BP of
73/40, HR 55, RR18, O2 Sat 98. He was given 4L NS with
improvement but not resolution of his hypotension. He received
glucagon and calcium x2 with transient resolution of his
hypotension and bradycardia
Past Medical History:
1. DMII: neuropathy per patient; A1c in [**7-9**] 6.3
2. Hypertension
3. Hypercholesterolemia
4. Diastolic dysfunction with EF 53% on stress MIBI [**6-9**]
5. Seizure disorder
6. GERD
7. Depression/Anxiety
8. Lumbar spinal stenosis
9. h/o C3, C7 fractures
10. DJD
11. Nodule in thecal sac
12. Neurogenic bladder
13. s/p L cataract surgery
[**37**]. Vit B12 deficiency
15. Atypical CP
16. Frequent falls thought to be from peripheral neuropathy
17. hyponatremia - baseline 128-131
Social History:
lives alone with visiting RN qwk. takes own meds and says has [**Last Name **]
problem with this
Tobacco: ~45 pack year history; quit 30 years ago
EtOH: quit 30 years ago
celibate Buddhist monk. previously worked as [**Name6 (MD) **] OR RN until
slipped in OR and broke back/neck 30y ago.
Family History:
Father and sister with CAD
Mother with esophageal cancer
Physical Exam:
Upon arrival to the MICU
VS: Temp: 96.4 BP:108/54 HR:62 RR:16 O2sat 96 2LNC
GEN: pleasant, comfortable, NAD
HEENT: PERRL on the R, surgical pupil on the L, [**Name6 (MD) 3899**], anicteric,
MMM, op without lesions
NECK: no jvd, no carotid bruits
RESP: b/l lower lobe crackles
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e, warm, good pulses
SKIN: no rashes/no jaundice
NEURO: AAOx3. 5/5 strength throughout. No sensory deficits to
light touch appreciated.
Brief Hospital Course:
Patient was admitted to the MICU where within hours his vital
signs improved. His creatinine which was elevated from a
baseline of 0.9 to 3.2 rapidly improved back to his baseline
with IVF. As his SBP rose to 140, he was started on metoprolol.
He is called out after 24+ hours of stability. During the rest
of his hospital course patient remained fully stable however
hypertensive. Therefore all his blood pressure medications were
resumed with the exception of Atenolol, which was replaced by
Metoprolol (for dosage see discharge instructions below).
# Hypotension, bradycardia: Thought to be due to atenolol and
amlodipine toxicity in setting of acute renal failure with
dehydration and diuresis with Lasix.
.
# ARF: Likely [**2-3**] dehydration exacerbated by home regimen of
lisinopril, furosemide, NSAID use, thought to be a combintion of
prerenal + ATN. Improved back to baseline with volume
resuscitation.
.
# Chronic diastolic CHF: remained stable and home medical
regiment was continued once BP fully stabilized. Lasix is not
being contintinued upon discharge.
# DM: Remained stable and well controlled. Continued insulin NPH
32 units q AM, 6 units qhs + sliding scale.
.
# Seizure disorder: Continued Keppra, neurontin
.
# Hypercholesterolemia: Home Atorvastatin
.
# Depression: Home antidepressants
.
# FEN: Diabetic, low salt diet, replete lytes, bowel regimen
.
# PPX: Heparin sc, PPI
Medications on Admission:
NPH 32 units q AM, 6 units qhs
Regular by sliding scale
ASPIRIN 81 MG TAB 1 tab po daily
LISINOPRIL 40 MG TABS 1 po bid
ATENOLOL 75 mg p.o. daily
NORVASC 10 MG TAB 1 po daily
LIPITOR 40 MG TAB 1 tab po daily
IMDUR 60 MG 1 tab po daily
LASIX 40 MG TABS 1 tab po daily
PAXIL 40 MG TAB 1 tab po daily
NEURONTIN 300 MG CAPS 4 caps po bid
KEPPRA 750 MG TABS 1 tab po bid
IBUPROFEN 800 MG TAB 1 po tid prn
PERCOCET TABS 5-325 MG 1-2 tabs po q 6-8 hrs PRN
CYANOCOBALAMIN 1000mcg sc q month
KETOCONAZOLE 2 % CREA
TRAZODONE HCL 50 MG TAB [**1-3**] po qhs prn insomnia
COLACE 100 MG CAPS 1 cap po bid
SENOKOT 8.6 MG TABS 1 tab po bid prn constipation
DITROPAN 5 MG TAB1 tab po bid prn
MECLIZINE HCL 12.5 MG TABS 1 tab po q 12 hours prn dizziness
PROTONIX 40 MG EC TAB 1 tab po daily
Discharge Medications:
1. Insulin
NPH insulin 32 units every morning and 6 units at bedtime plus
regular insulin sliding scale as instructed by primary care
doctor
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
8. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Gabapentin 400 mg Capsule Sig: Three (3) Capsule PO BID (2
times a day).
10. Levetiracetam 250 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
11. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
12. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 17718**] Health Care
Discharge Diagnosis:
Primary:
Hypotension
Acute Renal failure
Secondary:
1. DMII: neuropathy per patient; A1c in [**7-9**] 6.3
2. Hypertension
3. Hypercholesterolemia
4. Diastolic dysfunction with EF 53% on stress MIBI [**6-9**]
5. Seizure disorder
6. GERD
7. Depression/Anxiety
8. Lumbar spinal stenosis
9. h/o C3, C7 fractures
10. DJD
11. Nodule in thecal sac
12. Neurogenic bladder
13. s/p L cataract surgery
[**37**]. Vit B12 deficiency
15. Atypical CP
16. Frequent falls thought to be from peripheral neuropathy
17. hyponatremia - baseline 128-131
Discharge Condition:
Good
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet.
.
You were admitted for renal failure and hypotension. We
recommend not increasing your blood pressure and heart
medication without prior consultation with your Doctor. We
changed you Atenolol to Metoprolol.
(see below). And please do not continue with lasix until you are
seen by you doctor
.
Please call your doctor or 911 if you have lightheadedness,
chest pain, shortness of breath or any other health concerns.
Followup Instructions:
Follow up with your primary care doctor:
Wednesday [**1-31**] at 11:50 am with Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] C.
[**Telephone/Fax (1) 2393**]
|
[
"272.0",
"E942.9",
"357.2",
"276.51",
"530.81",
"345.90",
"724.02",
"584.9",
"458.29",
"250.60",
"564.81",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6741, 6804
|
3446, 4848
|
339, 357
|
7381, 7388
|
7955, 8123
|
2835, 2893
|
5672, 6718
|
6825, 7360
|
4874, 5649
|
7412, 7932
|
2908, 3423
|
284, 301
|
385, 2008
|
2030, 2512
|
2528, 2819
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,953
| 175,567
|
53317
|
Discharge summary
|
report
|
Admission Date: [**2107-3-16**] Discharge Date: [**2107-4-5**]
Date of Birth: [**2049-11-29**] Sex: F
Service: SURGERY
Allergies:
Aspirin / Sulfa (Sulfonamides) / Trazodone
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
Abd pain
Major Surgical or Invasive Procedure:
SBR X 2
Ex lap
Closure of abd with absorbable mesh
VAC dressing placement
History of Present Illness:
56F with multiple abd operations and large ventral hernias who
presented with abd pain and nausea for 2 days. Pain was diffuse
and crampy. Last BM 1 day previous and no flatus since that
time. Vomitting started the day of admission. No
F/C/Diarrhea/Constipation
Past Medical History:
Asthma
GERD
MI
Morbid obesity
s/p umbilical hernia repair
s/p multiple ventral hernia repairs
SBO
Social History:
NC
Family History:
NC
Physical Exam:
AVSS
NAD, morbidly obese
CTA(b)
RRR
Soft, obese, tender RLQ with muliple hernias
No rebound or guarding.
Draining track at umbilicus
No edema
Pertinent Results:
[**2107-3-16**] 05:00AM WBC-11.8* RBC-5.00 HGB-14.1 HCT-41.6 MCV-83
MCH-28.1 MCHC-33.8 RDW-13.6
[**2107-3-16**] 05:00AM PLT SMR-NORMAL PLT COUNT-356
[**2107-3-16**] 05:00AM LIPASE-22
[**2107-3-16**] 05:00AM ALT(SGPT)-22 AST(SGOT)-18 ALK PHOS-71 TOT
BILI-0.3
[**2107-3-16**] 05:00AM GLUCOSE-205* UREA N-17 CREAT-0.6 SODIUM-139
POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-30* ANION GAP-14
[**2107-3-16**] 08:42PM URINE RBC-0 WBC-[**3-12**] BACTERIA-OCC YEAST-NONE
EPI-0-2
[**2107-3-16**] 08:42PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2107-3-16**] 08:42PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.034
Brief Hospital Course:
Pt was admitted to the hostipal and monitored overnight. On HD
#2 she began having temps to 104.0. That night she became
hypotensive and somulent and was transferred to the ICU. She was
intubated and fluid resusitated. She was taken to the OR
emergently for exploration. She was found to have a closed loop
obstruction of her SB. 100 cm of SB were resected and she was
left open and transferred to the ICU. Post op she had severe
sepsis and was started on broad spectrum abx and Xigris. She
slowly improved and was weaned from her pressors. She stablized
and was taken back to the operating room for a washout and
closure. Intraoperatively, a focal area of necrosis of the SB
was identified and it was resected. She was closed with Dexon
absorbable mesh and a VAC was placed. Plastic surgery was
consulted intra-op and followed the her throughout her stay. She
was transferred back to the ICU and she slowly improved. She was
attempted to be weaned from the vent but was unable. Therefore
it was decided to proceed with a perc trach. After the trach was
placed she was able to wean from the ventilator and was
tolerating trach mask prior to discharge. A post-pyloric feeding
tube was placed intra-op and she was started on TF. She had high
stool output which was checked multiple times for C diff. All
were negative. Her TF were changed and her output decreased. She
had a PICC line placed for a 2 wk abx course of Vanco/Levo. She
had a MRSA/Ecoli bacteremia likely from her necrotic bowel. She
was afebrile for over 1 wk after starting the abx. PT/OT were
consulted and worked with her throughout her hospital stay.
Speech and Swallow evaluated her and she was able to pass her
beside evaluation. She will need a Video swallow when more
stable prior to starting to take PO.
Medications on Admission:
Theodur 300 QD
Claritin 10 QD
Nexium 40 QD
Prozac 40 QD
Klonipin 0.5 prn
Albuterol
Discharge Medications:
1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
Disp:*60 * Refills:*0*
2. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation
Q4H (every 4 hours) as needed.
Disp:*60 * Refills:*0*
3. Fluoxetine HCl 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
Disp:*60 Capsule(s)* Refills:*2*
4. Clonidine HCl 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QTHUR (every Thursday).
Disp:*60 Patch Weekly(s)* Refills:*2*
5. Enoxaparin Sodium 60 mg/0.6mL Syringe Sig: One (1)
Subcutaneous Q12H (every 12 hours).
Disp:*60 * Refills:*2*
6. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
Disp:*60 * Refills:*2*
7. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*400 ML(s)* Refills:*0*
8. Lorazepam 1 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed.
Disp:*60 Tablet(s)* Refills:*0*
9. Vancomycin HCl 1,000 mg Recon Soln Sig: 1.5 g Intravenous
twice a day for 5 days.
Disp:*5 * Refills:*0*
10. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Small Bowel Obstruction s/p ex lap small bowel resection X 2.
Abd washout and closure using dexon mesh.
MRSA pneumonia
MRSA and E coli bacteremia
Discharge Condition:
Stable
Discharge Instructions:
Trach Mask as tolerated.
VAC dressing on abd. Change dressing every 3 days.
PICC line in R antecub.
Chest PT
OOB to chair as tolerated.
Followup Instructions:
F/U with Dr. [**Last Name (STitle) **] in [**1-9**] wks for wound evaluation and down
sizing trach.
F/U Speech and Swallow for video swallow evaluation.
F/U Dr. [**First Name (STitle) 3228**] in 2 wks for wound evaluation and plan skin
grafting
Completed by:[**0-0-0**]
|
[
"518.82",
"552.21",
"493.90",
"038.42",
"995.92",
"788.5",
"458.9",
"552.9",
"557.0",
"530.81",
"996.69",
"278.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"53.51",
"43.11",
"99.15",
"00.11",
"54.59",
"45.79",
"96.07",
"54.72",
"38.91",
"54.25",
"31.1",
"99.04",
"45.73",
"93.57",
"33.21",
"38.93",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
4855, 4925
|
1734, 3510
|
310, 386
|
5115, 5123
|
1015, 1711
|
5307, 5579
|
834, 838
|
3643, 4832
|
4946, 5094
|
3536, 3620
|
5147, 5284
|
853, 996
|
262, 272
|
414, 677
|
699, 798
|
814, 818
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,586
| 105,708
|
28979
|
Discharge summary
|
report
|
Admission Date: [**2126-9-17**] Discharge Date: [**2126-9-23**]
Date of Birth: [**2060-5-8**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Vioxx
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Coronary artery bypass grafting times three (left internal
mammary to left anterior descending, saphenous vein graft to
diagonal, saphenous vein graft to obtuse marginal) on [**2126-9-17**]
History of Present Illness:
Mr. [**Known lastname 69850**] is a 66 year old male who developed fatigue/chest
pain this past [**Month (only) **]/[**Month (only) 205**] while playing tennis. The symptoms were
similiar to those he experienced in [**2112**] prior to receiving an
left anterior descending artery stent. His symptoms resolved
with rest however he has noticed a progressive decline in his
aerobic capacity. A stress echocardiogram was obtained which was
positive for ischemia. A cardiac catheterization was
subsequently performed
which showed severe left main and single vessel disease. Given
the severity of his disease, he has been referred for surgical
management.
Past Medical History:
- Coronary artery disease
- Hypertension
- Hyperlipidemia
- Diverticulitis
- Arthritis
- GERD
- PCI/Stent to LAD [**2112**]
- Achilles tendon rupture with repair [**2106**]
- Right rotator cuff surgery in [**2122**] and [**2123**], right
- Arthroscopy of knee, left
Social History:
Mr. [**Known lastname 69850**] is a high school guidance counselor. He smoked
1-1.5 packs per day for ten years, quiting in his 20s. He
reports drinking less than one alcoholic beverage per week.
Family History:
Mr. [**Known lastname 69851**] brother has coronary artery disease and diabetes.
Physical Exam:
Pulse: 85 Resp: 16 O2 sat: 97%
B/P Right: 134/77 Left: 118/81
Height: 5'7" Weight: 207lbs
General: Well-developed male in no acute distress
Skin: Warm [X] Dry [X] intact [X]
HEENT: NCAT [X] PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] Murmur [] grade ______
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] Edema -
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: Right: - Left: -
Pertinent Results:
Intra-op TEE [**2126-9-17**]:
Conclusions
Pre-Bypass:
The left atrium is normal in size. No spontaneous echo contrast
or thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage.
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%).
Right ventricular chamber size and free wall motion are normal.
The ascending, transverse and descending thoracic aorta are
normal in diameter with minimal atherosclerotic plaque. The
diameters of aorta at the sinus, ascending and arch levels are
normal.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis or aortic
regurgitation.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen.
Post-Bypass:
The patient is A-Paced on a phenylephrine infusion s/p 3 vessel
CABG
Left ventricular function is preserved with EF-55%. No WMA.
Normal functioning aortic valve and trivial MR remain.
There is a small right pleural effusion.
There is no echocardiographic evidence of a aortic dissection
post de-cannulation.
.
[**2126-9-23**] 06:10AM BLOOD Hct-27.0*
[**2126-9-22**] 05:40AM BLOOD WBC-6.3 RBC-2.69* Hgb-8.8* Hct-26.2*
MCV-97 MCH-32.7* MCHC-33.7 RDW-13.6 Plt Ct-236
[**2126-9-21**] 04:54AM BLOOD WBC-7.2 RBC-2.50* Hgb-8.5* Hct-24.1*
MCV-97 MCH-33.9* MCHC-35.2* RDW-13.5 Plt Ct-165
[**2126-9-20**] 02:55PM BLOOD Hct-23.0*
[**2126-9-20**] 10:19AM BLOOD WBC-7.8 RBC-2.67* Hgb-8.8* Hct-25.9*
MCV-97 MCH-33.1* MCHC-34.1 RDW-12.8 Plt Ct-145*
[**2126-9-23**] 06:10AM BLOOD PT-20.0* INR(PT)-1.9*
[**2126-9-22**] 05:40AM BLOOD PT-13.1* INR(PT)-1.2*
[**2126-9-21**] 04:54AM BLOOD PT-12.0 INR(PT)-1.1
[**2126-9-22**] 05:40AM BLOOD Glucose-144* UreaN-19 Creat-0.8 Na-139
K-4.6 Cl-104 HCO3-29 AnGap-11
[**2126-9-21**] 04:54AM BLOOD Glucose-103* UreaN-23* Creat-0.9 Na-142
K-3.8 Cl-105 HCO3-31 AnGap-10
[**2126-9-20**] 10:19AM BLOOD Glucose-136* UreaN-22* Creat-0.9 Na-140
K-4.0 Cl-103 HCO3-34* AnGap-7*
Brief Hospital Course:
Mr. [**Known lastname 69850**] was brought to the Operating Room on [**2126-9-17**] where he
underwent coronary artery bypass grafting times three (left
internal mammary to left anterior descending, saphenous vein
graft to diagonal, saphenous vein graft to obtuse marginal).
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring.
Post-operative day one found the patient extubated, alert and
oriented and breathing comfortably. The patient was
neurologically intact and hemodynamically stable, weaned from
inotropic and vasopressor support. Beta blocker was initiated
and the patient was gently diuresed toward the preoperative
weight. The patient was transferred to the telemetry floor for
further recovery. He experienced atrial fibrillation, which
converted to sinus rhythm with amiodarone. AFib returned and he
was started on coumadin. He remained in AFib/Flutter at
discharge. He received blood for a hct of 22%. The patient
developed a fever and blood was discontinued. Hematocrit rose
appropriately and remained stable. Stool guaiac was negative.
Chest tubes and pacing wires were discontinued without
complication. The patient was evaluated by the physical therapy
service for assistance with strength and mobility. By the time
of discharge on post-operative day 6 the patient was ambulating
freely, the wound was healing and pain was controlled with oral
analgesics. The patient was discharged to home in good
condition with appropriate follow up instructions.
Medications on Admission:
Coreg 3.15mg twice daily
Lipitor 80mg daily
Diovan 80mg daily
Aspirin 81mg daily
Prevacid 30mg daily
Multivitamins
Fish oil
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
4. Amiodarone 400 mg PO BID
400mg [**Hospital1 **] x 1 week, then 400mg daily x 1 week, then 200mg daily
RX *amiodarone 200 mg 2 tablet(s) by mouth twice a day Disp #*56
Tablet Refills:*0
5. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Col-Rite] 100 mg 1 capsule(s) by mouth
twice a day Disp #*60 Capsule Refills:*0
6. Furosemide 20 mg PO DAILY Duration: 5 Days
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*5 Tablet
Refills:*0
7. Potassium Chloride 20 mEq PO DAILY Duration: 5 Days
Hold for K+ > 4.5
RX *potassium chloride [Klor-Con] 20 mEq 1 packet by mouth daily
Disp #*5 Packet Refills:*0
8. HYDROmorphone (Dilaudid) 2-4 mg PO Q3H:PRN pain
RX *hydromorphone 2 mg [**1-14**] tablet(s) by mouth q3h Disp #*60
Tablet Refills:*0
9. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*30 Tablet Refills:*0
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Metoprolol Tartrate 12.5 mg PO BID
RX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth
twice a day Disp #*60 Tablet Refills:*0
12. Tamsulosin 0.4 mg PO HS
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
13. Warfarin 2 mg PO DAILY16 Duration: 1 Doses
dose to change per Dr. [**First Name (STitle) 4223**] for goal INR 2-2.5
RX *warfarin [Coumadin] 2 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
coronary artery disease
PMH:
- Hypertension
- Hyperlipidemia
- Diverticulitis
- Arthritis
- GERD
Past Surgical History:
- PCI/Stent to LAD [**2112**]
- Achilles tendon rupture with repair [**2106**]
- Right rotator cuff surgery in [**2122**] and [**2123**], right
- Arthroscopy of knee, left
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
No edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**] [**2126-9-26**]
10:45p
Surgeon Dr. [**Last Name (STitle) **] [**2126-10-16**] at 1:00p [**Telephone/Fax (1) 170**]
Cardiologist Dr. [**Last Name (STitle) 6254**] [**2126-10-10**] at 11:20am
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) 69852**] [**Name (STitle) 4223**] ([**Telephone/Fax (1) 69853**] in [**4-18**] 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
Coumadin for AFib
Goal INR 2-2.5
First draw [**2126-9-24**]
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease as directed by Dr. [**First Name (STitle) 4223**]
Results to phone [**Telephone/Fax (1) 69854**], fax [**Telephone/Fax (1) 69855**]
Completed by:[**2126-9-23**]
|
[
"401.9",
"530.81",
"414.01",
"413.9",
"272.4",
"562.10",
"V45.82",
"427.31",
"716.90",
"V58.66",
"780.60",
"427.32"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.15",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
7825, 7884
|
4544, 6129
|
282, 474
|
8220, 8385
|
2488, 4521
|
9172, 10123
|
1675, 1758
|
6304, 7802
|
7905, 8002
|
6155, 6281
|
8409, 9149
|
8025, 8199
|
1773, 2469
|
232, 244
|
502, 1153
|
1175, 1443
|
1459, 1659
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,707
| 196,566
|
5345
|
Discharge summary
|
report
|
Admission Date: [**2152-10-24**] Discharge Date: [**2152-10-28**]
Date of Birth: [**2092-4-12**] Sex: F
Service: MEDICINE
Allergies:
Compazine / Droperidol / Sulfonamides / Gadolinium-Containing
Agents / Demerol / Morphine / Haldol
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
sob and abdominal pain
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
Patient is a 60 yo female with pmhx significant for mast cell
degranulation syndrome with multiple admissions with flares who
presents with dyspnea. Pt reports that she began having her
usual flare symptoms of SOB, CP, nausea, and diarrhea this
afternoon that started off mild. She then began driving to [**Hospital1 18**]
as that is where she receives most of her care. Her symptoms
worsened during the drive and she attempted to use her epi pen,
but it was empty. She continued to drive and arrived at the ED.
She reports URI symptoms of cough, sore throat, congestion, body
aches, and subjective fevers for 3 days before onset of
symptoms. She had taken one day of azithromycin for this from
her PCP. [**Name10 (NameIs) **] denied other possible flares such as exercise,
etoh, asa, nsaids, opiates, insects. Of note, she has had three
admissions in the last month for similar episodes, the latest
being [**10-13**] to [**10-15**].
.
In the ED, initial vs were: HR 129, BP 119/109, R 18 O2 sat 100%
on NRB. She was given benadryl 50 mg IV x 1, solumedrol 125 mg
IV x 1, dilaudid 1 mg, 2 grams ativan, albuterol nebs.
.
On admission to the [**Hospital Unit Name 153**], initial vs were: 97.9 98 144/89 30 98%
on 4L She reported severe substernal chest pain and tightness
that radiated to her back but not her arms or jaw. She also
reported SOB, epigastric pain, and nausea. Her ekg was unchanged
from priors except for some diminished r wave progression. First
set of ces was negative. She was given another 2mg dilaudid,
25mg benadryl, 1mg ativan, and 8mg zofran. She was resting
comfortably after this medication was given.
Past Medical History:
- mast cell degranulation syndrome (MCDS): Followed by [**First Name8 (NamePattern2) 21734**]
[**Last Name (NamePattern1) **]
who is an allergist at [**Hospital1 112**], #[**Telephone/Fax (1) 21735**]. Also followed here by
Dr. [**Last Name (STitle) 79**] in GI. Has been intubated twice.
- Depression/anxiety/bipolar d/o, hx of SI
- MI in [**2147**] after receiving cardiac arrest dose epi instead of
anaphylactic dose epi
- HTN
- Erosive osteoarthritis
- GERD, gastritis and esophagitis on recent EGD [**2151-1-8**]
- Paradoxical Vocal Cord Dysfunction viewed on fiberoptic
laryngoscopy
- Anemia, iron studies c/w AOCD
- Hemorrhoids
- pt reports EGD demonstrated vegetable bezoar (?[**12-6**]).
- Status post hysterectomy and oophorectomy
- h/o MRSA infection (porthacath associated)
- portacath placed [**3-7**] - d/c'd [**2-4**] MRSA infection
- portacath placed [**2151-6-9**]
Social History:
Pt is divorced. Lives alone. She works as an ER tech in
[**Hospital3 **]. No tobacco or EtOH or illicit drugs. Son is
HCP [**Telephone/Fax (1) 21738**]
Family History:
Mother died of MI @ 76, Sister w/ breast cancer and bilateral
mastectomy.
Physical Exam:
afebrile, VSS, on room air
Gen- NAD
HEENT- ncat, mmd, perrl, eomi grossly
Neck- no lad, no tmg, no jvd
Cor- regular, no murmur
Pulm- diminished sounds, sparse wheezes
Abd- benign
Extrem- no c/c/e
Skin- aox4, cn2-12 intact grossly, no focal abnormalities
Pertinent Results:
CXR: Left lower lobe opacity may represent pneumonia. New right
lower lobe atelectasis. No pleural effusion or pneumothorax. The
left lower lobe findings could also represent pulmonary infarct,
although less likely.
[**2152-10-28**] 04:07AM BLOOD WBC-7.3 RBC-3.71* Hgb-10.8* Hct-32.3*
MCV-87 MCH-29.2 MCHC-33.6 RDW-14.7 Plt Ct-240
[**2152-10-24**] 08:30PM BLOOD WBC-8.6 RBC-4.52 Hgb-13.3 Hct-40.0 MCV-89
MCH-29.5 MCHC-33.3 RDW-16.7* Plt Ct-332#
[**2152-10-24**] 08:30PM BLOOD Neuts-73* Bands-1 Lymphs-11* Monos-8
Eos-2 Baso-0 Atyps-0 Metas-2* Myelos-2* Promyel-1*
[**2152-10-27**] 01:00PM BLOOD PT-11.4 PTT-22.1 INR(PT)-1.0
[**2152-10-28**] 04:07AM BLOOD Glucose-131* UreaN-15 Creat-0.7 Na-142
K-3.1* Cl-107 HCO3-26 AnGap-12
[**2152-10-24**] 08:30PM BLOOD Glucose-90 UreaN-21* Creat-1.0 Na-141
K-4.8 Cl-101 HCO3-30 AnGap-15
[**2152-10-25**] 11:58AM BLOOD CK(CPK)-28
[**2152-10-25**] 05:25AM BLOOD ALT-37 AST-19 LD(LDH)-358* CK(CPK)-33
AlkPhos-84 Amylase-36 TotBili-0.1
[**2152-10-25**] 11:58AM BLOOD CK-MB-2 cTropnT-<0.01
[**2152-10-25**] 05:25AM BLOOD CK-MB-2 cTropnT-<0.01
[**2152-10-24**] 08:30PM BLOOD cTropnT-<0.01
[**2152-10-25**] 05:25AM BLOOD Albumin-3.6 Calcium-8.2* Phos-3.7 Mg-2.5
[**2152-10-26**] 07:45PM BLOOD Type-ART FiO2-50 pO2-160* pCO2-36 pH-7.45
calTCO2-26 Base XS-2 Intubat-NOT INTUBA
[**2152-10-25**] 01:33AM BLOOD Type-ART pO2-70* pCO2-34* pH-7.48*
calTCO2-26 Base XS-2
Brief Hospital Course:
Patient is a 60 yo female with pmhx mast cell degranulation
syndrome who presents with recurrent flare.
.
1)Dyspnea: MI ruled out and CXR showed possible pneumonia.
Presentation likely multifactorial as this was typical of the
patient's acute flares of mast cell degranulation syndrome
exacerbations. Patient's ekg is not consistent with ACS and one
set of enzymes is normal. She does have some atalectasis vs.
consolidation on cxr and reports subjective fevers, cough of
green sputum recently which could be contributing. In addition,
likely combination of pain and anxiety. She has a respiratory
alkalosis which is consistent with this. Treated mast cell
degranulation with steroids, diphenhydramine, H2blockers,
gastrocrom.
2) Chest pain- MI ruled out with 3 sets neg cardiac enzymes
3) HTN- well-controlled; continued diltiazem.
4) OA- tylenol and plaquenil.
5)[**Name (NI) 14983**] Pt reports history of melena last week which has
resolved. Hematocrip abover her baseline and stable. EGD done
per Dr. [**Last Name (STitle) 79**] given recent symptoms, no evidence of active
bleeding, one polyp biopsied. Ms. [**Known lastname **] was provided Dr. [**Name (NI) 21744**] telephone number to follow up biopsy report.
6) Psychiatric: bipolar/anxiety/depression- continue duloxetine
Medications on Admission:
1. Doxepin 50 mg qhs
2. Zolpidem 10 mg qhs prn
3. Cromolyn 100 mg/5 mL Solution Sig: One (1) PO four times a
day.
4. Diltiazem HCl 180 mg QD
5. Hydroxyzine HCl 25 mg QID
6. Ranitidine HCl 150 mg [**Hospital1 **]
7. Duloxetine 60 mg Capsule, Delayed Release(E.C.) QD
8. Hydroxychloroquine 200 mg [**Hospital1 **]
9. Amphetamine-Dextroamphetamine 20 mg Capsule, Sust. Release 24
hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day.
10. Fexofenadine 180 mg QD
11. Omeprazole 20 mg [**Hospital1 **]
12. Zofran 8 mg TID prn
13. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet q8 prn
headache
14. Cholecalciferol (Vitamin D3) 800 unit daily
15. Asmanex Twisthaler 220 mcg (120 doses) Aerosol Powdr [**Hospital1 **]
Activated Sig: Two (2) Inhalation [**Hospital1 **] (2 times a day). Pt doesnt
remember taking this.
16. Prednisone taper finished yesterday
17. Vivelle-Dot 0.05 mg/24 hr Patch Semiweekly Sig: One (1)
patch Transdermal 2X/week.
Discharge Medications:
1. Doxepin 25 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO QID PRN
() as needed for pruritis.
4. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Fexofenadine 60 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
9. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
10. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
treatment Inhalation Q4H (every 4 hours) as needed.
11. Cromolyn 100 mg/5 mL Solution Sig: One Hundred (100) mg PO
QID (4 times a day).
12. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
13. Estradiol 0.05 mg/24 hr Patch Semiweekly Sig: One (1) Patch
Semiweekly Transdermal 2X/WEEK (2 times a week).
Discharge Disposition:
Home
Discharge Diagnosis:
mast cell degranulation syndrome
Discharge Condition:
stable
Discharge Instructions:
You were hospitalized with mast cell degranulation/activation
syndrome. Call Dr. [**Last Name (STitle) 79**] regarding your EGD biopsy results next
week.
Please call your PCP or Dr. [**Last Name (STitle) 79**], or go to ER depending on
severity of new abdominal pain, sob, chest tightness, or other
concerning symptoms.
Followup Instructions:
Please follow up with your allergist within the next 2
weeks.Provider: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2153-1-25**] 1:30
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2153-1-31**] 2:00
|
[
"786.05",
"211.2",
"401.1",
"786.59",
"427.89",
"578.1",
"300.4",
"285.29",
"279.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.16",
"45.30"
] |
icd9pcs
|
[
[
[]
]
] |
8472, 8478
|
4922, 6212
|
383, 389
|
8555, 8564
|
3505, 4899
|
8933, 9263
|
3139, 3215
|
7210, 8449
|
8499, 8534
|
6238, 7187
|
8588, 8910
|
3230, 3486
|
321, 345
|
417, 2046
|
2068, 2952
|
2968, 3123
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,632
| 168,374
|
50475
|
Discharge summary
|
report
|
Admission Date: [**2169-5-30**] Discharge Date: [**2169-6-5**]
Date of Birth: [**2099-3-25**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
CC: Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization and stent placement in right coronary
artery on [**2169-5-30**]
Cardioversion for atrial fibrillation on [**2169-6-2**]
History of Present Illness:
History of Present Illness: Ms. [**Known lastname 67888**] is a 70 year old female
with type II DM2 x5 years, HTN, severe osteoarthritis s/p left
total knee replacement, obesity, who presented to OSH ([**Hospital1 1474**])
with CP 10/10 intensity, occurring during physical therapy. She
noted mild cough, no associated symptoms, specifically denying
radiation, palpitations, or (pre)syncope.
Patient called EMS, VSS in field stable. At [**Hospital1 1474**], found to
have STE in inferior leads on EKG, Cr rise to 2.7 (baseline
1.6). Transferred to [**Hospital1 18**] for urgent PCI, demonstrating total
occlusion of RCA. RCA was stented with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (Prefixes) **] stent.
On ROS patient has experienced increasing edema of bilateral LE,
but no weight gain. She recalls vague nausea with occasional
vomiting over the past week, but no chest pain prior to this
episode.
Past Medical History:
Obesity
hypertension
osteoarthritis
noninsulin-dependent diabetes
Hysterectomy
bilateral knee arthroscopy
Social History:
The patient does not smoke, does not drink, and is unable to
exercise.
Family History:
Had several brothers with [**Name2 (NI) **] in their 40s, and a father with
possible afib
Physical Exam:
VS: 132/63, P 53, SpO2 100% RA
Gen: Obese, alert, female in no distress
CV: S1 S2 with I/VI Holosystolic murmur at base
Lungs: Clear in anterior and posterior fields bilaterally
Abd: Obese, non-tender, non-distended, positive bowel sounds
Ext: 4+ bilateral pitting edema. Trace pulses when edema
"sqeezed."
Skin: right groin cath site, dressing intact, no hematoma, no
bruit noted
Pertinent Results:
[**2169-5-30**] 05:00PM BLOOD WBC-13.7* RBC-3.39* Hgb-8.9* Hct-27.7*
MCV-82 MCH-26.4* MCHC-32.2 RDW-15.6* Plt Ct-207
[**2169-5-31**] 05:21AM BLOOD WBC-16.5* Hgb-9.6* Hct-28.5* Plt Ct-214
[**2169-6-1**] 07:40AM BLOOD WBC-19.2* RBC-3.62* Hgb-9.6* Hct-29.8*
MCV-82 MCH-26.6* MCHC-32.3 RDW-15.6* Plt Ct-204
[**2169-6-1**] 10:05AM BLOOD WBC-17.3* RBC-3.40* Hgb-8.8* Hct-28.5*
MCV-84 MCH-25.8* MCHC-30.7* RDW-15.6* Plt Ct-168
[**2169-6-2**] 04:04AM BLOOD WBC-14.4* RBC-3.30* Hgb-8.8* Hct-27.5*
MCV-84 MCH-26.6* MCHC-31.9 RDW-16.0* Plt Ct-175
[**2169-6-5**] wbc 10.9 hgb 9.9* hct 31.6* mcv 86
[**2169-6-1**] 10:05AM BLOOD Neuts-75.3* Bands-0 Lymphs-9.6* Monos-6.2
Eos-8.7* Baso-0.2
[**2169-6-2**] 04:04AM BLOOD Neuts-64.8 Lymphs-18.6 Monos-4.1
Eos-12.3* Baso-0.2
[**2169-5-30**] 05:00PM BLOOD PT-13.6* PTT-30.2 INR(PT)-1.2
[**2169-5-30**] 05:00PM BLOOD Ret Aut-1.1*
[**2169-5-30**] 05:00PM BLOOD Glucose-260* UreaN-55* Creat-2.2* Na-138
K-4.4 Cl-102 HCO3-21* AnGap-19
[**2169-5-31**] 01:10AM BLOOD K-3.8
[**2169-5-31**] 05:21AM BLOOD Glucose-101 UreaN-48* Creat-2.1* Na-141
K-4.0 Cl-101 HCO3-27 AnGap-17
[**2169-6-1**] 10:05AM BLOOD Glucose-199* UreaN-51* Creat-2.5* Na-138
K-4.4 Cl-100 HCO3-21* AnGap-21*
[**2169-6-2**] 04:04AM BLOOD Glucose-120* UreaN-59* Creat-3.5* Na-140
K-4.6 Cl-104 HCO3-23 AnGap-18
[**2169-5-30**] 05:00PM BLOOD CK(CPK)-884*
[**2169-5-31**] 01:10AM BLOOD CK(CPK)-1100*
[**2169-5-31**] 05:21AM BLOOD CK(CPK)-1024*
[**2169-5-30**] 01:15PM BLOOD CK(CPK)-117
[**2169-5-31**] 05:21AM BLOOD CK-MB-65* MB Indx-6.3* cTropnT-6.54*
[**2169-5-31**] 01:10AM BLOOD CK-MB-72* MB Indx-6.5*
[**2169-5-30**] 05:00PM BLOOD CK-MB-67* MB Indx-7.6* cTropnT-5.88*
[**2169-5-30**] 05:00PM BLOOD calTIBC-298 Ferritn-69 TRF-229
[**2169-6-1**] 10:05AM BLOOD TSH-1.4
[**2169-5-30**] 01:34PM BLOOD Type-ART O2 Flow-4 pO2-93 pCO2-38
pH-7.28* calHCO3-19* Base XS--7 Intubat-NOT INTUBA
[**2169-5-30**] 02:10PM BLOOD Type-ART O2 Flow-4 pO2-71* pCO2-48*
pH-7.25* calHCO3-22 Base XS--6 Intubat-NOT INTUBA
[**2169-5-30**] 02:43PM BLOOD Type-ART pO2-84* pCO2-40 pH-7.33*
calHCO3-22 Base XS--4 Intubat-NOT INTUBA
[**2169-5-30**] 04:57PM BLOOD Type-ART Temp-36.7 O2 Flow-4 pO2-138*
pCO2-40 pH-7.35 calHCO3-23 Base XS--3 Intubat-NOT INTUBA
INDICATIONS FOR CATHETERIZATION:
ST-elevation MI (inferior).
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Successful stenting of the RCA.
COMMENTS:
1. Coronary angiography of this right-dominant circulation
showed
single vessel CAD. The LMCA and the LAD had no flow-limiting
lesions.
The LCX had an ostial 50% stenosis. The RCA had a total
occlusion with a
filling defect at the PDA/PLB bifurcation.
2. Resting hemodynamics showed normal central aortic pressures
and
mildly elevated LV filling pressures.
3. Successful PTCA and stenting of the PLB with a 3.0 mm Cypher
drug-eluting stent. Final angiography showed no residual
stenosis, no
dissection and normal flow (see PTCA comments).
.
CXR [**2169-6-1**]: IMPRESSION: No evidence of pneumonia. No interval
change.
.
CT pelvis w/o contrast, CT abdomen without contrast [**2169-6-3**]:
IMPRESSION:
1. No retroperitoneal hematoma. Minor stranding in the right
groin, likely related to the procedure, but no significant
hematoma.
2. Contrast retained within the cortex of the kidneys
bilaterally. Clinically correlate as this may relate to ATN.
3. Cholelithiasis without evidence of acute cholecystitis.
4. Incidentally noted right renal angiomyolipoma.
.
knee x-ray [**6-4**]: Three views of the left knee show total knee
prosthesis in place essentially unchanged from prior study dated
[**2169-3-7**]. There is a knee effusion present. No radiographic
evidence of osteomyelitis.
.
Left upper extremity ultrasound [**2169-6-5**]: Doppler evaluation was
performed of left upper extremity arterial system. Doppler wave
forms at the subclavian, brachial, radial and ulnar arteries are
all triphasic. Pulse volume recordings are normal. The wrist
brachial index is 0.84.
.
BILATERAL LOWER EXTREMITY ULTRASOUND [**2169-6-4**]: [**Doctor Last Name **]-scale and
color Doppler son[**Name (NI) 867**] was performed of the right and left
common femoral, superficial femoral, and popliteal veins. Within
the left common femoral vein, there is intraluminal thrombus,
with loss of compressibility and partial occlusion of flow. In
the remaining distal vessels of the left lower extremity, and
within the right lower extremity, the remainder of the vessels
demonstrate normal flow, compressibility, waveforms, and
augmentation.
Brief Hospital Course:
*CAD: Patient was admitted from [**Hospital 1474**] hospital with a STEMI
after ST elevations were seen in the inferior leads. She was
sent to the cath lab for PCI and was found to have a normal
LMCA, mild irregularities in her LAD, 50 % ostial occlusion in
her left circumflex artery and a total occlusion with filling
defect at the PDA/PL bifurcation of the RCA. A wire was place
across the PDA stenosis, the stenosis was dilated with a balloon
and a Cypher [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] was placed. The patient was successfully
revascularized and was chest pain free throughout the remainder
of her hospitalization. Her ck peaked on [**5-31**] and started
trending down after that. She was continued on metoprolol, ASA,
lipitor and plavix. Her Ace inhibitor was held because of her
chronic renal insufficiency.
.
*Hyperglycemia/ metabolic acidosis: Patient was transferred to
the CCU from the cath lab because she became hyperglycemic
during her cardiac cath to a glucose of 276 and had a metabolic
acidosis. Her ABG showed: ph 7.28, pCO2 38, pO2 93 and bicarb
19. Her anion gap at admission was 15. It was thought that she
might be in DKA (although she is a type 2 diabetic and more
likely to be in a hyperosmolar acidosis) , so she was
transferred to the CCU and started on an insulin drip. Her
sugars trended down appropriately and her insulin drip was dc'd
after one day. She was put on sliding scale insulin and her
sugars remained under good control. Her bicarb trended back to
normal and her gap closed. Her chronic renal insufficiency was
also thought to contribute to the acidosis. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consult
was obtained and she was started on lantus at night and her
sliding scale was made more aggressive and used humalog instead
of regular insulin. At discharge she was on 12 units of lantus
at night and humalog sliding scale with good sugar control.
.
*Atrial fibrillation: Patient went into Afib on the morning of
[**2169-6-1**]. She became hypotensive after her afib started, down to
60s/30s and continue to be in the 80s-90s/30s-40s throughout the
remainder of the day. She was given IV fluid boluses for her
hypotension and her beta blocker was discontinued. She was
started on a heparin drip. She was also started on coumadin b/c
she is diabetic, has HTN and is btwn 65-75 with atrial
fibrillation. She was cardioverted on [**2169-6-2**] and her beta
blocker was re-started at a low dose. Cardioversion was
initially successful and pt's heparin and coumadin were stopped
b/c her hematocrit dropped slightly and the team was concerned
about a possible bleed. The patient reverted back to atrial
fibrillation two days later, was started on amiodarone 400 mg qd
which is supposed to be continued for one week. She is then
scheduled to start 200 mg qd. She was restarted on heparin and
coumadin (also secondary to a DVT that was discovered on the
same day). Her hematocrit remained stable.
.
*Acute on chronic renal failure: It appears that the patient has
had chronic renal insufficiency since [**8-29**]. Her baseline Cr
was ~ 1.6 prior to admission. A large part of this is likely
due to her diabetes. At admission her creatinine was 2.2. It
began to rise over the next few days to a maximum of 3.5. Her
ARF could have been secondary to hypotension, acute tubular
necrosis (especially since she had eosinophilia)from contrast,
or UTI. Her foley was dc'd and she was found to have a urinary
tract infection with klebsiella pneumonia and was started on
cipro on [**2169-6-2**]. She was hydrated with fluid boluses and this
was followed by administration of lasix to increase her urine
output. Over the next few days urine output increased and her
creatine trended down to 1.9. Her NSAIDS and lisinopril were
held during her stay.
.
* DVT: Patient was found to have DVT in her left common femoral
vein on [**2169-6-4**] after increased swelling was noted in her left
lower extremity (she had 4+ pitting edema bilaterally in her
lower extremities throughout her stay). She was started on a
heparin drip and re-started on her coumadin.
.
*Leukocytosis: Patient's white blood count at admission was 13,
then trended up to 19 during the admission. She was afebrile
throughout the admission but was noted to have a left shift on
her differential. This was thought to be due to her UTI or
secondary to a wound infection from a small decubitus ulcer on
her left buttock or from skin breakdown in her right groin at
her cath site. A chest s-ray did not show any evidence of
pneumonia. She was started on cipro for her UTI and empiric
cefazolin for possible wound infection. Her cefazolin was
changed to keflex on [**6-4**]. She also received 1 g IV vancomycin
on [**6-2**] for her wound infection. Wound care was consulted but
were unable to see her over the weekend.
.
*Left extremity pain: Pt has had pain and numbness in left arm
for several days that began 2 days post cath. The pain was from
her elbow to her hand. Her extremity was warm but radial pulse
seemed diminished and there was slight concern for an embolic
event that could have occurred during the cath. Pain resolved
during the stay and a LUE arterial u/s was done that ruled out
embolus. Was likely due to neuropathy.
.
* Anemia: Patient was noted to have an anemia at admission with
hematocrit of 27.7. She was normocytic, with normal TIBC and
ferritin and iron level of 28. Her retics were low at 1.1.
This anemia was thought to be secondary to CRI. She was not
transfused in hematocrit remained stable.
.
*Nutrition: Patient was on a diabetic diet throughout her
admission.
Medications on Admission:
Meds (outpatient): Lipitor 20, Celexa 20 qhs, Klonopin 0.5 qhs,
Estrogens, Lasix 40-80 qd, Glyburide 5, HCTZ 25, Motrin
(recently d/c), Indocin 50, Lisinopril 10 mg po qd, metformin
8750, metoprolol 50 mg po bid, triamcinolone, tylenol #3,
vicodin prn
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **]
Discharge Diagnosis:
1. Inferior myocardial infarction with stent placement
2. Atrial Fibrillation
3. Deep venous thrombosis
4. Diabetes type 2
5. Acute renal insufficiency on chronic renal insufficiency
6. Urinary Tract infection
Discharge Condition:
Good but requires knee brace for mobility
Discharge Instructions:
Your medications have been changed. Please take your
medications as prescribed. Please follow-up with your primary
care doctor within 1-2 weeks.
Please call your doctor or return to the ER if you have chest
pain, shortness of breath, dizziness or palpitations.
Followup Instructions:
Please keep the following scheduled appointments :
Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1882**], MD Where: [**Hospital6 29**]
Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2169-6-13**] 2:30
Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10486**], MD Where: [**Hospital6 29**]
ORTHOPEDICS Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2169-6-15**] 1:40
|
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icd9cm
|
[
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,656
| 190,930
|
46699
|
Discharge summary
|
report
|
Admission Date: [**2169-5-20**] Discharge Date: [**2169-6-16**]
Date of Birth: [**2104-7-4**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
pedestrian struck by car
Major Surgical or Invasive Procedure:
[**2169-5-20**] Debridement and irrigation of a R open tibia and fibula
fracture; application of an external fixator; application of a
vacuum sponge; debridement of a posterior knee wound and
irrigation of posterior knee wound; application of vacuum sponge
to the R posterior knee wound; debridement and irrigation of an
open L tibia fracture; application of an external fixator L
tibia fracture; debridement of R possible olecranon fracture
with irrigation.
[**2169-5-22**] Inferior vena cava filter placement via the femoral
route
[**2169-5-22**] 1. Irrigation and debridement down to and inclusive of
bone left tibia.
2. Irrigation debridement down to and inclusive of bone right
tibia.
3. Open reduction internal fixation of left proximal tibia and
proximal shaft fracture.
4. Intramedullary nailing right tibia fracture, modifier 22.
5. Removal left lower extremity external fixator
6. Removal right lower extremity external fixator.
7. Wound closure right posterior popliteal area wound.
8. Vac application of right tibia.
9. Vac application left tibia.
[**2169-5-25**] 1. Irrigation and debridement superficial down to and
inclusive of muscle of bilateral lower extremity open tibia
fractures and change of vacuum dressings.
2. Open reduction internal fixation right olecranon fracture.
History of Present Illness:
65 yo M was a pediatrian struck by a vehicle. The pt was found
100 ft from his shoes. The car was significantly damaged. He
was hypotensive in the field, and he was noted to have RLE
angularization. He was found awake with a GCS12 but intubated
for protection, brought to [**Hospital1 18**] where trauma survey including
pan imaging reportedly significant for BLE open tib-fib
fractures with preserved distal pulses, forehead contusion,
isolated posterior max wall fracture, cervical fracture,
multiple rib fractures with pulm contusion, poss
aspiration, small unilateral PTX, and no obvious intra-abdominal
injury.
Past Medical History:
CAD
Diabetes mellitus II
Asthma
COPD
Social History:
Previously independent, married, owns retail store
Family History:
Noncontributory
Physical Exam:
Vital signs stable, afebrile
GEN: NAD, follows simple commands with hands
NECK: Stoma
LUNGS: Bilateral rhonchi
CV: RRR, nl S1 and S2
ABD: Soft, NT, ND
JP x [**Street Address(2) 8582**].
EXT: B/L mutipodous boots, R arm in brace, R LE with 2+ edema
and flap
Pertinent Results:
[**2169-6-13**] 04:32AM BLOOD WBC-6.3 RBC-2.98* Hgb-9.0* Hct-28.9*
MCV-97 MCH-30.1 MCHC-31.0 RDW-16.5* Plt Ct-492*
[**2169-6-9**] 05:23AM BLOOD Neuts-75.1* Bands-0 Lymphs-15.7*
Monos-5.0 Eos-3.9 Baso-0.3
[**2169-6-9**] 06:31AM BLOOD PT-14.9* PTT-26.7 INR(PT)-1.3*
[**2169-6-13**] 08:21PM BLOOD Glucose-338* UreaN-18 Creat-0.8 Na-146*
K-4.4 Cl-117* HCO3-22 AnGap-11
[**2169-6-7**] 04:19AM BLOOD ALT-48* AST-24 AlkPhos-278* Amylase-110*
TotBili-0.8
[**2169-6-13**] 08:21PM BLOOD Calcium-7.2* Phos-2.8 Mg-2.1
Studies at admission:
CT head ([**5-20**]): 1. Small foci of subarachnoid hemorrhage,
without mass effect.
2. Depressed fracture through the posterior wall of the right
maxillary sinus with hemosinus.
3. Incompletely imaged fracture through the left lateral mass of
C2. Please refer to CT of the cervical spine for further
details.
CT abd/pelvis ([**5-20**]): 1. Multiple injuries involving the right
chest including fractures of ribs three through nine, fracture
of the right coracoid process, and contusions with traumatic
pneumatoceles in the right lung as well as a small medial right
pneumothorax. Some degree of aspiration may also be present as
there are secretions within the trachea.
2. Possible small right hepatic contusion, with a tiny amount of
perihepatic fluid. No additional intra-abdominal injury
identified.
3. Additional fractures involving the right inferior and
superior pubic rami.
4. Slit-like IVC, suggesting hypotension.
5. Incompletely characterized 3.1 cm right adrenal lesion. An
MRI can be
obtained on a non-emergent basis for further characterization.
6. Large right thyroid nodule - thyroid ultrasound is
recommended on a non-
emergent basis.
7. Incidentally: 3 cm infrarenal AAA, left renal cyst,
cholelithiasis,
sigmoid diverticulosis.
CT C-spine ([**5-20**]): 1. Left C2 lateral mass fracture extending
into the transverse foramen.
2. Left supraclavicular hematoma, not seen on the CT of the
torso.
3. Partially imaged right maxillary sinus opacification due to
posterior wall fractures seen on head CT.
4. Large right thyroid nodule measuring up to 4.6 cm, for which
thyroid
ultrasound is recommended on a non-emergent basis.
CTA lower extremity ([**5-20**]): 1. Patent vascularity in both lower
extremities without evidence of extravasation.
2. Comminuted fracture of tibia and fibula bilaterally,
extending into the
tibial plateau.
Brief Hospital Course:
Pt was brought to the ED intubated. Orthopedics was consulted
for the open bilateral tib-fib fractures. Orthopedics brought
the pt to the OR for bialteral lower extremity stabilization and
debridement of wounds. Vascular Surgery was consulted
postoperatively for concern over possible vascular injury to B/L
LE. Q1 hour vascular checks were initiated. Neurosurgery was
consulted due to head trauma which included a small SAH, C2
fracture, and a R maxillary sinus posterior wall fracture.
Neurosurgery recommended continuing the C-collar and to withold
anticoagulation. A short chronological description of Mr.
[**Known lastname 99132**] stay follows:
[**5-20**]: To OR. Decreased doppler signal from RLE pulse but
resolved intraoperatively. Received 3 units packed red blood
cells, 2 FFP, 4L crystolloid, 800 estimated blood loss. Blood
from ETT. Hematocrit declined overnight - 2 units PRBC.
[**5-21**]: Patient with left pneumothorax - treated with chest tube,
and required temporary assist control for respiratory acidosis.
Hematocrit dropping, 2 U pRBC transfused.
[**5-22**]: To OR with ortho for ORIF Left tibial (plate) and Right
tibial nail, IVC filter placed, 2 U pRBCs transfused, repeat
washout R elbow. Left CT with no respiratory variation, but no
respiratory status changes.
[**5-23**]: Weaned to cpap/ps; lasix gtt / albumin started. Plan for
OR on [**5-24**] for skin graft/muscle flap LE. Fever 101 - cultured.
HCT 20.6, transfuse 2uPRBC.
[**5-24**]: OR postponed given long procedure which pt. would be
unable to tolerate. CTA of the neck to rule out vertebral artery
dissection. Lasix drip started.
[**5-25**]: s/p OR with ortho for elbow; no further operative ortho
needs. Got 1 unit pRBCs intra-operative. Continued lasix gtt.
Weaning vent. Increased free water GI flushes given rising Na
and Cl.
[**5-26**]: Lasix gtt d'ced; replaced arterial line.
[**5-27**]: Started Vanc/zosyn; Pt. arouses to voice, opens eyes
spontaneously, +gag/+strong productive cough. Pt communicates by
nodding/mouthing words, copious bloody secretions from pulmonary
contusion.
[**5-29**]: Trach/peg, started [**Hospital1 **] lasix, increase vanc to q8,
plastics considered taking to OR [**Hospital 99133**] rehab planning started,
temp spiked-->pan cx
[**5-30**]: Paient persistently febrile, Pancx sent, Bronched today-->
Mild thick secretion, BAL sent, Left Chest D/C, Ct scan shows no
evidence of sinusitis, but C2 vertebrae slightly rotated. Pt.
tested for H1N1 flu, currently placed on Droplet & Contact
Precautions until virus can be ruled out.
[**5-31**]: OR with Plastics for Left lower extremity closure, right
lower extremity VAC change. PRS to change vac q3-4 days, plan
for right lower extremity flap. Vascular consult for right lower
extremity formal angiogram for pre-op planning.
[**5-31**]: I.D. consult for ?Influenza given fever and exposure to RN
with Influenza A. Prelim recs: Doubt flu, but given critical
care pt would recommend tamiflu prophylaxis. Consider CT Torso
(deferred for now per trauma) to eval for fever source.
[**6-1**]: On physical exam at 0400, pt. noted to be less responsive
than usual. labs recently drawn, BG at the time 39, Insulin gtt
off. Immediate recheck FS 103. Pt also with fever spike at the
time to 101.5, blood (peripheral and picc) and urine sent for
cx. RUQ U/S c/w gall bladder sludging; CT Torso pending;
[**6-2**]: Off antibiotics, Off the vent, Tolerating trach, and off
the contact precaution. Pt remained off the ventilator overnight
with respiratory status unchanged. Pt required frequent
suctioning for blood tinge/ rusty secretions. Trach mask weaning
as tolerated.
[**6-3**]: Decreased free water boluses to 250 q8, added Ambien. Temp
spike to 101.4 at [**2160**], blood cx and urine cx sent.
[**6-4**]: Transferred to floor
[**6-5**]: Angio done.
[**6-6**]: RUQ U/S: no evidence of cholecystitis
[**6-7**]: Lateral free flap and split thickness skin graft done by
plastics. Please see operative note. CXR: bibasilar
atelectasis/effusion vs PNA
[**6-8**]: TF advanced.
[**6-9**]: No events.
[**6-10**]: No events.
[**6-11**]: Bolus tube feeds begun.
[**6-12**]: Plastics begins dangling leg checks to test viability of
flap RLE. CT head done to evaluate mental status. TF held due
?aspiration. Vanc and Flagyl d'ced.
[**6-13**]: Erythromycin d'ced. Neurosurgery consulted again and
believes burr holes for increased subdural effusions not
necessary. Tube feeds restarted.
[**6-14**]: Patient hep locked.
[**6-15**]: Staples and sutures discontinued with exception of around
flap. Trach changed to 6 fenestrated noncuffed.
[**6-16**]: Pt d/c'ed to rehab in stable condition
Medications on Admission:
Nitroglycerin, ACE-I, metformin, isosorbide, albuterol,
salmeterol, creon
Discharge Medications:
1. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One
(1) Appl Ophthalmic TID (3 times a day) as needed for dry eye.
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Polyethylene Glycol 3350 100 % Powder Sig: Seventeen (17) g
PO DAILY (Daily) as needed for constipation.
5. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain.
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. Acetaminophen 160 mg/5 mL Solution Sig: 320-640 mg PO Q6H
(every 6 hours) as needed for fever.
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: Two (2) puffs Inhalation Q4H (every 4 hours)
as needed for trach mask.
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) puff
Inhalation Q4H (every 4 hours) as needed for while on trach
mask.
11. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Metoprolol Tartrate 5 mg/5 mL Solution Sig: 5-10 mg
Intravenous Q4H (every 4 hours) as needed for HR > 100, SBP >
160.
13. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback
Sig: 4.5 g Intravenous Q8H (every 8 hours): Continue till [**6-18**].
14. Metoclopramide 5 mg/mL Solution Sig: Fifteen (15) mg
Injection Q6H (every 6 hours).
15. Trach
Pt has been down-sized to a fenestrated trach. He can be
evaluated & decannulated at your facility as appropriate.
16. Insulin
FSBS:
0-70 mg/dL 1 amp D50
71-160 mg/dL 0 Units
161-180 mg/dL 6 Units
181-200 mg/dL 10 Units
201-220 mg/dL 14 Units
221-240 mg/dL 18 Units
241-260 mg/dL 22 Units
261-280 mg/dL 26 Units
281-300 mg/dL 30 Units
301-320 mg/dL 34 Units
17. Lantus 100 unit/mL Cartridge Sig: Thirty Five (35) Units
Subcutaneous at bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary Diagnosis: s/p pedestrian struck by car
-Small foci of subarachnoid hemorrhage
-Right maxillary sinus posterior wall fracture w/hemosinus
-C2 fracture of Left pedicle extending to transverse foramen
-Right pulmonary contusion/traumatic pneumatoceles
-Right #3-9th rib fractures
-Right coracoid process fracture
-Right acromion fracture
-Left supraclavicular hematoma
-Right hepatic contusion, tiny amount of perihepatic fluid
-Right superior/inferior pubic ramus fracture
-Bilateral lower extremity open fracture
Discharge Condition:
Stable.
Discharge Instructions:
Resume all home medications. Seek immediate medical attention
for fever >101.5, chills, increased redness, swelling, bleeding
or discharge from incision, chest pain, shortness of breath,
difficulty breathing, severe headache, increasing neurological
deficit, or anything else that is troubling you. No strenuous
exercise or heavy lifting until follow up appointment, at least.
Do not drive or drink alcohol while taking narcotic pain
medications. Call your surgeon to make follow up appointment.
Followup Instructions:
-Please follow-up with trauma clinic in 2 weeks. Call ([**Telephone/Fax (1) 4336**] to make an appointment.
.
-Please call [**Telephone/Fax (1) **] to make a follow up appointment in 4 weeks
with Dr. [**Last Name (STitle) 548**] from Neurosurgery for your C-Spine fx and head
bleed / subdural fluid collections. You will need a Head CT and
prior to your appointment, please let the secretary know this
when you make the appointment and she will arrage the scan as
well.
.
-Please call ([**Telephone/Fax (1) 9144**] to make an appointment to be seen in
Dr.[**Name (NI) 27488**] Plastic Surgery Clinic in 2 weeks.
Completed by:[**2169-6-16**]
|
[
"864.01",
"999.9",
"802.23",
"707.03",
"823.10",
"493.20",
"801.21",
"861.21",
"482.1",
"807.07",
"276.0",
"707.21",
"518.5",
"807.4",
"811.01",
"414.01",
"997.31",
"482.42",
"813.11",
"860.0",
"E814.7",
"507.0",
"805.02",
"823.32",
"E879.8",
"250.00",
"808.2",
"263.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.04",
"38.93",
"33.23",
"88.48",
"76.75",
"83.82",
"79.36",
"96.6",
"78.67",
"79.62",
"79.66",
"38.91",
"31.1",
"96.72",
"83.45",
"38.7",
"86.72",
"78.13",
"78.17",
"43.11",
"79.32"
] |
icd9pcs
|
[
[
[]
]
] |
11865, 11935
|
5142, 9787
|
338, 1634
|
12500, 12510
|
2737, 5119
|
13054, 13697
|
2427, 2444
|
9911, 11842
|
11956, 11956
|
9813, 9888
|
12534, 13031
|
2459, 2718
|
274, 300
|
1662, 2282
|
11975, 12479
|
2304, 2343
|
2359, 2411
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,955
| 128,642
|
53137
|
Discharge summary
|
report
|
Admission Date: [**2105-3-14**] Discharge Date: [**2105-3-25**]
Date of Birth: [**2058-6-1**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Cold Right Leg
Major Surgical or Invasive Procedure:
[**2105-3-14**]
Right femoral-popliteal thrombectomy, attempted
right iliac thrombectomy, left to right femoral-femoral
bypass with 8-mm PTFE graft and for compartment fasciotomy of
right lower leg.
History of Present Illness:
46 M presented to [**Hospital6 33**] today with worsening
right foot pain x3 days. Pain is sharp, constant and located in
right foot and calf. Today at 1pm pain worsened considerably
and
he decided to go to ER. Pt was given heparin bolus, 7050 units
and on 1050 units/hour.
Past Medical History:
PMH:
1. HTN
2. EtOH abuse
3. Tobacco dependence
4. s/p back surgery, fractured ribs
No history of PVD, stroke or MI
Social History:
SH: Lives at home. Drinks ~6 beers/day. Smokes 1 ppd. No IVDA
Family History:
FH: NC
Physical Exam:
PE
97.6 F 110 143/87 16 94% RA
Gen: pt in pain, intoxicated, difficulty focusing secondary to
pain. Dry mucus membranes, no jaundice
CV: tachy without murmur
Pulm: CTA
Abd: soft, nontender, nondistended, no pulsatile mass, no bruit
LE:
Right (affected): warm. No open wounds or sores.
Decreased motor, decreased sensation at the 1st toe interspace
as
compared to the right. Foot and calf are mildly tender to
palpation and
dorsiflexion. MuFasciotomy site is C/D/I
Left: warm without edema or tenderness. Good cap refill.
Pertinent Results:
[**2105-3-22**] 07:48AM
BLOOD WBC-9.8 RBC-3.58* Hgb-10.6* Hct-32.3* MCV-90 MCH-29.5
MCHC-32.7 RDW-14.0 Plt Ct-252
[**2105-3-25**] 08:45AM
BLOOD PT-15.1* INR(PT)-1.3*
[**2105-3-22**] 07:48AM
BLOOD Glucose-106* UreaN-18 Creat-1.0 Na-138 K-4.4 Cl-102
HCO3-29 AnGap-11
[**2105-3-19**] 09:25AM
BLOOD ALT-130* AST-181* CK(CPK)-2421* AlkPhos-62 TotBili-0.4
[**2105-3-22**] 07:48AM
BLOOD Calcium-8.2* Phos-3.7 Mg-1.9
[**2105-3-15**] 07:15PM
URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010
URINE Blood-LG Nitrite-NEG Protein-75 Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
URINE RBC-0-2 WBC-0-2 Bacteri-FEW Yeast-NONE Epi-0
ECHO:
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Right ventricular chamber size and free wall motion are
normal. The ascending aorta is mildly dilated. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. The
mitral valve leaflets are mildly thickened. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
No cardiac source of embolus identified (cannot definitively
exclude).
HEAD CT:
IMPRESSION:
1. No acute intracranial abnormality.
2. Pansinus disease with mucosal thickening of the paranasal
sinuses and
opacification of the mastoid air cells and fluid within the
middle ear
cavities.
Brief Hospital Course:
pt admitted with cold leg
Emergently taken to the OR for:
PROCEDURE: Right femoral-popliteal thrombectomy, attempted
right iliac thrombectomy, left to right femoral-femoral
bypass with 8-mm PTFE graft and for compartment fasciotomy of
right lower leg.
Vac placed changed every three days
Heparin started post operative, coumadin started
Heparin changed to Lovenox, being bridged with coumadin
INR goal is [**3-4**]
PT / Case management for Rehab.
Pt without insurance placement at [**Last Name (un) 109446**]
F/U ordered
Echo r/o source of thrombus
Medications on Admission:
unknown
Discharge Medications:
1. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q1HPRN () as
needed for per ciwa scale.
2. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
3. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: Titrate for INR goal 2.5-3. Tablet(s)
4. Enoxaparin 100 mg/mL Syringe Sig: One (1) 90 mg Subcutaneous
Q12H (every 12 hours): Please give until INR > 2 on coumadin.
5. Cortisone 1 % Cream Sig: One (1) Appl Topical QID (4 times a
day).
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
7. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours): CIWA protocol
.
11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
12. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
14. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours).
15. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as
needed for wheezing.
16. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
18. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
19. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
20. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
Acute ischemia of the right lower extremity with iliac and
popliteal artery thrombosis.
Hypertension
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Lower Extremity Bypass Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
?????? Elevate your leg above the level of your heart (use [**3-4**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? Unless you were told not to bear any weight on operative foot:
?????? You should get up every day, get dressed and walk
?????? You should gradually increase your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over 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
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 100.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2105-4-2**] 12:40
Completed by:[**2105-3-25**]
|
[
"V45.89",
"401.9",
"305.1",
"592.0",
"444.22",
"305.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"88.01",
"39.29",
"88.48",
"83.09",
"38.08"
] |
icd9pcs
|
[
[
[]
]
] |
5662, 5735
|
3199, 3761
|
328, 529
|
5881, 5881
|
1655, 2960
|
8851, 9038
|
1072, 1081
|
3819, 5639
|
5756, 5860
|
3787, 3796
|
6029, 8418
|
8444, 8828
|
1096, 1636
|
274, 290
|
557, 836
|
2970, 3176
|
5896, 6005
|
858, 975
|
991, 1056
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,528
| 123,777
|
39106
|
Discharge summary
|
report
|
Admission Date: [**2198-5-18**] Discharge Date: [**2198-5-25**]
Date of Birth: [**2133-2-5**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor First Name 5188**]
Chief Complaint:
S/P sigmoid colectomy anastomotic leak, and ileostomy with
sepsis.
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Per Pt discharge summary from OSH: Pt is a 65 F who
underwent lap sigmoid resection on [**5-3**] for recurrent sigmoid
diverticulitis. On [**5-15**] (POD12) pt was readmitted to [**Hospital3 **] Center abd pain, WBC 19. CT revealed pelvic fluid with
air bubbles though to be indicative of anastomosis leak. Pt was
taken back to OR for ex lap on [**5-16**] at which point dense SM
adhesions and socked in pelvis were encountered. After extensive
adhesionolysis, rectosomoid anastomose was inspected and found
to
have a small air leak in lateral aspect. Fluid collection of
pelvis was evacuated. Rectosigmoid anastomose was taken down and
new one was created with EEA stapling device after mobilization
both the splenic and hepatic flexures. Rectosigmoid anastomoses
was noted to be without leak or extravesation under bubble test
with rigid proctosopy. Divering loop ileostomy was placed as was
a 19 [**Doctor Last Name 406**] drain into the pelvis. Pt was sent to ICU and kept on
ventilator overnight.
During line placement she received a small apical pneumothorax
of
left lung, so a 20 french chest tube was placed, resulting in
resolution of pneumothorax. Pt was unable to wean from
ventilator.
Post operatively pt was transfused 2 units of blood in the first
24 hrs, second 2 units next 48 hours. Pt was Put on Zosyn.
Ileostomy was functioning. CXR showed near resolution of
penumothorax. Pt was transferred to [**Hospital1 18**] SICU per pt family
request.
Past Medical History:
PMH: HTN, HLP , Diverticitis, Uterine fibroids.
PSH: Tubal ligation, appendectomy L colon resection 30 yrs ago.
Social History:
No ETOH, + cigarettes,
Physical Exam:
On Admission:
PE:97.8 97.9 64 130/60 13 100% CMV Vt 500 rr 12 Fi02 35% Peep 5
Intubated/ sedated
Card: RRR s1 S2 no murmurs appreciated
Pul: wheeze on left, breath sounds bilateral,
chest tube: wall suction, serosang, no leak, no fluctuation
JP: serosang discharge
Abd: midline incision ostomy+ stool and gas
inc: no erythema, no edema + discharge from incision
ext: non pitting edema bilateral
On discharge:
afebrile vital signs stable
Gen: NAD, AOx3
CVS: reg
Pulm: no respiratory distress
Abd: open surgical wound, clean edges fat exposed, whitish
fibrinous material over fascia, packed moist to dry
Pertinent Results:
[**2198-5-19**] 05:05AM BLOOD freeCa-1.06*
[**2198-5-20**] 03:39AM BLOOD freeCa-1.09*
[**2198-5-19**] 09:42AM BLOOD O2 Sat-98
[**2198-5-20**] 03:39AM BLOOD O2 Sat-98
[**2198-5-18**] 07:48PM BLOOD Lactate-0.9
[**2198-5-19**] 05:05AM BLOOD Lactate-0.9
[**2198-5-19**] 09:42AM BLOOD Lactate-0.7
[**2198-5-20**] 03:39AM BLOOD Lactate-0.8
[**2198-5-18**] 07:48PM BLOOD Type-ART pO2-122* pCO2-37 pH-7.42
calTCO2-25 Base XS-0
[**2198-5-19**] 05:05AM BLOOD Type-ART pO2-122* pCO2-40 pH-7.42
calTCO2-27 Base XS-1
[**2198-5-19**] 09:42AM BLOOD Type-ART pO2-137* pCO2-35 pH-7.40
calTCO2-22 Base XS--1
[**2198-5-19**] 11:27AM BLOOD Type-ART pO2-104 pCO2-36 pH-7.39
calTCO2-23 Base XS--2
[**2198-5-19**] 01:03PM BLOOD Type-ART pO2-95 pCO2-36 pH-7.41
calTCO2-24 Base XS-0
[**2198-5-19**] 04:42PM BLOOD Type-ART pO2-109* pCO2-36 pH-7.42
calTCO2-24 Base XS-0
[**2198-5-20**] 03:39AM BLOOD Type-ART pO2-122* pCO2-38 pH-7.44
calTCO2-27 Base XS-2
[**2198-5-20**] 07:00AM BLOOD Vanco-16.0
[**2198-5-18**] 05:17PM BLOOD Albumin-1.9* Calcium-7.3* Phos-2.6*
Mg-1.8
[**2198-5-19**] 04:47AM BLOOD Calcium-7.2* Phos-2.6* Mg-1.7
[**2198-5-20**] 03:26AM BLOOD Calcium-7.3* Phos-3.1 Mg-1.6
[**2198-5-20**] 06:13PM BLOOD Calcium-7.6* Mg-1.6
[**2198-5-21**] 02:43AM BLOOD Calcium-7.5* Phos-3.2 Mg-2.2
[**2198-5-21**] 04:53PM BLOOD Calcium-7.7* Phos-3.4 Mg-1.5*
[**2198-5-22**] 03:07AM BLOOD Calcium-8.0* Phos-3.7 Mg-2.0
[**2198-5-23**] 02:32AM BLOOD Calcium-7.9* Phos-4.0 Mg-1.7
[**2198-5-24**] 02:19AM BLOOD Calcium-7.8* Phos-3.7 Mg-1.8
[**2198-5-18**] 05:17PM BLOOD ALT-22 AST-35 LD(LDH)-227 AlkPhos-115*
Amylase-89 TotBili-0.5
[**2198-5-21**] 02:43AM BLOOD ALT-14 AST-19 AlkPhos-98 TotBili-0.6
[**2198-5-24**] 02:19AM BLOOD ALT-14 AST-19 AlkPhos-62 TotBili-0.3
[**2198-5-18**] 05:17PM BLOOD Glucose-88 UreaN-13 Creat-0.6 Na-141
K-3.7 Cl-109* HCO3-23 AnGap-13
[**2198-5-19**] 04:47AM BLOOD Glucose-87 UreaN-13 Creat-0.7 Na-140
K-3.5 Cl-108 HCO3-23 AnGap-13
[**2198-5-20**] 03:26AM BLOOD Glucose-91 UreaN-11 Creat-0.6 Na-138
K-3.4 Cl-105 HCO3-24 AnGap-12
[**2198-5-20**] 06:13PM BLOOD K-3.3
[**2198-5-21**] 02:43AM BLOOD Glucose-123* UreaN-7 Creat-0.6 Na-139
K-3.6 Cl-103 HCO3-29 AnGap-11
[**2198-5-21**] 04:53PM BLOOD Glucose-112* UreaN-6 Creat-0.6 Na-139
K-3.8 Cl-101 HCO3-32 AnGap-10
[**2198-5-22**] 03:07AM BLOOD Glucose-98 UreaN-5* Creat-0.6 Na-141
K-3.9 Cl-104 HCO3-32 AnGap-9
[**2198-5-23**] 02:32AM BLOOD Glucose-111* UreaN-5* Creat-0.6 Na-139
K-3.3 Cl-101 HCO3-33* AnGap-8
[**2198-5-24**] 02:19AM BLOOD Glucose-94 UreaN-9 Creat-0.7 Na-141 K-3.5
Cl-102 HCO3-33* AnGap-10
[**2198-5-19**] 04:47AM BLOOD
[**2198-5-20**] 03:26AM BLOOD
[**2198-5-21**] 02:43AM BLOOD
[**2198-5-22**] 03:07AM BLOOD
[**2198-5-23**] 02:32AM BLOOD
[**2198-5-18**] 05:17PM BLOOD PT-18.6* PTT-32.6 INR(PT)-1.7*
[**2198-5-18**] 05:17PM BLOOD Plt Ct-482*
[**2198-5-19**] 04:47AM BLOOD Plt Ct-500*
[**2198-5-20**] 03:26AM BLOOD Plt Ct-486*
[**2198-5-21**] 02:43AM BLOOD PT-25.3* PTT-36.7* INR(PT)-2.4*
[**2198-5-21**] 02:43AM BLOOD Plt Ct-483*
[**2198-5-22**] 03:07AM BLOOD PT-25.8* PTT-33.7 INR(PT)-2.5*
[**2198-5-22**] 03:07AM BLOOD Plt Ct-453*
[**2198-5-23**] 02:32AM BLOOD PT-24.8* INR(PT)-2.4*
[**2198-5-23**] 02:32AM BLOOD Plt Ct-392
[**2198-5-18**] 05:17PM BLOOD Neuts-89.5* Lymphs-7.3* Monos-2.0 Eos-1.0
Baso-0.2
[**2198-5-18**] 05:17PM BLOOD WBC-19.5* RBC-3.08* Hgb-9.5* Hct-27.0*
MCV-88 MCH-30.9 MCHC-35.3* RDW-15.6* Plt Ct-482*
[**2198-5-19**] 04:47AM BLOOD WBC-15.7* RBC-3.04* Hgb-9.4* Hct-26.6*
MCV-88 MCH-30.8 MCHC-35.2* RDW-15.6* Plt Ct-500*
[**2198-5-20**] 03:26AM BLOOD WBC-13.2* RBC-3.09* Hgb-9.3* Hct-26.8*
MCV-87 MCH-30.1 MCHC-34.7 RDW-14.9 Plt Ct-486*
[**2198-5-21**] 02:43AM BLOOD WBC-12.3* RBC-3.18* Hgb-9.5* Hct-27.5*
MCV-86 MCH-29.9 MCHC-34.6 RDW-14.6 Plt Ct-483*
[**2198-5-22**] 03:07AM BLOOD WBC-13.2* RBC-3.22* Hgb-9.7* Hct-28.1*
MCV-87 MCH-30.1 MCHC-34.5 RDW-15.1 Plt Ct-453*
[**2198-5-23**] 02:32AM BLOOD WBC-9.5 RBC-3.07* Hgb-9.3* Hct-26.9*
MCV-87 MCH-30.1 MCHC-34.5 RDW-15.0 Plt Ct-392
[**2198-5-18**] 05:17PM URINE RBC-0-2 WBC-0-2 Bacteri-NONE Yeast-NONE
Epi-0-2
[**2198-5-18**] 05:17PM URINE Blood-SM Nitrite-NEG Protein-25
Glucose-NEG Ketone-15 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2198-5-18**] 05:17PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.027
Brief Hospital Course:
Patient admitted POD15 Sigmoid colectomy [**2-27**] diverticulitis, c/b
anastomotic leak. POD3 Exp-lap /ileostomy, and iatrogenic L
pneumothorax 2/2 L IJ CVC placement. She was admitted from OSH
to [**Hospital1 18**] SICU she was intubated, with a chest tube and required
1 pressor. She was on antibiotics. Her pressor was weaned off.
Her vent was weaned and she was extubated on [**5-20**] and her chest
tube was removed [**5-21**] as her PTX had resolved. She remained
afebrile and her ostomy output was good. Her diet was advanced
to regular which she tolerated well. On [**5-24**] she was
transferred to the floor. By time of discharge her pain was
controlled on PO pain meds, she was tolerating regular diet and
her wound dressings were being changed TID. She was evaluated
by physical therapy and she will be discharge to rehab.
Neurologic: Initially on Fentanyl and versed, intubated. The
vent was weaned and she was extubated. She was clear and
coherent by time of discharge and pain was controlled with PO
meds.
Cardiovascular: hemodynamics stable. MAP originally maintained
>65 with Levophed. TEE performed that showed cardiomyopathy,
[**Doctor Last Name 1754**]/ volume full requiring one pressor to keep MAPs up.
Pressors were weaned off and by time of discharge patient was
stable cardio vascularly with no active issues.
Pulmonary: On admission patient was on vent settings CMV: TV
500 cc RR: 12 PEEP: 5 cm/h2o FIO2: 35 %. Maintain SaO2: > 93 %.
On [**5-20**] the patient was extubated. Chest tube d/c'ed on [**5-21**]
as her PTX was resolved on CXR and by the time of discharge she
had minimal oxygen requirement with Sa02 saturation above 95%.
Gastrointestinal / Abdomen:Nutrition: Patient was originally
NPO, PPI, NGT to LCWS. TF with high residuals at OSH. TFs held
on [**5-17**]. open abd incision. wound dressing changes TID. She
did require further debridement of her wound and all the staples
were removed. ostomy intact with adequate stool output. By the
time of discharge she was tolerating regular diet.
Renal: Adequate UO, creatinine stable
Hematology: no issues
Endocrine: no issues
ID: afebrile WBC 19 on admission trended down to 9.5 wound cx >E
coli,has been on Zosyn and Vanco added for superficial wound
infection. On [**5-23**] antibiotics and reglan d/c'ed on. Urine
culture from [**5-18**]: no growth. Blood culture [**5-19**]: no growth to
date. Wound culture [**5-19**]: [**Female First Name (un) **] albicans
Medications on Admission:
see HPI
Discharge Medications:
1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
sepsis
At outside hospital: status post sigmoid colectomy complicated
by anastamotic leak stat post exploratory laparotomy with
ileostomoy [**5-15**] and iatrogenic left pneumothorax secondary left
IJ placement at outside hospital
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:
Please call if fever >101. Call if signs of wound infection
including increased redness and foul smelling discharge. Call
if chest pain or difficulty breathing. Call with any questions
or concerns.
Wound care: moist to dry dressing changes three times daily.
Keep wound clean.
Followup Instructions:
Please [**Month/Year (2) **] folllow up with your surgeon who performed the
procedure.
Also may call Dr. [**Last Name (STitle) 5182**] ([**Telephone/Fax (1) 15350**] to [**Telephone/Fax (1) **] follow
up in [**1-27**] weeks.
Please call your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] follow up
appointment in the next 2-4 weeks.
[**Name6 (MD) **] [**Last Name (NamePattern4) **] MD, [**MD Number(3) 5190**]
|
[
"305.1",
"112.3",
"562.10",
"V55.2",
"682.2",
"998.59",
"512.1",
"425.4",
"414.01",
"041.4",
"E878.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
9740, 9787
|
6975, 9458
|
382, 388
|
10063, 10063
|
2697, 6952
|
10549, 11021
|
9516, 9717
|
9808, 10042
|
9484, 9493
|
10246, 10446
|
2074, 2074
|
2484, 2678
|
275, 344
|
10458, 10526
|
416, 1881
|
2088, 2470
|
10078, 10222
|
1903, 2018
|
2034, 2059
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,935
| 164,950
|
48393
|
Discharge summary
|
report
|
Admission Date: [**2121-9-12**] Discharge Date: [**2121-10-12**]
Date of Birth: [**2046-4-15**] Sex: M
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 3918**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
PEG tube placement
Spinal Tap
Intubation
History of Present Illness:
HPI: 75 yo man with multiple myeloma in who presents from rehab
with altered mental status over past 7 days. History taken from
daughter who sees him daily at rehab. She states he is alert and
oriented at baseline but over the past 5-7 days has had poor
oral intake and has been less verbal than usual. She states he
usually knows his name and recognizes her but she admits he is
sometimes 'confused' and this is not a new process. He had
denied any cough, pain, dysuria, diarrhea, chest pain, dyspnea
and the rehab facility did not report any of these symptoms as
well.
.
In the ER urinalysis with many WBC's and bacteria, CXR clear on
my read, CT head with no acute process. Patient was given
vancomycin and zosyn in the ER. Vitals stable in ER, T 98 but
rose to 100.8 later on. Received 2.5 liters saline. Foley
catheter placed in ER.
Past Medical History:
1. Multiple myeloma: Diagnosed 12/[**2119**]. Initial presentation
sinus congestion --> found to have rapidly growing mass in left
paranasal sinus --> ENT endoscopic biopsy [**10/2120**] -->
plasmocytoma --> BMBx [**11/2120**] --> myeloma. No lytic lesions on
skeletal survey. Chemotherapy with Velcade and dexamethasone
started [**2120-12-24**].
2. Type 2 DM: Last A1c 8.0% 12/[**2119**]. In setting of starting
steroids, recent FS in the 300-400s. Has been on metformin and
glyburide.
3. Hypertension
4. Hypercholesterolemia: On Atorvastatin. Last cholesterol 147
[**5-/2120**]
5. Essential tremor
6. Hypothyroidism: History of Grave's disease. Was rx'd with
radioactive iodine.
7. Hyperparathyroidism: Borderline hypercalcemia. Increased
parathyroid uptake c/w adenoma seen on parathyroid scan in
3/[**2116**].
8. Lactose intolerance per OMR
Social History:
Originally from [**Country 15800**] and lives in rehab. He is a retired stock
trader. He has an occasional beer. He smoked when he was young.
He has 4 children.
Family History:
Non-contributory.
Physical Exam:
PE: 98.9, 131/72, 77, 20, 99% 3L, fsg 220
Gen- nad, aox1 (knew name), nad, arousable and follows commands
but sluggish
heent- jvp flat, dry MM
heart- rrr, no m/r/g
lungs- ctab
abdomen- soft, nt/nd, bs+, no hsm
ext- no edema
neuro- moves all 4 ext freely, unable to cooperate with full
exam, reflexes 2+ upper and lower ext, no clonus, perla, cn 2-12
intact
Pertinent Results:
[**2121-9-12**] 03:30PM GLUCOSE-251* UREA N-28* CREAT-1.9*
SODIUM-149* POTASSIUM-4.4 CHLORIDE-111* TOTAL CO2-24 ANION
GAP-18
[**2121-9-12**] 03:30PM CALCIUM-10.0 PHOSPHATE-3.5 MAGNESIUM-2.2
[**2121-9-12**] 03:30PM WBC-6.8 RBC-3.60* HGB-10.4* HCT-32.7* MCV-91
MCH-28.9 MCHC-31.8 RDW-16.7*
[**2121-9-12**] 03:30PM NEUTS-57 BANDS-21* LYMPHS-6* MONOS-9 EOS-1
BASOS-0 ATYPS-4* METAS-2* MYELOS-0 NUC RBCS-2*
[**2121-9-12**] 03:30PM PT-13.4 PTT-33.1 INR(PT)-1.1
.
Micro:
[**2121-9-19**] Cdiff positive
[**2121-9-12**] Blood culture: no growth - final
[**2121-9-16**], [**2121-9-18**], [**2121-9-20**] Blood culture- no growth final
[**2121-9-18**] Urine culture no growth
.
Studies:
-[**2121-9-18**] CT chest/abd/pevlis: 1. Bilateral moderate-sized
pleural effusions, with bibasilar airspace opacifications,
likely atelectasis; however, superinfection or aspiration cannot
be excluded.
2. Cardiomegaly. 3. Bilateral hypodensities in the kidneys, not
characterized on the current scan. These could be further
evaluated with ultrasound. Nonspecific fat stranding around the
kidneys, correlate with urinary analysis. 4. Anasarca. 5.
Suggestion of wall thickening at the rectum and sigmoid, with no
significant fat stranding, this finding could suggest colitis in
the appropriate clinical setting. Correlate with clinical
symptoms. 6. Compression fracture of vertebral body of T8 of
indeterminate age, correlate with point tenderness. Loss of
height of vertebral body of L5 of indeterminate age. 7.
Bilateral inguinal hernia, with fluid on the right.
-[**2121-9-16**] EEG: These findings suggest a moderate to severe
encephalopathy.
Medications, metabolic disturbances, and infection are among the
most
common causes. There were no epileptiform features or
electrographic
seizures. This telemetry captured no pushbutton activations.
-[**2121-9-16**] Renal US: IMPRESSION: 1. No hydronephrosis of left or
right kidney. 2. A few small cysts are seen in both kidneys. 3.
A small amount of free fluid is seen in the upper abdomen. 4.
Bilateral pleural effusions,
-[**2121-9-18**] MRI head: 1. No findings to explain patient's symptoms.
Chronic small vessel ischemic changes and cerebral atrophy.
2. No evidence of acute infarct. 3. Left cerebellopontine angle
isointense lesion measuring less than 1 cm, may represent
extension of the left cerebellar flocculus or soft tissue
lesion. Dedicated skull base pre-and post-contrast MR imaging is
recommended on a nonurgent basis for further evaluation. This
lesion is stable when compared to [**2119**].
[**2121-9-16**] Echo: The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Left ventricular systolic function is
hyperdynamic (EF 70-80%). There is no ventricular septal defect.
Right ventricular chamber size and free wall motion are normal.
There are three aortic valve leaflets. The aortic valve leaflets
are moderately thickened. There is a minimally increased
gradient consistent with minimal aortic valve stenosis. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Trivial
mitral regurgitation is seen. The left ventricular inflow
pattern suggests impaired relaxation. There is moderate
pulmonary artery systolic hypertension. There is a small
posterior pericardial effusion. There are no echocardiographic
signs of tamponade.
.
[**10-8**]:
IMPRESSION:
1. Large bilateral pleural effusions, worse than before with
associated
compressive atelectasis, diffuse soft tissue anasarca, and trace
perihepatic
free fluid, may reflect third spacing.
2. Multiple bilateral renal cysts, largest in the superior pole
of the right
kidney, incompletely characterized in the non-contrast setting.
3. T11 and T8 compression fractures may relate to underlying
multiple
myeloma, unchanged since the recent prior.
Brief Hospital Course:
This was a 75-year-old gentleman with a past medical history of
multiple myeloma, diabetes mellitus, hypertension, and
hypothyroidism who presented with altered mental status and
subsequently developed A. fib w/ RVR, ARF, thrombocytopenia,
anemia, C.diff, and MRSA in his sputum. He passed away on [**10-12**]
due to complications from these multiple medical conditions.
.
#CHANGE IN MENTAL STATUS: Unclear etiology for altered mental
status but possibilities include infection or neurologic
catastrophe such as hypoxic brain injury or multiple old
strokes. MRI, LP, and EEG were all negative for causative
pathology. Neurology was consulted and had no additional
work-up or treatment to recommend. The patient was started on
carbidopa/levidopa for ridigity and presumed Parkinson's.
Patient was kept comfortable and an effort was made to verbally
orient him at the bedside. He was able to respond to his name
(by moving his eyes) but remained non-verbal toward the end of
hospital admission.
.
#ATRIAL FIBRILLATION WITH RVR: The patient developed A. fib with
RVR and was transferred to the [**Hospital Unit Name 153**] for initation of rate
control. He was started on metoprolol, which was later changed
to diltiazem. He acheived good rate control on diltiazem.
.
#PEA ARREST: Patient went into cardiac (PEA) arrest on [**9-20**] and
was resuscitated at the bedside. He was intubated and
transferred to the ICU. He was stabilized and extubated without
complication. Diltiazem was restarted. Cardiac enzymes were
negative and echo showed mildly enlarged left atrium with
hyperdynamic LV function.
.
#ACUTE RENAL FAILURE: FeNa was 4.1%. Likely secondary to ATN
from hypervolemia or worsening multiple myeloma. His renal
function improved with multiple myeloma treatment. The patient
has a baseline Cr 0.9-1.1. Renal was following the patient
during this admission and had no further recommendations. The
patient's worst Cr was 2.7 and improved to 1.5. Bactrim was
discontinued to account for false elevation of creatinine.
.
#ELECTROLYTE ABNORMALITIES: Patient's electrolyes were closely
monitored throughout admission and repleted as necessary.
#ANEMIA/THROMBOCYTOPENIA: Thought to be due to multiple myeloma
and other chronic disease states. Mr. [**Known lastname **] [**Known lastname **] was given PRBCs
to maintain a Hct above 21. HIT antibodies were negative.
.
#MULTIPLE MYELOMA: The patient was treated with 3 cycles of high
dose Dexamethasone. His Creatinine, thrombocytopenia, anemia,
and other markers of multiple myeloma all improved after
treatment.
.
#DIABETES: The patient was treated with insulin sliding scale
and glargine. His blood sugars were difficult to control while
he was on dexamethasone. Nutrition was following for appropriate
tube feed recommendations.
.
#INFECTION: The patient developed MRSA in his sputum. He was
treated with 8 days of IV vancomycin. He also developed C. diff
after being treated for a UTI. He was treated with 14 days of IV
flagyl and po vancomycin. His diarrhea was rechecked [**2121-10-6**]
and it was negative for C.diff. On [**10-8**] a CT of his torso
demonstrated evidence of pneumonia. As per ID recommendations,
Mr. [**Known lastname **] [**Known lastname **] was started on a 7 day course of cefepime and
vancomycin.
.
#HYPOTHYROIDISM: Levothyroxine.
.
#NUTRITION: PEG with tube feeds. Nutrition service followed
patient closely.
.
#SECRETIONS: Toward the end of his life, Mr. [**Known lastname **] [**Known lastname **] had
difficulty clearing his secretions; most likely due to weak
musculature, poor cough effort, and central nervous system
issues. Respiratory therapy was called to help with suctioning.
.
#GOALS OF CARE: Multiple discussions were held with patient's
family and his healthcare team. His family was informed of his
dire prognosis, and the decision was made to make patient
DNR/DNI and not to pursue further cancer treatment. Patient's
family and healthcare team were intent on providing supportive
care and making the patient comfortable.
Medications on Admission:
Novolog sliding scale
milk of magnesia prn
tylenol prn
compazine prn
flexeril prn
oxycodone 10mg po q4h prn
flomax qhs
primidone 50mg po qhs
remeron 15mg po qhs
dulcolax prn
mylanta prn
protonix 40mg po daily
norvasc 10mg po daily
mvi daily
moexipril 30mg po bid
colace 100mg [**Hospital1 **]
oxycontin 10mg po bid
valtrex 500mg po qhs
levothyroxine 112mcg daily
propranolol er 240mg po daily
miralax daily
epogen 40,000 untis sq weekly
natural tears
Discharge Medications:
Patient expired.
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary: Delerium, UTI
Secondary: Multiple myeloma, demenia
Discharge Condition:
Patient expired.
Discharge Instructions:
Patient expired.
Followup Instructions:
Patient expired.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 3922**]
|
[
"250.00",
"293.0",
"482.42",
"427.5",
"427.31",
"227.1",
"427.2",
"V87.41",
"599.0",
"244.1",
"333.1",
"285.9",
"276.9",
"V15.3",
"272.0",
"008.45",
"276.2",
"401.9",
"518.81",
"276.0",
"287.5",
"584.9",
"271.3",
"203.00",
"252.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"99.25",
"96.6",
"41.31",
"43.11",
"38.93",
"03.31",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
11185, 11194
|
6597, 6982
|
291, 333
|
11298, 11316
|
2675, 6574
|
11381, 11492
|
2264, 2283
|
11144, 11162
|
11215, 11277
|
10669, 11121
|
11340, 11358
|
2298, 2656
|
230, 253
|
361, 1200
|
6998, 10643
|
1222, 2068
|
2084, 2248
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,941
| 157,200
|
3694
|
Discharge summary
|
report
|
Admission Date: [**2190-9-3**] Discharge Date: [**2190-9-9**]
Date of Birth: [**2136-12-24**] Sex: F
Service: MEDICINE
Allergies:
Vancomycin / Iodine; Iodine Containing / Tape / Ibuprofen /
Levofloxacin
Attending:[**First Name3 (LF) 13541**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
53yo F with diabetes type 1 c/b neuropathy w/chronic foley in
place, morbid obesity, wheelchair-bound, hypertension, coronary
artery disease s/p CABG, diastolic CHF, and sarcoidosis
complicated by chronic tracheostomy on 2.5 L/[**First Name3 (LF) **] trach collar at
home who p/w shortness of breath. She reports awaking this
morning and 30 [**First Name3 (LF) **] after waking noting relatively acute onset of
dypsnea. She has had this feeling many times before. This
occured as she was taking her morning medications. Denies
associated chest pain or palpitations. Denies any cough or
sputum production. Denies any fevers/chills or night sweats.
Also c/o nausea and vomiting which is chronic for her. Denies
hematemesis, diarrhea/constipation. Denies headache, visual
changes, dysuria/frequency. Reports compliance with her daily
medications. Denies any sick contacts.
On arrival to ED, vitals: T 98.4,HR 107, BP 212/98, RR 30 86%RA;
improved to 95% with trach mask. CXR showed bilateral pleural
effusions and retrocardiac opacity. EKG with no ischemic
changes. BNP 1511. Pt given 1 sublingual nitro with improvement
in her breathing and subsequently started on nitro gtt with
improved control of BP. Her nausea was treated with zofran,
compazine.
She was also found to have UTI & treated with a dose of zosyn
and clindamycin (b/c allergic to vanc & levo) (pseudomonal
coverage; ? pna). Blood cultures not sent prior to first dose of
antibiotics but sent prior to arrival to MICU, urine cultures
sent. Pt also given 80mg IV Lasix x1.
Prior to arrival to MICU, vitals were: HR 80, satting 98% (on
trach mask), RR 20 BP 153/86 on nitro gtt (12ml/hr).
Currently pt feels marked improvement in her breathing.
ROS: Denies chest pain, palpitations, + productive cough, denies
fevers/chills or night sweats. Denies dysuria/frequency.
Past Medical History:
1. DM type 1 since age 16 diagnosis (c/b neuropathy,
gastroparesis, nephropathy, retinopathy)
2. Sarcodosis ([**2175**])
3. Tracheostomy - [**3-13**] upper airway obstruction, sarcoid.
4. Arthritis - wheel chair bound
5. Neurogenic bladder
6. Sleep apnea
7. Asthma
8. Hypertension
9. Cardiomyopathy - diastolic dysfunction
10. Pulmonary hypertension
11. Hyperlipidemia
12. CAD s/p CABG [**2179**](SVG to OM1 and OM2, and LIMA to LAD)
last c. cath [**2187-2-28**]: widely patent vein grafts to the OM1 and
OM2, widely patent LIMA to LAD(distal 40% anastomosis lesion).
13. VRE, MRSA - unknown sources
14. s/p cholecystectomy
[**97**]. s/p appendectomy
16. Chronic low back pain-disc disease
17. Morbid obesity
18. Persistent left breast cellulitis
Social History:
Lives alone, has monogamous partner lives 15 [**Name2 (NI) **] away, denies
ethanol, tobacco use.
Family History:
No hx of CAD, diabetes in cousin and uncle
Father had MI in his 60s
Physical Exam:
Physical Exam on admission:
VITALS: T 98.4 , BP 170/80, P 80 R 22, 96 on 60% trach mask
GENERAL: speaks in complete sentences, no accessory muscle use.
HEENT: OP clear, EOMI, PERRL
NECK: Difficult to appreciate JVD. Chronic trach on TM.
CARD: tachycardic, RRR, normal S1/S2, no m/r/g
RESP: Distant BS bilaterally, no RRW, decreased BS at bases BL,
but no evidence of focal consolidation.
ABD: Obese, Soft/non-distended + bowel sounds. Nontender to
palpation. No rebound, rigidity, guarding.
NEURO: A&O x 3, CN II-XII intact
Pertinent Results:
EKG: NSR @ 99, LAD, No ST/T changes
Admission:
WBC: 11.3
N:87.3 L:9.1 M:2.6 E:0.8 Bas:0.1
Hct: 36 Plts 220
Labs:
132 /93 / 33 /156 AGap= 11
------------
4.4 / 28 / 1.0
Trop-T: <0.01
CK: 43
proBNP: 1511
Discharge:
[**2190-9-9**]
WBC 10.6 Hgb 11.3 Hct 32.9 Plt Ct 253
Glucose-205 UreaN-34 Creat-1.2 Na-131 K-3.7 Cl-91 HCO3-32
Micro:
URINE CULTURE (Final [**2190-9-6**]):
YEAST. ~6OOO/ML.
GRAM NEGATIVE ROD(S). ~1000/ML.
Imaging studies:
CXR: [**2190-9-6**]
The tracheostomy is at the midline in unchanged position. The
cardiomediastinal silhouette is enlarged but unchanged. There is
overall
improved aeration of the right base with resolution of
atelectasis but the left retrocardiac atelectasis is grossly
unchanged. There is no appreciable pleural effusion or
pneumothorax.
[**11-16**] ECHO:
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Overall left ventricular systolic function is
probably normal (LVEF>55%).
CT HEAD W/O CONTRAST
IMPRESSION: No evidence of acute intracranial abnormalities. No
change
compared to [**2189-9-4**].
Brief Hospital Course:
53 yo F with DM1, morbid obesity, CAD, diastolic CHF, and
sarcoidosis w/chronic tracheostomy who p/w SOB [**3-13**] HTN induced
flash pulm edema.
# Respiratory Distress: On arrival to ED the patient was 86%RA
and improved to 95% with trach mask. A CXR showed bilateral
pleural effusions and retrocardiac opacity and her BNP was 1511.
The pt was given 1 sublingual nitro with improvement in her
breathing and subsequently started on nitro gtt with improved
control of BP. The pt was also given 80mg IV Lasix in the ED.
The patient's respiratory distress was treated with diuresis
with an additional dose of IV lasix (20mg). The patient was
negative 8L during her stay in the MICU with improving
respiratory status. Upon transfer to the floor she was on
Hi-Flow, 15L at 40% FiO2 decreased from 60%FiO2. She continued
to auto-diurese and was an additional 2-3L negative. She was
placed back on her home dose of po lasix (40mg [**Hospital1 **]). Her
respiratory status returned back to baseline and the patient
reported that she was feeling much improved. The patients
respiratory distress was most likey mulitfactorial in origin
although most likely [**3-13**] pulmonary edema in setting of HTN.
Other contributing factors contributing include her chronic
sarcoid, interstitial disease and asthma. BNP elevated on
admission although not markedly so compared to previous CHF
exacerbations. The patient's CXR did show retrocardiac opacity
but has remained afebrile, minimal elevation WBC and no
antibiotics were given.
# ID/UTI: Pt has chronic indwelling foley. On admission the
patient had a +UA, but the patient was asymptomatic. She
received 1 dose of zosyn in ED and her foley was changed.
Antibiotics were held because there was no clinical evidence of
infection.
# DM1: The patient was continued on her home dosing of lantus
(62U), with regular sliding scale. Her glucose was elevated
ranging from 200-350. Her lantus dose was progressively
increased to 68U and came under control. She was dicharged back
on her home dose of lantus, at the patient's request, with close
follow-up with [**Last Name (un) **].
# Hypertension: In the ED the patient had elevated BP and given
sublingual nitro and started on a nitro gtt. Her BP came under
control and she was started back on her home BP regimen of BB
and Losartan. The patient's BP remained under control.
# Coronary artery disease: Was stable during admission. Pt
continued on home ASA 325, beta blocker, statin, and [**Last Name (un) **].
# HA, The patient complained of headache and a CT-head was
performed that showed no evidence of acute pathology. The
patient's HA resolved without treatment.
Medications on Admission:
Insulin 64 units glargine QHS
Insulin sliding scale
Benztropine 1 mg PO TID
Citalopram 20 mg PO DAILY
Losartan 25 mg PO DAILY
Furosemide 40 mg PO BID
Lorazepam 2 mg Tablet PO at bedtime as needed for insomnia.
Metoclopramide 10 mg PO BID
Metoclopramide 10 mg PO QIDACHS
Metoprolol Tartrate 50 mg PO BID
Simvastatin 20 mg PO once a day.
Hydrocodone-Acetaminophen 5-500 mg 1-2 Tablets PO three times a
day as needed for pain.
Aspirin 325 mg PO DAILY
Multivitamin PO once a day.
Slow-Mag 64 mg Tablet Sustained Release Sig: Three (3)
Tablet Sustained Release PO twice a day.
Docusate Sodium 100 mg PO BID
Salmeterol 50 mcg/Dose Disk with Device Inhalation Q12H
Fluticasone 110 mcg/Actuation Two Puff Inhalation [**Hospital1 **]
Gabapentin 300 mg PO TID
Omeprazole 20 mg PO twice a day.
Psyllium Packet PO TID
Compazine 1mg q6hrs prn
.
Discharge Medications:
1. Insulin Glargine 100 unit/mL Solution Sig: One (1) 62
Subcutaneous at bedtime.
2. Benztropine 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Tablet(s)
4. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Lorazepam 2 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
7. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO twice a
day.
8. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS.
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets
PO three times a day as needed for pain.
12. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Slow-Mag 64 mg Tablet Sustained Release Sig: Three (3)
Tablet Sustained Release PO twice a day.
15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
16. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) Disk
with Device Inhalation Q12H (every 12 hours).
17. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
18. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
19. Omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
20. Psyllium Packet Sig: One (1) Packet PO TID (3 times a
day).
21. Compazine 5 mg Tablet Sig: One (1) mg PO every six (6) hours
as needed for nausea.
22. Humalog 100 unit/mL Solution Subcutaneous
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary:
Hypoxic respiratory failure
Acute on chronic diastolic heart failure
Secondary:
Long standing diabetes mellitus type 1, uncontrolled, with
complications
Pulmonary sarcoidosis
Status post tracheostomy
Neurogenic bladder
Coronary artery disease
Discharge Condition:
Stable, normotensive, O2 saturation high 90's on 35% FiO2 trach
mask, wheel-chair bound, chronic foley inplace, AAOx3
Discharge Instructions:
It was a pleasure taking care of you while you were in the
hospital. You were admitted because you had shortness of
breath. It was thought that the reason for your respiratory
problem was due to increased fluid in your lungs. You were
given lasix to help urinate extra fluid out and your respiratory
status improved and returned to baseline. You also had a ECHO
of your heart and it was found to have normal function and no
significant change from previous studies. Additionally, you had
a CT scan of the head that was also normal.
Please follow up with the appointments below.
Please take the medications prescribed below.
Please contact your PCP or go to the [**Name (NI) **] if you experience
worsening shortness of breath, chest pain, coughing blood, fever
(>101.5), chills, nausea, vomiting, or other concerning
symptoms.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 161**] [**Name11 (NameIs) 162**] [**Name8 (MD) 163**], MD Phone:[**Telephone/Fax (1) 921**]
Date/Time:[**2190-9-13**] 2:30
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2190-9-20**]
12:10
Provider: [**First Name11 (Name Pattern1) 5445**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5446**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2190-10-4**] 2:50
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 13546**]
Completed by:[**2190-9-12**]
|
[
"250.51",
"401.9",
"428.0",
"357.2",
"416.8",
"596.54",
"786.3",
"716.90",
"250.41",
"272.4",
"493.90",
"278.01",
"428.33",
"414.00",
"346.90",
"V12.51",
"583.81",
"517.8",
"599.0",
"135",
"V45.81",
"327.23",
"536.3",
"425.4",
"362.01",
"250.61",
"V44.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10218, 10275
|
4913, 7572
|
337, 344
|
10571, 10691
|
3739, 4180
|
11573, 12199
|
3108, 3178
|
8455, 10195
|
10296, 10550
|
7598, 8432
|
10715, 11550
|
3193, 3207
|
294, 299
|
372, 2206
|
3221, 3720
|
2228, 2976
|
2992, 3092
|
4197, 4890
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,865
| 120,776
|
9938
|
Discharge summary
|
report
|
Admission Date: [**2145-5-3**] Discharge Date: [**2145-5-8**]
Date of Birth: [**2096-7-17**] Sex: F
Service: PLASTIC
Allergies:
Morphine / Gadolinium-Containing Agents / Vancomycin
Attending:[**First Name3 (LF) 28638**]
Chief Complaint:
Aquired absence right breast
Major Surgical or Invasive Procedure:
R free TRAM
Pertinent Results:
[**2145-5-4**] 04:45AM BLOOD WBC-13.2* RBC-3.47*# Hgb-9.7*# Hct-29.1*#
MCV-84 MCH-28.0 MCHC-33.5 RDW-13.9 Plt Ct-198
[**2145-5-4**] 04:45AM BLOOD Glucose-132* UreaN-12 Creat-0.9 Na-140
K-4.3 Cl-106 HCO3-28 AnGap-10
[**2145-5-4**] 04:45AM BLOOD Calcium-8.2* Phos-3.0 Mg-1.8
Brief Hospital Course:
The patient was admitted to the plastic surgery service on
[**2145-5-3**] and underwent R free TRAM. The patient tolerated the
procedure well. Throughout her hospital stay her flap appeared
viable with good vioptics and + doepplers. Her JP drains had
serosanginous drainage and her left lower abdomen JP was removed
on [**2145-5-7**]. She was discharged with her other JP drains in place
with VNA for drain care.
Neuro: Post-operatively, the patient received Dilaudid IV/PCA
with good effect and adequate pain control. When tolerating oral
intake, the patient was transitioned to oral pain medications.
CV/pulm: The patient was stable from a cardiovascular
standpoint; vital signs were routinely monitored.
GI/GU: Post-operatively, the patient was given IV fluids until
tolerating oral intake. Her diet was advanced when appropriate,
which was tolerated well. She was also started on a bowel
regimen to encourage bowel movement. Foley was removed on POD#1.
Intake and output were closely monitored.
ID: Post-operatively, the patient was started on IV cefazolin,
then switched to PO duricef prior to discharge. The patient's
temperature was closely watched for signs of infection.
At the time of discharge on POD#5, the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating, voiding without assistance, and pain was well
controlled.
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: 1.5 Tablet, Chewables PO
DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Take while taking dilaudid to prevent
constipation. .
Disp:*60 Capsule(s)* Refills:*2*
3. Duricef 500 mg Capsule Sig: One (1) Capsule PO twice a day
for 7 days.
Disp:*14 Capsule(s)* Refills:*0*
4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain: Do not drive while taking this
medication.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA of Eastern MA
Discharge Diagnosis:
Acquired deformity R breast
Discharge Condition:
Good.
Discharge Instructions:
No strenous activity. No pressure to your chest.
You were given a prescription for antibiotics. Please take as
directed until your drains are removed or as directed by Dr.
[**Last Name (STitle) **].
Return to the ER for shaking chills, fevers greater than 101.5,
increased redness, swelling, or drainage from your incision,
chest pain, shortness of breath, or any other concerning
symptoms.
Please continue taking your home medications and begin any new
medications as directed. Please continue drain care at home
with the help of VNA.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] in one week. Please call the office
to schedule an appointment.
|
[
"V15.3",
"V87.41",
"V45.71",
"V10.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"85.73"
] |
icd9pcs
|
[
[
[]
]
] |
2616, 2664
|
670, 2051
|
340, 354
|
2736, 2744
|
373, 647
|
3332, 3444
|
2074, 2593
|
2685, 2715
|
2768, 3309
|
272, 302
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,683
| 146,759
|
36644
|
Discharge summary
|
report
|
Admission Date: [**2164-8-11**] Discharge Date: [**2164-8-13**]
Date of Birth: [**2089-2-27**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Palpitations
Major Surgical or Invasive Procedure:
-none this admission
- (Left internal mammary->Left anterior descending artery, Left
lesser saphenous vein->Diagonal artery, Left Radial
artery->Obtuse
marginal artery, Right internal mammary->Distal right coronary
artery)
[**2164-7-16**] - Cardiac Catheterization
History of Present Illness:
This 75 year old female is s/p CABG with Dr. [**First Name (STitle) **] on [**2164-7-19**]
and had an uneventful postoperative course and was discharged to
rehab on [**2164-7-25**]. At rehab she has had intermittent
palpitations and had hypotension. She has been
seen by CT surgery and Dr. [**Last Name (STitle) **] and had her Lopressor stopped
and then restarted. Today she had more episodes of palpitations
and was sent to the
ED from the rehab. An EKG in the ambulance showed AF at 150 and
it resolved spontaneously. She has been in sinus rhythm since
she came to the ED.
Past Medical History:
Hypothyroidism
Osteoporosis
Hypertension
MI in her early 50s, treated medically
Arthritis
Gall stones
Depression
?TIA- facial numbness 6 yrs ago
Social History:
Occupation: Retired
Last Dental Exam: 3 weeks ago, needs 2 fillings
Lives with: alone
Race:Caucasian
Tobacco:denies
ETOH:denies
Family History:
Family History: (parents/children/siblings CAD < 55 y/o):denies
Physical Exam:
Pulse: 99 Resp: 20 O2 sat: 94% on RA
B/P Right: 121/65 Left:
Height: 5'2" Weight: 128 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Incisions: C/D/I, sternum stable
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None []L lesser saphenous incision healing well, L radial artery
incision healing well
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: n/a
Carotid Bruit Right: no Left: no
Pertinent Results:
[**2164-8-11**] 04:25PM BLOOD WBC-8.8 RBC-4.02* Hgb-11.9* Hct-36.8
MCV-92 MCH-29.6 MCHC-32.3 RDW-13.7 Plt Ct-360#
[**2164-8-12**] 04:48AM BLOOD WBC-8.1 RBC-3.54* Hgb-10.9* Hct-32.6*
MCV-92 MCH-30.8 MCHC-33.4 RDW-13.9 Plt Ct-306
[**2164-8-11**] 11:38PM BLOOD PT-12.3 PTT-22.3 INR(PT)-1.0
[**2164-8-12**] 04:48AM BLOOD Glucose-94 UreaN-16 Creat-0.7 Na-140
K-4.2 Cl-108 HCO3-25 AnGap-11
[**2164-8-11**] 04:25PM BLOOD cTropnT-0.03*
[**2164-8-12**] 04:48AM BLOOD CK-MB-NotDone cTropnT-0.03*
Brief Hospital Course:
On [**8-11**] at rehab Mrs.[**Known lastname 82908**] had intermittent palpitations and
became hypotensive.She has been seen postoperatively by CT
surgery and Dr. [**Last Name (STitle) **] and had her Lopressor stopped and then
restarted. Today she had more episodes of palpitations and was
sent to the ED from the rehab. An EKG in the ambulance showed
Atrial Fibrillation at 150 and it resolved spontaneously. She
was admitted to [**Hospital Ward Name 121**] 6 for further monitoring when shortly after
arrival her rhythm went back into rapid atrial fibrillation with
a ventricular response in the 150-160s and associated transient
hypotension. Mrs.[**Known lastname 82908**] was transferred to the CVICU for volume
resuscitation and close hemodynamic monitoring. She was treated
with Amiodarone and the Lopressor was discontinued. Upon arrival
to the CVICU she converted to normal sinus rhythm, in which she
has remained. HD#1 Beta-blocker was restarted with plans to
optimize as blood pressure tolerates. She remained
hemodynamically stable and was transferred to the step down
unit. Physical therapy was consulted for evaluation and
appropriate discharge placement. Anticoagulation was started per
the cardiac surgical covering attending. INR goal of 1.5-1.8 per
Dr.[**Last Name (STitle) **]. For the remainder of her hospital course was
uneventful and she was cleared for discharge to home on hospital
day #2. Her couamdin follow up will be with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3321**]
as confirmed with [**Doctor First Name **] the office assistant. All follow up
appointments were advised.
Medications on Admission:
Keflex 500 mg PO QID
Flonase 50 mcg nasal qAM
Levoxyl 75 mcg daily
Lopressor 50 mg PO BID
Imdur 30 mg PO daily
Plavix 75 mg PO daily
Temazepam 30 mg PO daily
Ultram 50 mg PO q 6 hours PRN
ASA 81 mg PO daily
Simvistatin 40 mg PO daily
Omeprazole 20 mg PO daily
Discharge Medications:
1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
5. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for PAIN.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
Disp:*1 unit* Refills:*2*
8. 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*
9. Amiodarone 400 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days: then 200mg daily on going.
Disp:*7 Tablet(s)* Refills:*0*
10. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
start on [**2164-8-21**].
Disp:*30 Tablet(s)* Refills:*2*
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
12. Coumadin 1 mg Tablet Sig: 1 1/2 tabs Tablet PO once a day:
take 1 1.2 tabs (2.5mg ) daily or advised by Dr. [**Last Name (STitle) 3321**].
Goal inr 1.5-1.8.
Disp:*90 Tablet(s)* Refills:*1*
13. Outpatient Lab Work
INR check [**2164-8-14**] and FAX to Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 49816**] for
couamdin titration.
Goal INR 1.5-1.8 per Dr. [**Last Name (STitle) **] for Afib
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
-Atrial Fibrillation
-status post [**2164-7-19**] - Coronary artery bypass grafting to four
vessels.
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**]
Followup Instructions:
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2164-8-20**] 1:30
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2164-10-9**] 10:20
Completed by:[**2164-8-13**]
|
[
"401.9",
"414.00",
"244.9",
"427.31",
"574.20",
"716.90",
"458.29",
"V45.81",
"412"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6476, 6547
|
2887, 4521
|
334, 601
|
6692, 6699
|
2377, 2864
|
7239, 7558
|
1559, 1608
|
4832, 6453
|
6568, 6671
|
4547, 4809
|
6723, 7216
|
1623, 2358
|
282, 296
|
629, 1210
|
1232, 1379
|
1395, 1527
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,561
| 118,183
|
16198
|
Discharge summary
|
report
|
Admission Date: [**2175-4-26**] Discharge Date: [**2175-5-2**]
Date of Birth: [**2149-12-28**] Sex: M
Service: Trauma Surgery
HISTORY OF PRESENT ILLNESS: Patient is a 25-year-old male
driver involved in a motor vehicle collision, where he was
unrestrained in high speed, ejected from the car, found [**10-11**]
feet from the car against a tree. The patient was
transferred to [**Hospital1 69**] and for
further management.
PHYSICAL EXAMINATION: It was noted that the patient was not
responsive, and intubated with a rapid sequence induction,
and on examination pupils were fixed and dilated. Midface
was stable. Tympanic membranes are clear bilaterally. Neck:
Trachea was midline. Cardiovascularly, no murmurs. Regular,
rate, and rhythm. Respiratory wise: There is no crepitus or
subcutaneous air. Bilateral breath sounds were heard.
Abdomen was soft, nontender, nondistended. Pelvis was
stable. Foley has gross hematuria from urine. Normal rectal
tone. No gross blood. Extremities: There was an abrasion
over the right rib, no gross deformities and 2+ pulses
throughout.
INITIAL LABORATORIES: Hematocrit of 39.4, white blood cell
count of 25. Coag: INR of 1.3. Urine showed large blood,
red blood cells greater than 1,000, white blood cells greater
than 50, many bacteria. Serum tox and urine tox were
negative. Creatinine of 1.1.
The patient had a chest x-ray which showed some pulmonary
contusion, and no widen mediastinum, no pneumothorax or
hemothorax on presentation.
On AP of the pelvis, no fracture or dislocation. CT scan of
the pelvis showed a right acetabular fracture. CT scan of
the C spine was negative. CT scan of the head showed left
subdural hemorrhage with no midline shift as well as a small
right traumatic subarachnoid hemorrhage.
HOSPITAL COURSE: The patient was transferred to the Surgical
Intensive Care Unit. Neurosurgery was consulted, and no ICP
monitoring indicated. Patient had q1h neurologic checks, and
repeat head CT scan did not show worsening of the bleed.
T-L-S films were obtained, and they were negative.
Cardiovascularly, the patient has been hemodynamically stable
and on maintenance fluids. Respiratory wise, the patient was
extubated on [**2-26**] without any problems on pulmonary
toiletry to follow.
Abdominal wise, the patient had a small liver laceration, and
serial hematocrits were obtained as well as GI prophylaxis
medications were given. On [**2-25**], it was thought that
the patient had retroperitoneal free air on CT scan. The
patient was taken to the OR, and underwent exploratory
laparotomy which was unremarkable. Patient had a J tube
placed in the OR. Patient returned back to the Intensive
Care Unit.
From genitourinary point-of-view, the patient continued to
make good urine output and hematuria resolved.
Heme wise, hematocrit was stable.
Infectious Disease: The patient did not continue antibiotics
beyond the initial 24 hour period.
Orthopedic issues: Per Orthopedics, the acetabular fracture
is nonoperative. He is full weightbearing on the left leg
and partial weightbearing on the right and the patient is to
followup with Orthopedics. Physical Therapy was consulted,
and will work with patient, and will likely require home
Physical Therapy to assist him back, to baseline.
Fluids, electrolytes, and nutrition: The patient had
episodes of hyponatremia and was thought to be cerebral salt
waste. The patient's free water restricted and normal saline
was given. Sodium corrected back to baseline to around
135-137. Patient's previous sodium levels were 120s, 126.
DISCHARGE MEDICATIONS:
1. Milk of magnesia.
2. Vicodin.
3. Colace.
DISCHARGE DIAGNOSES:
1. Right hip fracture.
2. Liver laceration.
3. L1 vertebral fracture.
4. Subarachnoid hemorrhage, left subdural.
5. Seventh rib fracture.
DISCHARGE CONDITION: The patient is discharged home in good
condition requiring home PT as well as VNA services for J
tube care.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 18153**], M.D. [**MD Number(1) 18154**]
Dictated By:[**Last Name (NamePattern1) 19796**]
MEDQUIST36
D: [**2175-5-2**] 09:43
T: [**2175-5-2**] 09:44
JOB#: [**Job Number 46228**]
|
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"511.8",
"852.00",
"864.05"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.39",
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"96.6",
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icd9pcs
|
[
[
[]
]
] |
3854, 4242
|
3693, 3832
|
3627, 3672
|
1822, 3604
|
470, 1804
|
176, 447
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,855
| 103,722
|
21418
|
Discharge summary
|
report
|
Admission Date: [**2181-9-8**] Discharge Date: [**2181-9-26**]
Date of Birth: [**2119-11-6**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
productive cough, shortness of breath
Major Surgical or Invasive Procedure:
Placement of PICC line
History of Present Illness:
61 y/o male with history of right lung Non Small Cell Cancer,
s/p right upper lobe lobectomy, severe COPD, and a history of
MRSA and psuedomanous PNA who presents from ED to ICU with
hypoxia and possible PNA. He recently had a 3 week
hospitalization for COPD exacerbation and treated for a
pneumonia with Bactrim (for MRSA) and levaquin (for
pseudomonas). He was discharged on [**8-6**] but continued to feel
SOB and was readmitted several days later where he grew out
pseudomonas Resistant to ciprofloxacin. Workup also included a
CXR which showed a question of interstitial process and CTA was
negative for PE but did reveal bilateral patchy infiltrates in
middle and lower lobes bilaterally c/w pneumonia. Pt was treated
with vancomycin and ceftaz during this hospital course, and was
discharged on prednisone taper.
.
He was doing well at home until 1 week PTA when he reports onset
of fevers to 101, weakness, SOB, pleuritic CP, cough. Denies any
arm or jaw pain, diaphoresis, nausea, palpitations. ROS + for
photophobia, dizziness with some balance loss, but no loss of
consciousness over this time period as well.
Pt therefore presented to [**Hospital **] hospital. He remained clinically
stable throughout his course at MVH - afebrile, BP
110s-130s/60s-70s, HR 60s-80s, RR 18-24 and sats of 93% on 3L ->
93% on 2L. His pulmonologist (Dr. [**Last Name (STitle) 14069**] was contact[**Name (NI) **] and
recommended transfer to [**Hospital1 18**] for possible bronchoscopy to
figure out why he is having recurrent COPD flares.
On arrival here, he states that his breathing feels comfortable.
Past Medical History:
1. Non-small cell lung cancer, s/p R upper lobectomy, partial R
fifth rib resection c/b chronic pain. No chemo or radiation.
2. COPD w/ severely reduced DLCO, FEV1, and FEV1/FVC ratio
3. h/o MRSA and pseudomonas PNA
4 UC - s/p multiple surgeries, most recently in late 80s. S/P
total colectomy and ileostomy
5. Steroid induced hyperglycemia
6. PFO
7. h/o cardiomegaly
8. h/o depression
Social History:
Married, 2 daughters, lives on the [**Name (NI) **]. Not current
smoker, quit in [**2177**] w/ dx of lung cancer, 40 pack-yr history.
Occasional EtOH use. Worked as a paiting contractor, retired
after lung cancer surgery.
Family History:
F died of lung cancer; M died of Alzheimer's. Has 3 sisters, all
older than him, healthy
Physical Exam:
Vitals - T 95.9, HR 95, BP 107/58, RR 20, O2 97% on high flow
face mask
General - awake alert, sitting up in bed, mask on, NAD
HEENT - PERRL, EOMI, dry MM
CVS - slightly tachycardic, no noted m/r/g
Lungs - diffuse insp and exp wheezes, scattered coarse rhonci at
bases, bronchial breath sounds on right middle airfield
Abd - tense, non-tender, ileostomy in place
Ext - no LE edema b/l
Pertinent Results:
ADMISSION LABS:
[**2181-9-8**] 10:15PM BLOOD WBC-9.3 RBC-3.40* Hgb-10.0* Hct-28.8*
MCV-85 MCH-29.4 MCHC-34.6 RDW-15.4 Plt Ct-280#
[**2181-9-8**] 10:15PM BLOOD Neuts-80* Bands-10* Lymphs-3* Monos-6
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0 NRBC-1*
[**2181-9-8**] 10:15PM BLOOD PT-16.1* PTT-31.4 INR(PT)-1.5*
[**2181-9-8**] 10:15PM BLOOD Glucose-262* UreaN-65* Creat-2.8*#
Na-129* K-4.1 Cl-87* HCO3-24 AnGap-22*
[**2181-9-9**] 05:39AM BLOOD ALT-122* AST-155* LD(LDH)-347*
AlkPhos-118* Amylase-64 TotBili-0.5
[**2181-9-10**] 05:10AM BLOOD ALT-79* AST-52* LD(LDH)-311* AlkPhos-115
TotBili-0.4
[**2181-9-13**] 04:14AM BLOOD ALT-14 AST-1 LD(LDH)-255* AlkPhos-108
TotBili-0.3
[**2181-9-9**] 05:39AM BLOOD Lipase-12
[**2181-9-10**] 05:10AM BLOOD Lipase-13
[**2181-9-9**] 05:39AM BLOOD Albumin-2.5* Calcium-7.7* Phos-6.6*#
Mg-2.1
[**2181-9-13**] 04:14AM BLOOD calTIBC-160* Ferritn-1317* TRF-123*
[**2181-9-9**] 08:26AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE IgM
HBc-NEGATIVE IgM HAV-NEGATIVE
[**2181-9-9**] 08:26AM BLOOD HCV Ab-NEGATIVE
[**2181-9-9**] 01:59AM BLOOD Type-ART pO2-110* pCO2-40 pH-7.38
calTCO2-25 Base XS-0 Intubat-NOT INTUBA
[**2181-9-8**] 10:31PM BLOOD Lactate-2.4*
Pertinent Labs/Studies:
.
CHEST (PORTABLE AP) [**2181-9-8**] 10:10 PM
IMPRESSION:
1. New right middle lung opacification most consistent with
newly developing pneumonia given acuity of onset (1 month).
2. Underlying chronic obstructive pulmonary disease, status post
right thoracotomy.
.
[**2181-9-24**]: Portable CXR -
IMPRESSION:
Minimal worsening of right pneumonia, superimposed upon severe
emphysema. It is difficult to exclude a component of
necrotizing infection.
Persistent air collection at right apex, likely due to a
postoperative
pneumothorax, unchanged since recent radiograph, but worse when
compared to older studies from [**2181-7-20**].
.
[**2181-9-11**]: Echocardiogram
Conclusions:
1. The left ventricular cavity size is normal. Overall left
ventricular
systolic function cannot be reliably assessed.
2. The mitral valve leaflets are mildly thickened. The mitral
valve is not well seen.
3. There is no obvious vegetations seen, but the cardiac valves
are not well seen.
.
.
MICROBIOLOGY:
[**2181-9-9**] SPUTUM Source: Expectorated.
GRAM STAIN (Final [**2181-9-9**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
1+ (<1 per 1000X FIELD): BUDDING YEAST.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI.
RESPIRATORY CULTURE (Final [**2181-9-13**]):
OROPHARYNGEAL FLORA ABSENT.
STAPH AUREUS COAG + MODERATE GROWTH.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
YEAST. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
| PSEUDOMONAS AERUGINOSA
| |
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- =>4 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S =>16 R
IMIPENEM-------------- 8 I
LEVOFLOXACIN---------- =>8 R
MEROPENEM------------- 8 I
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
PIPERACILLIN---------- 8 S
PIPERACILLIN/TAZO----- 8 S
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TOBRAMYCIN------------ =>16 R
VANCOMYCIN------------ <=1 S
.
Blood cultures:
[**2181-9-8**] to [**2181-9-15**]: No growth
.
Urine:
[**2181-9-9**]: No growth
[**2181-9-20**]: No growth
.
Stool:
[**2181-9-24**]: C. Diff - negative
Discharge Labs:
.
[**2181-9-26**] 05:25AM BLOOD WBC-8.2 RBC-3.03* Hgb-9.5* Hct-25.7*
MCV-85 MCH-31.4 MCHC-37.1* RDW-16.6* Plt Ct-179
[**2181-9-26**] 05:25AM BLOOD Glucose-118* UreaN-22* Creat-0.7 Na-134
K-3.6 Cl-95* HCO3-30 AnGap-13
[**2181-9-26**] 05:25AM BLOOD Calcium-8.3* Phos-3.2 Mg-1.6
Brief Hospital Course:
61 y/o M w/ h/o NSCLC s/p RUL lobectomy, severe COPD, recurrent
pna over past couple months, with righ sided PNA
(MRSA/Pseudomonas) and severe hypoxia requiring significant O2
suppplementation.
.
1. PNA with Severe Hypoxia: Had right multilobar PNA with
MRSA/Pseudomonas growing from sputum, with WBC count of 9,000
and bandemia as high as 22%, elevated anion gap, and elevated
lactate to 2.4. Also has poor underlying lung function from COPD
(FEV 1.2L in [**2181-7-20**]) and h/o right upper lobe lobectomy.
Patient was initially treated with high flow face mask of 15 L
at 40% with additional NC with saturations varying from 88 to
98%, but with continued frequent coughing which causes
desaturations. The patient has since decreased his oxygen
requirement to Venti amsk at 12 lpm with O2 sats rangin 89 to
97%. The patient continues to cough and is draining sputum well
with transition from dark brown thick sputum to thinner
grey/clear sputum. The patient had one episode small volume
blood tinged sputum on [**2181-9-24**] attributed to inflammation from
underlying PNA. The patient is currently being treated with
Linezolid for a planned 21 day course for MRSA as well as
Ceftazidime, again for a planned 21 day course for Pseudomonas.
Amikacin was added for syndergy and to avoid resistance with a
planned 14 day course (ending dates specified on discharge
meds). The patient will be discharged with need for continued
O2 suppplementation to keep sats >90% and <94% with O2 weaning
as possible. The patient will continue to require ongoing Chest
PT and physical therapy as well.
.
2. COPD: Has h/o COPD on montelukast, spiriva, advair, flovent,
prednisone 10mg at home with PFT's showing FEV of 1.2 L (42%
predicted), FEV1/FVC ratio of 42 (59% predicted), 6 L TLC, and
elevated Residual Volume (193% predicited). He was given Advair,
Monteleukast, Prednisone 60 mg DAily tapered down to 30 mg Daily
as well as Atrovent nebulizers. The patient is followed by Dr.
[**Last Name (STitle) 14069**], his outpatient pulmonolgist with whom he should continue
to be followed after discharge.
.
3. Anxiety: Patient was experiencing a significant amount fo
anxiety during this admission, likely at least partly
attributable to his air hunger. The patient was maintained on
Clonopin with hold parameters with Ativan rescues as needed.
.
4. Acute renal failure: Patient presented with ARF with Cr to
2.8 which resolved rapidly with fluids down to baseline of 0.7.
.
5. Chest Pain: Had right sided chest pain, which is diffuse and
pleuritic, likely due to PNA. Treated with MSSR 45 mg [**Hospital1 **] and IV
morphine for breakthrough pain.
.
6. Abdominal pain: Patient has been experiencing ongoing
abdominal pain for a few days. A KUB showed a non-obstructive
bowel gas patterns and the patient's ostomy continues to drain
well. The patient has good appetite without Nausea/vomiting. C.
Diff was negative x 1. The patient did have an elevated
amylase/lipase, now trending down. Pain did not radiate to back
and again patient was tolerating PO well without any
exacerbation of pain. The patient's symptoms are exacerbated
with coughing and are likely secondary to musculoskeletal strain
from frequent coughing. Treating pain as above with MS SR 45 [**Hospital1 **]
with rescue doses.
.
6. Transaminitis: Presented with elevated liver enxymes which
trended down to normal. Hepatitis panel negative for Hep B or C.
.
7. H/o LLL nodule and several other areas of focal scarring:
should be followed with serial CT scans in the future by
outpatient providers.
.
8. H/o right upper lobe lung ca: Not active currently. Sputum
for cytology was negative for malignant cells. No history of
chemo or radiation.
.
9. H/o thrush: Likely related to inhaled staeroids. Continued
his outpt nystatin.
.
10. Steroid Induced Hyperglycemia: Treated with 70/30 insulin
[**Hospital1 **] at AM dose of 40 and PM dose of 22.
.
11. Anemia: Labs consistant with Anemia of chronic disease. Also
was guaiac positive. Needs to be followed in the future. He is
s/p colectomy for Ulcerative colitis.
.
12. Ulcerative colitis: S/P colectomy and ileostomy. Not on any
medications for UC.
.
Code: Full
.
Communication: wife [**Name (NI) **] (h) [**Telephone/Fax (1) 56560**] (c) [**Telephone/Fax (1) 56561**],
daughter [**Name (NI) **] [**Name (NI) 56562**] ([**Telephone/Fax (1) 56563**]
Medications on Admission:
Montelukast 10 mg PO DAILY
Tiotropium Bromide 18 mcg DAILY
Flovent 110 2 puffs [**Hospital1 **]
Prednisone 10mg daily
mucinex 600mg tid
Multivitamin PO DAILY
Fluticasone-Salmeterol 250-50 mcg [**Hospital1 **]
Benzonatate 100 mg PO TID
Senna 8.6 mg PO BID PRN
Docusate Sodium 100 mg PO BID PRN
Nexium 40 mg twice a day.
Morphine 30 mg Tablet Sustained Release PO Q12H
morphine 15mg IR PO q8hr PRN
Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
Discharge Medications:
1. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Nystatin 100,000 unit/mL Suspension Sig: 100,000 MLs PO QID
(4 times a day).
4. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H
(every 6 hours) as needed.
5. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**11-20**] Sprays Nasal
TID (3 times a day).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to
6 hours) as needed for anxiety.
8. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML
Miscell. Q4-6H (every 4 to 6 hours) as needed.
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
12. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day): Continue until patient is
regularly ambulatory, than may D/C.
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
14. Ipratropium Bromide 0.02 % Solution Sig: One (1) inhalation
Inhalation Q4H (every 4 hours) as needed.
15. Clonazepam 0.25 mg Tablet, Rapid Dissolve Sig: One (1)
Tablet, Rapid Dissolve PO three times a day: Hold for RR < 16.
16. Guaifenesin 600 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO BID (2 times a day).
17. Morphine 15 mg Tablet Sustained Release Sig: Three (3)
Tablet Sustained Release PO Q12H (every 12 hours).
18. Linezolid 600 mg/300 mL Parenteral Solution Sig: Six Hundred
(600) mg Intravenous Q12H (every 12 hours) for 5 days: First
dose: [**2181-9-10**]
Continue for total of 21 day course
Last dose: [**2181-9-30**].
19. Ceftazidime-Dextrose (Iso-osm) 2 g/50 mL Piggyback Sig: Two
(2) grams Intravenous Q8H (every 8 hours) for 7 days: First
dose: [**2181-9-12**]
Continue for total of 21 day course
Last dose: [**2181-10-2**].
20. Amikacin 250 mg/mL Solution Sig: One (1) gram Injection Q24H
(every 24 hours) for 3 days: First dose: [**2181-9-15**]
Continue for total 14 day course
last dose: [**2181-9-28**].
21. Dolasetron 12.5 mg/0.625 mL Solution Sig: 12.5 mg
Intravenous Q8H (every 8 hours) as needed for nausea /vomiting.
22. Morphine 2 mg/mL Syringe Sig: Two (2) mg Injection Q4H
(every 4 hours) as needed for breakthrough pain.
23. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): Continue for 1 week. Wean as possible over following 2
to 3 weeks to 10mg daily as possible.
24. Insulin NPH-Regular Human Rec 100 unit/mL (70-30) Suspension
Sig: see instructions units Subcutaneous once a day: Please
provide 40 units qam
22 units qhs.
25. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1)
unit Subcutaneous four times a day: Please provide Humalog
sliding scale with meals and at bedtime per provided sliding
scale in addition to standing Insulin 70/30 .
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 701**]
Discharge Diagnosis:
Primary:
MRSA/Pseudomonas Pneumonia
COPD exacerbation
Abdominal Pain
Steroid induced hyperglycemia
Anxiety
.
Secondary:
History of Non small cell Lung Ca s/p pneumonectomy
Ulcerative Colitis
Anemia
Discharge Condition:
Fair. Patient with ongoing O2 requirement above baseline.
Symptomatically improved, hemodynamically stable.
Discharge Instructions:
1. Please take all medications as prescribed
.
2. please keep all outpatient appointments
.
3. Please return to the hospital for symptoms fevers/chills,
worsening respiratory status, shortness of breath, chest pain,
or any other concerning symptoms
Followup Instructions:
1. Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] on discharge. Please
call his office at [**Telephone/Fax (1) 36558**] to make an appointment
.
2. Please follow up with your Pulmonologist within one week of
discharge from your rehab facility. Please call his office to
schedule an appointment.
|
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[
[
[]
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] |
[
"38.93",
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icd9pcs
|
[
[
[]
]
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15201, 15283
|
7249, 11601
|
308, 333
|
15525, 15635
|
3140, 3140
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15932, 16274
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2734, 3121
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231, 270
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361, 1960
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3156, 6933
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1982, 2371
|
2387, 2612
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,615
| 167,692
|
21743
|
Discharge summary
|
report
|
Admission Date: [**2190-12-8**] Discharge Date: [**2190-12-15**]
Date of Birth: [**2105-7-21**] Sex: F
Service: NEUROLOGY
Allergies:
Atorvastatin
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
Code Stroke
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
Patient is an 85-year-old woman with history of dementia and
atrial fibrillation off coumadin for few weeks now,
hypertension,
Parkinson's disease, hypothyroidism and who is a nursing home
resident was transfered from OSH for evaluation of "change in
mental status". She was intubated when she came to [**Hospital1 18**] ED.
Next, code stroke was called.
HPI obtained from the chart, family and ED team. She was last
well see at baseline this am around 8, when she was able to walk
with support as usual. She had a fall last night aorund 8 pm.
However over the course of the day she was more lethargic and
found not herself. The exact onset of this new symptom is not
clear but somewhere between 8 am and 3 pm when her daughter
visited and found her to be extremely lethargic. She was tekn to
the OSH where she got intubated for airway protection . I
couldnt
locate the OSH ED sheet for more details. she underwent CT head
which showed possible left MCA stroke. She was transfered to
[**Hospital1 18**].
Past Medical History:
HTN
hypercholesterolema
afib
cognitive dysfunction
hypothyroidism
chronic leg pain
h/o c diff
congestive heart failure
Social History:
She is married and lives with her husband. Daughter is her
caregiver and is a nurse. They live in a multidwelling home,
daughter lives upstairs.No tob (quit 40y ago). No ETOH.
Family History:
non contributory
Physical Exam:
HR:110 BP:166/112 Resp:16 O(2)Sat:98
General: Elderly, Intubated, not following commands
HEENT: NC/AT
Neck: No mass. bruit.
Chest: Posterior and anterior exam clear to auscultation
bilaterally
Cardiac: irregularly irregular, no murmurs
auscultation
Abdomen: +BS, soft, non-tender, non-distended, ecchymosis
Extremities: warm, no edema
Neurological
Intubated, eyes open intermittently, not following any commands
Pupils [**2-2**] Bl reactive and symmetric
Doesnt cooperate for EOM testing
face looks symmetric but exam difficult owing to intubated state
Moves left side spontaneosuly
withdraws all limbs to painful stimuli , less so with the right
UE and LE.
DTRS; 1 plus and symmetric
BL plantars up
ON DISCHARGE
Patient expired
Pupils fixed/dilated
No spontaneous respirations
No heart sounds
No pulse
Pertinent Results:
[**2190-12-8**] 08:09PM TYPE-ART TEMP-37.2 O2-100 PO2-145* PCO2-29*
PH-7.42 TOTAL CO2-19* BASE XS--3 AADO2-553 REQ O2-90
INTUBATED-INTUBATED COMMENTS-GREEN TOP
[**2190-12-8**] 08:09PM GLUCOSE-90 K+-3.2*
[**2190-12-8**] 08:09PM HGB-14.2 calcHCT-43
[**2190-12-8**] 08:00PM GLUCOSE-97 UREA N-21* CREAT-1.1 SODIUM-141
POTASSIUM-3.1* CHLORIDE-110* TOTAL CO2-20* ANION GAP-14
[**2190-12-8**] 08:00PM estGFR-Using this
[**2190-12-8**] 08:00PM cTropnT-0.02*
[**2190-12-8**] 08:00PM proBNP-3253*
[**2190-12-8**] 08:00PM WBC-14.9*# RBC-4.85 HGB-13.6 HCT-40.5 MCV-84
MCH-28.0 MCHC-33.5 RDW-15.8*
[**2190-12-8**] 08:00PM PLT COUNT-303
[**2190-12-8**] 08:00PM PT-15.4* PTT-24.2 INR(PT)-1.3*
[**2190-12-8**] 08:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.023
[**2190-12-8**] 08:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2190-12-8**] 08:00PM URINE RBC-0 WBC-0-2 BACTERIA-FEW YEAST-FEW
EPI-0
[**2190-12-8**] 08:00PM URINE URIC ACID-FEW
Brief Hospital Course:
Patient was initially admitted after a code stroke was called.
She arrived from an OSH intubated. Her daughter had noted her to
be somnolent and non-responsive at home.
She was admitted to the neuro-ICU. She was found to have a large
left MCA ischemic stroke with ICA occlusion. Family was told
about her prognosis, but wished to wait to withdraw care until
her husband could visit (he was an inpatient at [**Hospital1 2025**]). Family
decided on [**2190-12-14**] that they would like to move towards comfort
measures only and have her extubated.
She had developed several infections, including a staph
pneumonia and c. diff colitis and was on Cefepime, Vancomycin,
Flagyl and Fluconazole, but continued to spike low-grade temps
and had rising leukocytosis. Antibiotics were withdrawn on
[**2190-12-14**].
Patient was made CMO during family meeting with palliative care,
ICU, and neurology present. She was made comfortable and died at
1:50 pm on [**2190-12-15**].
Medications on Admission:
trazodone 50 mg Tablet Sig: 0.25 Tablet PO HS: PRN as needed
for agitation, insomnia.
multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours).
donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for rib pain.
levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q48H
(every 48 hours) for 3 doses: Due for doses Monday, Weds,
Friday.
aspirin, buffered 325 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). diltiazem HCl 360 mg Capsule, Sust. Release 24 hr Sig:
One
(1) Capsule, Sust. Release 24 hr PO once a day.
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
Completed by:[**2190-12-15**]
|
[
"272.0",
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"112.2",
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"433.11",
"294.9",
"482.42",
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] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
5693, 5702
|
3608, 4577
|
287, 299
|
5753, 5762
|
2546, 3585
|
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|
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|
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|
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4603, 5638
|
5786, 5795
|
1720, 2527
|
236, 249
|
327, 1335
|
1357, 1477
|
1493, 1671
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,559
| 193,401
|
41317
|
Discharge summary
|
report
|
Admission Date: [**2188-2-18**] Discharge Date: [**2188-2-21**]
Date of Birth: [**2121-6-21**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
right hand numbness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The pt is a 66 year-old right-handed man with a history of HTN
and HLD who is transferred from an OSH with a left thalamic
hemorrhage. According to his wife, when he woke up this morning
he was feeling fine, but around 8am he was sitting in a chair,
talking to her, when he suddenly began to complain of feeling
dizzy and that his right hand felt numb. During this time his
family also noted that his speech sounded slightly slurred,
though the words he was speaking still made sense. They brought
him to [**Hospital3 1280**] hospital, where it was noted that he wasn't
using his right side as much, and he also had some degree of
confusion. They noted that he did not remember his DOB or his
wife's name, though did seem to recognize her. He underwent a
CT head there, which showed a ~2.5 cm left thalamic and basal
ganglia hemorrhage. Blood pressures there were reportedly
160-180s systolic. He was intubated (unclear whether this was
for increasing somnolance or simply for transfer) and was then
transferred to [**Hospital1 18**]. He was seen by Neurosurgery who did not
feel there was any surgical intervention needed, at which point
Neurology was consulted.
Past Medical History:
- HTN
- HLD
Social History:
Lives in [**Location 17566**] with his wife and son. Retired [**Name2 (NI) 68444**]
worker. No EtOH, smoking or illicits.
Family History:
Mother died in her 60s and father died in his 70s of
complications from obesity. Brother with TTP.
Physical Exam:
Vitals: T: 97.5 P: 64 R: 16 BP: 143/88 SaO2: 100% intubated.
General: Intubated
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Intubated, not opening eyes to voice or painful
stimuli, not following commands.
-Cranial Nerves: Pupils 4->2mm and symmetric. Sluggish corneals
bilaterally, though does make purposeful movements towards his
face with left arm when tested. Negative oculocephalics, intact
gag.
-Motor/Sensory: Increased tone in bilateral lower extremities
with adduction and extension in response to all stimuli.
Purposeful movements of the left arm spontaneously and in
response to painful stimuli. Extension of the right arm in
response to pinch.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 3 2 3 3 2
R 2 3 2 3 2
Plantar response was extensor bilaterally.
Pertinent Results:
[**2188-2-18**] 11:50AM BLOOD WBC-6.8 RBC-4.80 Hgb-14.3 Hct-42.6 MCV-89
MCH-29.8 MCHC-33.5 RDW-13.4 Plt Ct-173
[**2188-2-18**] 11:50AM BLOOD Neuts-86.6* Lymphs-9.1* Monos-3.0 Eos-0.7
Baso-0.6
[**2188-2-18**] 11:50AM BLOOD PT-12.6 PTT-23.2 INR(PT)-1.1
[**2188-2-18**] 11:50AM BLOOD Glucose-107* UreaN-22* Creat-0.9 Na-139
K-3.9 Cl-106 HCO3-24 AnGap-13
[**2188-2-19**] 02:00AM BLOOD %HbA1c-5.5 eAG-111
[**2188-2-19**] 02:00AM BLOOD Triglyc-85 HDL-45 CHOL/HD-3.6 LDLcalc-100
IMAGING:
NONCONTRAST HEAD CT
Stable appearance of left thalamic hemorrhage compared with
outside films submitted for comparison with no new hemorrhage
and no mass
effect.
MRI/MRA HEAD AND NECK
1. Resolving hemorrhage within the left thalamus without an
underlying lesion or vascular anomaly.
2. Unremarkable cervical and intracranial arterial vasculature.
Brief Hospital Course:
66 YO RHM with h/o HTN, HL presented with dizziness and right
hand numbness, found to have L thalamic intracranial hemorrhage
at OSH and transferred to [**Hospital1 18**] for further management.
The patient's mental status reportedly declined during
evaluation at OSH, and he was intubated for airway protection.
He was admitted to the neuro ICU on arrival, and exam was
limited by intubation/sedation, but notable for reactive pupils,
sluggish corneals and intact gag, with purposeful movements of
the left arm, extension of the right arm, and extension and
adduction of the bilateral lower extremities, with diffuse
hyper-reflexia.
Patient was able to be extubated on hospital day 2 without
difficulty. He was tranferred to the neurology floor.
His exam at this point showed disorientation and inattention, as
well as right upper and lower extremity weakness 4/5 in a UMN
pattern, and hypereflexia on the right. His mental status
improved over the next 36 hours, and he was oriented x 3 with
improved attention by date of discharge.
Patient was treated with BP management. He was restarted on
lisinopril and this was titrated to 20 mg by day of discharge.
He was continued on simvastatin.
PT/OT recommended acute rehab.
Medications on Admission:
- Lisinopril
- Simvastatin
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. insulin regular human 100 unit/mL Solution Sig: per sliding
scale Injection ASDIR (AS DIRECTED).
4. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
6. famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]
Discharge Diagnosis:
L thalamic hemorrhage
hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted with a bleed in your brain caused by high
blood pressure. Your were monitored closely and your blood
pressure was controlled with additional medications.
Followup Instructions:
Please follow up in the [**Hospital 4038**] Clinic:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
[**Telephone/Fax (1) 2574**]
[**Hospital Ward Name 23**] Clinical Center [**Location (un) **]
Date/Time:[**2188-4-21**] 2:30
|
[
"401.9",
"431",
"348.30",
"272.4",
"780.97",
"784.59",
"784.51",
"796.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
5865, 6010
|
3940, 5165
|
333, 340
|
6089, 6089
|
3085, 3917
|
6469, 6719
|
1736, 1838
|
5243, 5842
|
6031, 6068
|
5191, 5220
|
6272, 6446
|
2473, 3066
|
1853, 2359
|
274, 295
|
368, 1542
|
6104, 6248
|
1564, 1578
|
1594, 1720
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,911
| 102,055
|
44822
|
Discharge summary
|
report
|
Admission Date: [**2123-8-31**] Discharge Date: [**2123-9-6**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1171**]
Chief Complaint:
Chest pain and shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The pt is a 97-yo Russian-speaking man w/ h/o CAD s/p BMS
[**11/2122**] and angioplasty [**5-/2123**], CHF (EF 40%), HTN, h/o GI
bleeding and colon Ca, who presented to the ED for evaluation of
chest pain. CP consistently 4-5x/day both with exertion and at
rest, always responding to SL NTG. Pt saw his cardiologist on
the day PTA, at which point the decision was made to pursue
optimization of medical management rather than interventions.
However, on the morning of admission, the pt developed more
severe chest pain with radiation to the left shoulder, assoc w/
SOB and diaphoresis, non-responsive to SL NTG, so he came to the
ED for evaluation. In the ED - VS Temp 97.8F, HR 100, BP 85/53,
R 18, O2-sat 100. Hct 20 (baseline 28), with Guaiac + brown
stool. The pt reported dark stools x3 months, and has never been
scoped [**2-13**] cardiac risk factors. The pt was started on PRBCs for
transfusion, but he developed chest pain and diaphoresis, so the
transfusions were stopped for concern for a transfusion
reaction. Per the blood bank there was no evidence of a
transfusion reaction. The pt was seen by Cardiology, who wanted
to continue ASA / Plavix but not start heparin gtt. Upon
transfer to the floor, the pt triggered for HR 130s and RR >30.
He had 2/10 chest pain with ECG showing worsening ST depressions
precordially, which resolved with Nitro gtt and Lopressor. He
then received an additional 2units PRBCs + Lasix.
.
At 1230 am pt noted by nursing to have BP 50's/30's on automatic
cuff, mentating well, asymptomatic. Of note he had been given
lasix 20mg IV x1 at 8pm when he was noted to be tachypnic to
30's, O2 sat 93-94% on 3-4L, diffuse crackles and expiratory
wheezing with chest xray per the radiology resident showing
worsened pulmonary edema compared with admission. He responded
well to lasix with resolution of respiratory distress and put
out 600+ ml of urine with blood pressures 110-120. At 8pm he
was given amlodipine 2.5mg. At 11pm he was given metoprolol
37.5mg and terazosin 1mg. At 12:30 he was noted to be
hypotensive as above on bp check. Recheck with manual cuff with
blood pressure of 70's/40's, HR 70-73, RR 18, 97% on 2L NC. He
was given 500ml NS with improvement of SBP to 76. At that time
he had completed his second unit PRBC and his third unit was
started. Of note he had a large melanotic stool in the early
evening. After observing for 30-40 minutes blood pressure
remained in the low 70's systolic so he was given an additional
250ml NS. He remained asymptomatic throughout. EKG showed
improvement in precordial ST segment depressions compared with
admission.
Past Medical History:
--Coronary Artery Disease - s/p BMS to OM2, D1, LCX ([**2122-11-16**])
for unstable angina with TWI in V2-V4
- NSTEMI s/p cardiac cath and balloon angioplasty on [**2123-5-24**]
--CHF, systolic EF 40% and [**Date Range 7216**] dysfunction with sever LVH
--Valvular disease - moderate aortic stenosis, mild to moderate
aortic and mitral regurgitation, ?bicuspid congenital valves
--HTN
--COPD
--Gout
--DJD - bilateral knee pain
--h/o chronic pyelonephritis
--s/p bladder stone removal
--Colon cancer
Social History:
Social history is significant for occasional cigarrettes
socially 20 years ago. He drinks about 1 glass of wine or
alcoholic drink /week. He is from [**Country 532**] and worked as a
general surgeon in [**Location (un) 4551**]. He retired at age 63 due to his hand
tremor. He has been widowed for 8 years and lives alone in
[**Location (un) **]. He has children in the area who are helpful. The pt
lives alone in [**Location (un) **] with an aid who comes to clean the apt
and bathe him. His son lives nearby. He is a retired general
surgeon.
.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
.
Physical Exam:
VS - Temp F, BP 85/53, HR 72, R 25, O2-sat 99% 2L
GENERAL - elderly man in NAD, comfortable, interactive
HEENT - PERRL, EOMI, sclerae anicteric, MMM
NECK - supple
LUNGS - CTA bilat, no r/rh/wh
HEART - RRR, nl S1-S2, no MRG
ABDOMEN - +BS, soft/NT/ND, no HSM
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
Pertinent Results:
[**2123-8-31**] 09:30AM BLOOD WBC-5.7 RBC-2.77*# Hgb-5.9*# Hct-20.0*#
MCV-72*# MCH-21.4*# MCHC-29.6* RDW-18.6* Plt Ct-236
[**2123-8-31**] 04:05PM BLOOD WBC-8.0 RBC-3.13* Hgb-6.6* Hct-23.8*
MCV-76* MCH-21.0* MCHC-27.6* RDW-17.6* Plt Ct-250
[**2123-9-1**] 03:16AM BLOOD WBC-8.1 RBC-3.71* Hgb-8.9*# Hct-29.3*
MCV-79* MCH-23.9*# MCHC-30.2* RDW-17.1* Plt Ct-194
[**2123-8-31**] 09:30AM BLOOD Neuts-73.8* Lymphs-19.4 Monos-3.7 Eos-2.8
Baso-0.4
[**2123-9-1**] 03:16AM BLOOD PT-14.3* PTT-28.6 INR(PT)-1.2*
[**2123-9-1**] 03:16AM BLOOD Glucose-108* UreaN-42* Creat-1.3* Na-145
K-4.2 Cl-110* HCO3-26 AnGap-13
[**2123-9-1**] 03:16AM BLOOD ALT-12 AST-21 LD(LDH)-165 CK(CPK)-84
AlkPhos-87 TotBili-0.8
[**2123-8-31**] 09:30AM BLOOD cTropnT-0.03*
[**2123-8-31**] 04:05PM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2123-8-31**] 11:24PM BLOOD CK-MB-NotDone cTropnT-0.09*
[**2123-9-1**] 03:16AM BLOOD CK-MB-NotDone cTropnT-0.13*
Labs on Discharge:
[**2123-9-6**] 05:30AM BLOOD WBC-6.7 RBC-4.33* Hgb-10.9* Hct-34.5*
MCV-80* MCH-25.0* MCHC-31.4 RDW-18.8* Plt Ct-207
[**2123-9-6**] 05:30AM BLOOD Glucose-141* UreaN-43* Creat-1.1 Na-143
K-4.6 Cl-107 HCO3-29 AnGap-12
[**2123-9-6**] 05:30AM BLOOD CK(CPK)-35*
[**2123-9-6**] 05:30AM BLOOD CK-MB-NotDone cTropnT-0.19*
[**2123-8-31**] Chest Xray:Mild pulmonary edema has worsened, small
right pleural effusion and mild-to-moderate cardiomegaly stable.
No pneumothorax. No free subdiaphragmatic gas.
[**2123-9-3**] ECHO:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is 0-10mmHg. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is top
normal/borderline dilated. No masses or thrombi are seen in the
left ventricle. Overall left ventricular systolic function is
mildly depressed (LVEF= 40-45 %) with infero-lateral
hypokinesis. Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). There is no
ventricular septal defect. Right ventricular chamber size is
normal. with mild global free wall hypokinesis. The aortic root
is mildly dilated at the sinus level. The aortic valve leaflets
are severely thickened/deformed. There is moderate aortic valve
stenosis (area 1.0-1.2cm2). Mild (1+) aortic regurgitation is
seen. The aortic regurgitation jet is eccentric. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Moderate (2+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Brief Hospital Course:
Mr. [**Known lastname 95893**] is a [**Age over 90 **] yo M with PMH of severe CAD s/p multiple
prior PCI, moderate aortic stenosis, daily angina, anemia due to
chronic GI blood loss admitted with NSTEMI and hematocrit of 21.
.
1) NSTEMI/severe CAD- He has significant CAD hx s/p numerous
percutaneous interventions and stenting previously. He
presented with chest pain, worsening ECG findings with marked
precordial ST segment depressions and uptrending cardiac
enzymes. He was initially started on a nitroglycerin gtt and
was transferred to the floor with persistant chest pain. He was
given metoprolol 5mg IV x1 which resolved his hypertension,
tachycardia and chest pain. His hematocrit was noted to be 21
which was the likely causing factor of his worsening symptoms.
Given the severity of his symptoms and his multiple prior PCI he
was continued on his aspirin and plavix despite his GI blood
loss. Heparin was not started given the significant risk of
worsening his blood loss. Otherwise he was continued on maximal
medical management of his NSTEMI/CAD including ASA, plavis,
atorvastatin, metoprolol xl, isosorbide mononitrate. He is not
at this time considered to be candidate for additional PCI and
stenting. He will follow up with his outpatient cardiologist,
Dr. [**Last Name (STitle) 171**].
2)Anemia/GI bleeding - Pt has h/o colon Ca and melanotic stools
x1 on the day of admission. He has not had colonoscopy or
endoscopy due to his tenuous cardiac status but he has had
melena in the past making an upper GI source the likely cause of
his continued blood loss. He was transfused 4 units in the
first 24 hours of admission and a fifth unit on the day prior to
discharge. He did not have any additional melena and his
hematocrit remained generally stable, at 34 on the day of
discharge. He was initially treated with IV PPI [**Hospital1 **] and was
changed to po prior to discharge. He was followed by the GI
service who felt that the risks of Colonoscopy/EGD were much
higher than the benefits that he would receive from the
procedures. He was continued on aspirin and plavix despite the
bleeding given his cardiac status. He will follow up with
gastroenterology as an outpatient.
3) Hypotension - On admission patient was normotensive to
hypotensive despite gastrointestinal bleeding. During the
initial night his blood pressure dropped to a systolic in 70's
likely due to multiple etiologies including cardiac ischemia,
gastrointestinal bleeding and antihypertensive medications. In
addition he received lasix prior to the episode for dyspnea and
worsening pulmonary edema seen on CXR following transfusion. He
was transferred to the MICU for closer monitoring and care of
his hypotension. On arrival to the MICU the pt's SBP was in the
mid 80s and improving. He was given gently IV fluids and his
blood transfusion were continued to total of 4 units. He
remained asymptomatic throughout his hypotension with
improvement of EKG changes compared with admission EKG. His
antihypertensive medications were restarted slowly and he was
back on his full regimen prior to discharge with no recurrance
of hypotension or melena.
4) Acute on Chronic Systolic heart failure- mild to moderate
regional left ventricular systolic dysfunction with inferior
akinesis and inferior septal/inferior lateral [**Last Name (LF) 95894**], [**First Name3 (LF) **]
40%. Known modearte-to-severe aortic valve stenosis (area
0.9cm2) and left ventricular hypertrophy. He had repeat
echocardiogram which did not show any significant changes. He
did have intermittent periods of dyspnea which were thought most
likely to be due to intermittent flash pulmonary edema that
seemed to be provoked by pain or anxiety and responded to low
dose morphine 0.25mg x1 or NTG. In addition, when hypertensive
these episodes responded quickly to metoprolol 5mg IV x1. He
was not diuresed given poor oral intake during his admission and
hypotension on admission following lasix administration for
dyspnea.
5) AF with RVR - he remained in sinus rhythm during the majority
of his hospital stay but did have period of afib with RVR with
HR 110s while he was in the ICU. At that time his metoprolol
was at a lower dose of 12.5mg [**Hospital1 **]. His Metoprolol dose was
increased to back to 37.5mg [**Hospital1 **] and he did not have any
recurrance of Afib.
6) Bladder Spasm, penile pain - patient had episodes of severe
bladder spasm and pain for which he was evaluated by urology.
There was not evidence of urinary retention however foley
placement was difficulty due to his BPH. In addition, he had
[**7-22**] penile pain following foley placement which improved with
removing foley and morphine 0.25mg IV. In speaking with urology
there was not evidence of obstruction or retention. There was
no growth on urine culture however he was treated with bactrim
for 3 day course given that he had pyuria and bladder spasm.
7) Gout - cont home allopurinol. held colchicine
8) Hyperlipidemia - cont home statin
9) FEN - regular diet
10) FULL CODE, confirmed with pt and son
11) Communication - Son [**Name (NI) 12584**] primary contact: (H)
[**Telephone/Fax (1) 95895**], (W) [**Telephone/Fax (1) 95896**].
Daughter [**Name (NI) **]: [**Telephone/Fax (1) 95897**]
Medications on Admission:
allopurinol 300mg PO daily
ASA 325mg daily
amlodipine 2.5mg daily
atorvastatin 80mg daily
plavix 75mg daily
colace 100mg [**Hospital1 **]
colchicine .6mg [**Hospital1 **] prn
imdur 60mg daily
metoprolol succinate 37.5 mg [**Hospital1 **]
NTG 0.3 SL
pantoprazole 40mg [**Hospital1 **]
Polysaccharide Iron suppliment 150mg daily
terazosin 1mg qhs
Discharge Medications:
1. Ipratropium Bromide 0.02 % Solution Sig: One (1) Neb
Inhalation Q6H (every 6 hours).
2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
8. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day): last day of treatment is [**2123-9-7**].
9. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO DAILY (Daily).
10. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
12. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
13. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) Neb Inhalation every four (4) hours as needed for SOB.
14. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tab
Sublingual as directed as needed for chest pain: please take for
your chest pain, you may take every five minutes for up to three
pills. Please be cautious with this as it can cause low blood
pressure.
15. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO twice a day
as needed for Acute Gout.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1643**] Center
Discharge Diagnosis:
Severe Anemia likely due to gastrointestinal bleeding
Coronary Artery disease
Unstable Angina
NSTEMI
Chronic Systolic and [**Hospital6 7216**] heart failure, EF 40%, severe LVH
Moderate-severe AS (area 0.8-1.0cm2 in [**2123-3-17**])
COPD
Discharge Condition:
stable
Discharge Instructions:
You were admitted to the hospital because you were having severe
chest pain. You were found to have a low blood count of 21
which was likely the cause of your worsened chest pain. You
were transfused a total of 5 units PRBC during your hospital
stay. You were seen by the gastroenterologists who think that
you are losing blood in your GI tract. You did not have a
colonoscopy or endoscopy because of the severity of your heart
disease. At this time the gastroenterologists felt that it
would be risky to do either of these procedures. You will
likely continue to require occasional blood transfusions to
treat the blood loss becausing having a low blood count will
cause you to have more chest pain. You were discharged to rehab
to help work on your strength.
Medications:
1)You were changed to Flomax to treat your prostatic
hypertrophy. This is a better medication given your other
medical conditions. Please stop taking your terazosin.
2) Your dose of allopurinol was reduced to be more appropriate
for your age and kidney function.
3)
None of your other medications were changed.
Please follow up as below.
Please call your doctor or return to the hospital if you
experience any concerning symptoms including chest pain that is
wore or different than your usual angina, light headedness,
fainting, low blood pressure, difficulty breathing, evidence of
blood loss or any other worrisome symptoms.
Followup Instructions:
1) Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2123-9-15**] 2:20
2) Provider: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 4200**], M.D. Date/Time:[**2123-9-16**] 11:20
3) Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 13545**]
Date/Time:[**2123-9-23**] 11:00
Completed by:[**2123-9-7**]
|
[
"414.01",
"428.43",
"413.9",
"458.8",
"715.36",
"596.8",
"410.71",
"491.21",
"427.31",
"578.9",
"401.9",
"428.0",
"153.8",
"600.00",
"V45.82",
"396.8",
"274.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
14458, 14512
|
7145, 12418
|
304, 310
|
14794, 14803
|
4513, 5419
|
16264, 16721
|
4070, 4155
|
12814, 14435
|
14533, 14773
|
12444, 12791
|
14827, 16241
|
4170, 4494
|
230, 266
|
5439, 7122
|
338, 2959
|
2981, 3486
|
3502, 4054
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,149
| 128,758
|
28859
|
Discharge summary
|
report
|
Admission Date: [**2156-10-21**] Discharge Date: [**2156-11-1**]
Date of Birth: [**2134-10-14**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1666**]
Chief Complaint:
muscle aches, fever, rash
Major Surgical or Invasive Procedure:
Open muscle biopsy left thigh
Skin biopsy
History of Present Illness:
Ms. [**Known lastname **] is a 22 year old woman with history of depression
who presented to the emergency room with fever, headache, rash.
She had initially presented on [**10-19**] with headache and fever,
underwent a LP, and was ultimately discharged with diagnosis of
a viral syndrome. She returned the following day after fever to
104 at home, rash, worsened headache, bodyaches, and some
progressive dyspnea. After receiving approximately 4L over IVF
for tachycardia she developed increasing respiratory distress
and was taken to the MICU for further management. Of note, she
had started lamictal approximately 4 weeks prior to her initial
presentation.
.
Her review of systems at admission was positive for rigors,
fevers, fatigue, decreased oral intake, photophobia, nausea,
vomitting, blurry vision, minimal sore throat, feeling thirsty,
minimal cough productive of yellow sputum, intermittent
'all-over' abdominal pain, generalized weakness, low back pain
in the area of previous LP only, and rash over
face/torso/arms/legs that is mildly pruritic that started in the
ED on initial visit prior to medication administration.
Past Medical History:
1. Depression vs. bipolar, h/o suicide attempts
Social History:
Her parents are from [**Country 3594**]. Is a student at BU. Reports
tobacco use, last age 15, MJ use, last last night, occ etoh (2
glasses/week).
Family History:
DM in mother's side of family, parents/younger sister healthy
Physical Exam:
VS: T: 97.2 HR: 108 BP: 110/72 RR: 31 Sat: 95% on NRB
Gen: Fatigued, tachypneic but relatively comfortable
[**Name (NI) 4459**]: NCAT, [**Name (NI) 2994**], sclera injected, OP with whitish exudate,
tonsillar enlargement, mild errythema, mm moist, moderate
photophobia. Tounge pierced--looks clean.
Neck: Mild stiffness, no LAD, JVD 8cm
CV: tachycardic but no m/r/g
Resp: Diffusely coarse, bronchial breath sounds, rales at bases,
with ? egohpany at bases
Abdomen: Soft, diffusely tender to palpation with guarding, no
rebound, no obvious HSM by percussion or palpation
Ext: No c/c/e. DP/radial pulses 2+ bilaterally
Neuro: A + O x3, CN II-XII intact, Motor [**5-15**] both upper and
lower extremities, sensation intact to light touch
Skin: Diffuse, blanching erythematous patches across face,
sparing periorbital area, neck, trunk, upper extremities,
sparing palms & soles, stops on upper thighs. No blistering or
mucosal lesions
Pertinent Results:
[**2156-10-21**] 01:00AM WBC-8.6 RBC-3.89* HGB-11.5* HCT-32.9* MCV-85
MCH-29.6 MCHC-35.0 RDW-12.9
[**2156-10-21**] 01:00AM PLT SMR-NORMAL PLT COUNT-195
[**2156-10-21**] 01:00AM NEUTS-89.7* BANDS-0 LYMPHS-8.4* MONOS-0.9*
EOS-0.7 BASOS-0.3
[**2156-10-21**] 01:00AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2156-10-21**] 01:00AM GLUCOSE-107* UREA N-7 CREAT-0.7 SODIUM-138
POTASSIUM-3.5 CHLORIDE-108 TOTAL CO2-17* ANION GAP-17
[**2156-10-21**] 01:00AM ALT(SGPT)-101* AST(SGOT)-129* ALK PHOS-38*
AMYLASE-88 TOT BILI-0.2
[**2156-10-21**] 01:00AM LIPASE-25
[**2156-10-20**] 12:30AM CEREBROSPINAL FLUID (CSF) PROTEIN-35
GLUCOSE-76
[**2156-10-20**] 12:30AM CEREBROSPINAL FLUID (CSF) WBC-3 RBC-1*
POLYS-48 LYMPHS-22 MONOS-30
[**2156-10-20**] 12:18AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.016
[**2156-10-20**] 12:18AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2156-10-20**] 12:18AM URINE RBC-0 WBC-[**3-15**] BACTERIA-FEW YEAST-NONE
EPI-[**6-20**]
[**2156-10-21**] 01:45AM ASA-NEG ETHANOL-NEG ACETMNPHN-14.6
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2156-10-21**] 01:45AM LITHIUM-0.5
[**2156-10-21**] 01:55AM LACTATE-1.1
[**2156-10-21**] 03:20AM URINE bnzodzpn-NEG barbitrt-POS opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2156-10-21**] 03:20AM URINE UCG-NEGATIVE
[**10-27**] TSH 5.1, T4 5.5, FT4 0.91
[**10-25**] ESR 29, CRP 91
[**10-27**] CK (peak) 24,665
[**10-25**] aldolase 54
.
MICRO
Parasite smear negative
HIV antibody negative, viral load undetectable
RPR negative
HCV antibody negative, viral load undetectable
HBV HBsAb+, HBsAg-, HBcAb-
HAV IgG+, IgM-
EBV VCA IgG+, EBNA IgG+, VCA IgM-
CMV IgG+, IgM-
Anti-streptolysisn O titer positive (titer 400-800)
Monospot negative
Influenza A, B antigen negative
Enterovirus PCR of CSF negative
[**Location (un) **] B serologies negative
Mycoplasma IgM negative
Leptospira antibody negative
Parvovirus IgG+, IgM-, PCR-
HHV6 PCR pending (as [**10-31**])
West [**Doctor First Name **] PCR pending (as of [**10-31**])
Anaplasma phagocytophilum pending (as of [**10-31**])
[**10-23**] fecal culture negative, campylobacter negative, C diff
negative
[**10-23**] viral culture negative to date (as of [**10-31**])
[**10-19**], [**10-21**], [**10-22**], [**10-23**] blood cultures negative
[**10-21**], [**10-22**] urine culture negative
[**10-22**] urine legionella antigen negative
[**10-21**] throat culture negative
[**10-20**] CSF gram stain no polys or organisms, culture negative
SPEP, UPEP negative
.
.
[**Last Name (un) **]
Anti [**Doctor First Name **]-1 negative
Anti PM1 pending (as of [**10-31**])
Anti SSA, SSB negative
Anti Scl70 negative
Anti Sm+, Sm/RNP+
Anti SRP pending (as of [**10-31**])
CH50 50, C3 128, C4 39
Anti MI-2 pending (as of [**10-31**])
[**Doctor First Name **] positive at 1:640, speckled
RF negative
.
.
[**10-21**] CT chest/abd/pelvis
1. Thickened septal lines at the lung bases with more focal
ground-glass and pulmonary opacities predominately at the right
lung base. This may represent developing ARDS or multifocal
pneumonia with superimposed interstitial edema.
2. Mild periportal and pericholecystic edema.
3. No evidence of acute appendicitis.
.
[**10-21**] TTE
The left atrium is elongated. A small secundum atrial septal
defect is present. Left ventricular wall thickness, cavity size
and regional/global systolic function are normal (LVEF 60-70%)
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. No masses or
vegetations are seen on the aortic valve. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. No mass or vegetation is seen
on the mitral valve. The estimated pulmonary artery systolic
pressure is normal. No vegetation/mass is seen on the pulmonic
valve. There is no pericardial effusion.
.
[**10-25**] CTA chest
CT CHEST POST-ADMINISTRATION OF INTRAVENOUS CONTRAST:
There has been interval decrease in the bibasilar effusions and
atelectasis when compared to the prior examination. There is
diffuse ground glass opacity throughout both lungs. The
previously seen multifocal patchy opacities have largely cleared
up but are now replaced by more diffuse ground glass appearance
to the lungs. There is stable appearance to the residual thymic
tissue seen in the anterior mediastinum. There is a stable small
pericardial effusion.
There is no central pulmonary embolism. Given the extent of
atelectasis and lung change, it is difficult to exclude
subsegmental pulmonary emboli. There is no aortic dissection.
The coronary arteries arise from the normal expected anatomical
location.
The visualized liver and spleen appear unremarkable.
MUSCULOSKELETAL: The bone windows do not show lytic or blastic
lesions.
1. Mixed responce with improvement and decreased size of the
bibasal effusions, atelectasis, and patchy opacities.
2. Diffuse ground glass opacity is now present throughout both
lungs which is more pronounced since the prior examination.
3. Differential again remains between an infectious process,
alveolar edema or evolving ARDS.
.
[**10-27**] MRI lower extremities
1. Diffuse edema within the musculature of the thighs
bilaterally, particularly in the rectus muscles and hamstring
muscles. No fascial enhancement or intramuscular abscess or
fluid collection is identified. The findings are consistent with
diffuse myositis.
2. Mild right greater trochanteric bursitis.
.
[**10-28**] CXR PA/LAT
FINDINGS: Two views compared with study one day earlier and
chest CTs dated [**10-25**] and [**2156-10-22**] and chest radiograph dated
[**2156-10-21**]. Over the series of studies, there has been significant
improvement in the diffuse bilateral lung disease. There are now
very small nodules, largely peripheral, predominating in the
right lung base. No focal consolidation and no pleural effusion
is seen. The cardiomediastinal silhouette and pulmonary vessels
are within normal limits.
.
[**10-26**] Skin Biopsy
Skin, right thigh, punch biopsy:
Pauci-inflammatory vacuolar interface dermatitis with melanin
incontinence, early thickening of the basement membrane zone
(PAS stain), and slight increase in dermal mucins (Alcian blue
stain), consistent with dermatomyositis in the appropriate
clinical setting (see note).
Note: No eosinophils are seen, however a drug reaction cannot be
entirely excluded.
.
[**10-29**] Thigh muscle biopsy
PENDING
Brief Hospital Course:
1. Fever, rash, weakness: Rash began as diffuse erythema and
papules, and is currently simply erythema over face/chest/back,
sparing palms & soles. Pt had leukocytosis with left shift, and
no eosinophilia. Throughout stay, fever, her wbc and rash
slowly decreased. Infection did not appear to be bacterial,
supported by negative LP, no focal findings on CXR, and negative
UA. Various etiologies were considered including viral
etiologies, drug reaction, and rheumatologic causes.
.
Accordingly, the patient was seen by multiple consultant
services including Infectious Diseases, Rheumatology, and
Dermatology. The differential for her presentation was thought
to include autoimmune inflammatory disorders such as
dermatomyositis, a drug reaction e.g. to lamictal, or a
post-viral syndrome. She had an extensive workup for infectious
etiologies which was non-revealing. Although many of her
clinical and laboratory findings were suggestive of
dermatomyositis, she did improve without systemic treatment, and
her muscle biopsy was not consistent with this diagnosis. Her
skin biopsy was consistent with dermatomyositis, but her muscle
biopsy showed toxic myonecrosis without findings consistent with
dermatomyositis. Additionally she had quite high CK levels
consistent with significant tissue death, which peaked during
the admission in the mid 20,000s before declining before
discharge.
.
Per dermatology, given the possibility that this was a drug
reaction, she should NOT ever retake lamictal or structurally
related compounds. She will need to follow up in rheumatology
clinic as an outpatient. She will continue working with physical
therapy as she recovers her muscle strength.
.
Despite the patient's denials to the contrary, her urine was
positive for barbituates and opiates at the time of admission,
which might raise the possibility of unknown toxins associated
with street pharmacology. A toxic ingestion was not diagnosed
and repeatedly denied by the patient but, given her history of
past suicide attempts by polypharmacy overdose, remained
possible. Her HIV and HCV tests were negative.
.
3. Depression: The patient was evaluated by the psychiatric
consult service who recommended discontinuation of all her
psychiatric medications as an inpatient, with prn ativan as
needed. Pending resolution of her elevated LFTs, she will
restart Zoloft. She will need close psychiatric followup as an
outpatient. As noted above, she should NOT take lamictal or
structurally related compounds in the future. She denied
suicidality both on arrival and at the time of discharge. Her
outpatient treater felt that she was unlikely to be suicidal and
actually felt that she had been improving psychiatrically over
the last several months. As above, she denied any recent drug
use although her urine tox screen was positive for opiates and
barbituates.
.
4. Hypothyroidism: Her TSH was mildly elevated but this is
unlikely to be diagnostic of a true hypothroid state in the
setting of an acute illness. She was therefore not started on
any thyroid hormone replacement in house. Her primary care
provider should repeat [**Name Initial (PRE) **] thyroid panel as an outpatient.
.
5. Respiratory Distress: Chest CT showed "ground-glass
appearance raising question of PNA vs. ARDS. Pt was on 4L 02
requirement at admission, but was soon weaned off O2. Tachypnea
improved and resolved over the course of admission. CTA showed
no PE. Symptomatic support was given.
.
6. Renal - Continued good renal function during admission. She
had an elevated protein/creatinine ratio; Upep showed no
monoclonal bands. She had a markedly elevated CK; we hydrated at
100 ml/hr, while monitoring respiratory function.
.
7. Depression: Psychiatry service was consulted. For concern for
drug reaction, we removed zoloft, Li and lamictal. Continued
ativan prn for anxiety. Zoloft was restarted given low suspicion
of involvement in drug reaction. Her outpatient psychiatrist was
contact[**Name (NI) **] and updated.
.
8. Anemia: Normocytic with an admitting level 34, climbed to
37.5 by time of discharge, etiology was unclear.
.
9. Transaminitis: plateaued during admission, consistent with
either drug reaction or toxic ingestion. A RUS UQ was negative.
.
10. Hypocalcemia. Seen on admission; resolved on discharge.
11. Hypothyroidism. TSH and free T4 showed mild hypothyroidism;
should be re-evaluated after symptoms resolve.
.
Medications on Admission:
zoloft->does not know dose
lithium->does not know dose
MVI
Lamictal - started 4 weeks ago
Discharge Medications:
1. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed: Take with food.
Disp:*30 Tablet(s)* Refills:*0*
2. Clobetasol 0.05 % Cream Sig: One (1) application Topical [**Hospital1 **]
(2 times a day) as needed for itching.
Disp:*1 tube* Refills:*0*
3. Zoloft 25 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. Outpatient Physical Therapy
Physical therapy [**2-14**] x/week, until judged recovered by her
primary care physician and physical therapist. Diagnosis:
bilateral myopathy of unknown etiology, drug reaction vs severe
viral reaction.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
1. myopathy
Secondary
2. depression
Discharge Condition:
Good, afebrile and with improved muscle strength, ambulating
with crutches
Discharge Instructions:
You came to the hospital with fevers, body aches, rash, and
weakness. You developed increasing breathing difficulties that
required that you be treated in the intensive care unit. You
underwent skin and muscle biopsies to help determine the cause
of your weakness. The cause of your symptoms is not known for
certain, but the cause is most likely either a reaction to the
lamictal, or a viral infection.
.
Please take your medications as directed and follow up with your
primary care doctor and the rheumatology clinic. You should have
your thyroid function tests repeated by Dr. [**First Name (STitle) **] as your tests in
the hospital suggested your thyroid might be a little
underactive. Please follow up with Dr. [**Last Name (STitle) 69630**] ([**Telephone/Fax (1) 69631**])
for treatment of your depression. Please follow up with the
dermatology clinic as well. All of these appointments are listed
below.
.
Call Dr. [**First Name (STitle) **] ([**Telephone/Fax (1) 7056**]) and seek medical attention at once
if you develop:
*** worsened weakness, worsening rash, difficulty breathing,
fevers, chills, sweats, depression or thoughts of hurting
yourself, or other symptoms that worry you or your family
Followup Instructions:
Primary care:
Please follow up with Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 7056**] in the next two
weeks.
.
Rheumatology:
Dr [**Last Name (STitle) 16618**], [**11-22**], 5 pm; [**Hospital Unit Name 69632**]. You will need Dr[**Last Name (STitle) 17650**] office to give a referral for
this visit; her office can fax the referral to [**Telephone/Fax (1) 44524**].
.
Psychiatry:
Please follow up with Dr. [**Last Name (STitle) 69630**] ([**Telephone/Fax (1) 69631**]) at your
appointment with her on Thursday at 1 pm.
.
Dermatology
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6730**], MD Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2156-12-10**] 3:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1672**] MD, [**MD Number(3) 1673**]
|
[
"710.3",
"443.0",
"E936.3",
"311",
"518.82",
"780.6",
"276.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.11",
"83.21"
] |
icd9pcs
|
[
[
[]
]
] |
14645, 14651
|
9476, 13884
|
344, 388
|
14738, 14814
|
2835, 9453
|
16072, 16889
|
1802, 1866
|
14024, 14622
|
14672, 14717
|
13910, 14001
|
14838, 16049
|
1881, 2816
|
278, 306
|
416, 1551
|
1573, 1622
|
1638, 1786
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,155
| 172,691
|
34254
|
Discharge summary
|
report
|
Admission Date: [**2130-11-15**] Discharge Date: [**2130-11-19**]
Date of Birth: [**2074-4-9**] Sex: F
Service: MEDICINE
Allergies:
Levaquin / Ciprofloxacin / Flagyl / Morphine Sulfate
Attending:[**First Name3 (LF) 949**]
Chief Complaint:
CHIEF COMPLAINT: GI bleeding
REASON FOR MICU TRANSFER: GI bleeding
Major Surgical or Invasive Procedure:
Endoscopy with banding [**2130-11-15**].
History of Present Illness:
Ms. [**Known lastname 4384**] is a 56 y/o female with primary sclerosing
cholangitis with cirrhosis, portal hypertension, ascites, and
known grade III varices who presented to [**Hospital3 25150**] (NH)
this morning with complaint of hematemesis. She reported feeling
unwell for about 48 hours and then in the morning felt nauseated
and vomited dark, clotted bloody material. She presented to the
local ER by EMS, and was reportedly hypotensive in the field
with SBP in the 80s, and given 250cc NS. In the ED, her HR was
97 and BP was 117/55, and essentially stable over the morning
hours. She received one additional liter of normal saline there
and 2 units of packed red cells. She was started on an
octreotide drip, given 2gm of IM ceftriaxone. She had two
subsequent episodes of emesis.
She was transferred to [**Hospital1 18**] for further evaluation and
management.
Upon arrival, she underwent EGD which showed grade III varices
that were banded x4. There was stigmata of bleeding seen from
the varices, and the remainder of the stomach and the duodenum
were endoscopically free of bleeding. She tolerated the
procedure well though complained of a dull [**7-19**] ache along her
esophagus, worse if she swallowed saliva.
.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, abdominal pain, diarrhea, constipation,
BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
- Cirrhosis: Due to secondary sclerosing cholangitis of unkown
etiology. Listed for [**Month/Year (2) **] on [**2129-11-4**] with a MELD score of
17. Complicated by portal venous hypertension and grade [**3-14**]
varices in the lower [**2-11**] of the esophagus accompained with
ascities. De-listed in [**10-18**] due to insurance.
- Chronic Celiac artery occlusion, [**2130-7-6**].
- Acute pancreatitis seondary to gall stone obstruction, s/p
spincterectomy, stone extraction and cholesysectomy [**2129-3-29**].
- Depression
- Irritable bowel syndrome
- Fibromyalgia
- GERD
- Hypertension
Social History:
Patient is a retired nurse who lives with her husband and two
daughters in [**Name (NI) **] [**Name (NI) 3844**], she feels safe in this
relationship. Her daughters have special education needs and the
family is very involved with theraputic horse back riding for
their children. She denies any tobacco history, had [**2-10**] drink a
week EtOH use prior to illness, and remote history of marajuana
use.
Family History:
Mother had significant depression, alcohol abuse and HTN.
Father Cardiovascular disease. Paternal Grandmother had "liver
cancer".
Physical Exam:
Vitals - T:99.5 BP:133/57 HR: 95 RR: 18 02 sat: 100% RA
GENERAL: Tired appearing but non-toxic. She remains drowsy after
the procedure with novel in hand
HEENT: OP dry
CARDIAC: II/VI SM at R/LUSB
LUNG: CTAB
ABDOMEN: protuberant, mild right sided tenderness mid u/l quads
EXT: trace-1+ edema
NEURO: CN grossly intact
DERM: no rashes appreciated
Pertinent Results:
Imaging:
EGD [**2130-11-15**]
Varices at the lower third of the esophagus (ligation)
Old and fresh blood noted in the stomach but no active bleeding
was noted.
Otherwise normal EGD to third part of the duodenum.
.
CXR Portable AP [**2130-11-15**]:
FINDINGS: There is no evidence of pneumomediastinum or free
intraperitoneal air. The heart size and mediastinal contours are
normal. Minimal linear atelectasis at left base with otherwise
clear lungs. Splenomegaly is noted within the upper abdomen.
.
Liver U/S [**2130-11-16**]:
1. Patent hepatic vessels, with hepatopetal flow in the portal
system. Slow flow in the main portal vein measuring
approximately 10 cm/sec.
2. Cirrhotic liver, with splenomegaly and a moderate amount of
ascites in the abdomen. 2.3-cm porta hepatis node.
3. CBD dilatation measuring up to 14 mm, similar to prior CT. No
obstructing stone or lesion identified.
.
Laboratory tests:
[**2130-11-15**] 04:13PM BLOOD WBC-9.4 RBC-2.81* Hgb-9.5* Hct-28.5*
MCV-102* MCH-33.8* MCHC-33.3 RDW-17.6* Plt Ct-228
[**2130-11-16**] 01:17AM BLOOD WBC-13.7* RBC-2.95* Hgb-9.6* Hct-29.1*
MCV-99* MCH-32.6* MCHC-33.0 RDW-17.8* Plt Ct-294
[**2130-11-17**] 05:10AM BLOOD WBC-8.7 RBC-2.40* Hgb-7.8* Hct-23.9*
MCV-100* MCH-32.4* MCHC-32.6 RDW-17.5* Plt Ct-258
[**2130-11-18**] 09:00AM BLOOD WBC-8.9 RBC-2.56* Hgb-8.4* Hct-26.6*
MCV-104* MCH-32.9* MCHC-31.6 RDW-17.2* Plt Ct-275
[**2130-11-19**] 06:25AM BLOOD WBC-9.1 RBC-2.33* Hgb-7.8* Hct-24.2*
MCV-104* MCH-33.3* MCHC-32.1 RDW-17.3* Plt Ct-244
[**2130-11-15**] 04:13PM BLOOD Neuts-79.0* Lymphs-16.7* Monos-3.0
Eos-0.8 Baso-0.5
[**2130-11-15**] 04:13PM BLOOD PT-17.4* PTT-34.3 INR(PT)-1.6*
[**2130-11-17**] 05:10AM BLOOD PT-16.9* PTT-34.0 INR(PT)-1.5*
[**2130-11-18**] 09:00AM BLOOD PT-16.9* INR(PT)-1.5*
[**2130-11-19**] 06:25AM BLOOD PT-17.2* INR(PT)-1.5*
[**2130-11-15**] 04:13PM BLOOD Glucose-95 UreaN-33* Creat-0.7 Na-138
K-5.4* Cl-108 HCO3-24 AnGap-11
[**2130-11-16**] 01:17AM BLOOD Glucose-112* UreaN-39* Creat-0.8 Na-139
K-6.4* Cl-109* HCO3-26 AnGap-10
[**2130-11-16**] 02:32AM BLOOD Glucose-123* UreaN-39* Creat-0.7 Na-140
K-4.9 Cl-111* HCO3-24 AnGap-10
[**2130-11-17**] 05:10AM BLOOD Glucose-120* UreaN-27* Creat-0.8 Na-140
K-3.8 Cl-110* HCO3-22 AnGap-12
[**2130-11-18**] 09:00AM BLOOD Glucose-94 UreaN-24* Creat-0.8 Na-138
K-4.4 Cl-108 HCO3-23 AnGap-11
[**2130-11-19**] 06:25AM BLOOD Glucose-91 UreaN-22* Creat-0.7 Na-137
K-4.2 Cl-108 HCO3-22 AnGap-11
[**2130-11-15**] 04:13PM BLOOD ALT-48* AST-100* LD(LDH)-180 AlkPhos-495*
TotBili-4.2*
[**2130-11-16**] 01:17AM BLOOD ALT-53* AST-126* LD(LDH)-375*
AlkPhos-505* TotBili-3.9*
[**2130-11-18**] 09:00AM BLOOD ALT-54* AST-109* LD(LDH)-156 AlkPhos-484*
TotBili-2.8*
[**2130-11-19**] 06:25AM BLOOD TotBili-2.4*
[**2130-11-15**] 04:13PM BLOOD Albumin-2.4* Calcium-8.1* Phos-3.5 Mg-1.9
[**2130-11-16**] 01:17AM BLOOD Calcium-8.5 Phos-4.1 Mg-2.1
[**2130-11-16**] 02:32AM BLOOD Albumin-2.5*
[**2130-11-17**] 05:10AM BLOOD Calcium-8.2* Phos-3.0 Mg-1.8
[**2130-11-18**] 09:00AM BLOOD Calcium-8.3* Phos-3.5 Mg-1.9
Brief Hospital Course:
Ms. [**Known lastname 4384**] is a 56 year old female with secondary sclerosing
cholangitis of unclear etiology and subsequent cirrhosis with
portal hypertension, history of recurrent SBP, who was admitted
to [**Hospital1 18**] for a variceal bleed.
.
# UGIB: The patient initially presented to OSH with hematemesis
and was transfused two units PRBCs prior to transfer to [**Hospital1 18**].
On arrival, she had an upper endoscopy that showed stigmata of
recent variceal bleed from grade III varices, and 4 bands were
placed. She had some mild-moderate post procedure discomfort and
one episode of emesis with a small amount of old clot seen. She
was treated with an octreotide infusion and IV PPI. Never
hemodynamically unstable. She responded appropriately to
transfusions was never hemodynamically unstable. In addition,
she completed a five day course of antibiotics with
ceftriaxone/cefpodoxime.
.
# Sclerosing Cholangitis/Cirrhosis: History of portal
hypertension, recurrent SBP and now presenting with variceal
bleed. Diuretics were held during the admission, with a plant
to restart at discharge. Additionally, she was treated with a
five day course of antibiotics for SBP prophylaxis ([**Date range (1) 23977**]).
Patient had planned a trip to [**Hospital3 **] for [**Hospital3 **]
evaluation, but in light of variceal bleed decided to postpone
her travel until repeat banding could be performed (several
weeks). The patient was discharged with a plan to follow-up at
[**Hospital1 18**] for repeat banding in [**4-13**] days.
.
#RUQ and epigastric pain: Initially felt to be related to
stretch from banding procedure. An upright CXR ruled out free
air and she was treated with dilaudid for symptomatic relief, as
well as maalox and sucralfate and the pain resolved.
.
#. Leukocytosis: Thought to be secondary to variceal bleed,
trended down over course of hospitalization. The patient
remained afebrile and received a five day course of antibiotics
for SBP prophylaxis.
.
# HTN: Nadolol was intially held out of concern for variceal
bleed and risk of hemodynamic instability. It was restarted
several days after banding, and well-tolerated.
.
# Depression: Continued home medications with sertraline.
.
# Fibromyalgia: Continued home medications with sertraline and
amitriptyline.
Medications on Admission:
(from OMR verified with patient)
Amitryptyline 20 mg po qhs
<<Augmentin 875-125 mg po daily (alt qmo with TMP-SMX, currently
off)
Furosemide 40 mg po qdaily
Nadolol 20 mg po daily
Sertraline 150 mg po daily
Spironolactone 100 mg po daily
Bactrim DS 800-160 mg po daily (currently on)
Ursodiol 1000 mg po BID
Discharge Medications:
1. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Sertraline 50 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
3. Amitriptyline 10 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
4. Ursodiol 250 mg Tablet Sig: Four (4) Tablet PO BID (2 times a
day).
5. 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*
6. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO BID (2 times
a day): Please dispense oral solution if possible.
Disp:*60 Tablet(s)* Refills:*0*
7. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
8. Aldactone 100 mg Tablet Sig: One (1) Tablet PO once a day.
9. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO once a
day: Take for one month then switch to bactrim.
10. Bactrim 80-400 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Diagnoses:
Cirrhosis
Sclerosing Cholangitis
Variceal bleed
Discharge Condition:
Good; hemodynamically stable, tolerating POs, ambulating,
improved.
Discharge Instructions:
You have a diagnosis of cirrhosis with portal hypertension, and
were admitted to the hospital for a variceal bleed. You were
given blood transfusions, and underwent endoscopy with banding
of your esophageal varices. You will need repeat banding of
these varices at the end of the coming week; [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 23170**] will
call you with the appointment for your banding procedure.
.
We made the following changes to your medications:
Start sucralfate: this medication will help to coat your
esophagus and may make it more comfortable for you to eat.
Start Pantoprazole: this is a medication to decrease acid
production in your stomach.
In addition, you were given a new prescription for Bactrim
suppression, a lower dose to be taken twice per day to avoid GI
upset.
We did not make any further changes to your home medications.
Please take all medications as prescribed.
.
It is extremely important that you call 911 or return to the
emergency room if you have another episode of bleeding - either
bright red blood or black tarry stools. Please call your doctor
or
return to the ED if you experience any fever, chills, shortness
of breath, dizziness, chest pain or other complaints.
Followup Instructions:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 23170**] will call you with your appointment for repeat
banding; it will likely be this coming wed, [**Last Name (un) **], or friday.
Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2131-1-10**] 11:20
|
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"447.4",
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"571.5",
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"V49.83",
"414.01",
"576.1",
"456.20",
"311"
] |
icd9cm
|
[
[
[]
]
] |
[
"42.33"
] |
icd9pcs
|
[
[
[]
]
] |
10127, 10133
|
6524, 8823
|
381, 424
|
10236, 10306
|
3485, 6501
|
11587, 11913
|
2971, 3104
|
9181, 10104
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10154, 10215
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10330, 10783
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3119, 3466
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10812, 11564
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292, 343
|
452, 1917
|
1939, 2532
|
2548, 2954
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,660
| 114,875
|
27306
|
Discharge summary
|
report
|
Admission Date: [**2128-5-9**] Discharge Date: [**2128-6-1**]
Date of Birth: [**2050-6-10**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Change in mental status
Major Surgical or Invasive Procedure:
Tracheostomy placemnet
PEG tube placement
IVC filter placement
History of Present Illness:
The patient is a 77 year old man with a h/o atrial fibrillation
transferred from an outside hospital for unresponsiveness
(intubated/sedated at OSH). Patient reportedly has not been his
"normal self" lately. He has been more agitated (getting
ativan), confused, and lethargic at times. He had had several
hospital visits for a pneumonia and had been on vancomycin and
levoquin. Patient reportedly found unresponsive with "eyes
rolled back". He was not shaking or tremoring. An ambulance
was called and he was taken to [**Hospital **] Hospital. There he was
found to be minimally responsive, blood pressures 170s to 180s
over 80's, with a fever to 102.2, his blood sugar was 61, and
NIH stroke scale was calculated at 24 primarily for minimal
movement on the right, no verbal output, and decreased level of
attention. He was treated with unasyn, levaquin, IVF and loaded
with dilantin.
Two hours later the patient received a head ct which showed a
left frontal hypodensity. Three hours later, he remained
lethargic and was intubated for airway protection (etomidate,
succin., vecuron.). He was transferred and arrived at [**Hospital1 18**]
approximately 90 minutes later.
Past Medical History:
-h/o recent LLL pna
-deafness since 20yrs ago
- blindness since childhood - optic nerve atrophy?
-adult onset diabetes
-h/o decreased vision
-h/o dvt's
-h/o atrial fibrillation
-esophagitis
-h/o seizures
-h/o closed head injury
Social History:
Sister is HCP Resident of [**Location (un) 511**] Home for Deaf. The
patient lives at the home for the deaf, and does not smoke or
drink alcohol.
Family History:
No family history of strokes.
Physical Exam:
Vitals: 102.2 126 164/102 20
General: older man in no distress, intubated
Neck: supple
Lungs: decreased breath sounds at bases
CV: tachcardic, no murmur appreciated
Abdomen: non-tender, non-distended, bowel sounds present
Ext: warm, no edema
Neurologic Examination:
intubated and sedation; no eye opening to loud voice or [**Last Name (un) **];
agitated to sternal rub; pupils reactive to light 3 to 1 mm
b/l;
no blink to threat b/l, intact corneal; facial asymmetry
difficult to appreciate with intubation tube; slightly increased
tone throughout (L>R), spontaneous mvt in left arm and leg,
withdraws to noxious stimuli on right arm and leg (left side
too), reflexes 2+ at knees, 1 at ankles, 2 in Bic, Tric, [**Last Name (un) 1035**],
toe up on right, equiv. on left
EXAM AT DISCHARGE:
Pertinent Results:
MRA BRAIN W/O CONTRAST [**2128-5-9**] 9:04 PM
MRI OF THE BRAIN WITH MRA OF THE CIRCLE OF [**Location (un) **]
CLINICAL INDICATION: Infarction and neurologic deficit.
Multiplanar T1- and T2-weighted images of the brain was
obtained. MRA of the circle of [**Location (un) 431**] was performed according to
standard departmental protocol.
No prior brain MRIs are available for comparison. There is a
moderate-sized area of diffusion abnormality involving the left
frontal lobe and a smaller region involving the left internal
capsule consistent with areas of subacute infarction. These
might contain byproduct of blood due to susceptibility. The
ventricular system is symmetrical without hydrocephalus.
Scattered areas of magnetic susceptibility are noted within the
left basal ganglia and the right parietal [**Doctor Last Name 352**]-white junction.
These could represent areas of hemosiderin deposition or foci of
amyloid angiopathy. Correlation with CT of the brain would be
helpful to exclude the possibility of hemorrhagic lesions. T2
hyperintensity is noted within the brainstem and periventricular
white matter suggestive of chronic microvascular ischemic or
gliotic changes. No subdural hemorrhage is seen. The study is
degraded by motion artifact. There is opacification of the
paranasal sinuses.
Signal flow voids are present along the intracranial portions of
the carotid and basilar arteries. There is absence of signal
flow void within the right vertebral artery suggestive of total
occlusion.
IMPRESSION: Diffusion abnormality involving the left internal
capsule and the left frontal lobe most likely consistent with
areas of subacute infarction. Overall study was degraded by a
motion artifact. Scattered foci of magnetic susceptibility
suggestive of possible amyloid angiopathy. There is suggestion
of a small left-sided developmental venous anomaly involving the
left parietal lobe. Correlation with gadolinium-enhanced images
might be helpful along with followup. Areas of chronic ischemia
are seen within the brainstem and thalami.
MRA of the circle of [**Location (un) 431**] was performed according to standard
departmental protocol. There is significant ectasia and
dilatation of the distal vertebrobasilar circulation with slight
aneurysmal fusiform dilatation of the proximal basilar artery.
There is significant tortuosity of the cavernous ICA. The right
distal vertebral artery is not visualized and is probably
totally excluded. No intracranial aneurysms are seen involving
the anterior or middle cerebral arteries.
IMPRESSION: Significant ectasia of the distal vertebrobasilar
circulation with mild fusiform aneurysmal dilatation of the
proximal basilar artery. Total occlusion of the right distal
vertebral artery. The intracranial circulation was otherwise
patent.
CT HEAD W/O CONTRAST [**2128-5-11**] 9:20 AM
FINDINGS: There is redemonstration of the large left posterior
frontal acute infarction with a small amount of hemorrhagic
contents. Infarction also appears to extend to the posterior
limb of the left internal capsule where the largest hemorrhagic
component, approximately 3 mm in size is visualized. These
findings were demonstrated on the prior MR study. There is a
minor amount of mass effect caused by the infarct, as shown by
continued demonstration of a few millimeters rightward bowing of
the septum pellucidum. There has been no change in ventricular
size. The prominently ectatic and partially calcified visualized
distal left vertebral artery as well as basilar artery are
imaged. There are likely ectatic as well as calcified components
involving the cavernous portion of the left internal carotid
artery with atherosclerotic calcification of the cavernous
portion of the right internal carotid artery. There is a
moderate amount of mucosal thickening in the right ethmoid
sinus, with a meniscus-shaped soft tissue density, probably
fluid and mucosal thickening, within the posterior aspect of the
right and left sphenoid air cells.
CAROTID SERIES COMPLETE PORT [**2128-5-10**] 1:03 PM
FINDINGS: Duplex evaluation was performed of both carotid
arteries. Minimal plaque was identified.
On the right, peak systolic velocities are 107, 84, 104 in the
ICA, CCA, and ECA respectively. The ICA to CCA ratio is 1.3.
This is consistent with less than 40% stenosis.
On the left, peak systolic velocities are 115, 92, 140 in the
ICA, CCA, and ECA respectively. The ICA to CCA ratio is 1.3.
This is consistent with less than 40% stenosis. The right
vertebral artery was not visualized due to an IV line and the
jugular vein. There is antegrade flow in left vertebral artery.
IMPRESSION: Minimal plaque with bilateral less than 40% carotid
stenosis.
Cardiology Report ECHO Study Date of [**2128-5-12**]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: 3.2 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: 5.1 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: 4.8 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: *1.3 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: *1.3 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 3.6 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: >= 60% (nl >=55%)
Aorta - Valve Level: 3.6 cm (nl <= 3.6 cm)
Aorta - Ascending: *3.6 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.5 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 0.6 m/sec
Mitral Valve - A Wave: 0.8 m/sec
Mitral Valve - E/A Ratio: 0.75
Mitral Valve - E Wave Deceleration Time: 215 msec
TR Gradient (+ RA = PASP): *19 to 27 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
Findings:
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
Overall normal LVEF
(>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic root diameter. Mildly dilated ascending
aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets. No AS.
Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
Mild PA
systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: No pericardial effusion.
Conclusions:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The ascending aorta is mildly dilated. The aortic
valve leaflets are mildly thickened. There is no aortic valve
stenosis. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
No cardiac source of embolus identified (cannot definitively
exclude).
Agitated saline contrast study at rest (2 injections) revealed
evidence of intracardiac shunt consistent with the presence of
an atrial septal defect (or stretched patent foramen ovale).
Neurophysiology Report EEG Study Date of [**2128-5-12**]
OBJECT: 77-YEAR-OLD MAN WITH LEFT FRONTAL STROKE, R/O SEIZURE
ACTIVITY. THE HEART WAS MONITORED BECAUSE DISORDERS OF HEART
RHYTHMS
[**Month (only) **] PRODUCE NEUROLOGICAL COMPLAINTS AS DESCRIBED ABOVE DISORDERS
SUCH AS
SEIZURES, WHEN SYMPTOMATIC, [**Month (only) **] PRODUCE CARDIAC ARRHYTHMIAS.
TIME SAMPLES: In wakefulness, the background over the entire
left
hemisphere is low voltage and slow in the 7 Hz theta frequency
range.
In addition, there is diffuse delta frequency slowing seen over
the
entire left hemisphere. In addition, there are bursts of
generalized
slowing in the [**2-9**] Hz delta frequency range.
BACKGROUND: Over the right hemisphere is also slow with the [**7-14**]
Hz
theta frequency range but well-defined. There are sharp features
over
the right parietal region with phase reversing around P4.
PUSHBUTTONS: There is one pushbutton event recorded. There is no
seizure activity recorded in this file.
AUTOMATIC SEIZURE DETECTIONS: Captured three events. Two events
represent movement artifact due to manipulation of the
respiratory
tubes. The third event is due to a technical artifact over the
O2 lead.
AUTOMATIC SPIKE DETECTIONS: This algorithm captured 186 events.
The
majority of the events were due to movement artifact. Some
events
show moderate to high voltage sharp slowing with phase reversing
around
P4.
SLEEP: Review of the time sample showed some prolonged episodes
of slow
wave sleep. In this episode, the background asymmetry was not as
emphasized as in wakefulness.
CARDIAC MONITOR: Normal sinus rhythm wtih a rate of 84 bpm.
IMPRESSION: This is an abnormal 24-hour discontinuous EEG
telemetry
obtained in wakefulness progressing to stage IV sleep due to the
presence of slow background activity and low voltage activity
over the
entire left hemisphere with intermixed delta frequency slowing.
In
addition, there is sharp slowing with phase reversing in the
right
parietal region. This finding suggests cortical and subcortical
dysfunction over the entire left hemisphere with cortical
dysfunction
over the right parietal region. The background activity suggests
deep,
midline subcortical dysfunction and is consistent with a mild
diffuse
encephalopathy. There were no clear epileptiform discharges
seen.
PERC G/G-J TUBE PLMT [**2128-5-14**] 7:55 AM
PHYSICIANS: [**First Name8 (NamePattern2) **] [**Doctor Last Name 26181**] and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3175**] with Dr. [**First Name (STitle) 3175**], the
attending radiologist, present and supervising during the
procedure.
PROCEDURE: Following written informed consent, the patient was
positioned supine on the angiography table. A preprocedure
timeout was performed to confirm patient, procedure, and site.
Standard sterile prep and drape of the ventral abdomen.
Initial fluoroscopy confirmed appropriate positioning of the
nasogastric tube within the proximal stomach. Air outlined the
transverse colon which is situated inferior to the gastric air
bubble. Air was insufflated through the nasogastric tube to
distend the stomach. Local anesthesia with 10 cc of 1% lidocaine
subcutaneously. Using fluoroscopic guidance and a 19-gauge
needle, two percutaneous T-fasteners were placed in the stomach
near the junction of the proximal two-thirds and distal
one-third. In each instance confirmation of positioning of the
needle in the stomach lumen was confirmed by efflux of air from
the needle and by the instillation of contrast outlining rugal
folds of the stomach. After placing the second T- fastener, a
0.035-inch guidewire was advanced through the needle into the
stomach and the needle was exchanged for a 5-French Kumpe
catheter. Using a guidewire and Kumpe catheter, the guidewire
was advanced beyond the ligament of Treitz into the jejunum. The
catheter was exchanged for 10-French and then 12-French fascial
dilators and then a 14-French peel-away sheath. A 14-French
[**Doctor Last Name 9835**] gastrojejunostomy catheter was placed over the guidewire
through the sheath and positioned with its tip in the proximal
jejunum. The peel-away sheath and guidewire were removed. The
catheter's locking loop was formed within the second portion of
the duodenum. Contrast injection through the catheter confirmed
appropriate positioning of the catheter tip within the jejunum.
Peristalsis was present within the opacified jejunal loops.
The catheter was flushed with saline and then capped. The
catheter was fixed in place with a StatLock device and a sterile
dressing was applied. The catheter can be used in four hours
post- procedure if there are no signs of peritonitis. The cotton
roll anchors for the T-fasteners should be removed in seven- ten
days.
IMPRESSION: Successful placement of a 14-French [**Doctor Last Name 9835**]
gastrojejunostomy catheter with tip in the jejunum. The catheter
can be used four hours post- procedure if there are no signs of
peritonitis.
[**2128-5-9**] 05:45PM %HbA1c-10.0* [Hgb]-DONE [A1c]-DONE
[**2128-5-9**] 04:21PM LACTATE-3.5* NA+-140 K+-5.1
[**2128-5-9**] 08:24PM CEREBROSPINAL FLUID (CSF) PROTEIN-65*
GLUCOSE-134
[**2128-5-9**] 08:24PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-16*
POLYS-81 LYMPHS-19 MONOS-0
[**2128-5-9**] 08:24PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-67*
POLYS-90 LYMPHS-10 MONOS-0
[**2128-5-9**] 04:21PM HGB-15.0 calcHCT-45
[**2128-5-9**] 04:20PM GLUCOSE-281* UREA N-9 CREAT-0.9 SODIUM-134
POTASSIUM-7.9* CHLORIDE-98 TOTAL CO2-20* ANION GAP-24*
[**2128-5-9**] 04:20PM ALT(SGPT)-45* AST(SGOT)-71* LD(LDH)-995* ALK
PHOS-120* AMYLASE-105* TOT BILI-0.8
[**2128-5-9**] 04:20PM LIPASE-29
[**2128-5-9**] 04:20PM ALBUMIN-3.7 CALCIUM-9.0 PHOSPHATE-3.2
MAGNESIUM-1.8
[**2128-5-9**] 04:20PM TRIGLYCER-170*
[**2128-5-9**] 04:20PM TSH-0.69
[**2128-5-9**] 04:20PM PHENYTOIN-20.1*
[**2128-5-9**] 04:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-6.0
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2128-5-9**] 04:20PM WBC-9.4 RBC-4.73 HGB-15.1 HCT-43.8 MCV-93
MCH-31.9 MCHC-34.5 RDW-15.0
[**2128-5-9**] 04:20PM NEUTS-79.5* LYMPHS-15.1* MONOS-4.2 EOS-0.4
BASOS-0.7
[**2128-5-9**] 04:20PM PLT COUNT-429
[**2128-5-9**] 04:20PM PT-13.8* PTT-21.9* INR(PT)-1.2*
Title: WOUND CARE
Asked to evaluate Mr. [**Known lastname 66946**] for impairment in skin integrity.
He is a 77 year old male admitted from NH for the deaf in
[**Location (un) 4047**]. Medical history: Afib, PNA, DM, DVT's, Seizures,
Closed Head Injury, deafness.
He has had frequent stooling. He has an erythematous rash with
fungal involvement B/L groin, medial thighs, perianal tissue,
gluteals, and coccyx. There are two partial thickness ulcers
B/L
gluteals related to excoriation. Each site is approx. 1.5 x 1
cm., 100% pink and superficial, irregular wound edges, no
drainage, periwound tissue is erythemic with fungal infection.
There is no edema, induration, crepitus, or fluctuance.
Alb 2.7 on [**5-16**], Hgb 10.4, Hct 32.2, Glucose 149, BUN 3
Recommendations: Pressure relief measures per pressure ulcer
guidelines.
On Atmos Air Air Mattress for pressure relief
Turn and repostion every 1-2 hours off back
If OOB, limit sit time to one hour at a time
and sit on a pressure relief cushion
Gentle cleansing perianal and gluteal tissue
with foam cleanser
Pat dry
Apply antifungal ointment to affected skin,
follow with Double Guard Zinc Oxide Paste -
esp over partial thickness ulcers on
gluteals
follow with Aloe Vesta Moisture Barrier
Ointment TID and prn
Support nutrition
CXR [**5-24**]:
CHEST AP: There is interval development of left retrocardiac
opacity and an evolving opacity in the left perihilar region. A
right IJ line is seen with its tip in the right atrium.
Tracheostomy tube is in place. Linear atelectasis is present in
the right lung base.
An IVC filter is in place. Splenic artery calcification is
noted.
IMPRESSION: New retrocardiac consolidation with an evolving left
hilar pneumonia.
CTA [**5-19**]:
INDICATION: Tachypnea, fever, and increased sputum in a patient
with known deep venous thrombosis.
COMPARISON: No previous chest CT. Abdominal CT of one day prior
is available for correlation.
TECHNIQUE: Axial multidetector CT images of the chest were
obtained without contrast utilizing low-dose technique and then
with intravenous Optiray administered at 2 cc per second via a
central venous catheter. Multiplanar reformatted images were
obtained.
CHEST CT ANGIOGRAM: Good opacification of the pulmonary arteries
was achieved despite the slow rate of injection. Filling defects
are present in the lobar arteries to the right upper and right
lower lobes, as well as in many of their segmental and
subsegmental branches, consistent with acute pulmonary embolism.
No left-sided pulmonary emboli are identified. Extensive
atherosclerotic calcifications are present in the aorta and
coronary arteries. There is no pericardial effusion.
Small bilateral pleural effusions are present, previously noted
on the abdominal CT of one day earlier. There is no enhancement
of pleural surfaces and no evidence of loculation to suggest
empyema, although empyema cannot be excluded by CT scan. There
is moderate atelectasis in both lower lobes. The
tracheobronchial tree is patent to the subsegmental levels.
The imaged portions of the liver and spleen appear unremarkable.
Extensive splenic artery calcifications are noted. There are no
suspicious lytic or sclerotic bone lesions.
CT RECONSTRUCTIONS: Multiplanar reconstructions confirm the
findings demonstrated on the axial images. Value grade is 2.
Findings were discussed with Dr. [**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) **] at 5 p.m. on
[**2128-5-18**].
IMPRESSION:
1. Pulmonary emboli in the right upper and right lower lobar
arteries and their segmental and subsegmental branches.
2. Small bilateral pleural effusions. Empyema cannot be excluded
by CT scan.
3. Moderate bibasilar atelectasis.
4. Atherosclerosis in the aorta and coronary arteries.
LE U/S:
FINDINGS: Grayscale and Doppler son[**Name (NI) 1417**] of both common
femoral, superficial femoral and popliteal veins were performed.
Thrombus is identified in both lower extremities extending from
the common femoral veins to the popliteal veins. The thrombus
appears occlusive on the left side. On the right, there is a
large rounded but nonocclusive thrombus within the right common
femoral vein. It appears somewhat unstable in appearance. More
echogenic contours in the right superficial femoral vein may
represent chronic thrombus. These findings were discussed with
Dr. [**Last Name (STitle) 724**] at 4:45 p.m., [**2128-5-14**].
IMPRESSION: Extensive bilateral lower extremity DVTs as
described above.
Brief Hospital Course:
The patient is a 77 year old man with a history of afib p/w
fever and decreased responsiveness. Neuroimaging consistent with
subacute left frontal infarction with hemorrhagic conversion and
chronic hypertensive microangiopathy.
1. Neurologic:
The patient is deaf and legally blind at baseline. His initial
exam on presentation: No eye opening to noxious stimuli
(although has opened eyes briefly to sternal rub). Pupils:
briskly reactive, left irregular post-surgical. Right faical
weakness, OCRs and corneals intact. Withdraws left arm, and
both legs to noxious stimuli, minimal proximal withdrawal of
right arm to noxious. Both toes up bilaterally. MRI/MRA was
performed and showed left frontal DWI bright, T2 FLAIR
hyperintensity, likely aubacute infarction; susceptibility
artefact into left frontal stroke bed and ipsilateral posteior
internal capsule with extension into posterior [**Doctor Last Name 534**] of left
lateral ventricle. Carotid U/S showed < 40% stenosis.
EEG was abnormal 24-hour discontinuous EEG telemetry obtained
in wakefulness progressing to stage IV sleep due to the presence
of slow background activity and low voltage activity over the
entire left hemisphere with intermixed delta frequency slowing.
In addition, there is sharp slowing with phase reversing in the
right
parietal region. Corrected dilantin levels were initially
slightly supratherapeutic. The patient was in the ICU for
several weeks with no neurological improvement. Trach and peg
were placed as he could not be weaned from the vent or fed.
When transferred to the floor, dilantin was discontinued for no
real suggestion of seizure activity (medication had been started
for EEG rather than clinical finding). After several weeks of
no neurological progress on the floor, and several days after
dilantin was discontinued, he began to wake up and move both
extremities spontaneously. He was treated with coumadin due to
the likely embolic nature of the stroke, as well as various
comorbidities (including afib, dvt's and PEs). On the day of
discharge, he was awake and alert; he could not follow verbal
commands (deaf and legally blind) but appeared to be scanning
sentences when written in large, dark, block letters. He had no
speech production. He did, however, pick up on nonverbal cues
at times, lifting his arm appropriately when presented with a
blood pressure cuff. He continued to move his arms and legs
very well, thought could not follow commands to test specific
muscle strength; he could get out of bed to chair with a lot of
assistance. He showed normal sensation to light tactile
stimulation on four extremites and face (tickling) with
localization. He worked well with PT and had made some
neurological progress; rehab facility was suggested, and he was
transferred there when medically stable.
2. Respiratory:
He initially had a pneumonia treated with Zosyn + Flagyl x 7 day
course early in the hospitalization. For failure to wean from
the vent, a trach was placed. He tolerated trachmask, and was
transferred to the stepdown unit on the floor. Later, on the
floor, after DVT's had been detected on LE u/s, and after a
filter had been placed and the patient started on coumadin, he
developed persistent tachycardia, tachypnea and low sats; CTPA
was performed and revealed several PE's in the right lung. He
was continued on coumadin and heparin (discontinued when
coumadin therapeutic) and respiratory rate and tachycardia
improved greatly within 3-4 days. He also developed increased
secretions and the need for suctioning the trach site; chest
xray showed a new pneumonia and he was initially treated with
flagyl and levaquin; this was switched to flagyl + zosyn when he
dropped his bp to 80s as well as sats once again. He improved
the following day, and as his clinical status improved, he made
neurological headway as well. He should remain on flagyl +
zosyn for completion of 14 day course(to be completed at rehab
facility on [**2128-6-7**]).
3. CVS -
He was found to be in atrial fibrillation initially requiring
rate control; Echo showed EF>55%, ASD (likely) vs PFO. He was
treated with heparin and coumadin, and transitioned to coumadin
alone when INR was therapeutic. His rate normalized later in
the hospitalization once infections and pulmonary embolus were
better treated. Lower extremity ultrasounds were checked
revealing bilateral LE DVTs: thrombus occlusive on the left
side. Nonocclusive thrombus right common femoral vein,
unstable in appearance. More echogenic contours in the right
superficial femoral vein may represent chronic thrombus. He had
a R IVC placed; arteriogram was performed to evaluate IVC filter
via R IJ; duplicate left renal system noted and left iliac vein
not seen. Subsequent to filter placement, abdominal CT-venogram
was performed which revealed a tortuous renal artery (see
results section). Subsequent to filter placement, he developed
pulmonary embolism and
4. Endocrine: he was placed on an insulin sliding scale, close
fingersticks were checked. Blood sugars were elevated and Hba1c
>10. Sliding scale was tightened around the time of discharge.
5. Renal: monitor ins/outs; occasionally he had low urine
output and required fluid boluses. Ins and outs were even and
renal function was adequate at discharge.
6. ID: Bcx, UCx, CSF Cx were negative. LP had been performed and
CSF was not suspicious for meningitic/encephalitic picture. He
was treated twice for pneumonia (see above). He does have a
history of cdiff, but is on flagyl currently. He had no cdiff
during this admission.
7. GI: he underwent PEG (G-J tube) placement by IR, and tube
feeds were started and eventually achieved goal. Hospital course
was complicated by GI bleeding and dropping hematocrits,
requiring blood transfusions. As his INR was not therapeutic at
the time, this was thought potentially related to bowel
ischemia. Coumadin was continued despite GI bleeding, as he had
overwhelming coagulopathic disorders (PEs, DVTs, ASD in heart,
stroke). GI was consulted and recommended PPI; they did not
feel scope would be beneficial as it would not change
management, and that he would need to be continued on coumadin.
GI bleeding stopped when INR was therapeutic, and he tolerated
coumadin well. Tube feeds had been held for GI workup, and were
restarted once the patient's GI bleeds had stablized. He has
brown OB+ stool at this time. He should have egd and
colonoscopy as an outpatient.
8. CODE STATUS:
This was addressed with his HCP, his sister [**Name (NI) 66947**] [**Name (NI) 66946**]
[**Telephone/Fax (1) 66948**]. He was made DNR/DNI.
Medications on Admission:
-insulin
-plavix
-protonix
-scopalamine patch
-glyburide
-trazodone
-milk of magnesia
-colace
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Cartridge [**Telephone/Fax (1) **]: use as
directed below Injection ASDIR (AS DIRECTED): Check BG 4x/d
-If bg<70 give [**2-9**] amp d50
-If bg 71-150 do nothing
-If bg 151-200 give 3 units insulin
-If bg 201-250 give 6 units insulin
-If bg 251-300 give 9 units insulin
-If bg 301-350 give 12 units insulin
-If bg >350 give 12 units insulin and notify MD.
2. Acetaminophen 325 mg Tablet [**Month/Day (2) **]: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for fever.
3. Docusate Sodium 150 mg/15 mL Liquid [**Month/Day (2) **]: One (1) PO BID (2
times a day) as needed.
4. Senna 8.6 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID (2 times a
day) as needed.
5. Warfarin 2 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO HS (at bedtime).
6. Piperacillin-Tazobactam 4.5 g Recon Soln [**Month/Day (2) **]: One (1) Recon
Soln Intravenous Q8H (every 8 hours) for 7 days: please
continue until [**2128-6-7**]; d/c central line when abx complete.
7. Metronidazole 500 mg IV Q8H
8. Flagyl 500 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO three times a day
for 7 days: please continue until [**2128-6-7**].
9. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN
10ml NS followed by 1ml of 100 units/ml heparin (100 units
heparin) each lumen QD and PRN. Inspect site every shift
10. Prevacid 15 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
Left frontal stroke
Bilateral lower extremity DVT
Pulmonary Embolism
Duplicate left renal system
Atrial fibrillation
GI Bleed - likely related to bowel ischemia
Atrial septal defect (vs PFO)
Pneumonia x 2
Discharge Condition:
Stable - please see d/c summary for d/c exam.
Discharge Instructions:
Please [**Name8 (MD) 138**] MD or return to ED if new symptoms of focal weakness
or new neurological impairment.
Followup Instructions:
Please call Dr.[**Name (NI) 35878**] office for f/u appointment (neurology)
after discharge from rehab (in [**7-15**] weeks) ([**Telephone/Fax (1) 7394**].
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2128-6-1**]
|
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|
[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,890
| 166,927
|
29604
|
Discharge summary
|
report
|
Admission Date: [**2167-9-27**] Discharge Date: [**2167-10-5**]
Date of Birth: [**2114-2-4**] Sex: F
Service: MEDICINE
Allergies:
Clindamycin / Morphine / Tetracycline / Penicillins
Attending:[**First Name3 (LF) 477**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
R pleurodesis with chesttube placement [**2167-9-28**]
History of Present Illness:
53 year-old female with metastatic breast cancer with known
pulmonary, liver and bone metastases admitted from home with
increasing shortness of breath at rest and with exertion.
Pt recently admitted to [**Hospital1 **] [**Date range (1) **] with sob and dyspnea
at the time underwent Left sided thoracentesis with improvement
in sympotms. States she felt better (no sob, no cough) for ~[**2-1**]
days and since than has progressively felt worse. Specifically
sob with lying flat and DOE. Denies any chest pain. Has also had
a cough but denies fevers, chills, nausea, vomiting. Denies sick
contacts or recent travel. Of note patient was scheduled for a
MRI as an outpatient for monitoring of known bony metastases,
however, did not feel like she would be able to lie flat for it.
.
Currently she has minimal symptoms of sob while sitting up in a
chair. + cough. ROS had episode of diarrehea after a CT scan ~1
week ago, however, states this is improved now. Denies any
worsening of her baseline back pain. denies any numbness,
tingling or bladder or stool incontinence.
Past Medical History:
1. Breast Cancer: Diagnosed with post-menopausal infiltrating
carcinoma with ductal and lobular features in [**3-/2165**], ER
positive and PR negative, Her-2 negative. Status post
right-sided modified radical mastectomy with combined sentinel
lymph node and lymph node dissection. 2 sentinel LN positive as
well as 3 nonsentinel LN for a total of 5 out of 30 sampled
lymph nodes positive. Lymphovascular invasion was present as
well. The tumor was grade [**1-31**]. She completed dose-dense
Adriamycin and Cytoxan followed by 4 cycles of dose-dense Taxol
with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 13648**]. Following this, she underwent XRT to
the chest wall, followed by Arimidex in 11/[**2164**]. In [**12/2166**], she
began to feel a sensation of a muscle pull between the shoulders
of the mid to upper back. Imaging ultimately revealed recurrent
disease in the spine. She started Xeloda [**1-/2167**], and received
XRT to T2. Had been receiving Taxotere and Avastin, stopped in
[**8-7**].
2. Hypertension
3. Seasonal allergies
Social History:
She lives with her husband in [**Name (NI) 21892**], [**State 350**].
Non-smoker.
Family History:
Not reviewed with patient.
Physical Exam:
VITALS:
T 96.2 BP 119/76 HR 102 RR 24 O2 95%RA
.
GEN: Middle aged female in nad, pleasant.
HEENT: Anicteric, MMM, PERRL
RESP: Good air movement with slight decreased bs at left base.
NO crackles or wheezing.
CVR: RRR. Normal S1, S2. No r/m/g
Abd: soft, obese, nt
Ext: no edema
Neuro: A&O X 3, CN II-XII intact, strength 5/5 upper and lower
ext and symmetrical.
Pertinent Results:
[**2167-9-30**] Pleural fluid:
POSITIVE FOR MALIGNANT CELLS; consistent with metastatic
adenocarcinoma.
.
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2167-10-5**] 12:00AM 6.0 3.45* 10.4* 33.0* 96 30.1 31.4 15.4
200
[**2167-10-4**] 12:00AM 4.5 3.37* 10.3* 32.4* 96 30.6 31.9 15.6*
158
[**2167-9-30**] 03:28AM 8.6 3.75* 11.5* 35.8* 96 30.6 32.0 15.9*
147*
[**2167-9-29**] 12:15AM 12.1*# 4.16* 12.8 41.0 99* 30.7 31.2
15.7* 255
[**2167-9-28**] 12:30AM 5.5 3.95* 12.0 37.5 95 30.3 32.0 15.9*
216
.
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2167-10-5**] 12:00AM 95 25* 1.5* 140 3.6 109* 23 12
[**2167-10-4**] 12:00AM 89 31* 1.6* 137 3.6 106 22 13
[**2167-10-1**] 12:00AM 101 39* 2.2* 140 3.9 108 21* 15
[**2167-9-30**] 04:26PM 124* 37* 2.2* 139 4.1 107 21* 15
[**2167-9-28**] 12:30AM 90 15 0.7 140 4.0 106 24 14
.
Admission CXR [**2167-9-27**]
In comparison with the study of [**9-21**], there is little change in
the bilateral pleural effusions, more prominent on the left. The
area of increased opacification at the right base has not
progressed and may well have represented only fortuitous
superimposition of vascular structures. Some atelectatic change
is seen in the retrocardiac region.
Brief Hospital Course:
ASSESSMENT/PLAN: 53 yo F with metastatic breast ca and known
bilateral pleural effusions admitted with dyspnea for
pleurodesis.
.
# Dyspnea: Initially admitted with dyspnea due to bilateral
pleural effusion, underwent L pleurodesisi with chesttube
placement. Also underwent R thoracentesis to drain off pleural
fluid. Respirations improved however pt did not feel that she
could lay flat due to fear of dyspnea as well as pain for MRI
lumbar area that had been scheduled to evaluate for mets to
spine. CT was d/c'ed without incidence - no pneumothorax. Pt was
weaned off oxygen prior to discharge home.
.
# Respiratory distress: Developed acidemia and hypoxia after
overdose on Dilaudid PCA pump. Pt was started on Narcan drip.
Hypercarbic respiratory failure improved without intubation,
however required BIPAP. All pain medications were held except
tylenol. Pt was continued on supplemental O2 and weaned to off
and aggressive incentive spirometry. At discharge, pt had
adequate sats on room air.
.
# UTI: Pt with complaint of dysuria, per UA, urine culture with
lactobacillus. Pt completed a 3 day course of ciprofloxacin.
.
# Acute renal failure: Pt developed acute renal failure while in
the intensive care unit. FeNa < 1%, Cr.levels improved daily
with gentle rehydration. Cr. was 1.5 at discharge.
.
# T/L spine metastasis: Although no worsening of symptoms
currently, she was scheduled for outpt MRI, however was unable
to lay flat due to orthopnea related to L pleural effusion.
After b/l pleural effusions had been drained, pt was reluctant
to undergo the MRI in house in part due to fear of orthopnea
when flat and pain. She is to undergo MRI as an outpatient.
.
# Hypertension: Was well controlled on home regimen metoprolol
100mg daily.
.
# Pain: From L pleurodesis and s/p CT placement/removal, had
been placed on dilaudid PCP for pain control however overdosed
and had [**Hospital Unit Name 153**] stay. Upon return to the floor, pt was fearful of
overdose and used minimal pain meds. Oxycodone as needed as well
as acetaminophen scheduled.
.
Pt reached maximal hospital benefit and was discharged home to
follow up with PCP and oncologist.
Medications on Admission:
2:2:2 solution - benadryl, maalox and viscous lidocaine
Metoprolol 100 mg daily
Oxycodone prn
Protonix 40mg daily
Tessalon perle prn.
Famciclovir 500 mg [**Hospital1 **] (started 1 wk ago for ?oral HSV)
*
ALLERGIES: She reports allergies to PCN (rash), Clindamycin
(rash) and tetracycline (rash).
Discharge Medications:
1. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*60 Tablet(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).
4. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 2 days.
Disp:*4 Tablet(s)* Refills:*0*
5. Lidocaine-Diphenhyd-[**Doctor Last Name **]-Mag-[**Doctor Last Name **] 200-25-400-40 mg/30 mL
Mouthwash Sig: Five (5) ml Mucous membrane PRN.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Bilateral pleural effusions
Metastatic breast CA
Hypertension
Discharge Condition:
Good, O2sats 95% RA
Discharge Instructions:
You were admitted with shortness of breath, we have drained the
fluid from around your lung.
.
We have not made any changes to your home regimen. Please take
Cipro for 2 additional days.
.
Please come to the ED or call your PCP if you develop
chestpains, worsening shortness of breath, fevers or any other
worrisome symptoms.
Followup Instructions:
Stitch removal: Please come to interventional pulmonology on
[**Hospital Ward Name **], [**Location (un) **] to have your stitches reomved.
[**Telephone/Fax (1) 3020**]
.
Please call your oncologist to make an appointment within 2
weeks of discharge
.
You will need to have MRI of lumbar spine rescheduled after
visit with your oncologist
[**Name6 (MD) **] [**Name8 (MD) 490**] MD, [**MD Number(3) 491**]
|
[
"518.81",
"197.7",
"599.0",
"197.2",
"401.9",
"965.09",
"197.0",
"584.9",
"E850.2",
"276.2",
"V10.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.92",
"34.04",
"34.91",
"34.09"
] |
icd9pcs
|
[
[
[]
]
] |
7552, 7601
|
4396, 6553
|
330, 386
|
7707, 7729
|
3111, 4373
|
8103, 8540
|
2686, 2714
|
6901, 7529
|
7622, 7686
|
6579, 6878
|
7753, 8080
|
2729, 3092
|
271, 292
|
414, 1487
|
1509, 2571
|
2587, 2670
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,866
| 189,358
|
18655
|
Discharge summary
|
report
|
Admission Date: [**2188-7-31**] Discharge Date: [**2188-8-4**]
Service: Trauma Surgery
HISTORY OF PRESENT ILLNESS: The patient is an 82-year-old
gentleman status post a fall from a height of approximately
three steps due to loss of balance. The patient fell,
striking the left side of his face. He denied loss of
consciousness.
He had a workup at an outside hospital ([**Hospital3 15175**]) where he underwent a computed tomography scan of
his cervical spine showing a C5-C6 injury with reported
evidence of possible spinal cord injury. There was also a
question of a possible dislocation in the C5-C6 region.
There was a report of a possible C3-C4 posterior dislocation
of the cervical spine. The patient was reportedly
complaining of bilateral hand tingling at the outside
hospital. He was started on a steroid protocol at the
outside hospital and subsequently transferred to [**Hospital1 346**] Emergency Department for spinal
service management.
PAST MEDICAL HISTORY: (The patient's past medical history
included that of)
1. Non-insulin-dependent diabetes mellitus.
2. Hypertension.
3. Question of an aneurysm.
4. Previous myocardial infarction.
MEDICATIONS ON ADMISSION: The patient's medications on
admission included allopurinol, hydrochlorothiazide, aspirin,
Monopril, potassium chloride, terazosin, and Zocor.
ALLERGIES: The patient's allergies included BEE STINGS.
SOCIAL HISTORY: Social history was noncontributory;
negative.
PHYSICAL EXAMINATION ON PRESENTATION: The patient's vital
signs upon presentation to the Emergency Department included
the following. His blood pressure was 187/83, his heart rate
was 65, his respiratory rate was 16, and his oxygen
saturation was 94%. Temperature was not initially recorded.
In general, the patient was alert and oriented times three
with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2611**] Coma Scale of 15. The patient was in no acute
distress. Head, eyes, ears, nose, and throat examination
revealed pupils were 3 mm bilaterally reactive. The tympanic
membranes were clear bilaterally. His midface was stable to
palpation. He had several superficial abrasions. There was
no malocclusion noted. His neck was in a cervical collar.
The trachea was midline. Cardiovascular examination revealed
a regular rhythm. Normal first heart sounds and second heart
sounds. Pulmonary examination revealed breath sounds to be
equal bilaterally with no crepitus on palpation. His abdomen
was soft, nontender, and nondistended. The FAST examination
was negative. His back revealed no stepoff or tenderness.
His pelvis was stable to [**Doctor Last Name **] and was nontender to palpation.
His rectal examination revealed a normal tone and heme-occult
negative. His extremities revealed no deformities or
dislocations. His pulses were 2+ and intact bilaterally.
His neurologic examination revealed his motor strength to be
[**6-2**] throughout. His sensory examination was grossly intact
bilaterally. Cranial nerves II through XII were grossly
intact. There was a question of some 2:1 point
discrimination deficit. Reflexes of the patella and Achilles
were brisk and equal bilaterally. There was no urinary or
fecal incontinence noted.
PERTINENT LABORATORY VALUES ON PRESENTATION: The patient's
laboratory data on the day of admission revealed his white
blood cell count was 5.9, his hematocrit was 38.6, and his
platelets were 171. Coagulation studies revealed his
prothrombin time was 12.7, his partial thromboplastin time
was 27.9, and his INR was 1.1. The patient's electrolytes
were as follows. His sodium was 143, potassium was 4.1,
chloride was 102, bicarbonate was 27, blood urea nitrogen was
15, creatinine was 0.9, and his blood glucose was 107. The
patient's serum toxicology and urine toxicology showed serum
positive for benzodiazepines. His urine toxicology was
negative.
PERTINENT RADIOLOGY/IMAGING: A chest x-ray revealed no
fractures or dislocations. No pneumothorax or hemothorax was
noted. His mediastinum was within normal limits. The final
impression was that of a prominent mediastinum which could
have been secondary to technique where an aortic injury was
not necessarily excluded. There were no fractures noted.
A computed tomography of the brain was also obtained. There
was no acute bleed or acute intracranial injury noted.
A computed tomography of the cervical spine was also obtained
in the Emergency Department which showed a C3-C4
hyperextension dislocation. The final impression of the
computed tomography of the cervical spine was as follows; a
grade 1 retrolisthesis of C3-C4 with significant spinal
stenosis. There was a question of lateral angulation of the
left C3 facet. Given his history of trauma and neurologic
symptoms, a magnetic resonance imaging was recommended.
ASSESSMENT: The patient is an 83-year-old gentleman, status
post a fall with a C3-C4 hyperextension and dislocation
injury which may have been chronic in nature. However, an
acute injury on top of his chronic lesion could not be ruled
out as well as his hand paresthesias.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: The
patient was admitted to the Intensive Care Unit. His steroid
protocol was continued; which consisted of an intravenous
dose of 2400 mg of Solu-Medrol continually over the first day
of admission.
The patient was made nothing by mouth and was admitted for
neurologic checks and a magnetic resonance imaging of his
cervical spine. He was continued on his home medications and
gastrointestinal prophylaxis.
During the patient's admission, on approximately [**7-31**], the
patient underwent a magnetic resonance imaging of his
cervical spine which showed severe cervical spondylosis and
multiple levels of severe spinal canal stenosis with
impingement of his cervical spine at the C3-C4, C4-C5, and
C5-C6 levels. An injury of the intraspinous ligament at
C3-C4 level was also noted. However, there was no frank
edema seen within the spinal cord itself.
Because of this, the patient was maintained in a cervical
hard collar throughout his hospital course. The patient was
placed on fall precautions, and a Neurosurgery consultation
was immediately obtained upon the day of admission.
The [**Hospital 228**] hospital course was as follows. The patient's
intravenous Solu-Medrol drip was continued for 24 hours; as
per Neurosurgery recommendations. During this time, the
patient did have episodes of delirium and agitation. This
was discussed with the Neurosurgery team. It was decided to
keep the patient on his steroid drip; to complete the steroid
protocol for an acute spinal cord injury.
The patient was experiencing hallucinations and some
agitation. The patient was placed in four-point restraints
for his own safety and one-to-one monitoring was obtained.
The patient's motor and sensory examinations remained intact
during this time, and his paresthesias resolved during his
hospitalization. His vital signs remained stable throughout
his hospitalization. He was transferred to the Surgical
Intensive Care Unit for close monitoring during his period of
agitation. His neurologic examination remained intact
throughout. He was treated with some Ativan and Haldol
during this time of agitation, and he completed his 24-hour
steroid protocol.
The patient's agitation resolved, and he was transferred back
to the surgical floor where his hard collar remained on at
all times. Physical Therapy was consulted. The patient
remained neurologically stable throughout the remainder of
his hospital course. His vital signs also remained stable,
and his paresthesias completely resolved. He developed no
new neurologic deficits of any kind during his hospital stay.
There were some reports from the nursing staff that the
patient self-discontinued his cervical collar several times
which had to be replaced. This issue was resolved with the
patient's family explaining to the patient the need for
maintaining the collar at all times.
It was suggested by Physical Therapy that the patient go to a
full inpatient rehabilitation center; however, the family
refused this and wanted to take the patient home under their
own supervision. It was discussed with the family and
explained to them the risks of the patient removing his
cervical collar and suffering an injury to his spinal cord
resulting in paralysis or possible death if he did not keep
his cervical collar on at all times until his follow-up
appointment. The family acknowledged this and consent was
also signed.
Therefore, the patient was stable and was able to be
discharged in the care of his family.
CONDITION AT DISCHARGE: The patient's condition on discharge
was stable.
DISCHARGE STATUS: The patient's discharge status was with
his family to home, under close 24-hour observation
acknowledged by his family.
DISCHARGE DIAGNOSES: His discharge diagnoses included the
following; status post closed head injury with significant
cervical spinal stenosis (as shown on magnetic resonance
imaging).
MEDICATIONS ON DISCHARGE: (Discharge medications included
the following)
1. Hydrochlorothiazide 25 mg by mouth once per day.
2. Atenolol 50 mg by mouth once per day.
3. Diazepam 5 mg by mouth at night.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient had an appointment at the Trauma Clinic for a
reassessment of his injury, and the telephone number was
provided to the patient [**Numeric Identifier 51193**]). The patient was to
call to schedule an appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
at the [**Hospital Unit Name **], [**Location (un) 10043**].
2. The patient had an appointment with neurosurgeon Dr.
[**First Name8 (NamePattern2) **] [**Name (STitle) 1327**] (telephone number [**Telephone/Fax (1) 2992**]) following his
flexion/extension neck films which were to be obtained as an
outpatient. This was discussed with the patient, and he
agreed and understood, as well as his family.
3. The patient was to report to Radiology for his
flexion/extension films prior to seeing Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1327**] in
approximately two weeks' time of his discharge.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. 2923
Dictated By:[**Name8 (MD) 5541**]
MEDQUIST36
D: [**2188-10-16**] 15:00
T: [**2188-10-20**] 08:36
JOB#: [**Job Number 51194**]
|
[
"E932.0",
"721.0",
"E849.0",
"250.00",
"952.05",
"E880.9",
"782.0",
"292.12",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8886, 9050
|
9077, 9257
|
1201, 1403
|
9290, 10445
|
5164, 8659
|
8674, 8864
|
126, 968
|
991, 1174
|
1420, 5130
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,723
| 153,663
|
51526+51527
|
Discharge summary
|
report+report
|
Admission Date: [**2178-6-9**] Discharge Date: [**2178-6-29**]
Date of Birth: [**2124-9-1**] Sex: M
Service: Surgery/Transplant
HISTORY OF PRESENT ILLNESS: The patient is a 53-year-old
male with a past medical history significant for post acute
tubular necrosis with end-stage renal dialysis (who had been
on hemodialysis) with hypertension and type 2 diabetes who is
status post cadaveric renal transplant approximately nine
days prior to admission.
He had been discharged to home two days earlier, but while at
home had been noted to have progressive difficulty voiding
and increasing pain in his abdomen. He came to the Clinic
and was unable to give a urine sample. He was admitted for
this. He denied nausea, vomiting, fevers, chills, night
sweats, shortness of breath, or dyspnea. He had not been
hemodialyzed during the postoperative period.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Type 2 diabetes.
3. Post infectious acute tubular necrosis.
4. End-stage renal disease; had been on hemodialysis for
approximately three years prior to transplant.
PAST SURGICAL HISTORY:
1. Left arteriovenous fistula.
2. Status post cadaveric renal transplant.
MEDICATIONS ON ADMISSION: (Medications on admission
included)
1. FK506 6 mg p.o. twice per day.
2. CellCept [**Pager number **] mg p.o. twice per day
3. Prednisone 20 mg p.o. once per day.
4. Protonix 40 mg p.o. once per day.
5. Valcyte 450 mg p.o. every other day.
6. Nystatin swish-and-swallow once per day four times per
day.
7. Lopressor 25 mg p.o. twice per day.
8. Norvasc 5 mg p.o. once per day.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on admission revealed temperature was 97.9, heart rate was
62, respiratory rate was 18, blood pressure was 139/92, and
oxygen saturation was 97% on room air. Blood glucose was
258. Head and neck examination revealed equal pupils.
Extraocular movements were intact. Lungs were clear to
auscultation bilaterally. Heart was regular in rate and
rhythm. Normal first heart sounds and second heart sounds.
His abdomen was soft and nontender over the graft. There was
guarding or rebound. His bowel sounds were slightly
decreased. His extremities were without cyanosis, clubbing,
or edema.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratory
values on admission revealed white blood cell count was 10.3,
hematocrit was 30.7, and platelets were 274. Sodium was 131,
potassium was 5.5, blood urea nitrogen was 90, creatinine was
4.5, and blood glucose was 119. Calcium, magnesium, and
phosphate were 10.7, 5, and 2.5.
HOSPITAL COURSE: The patient was admitted from the Clinic
to the service of Dr. [**First Name (STitle) **] on [**2178-6-9**].
On [**2178-6-9**], additionally, the patient had an ultrasound
which demonstrated a peritransplant fluid collection. No
hydronephrosis in the transplanted kidney. The patient was
started on Levaquin and Flagyl for a 7-day course when he was
admitted. A Foley was placed and drained approximately 145
cc and continued to have good urine output post the Foley
being placed. Additionally, the patient was started on
Kayexalate for his high potassium value.
He had a percutaneous drain placed on [**6-10**] which drained
approximately 900 cc of old blood and fluid; it was thought
not to be an abscess. He was moved back to a regular diet on
hospital day two.
On [**2178-6-12**], on hospital day three, the patient was found
to be in atrial fibrillation. The patient was changed from
his usual dose of carvedilol to metoprolol and titrated for
control of his atrial fibrillation. The Cardiology Service
was consulted. They recommended rate control with Lopressor,
and an echocardiogram, as well as to start Coumadin. The
patient was started on Coumadin on [**6-24**] for a goal INR of 2
to 2.5.
Throughout his hospitalization, after the initial drain was
placed under ultrasound-guidance the patient continued to
have a moderate amount of drain output. Successful
ultrasound on [**6-16**] and [**6-19**] demonstrated residual
transplant fluid collections which increased in size until
[**6-16**].
On [**6-19**], the patient was taken to the operating room with
Dr. [**First Name (STitle) **] for creation of a peritoneal window and a kidney
biopsy. He tolerated this procedure well with approximately
100 cc of crystalloid and minimal blood loss. A follow-up
ultrasound after this demonstrated a very small residual
fluid collection.
Additionally, on [**6-19**], the patient underwent a stress MIBI
which demonstrated marked ventricular enlargement with
hypokinesis and an ejection fraction of 44%; consistent with
a cardiomyopathy.
On [**2178-6-16**] the Podiatry Service was consulted for toe
pain and Raynaud's phenomenon. They recommended no treatment
for this and to follow up with their Clinic.
The patient continued to do postoperatively on [**2178-6-17**]
to [**2178-6-29**]. He was started back on his usual home
medications. Additionally, he was slowly coumadinized to his
goal INR. Per the Cardiology Service, additionally, the
patient was begun on a regimen of amiodarone for control of
his atrial fibrillation.
On [**2178-6-19**], on postoperative day two, the patient's
pigtail drain was discontinued.
The remainder of the hospitalization from [**2178-6-19**] to
[**2178-6-29**] was marked by slowly deteriorating renal
function with creatinine climbing from a value of 3.8 into
the low 5s. These were felt to be stable at this value.
On [**2178-6-21**], the Vascular Surgery Service was consulted
for cyanotic-appearing feet. The Vascular Surgery Service
felt the changes in his feet were likely secondary to his
Raynaud's and were chronic changes.
On [**2178-6-29**], with the patient's renal function stable,
and his ability to tolerate a regular diet, and able to
ambulate, and have his pain well controlled, and his
abdominal examination benign and unchanged for several days,
it was decided to discharge the patient to home. A followup
on his pathology demonstrated no events of acute or chronic
rejection. His immunosuppressive regimen was changed to
include only Rapamune, CellCept, and prednisone. From a
cardiovascular standpoint, his atrial fibrillation was
stabilized on a regimen of amiodarone and Lopressor. From a
renal standpoint, again, the biopsy showed no evidence of
acute or chronic rejection. His creatinine remained elevated
but stable at a value of approximately 5.2 to 5.3. Followup
was to be as per the transplant coordinator.
MEDICATIONS ON DISCHARGE:
1. Valcyte 450 mg p.o. every other day.
2. Protonix 40 mg p.o. once per day.
3. Bactrim one tablet p.o. once per day
4. Nystatin oral suspension 5 mL p.o. four times per day.
5. Insulin sliding-scale.
6. Colace 100 mg p.o. twice per day.
7. Venlafaxine 75 mg p.o. twice per day.
8. Dilaudid 4 mg p.o. q.3-4h. as needed (for pain).
9. Bisacodyl 10 mg p.o./p.r. once per day as needed (no
stool).
10. Sarna lotion one application topically three times per
day as needed.
11. Benadryl 25 mg p.o. q.h.s.
12. Aspirin 81 mg p.o. once per day.
13. Rosiglitazone maleate 4 mg p.o. twice per day.
14. Amiodarone 400 mg p.o. once per day.
15. Lopressor 12.5 mg p.o. twice per day.
16. Mycophenolate mofetil 1000 mg p.o. twice per day.
17. Prednisone 50 mg p.o. once per day.
18. Hydralazine 25 mg p.o. q.6h.
19. Isordil 30 mg p.o. once per day.
20. Tylenol.
21. Coumadin 3 mg p.o. once per day.
DISCHARGE DIAGNOSES: Lymphocele, status post cadaveric
renal transplant. Secondary diagnoses as in the Past Medical
History above.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1331**]
Dictated By:[**Name8 (MD) 16207**]
MEDQUIST36
D: [**2178-6-29**] 03:46
T: [**2178-7-1**] 08:30
JOB#: [**Job Number **]
Admission Date: [**2178-6-9**] Discharge Date: [**2178-7-14**]
Date of Birth: [**2124-9-1**] Sex: M
Service:
This is a death discharge dictation for Mr. [**Known lastname 6359**].
HISTORY OF PRESENT ILLNESS: The patient is a 53 year old
male, with past medical history of end stage renal disease,
hypertension, type II diabetes, and congestive heart failure,
who is status post a cadaveric renal transplant, which was
performed on [**2178-5-31**].
The patient had been discharged home initially following his
renal transplant on the 11th but returned on the [**2178-6-9**]. He returned for increasing abdominal pain and
difficulty voiding. At that time, he was found to have a
lymphocele around his transplanted kidney. He underwent CT
guided drainage of this lymphocele initially and then went to
the operating room on [**2178-6-17**] for creation of a peritoneal
window and lymphocele drainage. Following this, the patient
initially did well. He was evaluated by the cardiology
service on the [**6-12**]. He was found to be in atrial
fibrillation. They continued to follow the patient
throughout his hospitalization.
The patient did well initially following creation of his
peritoneal window. However, on the [**6-1**], the patient
began to complain of some chest pain and shortness of breath.
At that time, cardiac enzymes demonstrated a small treponin
leak. This was partially attributed to his congestive heart
failure by the cardiology service. He was transferred to the
Intensive Care Unit on the [**2178-7-2**], where he stayed
until about the [**2178-7-14**].
While in the Intensive Care Unit, he was evaluated by the
renal service and underwent successful round of hemodialysis
given his worsening renal failure.
Initially, he was seen by the infectious disease service.
The [**2178-7-14**], he was transferred from the Intensive
Care Unit to the regular surgical floor. At approximately
3:30 a.m., the surgical team was contact[**Name (NI) **]. The patient had
been found in bed unresponsive. ACLS protocols were
initiated. Resuscitative effort lasted approximately 20
minutes without the ability to recapture heart activity. 12
lead electrocardiogram was performed which demonstrated
asystole. The patient was pronounced dead at approximately
3:50 a.m. on [**2178-7-14**].
After resuscitative efforts, the patient was pronounced dead
at approximately 3:50 a.m. on [**2178-7-14**].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1331**]
Dictated By:[**Doctor Last Name 106831**]
MEDQUIST36
D: [**2178-7-14**] 04:36
T: [**2178-7-14**] 04:11
JOB#: [**Job Number 106832**]
|
[
"427.31",
"425.9",
"410.71",
"996.81",
"789.5",
"584.9",
"276.7",
"590.80",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"55.24",
"55.23",
"39.95",
"54.91",
"99.15",
"00.14",
"96.71",
"96.04",
"54.0",
"38.93",
"00.13"
] |
icd9pcs
|
[
[
[]
]
] |
7513, 8081
|
6575, 7490
|
1210, 2620
|
2639, 6548
|
1106, 1183
|
8110, 10584
|
894, 1083
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,155
| 155,887
|
47880
|
Discharge summary
|
report
|
Admission Date: [**2175-1-11**] Discharge Date: [**2175-1-17**]
Service:
HISTORY OF PRESENT ILLNESS: This is a 78-year-old
right-handed man status post resection of a left frontal
meningioma in [**2167**]. He had two follow-up CT scans which
showed no evidence of any recurrence or residual tumor. Over
the last two weeks, his wife has noted increasing mental
slowing, along with an unsteady gait. He then had a
follow-up MRI scan of the head which showed a recurrence of
the left frontal meningioma which was approximately 8 cm in
its largest diameter. There was significant mass affect and
edema. There was also evidence of hemorrhage within the
tumor. The patient was otherwise awake and alert. He had no
headache, nausea, vomiting or incontinence.
PAST MEDICAL HISTORY: Coronary artery bypass grafting,
hypertension, hypercholesterolemia.
PREOPERATIVE MEDICATIONS: Vasotec, Atenolol, Norvasc,
Dyazide, Lipitor, Proscar, Heparin, Xalatan, Alphagan,
Tylenol, Colace, Dilantin.
SOCIAL HISTORY: He is a retired electrical engineer. He
lives independently with his wife.
PHYSICAL EXAMINATION: The patient was awake and alert. He
was easily distracted. He had a clear left gaze preference
and right hemineglect. His strength was actually quite good
in both upper extremities. His previous craniotomy incision
was well healed. There was no subgaleal fluid. His
extraocular motions were intact, once we got him to look past
the midline to the right. His cranial nerves II-XII were
otherwise intact. He had a right pronator drift. His
coordination was good. He was slightly hyperreflexic on the
right. His right toe was upgoing. His speech was slightly
slurred and dysarthric. His comprehension was good.
HOSPITAL COURSE: The patient had a recurrence of his left
frontal meningioma. It was noted that at his previous
surgery, this was an extremely bloody tumor. In addition,
there was evidence of hemorrhage within the tumor. For that
reason, the patient was initially sent to [**Hospital6 15291**] for an angiogram and embolization of the tumor. At
that time, the medial portion of the tumor was found to be
fed from the right superficial temporal artery. This was
embolized. The majority of the tumor was fed by small peel
vessels of the left anterior cerebral and middle cerebral
artery. These were not amendable to embolization. The
patient tolerated this procedure well.
The patient was then loaded on Dilantin 4 mg p.o. q.i.d. and
was written for a sliding scale Insulin coverage. In
addition, he was started on Dilantin 100 mg t.i.d. At his
previous surgery, it was noted that the patient was quite
sensitive to Dilantin; he would become overly sedated on
levels that were barely therapeutic. The patient tolerated
both the Dilantin and the Decadron well. He had no
complications from his angiogram.
He was taken to the Operating Room on [**1-13**]. At that
time, he underwent a left frontal craniotomy for his
meningioma. There was diffuse infiltration of the dura.
There was also two remote smaller nodules of tumor; one over
the inferior frontal lobe and one over the temporal lobe. A
gross total resection was achieved. The patient tolerated
the procedure well.
For the first 36 hours, he was kept in the Intensive Care
Unit. He was easily arousable. He had a mild right
hemiparesis. His speech continued to be a bit slurred. He
was sleepy but easily arousable. He was confused as to his
location. Over the next 24 hours, the patient became more
alert. He was much less confused. He was transferred to the
floor. He was kept on his Decadron and Dilantin. A
follow-up Dilantin level was only 5.2. For that reason, his
Dilantin was increased to 100 mg in the morning, 200 mg at
lunch, and 200 mg in the evening. With this, his Dilantin
level gradually rose to 9.7. He had no postoperative
seizures.
The patient gradually became more alert. His confusion was
greatly cleared. His speech was still a bit dysarthric. He
would sit up in a chair for hours on end. He had difficulty
walking without assistance. His hemiparesis gradually began
to improve. It was felt that the patient would be an
excellent rehabilitation candidate. His wounds remained
clean and dry. He was tolerating a regular kosher diet.
DISCHARGE DIAGNOSIS:
1. Left frontal meningioma.
2. Coronary artery disease.
3. Hypertension.
CONDITION ON DISCHARGE: Fair.
FOLLOW-UP: The patient should keep his wound clean and dry.
He will need to be closely supervised with his walking. He
still tends to neglect his right side. He will be seen in
follow-up in ten days. His Decadron has continued at 4 mg
q.i.d. He should undergo a slow taper and be tapered
completely off the Decadron over a [**9-10**] day period.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3653**], M.D. [**MD Number(1) 3654**]
Dictated By:[**Last Name (NamePattern4) 3655**]
MEDQUIST36
D: [**2175-1-17**] 15:53
T: [**2175-1-17**] 16:30
JOB#: [**Job Number 101034**]
CC7 Nurse's station(cclist)
|
[
"272.0",
"E932.0",
"424.1",
"225.2",
"251.8",
"414.01",
"401.9",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.51"
] |
icd9pcs
|
[
[
[]
]
] |
4312, 4389
|
1759, 4291
|
892, 1003
|
1120, 1741
|
113, 772
|
795, 865
|
1020, 1097
|
4414, 5083
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,698
| 137,559
|
23434
|
Discharge summary
|
report
|
Admission Date: [**2148-5-8**] Discharge Date: [**2148-5-14**]
Date of Birth: [**2101-7-10**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
DOE and prior endocarditis
Major Surgical or Invasive Procedure:
[**2148-5-8**] - Minimally invasive MV repair ( 36 mm [**Doctor Last Name 405**]
annuloplasty band)
[**2148-5-13**] - Right thoracentesis [**2148-5-13**]
History of Present Illness:
46 yo female with endocaridits in [**2146**] and mitral valve prolapse
and severe MR. She has increasing fatigue and was followed by
cardiology. Recent echo showed mild LAE, normal vent. fxn,
bileaflet MV prolapse, moderate to severe MR, nl. PASP. Cardiac
MR in [**3-18**] also showed EF 66%, severe MR [**First Name (Titles) 151**] [**Last Name (Titles) 28689**]. fraction
60%, and forward EF 26%, no CAD. Cath in [**4-18**] showed no CAD and
moderate to severe MR. Referred for surgical repair.
Past Medical History:
Low back pain
*
Mitral valve prolapse: Diagnosed in her teens on a routine
physical for gymnastics participation. Pt. does not know
etiology. Experiences heart palpitations lasting 20sec, more
often in past year. Was due for a month event monitor in
[**Month (only) **] but was hospitalized. Never had a syncopal episode but
had several pre-syncopal episodes in association with
palpitations. Always takes prophylactic antibiotics prior to
dental work or GYN procedures.
osteomyelitis [**2146**]
endocariditis [**2146**]
chronic anemia
Social History:
lives with husband
software analyst
smokes 1 ppd for 26 years
Family History:
21 yo daughter recently diagnosed with [**Name (NI) 60082**]??????s ataxia.
Grandfather had basal cell carcinoma. Father has HTN and rotated
heart as a result of being very tall and thin. No history of
diabetes. No other history of cancer or heart disease.
Physical Exam:
5'[**52**]" 132 #
HR 89
RR 15 116/63
NAD
skin/HEENt unremarkable
neck supple with full ROM/ no bruits
CTAB
RRR 2/6 SEm
no organomegaly, soft, NT, ND
warm and well-perfused, no edema
no varicosities
neuro grossly intact
2+ bilat. fem/DP/PT/radials
Pertinent Results:
[**2148-5-13**] 05:06AM BLOOD WBC-7.1 RBC-2.91* Hgb-9.1* Hct-25.6*
MCV-88 MCH-31.1 MCHC-35.3* RDW-12.5 Plt Ct-207#
[**2148-5-13**] 05:06AM BLOOD Plt Ct-207#
[**2148-5-13**] 05:06AM BLOOD Glucose-110* UreaN-14 Creat-0.7 Na-140
K-4.4 Cl-104 HCO3-27 AnGap-13
[**2148-5-13**] 05:06AM BLOOD Calcium-9.2 Phos-3.8 Mg-1.7
[**2148-5-14**] CXR
Slight interval decrease in basilar air component of right
hydropneumothorax. No change in apical and anterior components.
Pneumomediastinum is no longer visible.
[**2148-5-12**] CT Scan
1. Small right-sided hydropneumothorax with dependent
atelectasis/consolidation. Small pneumopericardium.
2. Multiple hypoattenuating areas throughout the kidneys, some
of which are hyperdense, likely representing multiple cysts.
These are not definitively characterized on this study and could
be further evaluated with MRI.
3. Simple cysts also identified within the liver and this raises
the possibility of a polycystic kidney disease variant.
4. No evidence of retroperitoneal hematoma. Mild soft tissue
stranding surrounding the right common femoral artery and
presumed arterial puncture site with mild displacement of the
surrounding muscles.
[**2148-5-8**] ECHO
PRE-BYPASS:
1. 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. 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 and no aortic regurgitation. 5. The
mitral valve leaflets are moderately thickened. The mitral valve
leaflets are myxomatous. There is moderate/severe mitral valve
prolapse of the posterior leaflet and borderline prolapse of the
anterior leaflet . Severe (4+), eccentric, anteriorly directed
mitral regurgitation is seen. Systolic flow reversal is seen in
the right upper pulmonary veins. The vena contracta measures
between 0.7-0.8 cm in width.
6. The tricuspid valve leaflets are moderately thickened and
there is at least mild to moderate leaflet prolapse. The
tricuspid regurgitation jet is eccentric and may be
underestimated. It appears to be atl east mild to
moderate.
7. There is no pericardial effusion.
POST-BYPASS: The pt is receiving an infusion of phenylephrine
1. There is normal biventricular systolic function.
2. Mitral ring is seated well. Trace MR is seen. The mean
gradient across the valve is about 4mm of Hg. The average MVA
estimated by pressure half time is about 2.5 cm2. No gradient is
detected across the LVOT.
3. Aorta and Interatrial septum are intact
4. Other findings are unchanged
[**Last Name (NamePattern4) 4125**]ospital Course:
Mrs. [**Known lastname 60083**] was admitted to the [**Hospital1 18**] on [**2148-5-8**] for elective
surgical management of her mitral valve disease. She was taken
to the operating room where she underwent a minimally invasive
mitral valve repair utilizing a 36mm [**Doctor Last Name **] annuloplasty band.
Postoperatively she was taken to the cardiac surgical intensive
care unit for monitoring. By postoperative day one, she was
awake and extubated. Aspirin, beta blockade and a statin were
resumed. She was then transferred to the cardiac surgical step
down unit for further recovery. A small pneumothorax was noted
on her chest x-ray and her chest tube was left in place for an
extra day and then removed. She was gently diuresed towards her
preoperative weight. The physical therapy service was consulted
for assistance with her postoperative strength and mobility.
Mrs. [**Known lastname 60083**] noted some right leg numbness which was attributed
to irritation of the femoral nerve with groin cannulation. A
neurology consult was obtained and a pelvis CT scan was
performed to check for a retroperitoneal hemorrhage. This
revealed no evidence of a retroperitoneal hematoma, multiple
renal cysts, some simple liver cysts and a small right-sided
hydropneumothorax. Physical therapy continued to work with her
and her numbness continued to improve. As a follow-up chest
x-ray showed a persistent small right pneumothorax and pleural
effusion, thoracentesis was performed. 350cc of serous fluid
were drained as well as pockets of air. Mrs [**Known lastname 60083**] continued to
make steady progress and was discharged home on postoperative
day six. She will return Thursday [**5-16**] for a follow-up chest
x-ray. Mrs [**Known lastname 60083**] will follow-up with Dr. [**Last Name (Prefixes) **], her
cardiologist and her primary care physician as an outpatient.
She will follow-up with the neurology service as needed.
Medications on Admission:
ASA 81 mg daily
lisinopril 20 mg daily
amoxicillin prn
flexeril 10 mg prn
percocet prn
aleve prn
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 2 weeks.
Disp:*28 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:*2*
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) for 10 days.
Disp:*60 Tablet(s)* Refills:*1*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) for
2 weeks.
Disp:*14 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
1 weeks.
Disp:*7 Tablet(s)* Refills:*1*
7. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO once
a day for 1 weeks.
Disp:*7 Packet(s)* Refills:*1*
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
10. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
11. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*1*
12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] Vna
Discharge Diagnosis:
s/p min. inv. MV repair
chronic LBP/herniated disc
prior osteomyelitis [**12-16**]
anemia
right thoracentesis
prior endocarditis [**11-16**]
right femoral neuropathy
Discharge Condition:
stable
Discharge Instructions:
no driving for 2 weeks
may shower over incisions and pat dry
call for fever greater than 101, redness or drainage
no lotions, creams or powders on any incision
Followup Instructions:
see Dr. [**Last Name (STitle) 30362**] in [**1-15**] weeks
see Dr. [**Last Name (STitle) 696**] in [**2-16**] weeks
see Dr. [**Last Name (STitle) 1290**] in 4 weeks [**Telephone/Fax (1) 170**]
follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] from neurology
Chest X-ray [**2148-5-16**] as arranged
Completed by:[**2148-5-14**]
|
[
"285.9",
"424.0",
"512.1",
"401.9",
"355.8",
"511.9",
"722.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"35.12"
] |
icd9pcs
|
[
[
[]
]
] |
8621, 8679
|
347, 503
|
8889, 8898
|
2230, 4978
|
9106, 9471
|
1684, 1942
|
7106, 8598
|
8700, 8868
|
6982, 7083
|
8922, 9083
|
1957, 2211
|
5029, 6956
|
281, 309
|
531, 1029
|
1051, 1589
|
1605, 1668
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,727
| 192,993
|
51962
|
Discharge summary
|
report
|
Admission Date: [**2158-8-15**] Discharge Date: [**2158-8-22**]
Date of Birth: [**2096-11-3**] Sex: M
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 5810**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
61yoM with h/o chronic sCHF (40-45%), IDDM, HTN/HL, ESRD on HD
(Tues, Thurs, Sat), AFib/flutter not on Coumadin, chronic chest
pain who presented to his Cardiologist today with complaints of
fatigue, increased productive cough and wanted him to get
admitted due to AFib wtih RVR and mildly increased LE edema, but
pt refused and went home.
Later, pt's fiance made him come in as the pt wasn't feeling
better.
Initial Vitals - triggered on arrival: 99.2 150 157/88 28 100%
Non-Rebreather. Started on Bipap. CXR showed volume overload and
cardiomegaly. EKG showed AFib with RVR to 124 with inverted T
wave in the high lateral leads that doesn't appear different
from previous at least a month ago. Pt was given
Albuterol/Ipratropium nebs, 20 mg IV Diltiazem then 10 mg IV
Diltiazem then 180mg PO Diltiazem CR, 80 mg IV Lasix, 750 mg IV
Levaquin, SL NTG, and started Nitro gtt. Also given 1L NS.
Vitals before admission: Afebrile p92-106 144/75 25 100% Bipap
FiO2 70%, [**10-18**], and Nitro gtt at 1.2 mcg/kg/min. After arrival
of the HD nurses to initiate hemodialysis, they state that he is
10 kg over baseline wt. ROS difficult to obtain given pt being
Bipapped but he says he has chest pain, leg pain, foot pain,
head pain. He states he was taking in a lot of fluid recently
because it's so hot.
Past Medical History:
1. ESRD on HD T/Th/Sa at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9449**] [**Last Name (NamePattern1) **], [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 669**],
[**Telephone/Fax (1) 69669**]
2. Type 2 diabetes mellitus c/b peripheral neuropathy
3. Chronic systolic CHF with EF 30% ([**10/2156**] TTE)
4. Atrial fibrillation/AFlutter
- s/p ablation [**2153**]; s/p ablation x 2 in [**2155**]
- not on coumadin due to history of GIBs.
5. Hypertension
6. Dyslipidemia
7. History of GI bleeds: Duodenal, jejunal, and gastric AVMs s/p
thermal therapy; diverticulosis throughout colon
8. Chronic pancreatitis
9. ? HCV: HCV Ab + [**10/2150**], but neg [**2154**]
10. GERD
11. Gout: s/p arthroscopy with medial meniscectomy [**5-/2149**]
12. Depression with multiple hospitalizations due to SI
13. Polysubstance abuse: crack cocaine, EtOH, tobacco
14. recurrent chest pain following crack/cocaine use
- no evidence CAD on cath [**2155**]
15. Erectile dysfunction s/p inflatable penile prosthesis [**5-/2148**]
16. H/o C diff in [**2156-8-14**]
Social History:
Currently staying with his son
- tobacco: smokes occassional cigarette; longterm smoking
history > 42 pack years
- ETOH: reports last drink approx 5yrsd ago, hx of abuse with
associated withdrawal and DTs requiring detoxification.
- polysubstance abuse: repeat crack/ cocaine use; last 1 mth ago
Family History:
Mother had ESRD on HD, died from MI at the age of 58. 4 brothers
and 2 sisters, nearly all with DM2
Physical Exam:
FEX on admission to MICU
100.5 p108 133/68 100% on CPAP 8/5 FiO2 100%
Thin older M laying in bed appears uncomfortably with Bipap mask
on, able to answer some questions, EOMI, limited facial exam,
grossly distended external jugular on the R and L but internal
jugular more difficult to assess
Gross posterior inspiratory crackles bilaterally and gross
inspiratory rhonchi anteriorly
Irregular without apparent m/g heard over breath sounds
Soft NT ND, benign
BLE warm, hairless with minimal but present pitting edema to mid
shin
Extremities are warm. Radials easily palpable, DP's are not
CN 2-12, moving all extremities as he squirms around in bed,
conversant and alert.
FEX on transfer to floor
VS: T 98.2 P 83 RR 26 99%RA
GENERAL: Pleasant elderly man in NAD. AAOx3
HEENT: Muddy sclerae. PERRL. EOMI. OP clear.
HEART: Irregularly irregular. No murmurs, rubs, or gallops
noted.
PULM: Non labored. Dry crackles noted over left lung halfway up.
GI: Soft, nontender, nondistended. Normoactive BS. Liver feels
slightly enlarged but smooth and nontender.
EXT: Warm, well perfused. No CCE noted.
NEURO: AAOx3. CNII-XII intact. Strength exam notable for absent
dorsi and plantar flexion of rt foot. Decreased sensation to
prick in webbing between 1st and 2nd toe right foot. Babinski is
down going bilaterally.
SKIN: Rash with darkly pigmented discrete macules <1cm noted
diffusely over chest.
FEX on discharge
VS: BP 129-150/58-77 P53-82 RR18-20 95-97%RA
GENERAL: Pleasant elderly man in NAD. AAOx3
HEENT: Muddy sclerae. PERRL. EOMI. OP clear.
HEART: Irregularly irregular. No murmurs, rubs, or gallops
noted.
PULM: Non labored. Clear to auscultation bilaterally.
GI: Soft, nontender, nondistended. Normoactive BS. Liver feels
slightly enlarged.
EXT: Warm, well perfused. No CCE noted.
NEURO: AAOx3. CNII-XII intact. Strength exam notable for absent
dorsi and plantar flexion of rt foot. Able to wiggle toes.
SKIN: Rash with darkly pigmented discrete macules <1cm noted
diffusely over chest.
Pertinent Results:
LABS ON ADMISSION
[**2158-8-15**] 03:05AM WBC-9.1 RBC-3.84* HGB-11.3* HCT-33.8* MCV-88
MCH-29.5 MCHC-33.6 RDW-15.7*
[**2158-8-15**] 03:05AM NEUTS-83.7* LYMPHS-10.0* MONOS-3.5 EOS-2.3
BASOS-0.4
[**2158-8-15**] 03:05AM PT-12.5 PTT-26.9 INR(PT)-1.1
[**2158-8-15**] 03:05AM CALCIUM-9.2 PHOSPHATE-5.5* MAGNESIUM-2.5
[**2158-8-15**] 03:05AM CK-MB-4 cTropnT-0.19* proBNP-[**Numeric Identifier **]*
[**2158-8-15**] 03:05AM GLUCOSE-182* UREA N-57* CREAT-8.4*#
SODIUM-137 POTASSIUM-5.5* CHLORIDE-96 TOTAL CO2-25 ANION GAP-22*
[**2158-8-15**] 03:19AM LACTATE-2.4*
PERTINENT LABS
[**2158-8-15**] 11:06AM TYPE-ART PEEP-8 O2-70 PO2-85 PCO2-38 PH-7.50*
TOTAL CO2-31* BASE XS-5 INTUBATED-NOT INTUBA VENT-SPONTANEOU
[**2158-8-15**] 11:06AM LACTATE-1.3
[**2158-8-16**] 07:54AM BLOOD WBC-11.2* RBC-3.71* Hgb-11.3* Hct-33.3*
MCV-90 MCH-30.4 MCHC-33.9 RDW-15.8* Plt Ct-168
[**2158-8-18**] 08:40AM BLOOD WBC-6.4 RBC-4.21* Hgb-12.6* Hct-36.9*
MCV-88 MCH-30.0 MCHC-34.1 RDW-15.6* Plt Ct-212
[**2158-8-21**] 04:30AM BLOOD WBC-6.7 RBC-4.11* Hgb-12.0* Hct-35.6*
MCV-87 MCH-29.1 MCHC-33.6 RDW-15.1 Plt Ct-158
[**2158-8-16**] 05:30AM BLOOD Glucose-113* UreaN-37* Creat-6.0*# Na-138
K-5.5* Cl-92* HCO3-27 AnGap-25*
[**2158-8-18**] 08:40AM BLOOD Glucose-188* UreaN-82* Creat-7.2* Na-133
K-4.3 Cl-89* HCO3-24 AnGap-24*
[**2158-8-21**] 04:30AM BLOOD Glucose-188* UreaN-56* Creat-6.8*# Na-137
K-4.5 Cl-94* HCO3-26 AnGap-22*
[**2158-8-16**] 07:54AM BLOOD Albumin-3.9 Calcium-10.2 Phos-6.9* Mg-2.3
[**2158-8-18**] 08:40AM BLOOD Calcium-9.8 Phos-5.6* Mg-2.8*
[**2158-8-21**] 04:30AM BLOOD Calcium-9.8 Phos-5.5* Mg-2.6
[**2158-8-16**] 07:54AM BLOOD TSH-<0.02*
[**2158-8-20**] 11:00AM BLOOD TSH-<0.02*
[**2158-8-16**] 07:54AM BLOOD T4-14.8* T3-208*
[**2158-8-20**] 11:00AM BLOOD T4-15.9* T3-277* Free T4-3.2*
[**2158-8-18**] 08:40AM BLOOD PSA-2.8
[**2158-8-19**] 10:30AM BLOOD IODINE-PND
REPORTS
Cardiology Report ECG Study Date of [**2158-8-15**] 2:11:54 AM
Atrial fibrillation with rapid ventricular response. Compared to
the previous
tracing of [**2158-8-8**] the atrial rhythm has changed.
Read by: [**Last Name (LF) **],[**First Name3 (LF) **]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
124 0 92 326/438 0 -17 96
Radiology Report CHEST (PORTABLE AP) Study Date of [**2158-8-15**] 2:34
AM
AP UPRIGHT VIEW OF THE CHEST: Evaluation is limited by head
position and
exclusion of right costophrenic sulcus. Within this limitation,
moderate
cardiomegaly with left atrial enlargement are unchanged. There
is increased
interstitial and airspace opacity with pulmonary vascular
engorgement
compatible with edema. There are small bilateral pleural
effusions.
Degenerative changes of the thoracic spine is noted.
IMPRESSION: Cardiac decompensation and pulmonary edema.
Radiology Report -77 BY DIFFERENT PHYSICIAN [**Name9 (PRE) 2221**] Date of
[**2158-8-15**] 6:16 PM
Comparison is made with prior study performed the same day
earlier in the
morning.
There are lower lung volumes. Increasing bibasilar atelectasis.
Cardiomegaly
is stable. The apices of the lungs are obscure by patient's
chin. Moderate
pulmonary edema is unchanged. Small bilateral pleural effusions
are also
stable.
Radiology Report UNILAT LOWER EXT VEINS Study Date of [**2158-8-16**]
3:17 PM
TECHNIQUE: Duplex son[**Name (NI) **] of the right lower extremity.
FINDINGS: Grayscale and Doppler son[**Name (NI) **] of the bilateral common
femoral,
right superficial femoral, right popliteal, right posterior
tibial and right
peroneal veins was performed. There is normal compressibility,
flow and
augmentation of all visualized venous structures.
IMPRESSION: No evidence of DVT.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2158-8-17**] 3:21
AM
COMPARISON: [**2158-8-15**].
FINDINGS: As compared to the previous radiograph, the signs
indicative of
pulmonary edema have markedly decreased. Mild pulmonary edema,
however, are
still present. Minimal right pleural effusion. Unchanged
borderline size of
the cardiac silhouette. Decrease in extent of a pre-existing
retrocardiac
atelectasis. No newly appeared focal parenchymal opacities.
Radiology Report ANKLE (AP, MORTISE & LAT) RIGHT PORT Study Date
of [**2158-8-17**] 8:53 AM
COMPARISON: [**2156-1-12**].
FINDINGS and IMPRESSION: Three views of the right ankle. Ankle
mortise is
preserved. No acute fracture or dislocation. Talar dome is
smooth. Small
plantar calcaneal spur.
Radiology Report THYROID U.S. Study Date of [**2158-8-18**] 2:59 PM
INDICATION: Evaluation of patient with possible thyrotoxicosis.
COMPARISON: None available.
FINDINGS:
The exam was limited in evaluation due to the patient's
inability to lie flat.
The right thyroid lobe measures 5.6 x 2.5 x 2.8 cm.
The left thyroid lobe measures 4.4 x 3.2 x 1.7 cm.
Bilateral thyroid glands are homogeneous with no evidence of
nodules. No
evidence of increased flow throughout the thyroid lobes.
IMPRESSION: Limited study but no evidence of increased flow or
nodules
throughout the thyroid.
Radiology Report MR L SPINE W/O CONTRAST Study Date of [**2158-8-18**]
8:13 PM
TECHNIQUE: T1, T2 and inversion recovery sagittal and T2 axial
images of
lumbar spine acquired.
FINDINGS: There is diffuse low signal identified within the
visualized bony
structures consistent with renal osteodystrophy from the
patient's clinical
history of end-stage renal disease.
From T11-12 to L5-S1 level no significant disc bulge is
identified. No spinal stenosis is seen. There is no focal disc
herniation identified or high-grade foraminal narrowing seen.
There is no evidence of nerve root displacement
noted.
At L4-5 level, there is a small 5-mm hyperintensity seen to the
left of the
spinous process of L4 which could indicate a small incidental
ganglion cyst.
The distal spinal cord, paraspinal soft tissues are
unremarkable.
IMPRESSION: Diffuse low signal in the bony structures consistent
with renal
osteodystrophy. No evidence of significant disc bulge or
herniation, spinal
stenosis, foraminal narrowing or nerve root displacement.
Brief Hospital Course:
61 year old man with AFib/flutter and CHF (40-45%) admitted in
atrial fibriallation with rapid ventricular response and severe
volume overload leading to respiratory distress. Found to be
hyperthyroid and subsequently developed right foot drop.
ACTIVE PROBLEMS:
#Atrial fibrillation/flutter: Patient has long standing history
of atrial fibrillation and flutter with multiple failed
ablations in [**2153**] and [**2155**]. Presented in AFib with RVR leading
to impressive volume overload and respiratory distress. Patient
was placed on BiPap on admission to hospital. Rate was
controlled initially with IV diltiazem before maintenance
control with diltiazem 150 po qid. Rate was maintained in the
90's during most of his hospitalization. Volume overload was
initially treated with IV lasix, but as patient is ESRD and
[**Year (4 digits) 2286**] dependent, volume control was ultimately achieved with
multiple [**Year (4 digits) 2286**] sessions. Patient was transferred to the floor
on [**8-18**] after successful rate control and diuresis, and patient
had no 02 requirement. Patient has CHADS-2 score of 3, but is
maintained on [**Month/Day (1) **] prophylaxis due to history of GI bleed.
Patient was discharged to rehabilitation on diltiazem short
acting 150mg qid and [**Month/Day (1) **] with follow up in cardiology clinic on
[**9-4**] with Dr. [**First Name (STitle) 437**].
#CHF: Last echo on [**2158-7-5**] showed mild symmetric left
ventricular hypertrophy with mild global hypokinesis
(40-45%LVEF). Patient was continued on lisinopril 20, and HD for
volume control.
#Hyperthyroidism: Patient first noted to be hyperthyroid during
hospitalization in late [**2158-7-14**], likely due to amiodarone,
which the patient took from [**2155**]-[**2158-5-14**]. Endocrine was
consulted, and patient was started on methimazole 20 daily. ALP
was monitored following initiation of methimazole, and it did
not significantly increase. Additionally thyroid US was
performed which showed no nodules or increased blood flow.
Iodide levels were pending at the time of writing. Patient is to
continue taking methimazole on discharge and follow up in
endocrine clinic on [**2158-8-30**].
# Right foot paralysis: On [**8-16**], the patient first complained of
new onset right lower extremity calf pain. He denied having any
trauma to the area. An US was negative for DVT. An ankle x-ray
was performed on [**8-17**] which revealed no acute fracture or
dislocation. Patient then noted dense sensory loss of right foot
late on [**8-17**] with loss of plantar and dorsiflexion of ankle. Hip
and knee flexors were intact. BP cuff was noted to be on his
right thigh. Neurology was consulted who suspected compressive
sciatic nerve neuropathy. MRI of lumbar spine showed no evidence
of mass or cauda equina syndrome. Patient continued to have
difficulty moving foot on discharge to rehab.
#DM: Patient with longstanding history of insulin dependent
diabetes. His home regiment included 16 units lantus with
humolog SS with meals. On admission he was placed on 12 units
lantus with ISS. His blood sugars ran high throughout his
admission into the 200's and his lantus was increased to its
home dose of 16 units along with uptitration of ISS. Of note,
his blood sugar was >400 on morning of admission, but there was
not documentation of him recieving his pm Lantus. Patient was
continued on lisinopril 20 and atorvastatin 20 durin his
hospitalization.
#ESRD: Patient with history of end stage renal disease likely
due to diabetes. [**Month/Day (4) **] dependent for several years on
Tuesday, Thursday, Friday schedule. Access is with AV fistula in
his left arm. Patient received emergent [**Month/Day (4) 2286**] day of
admission for hypervolemia due to afib with RVR and subsequent
respiratory distress. Underwent 2 [**Month/Day (4) 2286**] sessions on [**8-15**], and
additional sessions on [**8-16**] and [**8-18**] before returning to his usual
Tuesday, Thursday, Saturday schedule on [**8-19**]. Patient was
maintained on low potassium and phosphorus diet and was treated
with nephrocaps and cincalet 30 daily during his
hospitalization. His sevelamer was increased to 3200mg tid with
meals.
OUTSTANDING STUDIES
-Iodide level
TRANSITIONAL ISSUES
-Needs close watching of blood glucose with adjustment to
insulin as needed.
-F/U TFT's 3-5 days post discharge and fax results to PCP.
Medications on Admission:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
3. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
4. insulin glargine 100 unit/mL Solution Sig: 12 units
Subcutaneous at bedtime.
5. insulin lispro 100 unit/mL Solution Sig: As directed
previously qAC [**Month/Day (4) 5910**] Subcutaneous as directed.
6. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY
7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for SOB wheeze.
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
11. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
12. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO 3X/WEEK (TU,TH,SA).
13. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO once a
day.
Disp:*60 Capsule(s)* Refills:*0*
14. DILT-XR 180 mg Capsule,Ext Release Degradable Sig: Three (3)
Capsule,Ext Release Degradable PO at bedtime. Disp:*90
Capsule,Ext Release Degradable(s)* Refills:*0*
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. atorvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. insulin glargine 100 unit/mL Solution Sig: Sixteen (16) Units
Subcutaneous at bedtime: Take as directed.
5. insulin lispro 100 unit/mL Solution Sig: 0-12 Units
Subcutaneous with meals: As previously directed by sliding
scale.
6. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: [**1-15**]
puffs Inhalation every six (6) hours as needed for shortness of
breath or wheezing.
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. sevelamer carbonate 800 mg Tablet Sig: Four (4) Tablet PO
TID W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*120 Tablet(s)* Refills:*6*
11. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 * Refills:*2*
12. gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
13. diphenhydramine HCl 25 mg Capsule Sig: [**1-15**] Capsules PO Q8H
(every 8 hours) as needed for itchiness.
Disp:*90 Capsule(s)* Refills:*2*
14. methimazole 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
15. diltiazem HCl 30 mg Tablet Sig: Five (5) Tablet PO QID (4
times a day). Tablet(s)
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] Rehabilitation & Nursing Center - [**Location (un) 538**]
Discharge Diagnosis:
Atrial Fibrillation/Flutter
Hyperthyroidism
End stage renal disease
Neuropathy
Discharge Condition:
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Dear Mr. [**Known lastname 107485**],
You were admitted to the hospital because you were having
difficulty breathing. We found that you had gone back into an
abnormal heart rhythm called atrial fibrillation causing your
heart to beat so fast it couldn't effectively pump blood to your
body. We think one reason this keeps happening is because your
thyroid levels are too high. We slowed down your heart rate
with medications and removed the fluid that was filling your
lungs and legs with hemodialysis. We also started a medication
to decrease the amount of hormone your thyroid makes. Finally,
before you left, you started having trouble moving your right
foot. We think this is because a nerve in your leg was
compressed while you were laying in bed.
You will be going to a rehabilitation facility to help increase
your mobility. Please attend the following appointments we have
scheduled for you, including appointments with endocrinologists
(thyroid doctors) and nephrologists (kidney doctors). Note the
following changes to your medications:
START Methimazole 20mg daily
START diphenhydramine (benadryl) 25-50mg up to 3 times a day for
itching
INCREASE sevelamer to 4 tablets with meals daily
INCREASE gabapentin to 300 mg at night
INCREASE your lantus (long acting insulin) to 16 units at night
CHANGE Diltiazem to 150mg four times a day
Please taking the remainder of your medications as previously
prescribed. It has been a pleasure taking care of you.
Followup Instructions:
Department: [**Hospital3 249**]
When: MONDAY [**2158-8-28**] at 9:30 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: WEDNESDAY [**2158-8-30**] at 3:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2164**], MD [**Telephone/Fax (1) 1803**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: MONDAY [**2158-9-4**] at 10:00 AM
With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: NEUROLOGY
When: THURSDAY [**2158-9-21**] at 11:30 AM
With: DRS. [**Name5 (PTitle) **] & [**Doctor Last Name 37664**] [**Telephone/Fax (1) 2846**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: TRANSPLANT CENTER
When: MONDAY [**2158-8-28**] at 8:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
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"585.6",
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"355.8",
"305.60",
"V45.11",
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"428.0",
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icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
18534, 18688
|
11219, 15595
|
289, 296
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18811, 18886
|
5178, 11195
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20488, 21993
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3049, 3151
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15621, 16955
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3166, 5159
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20049, 20465
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230, 251
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324, 1623
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18901, 18970
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1645, 2718
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2734, 3033
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,840
| 137,976
|
27337
|
Discharge summary
|
report
|
Admission Date: [**2199-4-29**] Discharge Date: [**2199-5-11**]
Date of Birth: [**2125-9-1**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
new onset SOB and fevers
Major Surgical or Invasive Procedure:
none
History of Present Illness:
73 yo female with tissue AVR in [**2195**] ( [**Hospital1 112**]) presented to
[**Hospital1 11485**] Med. Ctr. on [**4-24**] from extended care facility with new
onset SOB and fevers. Had prior hospitalization at [**Hospital1 17436**] Med
[**Date range (1) 67001**] with fever and weakness. Had + blood cultures there for
strep. Had 4 week course of vanco, gentamicin and ceftriaxone.
TEE at that time showed no vegetations. She then developed C.
Diff. and was treated with flagyl and discharged back to her
ECF. Bone marrow asp. for WBC 0.6 done on [**4-26**] at [**Hospital1 11485**].
Results were pending. Echo on [**4-26**] showed vegetation on MV, no
significant MR. BCs + for staph from PICC line which has since
been removed.Became hypotensive on [**4-3**], and transferred to
ICU for dopamine and levophed drips. Gentamicin and vancomycin
restarted. Dopa weaned off . Developed AFib on [**4-28**] and started
on po digoxin. UO remained low at time of surgical
evaluation.Transferred in to [**Hospital1 18**] [**4-29**] for definitive treatment.
Past Medical History:
AVR [**2195**] ( tissue)
strep bacteremia
C. diff.
HTN
CHF
IBS
DM 2
thrombocytopenia
elev. chol.
anemia
GI bleed with colon AVM
bilat. TKR
TAH
cholecystectomy
Social History:
remote smoker
Physical Exam:
awake, alert and oriented
98.5 117/71 HR 72 RR 20
PERRL, sclera anicteric
right IJ TLC
rhonchi in lungs
abd obese, soft, NT, no organomegaly
extrems with edema, and + distal pulses
Pertinent Results:
TTE [**4-25**] at OSH: EF 65-75%, poss. AV vegetation, MAC, mild to
mod. MR, MV vegetation, mild to mod. TR.
[**2199-5-10**] 02:11AM BLOOD WBC-23.4* RBC-3.17* Hgb-10.1* Hct-30.1*
MCV-95 MCH-31.8 MCHC-33.4 RDW-18.7* Plt Ct-147*
[**2199-5-8**] 02:22AM BLOOD Neuts-86.5* Lymphs-8.2* Monos-4.7 Eos-0.1
Baso-0.4
[**2199-5-8**] 02:22AM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-1+
Macrocy-2+
[**2199-5-10**] 02:11AM BLOOD PT-18.3* PTT-42.0* INR(PT)-1.7*
[**2199-5-10**] 02:11AM BLOOD Plt Ct-147*
[**2199-5-9**] 01:54AM BLOOD Fibrino-183
[**2199-5-10**] 02:11AM BLOOD UreaN-32* Creat-3.0* Na-128* Cl-93*
HCO3-27
[**2199-5-3**] 01:26AM BLOOD ALT-27 AST-60* AlkPhos-122* Amylase-63
TotBili-2.0*
[**2199-5-3**] 01:26AM BLOOD Lipase-55
[**2199-5-10**] 02:11AM BLOOD Calcium-8.5 Phos-3.7 Mg-2.3
[**2199-5-6**] 03:09AM BLOOD calTIBC-135* TRF-104*
[**2199-5-9**] 03:14PM BLOOD Digoxin-1.8
[**2199-5-10**] 06:04AM BLOOD Type-ART pO2-87 pCO2-46* pH-7.41
calHCO3-30 Base XS-3
[**2199-5-10**] 02:27AM BLOOD freeCa-1.12
Brief Hospital Course:
Admitted here on [**4-29**]. Blood cultures repeated, echo done, and
ID/hematology/cardiology consults obtained. Abx therapy
continued for endocarditis. Dr. [**Last Name (STitle) 914**] consulted from cardiac
surgery. She remained in Afib/flutter. TEE showed MV vegetation,
no abscess and good LV function. Levophed weaning continued and
flagyl restarted. She received lovenox for prophylaxis and Afib.
Dental consult completed and cath done [**5-2**]. This revealed
normal coronaries and surgery was planned for the following
week.Wound care ( skin impairments) and social work consults
also done.Received a feeding tube and had line changed on [**5-7**].
WBCs rose to 23.9. Dr. [**Last Name (STitle) 914**] had a detailed discussion with
patient and family about significant risks/ benefits of future
surgery.Could not tolerate levophed weaning completely.
Creatinine rose on [**5-8**], and urine output began to decrease on
[**5-9**] with creat now 2.5, rising to 3.0 on [**5-10**]. Patient stated
she wished to have care withdrawn on [**5-10**] and refused dialysis
or intubation. This was discussed by Dr. [**Last Name (STitle) 914**] with the
patient and family and it was her wish to have comfort measures
only and DNR instituted. She was alert and oriented at the time
of her decision. Morphine drip started and levophed drip/tube
feeds discontinued.Family remained at her side.Pt. expired at
3:05 PM on [**5-11**] and pronounced by Dr. [**Last Name (STitle) **].
Medications on Admission:
nexium 20 mg daily
gentamicin 50 mg q 8 hours
vancomycin 1 gm every 18 hours
KCL 20 daily
digoxin 0.125 mg daily
insulin gtt
lasix 40 mg daily
levophed 0.15 mcg/kg/min
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
endocarditis
sepsis
renal failure
AFib
HTN
CHF
NIDDM
IBS
thrombocytopenia
elev. chol.
anemia
prior GI bleed with colonic AVM
prior AVR [**2195**]
Discharge Condition:
expired
Discharge Instructions:
none
Completed by:[**2199-5-24**]
|
[
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"V49.75",
"995.92",
"428.0",
"110.3",
"584.9",
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icd9cm
|
[
[
[]
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] |
[
"96.6",
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icd9pcs
|
[
[
[]
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4605, 4614
|
2884, 4358
|
344, 350
|
4803, 4812
|
1865, 2861
|
4576, 4582
|
4635, 4782
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4384, 4553
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4836, 4871
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1661, 1846
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280, 306
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378, 1432
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1454, 1614
|
1630, 1646
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,494
| 135,859
|
50118
|
Discharge summary
|
report
|
Admission Date: [**2161-4-17**] Discharge Date: [**2161-4-23**]
Date of Birth: [**2109-2-4**] Sex: M
Service: NEUROSURGERY
Allergies:
Nsaids / Codeine
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
[**4-17**] Left Craniotomy for emergent Epidural Hematoma Evacuation
History of Present Illness:
Pt is a 52m with history of seizure disorder who has not been
taking his seizure medications. This evening he was noted to
have a tonic clonic seizure and fell backwards striking his
head. He was taken to OSH where a head CT showed a left
parieto-occipital EDH measuring 3cm. He became more lethargic at
OSH and was intubated as a result. Per OSH report he was moving
all 4 limbs upon arrival. He was given 1g of Dilantin and
transferred to [**Hospital1 18**] for further evaluation.
Past Medical History:
Seizure Disorder
Social History:
drug/ETOH abuse
Family History:
unknown
Physical Exam:
On Admission:
T: BP: 136/84 HR: 89 R O2Sats 100
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 3mm-2mm bilaterally
Neuro:
Mental status: Intubated. Eyes open to noxious stimuli, not
following commands.
Motor: Moving LUE purposefully, withdraws both lower extremities
to noxious briskly. Extensor posturing in RUE
On Discharge:
Aphasic intermittently-follow some commands, oriented to self,
"hospital" and month/year, full stength. Improved exam, more
verbal. Answers questions approp w/yes and no questions.
Pertinent Results:
CT HEAD [**4-17**]
1. Rapidly enlarging left parietal epidural hemorrhage
underlying a large
left parietal bone fracture.
2. Concurrent multicompartmental hemorrhage including left
temporal subdural hemorrhage, supratentorial subdural
hemorrhage, left-sided subarachnoid hemorrhage, trace right
occipital subdural hemorrhage, and focal hemorrhagic contusions
in the left temporal and parietal lobes.
3. Non-displaced right occipital fracture through the skull base
extending
into the right occipital condyle without displacement. Subjacent
carotid
canal appears intact. However, if there is concern for vascular
injury, CTA could be acquired for further assessment.
4. Small amount of fluid layering in the sphenoid sinus and
ethmoid sinus
opacification. No obvious facial bone fracture. If concern,
dedicated sinus CT could be acquired once patient has
stabilized.
5. Large left parietal subgaleal hematoma.
6. 1-cm rightward subfalcine herniation. No evidence of
transtentorial or
uncal herniation at this time.
CT HEAD [**4-18**] POST-OP
1. Status post evacuation of left parietal epidural hematoma,
with
significant improvement of mass effect and midline shift.
Additional complex multicompartmental hemorrhage as above,
minimally changed.
2. Non-displaced left parietal and right occipital bone
fractures
CT HEAD [**4-20**]:
IMPRESSION:
1. Status post evacuation of left parietal epidural hematoma
with persistent foci of contusion, subarachnoid hemorrhage and
subdural hematoma, grossly stable since [**2161-4-18**].
2. Nondisplaced left parietal and right occipital bone
fractures.
LENIS [**4-22**]:
IMPRESSION:
1. DVT in both paired left posterior tibial veins.
2. No evidence of DVT in bilateral common femoral, superficial
femoral and
popliteal veins.
Liver/Gallbladder US [**4-22**]:
LIVER AND GALLBLADDER ULTRASOUND: The liver appears normal in
echotexture
with no evidence of focal liver lesions. The gallbladder shows
no evidence of gallstones. The common bile duct measures 0.3 cm
and is within normal limits. The right kidney measures 11 cm and
is within normal limits. The left kidney measures 12.1 cm and is
within normal limits. The spleen measures 10.6 cm and is within
normal limits. The main portal vein is patent.The abdominal
aorta is normal. The head and body of the pancreas appear
unremarkable. The tail of the pancreas is not visualized in this
study.
IMPRESSION: Normal abdominal ultrasound with no son[**Name (NI) 493**]
findings to
explain patient's elevated LFTs.
Brief Hospital Course:
On [**4-17**] the patient presented to the [**Hospital1 18**] ED with a left
epidural hematoma with poor exam and was taken emergently to the
operating room for a left sided craniotomy for evacuation of the
EDH as well as epidrual drain placement. He tolerated the
procedure well and was transported to the ICU post-operatively
still intubated. On [**4-18**] he was extubated in the afternoon and
on [**4-19**] his epidural drain was discontinued, he was bolused with
250mg of Dilantin for a level of 7.7 and he was transferred to
the SDU for further management.
On [**4-20**] his Dilantin level was 10.6. A repeat Head CT was done
which was stable. Patient was evaluated by PT/OT. Social Work
was also consulted. On [**4-21**] he was febrile and a fever work-up
was initiated. LFTs were drawn which were elevated. Dilantin was
changed to Keppra. A chest xray was done which was normal. A UA
was sent which was negative. LENIS were done which showed a left
posterior tibial vein DVT, vascular was curbsided and advised
that these do not need anticoagulation as superficial and would
just need a follow-up ultrasound in one week. Medicine was
consulted to ensure there was nothing more to consider: they
recommended following LFTs which were already trending down.
PT/OT recommended rehab and this was arranged.
Medications on Admission:
Tramadol, Dilantin(not taking)
Discharge Medications:
1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day) for 1 days: dose 3/24.
3. levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day): please begin this dose 3/25.
4. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Epidural Hematoma
Seizures
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge 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, and
Ibuprofen etc.
?????? You have been prescribed Keppra for anti-seizure medicine,
take it as prescribed.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
Followup Instructions:
?????? Please return to the office or have your staples removed at
rehab in [**8-9**] days from your date of surgery. Please make this
appointment if needed 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.
[**First Name (STitle) **], to be seen in 4 weeks.
?????? You will need a CT scan of the brain without contrast.
Completed by:[**2161-4-23**]
|
[
"V15.81",
"345.90",
"E885.9",
"305.90",
"801.21",
"784.3",
"453.42"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"38.91",
"01.24"
] |
icd9pcs
|
[
[
[]
]
] |
6032, 6102
|
4051, 5365
|
287, 358
|
6172, 6172
|
1525, 4028
|
7038, 7563
|
961, 970
|
5446, 6009
|
6123, 6151
|
5391, 5423
|
6324, 7015
|
985, 985
|
1323, 1506
|
239, 249
|
386, 872
|
999, 1116
|
6187, 6300
|
894, 912
|
928, 945
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,188
| 190,769
|
15139
|
Discharge summary
|
report
|
Admission Date: [**2162-9-30**] Discharge Date: [**2162-10-8**]
Date of Birth: [**2085-4-11**] Sex: M
Service: .
HISTORY OF PRESENT ILLNESS: This is a 77 year old white male
with a history of non-small cell lung cancer status post
radiation and x-ray treatment who is admitted for
bronchoscopy and stent revision. Starting in [**2162-4-9**], he
had increasing shortness of breath and dyspnea on exertion
and in [**2162-6-9**], he had a bronchoscopy done in [**State 622**]
which demonstrated migration of his left main bronchus stent
into his right main bronchus. No further treatment was done
at that point. The patient's symptoms persisted with
increasing shortness of breath.
On the day of admission, he also complained of a productive
cough with clear white sputum and occasional low-grade
temperatures. Recently, he completed a course of
Ciprofloxacin for 14 days. He has not had any fevers for two
weeks. He also complains of weight loss from 193 pounds to
165 pounds over the past several months.
He denied chest pain, nausea, vomiting, abdominal pain,
changes in bowel or bladder function or lower extremity
edema.
PAST MEDICAL HISTORY:
1. Non-small cell lung cancer diagnosed in [**2151**] with
radiation treatments and Taxol plus Carboplatin for six
months; the patient was then in remission for six months;
however, a [**2160**] PET scan revealed increased activity. He was
then treated with Navelbine and Carboplatin times one year.
2. Colon cancer diagnosed in 08/98 with resection of
malignant polyp and one positive lymph node. No chemotherapy
or radiation treatment done.
3. In [**2162-8-9**], small bowel obstruction, status post
surgery. Etiology unknown.
4. Pericardial effusion status post window 07/[**2161**]. Unknown
etiology of effusion.
5. Gastroesophageal reflux disease.
6. History of tobacco use.
7. Status post hernia repair [**9-/2158**].
8. Status post appendectomy in [**2110**].
9. Status post transurethral resection of the prostate times
two for benign prostatic hypertrophy.
ALLERGIES: Penicillin causes hives.
MEDICATIONS:
1. Zantac 150 mg p.o. q. day.
2. Combivent two puffs four times a day.
3. Guaifenesin 600 mg p.o. q. day.
SOCIAL HISTORY: The patient is a General. He lives with his
wife in [**Name (NI) 44133**], [**Name (NI) 622**]. Smoking history of two packs
per day for 30 years; quit 20 years ago. Drinks alcohol
approximately two drinks per night. No other drug use.
FAMILY HISTORY: No history of cancer.
PHYSICAL EXAMINATION: Vital signs 98.9 F.; blood pressure
130/92; pulse 83; respiratory rate 24; saturation of 97% on
room air. In general, he is a thin appearing man in no acute
distress, alert and oriented times three. HEENT: Pupils
equally round and reactive to light and accommodation.
Extraocular muscles are intact. Anicteric. Mucous membranes
were moist. No cervical or axillary lymphadenopathy. His
heart was regular rate and rhythm with no murmurs, rubs or
gallops. Lungs: He had bronchial breath sounds throughout.
Abdomen was soft, nontender, nondistended. Extremities with
no edema. Two plus distal pulses.
LABORATORY: White blood cell count 7.8, hematocrit 45,
platelets 387.
HOSPITAL COURSE: On [**2162-10-1**], the patient had a rigid and
flexible bronchoscopy which demonstrated obstruction of the
right main stem bronchus and 80% obstruction of the left
mainstem bronchus. He had balloon dilatation of bilateral
bronchi and removal of parts of two stents. He tolerated the
procedure well, however, on [**2162-10-3**], he had a hypoxic
episode on the Floor in which his O2 saturation dropped to
59% with face mask. Suctioning did not improve his
saturation. He was intubated and transferred to the Unit.
Repeat bronchoscopy revealed extensive mucous plugging. On
[**10-4**], he was successfully extubated in the Unit and
transferred to the Floor. On [**10-6**], he had a repeat
bronchoscopy done to remove additional mucous plugs.
During his hospital stay he also was found to have Gram
negative rods in his sputum and spike low-grade temperatures.
He was started on Clindamycin and Levaquin. After initiation
of antibiotics he became afebrile with decreased white blood
cell count. The patient continued to improve and on the day
of discharge, he was saturating 94 to 97% on room air with
ambulation. No further stent will be placed at this time.
He is to follow-up with Pulmonary Medicine in four to six
weeks for re-evaluation for stent placement.
CONDITION AT DISCHARGE: Stable.
DISCHARGE DIAGNOSES:
1. Non-small cell lung cancer.
2. Pneumonia.
3. Mucous plugging.
DISCHARGE STATUS: To home in [**State 622**].
DISCHARGE MEDICATIONS:
1. Guaifenesin 1200 mg p.o. twice a day.
2. Levaquin 500 mg p.o. q. day times eight days.
3. Combivent inhaler two puffs twice a day.
[**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1775**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1776**]
Dictated By:[**Name8 (MD) 3219**]
MEDQUIST36
D: [**2162-10-8**] 10:44
T: [**2162-10-14**] 14:37
JOB#: [**Job Number 44134**]
|
[
"E878.1",
"996.59",
"V10.05",
"519.1",
"530.81",
"518.5",
"V10.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.91",
"33.24",
"96.71",
"96.04",
"33.23"
] |
icd9pcs
|
[
[
[]
]
] |
2489, 2512
|
4563, 4680
|
4703, 5137
|
3234, 4517
|
2535, 3216
|
4533, 4542
|
159, 1150
|
1172, 2214
|
2231, 2472
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,849
| 128,785
|
46903+46904
|
Discharge summary
|
report+report
|
Admission Date: [**2175-1-30**] Discharge Date: [**2175-2-3**]
Date of Birth: [**2108-11-23**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Clindamycin / Aspirin /
Gentamicin / Penicillins
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
Anuria, Urosepsis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a 66 yo M with long standing secondary
progressive multiple sclerosis, paraplegia, multiple UTIs in the
setting of choronic indwelling suprapubic catheter presents from
[**Location (un) 86**] Home with lethargy and anuria for a day.
.
Per the [**Location (un) 86**] Home nursing staff, the patient is not alert and
oriented at baseline, and after lunch yesterday suddenly became
lethargic and unresponsive. The nursing staff denies any chest
pain, shortness of breath, nausea or vomiting at the time. Vital
signs taken at the time revealed no fever and were otherwise
stable. The patient was then sent to the [**Hospital1 18**] ED for further
management.
.
Of note, the patient has had very poor oral intake (both solid
and liquid) due to a flare of his [**Hospital1 **] [**Hospital1 99497**]. He also
did reportedly have some dental work done recently, although the
precise nature of this dental work could not be clarified.
.
Upon arrival to the ED vitals were: T 99.4, HR 101, BP 124/74,
RR 16, O2Sat 92% RA. The patient received vancomycin, cefepime
for empiric antibiotic coverage. The patient was then noted to
be persistently hypotension to the 70s systolic and was
initially on peripheral norepinephrine after failed attempts
were made at placing right IJ and subclavian CVL. He then
received 5L NS, although reportedly he remained anuric
throughout his ED course. His physical exam was notable for a
distended abdomen without tenderness. Labs pertinent for
elevated WBC to 19 and elevated Cr to 1.6. Initial UA
significant for large leuks (130 WBC, 200 RBC, many bacteria).
CXR demonstrated stable appearance of L basilar consolidation
and effusion (stable compared to previous CXRs going back to
[**2171**]). Patient had two PIVs in place and was taken off levophed
prior to transfer to the ICU. Vitals prior to transfer to the
MICU were: T 99.2, HR 88, BP 141/94, O2Sat 99% 2L NC.
Past Medical History:
-Secondary progressive MS ([**2125**]): Failed steroids
-Paraplegia
-T9-T11 discitis / osteomyelitis / phlegmon / intraosseus
abscess
- S/P 10 week course empiric Vanco/Zosyn/Flagyl ending
[**2171-10-23**]
-Dementia
-GERD
-Chronic constipation
-Seizure disorder
-[**Month/Day/Year 99496**] [**Month/Day/Year 99497**]
-Urinary retention necessitating indwelling Foley
-Recurrent UTI, urosepsis
- VRE, ESBL Klebsiella, Proteus, E. coli
- CVL infection [**1-30**] with Proteus
-Decubitus ulcers: Extremities, thoracic spine
-Temporomandibular joint pain
-Cholecystitis (s/p cholesystostomy tube placement)
-Decreased visual acuity
Social History:
Resident at [**Location (un) 86**] Home since [**9-1**]. Formerly worked as an
elementary school math teacher. Denies tobacco, alcohol, drug
use.
Family History:
# Mother, alive: Asthma, macular degeneration
# Father, died at 88: Unknown, possibly had MI's
# Siblings (two sisters): One with MS
Physical Exam:
Admission Exam:
Vitals: 131/58 87 99% RA
Gen: elderly man, paraplegic, NAD
HEENT: Sclera anicteric, OP clear
CV: RRR, no m/r/g
Lungs: clear anteriorly. Limited posterior exam as patient
cannot turn-scattered crackles at left base posterior, right
lung field CTA
Abs: soft, nontender, + distention, +BS
Ext: no pedal edema
Neuro: alert and oriented, strange affect
.
Discharge Exam:
Pertinent Results:
Initial Labs:
[**2175-1-30**] 10:19PM GLUCOSE-138* LACTATE-1.8 NA+-148 K+-3.2*
CL--115*
[**2175-1-30**] 10:17PM GLUCOSE-146* UREA N-29* CREAT-1.1 SODIUM-149*
POTASSIUM-3.2* CHLORIDE-115* TOTAL CO2-19* ANION GAP-18
[**2175-1-30**] 10:17PM PT-12.5 PTT-22.7 INR(PT)-1.0
[**2175-1-30**] 05:06PM GLUCOSE-131* LACTATE-1.5 K+-GREATER TH
[**2175-1-30**] 05:00PM GLUCOSE-131* UREA N-40* CREAT-1.6* SODIUM-144
POTASSIUM-4.5 CHLORIDE-107 TOTAL CO2-23 ANION GAP-19
[**2175-1-30**] 05:00PM estGFR-Using this
[**2175-1-30**] 05:00PM WBC-19.1*# RBC-4.58* HGB-13.4* HCT-42.2
MCV-92 MCH-29.3 MCHC-31.8 RDW-14.8
[**2175-1-30**] 05:00PM NEUTS-84.3* LYMPHS-9.0* MONOS-5.7 EOS-0.4
BASOS-0.5
[**2175-1-30**] 05:00PM PLT COUNT-428
.
#MICRO
BCx (ED)- Gram positive cocci in clusters
UCx- Pending
Legionella Urinary Ag- Neg
.
#URINE
[**2175-1-31**] 06:22PM URINE RBC-77* WBC-354* Bacteri-FEW Yeast-NONE
Epi-0
[**2175-1-31**] 06:22PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.012
[**2175-1-31**] 06:22PM URINE Blood-MOD Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
.
#ANEMIA
[**2175-2-1**] 05:46AM BLOOD Ret Aut-1.1*
[**2175-1-30**] 05:00PM BLOOD WBC-19.1*# RBC-4.58* Hgb-13.4* Hct-42.2
MCV-92 MCH-29.3 MCHC-31.8 RDW-14.8 Plt Ct-428
[**2175-1-31**] 05:14PM BLOOD WBC-9.4# RBC-3.31*# Hgb-10.1*# Hct-30.5*#
MCV-92 MCH-30.4 MCHC-33.0 RDW-14.6 Plt Ct-320
[**2175-2-1**] 05:46AM BLOOD WBC-6.4 RBC-3.20* Hgb-9.6* Hct-29.1*
MCV-91 MCH-30.1 MCHC-33.1 RDW-14.5 Plt Ct-305
Brief Hospital Course:
66 year old male with history of MS, suprapubic catheter
w/recurrent UTIs presenting with lethagy and anuria. On
admission, the patient had a leukocytosis to 19, tachycardia,
hypotension and he was admitted to the MICU. He was started on
IV linezolid/meropenem. He was seen by urology who relieved a
SPT obstruction after which he had good urine output. His
condition improved with IV fluids and antibiotics and he was
transferred to the floor. On the floor, he remained afebrile
without leukocytosis. A blood culture from [**1-30**] (1 of 2) was
positive for coag negative staph which was felt to be a
contamination. His urine culture was also contaminated and
therefore not speciated. Subsequent urine cultures were
negative. He will be discharged on a total 14 day course of
antibiotics (PO linezolid and IV ertapenem) for presumed
urosepsis. Other issues during his admission includes anemia
with iron studies suggesting anemia of chronic disease. He also
presented with acute kidney injury which resolved with IVF. His
electrolytes were repleted prn and was notable for low phos
which returned to [**Location 213**] with IV repletion. A PTH was chacked
to look for primary or secondary hyperparathyroid, but this was
pending prior to discharge. We would recommend follow-up of his
phos by his PCP in addition to checking vitamin D levels. He
also did have some loose stools and C diff was negative. His
bowel regimen was held during most of his hospitalization. In
regards to MS and his other chronic medical issues, his home
medications were continued. As a side note, pleural effusions
and LLL consolidation were noted on CXR and were determined to
be stable compared to prior films. These findings have been
present since at least [**2171**] and per his PCP are likely secondary
to chronic atelectasis.
Medications on Admission:
1. cefdinir 300 mg Capsule Sig: Two (2) Capsule PO once a day.
2. famotidine 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. levetiracetam 250 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Tums Oral
8. baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
9. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
10. carbamazepine 200 mg Tablet Sig: 1.5 Tablets PO TID (3 times
a day).
11. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
dose PO DAILY (Daily).
12. misoprostol 200 mcg Tablet Sig: One (1) Tablet PO QID (4
times a day).
13. bisacodyl 10 mg Suppository Sig: One (1) suppository Rectal
once a day as needed for constipation.
14. Milk of Magnesia 400 mg/5 mL Suspension Oral
15. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO every four (4)
hours as needed for fever or pain: do not exceed 4 g in 24 hrs.
16. oxycodone 5 mg Tablet Sig: Two (2) Tablet PO every four (4)
hours as needed for pain: do not combine with alcohol. do not
drive while taking this medication.
17. Peridex 0.12 % Mouthwash Sig: Fifteen (15) mL Mucous
membrane twice a day.
18. benzocaine Mucous membrane
Discharge Medications:
1. cefdinir 300 mg Capsule Sig: Two (2) Capsule PO once a day.
2. famotidine 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. levetiracetam 250 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Tums Oral
8. baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
9. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
10. carbamazepine 200 mg Tablet Sig: 1.5 Tablets PO TID (3 times
a day).
11. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
dose PO DAILY (Daily).
12. misoprostol 200 mcg Tablet Sig: One (1) Tablet PO QID (4
times a day).
13. bisacodyl 10 mg Suppository Sig: One (1) suppository Rectal
once a day as needed for constipation.
14. Milk of Magnesia 400 mg/5 mL Suspension Oral
15. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO every four (4)
hours as needed for fever or pain: do not exceed 4 g in 24 hrs.
16. oxycodone 5 mg Tablet Sig: Two (2) Tablet PO every four (4)
hours as needed for pain: do not combine with alcohol. do not
drive while taking this medication.
17. Peridex 0.12 % Mouthwash Sig: Fifteen (15) mL Mucous
membrane twice a day.
18. benzocaine Mucous membrane
19. linezolid 600 mg Tablet Sig: One (1) Tablet PO twice a day
for 9 days.
Disp:*18 Tablet(s)* Refills:*0*
20. ertapenem 1 gram Recon Soln Sig: One (1) g Intravenous once
a day for 9 days.
Disp:*9 g* Refills:*0*
21. Vitamin D-3 400 unit Capsule Sig: One (1) Capsule PO once a
day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 86**] Home - [**Location (un) 86**]
Discharge Diagnosis:
Primary:
sepsis
acute renal failure
Secondary:
multiple sclerosis
paraplegia
seizure disorder
GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Paraplegic
Discharge Instructions:
You were admitted to [**Hospital1 69**] for
fatigue and decreased urination. You were treated with fluids
and antibiotics for infection causing low blood pressure. Your
suprapubic catheter was blocked and was fixed by the urology
team. Your phosphate was found to be low and was repleted.
The following changes were made to your home medications:
START Linezolid 600 mg twice a day by mouth for 9 days
START Ertapenem 1 g intravenous daily for 9 days
Start vitamin D
Please continue your other home medications.
Followup Instructions:
Please see your primary care physician as needed. Please see
urology as needed.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
Admission Date: [**2175-2-3**] Discharge Date: [**2175-2-8**]
Date of Birth: [**2108-11-23**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Clindamycin / Aspirin /
Gentamicin / Penicillins
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Positive blood culture
Major Surgical or Invasive Procedure:
IR guided PICC placement
History of Present Illness:
Please see Discharge Summary Note from [**2175-2-4**]
.
In brief, this is a 66 yo M with multiple sclerosis, [**Month/Day/Year 78605**],
suprapubic catheter, and multiple UTIs admitted 3/7-311 with
lethargy and anuria. He was febrile in the ED and was given
vanc/cefepime/levo and IVF for hypotension. He appeared septic
and was admitted to the MICU. In the MICU, he did not need
pressors and was treated with linezolid and meropenem to cover
most likely urinary pathogens given a history of VRE and
pseudomonas. He was discharge earlier in the day on Linezolid
and ertapnem. Blood cx subsequently returned positive for GPCs
in clusters so he was directly readmitted back to CC7. per
attending discussion with ID, vancomycin was recommended rather
than linezolid for coverage.
Past Medical History:
1) Secondary progressive MS ([**2125**]): Failed steroids
2) [**Year (4 digits) **]
3) T9-T11 discitis / osteomyelitis / phlegmon / intraosseus
abscess
- s/p 10 week course empiric Vanco/Zosyn/Flagyl ending [**2171-10-23**]
4) Dementia
5) GERD
6) [**Month/Day/Year 8304**] constipation
7) Seizure disorder
8) [**Month/Day/Year 99496**] [**Month/Day/Year 99497**]
9) Urinary retention due to neurogenic bladder and urethral
stricture
- s/p suprapubic catheter [**11/2173**]
- Recurrent UTI, urosepsis with VRE, ESBL Klebsiella, Proteus,
E. coli
10) Central line infection [**1-/2171**] with Proteus
11) Decubitus ulcers: extremities, thoracic spine
12) Temporomandibular joint pain
13) Cholecystitis (s/p cholesystostomy tube placement)
14) Decreased visual acuity
Social History:
Resident at [**Location (un) 86**] Home since [**9-1**]. Formerly worked as an
elementary school math teacher. Denies tobacco, alcohol, drug
use.
Family History:
# Mother, alive: Asthma, macular degeneration
# Father, died at 88: Unknown, possibly had MI's
# Siblings (two sisters): One with MS
Physical Exam:
On Admission:
Vitals: 99.1 140/84 88 20 96%RA
Gen: elderly chronically ill appearing man, appears older than
stated age, paraplegic, NAD
HEENT: Sclera anicteric, PERRL. EOMI. No conjuctival injection.
No exudate. Poor dentition with pain with palpation L upper
teeth, no focal abscess appreciated or purulence. L tender
cervical LAD. CV: RRR, no m/r/g
Lungs: clear anteriorly with crackles left base. No wheezes or
rhonchi
Abs: soft, nontender, mildly distented, +BS, no HSM. Suprapubic
catheter in place and draining urine. Slight tenderness
suprapubic region
Ext: no pedal edema, atrophic and contact[**Name (NI) **]. [**Name2 (NI) **] splinter
hemorrhages or [**Last Name (un) **] lesions or OSler's nodes. Left 2nd toe
with dried blood under nail bed.
Neuro: alert and oriented, rambles with flat affect, resting
tremor RUE
.
Pertinent Results:
#CBC
[**2175-2-4**] 02:00AM BLOOD WBC-8.1 RBC-3.61* Hgb-11.2* Hct-32.7*
MCV-91 MCH-31.1 MCHC-34.3 RDW-14.9 Plt Ct-447*
[**2175-2-4**] 02:00AM BLOOD Neuts-70.7* Lymphs-16.6* Monos-6.0
Eos-5.7* Baso-1.0
.
#URINE
[**2175-2-4**] 05:51AM URINE RBC-32* WBC-102* Bacteri-FEW Yeast-NONE
Epi-0
[**2175-2-4**] 05:51AM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG
.
#MICRO
[**2-2**] BCx- Coagulase negative staph(anaerobic), send to [**Hospital1 **] for
further speciation
[**1-30**] BCx- Coagulase negative staph (1/4 bottles)
[**2-4**] UCx- No growth to date
.
#ECHO
.
TTE
Conclusions
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Physiologic mitral regurgitation
is seen (within normal limits). There is borderline pulmonary
artery systolic hypertension. There is no pericardial effusion.
No vegetation seen (cannot definitively exclude).
Compared with the prior study (images reviewed) of [**2171-8-22**],
there is no significant change.
.
TEE
Patient did not tolerate esophageal intubation due to gag reflex
and severe cervical kyphosis.
Brief Hospital Course:
66 year old male with history of MS, suprapubic catheter
presents for admission after being found to have a positive
blood culture after being discharged from hospitalization for
sepsis of unidentified source.
.
During his first hospital course, no organism had been
identified and the patient appeared clinically well with no
fevers or white count. He was originally discharged on
linezolid and meropenem for broad empiric coverage given history
of resistant bugs in the past. He had had one set blood cx
positive for coag-negative GPC which was presmued to be a
contaminant. However, when a second BCx (from [**2-2**]) returned
positive with a similar profile shortly after discharge, he was
readmitted for further work-up. ID was consulted, and they
recommended changing his antibiotic course to vancomycin and
meropenem. He continued to appear clinically well with no fevers
or leukocytosis and surveillance blood cultures were negative.
He underwent a TTE to r/o endocarditis but the image quality was
poor. A TEE was attempted but the patient did not tolerate the
procedure. ID recommended continuing vancomycin until [**2-18**] and
completing the course of carbapenem through [**2-13**]. They will
follow him and weekly labwork in [**Hospital 4898**] clinic.
.
In regards to access, his L PICC was found to be partially
thrombosed and was removed. The IV team was unable to obtain
peripheral access and unable to obtain a PICC in the Right arm.
IR was able to place a PICC in the right arm. He will follow-up
in [**Hospital 4898**] clinic.
Medications on Admission:
1. cefdinir 300 mg Capsule Sig: Two (2) Capsule PO once a day.
2. famotidine 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. levetiracetam 250 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Tums Oral
8. baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
9. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
10. carbamazepine 200 mg Tablet Sig: 1.5 Tablets PO TID (3 times
a day).
11. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
dose PO DAILY (Daily).
12. misoprostol 200 mcg Tablet Sig: One (1) Tablet PO QID (4
times a day).
13. bisacodyl 10 mg Suppository Sig: One (1) suppository Rectal
once a day as needed for constipation.
14. Milk of Magnesia 400 mg/5 mL Suspension Oral
15. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO every four (4)
hours as needed for fever or pain: do not exceed 4 g in 24 hrs.
16. oxycodone 5 mg Tablet Sig: Two (2) Tablet PO every four (4)
hours as needed for pain: do not combine with alcohol. do not
drive while taking this medication.
17. Peridex 0.12 % Mouthwash Sig: Fifteen (15) mL Mucous
membrane twice a day.
18. benzocaine Mucous membrane
19. linezolid 600 mg Tablet Sig: One (1) Tablet PO twice a day
for 9 days. Disp:*18 Tablet(s)* Refills:*0*
20. ertapenem 1 gram Recon Soln Sig: One (1) g Intravenous once
a day for 9 days. Disp:*9 g* Refills:*0*
21. Vitamin D-3 400 unit Capsule Sig: One (1) Capsule PO once a
day.
Discharge Medications:
1. famotidine 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. levetiracetam 250 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
6. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO QID (4 times a day) as needed for
indigestion.
7. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
8. carbamazepine 200 mg Tablet Sig: 1.5 Tablets PO TID (3 times
a day).
9. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily).
10. misoprostol 200 mcg Tablet Sig: One (1) Tablet PO QIDPCHS (4
times a day (after meals and at bedtime)).
11. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
12. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
13. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain.
14. oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours) as needed for pain.
15. chlorhexidine gluconate 0.12 % Mouthwash Sig: One (1)
Mucous membrane [**Hospital1 **] (2 times a day).
16. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
17. cefdinir 300 mg Capsule Sig: Two (2) Capsule PO once a day.
18. benzocaine Mucous membrane
19. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day.
20. vancomycin 500 mg Recon Soln Sig: 1250 (1250) mg Intravenous
Q 12H (Every 12 Hours) for 10 days.
Disp:*[**Numeric Identifier 16351**] mg* Refills:*0*
21. ertapenem 1 gram Recon Soln Sig: One (1) Intravenous once a
day for 6 days.
Disp:*6 g* Refills:*0*
22. Outpatient Lab Work
LAB TESTS: CBC, BUN, Crea, LFTs, ESR, CRP, Vanco trough
FREQUENCY: Qweekly starting [**2175-2-10**]
.
After completion of antibiotics on [**2-18**], please do weekly blood
cultures as well for 2 weeks.
.
All laboratory results should be faxed to Infectious disease
R.Ns. at ([**Telephone/Fax (1) 1353**]
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 86**] Home - [**Location (un) 86**]
Discharge Diagnosis:
Primary:
Bacteremia
Secondary:
MS
[**First Name (Titles) 78605**]
[**Last Name (Titles) **] suprapubic catheter
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: paraplegic
Discharge Instructions:
Dear Mr. [**Last Name (Titles) 99502**],
.
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted for bacterial infection of
your blood. You were given IV antibiotics and you improved. You
should continue the IV antibiotics for the course described
below.
.
We made the following changes to your medications:
START Vancomycin 1250 mg intravenous twice a day until [**2-18**]
START Ertapenem 1 g intravenous daily until [**2-13**]
START Vitamin D supplements
STOP Cefdinir 600 mg once a day WHILE you are taking ertapenem -
RESTART Cefdinir on [**2-13**]
.
Please continue your other home medications.
.
Your follow up information is below.
Followup Instructions:
Please see your primary care physician [**Last Name (NamePattern4) **] [**11-27**] weeks. Please see
your urologist as needed.
In addition, you will be seen by infectious disease in
outpatient antibiotic clinic. The following appointment has
been made for you:
[**2175-2-27**] at 10.10am with Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**Hospital **] clinic, [**Hospital Ward Name **]
Basement, [**Telephone/Fax (1) 3395**]
|
[
"598.9",
"276.8",
"996.74",
"785.52",
"E879.6",
"344.1",
"790.7",
"707.02",
"584.9",
"707.20",
"453.81",
"564.00",
"275.3",
"038.19",
"345.90",
"596.54",
"518.0",
"788.5",
"340",
"285.9",
"995.92",
"350.1",
"996.31",
"530.81",
"599.0",
"E849.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"38.97",
"00.14",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
21437, 21516
|
15945, 17498
|
11559, 11586
|
21673, 21673
|
14362, 15922
|
22497, 22958
|
13362, 13496
|
19180, 21414
|
21537, 21652
|
17524, 19157
|
21809, 22113
|
13511, 13511
|
10827, 10994
|
3680, 3680
|
22142, 22474
|
11497, 11521
|
11614, 12393
|
13525, 14343
|
21688, 21785
|
12415, 13182
|
13198, 13346
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,847
| 119,883
|
14747+56576
|
Discharge summary
|
report+addendum
|
Admission Date: [**2130-5-29**] Discharge Date: [**2130-6-2**]
Date of Birth: [**2082-10-10**] Sex: F
Service: PSU
HISTORY OF PRESENT ILLNESS: This is a pleasant 47-year-old
Caucasian female with a history of left breast cancer, status
post a lumpectomy with chemotherapy and radiation, who
elected to undergo bilateral risk reducing mastectomy and [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) 5884**] flap for immediate reconstruction. Please see the
operative notes by Dr. [**First Name (STitle) 3228**], and Dr. [**First Name (STitle) **], and Dr. [**Last Name (STitle) **]
for further information.
PAST MEDICAL HISTORY: History of left breast cancer, status
post lumpectomy.
MEDICATIONS ON ADMISSION: Arimidex, Effexor, Ativan,
Fosamax, and Flonase.
SUMMARY OF HOSPITAL COURSE: This pleasant 47-year old female
underwent the operative procedure on [**2130-5-29**] and was
admitted to the plastic surgical service for routine
postoperative care. She was admitted to the ICU for flap
checks and monitoring. She did well overnight. However,
around noon on postoperative day 1 she was found to be a bit
groggy, and medication review illustrated the patient had
gotten a significant amount of morphine via PCA and p.r.n.
doses in the trauma SICU. These medications were held for a
while, and then decreased in dosage by half, and the patient
subsequently seemed to improve. She did well during the
remainder of the day, and on the morning of postoperative day
2 she was noted to have a hematocrit of 19.7. She was
transfused 1 unit of autologous blood she had given prior to
surgery. She underwent the transfusion without any
significant problems. [**Name (NI) **] diet was advanced, and she was
transferred out to the floor on the evening of postoperative
day 2. On postoperative day 3, her Foley was discontinued and
the patient was encouraged to ambulate; which she did without
any difficult. On postoperative day 4, the patient was
ambulating without difficulty. She was noted, however, to
have a bit of a temperature on the evening of postoperative
day 3. On the morning of postoperative day 4, her UA was
negative and she was encouraged to use her IS. Her flaps at
that time were still in good condition with a good capillary
refill and good Doppler signals. She remained afebrile for
the rest of the day and felt comfortable going home.
DISCHARGE INSTRUCTIONS: She was given strict instructions to
return if she had any difficulty or continued to spike fevers
at home. She was to either call the office or return to the
emergency department.
DISCHARGE DIAGNOSES: Status post bilateral mastectomy with
bilateral deep inferior epigastric perforator flap
reconstruction.
DISCHARGE FOLLOWUP: She was to follow up with Dr. [**First Name (STitle) 3228**] on
Tuesday, [**6-6**].
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Discharged to home with services for
drain management; she currently still has [**Location (un) 1661**]-[**Location (un) 1662**]
drains in.
MEDICATIONS ON DISCHARGE: Include her preoperative
medications as well as aspirin 1.5 tablets 81 mg-tablets p.o.
daily, ferrous sulfate 325 mg p.o. daily, Duricef 500 mg 1
tablet p.o. b.i.d. (x 7 days), Percocet 5/325 mg take 1
tablet p.o. q.4-6h. p.r.n. for pain (dispensed 45), Colace
100 mg p.o. b.i.d. (while taking narcotic pain medication),
and iron.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3228**], M.D. [**MD Number(2) 8076**]
Dictated By:[**Doctor Last Name 22186**]
MEDQUIST36
D: [**2130-6-2**] 17:24:06
T: [**2130-6-3**] 10:13:16
Job#: [**Job Number **]
Name: [**Known lastname 7919**], [**Known firstname **] Unit No: [**Numeric Identifier 7920**]
Admission Date: [**2130-5-29**] Discharge Date: [**2130-6-2**]
Date of Birth: [**2082-10-10**] Sex: F
Service: PSU
ADDENDUM:
DISCHARGE DIAGNOSES:
1. Status post bilateral mastectomy with immediate
reconstruction, utilizing bilateral deep inferior
epigastric artery perforator flaps.
2. Postoperative anemia.
HOSPITAL COURSE: On postoperative day # 2, the patient was
noted to have a hematocrit of 19.7. Given the availability
of an autologous unit of packed red blood cells, she was
transfused 1 unit of her own blood on postoperative day # 2.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3675**], M.D. [**MD Number(2) 7921**]
Dictated By:[**Last Name (NamePattern1) 7922**]
MEDQUIST36
D: [**2130-6-15**] 09:10:43
T: [**2130-6-15**] 09:50:19
Job#: [**Job Number 7923**]
|
[
"V16.3",
"285.1",
"174.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.02",
"85.36",
"85.89"
] |
icd9pcs
|
[
[
[]
]
] |
2883, 3024
|
3920, 4090
|
3051, 3899
|
745, 795
|
4108, 4602
|
2411, 2593
|
824, 2386
|
2742, 2827
|
165, 639
|
662, 718
|
2852, 2859
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,710
| 194,851
|
13835
|
Discharge summary
|
report
|
Admission Date: [**2194-3-6**] Discharge Date: [**2194-3-9**]
Date of Birth: [**2122-4-12**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
EGD [**3-7**]
History of Present Illness:
HPI: Patient is a 71 yo Italian speaking female who was in
normal state of health until 1 day prior to admission when she
developed some abdominal cramping and discomfort. Pain was
mostly in upper abdomen/mid epigastric area. She ate some pizza
and felt better, then went to sleep. She awoke this am with
nausea and vomiting and noted that there were bright red blood
clotts in her emesis. She vomited multiple times and also had
diarrea that was black and sticky. After this, she felt dizzy
and was noted to be pale and diaphoretic by family members. [**Name (NI) **]
daughter called Dr. [**Last Name (STitle) **] and was told to come to the ED.
Denies any aspirin or nsaid use. She has never had bleeding
or black stools in the past. Denies alcohol use or liver
disease. Denies CP, SOB.
In the ED, NG lavage initially showed bright red blood but
cleared after 500cc. Patient had frank melena on rectal exam.
Had 1L IVF. Patient did not want blood transfusion. Upon
reaching the [**Hospital Unit Name 153**], patient now consents for blood, only if hct
drops further than 26.
Past Medical History:
IDDM, MDS (follows with Dr. [**Last Name (STitle) **], S/p lense replacement,
thrombocytopenia, hemorrhoids, htn, retinopathy, hearing loss
(no CAD hx, EF 55%, recent normal MIBI). Patient had screening
colonoscopy in [**2194-2-6**]
Social History:
Lives with husband and daughter. Independent in ambulation and
ADL's. No tobacco, no illicits, no ETOH, no NSAIDs or aspirin.
Family History:
Daughter with [**Name (NI) 1932**], brother with throat cancer, sister with
lung cancer, mother with "abdominal" cancer
Physical Exam:
vitals 99.5/ hr 75/ bp 140/42/ 97% on RA
GEN: appears stated age, well nourished, NAD flat in bed
HEENT: anicteric sclerae, no pallor, clear OP
NECK: supple, no JVD w/ upright positioning, no LAD
HEART: s1/s2, no murmurs, no rubs
LUNGS: clear B/L, no CVA tenderness
ABD: soft, non distended, nt, hypoactive BS, no fluid wave, no
masses appreciated
EXT: warm. trace edema B/L, pain w/ palpation B/L (pt reports
this is chronic) No tremor/ no asterixis
NEURO: CN II-XII intact, no focal deficits. 5/5 strength in all
4 extremities
Pertinent Results:
EGD [**3-7**]: 1_ One long, linear ulcer in the antrum and one small
ulcer in pylorus. These ulcers account for patient's GI bleed.
2) Three cords of grade II nonbleeding varices at the lower
third of the esophagus and middle third of the esophagus.
3) Erythema in the duodenal bulb compatible with duodenitis
.
C-scope [**2194-2-6**]: Polyp in the ascending colon
Grade 3 internal hemorrhoids Otherwise normal colonoscopy to
cecum.
.
EKG: nsr 76, L shift, TWi in V1,V2, no st changes
.
Abdominal US: IMPRESSION:
1. No evidence of portal vein thrombosis.
2. Cholelithiasis and gallbladder sludge with mild gallbladder
wall edema and small amount of pericholecystic fluid. The
gallbladder was not distended and there is no son[**Name (NI) 493**]
[**Name2 (NI) 515**] or evidence of common bile duct dilatation. No evidence
of acute cholecystitis.
3. Left kidney exophytic cyst stable compared to the prior
examination.
.
[**2194-3-6**] 04:20PM BLOOD WBC-8.0# RBC-2.96* Hgb-9.2* Hct-26.9*
MCV-91 MCH-31.1 MCHC-34.1 RDW-14.1 Plt Ct-159
[**2194-3-9**] 06:30AM BLOOD WBC-6.9 RBC-3.69* Hgb-10.9* Hct-32.5*
MCV-88 MCH-29.4 MCHC-33.4 RDW-16.6* Plt Ct-154
[**2194-3-9**] 06:30AM BLOOD Plt Ct-154
[**2194-3-9**] 06:30AM BLOOD Glucose-98 UreaN-11 Creat-0.8 Na-139
K-4.4 Cl-109* HCO3-23 AnGap-11
[**2194-3-9**] 06:30AM BLOOD Calcium-8.3* Phos-2.7 Mg-2.0
[**2194-3-7**] 12:02AM BLOOD calTIBC-269 Ferritn-70 TRF-207
[**2194-3-8**] 06:30AM BLOOD %HbA1c-8.3* [Hgb]-DONE [A1c]-DONE
[**2194-3-7**] 05:30PM BLOOD [**Doctor First Name **]-POSITIVE Titer-1:40
[**2194-3-7**] 05:30PM BLOOD Smooth-NEGATIVE
[**2194-3-7**] 12:02AM BLOOD HCV Ab-NEGATIVE
.
HELICOBACTER PYLORI ANTIBODY TEST (Final [**2194-3-10**]):
POSITIVE BY EIA.
Reference Range: Negative.
Brief Hospital Course:
This 71 yo female presented with bloody emesis, epigastric pain,
melena. An NG lavage cleared after 500cc in the ED. The
patient was admitted to the [**Hospital Unit Name 153**] for further management. Her
hospital course is discussed by problems.
.
1. GI bleed: Given the bloody emesis, it was thought to be most
likely an upper GI source, possibly gastric or duodenal ulcer.
The GI service evaluated the patient in the ED, and the patient
was planned to undergo EGD in the morning. She was made NPO w/
IVF hydration, and started on PPI IV BID. Her hct was
carefully monitored, remained relatively stable although down
from baseline. She initially refused to have a blood
transfusion, but then relented and was transfused 1 unit of
PRBCs. She then underwent EGD for evaluation, with results as
discussed above. She was found to have antral and pyloric
ulcers, but esophageal varices as well. Given these findings,
she was continued on the PPI [**Hospital1 **], and underwent work-up for
evidence of cirrhosis leading to portal hypertension. An
abdominal US showed patent flow in the portal system, and no
evidence of ascites or abnormal liver architecture. Initial
studies were sent, including hepatitis panels, smooth muscle
antibody, [**Doctor First Name **], iron studies. Liver function tests were sent,
which returned normal. Lipid panel was normal. The patient
will need further work-up as an outpatient to evaluate
non-cirrhotic portal hypertension leading to esophageal varices.
She was started on Propanolol for treatment of the varices.
Her hematocrit remained stable, with no further transfusion
requirements. The patient was instructed to follow-up with Dr.
[**Last Name (STitle) **]. The importance of this was also discussed with her
family. She remained hemodynamically stable.
.
2. IDDM: She was placed on her home NPH regimen, which was
initially halved while she was NPO, then slowly increased as her
diet increased. She was monitored with FS QID, and placed on
RISS for coverage. A Hgb A1c was checked, which was high at
8.3%, indicating suboptimal control. She will follow-up with
her PCP for diabetic control.
.
3. Thrombocytopenia: The patient had a known history of
thrombocytopenia with platelets ranging from 125-159 since [**2191**].
This was thought to be secondary to MDS, and the pt may be
undergoing bone marrow bx in the future. Her platelets were
monitored, and remained stable. Given this history, she was
provided pneumoboots rather than sc heparin for DVT prophylaxis.
.
4. HTN- The patient had been on Atenolol and Lisinopril at home.
These were initially held secondary to her GI bleed, then the
lisinopril was slowly restarted once her hematocrit was stable,
as her blood pressure remained stable. Her Atenolol was held as
the patient was on propanolol for the varices.
.
She was evaluated by PT prior to discharge, and cleared for a
safe discharge to home. She was tolerating a regular diabetic
diet at the time of discharge, and did not have any further
evidence of active bleeding. She was provided scripts for
Propanolol and the PPI. She will be followed up by her PCP and
Dr. [**Last Name (STitle) **] for further work-up of the esophageal varices.
Medications on Admission:
lisinopril
atenolol
Discharge Medications:
1. Propranolol 10 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*0*
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. Outpatient Lab Work
Hematocrit
Discharge Disposition:
Home
Discharge Diagnosis:
Esophageal Varices
Antral and Pyloric ulcers
Hypertension
Insulin Dependent Diabetes
Discharge Condition:
Good
Discharge Instructions:
We have started you on two new medications for the ulcers and
varices seen on EGD. Please continue to take these and all of
your medications as instructed. Please call your doctor or
return to the hospital if you develop fevers/ chills/ black
stools, chest pain or shortness of breath.
Followup Instructions:
Provider: [**Name10 (NameIs) 40053**],[**First Name8 (NamePattern2) 2352**] [**Last Name (NamePattern1) 9612**] MEDICINE (PRIVATE)
Phone:[**Telephone/Fax (1) 1144**] Date/Time:[**2194-3-21**] 2:00
.
Please call Dr.[**Name (NI) 12202**] office at [**Telephone/Fax (1) 1983**] for a follow-up
appointment within 2 weeks of discharge. You will need to
follow-up on lab work that was completed during your
hospitalization.
|
[
"238.7",
"401.9",
"287.5",
"531.40",
"250.00",
"456.1",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
8038, 8044
|
4339, 7566
|
324, 339
|
8173, 8180
|
2566, 4316
|
8516, 8939
|
1879, 2001
|
7636, 8015
|
8065, 8152
|
7592, 7613
|
8204, 8493
|
2016, 2547
|
273, 286
|
367, 1463
|
1485, 1720
|
1736, 1863
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
549
| 154,997
|
5829
|
Discharge summary
|
report
|
Admission Date: [**2161-8-8**] Discharge Date: [**2161-8-27**]
Date of Birth: [**2085-6-20**] Sex: F
Service: [**Hospital1 **] MEDICINE
HISTORY OF PRESENT ILLNESS: This is a 76-year-old female
with previous history of hypertension, atrial fibrillation
and sick sinus syndrome status post pacemaker who originally
presented to an outside hospital with acute pancreatitis
secondary to gallstone. She was treated at the outside
hospital with intravenous fluids and was put NPO for bowel
rest. However, she subsequently developed worsening
shortness of breath even though her pancreatitis was being
adequately treated. The thinking at that point was
congestive heart failure versus pneumonia versus ARDS. Her
hypoxia was slowly worsening and she was thus transferred to
the [**Hospital6 256**] on a regular floor.
She was originally being managed with antibiotics and
diuresis. However, on the second day of admission, the
patient became severely hypoxic with O2 saturations of about
60% to 70% on 100 nonrebreather. She had a transthoracic
echocardiogram which revealed an ejection fraction of 65%,
thus leaving the most likely explanation to be ARDS. The
patient was transferred to the Medical Intensive Care Unit
where she was intubated.
On the day of intubation, which was [**8-10**], she was also
started on two pressors, Levophed and vasopressin. At the
same time, there was a rising suspicion of worsening of her
pancreatitis which could have lead to her ARDS. Because of
this, she was started on a 10 day course of imipenem. On the
following day, she was found to have a low cortisol a.m.
level, so she was started on hydrocortisone 100 mg tid for
renal insufficiency. Imaging studies at this point revealed
the following: Head CT was negative for a bleed. Chest CT
showed ARDS and abdominal CT revealed no evidence of abscess
or necrosis in the pancreas. On [**8-16**], the patient had
urine culture and sputum cultures growing yeast and she was
started on a five day course of fluconazole which she
completed without complications. The patient's respiratory
status slowly improved and after about 10 days of intubation,
decision was made to try to extubate her. However, she
appeared difficult to extubate and appeared sedated. This
situation, however, improved and finally on [**8-21**], she
was extubated. At this point, she was transferred to our
care on the regular medical floor.
PAST MEDICAL HISTORY:
1. Hypertension
2. Atrial fibrillation
3. Sick sinus syndrome, status post pacemaker
4. Status post mitral valve replacement
HOME MEDICATIONS PRIOR TO ADMISSION TO OUTSIDE HOSPITAL:
1. Atacand
2. Lipitor
3. Digoxin
4. Zoloft
5. Coumadin
6. Lasix
MEDICATIONS UPON TRANSFER TO OUR FLOOR:
1. Coumadin 500 mg qd
2. Digoxin 0.125 mg qd
3. Zoloft 100 mg qd
4. Erythropoietin 10,000 units 3x a week
5. Heparin intravenous GTT
6. Regular insulin sliding scale
7. Lactulose 30 ml q6h prn
8. Dulcolax pr q hs prn
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: She lives alone and is widowed. Her son is
very involved in her care. There is no use of tobacco or
alcohol.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAM:
VITAL SIGNS: Temperature 97.6??????, blood pressure 125/62, pulse
74, respiratory rate 20 with saturations 97 on 4 liters nasal
cannula.
GENERAL: This is a chronically ill appearing woman smiling.
HEAD, EARS, EYES, NOSE AND THROAT: Pupils equal and reactive
to light. Extraocular movements intact. Oropharynx is
clear. Mucous membranes appear dry.
NECK: There is no lymphadenopathy. Jugular venous pressure
elevated to about 9 cm.
RESPIRATORY: Difficult to fully assess secondary to
deconditioning, however there are crackles about [**2-12**] of the
way up.
CARDIOVASCULAR: Regular rate, 4/6 systolic ejection murmur
best heard at the left upper sternal border. There is a also
a [**3-18**] holosystolic murmur best heard at the right upper
sternal border.
ABDOMEN: Soft, nontender, nondistended with hyperactive
bowel sounds, no mass and no liver edge.
EXTREMITIES: Lower extremities are puffy without pitting
edema and 2+ pulses.
NEUROLOGIC: Mental status alert and oriented to place, but
not to time. Comprehension appears intact. Language is
fluent. The patient is somewhat somnolent. Cranial nerves
are intact. Motor and sensory difficult to test secondary to
patient's noncompliance. There were no focal abnormalities.
LABORATORIES ON TRANSFER: White count 13.1, hematocrit 26.6,
platelets 235. Sodium 136, potassium 4.4, chloride 102,
bicarbonate 27, BUN 24, creatinine 0.5, glucose 128, PT 12.9
with INR of 1.2, PTT 50.2. ALT 18, AST 31, alkaline
phosphatase 73. Total bilirubin 0.6, amylase 126, lipase
361, calcium 7.8, phosphorus 3.5, magnesium 1.4. Her last
arterial blood gas and FIO2 of 50% showed pH 7.45, PCO2 45,
PO2 109.
BRIEF HOSPITAL COURSE UPON TRANSFER:
1. CARDIOVASCULAR: The patient was deemed to be slightly
volume overloaded. When she experienced the hypertensive
episode in the Medical Intensive Care Unit, she received over
11 liters of fluid to maintain hemodynamic instability. As a
consequence, she has been volume overloaded ever since then,
but has been able to ............ diurese without requiring
administration of Lasix. We therefore continued this and
patient was about 500 to 700 cc negative every day. Her
blood pressure remained in the range of systolic 110 to 130
and diastolic 60 to 70. We therefore did not restore her
outpatient Atacand. We continued her on Lipitor and digoxin.
Her rhythm remained to be chronic atrial fibrillation. In
this context, we also started Coumadin. She was originally
receiving 5 mg of Coumadin, but after three days of that
there was no significant improvement in her INR. We
therefore increased the dose of Coumadin to 7.5. She will
require close follow up of her INR until it reached a
therapeutic level between 2.5 and 3.5.
2. GASTROINTESTINAL: The patient's pancreatitis was
considered clinically resolved by the time she was admitted
to our service. She had no complaints of abdominal pain,
nausea, vomiting or any other signs to indicate a recurrence
of infection. She had received several days of TPN in the
Intensive Care Unit as well as a day of tube feeds. She was
receiving the tube feeds through a catheter placed in her
jejunum. For the first two hospital days on the floor, she
continued to receive tube feeds through the jejunal tube.
TPN, however was discontinued. On hospital day #3 on the
regular medical floor, she was started on clear fluids after
consultation with the gastroenterology service. She
tolerated this very well with no episodes of nausea or
vomiting. She was therefore advanced to full liquids and
this subsequently was advanced to a diet as tolerated. The
patient is very well on solid foods without complaints of
nausea, vomiting, abdominal pain or diarrhea. In addition to
this, she had a speech and swallow study which revealed
intact swallowing apparatus. The study was performed given
lengthy Medical Intensive Care Unit stay and possibility of
damage to the swallowing apparatus following 12 days of
intubation.
3. PULMONARY: ARDS had resolved during her Medical
Intensive Care Unit stay. The patient had a very low oxygen
requirement and subsequently was saturating 97% to 98% on
room air. Her respiratory exam continued to have occasional
crackles bilaterally at the bases which was attributed to a
resolution of her ARDS.
4. ANEMIA: The patient has been mildly anemic, however
clear etiology for this anemia was not reached. Her
hematocrit slowly increased from about 25 to 30 without any
transfusions. Stool guaiac was checked and was negative.
5. NEUROLOGY: The patient's mental status has been of
concern following her extubation. She remains very somnolent
most of the time, not oriented to be place. In addition, her
speech was very labored, sometimes not intelligible. Upon
careful neurological examination, there was no focal weakness
or any cranial nerve abnormalities that were detected. She
received a non contrast CT of the head which showed no
intracranial bleed. We therefore felt that her mental status
was mostly resolved for prolonged Intensive Care Unit stay
and did not require further investigation at this point. It
is quite likely that her mental status will slowly improve
with time.
DISCHARGE CONDITION: Stable
DISCHARGE STATUS: Discharge to [**Hospital6 23127**] in Acute Care Rehabilitation.
DISCHARGE DIAGNOSES:
1. Pancreatitis
2. ARDS
DISCHARGE MEDICATIONS:
1. Zoloft 100 mg po qd
2. Digoxin 0.125 po qd
3. Lipitor 10 mg po qd
4. Erythropoietin 10,000 units 3x a week
5. Coumadin 7.5 mg po qd
6. Tylenol 325 to 650 po q 4 to 6 hours prn
7. Lactulose 30 ml po q6h prn
8. Dulcolax 10 mg prn q hs
9. Heparin intravenous ............ guideline scale
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**]
Dictated By:[**Name8 (MD) 5094**]
MEDQUIST36
D: [**2161-8-27**] 03:53
T: [**2161-8-27**] 08:11
JOB#: [**Job Number **]
|
[
"V43.3",
"427.81",
"285.9",
"518.5",
"577.0",
"276.3",
"427.31",
"112.2",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"96.6",
"99.15",
"96.72",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
8416, 8509
|
3163, 3181
|
8530, 8557
|
8580, 9138
|
3196, 8394
|
186, 2433
|
2455, 3017
|
3034, 3146
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,866
| 101,912
|
48702
|
Discharge summary
|
report
|
Admission Date: [**2135-6-25**] Discharge Date: [**2135-7-7**]
Date of Birth: [**2084-5-28**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Enalapril
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
CC:[**CC Contact Info 35172**]
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname **] is a 51 yo male with a h/o ESRD on HD due to
amyloidosis (last HD Thursday) who is transferred from [**Hospital **]
Hospital for persistent hypotension. Per Dr.[**Name (NI) 4857**] note in
OMR, [**Hospital1 1501**] called to [**Hospital1 18**] HD unit on [**6-24**] to report that [**Known firstname **] had
disconnected his recently placed PD catheter. He was transported
into [**Hospital 2793**] Clinic and had 'transfer set' changed. Due to break
in sterility, 1 gram IP Vancomycin was infused empirically.
Catheter was taped down such that it would be more difficult for
patient to tamper with.
Upon returning to his [**Hospital1 1501**], Mr. [**Known lastname **] [**Last Name (Titles) **] was noted to
have increasing lethargy and hypotension and was transported to
[**Hospital **] Hospital, arriving at 3:45 p.m. At time of arrival, he
was reported as seeing bright blurred colors in front of eyes
and complaining of pain in fingers. His initial BP was recorded
as 54/40. With fluid resuscitation, BP's gradually increased
from 60's to 80 systolic, but then dropped to 68/42, prompting
initiation of dopamine gtt. HR remained in 70's until initiation
of dopamine gtt, then increased to 90's. Prior to transfer, he
received ASA 162 mg, hydrocortisone 100 mg IV, and gentamycin
150 mg IV, and dopamine gtt titrated up to 8 mcg/kg/hour for
target SBP >100. Blood cultures were drawn.
On arrival in the [**Hospital1 18**] ED, T 97.8, HR 83, BP 75/38, RR 18, SpO2
100% on 3L NC O2. He received cefepime 2 grams IV and morphine 4
mg IV for 6 out of 10 pain in his fingers.
Past Medical History:
ESRD secondary to amyloidosis -failed LRRT in [**7-5**] now on
hemodialysis (right groin line)
inferior vena cava stent
Sarcoidosis
Pulmonary aspergillosis - on chronic voriconazole
Type 2 Diabetes, on insulin
Chronic Hepatitis C
Hypertension
Sinusitis
Paroxysmal atrial fibrillation,
Clostridium difficile [**3-8**]
MRSA line sepsis
Renal osteodystrophy
Adrenal insufficiency
Upper extremity deep vein thrombosis ([**2132**])
Pancreatitis
Bilateral below the knee amputation
Right index and fifth finger amputations
Social History:
Smoked 1 pack per day X 30 years but quit. History of alcohol
abuse, but stopped 4 years ago. Previous drug use with cocaine
(+IV drug use), has been clean since about [**2127**]. Girlfriend
[**Last Name (un) 102399**] is involved in his care. Lives in a care home in
[**Location (un) 669**]. Mother lives nearby.
Family History:
Mother, brother with diabetes. No h/o kidney disease
Physical Exam:
VS: T 96.8, BP 110/67, HR 95, SpO2 100% on 3L
HEENT: clear OP, MMM, sclerae anicteric
CV: S1, S2, RRR, 2/6 systolic murmur best auscultated at LLSB,
Resp: Lungs clear b/l but with poor air movement throughout.
Abd: PD catheter intact, distended and diffusely tender,
diminished bowel sounds
Extrem: Right femoral catheter clean, dry, no erythema or
induration.
B/l BKA well healed, skin somewhat dry. No edema. Missing digits
of his hands with necrotizing segments distally.
Neuro: alert, oriented to self, place, year but not date; unable
to provided details of prior day or of his medical history
Pertinent Results:
[**2135-6-25**] 04:54AM GLUCOSE-88 UREA N-37* CREAT-6.0* SODIUM-140
POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-18* ANION GAP-22*
[**2135-6-25**] 04:54AM CALCIUM-10.2 PHOSPHATE-8.3* MAGNESIUM-2.0
[**2135-6-25**] 04:54AM CORTISOL-128.7*
[**2135-6-25**] 04:54AM WBC-9.3 RBC-3.95* HGB-11.3* HCT-39.6*
MCV-100* MCH-28.6 MCHC-28.6* RDW-19.8*
[**2135-6-25**] 04:54AM NEUTS-81.4* BANDS-0 LYMPHS-17.2* MONOS-1.0*
EOS-0.4 BASOS-0
[**2135-6-25**] 04:54AM PLT COUNT-359
[**2135-6-25**] 04:54AM PT-14.5* PTT-34.7 INR(PT)-1.3*
[**2135-6-25**] 01:37AM COMMENTS-GREEN TOP
[**2135-6-25**] 01:37AM LACTATE-0.6
[**2135-6-25**] 01:25AM GLUCOSE-75 UREA N-35* CREAT-5.9* SODIUM-138
POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-20* ANION GAP-19
[**2135-6-25**] 01:25AM CK(CPK)-74
[**2135-6-25**] 01:25AM CK-MB-NotDone cTropnT-0.35*
[**2135-6-25**] 01:25AM CALCIUM-10.1 PHOSPHATE-7.7* MAGNESIUM-2.0
[**2135-6-25**] 01:25AM WBC-11.3* RBC-4.11* HGB-11.8* HCT-41.1
MCV-100* MCH-28.8 MCHC-28.8* RDW-20.0*
[**2135-6-25**] 01:25AM NEUTS-79.2* BANDS-0 LYMPHS-18.2 MONOS-1.8*
EOS-0.7 BASOS-0.1
[**2135-6-25**] 01:25AM PLT COUNT-356
[**2135-6-25**] 01:25AM PT-12.9 PTT-33.2 INR(PT)-1.1
[**2135-6-25**] 01:00AM GLUCOSE-70 UREA N-35* CREAT-5.7*# SODIUM-139
POTASSIUM-5.0 CHLORIDE-106 TOTAL CO2-16* ANION GAP-22*
[**2135-6-25**] 01:00AM estGFR-Using this
[**2135-6-25**] 01:00AM CK(CPK)-170
[**2135-6-25**] 01:00AM cTropnT-0.29*
[**2135-6-25**] 01:00AM CK-MB-8
.
CXR [**6-25**]: IMPRESSION: Persistant right upper lobe ground glass
opacity, possibly infectious.
Brief Hospital Course:
Mr. [**Known lastname **] is a 50 year old man with history of end stage renal
disease secondary to amyloidosis, paroxysmal atrial
fibrillation, Type 2 diabetes on insulin admitted to the MICU
for hypotension and lethargy in the context of having the
transformer set changed of his peritoneal dialysis catheter.
# Change in mental status: Patient has progressive obtundation
with no obvious source on previous head CT. Repeat head CT
showing no evidence of acute intracranial process ([**6-27**]). Exam
was reportedly non focal, pt [**Name (NI) 9830**]0, and did not follow commands.
Pt currently non-responsive. Family contact and decision made
not to progressive with aggressive intervention for diagnosis
(i.e. no MRI, no intubation for imaging, no LP). Etiology
thought to be secondary to sepsis, ?meningitis for which he was
covered empirically with cefepime/vancomycin and also with
acyclovir. Additional etiology ?recent hypoglycemia, pt on IVF
with dextrose. Despite this therapy he continued not to respond.
After, several family meetings and involvment with social work
and palliative care a decision was made to make pt DNR/DNI with
no escalation of care. Over the last few days, pt's breathing
became more labored and his oxygen saturation declined. As pt
was DNR/DNI/no ICU transfer his respiratory status was made
comfortable. Despite continued broad spectrum antimicrobials and
continued dialysis sessions and treatment of transient
hypoglycemia, pt's mental status never improved and he was not
reactive even to sternal rub. On [**2135-7-6**], after meeting with
pt's girlfriend, HCP, and after discussion with patient's
family, decision was made to change the patient's status to CMO.
Pt was then placed on a morphine gtt and he passed away on
[**2135-7-7**] at 6am.
# Hypotension: The initial differential included distributive
shock due to infection vs. endocrine vs. cardiogenic. Given his
history of line infections and bacteremia and recent violation
of sterile PD catheter field, infectious etiology was considered
most likely. Exam on admission was significant for diffuse
abdominal tenderness, concerning for peritonitis. Also
considered was the HD line in right groin as possible source of
bacteremia. He had no other localizing symptoms.
He was started on vanc/cefepime as patient has h/o colonization
with both MRSA, pseudomonas. Blood cx were drawn at [**Hospital **]
Hospital, as well as at [**Hospital1 18**] - no growth to date at time of
discharge. An attempt was made to obtain peritoneal fluid for
cell count, cultures. He was on a dopamine gtt titrated to MAP
> 65, also received fluids at the OSH ([**Location (un) **]) and in the ED.
His dopamine was titrated off and he was transferred to the
medical floor where his blood pressures were stable, however his
mental status rapidly deteriorated.
# ESRD: The patient has been on dialysis secondary to amyloid,
currently on HD with plan for transition to PD. He is status
post peritoneal dialysis catheter placement [**6-10**], needs 2-3 weeks
to heal prior to use. Renal consult was following while he was
in the ICU. He was continued on his sevelamer at an increased
dose secondary to hyperphospetemia, cinecalcet. His vanc was
dosed at HD. HD sessions were continued until [**2135-7-6**] and the
renal team was very involved with the patient's care.
# Finger ischemia: The ischemia is consistent with history of
extensive
microvascular disease. He is not currently anticoagulated given
bleeding risk. He has previously been seen by Plastic Surgery
who felt his finger segment will auto-amputate. He generally
receives oxycodone PRN pain
# Thrombosis: The patient has known extensive inferior vena cava
clot burden to level of right atrium and likely involvement of
superior vena cava. There is a high degree of risk associated
with anticoagulation in this patient related to history of
hemodynamically signficant epistaxis, recurrent epistaxis, and
hemoptysis related to fungal lesion in left upper lobed of the
lung. The risks/benefits of anticoagulation have been discussed
at length during previous hospitalization, with decision not to
anticoagulate.
# DM2 uncontrolled with complications: The patient had several
episodes of hypoglycemia while on the floor which required amps
of D50 to correct. Pt was placed on a D5 gtt.
# PAF: The patient is currently in NSR. His beta blocker was
originally held in the setting of his hypotension.
# Sarcoidosis: The patient was on chronic prednisone.
# Pulmonary aspergillosis: The patient was continued on his
chronic suppressive voriconazole.
Medications on Admission:
1. Albuterol neb q4 hours
2. Metoprolol 12.5 mg [**Hospital1 **]
3. Omeprazole 20 mg daily
4. Prednisone 5 mg qAM
5. Prednisone 2.5 mg qHS
6. Bactrim 160/800 mg QHD
7. Colace 100 mg [**Hospital1 **]
8. Senna 8.6 mg [**Hospital1 **]
9. Nephrocaps
10. Bacitracin Zinc 500 unit/g Ointment [**Hospital1 **]
11. Sodium Chloride nasal spray [**Hospital1 **]
12. Voriconazole 200 mg Tablet [**Hospital1 **]
13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H
14. Lantus 100 unit/mL Cartridge Sig: Eight (8) units qHS and
sliding scale
15. Sevelamer HCl 800 mg Tablet Sig: Three (3) Tablet PO TID
16. Lactulose 15 mL [**Hospital1 **]
17. Bisacodyl 5 mg PO daily
18. Oxycodone 5 mg q4 hours PRN
19. Cinacalcet 30 mg daily
Discharge Medications:
N/A pt expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary:
Hypotension
Secondary:
ESRD [**3-5**] to amyloidosis
Discharge Condition:
expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
|
[
"276.7",
"117.3",
"E879.1",
"V49.75",
"348.39",
"401.9",
"070.54",
"427.31",
"V58.67",
"453.2",
"784.7",
"277.39",
"459.89",
"583.81",
"V66.7",
"996.62",
"135",
"567.23",
"250.00",
"458.9",
"995.91",
"585.6",
"038.9",
"V42.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"99.04",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
10510, 10519
|
5106, 5431
|
309, 316
|
10626, 10635
|
3526, 5083
|
10687, 10693
|
2836, 2891
|
10471, 10487
|
10540, 10605
|
9729, 10448
|
10659, 10664
|
2906, 3507
|
240, 271
|
344, 1948
|
5446, 9703
|
1970, 2489
|
2505, 2820
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,518
| 161,291
|
23484
|
Discharge summary
|
report
|
Admission Date: [**2117-4-12**] Discharge Date: [**2117-8-14**]
Date of Birth: [**2097-1-28**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4111**]
Chief Complaint:
Enterocutaneous Fistula
Major Surgical or Invasive Procedure:
Small Bowel resection, fistula repair
History of Present Illness:
This is a 20 year old male who sustained a gunshot wound in
[**5-26**]. He had multiple abdominal surgeries, detailed below. He
has had a recurrent enterocutaneous fistula, and presents today
for repair of the fistula
Past Medical History:
GSW [**5-26**]
s/p Ex Lap, distal pancreatectomy, splenectomy, repair of
gastric and colon injuries, and multiple abd surgeries for LOA
and fistulas
Social History:
No tobacco, EtOH, or IVDA
Family History:
Noncontributory
Physical Exam:
On admission:
VS: T- 96.3, HR-100, BP- 128/84, RR- 22, SAO2- 97%RA
GEN: Awake, alert, NAD
HEENT: AT/NC, no LAD, MMM
CV: RRR
PULM: CTAB
ABD: soft, nt, nd, large midline abdominal wound with fistula
present in superior aspect. Sump is in place-gauze is c/d/i.
Ostomy is in place with some output
EXT: Warm, well-perfused
Pertinent Results:
[**2117-4-12**] 10:39PM PT-13.0 PTT-29.4 INR(PT)-1.1
[**2117-4-12**] 10:39PM PLT COUNT-712*
[**2117-4-12**] 10:39PM WBC-11.8* RBC-4.06* HGB-11.2* HCT-35.1*
MCV-86 MCH-27.5 MCHC-31.9 RDW-15.4
[**2117-4-12**] 10:39PM calTIBC-329 TRF-253
[**2117-4-12**] 10:39PM ALBUMIN-4.2 CALCIUM-11.1* PHOSPHATE-5.3*#
IRON-72
[**2117-4-12**] 10:39PM LIPASE-17
[**2117-4-12**] 10:39PM GLUCOSE-87 UREA N-16 CREAT-1.2 SODIUM-140
POTASSIUM-4.1 CHLORIDE-98 TOTAL CO2-30* ANION GAP-16
CT A/P [**7-16**]:IMPRESSION: No abscess identified.
Brief Hospital Course:
The patient was brought to the operating room on [**5-26**] for
takedown of multipel EC fistulas and small bowel resection,
component separation and j-tube placement. He was taken back to
the OR the next day for an abdominal wall hematoma. During his
time in the hospital, he was maintained on TPN (3in1) and J-tube
feedings at a trophic level. VAC dressing was used initially on
the wound, in consultation with plastic surgery. On POD [**8-29**] the
patient spiked a fever to 104 and was started on broad spectrum
coverage, including antifungal. He eventually defervessed, but
no culture was definitively positive in this episode. He had a
central line placed for TPN/IV access. Social work was
consulted to help with coping, assisting throughout the
hospitalization. Psych was consulted as well after the patient
was found attempting to hang himself. He was kept on one to one
sitter and was continued on paxil and given standing ativan.
After this event, he had a period of relative non-[**Name2 (NI) 60157**],
being maintatined on TPN/NPO. His fistula improved over this
time with decreased output and closure by [**2117-5-10**]. An attempt
was made to start a clear liquid diet, but unfortunately his
fistula opened up again. He was placed back on strict NPO and
TPN. His fistula closed slowly over the next month. In this
time he had sump drains that were eventually d/c'ed as output
went down. Pt spiked fever on [**6-10**] and grew Klebsiella
Pneumonia out of his blood and cathter tip. He was started on
Amp and Gent. His fevers eventually abated. By [**6-22**] his
fistula was essentially closed. He had an attempted fistulogram
on [**6-29**], but there was no fistula to cannulate. He then began to
rapidly granulate and epithelialize his wound. We used [**1-24**]
stregnth Dakin's solution due to the suspicion of pseudomonas in
the wound. Patient spiked a fever to 104.1 on [**7-16**], and blood
cx's 2:2 grew gram positive coag neg staph. The patient's CVL
was changed over wire and original cath tip cultured (no
growth). There was no growth on mycobacterial or fungal cxs; on
suspicion of internal fistula leak, patient was given an
abdominal CT scan that showed no leakage or abscess formation.
Patient on regimen of vanco, ambisome. On HD98, patient had R SC
CVL d/c'ed and cx'ed (no growth) and new one placed in L SC.
Pt defervesced on HD98. On HD99 pt TF were increased to 40cc/hr
with qday dressing changes over old fistula site. Pt continued
on IV Abx with gradually increasing tube feeds as wound
continued to granulate. Dressing changes switched to NS from
[**1-24**] dakins. On HD 116, patient started on 30cc/hr of clears
advanced to 60/90cc qOH on HD 117. Pt maintained good tolerance
to PO intake, and on HD119 started on soft diet. CVL was d/c'ed
on HD 120. Calorie counts were started on HD 121 (1555kcal,
1083kcal, 874kcal on three consecutive days) and TF cycled at
night starting on HD122. On HD124 tube feeds were d/c'ed, and on
HD 125 patient was discharged home.
Medications on Admission:
Fluconazole 400'
Phosphlo [**1-24**]"
benadryl 25""
lovenox 40'
loperamide 2""
nystatin S+S
Fentanyl patch
Discharge Medications:
None
Discharge Disposition:
Home
Discharge Diagnosis:
Enterocutaneous fistula
Discharge Condition:
good
Discharge Instructions:
Please restart your home medications. Please call a doctor or
go to the emergency room if you experience chills or fever
101.5F, intractable nausea or vomiting, or pain unrelieved by
medication. You wound should have wet-to-dry dressings applied
every day. Your J-tube should be flushed twice a day with
saline as instructed by your nurse. You may eat a soft regular
diet as tolerated.
Followup Instructions:
Please see Dr. [**Last Name (STitle) 957**] in clinic on [**2117-8-30**]. Please call
([**Telephone/Fax (1) 376**] to make an appointment.
Completed by:[**2117-8-22**]
|
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25,256
| 170,994
|
12434
|
Discharge summary
|
report
|
Admission Date: [**2162-2-4**] Discharge Date: [**2162-3-16**]
Date of Birth: [**2123-3-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
Chief Complaint: Low oxygen saturation at clinic
Reason for MICU admission: hypercarbic respiratory failure
Major Surgical or Invasive Procedure:
Intubation/mechanical ventilation
Arterial line placement
s/p tracheostomy placement [**2162-3-8**]
History of Present Illness:
38M with NHL s/p alloSCT [**2155**] and DLI [**2156**], in remission but
with chronic GVHD including bronchiolitis obliterans and severe
restrictive lung disease, initially admitted to [**Year (4 digits) 3242**] service on
[**2-4**] with shortness of breath, now transferred to MICU for
hypercarbic respiratory failure.
.
He was at routine clinic visit on [**2-4**] and noted shortness of
breath and sats 93% RA. He had had recent outpatient treatment
for pneumonia starting [**1-21**], briefly interrupted due to elevated
bilirubin. Has been on very low dose IL-2 subcutaneously at
home, last received prior to admission.
.
During his hospital course, he was treated with cefepime and
levofloxacin (now day 14). Pulmonary was consulted and
recommended chest PT and hypertonic saline. He remained on RA
for the most part, maintaining sats in 90-97% range. Afebrile
with exception of T100.5 on [**2-9**] and 100.3 this morning. IL-2
was stopped at admission and tacrolimus was trialed for enhanced
immunosuppresion, but was stopped today due to development of
tremor in the past few days.
On rounds this AM he noted fatigue without new respiratory
symptoms. Got chest PT, lasix 20 mg, vancomycin, and nebs.
During the course of the morning he looked more fatigued then
started working harder to breathe. CXR was grossly unchanged. He
was started on 1-2L O2. Somnolence then developed and he needed
to be lifted from chair to bed. ABG done and pending at the time
of transfer. He was working hard to breathe but not responding
to verbal stimuli. He was rapidly transported to the [**Hospital Unit Name 153**] and
intubated. Immediately prior to intubation he was apneic and
required bag ventilation.
.
Review of Systems:
(+) Unable to obtain; see admission note. Notables include
significant weight loss for which GI was consulted, and
development of bilateral LE edema (as well as some in UEs).
Past Medical History:
Past Oncologic History:
- [**4-/2154**] p/w fevers, night sweats, and weight loss in the
setting of a left inguinal lymph node.
- CT scan: 15x14x10cm mass in the LUQ.
- Bx grade II/III follicular lymphoma.
- Treated with six cycles of CHOP/Rituxan with good response,
but showed evidence for relapse in [**12/2154**] and was treated with
MINE chemotherapy for two cycles.
- [**3-/2155**]: Underwent stem cell mobilization with Cytoxan followed
by autologous stem cell transplant in
- [**7-/2155**]: Noted for disease recurrence. He was initially treated
with a course of Rituxan without response followed by Zevalin
with
- [**3-/2156**]: Noted progression of his disease. He was treated with
one cycle of [**Hospital1 **] followed by one cycle of ESHAP.
- [**2156-7-29**]: Nonmyeloablative allogeneic stem cell transplant
with a [**5-30**] HLA-matched unrelated donor with Campath conditioning
- Six-month follow-up CT noted for disease progression.
- [**1-/2157**]: Received donor lymphocyte infusion in , complicated by
acute liver/GI GVHD grade IV, for which [**Known firstname **] required a
prolonged hospitalization in the summer of [**2156**].
- Multiple GI bleeds requiring ICU admissions and multiple
transfusions and embolization of his bleeding.
- Noted to have CNS lesions felt consistent with PTLD and this
was treated with a course of Rituxan. No evidence for recurrence
of the PTLD.
- Acute liver GVHD, on CellCept, prednisone, and photophoresis.
- [**2157-12-28**] Photophoresis was d/c'd due to episodes of
bacteremia and eventual removal of his apheresis catheter.
- [**2158-6-13**] restarted photopheresis on a weekly basis on , but
then discontinued this again on [**2158-9-7**] as this was felt not
to be making any impact on his liver function tests.
- undergone phlebotomy due to iron overload with corresponding
drop in his ferritin. He has continued with transient rises in
his transaminases and bilirubin and has remained on varying
doses of CellCept and prednisone which has been slowly tapered
over the time.
- [**2160-1-10**] CellCept discontinued.
- [**2159-1-19**] admission due to increasing right hip pain. MRI
revealed edema and infiltrating process in the psoas muscle
bilaterally. After extensive workup, this was felt related to an
infection and required several admissions with completion of
antibiotics in 03/[**2158**].
- [**7-/2160**]: Last scans showed no evidence for lymphom and he has
remained in remission.
- [**2160-10-20**]: URI and treatment with course of Levaquin.
- [**2160-11-13**] completed a 4 week course of Rituxan to treat his
GVHD.
-In [**5-/2161**], noted to have tiny echogenic nodule on abdominal
[**Year (4 digits) 950**]. MRI of the liver also showed this nodule but was not
as concerning on review and he is due to have a repeat MRI
imaging in early [**Month (only) **].
-- GI varices and attempts at banding have been unsuccessful due
to difficulty with passing the necessary instruments. He has
been on a low dose beta blocker as well as simvastatin, which
was started on [**2161-7-7**] to help with medical management of his
varices.
-On [**2161-8-3**], worsening cough and was noted to have a small
new pneumothorax in the left apical area. This has essentially
resolved over time
- Issues with weight loss (followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]);
multiple tests done with no etiology found; question
malabsorption related to GVHD
- Has on and off respiratory infections and has been treated
with antibiotics with possible pneumonia. Question underlying
exacerbations of pulmonary GVHD in setting of his URIs.
- Currently receives IVIG every month.
.
Other Past Medical History:
1. Non-Hodgkin's lymphoma s/p allo SCT
2. Grade 4 Acute GVHD of GI/liver following DLI with GI bleed,
chronic transaminitis, portal HTN with esophageal varices (not
able to band)
3. History of intracranial lesions felt consistent with PTLD.
4. Extensinve chronic GVHD of lung, liver, skin, mucous
membranes.
5. Grade II esophageal varices, intollerant to beta blockade.
6. HSV in nasal washing [**11/2159**](completed course of Valtrex)
7. Hypothyroidism
8. hx of Psoas muscle infection
.
Social History:
Smoke: never
EtOH: none currently; occassional use prior to NHL dx
Drugs: never
Born in [**Country **] and moved to the U.S. for college ([**Hospital1 **]).
Married in [**2160-8-25**] and lives in [**Location **]. No children.
Stays at home and writes (currently writing a book on being
diagnosed with cancer at young age).
Family History:
Without history of lymphoma or other cancers in the family
No FHx of DM or HTN
Mother: Alive, Thyroid disease
Father: [**Name (NI) 38646**] cardiac cath with angioplasty of 2 vessels,
asthma
2 older brothers: alive and well
Physical Exam:
VS: 96.6 129 110/77 21 100%
AC FiO2 100%, VT: 350, RR: 24, PEEP 5
GEN: intubated, sedated, cachectic.
HEENT: PERRL 4->3, oropharynx clear.
Neck: Thin, JVD to 3 cm ASA.
CV: tachy, regular, S1 S2, no mrg apprciated.
PULM: Poor air entry bilaterally, no wheezes/rhonchi/crackles
appreciated.
ABD: audible bowel sounds, tense abdomen though appears
nontender.
LIMBS: 2+ pitting edema bilaterally, warm.
NEURO: sedated, moving all extremities prior to intubation. Post
intubation with some posturing and tremors of RUE in particular,
?tacro effect.
SKIN: diffuse scattered GVHD associated rash.
Pertinent Results:
CBC
[**2162-2-20**] 03:55AM BLOOD WBC-6.7 RBC-2.94* Hgb-9.0* Hct-27.5*
MCV-93 MCH-30.6 MCHC-32.7 RDW-16.3* Plt Ct-95*
[**2162-2-19**] 04:14AM BLOOD WBC-8.9 RBC-3.21* Hgb-9.5* Hct-30.4*
MCV-95 MCH-29.7 MCHC-31.3 RDW-16.4* Plt Ct-100*
[**2162-2-18**] 04:29AM BLOOD WBC-9.8 RBC-3.32* Hgb-9.9* Hct-31.8*
MCV-96 MCH-29.7 MCHC-31.0 RDW-16.4* Plt Ct-130*
[**2162-2-17**] 01:08PM BLOOD WBC-11.0 RBC-3.63* Hgb-10.7* Hct-35.6*
MCV-98 MCH-29.5 MCHC-30.1* RDW-15.8* Plt Ct-135*
CHEMISTRY
[**2162-2-20**] 03:55AM BLOOD Glucose-131* UreaN-19 Creat-0.3* Na-138
K-4.2 Cl-100 HCO3-32 AnGap-10
[**2162-2-19**] 04:14AM BLOOD Glucose-88 UreaN-20 Creat-0.3* Na-137
K-4.2 Cl-102 HCO3-30 AnGap-9
[**2162-2-18**] 04:29AM BLOOD Glucose-83 UreaN-21* Creat-0.4* Na-138
K-4.3 Cl-101 HCO3-30 AnGap-11
[**2162-2-17**] 01:08PM BLOOD Glucose-168* UreaN-27* Creat-0.4* Na-141
K-4.4 Cl-97 HCO3-37* AnGap-11
[**2162-2-19**] 04:14AM BLOOD ALT-51* AST-67* AlkPhos-249* TotBili-1.5
[**2162-2-17**] 01:08PM BLOOD ALT-76* AST-72* LD(LDH)-332* CK(CPK)-31*
AlkPhos-297* TotBili-1.2
[**2162-2-17**] 12:29AM BLOOD ALT-80* AST-78* LD(LDH)-278* AlkPhos-287*
TotBili-1.0
[**2162-2-16**] 12:00AM BLOOD ALT-86* AST-109* LD(LDH)-317*
AlkPhos-338* TotBili-1.2 DirBili-0.8* IndBili-0.4
[**2162-2-20**] 03:55AM BLOOD Calcium-8.5 Phos-3.0 Mg-1.7
MICRO
[**2162-3-4**] 1:08 pm BRONCHOALVEOLAR LAVAGE RIGHT LOWER LOBE.
GRAM STAIN (Final [**2162-3-4**]): 3+ (5-10 per 1000X FIELD):
POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2162-3-8**]): KLEBSIELLA PNEUMONIAE.
~1000/ML.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- =>128 R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
REPORTS
CXR PA/LAT [**2162-2-4**]:
Increased consolidation at the base of the left lung is
accompanied by new
small left pleural effusion, could be pneumonia. Right lung
generally clear aside from mild peribronchial infiltration in
the right upper lobe. Heart size normal. No evidence of central
adenopathy.
ECHO [**2162-2-18**]
IMPRESSION: Vigorous biventircular systolic function. No
clinically-significant valvular disease seen. Normal estimated
intracardiac filling pressures.
ABDOMINAL U/S [**2162-2-19**]:
FINDINGS: Since prior examination, there has been interval
development of a moderate-to-severe amount of intra-abdominal
ascites. The largest pocket of ascites is noted within the right
lower quadrant measuring up to 13.6 cm in anterior-posterior
dimensions, approximately 1 cm from the skin surface.
IMPRESSION: Moderate-to-severe intra-abdominal ascites with
largest pocket in right lower quadrant
.
CXR [**2162-3-8**]:
Left lower lobe remains entirely consolidated. Small left
pleural effusion is larger. Right infrahilar consolidation is
stable. Tip of the new tracheostomy tube is just a few
millimeters above the carina, probably not
optimal. Feeding tube ends in the stomach. No right pleural
effusion. Heart size normal. Right PIC line ends in the upper
right atrium. Findings were discussed by telephone with the
patient's nurse at the time of dictation.
.
Discharge Labs:
[**2162-3-10**] 05:19AM BLOOD WBC-5.5 RBC-2.84* Hgb-8.2* Hct-27.2*
MCV-96 MCH-28.9 MCHC-30.1* RDW-16.3* Plt Ct-166
[**2162-3-6**] 03:15AM BLOOD Neuts-77* Bands-2 Lymphs-15* Monos-4
Eos-1 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2162-3-10**] 05:19AM BLOOD Glucose-66* UreaN-13 Creat-0.2* Na-142
K-3.6 Cl-108 HCO3-24 AnGap-14
[**2162-3-8**] 03:47AM BLOOD ALT-40 AST-41* LD(LDH)-225 AlkPhos-259*
TotBili-0.9
[**2162-3-10**] 05:19AM BLOOD Calcium-6.6* Phos-1.5* Mg-1.5*
[**2162-2-25**] 03:20AM BLOOD calTIBC-316 VitB12-1776* Folate-GREATER
TH Ferritn-230 TRF-243
[**2162-3-3**] 12:06AM BLOOD TSH-0.71
[**2162-2-17**] 08:50AM BLOOD tacroFK-9.1
[**2162-3-8**] 08:51PM BLOOD Type-ART pO2-177* pCO2-65* pH-7.33*
calTCO2-36* Base XS-6
[**2162-3-4**] 04:27AM BLOOD Lactate-1.0
Brief Hospital Course:
38M with NHL s/p alloBMT complicated by multi-organ GVHD and BO
with severe baseline lung disease and CO2 retention, presenting
with dyspnea and cough, now transfered to [**Hospital Unit Name 153**] for hypercarbic
respiratory failure.
.
# Hypercarbic respiratory failure. The etiology of his
respiratory failure was thought to be most likely [**1-26**] 3 factors:
1) worsening pulmonary GVHD 2) cirrhosis also likely [**1-26**] GVHD
and may benefit from a therapeutic para to help his breathing 3)
low negative inspiratory force (NIF) values, suggestive of weak
muscles of respiration, possibly secondary to ICU or steroid
myopathy. Infection thought to be less likely given negative
BAL. CTA negative for PE. Therefore, although vanc, levo, and
cefepime were continued, pt was started on methylprednisolone
50mg IV Q12H. CT head for somnolence negative. After discussion
with his oncologist and the primary medical team, CT surgery was
consulted for tracheostomy and GI was consulted about placing a
PEG tube. Patient was tried several times on PSV and a vent
weaning trial in the days leading up to the scheduled operation
and the patient was noted to tolerate progressively lower
pressure support. PEG and trach placement was tentatively
scheduled for [**2162-2-26**] but the patient's condition improved and he
was extubated on the morning of [**2162-2-26**]. He intermittently
required NIPPV for respiratory fatigue but in general his ABGs
were reassuring enough for him to remain on oxygen
supplementation alone. On [**2-28**], the patient appeared to be in
respiratory fatigue which continued and worsened with increasing
tachycardia in the setting of pt spiking fevers. As a result, he
was reintubated on [**2162-3-3**]. A bronchoscopy was performed which
revealed GNRs in the sputum. He was kept on broad spectrum
antibiotic coverage and was switched to Meropenem when BAL
cultures showed Klebsiella pneumoniae sensitive to this
antibiotic. On [**3-8**], a trach was placed at the bedside without
difficulty. He was able to tolerate breathing without
ventilatory support for 1.5 hours by [**2162-3-14**], but otherwise was
on pressure support, with a PSV of 12 and PEEP of 5. He
completed an 8 day course of meropenem on [**2162-3-15**].
.
#Fever. The patient was noted to have increasing leukocytosis
and low grade temps on [**2162-3-2**]. [**Date Range 3242**] was consulted and recommended
that we check CT sinus, CT chest, and start empiric antibiotic
treatment with vanc/cefepime/voriconazole. The results of the
CT sinus and CT chest were consistent with marked interval
worsening of right lower lobe pneumonia.. Culture data from BAL
was consistent with meropenem-sensitive klebsiella pneumonia.
The patient was started on this antibiotic with resolution of
his fevers. Just prior to discharge, the patient thought he may
have aspirated some contents of his NG tube which had been
dislodged overnight. A new Dobhoff was placed by IR on [**3-10**]. He
did have a low grade fever to 100.5F on [**3-10**]. As a result, he
was started on Vancomycin, per [**Month/Year (2) 3242**] recommendations. C. difficile
toxin was negative x 2, and vancomycin was stopped on [**2162-3-12**],
with no further fevers.
.
#Diarrhea/loose stools. Mr. [**Known lastname 38598**] reported frequent loose stools
on [**3-11**]. He was started empirically on po vanco, per [**Month/Year (2) 3242**]
recomendations, and stopped once C. Diff toxin was negative.
.
# Hypotension. Normotensive prior to intubation but had some
prolonged low BPs most likely secondary to positive pressure
effects and sedation. CTA negative for PE. TTE also wnl.
Neosynephrine quickly weaned off. Normotensive since
extubation.
.
# Tremor. Occurring on [**Month/Year (2) 3242**] floor prior to events, though ?med
effect from tacro. Low suspicion for seizure activity given
chronicity and with normal mental status prior. Resolved during
ICU stay.
.
# Edema. New this admission, though to be [**1-26**] IVFs. Past
echocardiograms have all been within normal limits. A TTE on
this admission was similarly normal, but his symptoms did
self-resolve. [**Month (only) 116**] have been related to cirrhosis although
albumin only 3.6.
.
# Non-Hodgkin's lymphoma s/p allo [**Month (only) 3242**]: Most recent PET scan with
no evidence of recurrent disease and he remains in remission.
.
# GVHD. Respiratory plan as above, prednisone and MMF per above,
PPx with bactrim DS and Acyclovir. On [**2162-3-13**], patient was
treated with one dose of rituxan.
.
# Elevated LFTs. At baseline from GVHD.
.
# Hypothyroidism. No active issues. Levothyroxine 125 mcg daily
M-Saturday was continued.
.
# Gastric varices. Asymptomatic. No e/o GI bleed. Metoprolol
restarted at 12.5 mg PO BID.
.
# Nutrition: Patient was advanced to a regular diet with
supplemental Ensure on [**2162-2-26**] after extubation. A Dobhoff was
placed by IR on [**3-10**] as patient was unable to keep up with
adequate po intake for caloric needs. He will require tube feeds
based on nutrition recommendations until he is able to maintain
adequate po intake.
.
CODE STATUS: FULL CODE (confirmed)
Medications on Admission:
ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - 2 puffs(s)
inhaled q 4-6h as needed for chest tightness/SOB/exposure to
cold
air
ALBUTEROL SULFATE - 2.5 mg/3 mL (0.083 %) Solution for
Nebulization - 1 neb inhaled four times daily as needed for
shortness of breath
AZITHROMYCIN - (On Hold from [**2162-1-28**] to unknown for on
levaquin) - 250 mg Tablet - 1 (One) Tablet(s) by mouth three
times a week Start after Zpak completed
BUDESONIDE-FORMOTEROL [SYMBICORT] - 160 mcg-4.5 mcg/Actuation
HFA
Aerosol Inhaler - 2 puffs inhaled twice daily
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - 50,000 unit Capsule -
1
(One) Capsule(s) by mouth once a week
ERYTHROMYCIN - (Prescribed by Other Provider) - 5 mg/gram
Ointment - [**12-28**] inch to both eyes at bedtime.
FAMCICLOVIR - 250 mg Tablet - 2 (Two) Tablet(s) by mouth twice a
day
IPRATROPIUM BROMIDE - 0.2 mg/mL (0.02 %) Solution - 1 vial
nebulized three times daily as needed for cough and shortness of
breath
ISOSORBIDE DINITRATE - 5 mg Tablet - one to 1(one) Tablet(s) by
mouth daily
LEVOFLOXACIN [LEVAQUIN] - (Prescribed by Other Provider) - 250
mg Tablet - 2 Tablet(s) by mouth once a day for 14 days started
on [**2162-1-21**]
LEVOTHYROXINE [LEVOXYL] - 125 mcg Tablet - 1 (One) Tablet(s) by
mouth once a day Monday - Saturday. - No Substitution
LIPASE-PROTEASE-AMYLASE [CREON] - (Prescribed by Other Provider)
- 60,000 unit-[**Unit Number **],000 unit-[**Unit Number **],000 unit Capsule, Delayed
Release(E.C.) - 3 Capsule(s) by mouth three times a day Take
with
meals
LOFEMAX - (Prescribed by Other Provider) - - 1 drop to right
eye daily
LORAZEPAM - 0.5 mg Tablet - 1 to 2 Tablet(s) by mouth at bedtime
as needed for insomnia
METOPROLOL SUCCINATE - 25 mg Tablet Sustained Release 24 hr - 1
(One) Tablet(s) by mouth once a day
MYCOPHENOLATE MOFETIL - (Prescribed by Other Provider: [**Name Initial (NameIs) **]) -
250 mg Capsule - 1 (One) Capsule(s) by mouth twice a day
NYSTATIN - 100,000 unit/mL Suspension - 5 (Five) ml(s) by mouth
four times a day
PREDNISONE - (Prescribed by Other Provider) - 10 mg Tablet - 2
(Two) Tablet(s) by mouth once a day
SIMVASTATIN - 20 mg Tablet - 1 Tablet(s) by mouth daily
SULFAMETHOXAZOLE-TRIMETHOPRIM - 800 mg-160 mg Tablet - 1 (One)
Tablet(s) by mouth three times a week (Monday, Wednesday,
Friday)
MULTIVITAMINS-MINERALS-LUTEIN [CENTRUM SILVER] - (Prescribed by
Other Provider) - 500 mcg-250 mcg Tablet, Chewable - 1 (One)
Tablet(s) by mouth once a day
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Non hodgkins lymphoma
Hypoxic respiratory failure
Klebsiella Pneumonia
Bronchiolitis Obliterans
GVHD
Discharge Condition:
stable, s/p tracheostomy, afebrile, on PSV.
Followup Instructions:
Patient should have close monitoring and follow-up with [**Hospital1 3242**]
while at rehab, and should see his oncologist within 1 week of
discharge from rehabilitation facility.
|
[
"518.84",
"571.5",
"996.85",
"E932.0",
"511.9",
"249.00",
"456.8",
"279.52",
"799.02",
"202.00",
"V46.11",
"482.0",
"280.9",
"E878.0",
"796.3",
"486",
"E849.8",
"507.0",
"579.9",
"516.8",
"456.21",
"572.3",
"427.0",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"33.23",
"38.93",
"96.6",
"96.04",
"31.1",
"96.72",
"99.15",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
19774, 19853
|
12140, 17269
|
423, 524
|
19998, 20043
|
7874, 11337
|
20066, 20248
|
7014, 7239
|
19874, 19977
|
17295, 19751
|
11354, 12117
|
7254, 7855
|
2271, 2448
|
292, 385
|
552, 2252
|
6165, 6656
|
6672, 6998
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,566
| 171,003
|
4382
|
Discharge summary
|
report
|
Admission Date: [**2167-12-24**] Discharge Date: [**2167-12-30**]
Date of Birth: [**2096-2-18**] Sex: M
Service: MEDICINE
Allergies:
Bactrim / Penicillins
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
right IJ catheter
History of Present Illness:
71 yo male with hx of MM (IIIA kappa) s/p autoBMT with relapse,
PAF, subdural hematoma who presents with hypoxia and altered
mental status. Pt was discharged after short hospital stay
[**2086-10-12**] for shortness of breath. He was treated with a short
course of Azithromycin and steroids, but was seen by the
pulmonary service who felt that his SOB mostly due to
deconditioning. The patient was discharged with stable
respiratory status and was doing well at rehab until [**12-19**] when
he had more lethargy and was not able to get out of bed. His
sister who visits frequently states that he had productive [**Month/Year (2) **]
and was complaining of being cold with no clear chills or sweats
but was complaining of thirst. He didn't have any shortness of
breath but was becoming more confused and less coversant with
only one word answers yesterday. This am at rehab he was noted
to have worsening mental status so he was transferred to [**Hospital1 18**].
In the ED he was found to be in ARF with hypernatremia to 153
and hypoxic briefly requiring bipap. He spiked a fever to 101.5
and was given cefepime and vancomycin due to his indwelling
foley and midline with 10mg of decadron given recent steroid
use.
Past Medical History:
1) Multiple myeloma: dx [**2164-12-23**], Stage IIIA with kappa light
chains. He was intolerant to thalidomide/Decadron but responded
well to Cytoxan/Decadron. [**7-26**] he underwent autoBMT with
remission until [**2166**] when he was found to have >60% plasma
cells. He was pulsed with Decadron. On [**2167-8-25**], he was started
on Velcade.
2. Diabetes insipidus dx [**7-28**]
3. Hypertension
4. Restrictive/Obstructive lung disease:
5. Paroxysmal Atrial Fibrillation
6. Hypercholesterolemia
7. Osteoarthritis s/p bilat TKR [**2160**], [**2161**].
8. MVA [**2147**]-lumbar discectomy
9. Subdural hematoma in [**2167-9-23**].
10. Hiatal hernia
Social History:
Divorced, has been in and out of rehab for hospitalizations
recently. Sister visits him frequently. [**Year (4 digits) 8735**] meat worker,
originally from [**Doctor Last Name 15076**]. Denies history of tobacco, alcohol use.
Family History:
No family history of cancer. Doesn't know how his parents died.
Brother and sisters have heart disease.
Physical Exam:
PE- T 96.2 HR 88 BP 122/75 RR 15 O2 Sats 98% 4L
Gen-difficult to arouse and not responsive to verbal stimuli
HEENT-PERRL, MMdry, no elev JVP, OP clear, neck supple
Hrt-RRR, nS1S2 no MRG
Lungs-poor air movement, mild diffuse rhonchi
Abd-soft, NT, mildly distended, no HSM
Extrem-2+rad and dp pulses, no LE edema
Neuro-opens eyes to sternal rub, absent patellar and bicep
reflexes, positive dolls.
Skin-ichthyosis, left midline without erythema
Pertinent Results:
[**2167-12-24**] 10:37PM CK(CPK)-59
[**2167-12-24**] 10:37PM CK-MB-2 cTropnT-0.08*
[**2167-12-24**] 09:19PM GLUCOSE-121* UREA N-66* CREAT-3.7*
SODIUM-152* POTASSIUM-5.3* CHLORIDE-113* TOTAL CO2-31 ANION
GAP-13
[**2167-12-24**] 09:19PM ALBUMIN-3.2* CALCIUM-11.7* PHOSPHATE-6.5*#
MAGNESIUM-2.3 URIC ACID-13.1*
[**2167-12-24**] 05:59PM URINE HOURS-RANDOM UREA N-525 CREAT-90
SODIUM-38 TOT PROT-795 PROT/CREA-8.8*
[**2167-12-24**] 05:59PM URINE OSMOLAL-400
[**2167-12-24**] 05:59PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2167-12-24**] 05:59PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2167-12-24**] 05:59PM URINE RBC-2 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
[**2167-12-24**] 05:06PM CK(CPK)-70
[**2167-12-24**] 05:06PM CK-MB-2 cTropnT-0.09*
[**2167-12-24**] 03:56PM TYPE-ART PO2-171* PCO2-57* PH-7.35 TOTAL
CO2-33* BASE XS-4 INTUBATED-NOT INTUBA
[**2167-12-24**] 01:02PM GLUCOSE-106* UREA N-61* CREAT-3.8*
SODIUM-152* POTASSIUM-5.4* CHLORIDE-115* TOTAL CO2-30 ANION
GAP-12
[**2167-12-24**] 10:38AM TYPE-ART TEMP-38.3 O2 FLOW-2 PO2-104 PCO2-67*
PH-7.31* TOTAL CO2-35* BASE XS-5 INTUBATED-NOT INTUBA
[**2167-12-24**] 10:38AM K+-5.0
[**2167-12-24**] 10:12AM TYPE-ART PO2-59* PCO2-60* PH-7.37 TOTAL
CO2-36* BASE XS-6
[**2167-12-24**] 10:12AM LACTATE-1.0
[**2167-12-24**] 10:10AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2167-12-24**] 10:10AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2167-12-24**] 10:10AM URINE RBC-[**1-25**]* WBC-0-2 BACTERIA-RARE
YEAST-NONE EPI-0
[**2167-12-24**] 10:00AM GLUCOSE-99 UREA N-63* CREAT-3.9*# SODIUM-153*
POTASSIUM-5.9* CHLORIDE-112* TOTAL CO2-31 ANION GAP-16
[**2167-12-24**] 10:00AM estGFR-Using this
[**2167-12-24**] 10:00AM VALPROATE-21*
[**2167-12-24**] 10:00AM WBC-3.4* RBC-2.44* HGB-7.9* HCT-24.7*
MCV-101* MCH-32.4* MCHC-32.0 RDW-22.8*
[**2167-12-24**] 10:00AM NEUTS-67 BANDS-5 LYMPHS-20 MONOS-4 EOS-0
BASOS-0 ATYPS-2* METAS-2* MYELOS-0 NUC RBCS-2*
[**2167-12-24**] 10:00AM HYPOCHROM-2+ ANISOCYT-3+ POIKILOCY-2+
MACROCYT-3+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+
[**2167-12-24**] 10:00AM PLT SMR-LOW PLT COUNT-113*
[**2167-12-24**] 10:00AM PT-11.2 PTT-21.5* INR(PT)-0.9
.
ADmission CXR
Lung volumes remain low with particular elevation of the left
lung base. There is no edema, pneumonia, or pleural effusion.
The heart size is top normal, unchanged. Multiple right and left
rib fractures are seen in various stages of healing. There is no
pneumothorax. A severe degenerative deformity is present at the
left shoulder.
.
Brief Hospital Course:
71 yo male with hx of MM (IIIA kappa) s/p autoBMT with relapse,
PAF, subdural hematoma who presents with hypoxia and altered
mental status. pt. was hypotensive, started on dopamine and
transitioned to Levophed. Subclavian line was placed. s/p 2u
prbcs w/ lasix. The patient expired after goals of care were
changed to CMO. Hosp course leading up to death:
.
# Altered mental status - Patient had many etiologies to explain
his altered mental status. He was on decadron, hypercalcemic,
hypernatremic, likely uremic, and hypercarbic. He also had a
fever so infectious etiologies could not be excluded. We
treated him with aggressive IVF to stabilize his electrolytes.
His mental status improved somewhat during his stay. He also
received IV antibiotics to treat for occult infection. He
tolerated this well. Then in the setting of his atrial
fibrillation with RVR, the patient became more altered. His
agitation persisted despite the addition of geodon. We had a
discussion with the HCP given his persistent agitation and
delirium. As his prognosis for MM was poor and his delirium and
atrial fib with RVR (see below) were acute issues, it was
decided to change the goals of care to comfort only.
.
# Comfort: on [**2167-12-29**], the goals of care were changed to comfort
only. The patient was started on a morphine gtt and ativan prn.
He was monitored closely by the medical team and was
comfortable. He expired on [**2167-12-30**] at 3:47 am.
.
# Multiple myeloma - We were in contact with his primary
oncologist and continued the steroids as previously prescribed.
.
# Acute on chronic RF-Likely a prerenal state leading to ATN
from volume depletion with MMM and poor skin turgor on exam.
Pt's last presentation of MM flare was in similar fashion so
must consider that Bence [**Doctor Last Name **] proteinuria could have lead to
proteinuria with uremia. We consulted with renal who assisted
in management of his acid/base and fluid status.
.
# Atrial fibrillation: The patient went into atrial fibrillation
with RVR on [**2167-12-26**] and several times on subsequent occasions.
It was treated with diltiazem IV pushes initially but then
required a diltiazem gtt. We restarted his nodal agents but
continued to have difficulty with his rate control. Oftentimes
RVR was associated with anxiety and agitation.
.
# Code-CMO
.
[**Name (NI) 18888**] HCP [**Name (NI) 18882**] [**Telephone/Fax (1) 18889**] [**Name2 (NI) 18890**] [**Telephone/Fax (1) 18891**]
Medications on Admission:
1. Metoprolol Tartrate 100mg tid
2. Desmopressin nasal [**Hospital1 **]
3. Ziprasidone HCl 40 mg [**Hospital1 **]
4. Pantoprazole 40 mg qd
5. Tiotropium Bromide 18 mcg qd
6. Divalproex 250 mg Tablet delayed qd
7. Oxycodone 10 mg Tablet SR q12
8. Diltiazem HCl 30 mg tid
9. Benzonatate 100 mg tid
10. Guaifenesin 100 [**3-31**] q6h
11. Salmeterol 50 q12h
12. Trazodone 50 mg qhs
13. Furosemide 40 mg qd
14. Oxycodone 5 mg q4h prn
15. Albuterol neb q6h
16. procrit
17. decadron 6mg tid
18. MOM and bisacodyl
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary:
- respiratory failure
- multiple myeloma
- delirium
Secondary
- hypernatremia
- hypercalcemia
- dehydration
- atrial fibrillation with RVR.
Discharge Condition:
expired
Discharge Instructions:
You were admitted with altered mental status. Your hospital
course was complicated by atrial fibrillation, hypercalcemia,
hypernatremia, and confusion. You did not improve. Per
discussions with your family, we focused on comfort measures.
You died at 3:47am on [**2167-12-30**].
Followup Instructions:
none
|
[
"584.9",
"427.31",
"272.0",
"275.42",
"518.81",
"585.9",
"996.85",
"203.00",
"253.5",
"276.0",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8866, 8875
|
5804, 8280
|
304, 323
|
9068, 9078
|
3082, 5781
|
9408, 9416
|
2496, 2603
|
8837, 8843
|
8896, 9047
|
8306, 8814
|
9102, 9385
|
2618, 3063
|
245, 266
|
351, 1566
|
1588, 2236
|
2252, 2480
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,827
| 163,375
|
33336
|
Discharge summary
|
report
|
Admission Date: [**2129-3-10**] Discharge Date: [**2129-3-25**]
Date of Birth: [**2050-3-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Unresponsiveness/fever
Major Surgical or Invasive Procedure:
Mechanical intubation.
Tracheostomy
Percutaneous gastrostomy tube.
Central venous catheter insertion.
History of Present Illness:
78 yo M h/o HTN, ESRD on HD, asthma admitted with
fever/unresponsiveness. Pt has a complicated recent medical
history and received all of his prior medical care at [**Hospital1 336**].
Briefly, the patient was discharged from [**Hospital1 336**] [**2-23**] after an
admission for urosepsis. Two days later he was admitted ([**2-25**])
for resp distress and fever, requiring intubation. He was
diagnosed with septic shock. Blood cultures ultimately grew VRE
with possible source and HD line which was pulled. Pt also
diagnosed with VRE UTI and E coli UTI (Cxs unavailable). Pt was
placed on CTX and linezolid for a planned three week course. Pt
was discharged [**3-9**] to [**Hospital **] Healthcare. This afternoon pt
was found to be unresponsive to painful stimuli, T 102.4, bp
150/80, hr 117, rr 20, sat 94% 5L NC. On arrival EMS noted pt's
mouth clenched, placed nasal trumpets. Coffee ground material
suctioned from mouth. [**Hospital1 336**] questionably on diversion: patient
brought to [**Hospital1 18**].
.
In the ED, initial vitals t102.7, hr 132, bp 154/96, rr 31, 100%
nrb. Because of pt's clenched jaws nasotracheal intubation
performed. wbc 6.4. lactate 2.8. u/a 11-20 wbcs, few bact. ekg:
ST@126 bpm, nml axis/int, TWF in I, L, v2-4, no priors. CT head
negative. In the [**Name (NI) **] pt given tylenol 650 mg pr, vanc 1 gram,
cefepine 2 gm, fent/versed, protonix 40 mg, and approx 3 L of NS
to maintain BP. Pt transferred to MICU.
Past Medical History:
HTN
gout
ESRD on HD, has one kidney
asthma
GERD
Social History:
daughter is HCP
Family History:
noncontributory
Physical Exam:
Temp 96.7
BP 141/72
Pulse 104
Resp 22
O2 sat 100% on ac 450X16, fio2 100, peep5
Gen - intubated, sedated
HEENT - Pupils sluggishly reactive, adentulous, mucous membranes
dry
Neck - no JVD, no cervical lymphadenopathy
Chest - rhonchorous anteriorally
CV - tachy regular, no murmurs
Abd - Soft, nondistended, with hypoactive bowel sounds
Extr - No edema
Neuro - sedated
Skin - No rash
Discharge exam:
BP:97/52 off of anti-hypertensives, on PO midodrine. HR:
90s-100s
Gen - Responds to vocal stimuli with opening eyes, tracks with
eyes, blinks to threat
HEENT: PERRL
Neck: No JVD
Chest: + Rhonchi
CV: RRR no murmurs
Abd: ND, +BS
EXT: No oedema
SKIN: No rashes
Pertinent Results:
[**2129-3-10**] 07:30PM BLOOD WBC-6.4 RBC-4.09* Hgb-12.0* Hct-36.1*
MCV-88 MCH-29.5 MCHC-33.3 RDW-19.8* Plt Ct-137*
[**2129-3-11**] 02:03AM BLOOD WBC-6.1 RBC-3.07* Hgb-9.1* Hct-27.3*
MCV-89 MCH-29.5 MCHC-33.2 RDW-19.9* Plt Ct-82*
[**2129-3-23**] 03:11AM BLOOD WBC-6.1 RBC-2.80* Hgb-8.5* Hct-26.2*
MCV-94 MCH-30.4 MCHC-32.5 RDW-21.5* Plt Ct-245
[**2129-3-24**] 03:21AM BLOOD WBC-6.5 RBC-2.44* Hgb-7.7* Hct-23.7*
MCV-97 MCH-31.5 MCHC-32.4 RDW-22.7* Plt Ct-257
[**2129-3-25**] 04:20AM BLOOD WBC-6.4 RBC-2.42* Hgb-7.4* Hct-23.5*
MCV-97 MCH-30.8 MCHC-31.6 RDW-21.8* Plt Ct-378
[**2129-3-23**] 03:11AM BLOOD PT-16.0* PTT-150* INR(PT)-1.4*
[**2129-3-24**] 03:21AM BLOOD PT-14.9* PTT-35.8* INR(PT)-1.3*
[**2129-3-25**] 04:20AM BLOOD PT-22.1* PTT-68.0* INR(PT)-2.1*
[**2129-3-10**] 07:30PM BLOOD Glucose-91 UreaN-16 Creat-4.2* Na-141
K-3.2* Cl-101 HCO3-25 AnGap-18
[**2129-3-11**] 02:03AM BLOOD Glucose-162* UreaN-15 Creat-3.8* Na-142
K-2.6* Cl-107 HCO3-24 AnGap-14
[**2129-3-11**] 10:57PM BLOOD Glucose-110* UreaN-17 Creat-3.8* Na-142
K-3.2* Cl-107 HCO3-22 AnGap-16
[**2129-3-23**] 03:11AM BLOOD Glucose-107* UreaN-18 Creat-3.2* Na-143
K-3.8 Cl-112* HCO3-22 AnGap-13
[**2129-3-24**] 03:21AM BLOOD Glucose-67* UreaN-14 Creat-2.6* Na-143
K-3.8 Cl-110* HCO3-24 AnGap-13
[**2129-3-25**] 04:20AM BLOOD Glucose-78 UreaN-19 Creat-3.3* Na-143
K-3.9 Cl-109* HCO3-26 AnGap-12
[**2129-3-10**] 07:30PM BLOOD Albumin-2.7* Calcium-8.9 Phos-3.1 Mg-1.4*
[**2129-3-11**] 02:03AM BLOOD Calcium-7.4* Phos-3.5 Mg-1.2*
[**2129-3-11**] 10:57PM BLOOD Calcium-7.5* Phos-2.7 Mg-2.1
[**2129-3-23**] 03:11AM BLOOD Calcium-7.9* Phos-3.2 Mg-2.0
[**2129-3-24**] 03:21AM BLOOD Calcium-7.7* Phos-2.9 Mg-1.7
[**2129-3-25**] 04:20AM BLOOD Calcium-7.8* Phos-4.6*# Mg-1.8
[**2129-3-21**] 04:44AM BLOOD calTIBC-65* Ferritn-1172* TRF-50*
[**2129-3-18**] 04:00PM BLOOD VitB12-1402*
[**2129-3-10**] 08:15PM BLOOD Type-ART pO2-532* pCO2-40 pH-7.47*
calTCO2-30 Base XS-5 -ASSIST/CON Intubat-INTUBATED
[**2129-3-11**] 02:15AM BLOOD Type-ART Temp-35.4 FiO2-100 pO2-516*
pCO2-40 pH-7.40 calTCO2-26 Base XS-0 AADO2-177 REQ O2-38
Intubat-INTUBATED
[**2129-3-12**] 03:52AM BLOOD Type-ART Temp-35.8 Rates-18/ Tidal V-560
PEEP-5 FiO2-40 pO2-119* pCO2-36 pH-7.45 calTCO2-26 Base XS-2
Intubat-INTUBATED Vent-CONTROLLED
[**2129-3-21**] 09:19PM BLOOD Type-ART Temp-37.0 Rates-/24 Tidal V-500
PEEP-8 FiO2-50 pO2-109* pCO2-36 pH-7.47* calTCO2-27 Base XS-2
Intubat-INTUBATED Vent-SPONTANEOU
[**2129-3-22**] 03:52AM BLOOD Type-ART Temp-36.1 Rates-/24 Tidal V-550
PEEP-8 FiO2-50 pO2-128* pCO2-35 pH-7.44 calTCO2-25 Base XS-0
Intubat-INTUBATED Vent-SPONTANEOU
[**2129-3-23**] 03:22AM BLOOD Type-ART Temp-38.2 PEEP-5 FiO2-40
pO2-148* pCO2-43 pH-7.44 calTCO2-30 Base XS-5 Intubat-INTUBATED
[**2129-3-10**] 07:27PM BLOOD Lactate-2.8*
[**2129-3-15**] 07:17PM BLOOD Lactate-2.9*
[**2129-3-15**] 08:46PM BLOOD Lactate-3.6*
[**2129-3-19**] 07:22PM BLOOD Lactate-1.4
TEST RESULT
---- ------
HEPARIN DEPENDENT ANTIBODIES NEGATIVE
COMMENT: Negative for Heparin PF4 Antibody by
[**Doctor First Name **].
Complete report on file in the laboratory.
Test Result Reference
Range/Units
GAD-65 AB <1.0 <=1.0 U/ML
TEST PERFORMED AT:
[**Company **] [**Doctor Last Name **] INSTITUTE
[**Numeric Identifier 14272**] P.0. BOX [**Numeric Identifier 19430**]
CHANTILLY, [**Numeric Identifier 19431**]
CT Head on [**2129-3-10**]:
NON-CONTRAST HEAD CT
No priors are available. There is no evidence of intracranial
hemorrhage, mass effect, shift of midline structures,
hydrocephalus, or acute major vascular territorial infarct. Ex
vacuo dilatations of the lateral ventricles is consistent with
the underlying atrophy, which is likely age appropriate.
Periventricular hypoattenuating changes within the white matter
are consistent with chronic small vessel disease. Mild
atherosclerotic disease is noted within the anterior and
posterior circulations. Soft tissues are unremarkable. No
underlying osseous abnormalities are identified. There is dense
opacification involving the sphenoid sinuses, right and left
maxillary sinuses, and the majority of the ethmoid air cells.
The frontal sinuses are well aerated. There is near-complete
opacification with increased sclerosis involving the mastoid air
cells.
IMPRESSION:
No acute intracranial pathology. Chronic-appearing sinus disease
as described above
CT Abd/Pelvis on [**2129-3-10**]:
IMPRESSION:
1. Rectosigmoid colitis, likely infectious or inflammatory.
2. Centrilobular and tree-in-[**Male First Name (un) 239**] opacities within the visualized
lung bases with bilateral small pleural effusions, left slightly
greater than right. Findings are most suggestive of an
underlying infectious bronchiolitis, aspiration or due to
chronic [**Doctor First Name **] infection.
3. Bilateral hypoattenuating renal lesions, some of which are
clearly simple cysts and others which are not definitively
characterized. Right sided hyperattenuating lesions,
incompletely characterized. Underlying neoplasm cannot be
excluded. Given the atypical location of the kidney, ultrasound
will likely not be able to assess this and an MRI would be
recommended on a non-emergent basis to exclude neoplasm.
4. Diffuse aortic ectasia with right common iliac
ectasia/aneurysm as described above.
[**2129-3-13**]:
BILATERAL UPPER EXTREMITY ULTRASOUND.
Grayscale and color Doppler son[**Name (NI) 1417**] of the right and left
internal jugular, subclavian, axillary, brachial, basilic, and
cephalic veins was performed. The left internal jugular vein
does not demonstrate any flow and is not compressible compatible
with an intraluminal thrombus; it is small in caliber. A PICC
line is noted within the left brachial vein. The remainder of
the veins demonstrate normal flow, compressibility,
augmentation, and waveforms.
IMPRESSION: Findings consistent with a left internal jugular
vein occlusive thrombus; given its small caliber this may be a
chronic finding.
Chest x-ray [**2129-3-10**]:
IMPRESSION:
1. Advancement of endotracheal tube and nasogastric tube advised
as described above.
2. Ill-defined reticular opacity within the mid right hemithorax
is of uncertain etiology, may represent a small focus of
infection/aspiration, linear atelectasis, or regions of
scarring.
[**2129-3-16**] CT Chest:
IMPRESSION:
1. Innumerable bilateral pulmonary nodules noted in the left
upper lobe measuring 8 mm. Close attention and short-term
followup at three months is recommended. Entered in critical
results communication.
2. Bilateral pleural effusions, left more than right. Evidence
of patchy tree and [**Male First Name (un) 239**] opacities predominantly at bilateral lung
bases may represent inflammatory or a multifocal infectious
process.
3. Multiple low-attenuating lesions within the left kidney as
described above.
4. No evidence of superior vena cava syndrome.
5. Mild aortic ectasis without aneurysmal dilation.
MRI Head on [**2129-3-17**]:
FINDINGS: There is no evidence of hemorrhage, edema, mass, mass
effect, or infarction. There is a prominent amount of bilateral
extra-axial CSF, which is noted to have increased signal
throughout on FLAIR images, suggestive of increased protein
content within this fluid. CSF within the ventricular system
shows normal FLAIR signal intensity.
There is some moderate periventricular white matter FLAIR signal
hyperintensity, most consistent with chronic microangiopathic
change. A tiny focus of increased diffusion signal just lateral
to the atrium of the left lateral ventricle most likely
represents T2 shine through artifact. No other diffusion
abnormality is detected.
There is a moderate amount of fluid seen within the sphenoid
sinus, and posterior ethmoid air cells, most probably related to
the patient's intubated status.
Visualized vascular flow voids are normal.
IMPRESSION: Abnormal increased FLAIR signal in the extra-axial
CSF spaces relative to CSF in the ventricles is suggestive of
increased protein content, and could be seen with meningitis.
Please correlate with results from lumbar puncture.
Echocardiogram on [**2129-3-18**]:
Findings
LEFT VENTRICLE: Suboptimal technical quality, a focal LV wall
motion abnormality cannot be fully excluded. Overall normal LVEF
(>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Suboptimal image quality - poor parasternal views. Suboptimal
image quality - poor apical views. Suboptimal image quality -
poor subcostal views.
Conclusions
Very limited image quality. Due to suboptimal technical quality,
a focal wall motion abnormality cannot be fully excluded.
Overall left ventricular systolic function is grossly normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are also grossly normal. There is no pericardial effusion.
EEG on [**2129-3-12**]:
IMPRESSION: This is an abnormal portable EEG due to the abnormal
background consisting of low voltage fast activity intermixed
with
bursts of moderate amplitude generalized delta frequency slowing
consistent with a mild to moderate encephalopathy suggesting
dysfunction
of bilateral subcortical or deep midline structures.
Medications,
metabolic disturbances, and infection are among the common
causes of
encephalopathy but there are others. There were no areas of
prominent
focal slowing although encephalopathic patterns can sometimes
obscure
focal findings. There were no epileptiform features and no
electrographic seizure activity was noted. The low voltage fast
background activity likely reflects medication effects from
concomitant
benzodiazepine or barbiturate admininstration.
Chest x-ray [**2129-3-23**]:
FINDINGS: In comparison with study of [**3-23**], there is little
change. The various monitoring and support devices remain in
place. Mild prominence of interstitial markings with several
dense small granulomas at the left base and old right rib
fractures are again noted. There is also some thickening of the
lateral aspects of the minor fissure.
Brief Hospital Course:
1. Sepsis: Pt meets SIRS criteria with urine as suspected
source. Pt's BP responded well to fluid challenge. He required
pressors in setting of initiating HD, and was weaned off the
Phenylephrine on [**2129-3-21**] (transitioned to PO midodrine 10mg
prior to dialysis) Antibiotic coverage as follows: Initially
continued linezolid for h/o VRE and broadened from
ceftriaxone=>cefepime. Linezolid was discontinued for
thrombocytopenia on [**3-13**]. Spiked temp to 102 on [**3-15**] with
worsening secretions, added Vancomycin and cefepime=>meropenem
for better GN coverage. Vancomycin discontinued on [**3-18**] given
worsening thrombocytopenia. He was started on
daptomycin/meropenem meningitis doses on [**3-19**] given
unresponsiveness in absence of sedation since admission and MRI
with extra-axial CSF protein noted. LP attempted on [**3-20**] per
attending and resident, unsuccessfully-pt already on meningitis
doses of Abx. Patient's femoral line placed in ED was pulled,
his L PICC line and tip were sent for culture on [**3-20**]. Sputum
positive for Pseudomonas, sensitive to meropenem which was
continued for tx of VAP, to finish course of meropenem 500mg
daily, last day on [**2129-3-28**]. Daptomycin was discontinued
on [**2129-3-22**] given absence of Gram positives in culture data.
2. Respiratory distress: Pt was initially nasally intubated due
to locked jaw and unresponsiveness at his NH and upon ED
presentation. His NT was switched over to ETT. He remained
intubated due to unresponsiveness in absence of sedation for at
east 1 week. Additionally the patient had significant amt. of
secretions with little gag. Tracheostomy and PEG on [**2129-3-23**].
He had a trial on trach collar on [**3-24**] but had to go back on to
pressure support ventilation due to respiratory fatigue.
3. Neuro: Dementia and mobility disorder likely secondary to
severe Parkinson's disease. He was started on Sinemet at [**Hospital1 336**]
and titrated to escelating doses prior to transfer which was
continued here with some improvement. MRI (non contrast) done
with extraaxial protein noted, non-specific finding but
?meningitis. LP attempt on [**3-20**] w/attndg-unsuccessful. Sinemet
dose uptitrated to 250/50 TID. Patient should receive tube
feeds at night so that they do not interfere with Sinemet
absorption.
4. Thrombocytopenia: presumed from linezolid and sepsis.
Received 1 unit of platelets, HIT negative, and subsequently
resolved. Patient continued to receive heparin gtt for left IJ
clot until INR was therapeutic.
5. ESRD on HD: On Monday/Wednesday/Friday schedule at [**Hospital1 336**].
Renal following, CVVH attempted on several occasions due to
hypotension. HD initially not tolerated due to hypotension, but
now tolerating with pre-treatment with 10mg midodrine.
6. Ileus: Pt started on reglan on [**3-20**] for ? ileus, which was
discontinued once the ileus resolved resolved.
7. HTN: Discontinued anti-hypertensives given persistent
hypotension and requiring midodrine to maintain this.
8. Nutrition: Tube feeds, Probalance full strength at rate of
130/hour, cycled from 9PM to 7AM, held for residuals > 150, free
water flushes q6H. Cycled at night to avoid interference with
Sinemet absorption.
9. Prophylaxis: Started on warfarin for 6 weeks for left IJ
thrombosis.
10. Code status - full code
Communication: With Daughter, [**First Name8 (NamePattern2) **] [**Known lastname 22924**] Work:[**Telephone/Fax (1) 77390**]
Home:[**Telephone/Fax (1) 77391**]
Medications on Admission:
meds at rehab:
linezolid 600 mg [**Hospital1 **] (to be finished [**3-13**])
CTX one gram daily (to be finished [**3-16**])
norvasc 5 mg daily
sinemet 25/250 tid
catapres 0.2 mg qweek
atrovent
coumadin 2 mg daily
toprol 150 mg daily
folate
prevacid
atrovent
allopurinol 100 mg daily
spiriva
epogen 20,000 units qHD
albuterol
MOM
senna
tylenol
dulcolax
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol [**Month/Day (2) **]: 6-10 Puffs Inhalation
Q4H (every 4 hours).
2. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Month/Day (2) **]: 6-8 Puffs
Inhalation Q4H (every 4 hours).
3. Chlorhexidine Gluconate 0.12 % Mouthwash [**Month/Day (2) **]: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
4. Acetaminophen 160 mg/5 mL Solution [**Hospital1 **]: One (1) PO Q6H
(every 6 hours) as needed.
5. Midodrine 2.5 mg Tablet [**Hospital1 **]: Three (3) Tablet PO TID (3 times
a day).
6. Warfarin 2.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY16 (Once
Daily at 16).
7. Carbidopa-Levodopa 25-250 mg Tablet [**Hospital1 **]: One (1) Tablet PO
TID (3 times a day): Please give morning dose 1 hour after tube
feedings are turned off.
8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day.
9. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN
10ml NS followed by 1ml of 100 units/ml heparin (100 units
heparin) each lumen QD and PRN. Inspect site every shift
10. Heparin Flush PICC (100 units/ml) 2 mL IV DAILY:PRN
10 ml NS followed by 2 mL of 100 Units/mL heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
11. Meropenem 500 mg Recon Soln [**Last Name (STitle) **]: One (1) Recon Soln
Intravenous Q24H (every 24 hours) for 3 days: Please give after
dialysis on days when patient goes for dialysis. Last dose is
[**2129-3-28**].
12. Sodium Citrate 4% 1 mL IV ASDIR
after HD sessions, please lock catheter with citrate solution,
fill to volume specified on each port.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary diagnoses:
Nosocomial pneumonia
Septic shock
Parkinson's disease
Left IJ thrombosis
Acute renal failure
Discharge Condition:
Stable on ventilator, tolerating G-tube.
Discharge Instructions:
You were admitted for treatment of pneumonia and low-blood
pressure. You required placement of a breathing tube and a
tracheostomy tube for long-term use of a mechanical ventilatory
(breathing machine). You received antibiotics for the
pneumonia. You received hemodialysis for kidney failure. You
were also found to have a clot in a vein of your neck and will
need to be on a blood thinner for 6 weeks.
Followup Instructions:
You have an appointment made in the neurology movement disorders
clinic on [**2129-4-6**] at 4PM with Dr. [**First Name (STitle) **] [**Name (STitle) **] in the [**Hospital Ward Name 23**]
Clinical Center, [**Location (un) **] on [**Location (un) 830**]. Please call
[**Telephone/Fax (1) 1040**] to reschedule the appointment or with any
questions.
Please follow-up with your primary care physician [**Last Name (NamePattern4) **] 2 weeks.
Completed by:[**2129-3-25**]
|
[
"585.6",
"999.9",
"785.52",
"518.81",
"507.0",
"294.10",
"584.9",
"287.4",
"482.1",
"453.8",
"009.0",
"331.82",
"995.92",
"038.0",
"322.9",
"458.21",
"285.8",
"560.1",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"38.93",
"00.14",
"96.05",
"96.04",
"43.11",
"99.07",
"99.05",
"96.72",
"99.04",
"39.95",
"33.23",
"31.1"
] |
icd9pcs
|
[
[
[]
]
] |
18522, 18593
|
12949, 16455
|
338, 442
|
18749, 18792
|
2750, 12926
|
19247, 19720
|
2040, 2057
|
16858, 18499
|
18614, 18728
|
16481, 16835
|
18816, 19224
|
2072, 2456
|
2472, 2731
|
276, 300
|
470, 1919
|
1941, 1991
|
2007, 2024
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,950
| 110,028
|
24923
|
Discharge summary
|
report
|
Admission Date: [**2116-10-22**] Discharge Date: [**2116-11-4**]
Date of Birth: [**2036-4-29**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Dyspnea/Chest Pain
Major Surgical or Invasive Procedure:
[**2116-10-27**] - Coronary Artery Bypass Graft x 3 (Lima to LAD, SVG to
Diag, SVG to PDA)
History of Present Illness:
80 y/o female transferred from [**Hospital3 **] center for
pre-op evaluation regarding CABG. Initially presented with
SOB/CP at outside hospital. Cardiac cath revealed 3VD (LAD 70%,
LCX 50%, RCA 905).
Past Medical History:
Hypertension
Hypercholesterolemia
"Renal Tumor" s/p Left Nephrectomy
Hearing Impaired
Urinary Tract Infection
Social History:
Denies ETOH ot tobacco abuse.
Family History:
Father died of MI at 83. Brother MI at 42 and died of MI at 68.
Another brother had MI at 48. 2 Brothers had sudden death from
aneurysms at ages 55, 65.
Physical Exam:
VS: 70 140/70 16 99% on 2L
General: WD/WN, age appropriate WF in NAD
Head: NC/AT
Neck: Without masses or Bruits
Lungs: CTAB, decreased bs at bases bilat.
Heart: +S1S2, -c/r/m/g
Abd: Soft, NT/ND +BS, Left flank incision well-healed
Ext: Bilat. Varicosities, 1+ edema (R>L)
Neuro: Grossly non-focal, A&O x 3
Pertinent Results:
Carotid U/S [**10-23**]: <40% stenosis [**Country **], No significant stenosis
of [**Doctor First Name 3098**]
Echo [**10-23**]: EF>55%, -AS/AI, Trivial MR, preserved biventricular
systolic function
[**2116-10-22**] 07:15PM BLOOD WBC-7.0 RBC-4.39 Hgb-13.6 Hct-38.5 MCV-88
MCH-31.0 MCHC-35.2* RDW-12.9 Plt Ct-256
[**2116-10-31**] 06:35AM BLOOD WBC-9.6 RBC-4.33 Hgb-13.5 Hct-38.1 MCV-88
MCH-31.1 MCHC-35.3* RDW-14.2 Plt Ct-121*
[**2116-10-22**] 07:15PM BLOOD PT-12.8 PTT-44.4* INR(PT)-1.1
[**2116-10-30**] 02:18AM BLOOD PT-12.5 PTT-29.7 INR(PT)-1.0
[**2116-10-22**] 07:15PM BLOOD Glucose-148* UreaN-22* Creat-1.1 Na-133
K-3.8 Cl-96 HCO3-26 AnGap-15
[**2116-11-1**] 01:20PM BLOOD Glucose-135* UreaN-25* Creat-1.1 Na-134
K-4.3 Cl-99 HCO3-23 AnGap-16
[**2116-10-22**] 06:07PM URINE Blood-LG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-TR
[**2116-10-22**] 06:07PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.011
[**2116-10-23**] Carotid Duplex Ultrasound
1. Mediastinal and bilateral hilar lymphadenopathy. Further
evaluation with a contrast- enhanced chest CT is recommended.
2. No evidence of pneumonia or overt CHF.
[**2116-10-23**] ECHO
The left atrium is normal in size. 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. Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. The pulmonary artery systolic
pressure could not be determined. There is an anterior space
which most likely represents a fat pad.
[**2116-10-24**] CXR
Lungs are mildly hyperinflated. Heart is at the upper limits of
normal or slightly enlarged. The aorta is calcified and
unfolded. Mild prominence of the right paratracheal soft tissues
likely reflects vascular ectasia in someone of this age. No CHF,
infiltrate, or effusion is identified. Subsegmental atelectasis
or scarring is present at both bases. Minimal blunting of both
costophrenic angles is noted.
[**2116-10-29**] CXR
Lung volumes are decreased slightly following extubation. There
is more atelectasis at the base of the left lung, but no change
in tiny left pleural effusion or any indication of pneumothorax
following removal of the left pleural drain. Cardiomediastinal
silhouette has enlarged minimally, but still normal caliber.
Right lung grossly clear. A Swan-Ganz catheter tip projects over
the main pulmonary artery.
[**2116-11-3**] Head CT
1. No evidence for acute intracranial hemorrhage. Small low
attenuation is seen involving the periventricular white matter,
nonspecific probably related to chronic microvascular ischemic
changes. Hyperostosis frontalis. If there is clinical suspicion
for an acute ischemic event, correlation with MRI would be
helpful if clinically indicated.
[**2116-11-3**] EEG
Official results pending
By report it was completely normal.
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the [**Hospital1 18**] via transfer from [**Hospital1 62664**] center on [**2116-10-22**] for surgical management of her
coronary artery disease. She underwent routine pre-operative
work-up which included a carotid u/s and echocardiogram. Please
see pertinent results. Ms. [**Known lastname **] also had renal and cardiology
consults pre-operatively. Ciprofloxacin was started for a
urinary tract infection. Ms. [**Known lastname **] was stable on medical
management and her surgery was delayed secondary to bed
availability. On [**2116-10-27**], Ms. [**Known lastname **] was taken to the operating
room where she underwent Coronary Artery Bypass Grafting to
three vessels. She tolerated the procedure well.
Postoperatively, she was transferred to the cardiac surgical
intensive care unit in stable condition. Pt. remained intubated
through operative day one secondary to mild metabolic acidosis.
She was weaned from mechanical ventilation and was extubated by
postoperative day two. Ms. [**Known lastname **] developed several runs of
ventricular tachycardia and Amiodarone was started. She also had
elevated blood pressure which required nitroglycerin which was
ultimately weaned off without difficulty. Her chest tubes and
pacing wires were removed per protocol. On postoperative day
three to the telemetry floor on POD #3. She was gently diuresed
towards her preoperative weight. The physical therapy service
was consulted for assistance with her postoperative strength and
mobility. Beta blockade was titrated for optimal heart rate and
blood pressure support. On postoperative day seven, Ms. [**Known lastname **]
became acutely confused. A neurology consult was obtained and a
head CT scan was performed. This revealed several areas of old
lacuna infarcts but no new acute infarcts or hemorrhages. An
EEG was performed which was reported as normal. Her zantac was
discontinued. Her mental status cleared. Ms. [**Known lastname **] continued to
make steady progress and was discharged home on postoperative
day eight. She will follow-up with Dr. [**Last Name (STitle) **], her cardiologist
and her primary care physician as an outpatient.
Medications on Admission:
1. Toprol XL 50mg qd
2. Heparin gtt
3. HCTZ 12.5mg qd
4. Levaquin 250mg qd
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*1*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(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. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
6. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 10
days.
Disp:*40 Capsule, Sustained Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 805**] [**Last Name (NamePattern1) **] Care
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3
Hypertension
Hypercholesterolemia
"Renal Tumor" s/p Left Nephrectomy
Acute postoperative confusion
Discharge Condition:
Good
Discharge Instructions:
Can take shower. Wash incisions with warm water and gentle soap.
Gently pat dry. Do not apply lotions, creams, ointments, or
powders to incisions.
Do not lift more than 10 pounds for 2 months.
Do not drive for 1 month.
If you notice any drainage from incisions, redness or fever
greater than 101, please call office immediately.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] in 4 weeks (Call [**Doctor First Name **] at
[**Telephone/Fax (1) 62665**] to schedule appointment in [**Location (un) 37361**], RI)
Follow-up with Dr. [**Last Name (STitle) 62666**] in [**1-30**] weeks
Follow-up with Dr. [**Last Name (STitle) **] in [**12-29**] weeks
Completed by:[**2116-11-4**]
|
[
"403.91",
"386.00",
"V12.59",
"454.9",
"411.1",
"V10.53",
"293.9",
"272.4",
"414.01",
"780.2",
"276.2",
"585.3",
"427.1",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"39.61",
"36.12",
"36.15",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
7659, 7797
|
4529, 6719
|
341, 433
|
8000, 8006
|
1354, 4506
|
8383, 8727
|
859, 1013
|
6844, 7636
|
7818, 7979
|
6745, 6821
|
8030, 8360
|
1028, 1335
|
283, 303
|
461, 663
|
685, 796
|
812, 843
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,007
| 132,459
|
16036
|
Discharge summary
|
report
|
Admission Date: [**2195-10-16**] Discharge Date: [**2195-10-26**]
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 33596**]
Chief Complaint:
Abdominal Pain, Fever
Major Surgical or Invasive Procedure:
percutaneous cholecystostomy tube placement
History of Present Illness:
83 y/o F MMP inclduign CRI, HTN, CHF extended ICU admit
[**Date range (1) 45889**]/05 at [**Hospital1 18**] for ARF requiring HD, resp failreu seoncary
to CHF, PNA requiring trach, CDiff, who was dc'd to rehab at
that time and is now returning with fever, LLQ pain, and
diarrhea. Patient's trach was decannulated on [**10-5**]. She still
has a PEG tube in place but is eating. Patient noted to have
developed diarrhea early in [**9-28**] which persists. On [**2195-10-11**],
patient developed n/v and RUQ tenderness. She was made NPO on
[**2195-10-13**]. A urine Cx grew > 100,000 GNR's on [**10-15**]. A PICC line
was placed for CTX/Amp at rehab. her Cr was noted to bump from
?1.9 to 2.5 to 3.3, lipase ws 550, amylase 123, Cdiff was
negative. Abdominal U/S showed gallbladder wall thickening, no
stones, + [**Doctor Last Name 515**], KUB was negative. Because of MMP, patient
sent to [**Hospital1 18**] for further management.
In ED, patient noted to have bicarb of 12, AG of 16, VBG
7.22/32/36. [**Doctor First Name **] was 268 and lipase 539. She was febrile to 102.6
but all other VSS. She was having profuse green, watery
diarrhea. After about 1 L of fluid her labs were repeated
without improvement and she was therefore admitted to the MICU.
A Ct ABdomen was ordered. Patienr received Vanco/Levo/Flagyl.
Patient currently reports she is having persistent diarrhea x 6
months. She is a poor historian
Past Medical History:
- GERD
- HTN
- Hypercholesterolemia
- Hypothyroidism; s/p left thyroidectomy
- CHF
- Anemia - Iron deficiency, Vit B12 deficiency, [**2-25**] CRI
- Recurrent cellulitis
- h/o pancreatitis s/p ERCP and sphincterotomy [**1-26**]
- CRI (baseline Cr 1.6-1.8)
- Osteopenia
- s/p lumbar surgeries
- s/p appy
- macular degeneration
- COPD
- left trochanteric bursitis
- osteoporosis
- benign familial tremor
- hysterectomy [**2180**]
- cataracts
- inner ear operation [**2170**]
- broken toe childhood
- left neck surgery
- severe cerivcal stenosis
Social History:
Lives alone, independent in ADLs/IADLs. Retired, worked for
father who was bookbinder. Two sons who are attornies, 1 in
[**Location (un) 45887**]. + tobacco - 3 ppd, quit 15 yrs ago. No EtOH, no
IVDA.
Family History:
dad, brother - CAD; mom [**12-25**] pna; son- asthma; father- TB
Physical Exam:
Tm 102.6, Tc 98.6; HR 67; BP 150/78; RR 16; 99% RA
GEN: elderly female, NAD, alert
HEENT: o/p with dry MMM
NECK: JVP 8 cm
CV: S1S RRR. No murmurs
LUNGS: decreased at left base, crackels at R base
ABD: bruised on lower abdomen, slightly distended, good BS,
voluntary guarding, surgical scars, [**Last Name (un) **] rebound, not tender in
one particular area
Rectal: ob+ per ED resident
EXT: trace edema, toes without erythema, bruising on wrists b/L
from abgs
Pertinent Results:
US ABD LIMIT, SINGLE ORGAN
Reason: Please evaluate for signs of choledocholithiasis,
pancreatit
[**Hospital 93**] MEDICAL CONDITION:
83 year old woman with hx C.diff, pancreatitis, here with abd
pain, fever, [**First Name9 (NamePattern2) **] [**Doctor First Name **], lipase, CT without pancreatitis or stone.
REASON FOR THIS EXAMINATION:
Please evaluate for signs of choledocholithiasis, pancreatitis.
LIMITED EVALUATION OF THE ABDOMEN.
CLINICAL HISTORY: Pancreatitis, abdominal pain, evaluate for
choledocholithiasis.
FINDINGS: Limited evaluation of the right upper quadrant and
common bile duct was performed. Shadowing stones are present in
the gallbladder. There is layering sludge and [**Doctor Last Name 5691**] as well
within the gallbladder. There is no significant gallbladder wall
thickening. There is no pericholecystic fluid. The left and
right hepatic ducts are dilated and the common bile duct is
dilated as well to the level of the pancreatic head. The CBD
measures 16 mm in diameter. An ERCP from [**2193**] also demonstrates
significant dilatation of the common bile duct. No shadowing
stones are seen within the common bile duct. No echogenic debris
is present within the common bile duct. No mass is seen within
the pancreatic head. There is no peripancreatic fluid
collection.
There is no pancreatic duct dilatation.
IMPRESSION:
1. Cholelithiasis without evidence of cholecystitis.
2. No choledocholithiasis as clinically questioned.
3. Dilatation of the left and right hepatic ducts as well as the
common bile duct. These findings were seen on the recent CT and
common bile duct dilatation was noted on an ERCP from [**2193**].
.
GB DRAINAGE,INTRO PERC TRANHEP BIL US [**2195-10-22**] 1:34 PM
GB DRAINAGE,INTRO PERC TRANHEP; GUIDANCE PERC TRANS BIL DRAINA
Reason: for drainage
[**Hospital 93**] MEDICAL CONDITION:
83 year old woman with acute cholecystitis, poor operative
candidate
REASON FOR THIS EXAMINATION:
for drainage
ULTRASOUND-GUIDED PERCUTANEOUS CHOLECYSTOSTOMY
CLINICAL HISTORY: Cholecystitis, poor surgical candidate.
Limited images of the gallbladder demonstrate a large amount of
sludge and shadowing stones in a distended gallbladder. The
extrahepatic common duct is enlarged measuring 1.5 cm in
diameter.
The advantages and complications of the procedure were explained
to the patient. Written informed consent was obtained. A
preprocedure timeout was called to confirm the patient's
identity and type of procedure to be performed. The patient was
prepped and draped in the usual sterile fashion. Lidocaine 1%
was used as a topical anesthetic and a nurse [**First Name (Titles) 11025**] [**Last Name (Titles) 45890**]l and Versed intravenously. Under ultrasound guidance, an
8 French catheter was inserted into the gallbladder.
Approximately 100 cc of purulent fluid were removed. The
catheter was coiled and ultrasound demonstrated proper placement
of the catheter. The patient tolerated the procedure
satisfactorily. There were no complications. Dr. [**First Name (STitle) **] was
present for all significant portions of the procedure.
IMPRESSION: Status post ultrasound-guided percutaneous
cholecystostomy with placement of an 8 French drainage catheter.
.
CT ABDOMEN W/O CONTRAST [**2195-10-21**] 9:24 PM
CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST
Reason: R/O ANY free air, no PO or IV contrast please
Field of view: 40
[**Hospital 93**] MEDICAL CONDITION:
83 year old woman with acute cholecystitis
REASON FOR THIS EXAMINATION:
R/O ANY free air, no PO or IV contrast please
CONTRAINDICATIONS for IV CONTRAST: CRI
TECHNIQUE: 64-MDCT axial images of the abdomen were obtained
without oral or IV contrast.
CT OF THE ABDOMEN WITHOUT ORAL OR IV CONTRAST: There are
bilateral moderate- sized pleural effusions with associated
atelectasis. There is no pericardial effusion.
The patient is status post G-tube placement which appears to be
in good position.
There are multiple gallstones within gallbladder and thickening
of the wall and inflammatory changes around the gallbladder
consistent with the known diagnosis of acute cholecystitis. The
common bile duct is prominent measuring approximately 15 mm but
is not particularly changed when compared to [**2195-10-13**].
There is no evidence of free air in the abdomen. The appearance
of the kidneys are unchanged when compared to the prior study.
There is again noted a cyst in upper pole of the left kidney.
There is no evidence of hydronephrosis. There are multiple small
retroperitoneal mesenteric lymph nodes, which are stable when
compared to the prior study. These do not meet CT criteria for
pathology.
CT OF THE PELVIS WITHOUT ORAL OR IV CONTRAST: There is no free
fluid or free air in the pelvis. There is a Foley catheter
within the urinary bladder. The sigmoid, rectum, and adnexa are
stable when compared to the prior study.
BONE WINDOWS: The patient is status post posterior spinal fusion
of L3/L4/L5/S1. There are severe degenerative changes of the
lumbar spine. There are no suspicious lytic or blastic lesions.
Imaging of the bone is limited due to artifact coming from
hardware.
IMPRESSION:
1. Findings consistent with acute cholecystitis. No evidence of
free air.
2. Bilateral pleural effusions.
.
[**2195-10-15**] 06:15PM WBC-6.5# RBC-3.42* HGB-10.1* HCT-31.8* MCV-93
MCH-29.5 MCHC-31.7 RDW-15.8*
[**2195-10-15**] 06:15PM LIPASE-539*
[**2195-10-15**] 06:15PM CALCIUM-7.7* PHOSPHATE-4.3# MAGNESIUM-1.2*
[**2195-10-15**] 06:15PM ALT(SGPT)-13 AST(SGOT)-16 ALK PHOS-78
AMYLASE-268* TOT BILI-0.2
.
Alanine Aminotransferase (ALT) 5 IU/L 0 - 40
PERFORMED AT WEST STAT LAB
Asparate Aminotransferase (AST) 9 IU/L 0 - 40
PERFORMED AT WEST STAT LAB
Lactate Dehydrogenase (LD) 222 IU/L 94 - 250
PERFORMED AT WEST STAT LAB
Alkaline Phosphatase 68 IU/L 39 - 117
PERFORMED AT WEST STAT LAB
Amylase 41 IU/L 0 - 100
PERFORMED AT WEST STAT LAB
Bilirubin, Total 0.3 mg/dL 0 - 1.5
PERFORMED AT WEST STAT LAB
Brief Hospital Course:
83 year-old female with MMP p/w nausea, abdominal pain,
diarrhea. Patient was initially admitted to the MICU for
pancreatitis, metabolic acidosis and acute renal failure, which
improved with electrolyte repletion and hydration. Patient was
then transferred to the floor and the following issues were
addressed during her hospital admission:
1. Nausea/Vomiting/Abdominal Pain
On admission, patient presented with laboratory values
consistent with pancreatitis, though no evidence of such on CT
Abdomen. Chronic cholelithiasis, thickened gallbladder wall, and
dilated CBD were seen on ultrasound dated [**10-16**], but no overt
cholesytitis on exam dated unchanged from prior studies. Patient
was kept NPO and started on IV fluids, and her enzymes trended
down initially. Patient was followed by the ERCP team, who
recommended MRCP first before ERCP as patient was poor procedure
candidate given her MMP and clinical status. Patient did not
tolerate MRCP. On day 7 of hospital admission, patient spiked a
temperature while on Imipenem/Flagyl (for Klebsiella UTI and
presumed cholecystitis). Her abdominal exam continued to reveal
diffuse abdominal tenderness, especially pronounced in the RUQ.
Work-up included repeat RUQ ultrasound, which showed evidence of
pericholecystic fluid and acute cholecystitis. CT Abdomen was
without evidence of free air. Patient was evalued by ERCP and
surgery, and it was felt that patietn was poor surgical
candidate, and decision to place percutaneous cholecystostomy
tube by Interventional Radiology was finally reached. Patient
tolerated procedure well. As patient is poor surgical candidate
at this time, tube will be left in place for at least 4-6 weeks;
she has follow-up with general surgery scheduled, at which point
further management options will be assessed. Patient will
continue on Imipenem/Cilastatin for 14-days after procedure. As
patietn had been NPO for several days, tube feeds were
re-started and patient's PO diet was advanced as tolerated.
Patient received Anzement q8h PRN for nausea, and symptoms began
to resolve once drain was placed.
.
2. UTI
Urine culture from rehab grew out Klebsiella resistant to most
antibiotics except Imipenem. Patient recevied 7-day course of
Imipenem, and repeat Urine culture was negative for this
organism. A repeat UA grew out yeast, for which foley was
changed. Subsequent UCx again grew out yeast, and patient was
given 1-time dose of DiFlucan.
.
3. Diarrhea
Patient with a history of chronic C. Diff colitis, for which she
has been treated with Flagyl several times. Patient had been
started on PO Vanc at OSH, but there was no evidence that her C.
Diff was Flagyl-resistant, so patient was re-started on
Metronidazole 500mg PO TID on [**10-16**], for 14-day course. Three C.
Diff A toxins were negative as inpatient; C. Diff toxin B assay
was sent, results pending. If assay returns negative,
Metronidazole should be discontinued. Patient's diarrhea
improved with treatment of acute cholecystitis, but patient
continued to experience intermittent loose, non-watery bowel
movements of multifactorial etiology (re-starting tube feeds,
possible C. Diff colitis, medication-induced).
.
4. Nutrition
Due to pancreatitis and then cholecystitis, patient had been
kept NPO for several days. Once drain was placed, patient was
re-started on tube feeds, as patient's nutritional status had
declined significantly - Albumin was as low as 2.6. Goal was to
have temporary tube feeds in place with concurrent PO intake,
and to d/c tube feeds once PO intake was adequate.
.
5. Renal Failure
Patient's Cr on admission was 3.0, with baseline Creatinien
around 1.9-2.0. FeNa at that time was 1.62% (in setting of
diuretic use and UTI). Etiology was thought to be pre-renal
picture from diarrhea leading to ATN, with component of
Klebisella UTI playing a role. With hydration, patient's
Creatinine improved and returned to baseline on discharge. ACE
inhibitors were avoided for BP control in this setting.
.
6. CHF: CXR on admission demonstrated mild CHF, with increased
JVP on exam. Patient likely has diastolic dysfunction as EF
normal on last ECHO in [**7-28**]. With fluid hydration for
pancreatitis, patient demonstrated signs of fluid overload.
Repeat CXR on hospital day 8 showed fluid overload with possible
underlying PNA (patient already on Imipenem). Patient was
diuresed with PRN lasix IV, and she symptomatically and
clinically improved.
.
7. HTN: Blood Pressure medications were held initially in the
ICU and on the floor, as mesenteric ischemia was on the
differential for patient's complaints -- within limits, HTN was
allowed for better gut perfusion; once diagnosis of acute
cholecystitis was made, Metoprolol and Norvasc were restored,
and Hydralazine was added to the regimen.
.
8. Anemia
Patient with baseline renal insufficiency, required 1 unit PRBCs
for HCT < 28. Hct therafter remaiend stable. There was a
question of possible transfusion reaction after event vs. fluid
overload, as patient presented with shortness of breath
necessitating NRB mask after xfusion, which improved with IV
Lasix administration. Patient also had low-grade fever, but
patient had spiked a temperature the evening before and was
being treated for her cholecystitis.
9. Hypothyroidism
During period of inadequate PO intake, patient was placed on IV
levothyroxine. Once PO/tube feeds restarted, Levothyroxine PO
instituted.
10. Psych: As patient's abdominal symptoms improved, Celexa was
re-started for depression.
Medications on Admission:
Atenolol 50mg PO TID
Heparin SC BID
Aranesp 25mc/mL qweek
Norvasc 10mg PO qd
Lipitor 60mg PO qd
Haldol 1 q 12PRN
Levothyroxine 125 mcg qd
Ritalin 2.5 qd
Percocet 5 qd prn
Ambien 2.5 qhs prn
Combivent PRN
Iron 325 qd
Lansoprazole 30
Zofran 2
Celexa 20 PO qd
MVI
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
3. Aranesp 25 mcg/mL Solution Sig: One (1) Injection once a
week.
4. Norvasc 5 mg Tablet Sig: One (1) Tablet PO once a day: Please
titrate back to 10mg dose if tolerated.
5. Lipitor 40 mg Tablet Sig: One (1) Tablet PO once a day.
6. Levothyroxine Sodium 125 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Insulin
Please add to tube feeds based on patient's fingersticks.
Patient recently re-started on tube feeds
9. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
10. Dolasetron 12.5 mg/0.625 mL Solution Sig: One (1)
Intravenous Q8H (every 8 hours) as needed.
11. Imipenem-Cilastatin 500 mg Recon Soln Sig: 250mg Recon Solns
Intravenous Q12H (every 12 hours) for 9 days.
12. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day): Please d/c if C. Diff B Toxin negative (please
call [**Hospital1 18**] to get final result).
13. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
14. Lasix Oral/IV: PRN
Discharge Disposition:
Extended Care
Discharge Diagnosis:
acute cholecystitis, pancreatitis, hypertension, CHF, anemia,
hypothyroidism, COPD, chronic renal insufficiency
Discharge Condition:
abdominal pain resolved, mild residual nausea, afebrile
Discharge Instructions:
Please take all medications as prescribed. Please check
electrolytes routinely to watch for re-feeding syndrome. If you
develop shortness of breath, abdominal pain, chest pain, please
contact your provider or report to the Emergency Room
immediately.
Followup Instructions:
1. Please call hospital in 2 days to determine sensitivities for
Enterococcus from Bile Fluid Cx. Patient is currently on
Imipenem, organisms will most likely be sensitive to this drug
per ID, but please f/u to confirm.
.
2. Please follow-up with C. Diff Toxin B assay (send out lab
from [**Hospital1 18**]). If negative, Metronidazole can be discontinued.
.
3. General Surgery Follow-up for either elective cholecystectomy
and/or removal of percutaneous drainage: Provider: [**Name10 (NameIs) **] [**Name8 (MD) 20249**], MD Date/Time:[**2195-11-27**] 9:45
Completed by:[**2195-10-26**]
|
[
"041.3",
"584.5",
"244.1",
"008.45",
"401.9",
"574.61",
"511.9",
"428.30",
"577.0",
"599.0",
"276.2",
"424.0",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"99.04",
"51.01",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
16148, 16163
|
9069, 14561
|
253, 299
|
16319, 16377
|
3099, 3197
|
16676, 17265
|
2539, 2605
|
14873, 16125
|
6521, 6564
|
16184, 16298
|
14587, 14850
|
16401, 16653
|
2620, 3080
|
192, 215
|
6593, 9046
|
327, 1737
|
1759, 2303
|
2320, 2523
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,970
| 180,158
|
38131
|
Discharge summary
|
report
|
Admission Date: [**2197-4-7**] Discharge Date: [**2197-4-10**]
Date of Birth: [**2125-8-18**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
Bowel Perforation
Major Surgical or Invasive Procedure:
[**2197-4-7**]: Exploratory laparotomy with loop ileostomy and biopsy of
peritoneal nodule.
History of Present Illness:
Mr [**Known lastname 85080**] is a 71 year old man transferred from an OSH
with acute onset abomdinal pain and hypotension with acute renal
failure found to have free air on a CT scan. He states he has
been having worsening abdominal pain for quite some time, cannot
quantify, of which he did not see a physician [**Name Initial (PRE) **]. The pain
became acutely worse and diffuse this morning. No nausea or
vomiting. Has been having small loose stools, no blood, last BM
this AM. +flatus. Has been having decreased PO intake and
decreased appetite for a while as well, with unknown amount of
weight loss. No fevers or chills until today. Pain is severe
and diffuse. At OSH, found to have creatinie 2.5 and WBC 17,
and
CT showed likely obstructing transverse colon mass with
distended
right colon and free air, with significant tumor in liver,
concerning for metatstatic obstructing colon cancer. never had
a
colonoscopy. Hypotension treated with 2L IVF and Zosyn, started
on Dopamine prior to transfer. Arrival here transitioned to
Levophed with BPs improved in low 100s, HR 100. Foley placed in
ED with 50cc dark urine return.
Past Medical History:
PMH:
HTN
IDDM
right AKA [**2171**] for tumor
left ?wedge lung resection for nodules in 80s
[**Last Name (un) 1724**]:
Lasix 20 mg daily
Enalopril
Lipitor
Diltiazem
MVI
ALL: NKDA
Social History:
SH: No smoking (quit 7 years ago, 1ppd), no ETOH (quit 5 yrs
ago). Has prosthesis but uses crutches. Lives with his
children.
Family History:
FH: no family history of colon cancer
Physical Exam:
PE:
NAD with face mask, conversing easily, A+O x 3
decreased BS bases, tachypnic
tachycardic, well healed sternal incision
distended, tender diffusely with deep palpation without rebound
or guarding
no c/c/e
Pertinent Results:
[**2197-4-7**] 09:06PM LACTATE-6.6*
[**2197-4-7**] 09:00PM GLUCOSE-87 UREA N-34* CREAT-2.6* SODIUM-142
POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-25 ANION GAP-20
[**2197-4-7**] 09:00PM WBC-21.3* RBC-4.85 HGB-11.8* HCT-38.5*
MCV-79* MCH-24.2* MCHC-30.6* RDW-16.4*
Brief Hospital Course:
Pt was taken from ED to OR for above procedure given bowel
perforation. Although the operation was technically successful,
the patient required significant pressors and fluid
requirements.
He was tx to the ICU in critical condition. He further
deteriorated hemodynamically and declined from a respiratory
standpoint. By [**2197-4-10**] he was profoundly septic and in multiple
system organ failure. After extensive discussion with the
family, he was made CMO and expired on [**2197-4-10**] at 2:40PM.
Medications on Admission:
See above.
Discharge Medications:
None.
Discharge Disposition:
Expired
Discharge Diagnosis:
Bowel perforation
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
Completed by:[**2197-4-10**]
|
[
"995.92",
"518.5",
"569.83",
"197.7",
"785.52",
"567.29",
"V10.81",
"789.59",
"401.9",
"584.9",
"V10.11",
"729.73",
"V49.76",
"276.2",
"276.1",
"788.5",
"250.00",
"560.9",
"197.6",
"153.1",
"038.42"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"46.01",
"54.23"
] |
icd9pcs
|
[
[
[]
]
] |
3126, 3135
|
2533, 3035
|
331, 424
|
3196, 3205
|
2246, 2510
|
3258, 3293
|
1962, 2002
|
3096, 3103
|
3156, 3175
|
3061, 3073
|
3229, 3235
|
2017, 2227
|
274, 293
|
452, 1596
|
1618, 1800
|
1816, 1946
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,157
| 103,371
|
41179
|
Discharge summary
|
report
|
Admission Date: [**2109-3-28**] Discharge Date: [**2109-4-5**]
Date of Birth: [**2041-12-10**] Sex: F
Service: MEDICINE
Allergies:
Latex
Attending:[**First Name3 (LF) 7299**]
Chief Complaint:
stridor
Major Surgical or Invasive Procedure:
Rigid bronchoscopy with baloon dilation of tracheal stenosis
History of Present Illness:
67 yo woman with DM, HTN, myasthenia [**Last Name (un) 2902**] initially admitted
to Neurology for stridor, now being transferred to the MICU for
continued management of stridor.
.
The patient was recently admitted to [**Hospital1 18**] [**Date range (3) 89696**] for
management of a myasthenic crisis. During that admission, the
patient was in the Neuro ICU. She was intubated for eight days
during that stay. She was treated with plasmapheresis and
immunomodulators, cellcept, mesthinon and prednisone. Her
symptoms improved and she was discharged to rehab. She was
discharged from rehab on Saturday and felt in her normal state
of health until Tuesday night. On Tuesday, she felt acutely
short of breath.
.
In the ED, ENT was consulted who was able to rule out upper
respiratory source of stridor. They thought that she had
evidence of mild edema from reflux. She was admitted to the
Neuro service for observation. She was treated with racemic
epinephrine, however did not have complete relief. As her
stridor did not improve, Pulmonary was consulted. They were
concerned about her respiratory status and thought she should be
monitored more closely in the MICU.
.
Before the patient arrived in the MICU, a CT neck/chest was
performed which showed evidence of severe tracheal narrowing
distal to the vocal cords. She feels persistent dyspnea, worse
with expiration.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough. 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:
- MG - diagnosed about 3 years ago with body weakness, diplopia,
dysarthria, has only been on Mestinon 60 mg QID
- DM
- HTN
- HLD
Social History:
Lives at home with a husband but she indicated that
their relationship was strained. She is a long term smoker,
smoked 1PPD for 50
years, has cut down to 1/4 pack over last few years. No etoh,
no
drugs
Family History:
No family history of MG or other neurological
diseases. Some DM in the family.
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: significant stridor, louder with inspiration than
expiration, MMM
Lungs: stridor heard through all lung fields, 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
Pertinent Results:
[**2109-4-5**] 07:35AM BLOOD WBC-9.8 RBC-3.73* Hgb-12.0 Hct-35.4*
MCV-95 MCH-32.0 MCHC-33.8 RDW-15.5 Plt Ct-302
[**2109-3-28**] 01:15PM BLOOD WBC-8.5 RBC-3.72* Hgb-11.6* Hct-34.8*
MCV-93 MCH-31.1 MCHC-33.2 RDW-15.2 Plt Ct-546*
[**2109-3-28**] 01:15PM BLOOD Neuts-55.1 Lymphs-35.1 Monos-7.2 Eos-1.7
Baso-0.9
[**2109-4-4**] 06:30AM BLOOD PT-11.4 PTT-34.7 INR(PT)-0.9
[**2109-3-28**] 01:15PM BLOOD PT-12.8 PTT-24.0 INR(PT)-1.1
[**2109-4-5**] 07:35AM BLOOD Glucose-161* UreaN-23* Creat-0.7 Na-140
K-4.6 Cl-103 HCO3-26 AnGap-16
[**2109-3-28**] 01:15PM BLOOD Glucose-133* UreaN-18 Creat-0.6 Na-140
K-4.1 Cl-101 HCO3-27 AnGap-16
[**2109-3-28**] 01:15PM BLOOD CK(CPK)-18*
[**2109-3-28**] 01:15PM BLOOD cTropnT-<0.01
[**2109-4-4**] 06:30AM BLOOD Calcium-9.5 Phos-4.3 Mg-2.2
[**2109-3-28**] 01:15PM BLOOD Calcium-8.8 Phos-4.4 Mg-2.0
[**2109-3-28**] 01:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2109-3-28**] 03:15PM BLOOD Type-ART pO2-206* pCO2-43 pH-7.45
calTCO2-31* Base XS-5
.
CHEST XRAY IMPRESSION: No acute cardiopulmonary abnormality.
.
CT TRACHEA
IMPRESSION:
1. Focal, fixed stenosis of the trachea at the level of the
thoracic inlet as characterized above.
2. Secretions in the right main stem bronchus as well as in the
right lower lobe bronchus, with resultant air trapping in the
right lower lobe.
3. Coronary arterial calcification.
Brief Hospital Course:
HOSPITAL COURSE
67 yo female with history of myasthenia [**Last Name (un) 2902**], DM, HTN, HLD,
Glaucoma and cataracts with recent hospitalization for MG crisis
s/p intubation, admitted for stridor, found to have significant
tracheal narrowing. Underwent ballowing for tracheal narrowing.
Pt was discussed with neurology attending Dr. [**First Name8 (NamePattern2) 9485**] [**Last Name (NamePattern1) **]
who agreed to coordinate follow up during a rapid prednisone
taper in preparation of reconstructive tracheal surgery in the
near future. Pt was ultimately scheduled to follow-up in
musculoskeletal neurology clinic for management of taper.
.
ACTIVE ISSUES
# Tracheal Narrowing: Likely secondary to intubation during
recent hospitalization. The patient's symptoms improved with
heliox, likely because of improvement in turbulent flow. IP
consulted and took patient to OR she was foujnd to have tracheal
narrowing to 5mm. Balloon dilation was completed post procedure
diameter was 1.2cm. Her stridor returned with exertion the
following day. A second bronchoscopy revealed 1.0cm and stable.
Her stridor was stable for the duration of the hospital stay.
Combined follow-up with IP and thoracic surgery arranged for 2
weeks post discharge for discussion of recontructive surgery. A
rapid prednisone taper was initiated to prepare for surgery.
.
# Myasthenia [**Last Name (un) **]: Well controlled after recent crisis.
Continued on prednisone, Mycophenolate Mofetil 500 mg PO BID,
Pyridostigmine Bromide 60 mg PO/NG Q6H, (per neurology will need
to be on this medication for prolonged period of time until
cellcept is therapeutic). Prednisone was tapered in preparation
for future surgery. Follow-up with outpatient neurology was
arranged to manage medication therapy in setting of recent
crisis and plan for prednisone taper.
# HLD: Continued Pravastatin 10 mg PO DAILY
.
# DM: Continued metformin and insulin, when restart diet will
give diabetic
.
# HTN: Continued valsartan.
.
# Glaucoma: Lumigan *NF* (bimatoprost) 0.03 % OU QHS
.
TRANSITIONAL ISSUES
Medical Management: Rx for albuterol given for symptoms of
wheeze, prednisone taper
Follow-up: PCP, [**Name10 (NameIs) 1092**] Surgery and IP
Medications on Admission:
Aspirin 81 mg PO/NG DAILY
Pravastatin 10 mg PO DAILY
Docusate Sodium 100 mg PO BID
Acetaminophen 650 mg PO/NG Q6H:PRN pain, temp > 100.4
Senna 1 TAB PO/NG [**Hospital1 **]:PRN constipation
Mycophenolate Mofetil 500 mg PO BID
traZODONE 50 mg PO/NG HS:PRN insomnia
Pyridostigmine Bromide 60 mg PO/NG Q6H
Pantoprazole 40 mg PO Q24H
MetFORMIN (Glucophage) 500 mg PO BID
Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
Nicotine Patch 7 mg TD DAILY
Valsartan 40 mg PO/NG DAILY
Lumigan *NF* (bimatoprost) 0.03 % OU QHS
Insulin SC (per Insulin Flowsheet) Sliding Scale
Ipratropium Bromide Neb 1 NEB IH Q4H:PRN wheezing
PredniSONE 60 mg PO/NG DAILY Start: In am
Sulfameth/Trimethoprim SS 1 TAB PO/NG DAILY
Calcium Carbonate 500 mg PO/NG TID W/MEALS chewable
Vitamin D 400 UNIT PO/NG [**Hospital1 **]
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
2. pravastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain, temp > 100.4.
5. ibuprofen 100 mg/5 mL Suspension Sig: Four (4) mL PO every
six (6) hours as needed for headache.
6. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**12-9**]
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
7. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. pyridostigmine bromide 60 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours).
10. sennosides 12 mg Capsule Sig: One (1) Capsule PO twice a day
as needed for constipation.
11. Bactrim 400-80 mg Tablet Sig: One (1) Tablet PO once a day.
12. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
13. latanoprost 0.005 % Drops Sig: One (1) both eyes Ophthalmic
at bedtime.
14. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
15. omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
16. valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
17. prednisone 10 mg Tablet Sig: Take 5 tablets for 3 days, then
take 4 tablets for 3 days, take 3 tablets for 3 days, take 2
tablets for 3 days and then take 1 tablet for 3 days, then STOP
Tablet PO DAILY (Daily).
Disp:*45 Tablet(s)* Refills:*0*
18. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**12-9**] Inhalation every 4-6 hours as needed for shortness of
breath or wheezing for 10 months.
Disp:*1 inhaler* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
1. Tracheal Stenosis
Secondary
1. Myasthenia [**Last Name (un) 2902**]
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for evaluation of stridor. You were admitted
to the medical intensive care unit. Imaging revealed focal
narrowing in your trachea, tracheal stenosis. This occured
likely as an unfortunate complication of your recent intubation
while hospitalized previously for myasthenia [**Last Name (un) 2902**]. Our
interventional pulmonologists performed a brochoscopy and were
able to balloon open this stenosis. Your stridor improved
however did not resolve. You were evaluated by a our thoracic
surgeons who will plan with interventional pulmonology surgical
reconstruction of your trachea. Before surgery, we will need to
discontinue your prednisone as this medication interferes with
wound healing. We discussed management of your myasthenia [**Last Name (un) 2902**]
with your neurology team. We discussed your admission with
neurology. Neurology will arrange follow-up with you as you
transition off prednisone.
It is safe for you to go home. It is important that you monitor
your symptoms closely. You will have stridor and some shortness
of breath with exercise as your tracheal stenosis still exists.
If you have any worsening of your symptoms, including acute
shortness of breath please return to the emergency department or
clinic depending on the severity of your symptoms.
The following changes were made to your medication list:
1. DECREASE prednisone by ten milligrams every 3 days:
Prednisone taper is 50mg x 3 days, 40mg x 3 days, 30mg x 3 days,
20mg x 3 days, 10mg x 3 days.
Followup Instructions:
Pt is scheduled to be seen in [**Hospital 7817**] Clinic on [**2109-4-10**]
Campus: EAST Best Parking: [**Street Address(1) 592**] Garage
Name: [**Last Name (LF) 89697**],[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
Address: 5 INDUSTRIAL DR [**Last Name (STitle) **], [**Location (un) **],[**Numeric Identifier 84441**]
Phone: [**Telephone/Fax (1) 89698**]
Appointment: Friday [**2109-4-12**] 2:00pm
Department: WEST [**Hospital 2002**] CLINIC
When: TUESDAY [**2109-4-23**] at 9:30 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 3020**]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: WEST [**Hospital 2002**] CLINIC
When: TUESDAY [**2109-4-23**] at 9:00 AM
With: [**Name6 (MD) 1532**] [**Last Name (NamePattern4) 8786**], MD [**Telephone/Fax (1) 3020**]
Department: NEUROLOGY
When: THURSDAY [**2109-6-6**] at 2:30 PM
With: [**First Name8 (NamePattern2) 539**] [**Last Name (NamePattern1) 540**] MD [**Telephone/Fax (1) 541**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"V15.82",
"401.9",
"358.00",
"997.39",
"E879.8",
"250.00",
"285.9",
"519.19",
"272.4",
"V58.67",
"786.1",
"492.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.99",
"33.23"
] |
icd9pcs
|
[
[
[]
]
] |
9599, 9605
|
4552, 6770
|
274, 336
|
9730, 9730
|
3151, 4529
|
11416, 12596
|
2575, 2657
|
7664, 9576
|
9626, 9708
|
6796, 7641
|
9881, 11392
|
2672, 3132
|
1768, 2184
|
227, 236
|
364, 1749
|
9745, 9857
|
2206, 2338
|
2354, 2559
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,719
| 197,340
|
6820+55787
|
Discharge summary
|
report+addendum
|
Admission Date: [**2148-11-25**] Discharge Date: [**2148-12-7**]
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Penicillins / Macrodantin / Ivp Dye,
Iodine Containing
Attending:[**First Name3 (LF) 11495**]
Chief Complaint:
chest pain and shortness of breath
Major Surgical or Invasive Procedure:
1)Cardiac catheterization with stenting of left circumflex
artery with DES
2)Surgical exploration of the retroperitoneal space
History of Present Illness:
The patient is an 82 yo female with HTN, CAD s/p MI x 2 (94 and
99), CHF (EF 55-60% [**2148**]), afib, NSVT, COPD with recent flare
who presented to [**Hospital3 3583**] with an episode of rest angina,
was found to be in rapid afib with rate 140 and returned back to
NSR after Diltiazem. She was found to have a TnI of 0.3 (pos
>.4, neg < .04), so she was sent to [**Hospital1 18**] for cardiac
catheterization.
.
She had been admitted there approximately three weeks ago for a
COPD exacerbation and had been home for a week when these
symptoms began. She was going to walk her dog when she
developed sudden onset chest pressure, similar to anginal and
pre-infarct sx she had before. She took two ntg that failed to
relieve her sx, so she went into [**Hospital3 3583**]. There she was
in rapid afib with rate 140 and was initially rate controlled
with Diltiazem and spontaneously converted to NSR. She also was
found to have ST-depressions in V5-V6 and a TnI of 0.3 (with
normal CKs) so was sent to [**Hospital1 18**] for cath.
.
Here, at the time of cath, she was found to have severe PVD with
an occluded right iliac and a narrowed aortic lumen; she had a
cypher stent placed in the LCX. Immediately post-cath, she
denied ongoing sx.
ROS: Denies LH, chest pain, palpitations, orthopnea, pnd, le
edema, dyspnea, cough, sputum, wheeze, abd pain, n/v/d, dysuria,
hematuria, or frequency. She is, however, constipated.
.
Past Medical History:
PMH:
1)HTN
2)Hypercholesterolemia
3)CAD: MI [**2136**], PTCA to ramus; MI [**2141**], PTCA to RCA
4)CHF: [**2145**] echo with EF 40-45%, aortic root dilation, [**2-5**]+ ar,
1+mr
5)Afib
6)NSVT
7)PVD
8)COPD
9)GERD
10)Nephrolithiasis
Social History:
She lives alone and is mainly indepedent in ADLs (some help from
neighbors). 60 pack yrs, now down to 4 cigs a day. No etoh.
Has son and daughter-in-law in area.
Family History:
Both sisters died of breast cancer in 50's. Mother died at 100,
father at 85. Son with DM.
Physical Exam:
T 96.0, bp 140/58, hr 78, rr 24, spo2 90-97% 100% FM
gen- elderly f, chronically ill, with face mask on in NAD
heent- op clear MMM
neck- thyroid [**Doctor First Name **] scar, no thyromegaly, no cervical lad. R IJ
in place.
cv- rrr with mult PVCs, s1s2, no m/r/g
pul- decreased BS at bases R>L, no w/c/r
abd- surgical scar with staples midline w/o signs of infection.
soft and mildly distended, generalized tenderness, + BS.
extrm- no cyanosis/edema, warm/dry, 1+ dp pulses bilat, L
femoral bruit, 1+ fem pulses b/l.
nails- no clubbing, brittle, no pitting/indentations
neuro- a&ox3, no focal cn/motor deficits
Pertinent Results:
[**2148-11-25**] 11:35PM HCT-35.7*#
[**2148-11-25**] 11:35PM PT-14.9* PTT-43.6* INR(PT)-1.3*
[**2148-11-25**] 09:16PM GLUCOSE-197* UREA N-18 CREAT-0.6 SODIUM-140
POTASSIUM-4.0 CHLORIDE-110* TOTAL CO2-22 ANION GAP-12
[**2148-11-25**] 09:16PM ALT(SGPT)-12 AST(SGOT)-12 LD(LDH)-172
CK(CPK)-24* ALK PHOS-43 TOT BILI-0.2
[**2148-11-25**] 09:16PM CK-MB-NotDone cTropnT-0.02*
[**2148-11-25**] 09:16PM CALCIUM-6.5* PHOSPHATE-3.4 MAGNESIUM-1.7
[**2148-11-25**] 09:16PM WBC-23.3* RBC-3.27* HGB-9.5* HCT-27.7* MCV-85
MCH-29.0 MCHC-34.2 RDW-15.3
[**2148-11-25**] 09:16PM NEUTS-91.5* BANDS-0 LYMPHS-5.7* MONOS-2.8
EOS-0 BASOS-0
[**2148-11-25**] 09:16PM PLT SMR-NORMAL PLT COUNT-246
[**2148-11-25**] 09:16PM PT-14.4* PTT-62.6* INR(PT)-1.3*
[**2148-11-25**] 06:12PM HCT-34.8*
[**2148-11-25**] 03:45PM WBC-21.3*# RBC-4.23 HGB-12.2 HCT-35.3* MCV-84
MCH-28.9 MCHC-34.5 RDW-15.2
[**2148-11-25**] 03:45PM NEUTS-96.2* BANDS-0 LYMPHS-2.7* MONOS-1.1*
EOS-0 BASOS-0
[**2148-11-25**] 03:45PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2148-11-25**] 03:45PM PLT SMR-NORMAL PLT COUNT-239
.
[**11-25**] Cath: COMMENTS:
1. Selective coronary angiography of this right dominant system
revealed a single vessel CAD. The LMCA was patent. The LAD had
mild
non-obstrcutive disease. The LCx had an 80% proximal stenosis.
The RCA
had a 30% proximal and a 50% distal stenoses.
2. Resting hemodynamics revealed a normal left sided filling
pressure.
There was a moderate systemic arterial hypertension with SBP of
160 mm
Hg.
3. Left ventriculography was deferred.
4. There was difficulty with right femoral access. Having
obtained a
femoral access on the left, an abdomianl aortography revealed an
occluded right external iliac artery and a 60% stenosis at the
origin of
the right common iliac artery. Left iliac artery was patent.
There was
a diffuse aortic atherosclerosis with a 70% distal stenosis, an
infrarenal aneurism and a 20 mm Hg gradient.
5. The lesion in the proximal LCX was predilated with a 2.0 mm
balloon
and stented with a 2.5 mm Cypher stent with lesion reduction to
80%. The
final angiogram showed TIMI III flow with no residual stenosis,
no
dissection and no embolisation. (see PTCA comments)
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Normal LV diastolic function.
3. Occluded right external iliac artery, stenosed right common
iliac
artery.
4. Diffuse aortic atherosclerosis; distal aortic stenosis;
infrarenal
aneurism.
5. Succesful stenting of the LCX lesion (drug eluting)
.
CT abd and pelvis: IMPRESSION:
1. Largest right-sided retroperitoneal hematoma extending from
the base of the right kidney downward into the right groin with
a likely active extravasation overlying the right common iliac
vessel.
2. Small hypodensities within the right and left lobes of the
liver not completely characterized in this study characterized
on this study.
3. Bilateral low density kidney lesions not completely
characterized on the study. If there is further clinical concern
ultrasound can be performed both on the liver and kidneys for
better evaluation not emergently.
4. Adrenal adenoma.
.
TEE:
Conclusions:
The left atrium is moderately dilated. No mass/thrombus is seen
in the left atrium or left atrial appendage. Left ventricular
wall thicknesses are normal. Overall left ventricular systolic
function is mildly depressed. The calculated myocardial
performance index was 0.35 (MPI A = 4460. ms; MPI B = 331 ms).
Tissue velocity imaging E/e' is elevated (>15) suggesting
increased left ventricular filling pressure (PCWP>18mmHg).
Transmitral Doppler and tissue velocity imaging are consistent
with Grade II (moderate) LV diastolic dysfunction. Resting
regional wall motion abnormalities include mild inferior wall
hyppokinesia.. Right ventricular chamber size and free wall
motion are normal. There is no mass/thrombus in the right
ventricle. The aortic root is moderately dilated. The ascending
aorta is mildly dilated. There are complex (>4mm) atheroma in
the ascending aorta. There are complex (>4mm) atheroma in the
aortic arch. The aortic valve leaflets (3) appear structurally
normal with
good leaflet excursion. Moderate (2+) aortic regurgitation is
seen. The mitral valve leaflets are structurally normal. Mild
(1+) mitral regurgitation is seen. The left ventricular inflow
pattern suggests impaired relaxation. There is mild pulmonary
artery systolic hypertension. There is a small to moderate
sized pericardial effusion. The effusion appears loculated.
Brief Hospital Course:
This is an 82F with CAD, CHF, pAfib, h/o nsvt, PVD, and a recent
COPD flare admitted to [**Hospital3 3583**] with afib with RVR and
demand ischemia. She was transferred here and received a LCX
DES. Post cath the pt became hypotensive and received ~2L NS
with little response in BP. She complained of some LBP and was
diaphoretic with nausea. Dopamine was started and the patient
had a CT scan which showed a large right-sided RP bleed.
Vascular surgery was consulted, did an angiogram which did not
localize the bleed and then took her to surgery for exploration
of the retroperitoneal space. They ligated a large branch of the
distal external iliac artery that was bleeding, several small
venous structures, and a small side branch of the distal
external iliac artery which was surrounded by fresh clot. At
that time, there was no evidence of active bleeding. The patient
was kept in the SICU and was extubated on [**11-27**]. She was
transferred to the CCU and the following issues were addressed
during her admission:
.
1 RP bleed s/p surgical exploration: The bleed is likely
secondary to the difficulty obtaining right femoral access
during the cardiac catheterization due to the occluded right
external iliac artery. As described above, several small
arteries were ligated and the patient's BP subsequently
stabilized. In total, she received 12u PRBC, 4u FFP, 2u cryo,
and 4 bags of platelets. The incision was healing appropriately
and her BP and hct had stabilized by the time of discharge. The
patient has a follow up appointment with Dr. [**Last Name (STitle) **] of vascular
surgery for the removal of her abdominal staples.
.
2 Hypoxia: The patient was intubated for the surgical
exploration of her abdomen. She was extubated two days s/p
surgery and was found to have a high 02 requirement that was
attributed to a combination of acute bronchitis, pleural
effusions/fluid overload, and splinting from surgery. CXR was
negative for infiltrate. Her pain was controlled with oxycodone
prn and Tylenol ATC. She was treated for bronchitis initially
with Cipro which was then discontinued after three days as the
pt was afebrile and a bacterial etiology was not felt to be
likely. For her bronchitis, the patient was continued on
Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **], Ipratropium Bromide
MDI 2 PUFF IH QID, tiotropium, and prn albuterol inhaler. She
was also put on stress dose steroids initially which were then
changed to a PO prednisone taper as her respiratory status
improved. Upon discharge she recieved her third dose of 30mg QD.
She is satting in the mid 90s on 2L NC. Her lung exam is much
improved with residual b/l rhonchi. She will need to continue
her steroid taper as an oupatient, in addition to her inhalers.
3. Cardiac:
A. Coronaries/CAD: The patient has a history of CAD s/p 2 MIs
('[**36**] and '[**41**]) and presented with afib with RVR and demand
ischemia to an OSH. She went to cardiac catheterization at [**Hospital1 18**]
and received a cypher stent to the LCx on [**11-25**]. She had a post
procedure retroperitoneal bleed as described above which was
treated surgically. CE were negative. Anticoagulation was held
during the bleed and restarted s/p surgery and stabilization of
the bleed. The patient was maintained on ASA 325mg, clopidogrel
75mg, atorvastatin 80mg, metoprolol 25 mg [**Hospital1 **], and benicar 20
QD.
.
B. Pump: The patient has a h/o CHF with an EF 55-60% on [**5-/2148**]
at [**Hospital3 3583**]. After surgery, the patient had b/l pleural
effusion seen on CXR. She was diuresed with lasix to improve her
respiratory status. For the remainder of her hospitalization she
appeared euvolemic on exam. She was kept on a 2g Na diet. Once
she was euvolemic, we changed her lasix to HCTZ/Triamterene as
this will both diurese and have an anti-hypertensive effect.
Additionally, the patient was hypokalemic and had trouble taking
the PO KCL secondary to GERD.
.
C. Rhythm: The patient has a h/o Afib and NSVT. She had a few
episodes of asymptomatic NSVT and SVT. We monitored her on
telemetry, continued her on low dose metoprolol and repleted her
lytes as needed.
.
4. Leukocytosis: The patient had a leukocytosis which resolved
towards the end of her hospital stay. This was thought to be
secondary to high dose steroids for COPD vs infection from acute
bronchitis. CXR was negative for infiltrate. UA was clear x 2
and blood cx were negative. The patient was started on Cipro for
presumed acute bronchitis initially. However, as the patient
remained afebrile, the Cipro was discontinued after three days.
As her prednisone was tapered, her leukocytosis resolved.
.
Diarrhea: The patient developed diarrhea towards the end of her
hospitalization. An AXR showed a non-specific bowel gas pattern
with no evidence for obstruction. She was afebrile and c.diff
was negative. The patient was put on a BRAT diet x 1 day and the
diarrhea resolved. The cause of the diarrhea remaines unclear.
.
5. TCP: The patients platelets dropped to 88,000 and all
heparin products were discontinued. The platelets rose to 114
after one day off heparin products and were WNL upon discharge.
HIT AB pending.
.
6. GERD: The patient was maintained on pantoprazole during her
hospitalization and received maalox with her medications.
Medications on Admission:
-Metoprolol 12.5mg [**Hospital1 **]
-Atorvastatin 10mg daily
-Imdur 30mg [**Hospital1 **]
-ASA 325mg daily
-Benicar 20mg qHS
-Pantoprazole 40mg daily
-Darvocet prn
-Combivent 2puffs four times daily
-Fluticasone 2puffs [**Hospital1 **]
-Fluticasone nasal 2 puffs daily
-Furosemide 10mg daily
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Olmesartan 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
Disp:*240 Tablet(s)* Refills:*2*
8. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
9. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: Two (2)
Spray Nasal DAILY (Daily).
10. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
11. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
12. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Albuterol Sulfate 0.083 % Solution Sig: One (1) puff
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
Disp:*1 inhaler* Refills:*1*
14. Triamterene 50 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
15. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO PRN (as needed).
16. Hydrochlorothiazide 25 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
18. Prednisone 10 mg Tablet Sig: 1-2 Tablets PO DAILY (Daily)
for 5 days: Please take two pills for three days, then take one
pill for three days.
Disp:*9 Tablet(s)* Refills:*0*
19. insulin sliding scale
Glucose Insulin Dose
0-50 mg/dL [**2-5**] amp D50
51-149 mg/dL 0 Units
150-199 mg/dL 2 Units
200-249 mg/dL 4 Units
250-299 mg/dL 6 Units
300-349 mg/dL 8 Units
350-399 mg/dL 10 Units
20. oxygen
continue 02 at 2L/min continuous to keep sats in 90's.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 66**] Rehab & Nursing Center - [**Hospital1 392**]
Discharge Diagnosis:
1)Rapid atrial fibrillation with demand ischemia
2)Retroperitoneal bleed
Discharge Condition:
Stable
Discharge Instructions:
1)Please follow up with your PCP [**Name9 (PRE) **],[**First Name8 (NamePattern2) 640**] [**Last Name (NamePattern1) **]
[**Telephone/Fax (1) 25821**] upon discharge. If you experience CP, SOB,
dizzyness, or any other symptoms that concern you please call
your PCP or return to the ER.
.
Note: you have had a cardiac stent placed during this admission.
You must take your aspirin and plavix every day to prevent
failure of these stents which could be life threatening. Please
take all medications as prescribed.
Followup Instructions:
1)Please follow up with your PCP and cardiologist, [**Name9 (PRE) **],[**First Name8 (NamePattern2) 640**]
[**Last Name (NamePattern1) **] [**Telephone/Fax (1) 25821**], upon discharge.
2)Please follow up with your vascular surgeon, Dr. [**Last Name (STitle) **] to
have the staples removed on Wednesday, [**12-11**] at 3pm.
Completed by:[**2148-12-5**] Name: [**Known lastname 4422**],[**Known firstname 4423**] G Unit No: [**Numeric Identifier 4424**]
Admission Date: [**2148-11-25**] Discharge Date: [**2148-12-7**]
Date of Birth: [**2066-1-8**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Penicillins / Macrodantin / Ivp Dye,
Iodine Containing
Attending:[**First Name3 (LF) 1619**]
Addendum:
Just prior to discharge on [**12-5**], pt's BP was found to be 70/40
P70s just after receiving her am BP meds. She was asymptomatic.
The patient was kept in the hospital and the following issues
were addressed:
.
1. Hypotension: The patient'd pm BP meds were held [**12-5**] and she
was administered 1.5L NS over the course of the day with
subsequent SBPs in the high 90s, low 100s. The hypotension was
likely due to volume depletion caused by her diarrhea/loose
stools in addition to decreased PO intake secondary to her GERD
and thrush. All of this occurred in the setting of aggressive BP
management with metoprolol 25 [**Hospital1 **], HCTZ/Triampterene (as a
replacment for lasix due to recurrent hypokalemia), Benicar 20
mg QD, and Imdur 30mg QD. Infection/sepsis was not likely given
she was afebrile and had no localizing sx with an improving lung
exam and 02 requirement. Given the patient's recent RP bleed,
there was concern for a recurrent bleed. Her groin exam was
unchanged. Her Hct dropped from Hct 38.9 before fluids to 35.5
s/p 1.5L NS and was thought to be dilutional. Repeat hcts were
stable. The patient was kept an additional two days to follow
her hcts and titrate her BP meds. As volume depletion was
thought to be the cause of her low BP, only the BBlocker was
restarted. She was also placed on on low dose spironolactone as
a K sparing diuretic and for BP control in addition to Toprol XL
25mg QD for her coronary disease. She tolerated these meds with
SBPs in the high 90s to 100s and was therefore discharged on
this regimen. She will need follow up with her PCP within [**Name Initial (PRE) **] week
after discharge from the extended care facility for further BP
titration and monitoring of her electrolytes.
.
2. Thrush: This is likely secondary to her steroid inhalers and
PO prednisone for COPD exacerbation. She was started on nystatin
swish and swallow QID. The patient was encouraged to take PO
liquids to prevent volume depletion.
.
3. diarrhea: The patient has been having loose stools at night
and was guiac pos x 2. Stool for C.diff toxin was sent x 1 and
was negative. Her bowel regimen is prn. Gastroenteritis is
possible but she has no vomiting and only occ nausea with meds.
There is no evidence of obstruction on AXR. Therefore, the
cause of her mild diarrhea (few loose BM/liquid stool/night) may
be either viral or secondary to resolving abdominal hematoma
with resultant irritation of GI system. We have advised a BRAT
diet.
.
4. guiac pos stool: Given the patient's sx of GERD, current PO
steroid regimen, and ASA for her stents, the ddx for her guiac
positive stools would include gastritis/gastric ulcer in
addition to lower GI pathology. However, she has no vomiting and
only mild nausea with medications. She also has no gross blood
per rectum and her hct is stable. Upon discharge the patient was
changed to a [**Hospital1 **] protonix regimen. Dr.[**Name (NI) 4425**] office was
notified about the patient's discharge plans and status. She
will need outpatient follow up for her guiac pos stools with
endoscopy vs EGD +/- H.pylori serologies. A copy of this dc
summary will be faxed to her PCP to ensure proper follow up.
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
3. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
Disp:*240 Tablet(s)* Refills:*2*
4. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
5. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: Two (2)
Spray Nasal DAILY (Daily).
6. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
7. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Albuterol Sulfate 0.083 % Solution Sig: One (1) puff
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
Disp:*1 inhaler* Refills:*1*
10. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO PRN (as needed).
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
12. Prednisone 10 mg Tablet Sig: 1-2 Tablets PO DAILY (Daily)
for 4 days: Please take two pills for one day starting [**12-8**],
then take one pill for three days.
Disp:*5 Tablet(s)* Refills:*0*
13. oxygen
continue 02 at 1L/min continuous to keep sats in 90's.
14. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
15. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
16. Nystatin 100,000 unit/mL Suspension Sig: Ten (10) ML PO QID
(4 times a day) for 7 days.
17. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 4426**] Rehab & Nursing Center - [**Hospital1 3983**]
Discharge Diagnosis:
1)Rapid atrial fibrillation with demand ischemia
2)Retroperitoneal bleed
Discharge Condition:
Stable
Discharge Instructions:
Please follow up with your PCP [**Name9 (PRE) 400**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4076**] [**Telephone/Fax (1) 4427**]
upon discharge. If you experience CP, SOB, dizzyness, or any
other symptoms that concern you please call your PCP or return
to the ER.
.
Note: you have had a cardiac stent placed during this admission.
You must take your aspirin and plavix every day to prevent
failure of these stents which could be life threatening. Please
take all medications as prescribed.
Followup Instructions:
1)Please follow up with your PCP and cardiologist, [**Name9 (PRE) 400**],[**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 4076**] [**Telephone/Fax (1) 4427**], upon discharge.
2)You are scheduled to have your staples removed on [**2148-12-11**]
3:00 with
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) 798**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 282**] SURGERY (NHB)
Date/Time:[**2148-12-11**] 3:00.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1622**] MD [**MD Number(2) 1623**]
Completed by:[**2148-12-7**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
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[
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3101, 5372
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5389, 7673
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22334, 22848
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2468, 3082
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248, 284
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478, 1905
|
1927, 2161
|
2177, 2343
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,555
| 198,781
|
5569
|
Discharge summary
|
report
|
Admission Date: [**2160-7-9**] Discharge Date: [**2160-7-16**]
Date of Birth: [**2106-10-1**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Malaise, SOB; fever, chills and rigors after using portho-cath.
Major Surgical or Invasive Procedure:
Left portho-cath removal on [**2160-7-11**]
History of Present Illness:
Mr. [**Known lastname **] is a 53-year-old man with Crohn's Disease, s/p total
proctocolectomy with ileostomy, c/b short gut syndrome, on
chronic TPN, with multiple recurrent line infections with MSSA,
CoNS, and GNRs, septic pulmonary emboli and bronchiectasis, who
is admitted with shortness of breath and rigors. The pt first
started feeling ill approx 2 weeks PTA with non-specific
complaints, and then developed night sweats and a non-productive
cough. He called Dr. [**First Name (STitle) 572**], who arranged for a Chest CT, which
showed multiple new lower lobe cavitating nodules concerning for
multiple septic emboli. Peripheral blood cultures were
reportedly negative at the time. He was to come in for repeat
blood cultures and cultures off his line, but over the last 2
days developed worsening symptoms of dyspnea on exertion,
right-sided chest pain, and rigors on the night PTA. He called
Dr. [**First Name (STitle) 572**] about these new symptoms, and was advised to come in
to the ED for concern of a recurrent line infection and septic
pulmonary emboli.
Past Medical History:
1. Crohn's disease- s/p multiple bowel resections, on 6-MP in
the past
2. Short Gut Syndrome on chronic TPN
3. Multiple central line infections with MSSA, E.Coli,
enterobacter, Stenotrophomonas, Acinetobacter, Klebsiella
4. H/o septic pulmonary emboli ([**10-1**], no endocarditis on TTE)
5. RML Bronchiectasis
6. Recent RUL nodular opacities of unclear etiology (followed by
Dr. [**Last Name (STitle) 575**]
7. Mild restrictive lung disease (PFTs [**1-31**])
.
PSH:
1. Proctocolectomy with ileostomy
2. Parathyroidectomy
3. Cholecystectomy
Social History:
Works in finance department at [**Hospital6 33**]. Wife is a
nurse manager. Lives with wife and 2 kids, 18 and 15yo. + h/o
tobacco-1ppd x 15-20y, quit 20y ago. Denies EtOH and IVDU.
Family History:
Mother family w/ CAD. MGM d. CVA age 85, MGF d. CHF age [**Age over 90 **], PGF
d. CHF age 86, PGM +DM2. Brother w/ early Parkinson's.
Physical Exam:
VS - Temp 98.7 F, BP 99/60, HR 72, R 14, O2-sat 94% RA
GENERAL - NAD, comfortable, appropriate
HEENT - PERRLA, EOMI, sclerae anicteric, dry MM, OP clear
NECK - supple, no thyromegaly or LAD
LUNGS - mild crackles at right base, otherwise CTA, good air
movement, resp unlabored, no accessory muscle use
HEART - RRR, nl S1-S2, +faint [**12-2**] SM
ABDOMEN - NABS, soft/NT/ND, liver edge ~3-4cm below RCM, no
splenomegaly, +ileostomy
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**3-31**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric
Pertinent Results:
On Admission:
[**2160-7-9**] 11:55AM WBC-8.5# RBC-4.55* HGB-11.8* HCT-35.5*
MCV-78* MCH-25.9*# MCHC-33.2 RDW-14.3
[**2160-7-9**] 11:55AM NEUTS-92.8* LYMPHS-5.4* MONOS-1.6* EOS-0
BASOS-0.2
[**2160-7-9**] 11:55AM PLT COUNT-118*
[**2160-7-9**] 11:55AM GLUCOSE-93 UREA N-22* CREAT-1.0 SODIUM-135
POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-21* ANION GAP-14
[**2160-7-9**] 11:55AM PT-14.6* PTT-33.5 INR(PT)-1.3*
[**2160-7-9**] 02:50PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.021
[**2160-7-9**] 02:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2160-7-9**] 02:10PM LACTATE-1.0
[**2160-7-9**] 08:46PM ALT(SGPT)-35 AST(SGOT)-34 LD(LDH)-211 ALK
PHOS-91 AMYLASE-74 TOT BILI-1.1
[**2160-7-9**] 08:46PM LIPASE-40
[**2160-7-9**] 08:46PM ALBUMIN-2.6* CALCIUM-7.3* PHOSPHATE-2.0*
MAGNESIUM-1.6 IRON-11*
[**2160-7-9**] 08:46PM calTIBC-203* VIT B12-1282* FOLATE-11.9
FERRITIN-689* TRF-156*
[**2160-7-9**] 08:46PM RET AUT-1.2
On Discharge:
[**2160-7-16**] 06:21AM BLOOD WBC-4.7 RBC-4.32* Hgb-11.1* Hct-33.3*
MCV-77* MCH-25.7* MCHC-33.3 RDW-14.6 Plt Ct-203
[**2160-7-16**] 06:21AM BLOOD Plt Ct-203
[**2160-7-16**] 06:21AM BLOOD Glucose-92 UreaN-17 Creat-1.1 Na-136
K-4.1 Cl-101 HCO3-27 AnGap-12
[**2160-7-16**] 06:21AM BLOOD ALT-79* AST-75* AlkPhos-116 TotBili-0.7
[**2160-7-16**] 06:21AM BLOOD Albumin-3.3*
Blood cutlure ER: S aureus ([**11-28**] in the ER)
Blood cutlures: Negative 5 (plus one fungal)
Catheter tip culture: no growth
Beta-D-glucan 412
Galactomanan 0.052
Cryptococcus negative
Histoplasma pending
Blastomycosis pending
CXR:
There is a central line with the tip at the cavoatrial junction.
There is
some added density in the right costophrenic angle, this is new
since the
prior examination and may represent a focus of consolidation.
Followup chest
radiograph is advised to clearance. Left lung is clear. The
cardiomediastinal silhouette is stable.
Echocardiogram:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is 0-10mmHg. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%).
Transmitral and tissue Doppler imaging suggests normal diastolic
function, and a normal left ventricular filling pressure
(PCWP<12mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis. No masses or vegetations are seen on the aortic valve.
No aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. Trivial mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2158-8-30**],
the findings are similar. If clinically suggested, the absence
of a vegetation by 2D echocardiography does not exclude
endocarditis.
CT scan:
1. Multiple new lower lobe, subpleural predominant poorly
defined nodules, a
few of which demonstrate cavitation. Considering history of
previous septic
emboli, recurrent septic emboli are a likely possibility.
Differential
diagnosis includes granulomatous infections (fungal and
mycobacterial),
vasculitis, and, less likely, cryptogenic organizing pneumonia
(rarely
cavitary).
2. Splenomegaly with marked increase in size of spleen since
recent study,
incompletely evaluated due to incomplete imaging.
Brief Hospital Course:
Patient came to the [**Hospital1 1388**] ER for fever, chills, SOB after
using his left portho-cath for his TPN. In the ED: VS were Temp
97.9 F, HR 77, BP 89/56, R 18, O2-sat 99% RA. He was given 3L NS
and Blood Cx were drawn. His BP responded to SBP 100. He
received Ceftriaxone and Vancomycin, and then spiked a
temperature to 101.3F with rigors, for which he received Tylenol
with good response. Given the pulmonary symptoms and recent
Chest CT scan, he also received Levofloxacin. UA was negative.
He was admitted to the ICU for further care.
In the MICU Mr. [**Known lastname **] had blood cultures done (which were
negative) and was started on Vancomycin/Ceftriaxone (Day 1
[**2160-7-10**]). Patient kept spiking fevers up to 102 F. Patient
had a repeat CXR that showed an infiltrate in the L lower lobe.
Patient received 3 L of NS to increase his SBP >90. THen
paitent's BP was stable for the next ~24 horus. Patient had a
TTE that ruled out endocarditis and was transfered to the
medical floor on [**Hospital Ward Name 121**] 2. SInce patient requiring 6-week course
of antibiotics it was decided not to pursue TEE, since it would
not change management.
On arrival to the floor patient spiked a Temp of 102. He was
given standing tylenol and IV fluids. Cultures were tried from
the portho-cath, but was no longer working. Cultures were taken
from the peripheral blood (negative) and fungal studies were
sent due to prior history of cadida sepsis and a cavitary lesion
in the lung. Surgery was consulted and the portho-cath was
removed later this day. Patient was afebrile the following day.
Cultures came back positive for S aureus, so ceftriaxone was
stopped.
On [**7-14**] a 3 lumen PICC line was placed. Patient was stable and
improving. However, beta-d-glucan came back at 412. Infectious
disease was consulted and suggested a repeat measurement to
check for trend and possible biopsy of the pulmonary lesion if
increasing. ID agreed with 6-week course of IV antibiotics due
to possible pulmonary septic emboli.
Patient was discharged home on Vancomycin and TPN. Follow up
with pulmonology, ID and GI were arranged. If patient's
galactomanan or beta-d-gluca increased patietn will require lung
biopsy as outpatient.
Medications on Admission:
- Cyanocobalamin 1000mcg/ml SC monthly (on the first of each
month)
- DTO 10-15gtt TID
- Warfarin 1mg daily
- Loperamide 2mg PO TID
- Iron [**Hospital1 **]
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed.
2. Opium Tincture 10 mg/mL Tincture Sig: Ten (10) Drop PO WITH
EVERY MEAL ().
3. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours) for 36 days.
Disp:*72 Piggybacks* Refills:*0*
4. Saline Flush 0.9 % Syringe Sig: One (1) Injection twice a
day for 36 days.
Disp:*72 Syringes* Refills:*0*
5. Saline Flush 0.9 % Syringe Sig: One (1) Injection three
times a day as needed for 36 days.
Disp:*36 Syringes* Refills:*2*
6. Heparin Flush 10 unit/mL Kit Sig: One (1) Intravenous twice
a day for 36 days.
Disp:*72 kits* Refills:*0*
7. Line care
Line care per protocol
8. Warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day.
9. Loperamide 2 mg Tablet Sig: One (1) Tablet PO three times a
day.
10. Cyanocobalamin 1,000 mcg/mL Solution Sig: One (1) Injection
once a month: SQ injection.
11. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO twice a day.
12. TPN
Please resume TPN as before
13. Laboratory values
Please take weekly CBC, Chem-7, LFTs, vancomycin trough and fax
to the Infectious Disease Clinic Attn Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 111**] at:
([**Telephone/Fax (1) 1353**]
Discharge Disposition:
Home With Service
Facility:
[**Last Name (un) 6438**]
Discharge Diagnosis:
Left portho-cath infection with possible pulmonary septic emboli
Discharge Condition:
Stable, breathing comfortably on room air.
Discharge Instructions:
You were seen at the [**Hospital1 18**] for fever and chills mostly after
using your portho-cath with an abnormal chest CT scan as
outpatient showing cavitary lesions in the left lower lobe. Your
WBC were slightly increased (normally go up with infection) and
your blood pressure was borderline. You received fluids,
antibiotics and were transfered to the ICU. Pulmonology was
consulted.
After being stable for almost 24 hours you were transfered to
the medicine floor. Surgery was consulted and they pulled your
left portho-cath. Your fevers and symptoms improved afterwards.
You were continued in antibiotics. You had multiple blood
cultures done, as well as other test for multiple infectious
agents including fungi, one blood cutlure from the ER was
positive for Staph aureus. You had an echocardiogram done, which
was negative for infection. We spoke with cardiology regarding
the posibility of doing another echocardiogram
(trans-esophageal) and they felt that it was not necessary.
Since you were afebrile and with negative blood cultures, we put
a PICC line for your TPN and antibiotics.
One of your fungal test was positive and infectious disease was
consutled. They recommended doing another test and follow up
closely.
You are being discharged home on antibiotics for at least 6
weeks. You are going to be followed by ID and pulmonology.
If you get fever, chills, rigors, the site of the PICC gets red,
painfull or anything that concerns you please call your PCP
[**Name Initial (PRE) 2227**].
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4465**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2160-8-1**] 9:20
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2160-8-11**] 4:00
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2160-8-11**] 3:40
Please follow up with your primary care as needed.
ID will follow laboratory values and get back to patient as
needed.
|
[
"415.12",
"E879.8",
"790.4",
"796.4",
"995.91",
"996.62",
"579.3",
"555.9",
"280.9",
"518.89",
"V44.2",
"038.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.05",
"38.93",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
10503, 10559
|
6777, 9011
|
378, 424
|
10667, 10712
|
3147, 3147
|
12265, 12798
|
2303, 2440
|
9218, 10480
|
10580, 10646
|
9037, 9195
|
10736, 12242
|
2455, 3128
|
4177, 6754
|
275, 340
|
452, 1524
|
3161, 4163
|
1546, 2088
|
2104, 2287
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,780
| 165,242
|
52097
|
Discharge summary
|
report
|
Admission Date: [**2175-1-16**] Discharge Date: [**2175-1-20**]
Service: MEDICINE
Allergies:
Penicillins / Vasotec
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Bradycardia
Major Surgical or Invasive Procedure:
Pacemaker Placement
History of Present Illness:
The pt is a 86y/o M with a PMH of biventricular CHF with EF 15%,
s/p CABG [**2167**] presenting with complete heart block.Recently
admitted [**Date range (1) 61817**] to BIDNH with dyspnea and was found to have
LLL PNA, treated with levaquin and azithromycin. He then
developed volume overload and was restarted on his home
diuretics. Of note, the patient declined a pacer placement.
Since discharge he reported feeling weak, not back to baseline
and with increased cough.The pt presented to BIDNH on [**2175-1-14**]
with complaints of weakness and CP. He was found to be in
complete heart block by EMS with HR 28 and BP 100 and was given
atropine en route to BIDNH ED. He became unresponsive in ED and
was intubated. Transcutaneous pacing started but he remained
hypotensive. Left SCL placed but no capture was obtained with
transvenous pacer. He was started on neosynephrien and dopamine
for hypotension. K 8.7 - hemolyzed and he was given calcium.
.
In the ED, initial vitals were HR: 80 [aced BP 144/47 RR 16
O2Sat: 92% RA. Patient received vancomycin 500mg IV, levaquin
750mg IV, Kayexelate 30g PR, Calcium gluconate 2gm IV, Insulin
10U IV and dextrose [**11-25**] amp for K of 6.1. Cardiology was called
and the patient had a transvenous pacer placed.
Past Medical History:
Biventricular Systolic Heart Failure EF 15-20% [**2174**]
Inferior myocardial infarction - [**2148**]
Cardiac History: CABG, in [**2168-1-9**] anatomy as follows: four
vessel coronary artery bypass graft was performed. LIMA to LAD,
SVG-diagonal, SVG - OM, SVG - PDA
Peptic ulcer disease.
History of diverticulitis
HTN
Hyperlipidemia
Mitral regurgitation/Aortic Stenosis
CKD
s/p transurethral resection of prostate
Social History:
Pt was widowed 2 years ago, has lived alone in [**Location (un) 620**] since and
was driving up until a few weeks ago. AFter first admission to
BIDN, he was discharged home with 24 hour non-skilled care and
was managing well with this help. Pt has 2 sone, one in Wash DC,
another in VT, who are very involved in patient's care and who
are concerned about his home situation after discharge. Pt has
been forgetful for a number of years but a formal dementia work
up has not been obtained per the son's knowledge. Pt is a
retired internist/cardiologist. Denies tobacco, occassional
EtOH.
Family History:
NC
Physical Exam:
Gen: WDWN elderly male, intubated and sedated
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple, no JVD
CV: RR, III/VI SM LUSB, No thrills, lifts.
Chest: No chest wall deformities, scoliosis or kyphosis. Clear
anteriorly, decreased BS L base, + bibasilar crackles
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: No femoral bruits. no LE edema b/l
.
Pulses:
Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Pertinent Results:
[**2175-1-20**]:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2175-1-20**] 07:10AM 5.9 3.41* 10.5* 30.8* 90 30.8 34.0 15.9*
141*
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2175-1-20**] 07:10AM 141*
[**2175-1-20**] 07:10AM 15.6* 29.0 1.4*
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2175-1-20**] 07:10AM 128* 76* 2.5* 139 4.3 100 30 13
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2175-1-20**] 07:10AM 9.0 3.7 2.3
negative urine cx [**1-18**], negative sputum cx x2.
Brief Hospital Course:
#. Complete Heart Block - The patient has a history of
brady/tachy physiology per outpatient cardiologist most recently
in slow atrial flutter at 3:1 AV block. He has previously
declined pacer placement. Now presenting with CHB, most likely
representing progression of his underlying conduction disease.
Patient is s/p permanent pacemaker now off all pressor support.
PPM set at a rate of 60 currently. Completed 3 days of
clindamycin. F/U appt in device clinic on [**1-24**]. Right pacer
dressing will be changed at that appt.
.
# Acute Respiratory failure: now resolved ?????? patient was
intubated in the setting of complete heart block episode. Major
initial barrier to extubation was patient??????s mental status.
Initially concern for possible pnuemonia given sputum production
however patient afebrile without elevated white count and
previous treated for pneumonia. Has had 2 sputum samples that
show oropharangeal flora only.
.
#. Acute on chronic Severe Biventricular Systolic Heart Failure
?????? patient maintained on Coreg and low dose lipitor. Coreg was
restarted at lower dose and [**Last Name (un) **] was started on day of discharge.
Lasix at 60 mg daily (home dose)
.
#. Pleural Effusion - no clear evidence of PNA on CXR, likely
pulmonary edema related to severe CHF, no elevated WBC or fever,
recently treated for PNA with levaquin/azithromycin. Repeat
post-extubation CXR seems stable, no evidence of infection.
.
#. CAD - s/p CABG (4Vd in [**2167**])- No evidence that acute ischemia
led to CHB. Troponins on admission mildly elevated but flat in
the setting of renal failure.
Continue aspirin, beta blocker and statin
.
#. CKD - Cr 3.2 on admission, history of CKD with Cr ranging
from 2.5-3. Cr improved today to 2.5. Avoid nephrotoxins and
check lytes on Monday [**1-23**].
.
# Acute Delerium on Chronic Dementia- patient with underlying
dementia as per his son. [**Name (NI) **] has never had a dementia workup and
drove his car until recently. He is alert, calm, but with very
poor short term memory at this time. Has not needed Haldol in 24
hours. Pt will require fall precautions. An appt with a
geriatrician is scheduled at the memory clinic at [**Hospital1 18**] for
evaluation.
Please avoid benzodiazepines and anti-cholinergic medications
.
# Hematuria: resulting from foley trauma, no evidence of
infection. Bright red this am with tiny clots. Bladder scanned
and showed 165cc after 6 hours. Flomax restarted. Consider
continuous Foley irrigation if hematuria worsens. Push PO's of
thickened liquids.
.
#. HTN ?????? chronic. Well controlled on carvedilol and Losartan.
.
#. Hyperlipidemia - continue statin
.
#. Dysphagia: chronic cough concerning for silent aspiration.
Speech and swallow evaluation recommended ground solids with
nectar thick liquid, medications whole.
.
#. Uticaria: pt has macular red rash on lower back, thought to
be contact dermatitis. [**Name2 (NI) 6398**] lotion has been used successfully
for pruritis.
.
#. Disposition: Pt has 24 hour care at home, only set up in the
last week. Pt will need home safety evaluation by PT/OT to
assess level of care needed after discharge.
Medications on Admission:
Coreg 12.5mg [**Hospital1 **]
Centrum
Ecotrin 81mg daily
Allopurinol 100mg daily
Lasix 60mg daily
Lipitor 10mg daily
Metolazone 2.5mg every other day
Flomax 0.4mg daily
Potassium 10meq daily
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Multivitamins Tablet, Chewable Sig: One (1) Tablet PO
DAILY (Daily).
4. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**11-25**] Sprays Nasal
QID (4 times a day).
7. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
8. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
9. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Ten
(10) ML PO Q6H (every 6 hours) as needed.
10. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Complete Heart Block
Acute on Chronic Congestive Heart Failure
Pneumonia
Acute Renal Failure
Uticaria
Discharge Condition:
stable.
Discharge Instructions:
You had complete heart block with a heart rate of 20 and became
unresponsive on [**1-16**] requiring intubation and pacemaker
placement. You were on pressors to increase your blood pressure
for a few days but your blood pressure is normal now. All of
your culture results are negative to date. Because of your new
pacemaker, you cannot lift more than 10 pounds for 6 weeks and
should refrain from lifting your left arm over your head for 6
weeks. You will come back to the device clinic here at [**Hospital1 18**]
next Tuesday to get your pacer checked and the dressing removed
over the pacer site.
New medicines:
1. Your carvedilol was decreased to 6.25 mg twice daily
2. You were started on Losartan to decrease your blood pressure\
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs in 1 day
or 6 pounds in 3 days.
Adhere to 2 gm sodium diet
.
Please call provider if there is any increased bruising or
bleeding around the pacer site, if you have any fevers,
increased coughing, dizziness or chest pain.
Followup Instructions:
Cardiology:
DEVICE CLINIC [**Hospital Ward Name 23**] Clinical Center, [**Location (un) **], [**Location (un) **] [**Location (un) 86**]. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2175-1-24**] 9:00am
.
Primary care and Cardiology:
Dr. [**Last Name (STitle) 29111**] [**Name (STitle) 11302**] Phone: ([**Telephone/Fax (1) 107816**] Date/Time: Tuesday
[**2-7**] at 11:15am
Gerontology/Memory clinic: [**Hospital Unit Name **], [**Hospital Unit Name **] [**Last Name (NamePattern1) 8028**], [**Location (un) 86**]
Provider: [**First Name8 (NamePattern2) 1439**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 719**] Date/Time: [**2-2**] at 11am.
Completed by:[**2175-1-20**]
|
[
"787.20",
"412",
"486",
"E928.9",
"533.90",
"518.81",
"585.9",
"403.90",
"396.2",
"562.10",
"428.23",
"293.0",
"272.4",
"V45.81",
"428.0",
"708.0",
"867.0",
"426.0",
"414.8",
"599.70",
"427.32",
"V45.77",
"276.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.83",
"37.72",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
8310, 8382
|
3840, 6977
|
240, 262
|
8528, 8538
|
3230, 3817
|
9617, 10312
|
2608, 2612
|
7219, 8287
|
8403, 8507
|
7003, 7196
|
8562, 9594
|
2627, 3211
|
189, 202
|
290, 1550
|
1572, 1988
|
2004, 2591
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,362
| 117,787
|
1651
|
Discharge summary
|
report
|
Admission Date: [**2175-3-7**] Discharge Date: [**2175-3-19**]
Date of Birth: [**2111-11-23**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9554**]
Chief Complaint:
DOE
Major Surgical or Invasive Procedure:
none
History of Present Illness:
63 yo woman with CAD s/p CABG [**3-/2164**] (LIMA->LAD, SVG->D1,
SVG->PDA), CHF secondary to diastolic dysfunction, CRI=1.7,
anemia admitted for CHF management and ultrafiltration.
Past Medical History:
1. Hypertension.
2. Diabetes mellitus with last hemoglobin A1C of 8.7 in
12/[**2172**].
3. Chronic renal insufficiency baseline creat 1.7-2.0 .
4. Coronary artery disease status post coronary artery
bypass graft in [**2163**] (LIMA to LAD, SVG to D1 and PDCA), last
cath [**3-/2164**] with elev R and L filling pressures, PTCA of RCA and 2
VD; last ETT-MIBI [**6-22**] 6 min on [**Doctor Last Name 4001**] protocol, no reversible
defects.
5. Hypothyroidism.
6. Depression.
7. Osteoarthritis.
8. Hyperlipidemia.
9. CHF with EF 45-50% on last echo [**10-21**], mild LV systolic
dysfunction, mildly depressed LV function, inf and mid inf HK,
mild 1+MR.
10. Anemia - unclear etiology; baseline Hct 29-31, last iron
studies nl [**7-22**]; per pt, has never had EGD or colonoscopy
Social History:
SH: lives with her boyfriend at home, retired; previous tob user
2ppdx20 yrs, quit [**2155**]; no ETOH
Family History:
FH: sig for father who deceased in his 50s from cirrhosis
secondary to alcoholism; 1 brother deceased from MI in his 40s;
other brother who died of lymphoma in his 50s
Physical Exam:
98.6 56 150/70 18 96% RA
Gen: in NAD
HEENT: MMM, OP clear.
CV: RRR, + SEM at RUSB.
Lungs: + slight crackles at bases L>R.
Abd: S/NT/ND, +BS.
Ext: + chronic changes from edema, 2+ pitting edema B with
erythema.
Neuro: A&Ox3.
Pertinent Results:
[**2175-3-7**] 10:45PM URINE HOURS-RANDOM TOT PROT-33
[**2175-3-7**] 10:45PM URINE U-PEP-MULTIPLE P IFE-NO MONOCLO
[**2175-3-7**] 10:45PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2175-3-7**] 10:45PM URINE BLOOD-NEG NITRITE-POS PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-TR
[**2175-3-7**] 10:00PM PTT-78.4*
[**2175-3-7**] 03:20PM GLUCOSE-172* UREA N-69* CREAT-2.1* SODIUM-140
POTASSIUM-4.8 CHLORIDE-111* TOTAL CO2-22 ANION GAP-12
[**2175-3-7**] 03:20PM ALT(SGPT)-68* AST(SGOT)-39 LD(LDH)-247 ALK
PHOS-76 TOT BILI-0.6
[**2175-3-7**] 03:20PM proBNP-[**Numeric Identifier 9555**]*
[**2175-3-7**] 03:20PM TOT PROT-6.8 ALBUMIN-4.2 GLOBULIN-2.6
CALCIUM-9.0 PHOSPHATE-3.8 MAGNESIUM-2.0 IRON-57
[**2175-3-7**] 03:20PM calTIBC-322 FERRITIN-122 TRF-248
[**2175-3-7**] 03:20PM [**Doctor First Name **]-POSITIVE TITER-1:320
[**2175-3-7**] 03:20PM TSH-0.13*
[**2175-3-7**] 03:20PM [**Doctor First Name **]-POSITIVE TITER-1:320
[**2175-3-7**] 03:20PM PEP-NO SPECIFI
[**2175-3-7**] 03:20PM WBC-5.2 RBC-3.56* HGB-10.6* HCT-32.6* MCV-92
MCH-29.8 MCHC-32.5 RDW-16.9*
[**2175-3-7**] 03:20PM NEUTS-75.5* LYMPHS-16.1* MONOS-5.4 EOS-2.7
BASOS-0.3
[**2175-3-7**] 03:20PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-1+
[**2175-3-7**] 03:20PM PLT COUNT-159
[**2175-3-7**] 03:20PM PT-13.9* PTT-28.7 INR(PT)-1.2
MRA ABD: 1. No evidence of significant renal artery stenosis.
Small amount of atherosclerotic plaque within the proximal left
renal artery ( <50% narrowing).
2. Poor corticomedullary differentiation of both kidneys, on
pre-contrast sequences, suggest of chronic renal parenchymal
disease. Clinical correlation is recommended.
Brief Hospital Course:
# Cardiac:
a) pump/CHF: Pt came in with sig vol overload (JVD to angle jaw,
3+ LE pitting edema). Pt was entered in the UNLOAD trial and was
randomized to Ultrafiltration (UF). Over 2 days ~17 L of fluid
was taken off, at 500 cc/hour. Lasix was held while on UF, and
actos was d/c'd (can lead to retention of fluid). However, after
2 days the pt's Cr [**Known firstname **] and UF was stopped. Afterwards, no
further diuresis was attempted and the pt was fluid restricted
while Cr recovered. On [**3-18**] restarted lasix at low doses 20 [**Hospital1 **]
(previously had been 80 tid at home).
Weights: [**3-8**] 129.6 on initiation
.....[**3-9**] 118.9 am
.....[**3-12**] 115.2
.....[**3-15**] 116
.....[**3-18**] 114.8 before discharge.
.
b) CAD- h/o CAD s/p CABG. Pt was continued on a Statin, beta
blocker, and ASA was started.
.
c) Hypertension: On admission to the CCU pt's atenolol was
changed to Toprol XL 50. d/c'd hydralazine and Imdur, started
norvasc 5 qd initially. Continued valsartan at 80 qday and
clonidine patch was weaned off. As ultrafiltration removed a
great deal of fluid, the pt's BP decreased significantly and as
ARF ensued, her BP meds were taken off and ultrafiltration was
stopped. By [**3-15**], she was having hypertension during the night
so her toprol was increased to toprol 25mg [**Hospital1 **] for more
even-action throughout the day. BP meds were added back on as
kidney function improved and on [**3-18**] valsartan 40 was added back
and lasix was restarted at low dose. Her BP remained high and so
Isosorbide Dinitrate 20 mg TID was started as well as
Hydralazine 50 mg TID. Lasix was titrated up to 40mg daily.
These will be adjusted further as an outpatient.
.
d) Rhythm- Sinus. On tele.
.
# Renal failure: baseline Cr is 1.8-2.0. Creatinine [**Known firstname **] with
ultrafiltration to as high as 4.0 on [**3-13**]. This was likely due
to over-diuresis with the ultrafiltration leading to volume
depletion and pre-renal renal failure. Her antihypertensive
regimen was also down-titrated as her BP droped with rapid
volume correction. Urine lytes were consistent with ATN. Urine
eosinophils were negative. MRA look for renal artery stenosis
was positive for plaque but radiology did not feel this would be
physiologically signficant. The pt's creatinine trended down to
baseline with time and on discharge it was 2.1. She was
restarted on the [**Last Name (un) **] and lasix which will be adjusted as an
outpatient.
.
# Anemia: Hct dropped from 32.6 on admission to 27 after
admission. Iron (iron 57, ferritin 122), B12 ok. epo level was
high-normal. Thus, her anemia was felt to be likely anemia of
chronic disease. On [**3-14**], she was transfused 1 u PRBC. Hct
bumped to only 29.8. Stool was guiac negative. Subsequently,
however, her Hct improved without further transfusion and on
discharge Hct was 31.2.
.
# Endocrine: History of type II diabetes mellitus and
hypothyroidism. Her admission TSH was 0.13 (on levothyroxine
175) and HgbA1c 6.2. Levoxyl was decreased back to 150mcg.
Actose was held and pt was maintained on Lantus and Humalog.
.
# Depression: pt was felt to have a depressed affect and was
started on Celexa in house. Her mood improved slightly near her
discharge.
Discharge Medications:
1. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain,fever.
3. 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:*1*
4. Levothyroxine Sodium 150 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. White Petrolatum-Mineral Oil Cream Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day) as needed.
6. Citalopram Hydrobromide 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Isosorbide Dinitrate 20 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
8. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO BID (2 times a day).
Disp:*60 Tablet Sustained Release 24HR(s)* Refills:*2*
9. Hydralazine HCl 50 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*2*
10. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
12. Insulin Glargine 100 unit/mL Solution Sig: Twenty Six (26)
units Subcutaneous once a day.
Disp:*1 month supply* Refills:*0*
13. Humalog 100 unit/mL Solution Sig: per scale Subcutaneous
three times a day.
Disp:*1 month supply* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Congestive heart failure
type II diabetes mellitus
acute on chronic renal failure
Coronary artery disease s/p CABG
Discharge Condition:
Stable, afebrile.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1.5L
Please take your medications as directed.
Followup Instructions:
1) Provider: [**Name10 (NameIs) 1576**],[**Name11 (NameIs) 9119**] [**Name12 (NameIs) 9120**] MEDICINE (PRIVATE)
Where: ADULT MEDICINE UNIT [**Hospital3 **] HEALTHCARE - 1000
[**Location (un) **] - [**Location (un) 2352**], [**Numeric Identifier 9121**] Phone:[**Pager number **] Date/Time:[**2175-4-13**]
10:30
2) Please see Dr. [**Last Name (STitle) **] in [**11-20**] weeks for followup. You will be
called with an appointment. If you do not get called in [**11-20**]
days, please call [**Telephone/Fax (1) 3512**] to arrange an appointment.
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2139**]
|
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icd9cm
|
[
[
[]
]
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[
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[
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[]
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,959
| 167,558
|
30647
|
Discharge summary
|
report
|
Admission Date: [**2117-1-31**] Discharge Date: [**2117-2-18**]
Date of Birth: [**2068-6-22**] Sex: M
Service: MEDICINE
Allergies:
Cefepime
Attending:[**Last Name (NamePattern1) 4377**]
Chief Complaint:
Facial Swelling
Major Surgical or Invasive Procedure:
[**2117-1-31**] Thrombolysis of [**Month/Day/Year 17911**] clot via placement of thrombolysis
catheter into the internal jugular vein and the superior [**Month/Day/Year 17911**]
.
Right subclavian central venous line placed on [**2117-2-2**]; removed
on [**2117-2-18**].
.
[**2117-2-2**] Removal of Hickman catheter
.
[**2117-2-12**] Bronchoscopy and thoracocentesis
History of Present Illness:
A 48-year-old gentleman with a history of AML-M5B status post
matched unrelated allogeneic stem cell transplant with
Cytoxan/TBI conditioning on [**2116-8-25**] presenting with facial
swelling. The patient reports that he first noted the bilateral
facial and neck swelling yesterday morning. However his parents
have noticed mild swelling even on the day prior. Today in the
morning the patient noted worsening swelling also now involving
the L arm. He also noticed problems swallowing and felt that he
could not get his saliva down. He denies any problems breathing
at rest, but noticed shortness of breath with ambulation. On his
way to clinic this morning he felt LH and was trying to sit down
but then LOC and fell on his L side. When he recovered
consciousness he was trying to get up again but then lost
consciusness again falling forward onto his L face. He thinks
that he lost consciousness for several minutes. He also reports
that he has had HA and "sinus congestion" since yesterday, worse
when leaning forward. He reports a cough, worse in the morning
which preceeded the current symptoms. He was seen in clinic
4days prior and was started on Azithromycin.
.
Of note, he had his tunnelled catheter removed from his L IVC on
[**1-20**] and had one placed on the right.
.
ED COURSE: VS 97.3, 91, BP 115/88, RR 16, O2Sat 99RA. A CXR was
done, that showed no acute cardiopulmonary process. He received
600mg of Tylenol. An EKG was done unchanged from prior. He was
discharged from ED with likely allergic reaction.
.
He was seen again in Heme/[**Hospital **] clinic and was admitted to floor
for concern of [**Hospital 17911**] syndrome. IR was [**Name (NI) 653**], and [**Name2 (NI) **] underwent
CT imaging of head and chest. Bleeding/fracture was ruled out.
[**Name2 (NI) 17911**] clot was seen, and he was started on TPA gtt.
Sent to ICU for TPA/heparin treatment overnight.
.
ROS: negative for CP, SOB, abdominal pain, diarrhea,
constipation, f/c/ns, weight loss, dysuria, changes in the color
of the urine or stool.
.
Onc Hx:
Mr. [**Known lastname 72663**] is a 48-year-old gentleman who was diagnosed with
AML-M5B in [**4-/2116**] when he was admitted with a white blood count
of 200,000, requiring leukophoresis. He underwent 7 and 3
induction chemotherapy and achieved a complete remission,
although his course was complicated by diffuse pulmonary
hemorrhage. High-dose ARA-C was
administered with recovery of his counts. He also received a
dose of intrathecal ARA-C. He developed hepatic candidiasis
which was treated successfully with oral Diflucan, which delayed
his allogeneic stem cell transplant, but then he underwent
matched unrelated allogeneic stem cell transplant with Cytoxan
and TBI conditioning on [**2116-8-25**]. He did relatively well
post-transplant until [**10/2116**] when he developed left upper lobe
and bilateral opacities with he underwent BLL, which was
nondiagnostic and then proceeded to VATS biopsy with a diagnosis
of acute and organizing pneumonia. He had no other infectious
etiology found and he was begun on a prednisone for presumed
idiopathic BOOP and this has been tapered slowly over time. On
[**2116-12-31**], Mr. [**Known lastname 72663**] developed increasing cough, sore
throat
with yellow sputum. With worsening symptoms he was admitted on
[**2117-1-1**]. CT scan showed new right upper lobe hazy infiltrate
and nasal aspirate was positive for RSV. He was given a dose of
palivizumab and was treated with a course of levofloxacin.
Past Medical History:
* AML M5b dx [**4-14**]
--s/p induction with 7+3, HiDAC x1, and intrathecal araC
--s/p URD alloBMT [**2116-8-25**]
--participated in maribivir trial
* Pulmonary infiltrates, followed in pulmonary clinic
--s/p BAL [**2116-10-23**] and VATs [**2116-11-3**] with bx c/w organizing
pneumonitis although infection could not be excluded. All
cultures including myocobacterial, nocardia, PCP, [**Name10 (NameIs) 1065**], viral,
and legionella were negative
--tapering off of steroids currently on 15mg daily
* Diffuse pulmonary hemorrhage
* Hepatic candidiasis confirmed on biopsy
* Hypercholesterolemia
* Hypertension
Social History:
Works as estimator for construction industry -- occasional dust
exposures when visiting sites. Usually lives with his daugher,
has 2 daughters in their 20s, currently living with his parents.
He quit smoking 6 years ago (smoked about 12 years total on and
off), drinks alcohol episodically.
Has lived in [**Location (un) 5503**] area exclusively. No recent travel. No
pets. No known TB exposures.
Family History:
Non-contributory
He has 3 sisters who are healthy and no history of cancer in his
family.
Physical Exam:
T:99.8 BP:126/78 P:109 RR:28 O2 sats: 95% RA
Gen: NAD
HEENT: PERRL, EOMI, laceration on left eye (healing), no notable
edema of face and neck
CV: RRR no MRG, nl S1, S2
Resp: mild rhonchi/crackles bilaterally; no wheezing
Abd: NABS, soft, NTND, no guarding/rigidity/rebound
Back: no CVA tenderness
Ext: BUE with tense edema; BLE no c/c/e, 2+/4 symmetric pedal
pulses
Neuro: CN 2-12 intact, 5/5 strength bilaterally, Reflexes were
2+ bilaterally, Sensation was intact bilaterally
Pertinent Results:
ADMISSION LABORATORIES:
[**2117-1-31**] WBC-12.3 (DIFF: NEUTS-89.4 LYMPHS-6.0 MONOS-3.4 EOS-1.1
BASOS-0.2) HGB-10.1 HCT-29.5 PLT COUNT-308
[**2117-1-31**] SODIUM-137 POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-23 UREA
N-17 CREAT-0.8 GLUCOSE-131
[**2117-1-31**] PT-12.2 PTT-21.2 INR(PT)-1.0
[**2117-1-31**] CYCLSPRN-167
[**2117-1-31**] FIBRINOGE-327
.
OTHER LABORATORIES
[**2117-2-10**] 12:00AM BLOOD Gran Ct-5730
[**2117-2-10**] 05:01PM BLOOD TSH-0.51
[**2117-2-10**] 05:01PM BLOOD RheuFac-<3 CRP-7.2
[**2117-2-10**] 05:01PM BLOOD [**Doctor First Name **]-NEGATIVE dsDNA-NEGATIVE
[**2117-2-14**] Fibrino-676
[**2117-2-16**] Gran Ct-8070
[**2117-2-17**] 09:30PM BLOOD LMWH-0.62
.
.
VANCOMYCIN LEVELS
[**2117-2-12**] 06:00AM BLOOD Vanco-5.0
[**2117-2-14**] 07:00AM BLOOD Vanco-9.0
[**2117-2-15**] 07:22PM BLOOD Vanco-46.1
[**2117-2-16**] 06:05AM BLOOD Vanco-54.5
[**2117-2-17**] 12:10AM BLOOD Vanco-28.4
.
HYPERCOAGULABILITY WORKUP [**2117-2-10**]
Prothrombin Mutation: No Mutation Detected
Factor V: Q506 Mut. (FV Leiden) No Mutation Detected
BLOOD AT III-84
.
DISCHARGE LABORATORIES
[**2117-2-18**] Na-134 K-4.0 Cl-100 HCO3-24 UreaN-22 Creat-1.3
Glucose-82 Calcium-9.4 Mg-1.6 Phos-4.7
[**2117-2-18**] WBC-8.8 (DIFF: Neuts-77.4 Lymphs-12.1 Monos-8.9 Eos-1.3
Baso-0.3)Hgb-9.3 Hct-27.4 Plt Ct-304
[**2117-2-18**] PT-12.6 PTT-24.9 INR(PT)-1.1
[**2117-2-18**] ALT-16 AST-21 LD(LDH)-199 AlkPhos-193 TotBili-0.5
Albumin-3.3
UricAcd-3.9
.
MICROBIOLOGY
EBV genomes/10(5) lymphocytes
B-D-Glucans <31 pg/ml (NEGATIVE)
[**2117-2-10**] Immunology (CMV) CMV Viral Load-CMV DNA not detected
[**2117-2-10**] SEROLOGY/BLOOD CRYPTOCOCCAL ANTIGEN-negative
.
CULTURE DATA
BLOOD
-[**2117-2-1**] BLOOD CULTURE- No growth
-[**2117-2-2**] BLOOD CULTURE- No growth
-[**2117-2-17**] CATHETER TIP-IV NEGATIVE
.
URINE
-[**2117-2-10**] URINE Legionella Urinary Antigen -Negative
-[**2117-2-10**] URINE CULTURE-No growth
-[**2117-2-16**] URINE CULTURE-NEGATIVE
.
**********
BODY FLUID
**********
-[**2117-2-12**] PLEURAL FLUID
*GRAM STAIN: 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES. NO MICROORGANISMS SEEN.
*FLUID CULTURE: NO GROWTH.
*ANAEROBIC CULTURE: NO GROWTH.
*[**Year/Month/Day **] CULTURE: NO FUNGUS ISOLATED.
*ACID FAST SMEAR: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
*VIRAL CULTURE: NO VIRUS ISOLATED.
-[**2117-2-12**] 9:02 am BRONCHOALVEOLAR LAVAGE BRONCHOALVEOLAR
LAVAGE.
*GRAM STAIN
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN
PAIRS.
*RESPIRATORY CULTURE: 10,000-100,000 ORGANISMS/ML. OROPHARYNGEAL
FLORA.
*LEGIONELLA CULTURE: NO LEGIONELLA ISOLATED.
*Immunoflourescent test for Pneumocystis jirovecii (carinii):
NEGATIVE for Pneumocystis jirvovecii (carinii).
*[**Year/Month/Day **] CULTURE: NO FUNGUS ISOLATED.
*ACID FAST SMEAR: NO ACID FAST BACILLI SEEN ON CONCENTRATED
SMEAR.
*ACID FAST CULTURE: NO MYCOBACTERIA ISOLATED.
*NOCARDIA CULTURE: NO NOCARDIA ISOLATED.
**********
NASAL SWAB
**********
-[**2117-2-12**] Rapid Respiratory Viral Screen & Culture -NEGATIVE
******
SPUTUM
******
[**2117-2-9**] SPUTUM INDUCED
NOCARDIA & LEGIONELLA CULTURE
GRAM STAIN: <10 PMNs and <10 epithelial cells/100X field. 1+
(<1 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS. QUALITY OF
SPECIMEN CANNOT BE ASSESSED.
-RESPIRATORY CULTURE: MODERATE GROWTH OROPHARYNGEAL FLORA.
-Immunoflourescent test for Pneumocystis jirovecii (carinii):
NEGATIVE for Pneumocystis jirvovecii (carinii).
-[**Year/Month/Day **] CULTURE: NO FUNGUS ISOLATED. ACID FAST SMEAR: NO ACID
FAST BACILLI SEEN ON CONCENTRATED SMEAR.
-ACID FAST CULTURE: NO MYCOBACTERIA ISOLATED.
-LEGIONELLA CULTURE: NO LEGIONELLA ISOLATED.
-NOCARDIA CULTURE: NO NOCARDIA FOUND.
.
*********
RADIOLOGY
*********
Admission CXR [**2116-2-1**]: A right-sided subclavian catheter is
detected with tip in the proximal-to-mid [**Month/Day/Year 17911**]. No focal
consolidation is identified within the lungs. The
cardiomediastinal silhouette is stable in appearance. Calcified
bibasilar pleural plaques are consistent with previous asbestos
exposure.
.
CTA Chest [**2117-1-31**]
1. Large nearly occlusive thrombus within the [**Month/Day/Year 17911**] with small
offshoot into the left brachiocephalic vein consistent with
clinical picture of [**Month/Day/Year 17911**] syndrome and left arm swelling.
Findings were discussed personally with Dr. [**First Name (STitle) **] and the
interventional radiology team.
2. New bilateral left greater than right pleural effusions with
associated passive atelectasis.
3. Increased size of small pericardial effusion.
4. New axillary and anterior chest wall subcutaneous edema.
5. Calcified basilar pleural plaques associated reticulation,
indicating prior asbestos exposure.
6. Fatty atrophy of the pancreas.
.
ECHO [**2117-2-1**]
The left atrium is dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is
unusually small. Due to suboptimal technical quality, a focal
wall motion abnormality cannot be fully excluded. 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. There is no
ventricular septal defect. The number of aortic valve leaflets
cannot be determined. The aortic valve leaflets are mildly
thickened. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are not well
seen. There is mild pulmonary artery systolic hypertension.
There is a small pericardial effusion. The effusion appears
circumferential. There are no echocardiographic signs of
tamponade. IMPRESSION: Small left ventricular cavity with
hyperdynamic function and a mild resting gradient. Small
pericardial effusion without tamponade physiology. Mild
pulmonary artery hypertension. Compared with the prior study
(images reviewed) of [**2116-9-17**], the patient is now tachycardic,
the left ventricular cavity appears small and systolic function
is hyperdynamic. As a result, there is a mild resting outflow
tract gradient that increases with Valsalva. There is a small
pericardial effusion.
.
EKG [**2117-2-1**]
Sinus tachycardia. Low QRS voltage in the limb leads. Delayed R
wave
progression across the anterior precordial leads. Compared to
the previous tracing of [**2117-1-31**] the ventricular rate is faster.
Rate 108, PR 138, QRS 88, QT/QTc 336/420, P 73, QRS 22, T 68
.
PTA VENOUS Study Date of [**2117-2-2**]
PROCEDURE NAME: [**Date Range 17911**] venogram and PTA [**Date Range 17911**] stenosis.
A 36-hour followup TPA infusion [**Date Range 17911**] venogram was obtained with
injection of contrast through the indwelling 5 French vascular
sheath, which demonstrated further partial interval clearance of
thrombosis in upper [**Date Range 17911**], and a tight severe focal mid-[**Date Range 17911**]
stenosis.
The patient's right neck including indwelling vascular sheath
was prepped and draped in standard sterile fashion. Indwelling
5 French vascular sheath was exchanged for an 8 French vascular
sheath. Balloon dilatation was performed at segment of [**Date Range 17911**]
stenosis with 12 mm x 4 cm and 14 mm x 4 cm balloon catheters.
Followup venogram after balloon dilatation demonstrated
segmental stricture at mid [**Date Range 17911**] and thrombus in upper [**Date Range 17911**] with
multiple collateral veins. Balloon dilatation was then performed
with an 18 mm x 4 cm balloon catheter.
Followup venogram after balloon dilatation demonstrated much
interval
improvement of [**Date Range 17911**] stenosis and disappearance of collateral
veins and small residual thrombus in upper [**Date Range 17911**]. 8 French
vascular sheath was removed and an 7 French triple-lumen central
venous catheter was advanced over the wire with its tip
positioned at distal [**Date Range 17911**]/RA junction. Tunneled part of previous
right IJ Hickman catheter was removed uneventfully.
****IMPRESSION: Significant improvement in [**Date Range 17911**] stenosis and
thrombosis s/p TPA infusion and [**Name (NI) 17911**] PTA.
****RECOMMENDATION: Full anticoagulation with IV heparin and
warfarin for 3-6 months.
.
[**2117-2-5**] TRANSTHORACIC ECHO:
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity is small. Left ventricular systolic function
is hyperdynamic (EF 70-80%). The right ventricular cavity is
small. There is a small to moderate sized pericardial effusion.
The effusion appears circumferential. There is brief right
atrial diastolic invagination. There is also mild diastolic
invagination of the apical portion of the right ventricular free
wall. There is significant, accentuated respiratory variation in
tricuspid (but not mitral) valve inflow, consistent with
impaired ventricular filling.
Compared with the findings of the prior study (images reviewed)
of [**2117-2-4**], the pericardial effusion is similar in
size. However, abnormal repirophasic variation of right
venrticular inflow, and mild apical right ventricular diastolic
invagination, are now present, consistent with early cardiac
tamponade.
.
CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2117-2-7**]
FINDINGS: There is a large filling defect within the right main
pulmonary artery, at its bifurcation, consistent with pulmonary
embolus. Pulmonary emboli are also seen in several of the
segmental branches to the right middle and right lower lobe.
There are equivocal tiny filling defects in several of the
subsegmental pulmonary arteries in the left lower lobe.
There are large bilateral pleural effusions, and associated
minor bibasilar atelectasis. There is a small-to-moderate
pericardial effusion. In the upper lobes bilaterally, in a
predominantly bronchovascular distribution, there is new
airspace opacity and bronchial wall thickening, right greater
than left. Central bronchi are patent to the subsegmental
level. Previously noted thrombus within the upper [**Year/Month/Day 17911**] is more
difficult to evaluate on today's exam due to timing of contrast
bolus, but is probably still present, although it appears
slightly decreased in size, now occluding approximately half the
vessel lumen at the level of the top of the aortic arch (3, 33).
There are scattered small mediastinal and bilateral axillary
lymph nodes. Visualized portions of the upper abdomen are
unremarkable. Osseous structures are unremarkable.
IMPRESSION:
1. Pulmonary embolism in the right main pulmonary artery at the
bifurcation, with several smaller segmental pulmonary emboli on
the right, and possible small subsegmental pulmonary emboli on
the left.
2. Large bilateral pleural effusions, increased from prior exam.
Small-to- moderate pericardial effusion.
3. New [**Hospital1 **]-apical centrilobular airspace opacity and bronchial
wall thickening, right greater than left, concerning for
infectious pneumonia, less likely representing aspiration or
pulmonary edema.
4. Likely slight decrease in extent of partially occlusive
thrombus in the upper [**Hospital1 17911**], although timing of contrast bolus in
this study is suboptimal for evaluation of this region.
5. Unchanged appearance of calcified pleural plaques, consistent
with history of asbestos exposure.
.
[**2117-2-15**] TRANSTHORACIC ECHO
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%) Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis. Trace aortic regurgitation is
seen. The mitral valve leaflets are structurally normal. There
is no mitral valve prolapse. No mitral regurgitation is seen.
The estimated pulmonary artery systolic pressure is normal.
There is a small pericardial effusion. The effusion appears
circumferential. Where it is adjacent to the basal right
ventricle, the effusion is echo dense consistent with blood,
inflammation or other cellular elements. There are no
echocardiographic signs of tamponade. No right atrial diastolic
collapse is seen. No right ventricular diastolic collapse is
seen. Compared with the prior study (images reviewed) of
[**2117-2-10**], the effusion is slightly smaller.
.
[**2117-2-16**] CT CHEST WITHOUT CONTRAST
1. Improving but not completely resolved ground-glass opacities
in both lungs but predominantly at the lung apices indicate a
resolving pulmonary edema and/or pneumonia. The abnormality can
be visualized on a chest x-ray and so if the patient's clinical
symptoms are stable or are actually improving then follow up by
chest radiograph can be performed.
2. Considerable decrease in the pleural and pericardial
effusion.
.
*********
PATHOLOGY
*********
[**2117-2-12**] BAL- Negative for malignant cells.Reactive bronchial
cells and abundant pulmonary macrophages. No viral cytopathic
effects seen.
.
[**2117-2-12**] PLEURAL FLUID: NEGATIVE FOR MALIGNANT CELLS. Reactive
mesothelial cells and inflammatory cells. FLOW CYTOMETRY: Three
color gating is performed (light scatter vs. CD45) to optimize
blast and lymphocyte yield. B cells comprise ~1% of
lymphoid-gated events, are polyclonal, and do not express
aberrant antigens. T cells comprise ~90% of lymphoid gated
events and express mature lineage antigens (CD2, 3, 5, and 7).
No abnormal events are identified in the "blast gate."
INTERPRETATION: Non-specific T cell dominant lymphoid profile;
diagnostic immunophenotypic features of involvement by leukemia
or lymphoma are not seen in specimen.
Brief Hospital Course:
# [**Year/Month/Day 17911**] syndrome:
The patient had a history of AML and presented five months
following his matched unrelated allogeneic transplant with
evidence of [**Year/Month/Day 17911**] syndrome (an edematous face and bilateral upper
extremities). In the ED, he was stable, BP 115/88, HR 91, RR
16, O2Sat 99RA. EKG was done unchanged from prior. On the day
of admission, [**2117-1-31**], he underwent IR-guided [**Month/Day/Year 17911**] clot
thrombolysis and venous ballon stenting. The [**Month/Day/Year 17911**] clot likely
formed in the context of a foreign body (portocath) in [**Month/Day/Year 17911**]. (Of
note, the patient had this portocath was placed on [**2117-1-20**],
approximately 1.5 weeks prior to presentation). The right
subclavian Hickmann portocath was removed subsequently on
[**2117-2-2**]. He was then started on the heparin drip.
.
In the [**Hospital Unit Name 153**], he was also noted to have a new, small pericardial
effusion, unclear etiology likely related to [**Name (NI) 17911**] syndrome. He
was also thought to possibly have a thoracic duct obstruction
versus PE as well. Pulsus paradoxicus was consistently 8 mmHg
prior to transfer to the [**Name (NI) 3242**] unit; EKG was without alternans and
ECHO was without evidence of tampondade. He consistently had
sinus tachycardia in the unit and was felt to be intravascularly
dry though fluids were net positive in the unit. He received
several boluses in the unit with limited benefit. Also, with
the tachycardia and known [**Name (NI) 17911**] clot, there was concern for PE in
setting of [**Name (NI) 17911**] clot. CTA for PE was not repeated as long-term
management would not change, i.e. he is already on the heparin
ggt for [**Name (NI) 17911**] syndrome.
.
He was continued on the heparin drip until discharge. Coumadin
was begun after the final procedure
(bronchoscopy/thoracocentesis). He was discharged on a lovenox
bridge to coumadin. He will require longterm anticoagulation
for 3-6 months for [**Name (NI) 17911**] syndrome.
.
# Pulmonary embolism
CTA showed large right mainstem pulmonary embolism, likely the
cause of tachycardia and dyspnea. The patient also had several
small PEs bilaterally. For a HCT 25, he was tranfused 1 unit
pRBCs, and tachycardia improved 120s-->100. However, he
remained SOB with ambulation. It was unclear if PE is related
to malignancy as he is in remission for AML. It was also unclear
if the pulmonary emboli were associated with the initial clot
burden or if they were related to the lysis procedure in [**Name (NI) 17911**] and
downstream propogation. As mentioned above for [**Name (NI) 17911**] clot, the
patient will need a [**2-11**] month duration of anticoagulation.
Respiratory rate remained stable at approximately 24 and patient
has stable dyspnea on exertion but no hemodynamic compromise or
right ventricular dilation or strain.
.
# Pericardial effusion:
An ECHO on [**2-4**] revealed a small to moderate pericardial
effusion with Right atrial invagination during diastole however
no RV collapse, again a hyperdynamic LV. The patient was
transferred from the [**Month/Year (2) 3242**] service to [**Hospital Unit Name 196**] ([**Hospital1 1516**]) for closer
monitoring and to allow for closer proximity to cath lab/CCU in
case of the need for urgent pericardiocentesis. Upon transfer
the patient was found to be normotensive with a SBP consistently
above 130 and a pulsus of 4 to 6. He was tachycardic with a rate
in the 120s, with a 500cc bolus of NS and continual rate of
100cc/hr of NS his rate responded and slowed slightly to
100-110. A repeat ECHO on [**1-/2038**] revealed more right sided
compromise, the size of his effusion was unchanged by ECHO but
there was mild diatolic invagination of the apical portion of
the RV free wall and significant accentuated respiratory
variation in the tricuspid but not mitral valve inflow
consistent with impaired filling. His RA invagination during
diastole persisted. The effusion is circumferential and is 1.0 -
1.1 cm during diastole anterior to RV free wall. However, per
cardiology attending, Dr. [**Last Name (STitle) 696**], read not quite worsening;
pericardial effusion possibly simple effusion without evidence
of pretamponade, no evidence of tamponade. Serial ECHO showed
decreased in pericardial effusion and no evidence of tamponade
physiology. The etiology of the pericardial effusion was
unclear but per echo did not seem to be blood however this
evaluation was limited. Vascular surgery was involved; the
pericardial effusion was too small to intervene, i.e. drain or
place a pericardial window.
.
# ?Pulmonary infection
The patient was started on levofloxacin on [**2-4**] due to the
question of an infiltrate on chest radiograph to cover for a
community acquired pneumonia. On [**2117-2-7**] the patient spiked to
100.3 and given bilateral apical infiltrates on CT chest, he was
started on vancomycin in addition to levofloxacin. Infectious
disease was consulted. Bronchoscopy was performed on [**2117-2-12**].
No obvious endobronchial lesions were seen. No organism was
isolated on BAL microbiology studies or from other sputum
samples. He completed a course of levofloxacin on [**2117-2-13**] for
pneumonia. Repeat imaging showed improvement in the bilateral
apical opacities. Vancomycin was discontinued on [**2-16**]. He was
afebrile upon discharge.
.
# Pleural Effusions
Large to moderate bilateral pleural effusion increased from
admission were noted on CT chest on [**2117-2-7**]. Effusions were of
an unclear etiology and thought to be related to [**Date Range 17911**]
syndrome/PE. Thoracocentesis was performed on [**2117-2-12**]. No
microorganisms were isolated from the pleural fluid, and flow
cytometry/cytology of the fluid sample did not reveal neoplastic
cells. Repeat CT chest on [**2117-2-16**] showed considerable decrease
in the pleural effusions bilaterally.
.
# Acute renal failure
On admission, the patient's creatinine was 0.8, near baseline.
On [**2-14**], the patient's creatinine rose to 1.1 and on [**2-16**] was 1.3. Vancomycin was discontinued on [**2-16**]. The
acute renal failure was likely due to supratherapeutic
vancomycin levels in the setting of contrast nephropathy.
Creatinine remained stable upon discharge, 1.3. It is
recommended that the creatinine should be monitored closely as
an outpatient.
.
# Status post [**Month (only) 3242**]
Continued atovaquone for PCP prophylaxis and Voriconazole for
[**Month (only) 1065**] coverage along with acyclovir for zoster prophylaxis.
Continued Prednisone for BOOP. No evidence was present for
active GVHD at this time. He will remained on his current dose
of Neoral at 50 mg twice per day.
.
# FULL CODE
Medications on Admission:
ACETAMINOPHEN 325 mg [**12-9**] Q6h as needed for pain, fever
ACYCLOVIR 400 mg Q8h
ATOVAQUONE 750 mg/5 mL 10 ml Qdaily
Aluminum-Magnesium Hydroxide 15-30mls [**Hospital1 **] as needed
Amlodipine 10 mg Qdaily
BENZONATATE 100 mg TID a day as needed for cough
FOLIC ACID 1 mg--1 tablet(s) by mouth twice a day
HEXAVITAMIN --1 tablet(s) by mouth daily (daily)
LABETALOL 100 mg--1 tablet(s) by mouth twice a day
NEORAL 25 mg--2 capsule(s) by mouth twice a day
OXYCODONE 5 mg--1 tablet(s) Q6h as needed for pain
PREDNISONE 10 mg--1 tablet(s) by mouth once a day
Pantoprazole 40 mg--1 tablet(s) by mouth qdaily
URSODIOL 300 mg--1 capsule(s) by mouth twice a day
VOriconazole 400mg [**Hospital1 **]
ZITHROMAX 250 mg Qdaily
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO twice a day.
2. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
3. Cyclosporine Modified 25 mg Capsule Sig: Two (2) Capsule PO
Q12H (every 12 hours).
4. Prednisone 10 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. Voriconazole 200 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours).
7. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
8. Atovaquone 750 mg/5 mL Suspension Sig: Ten (10) mL PO DAILY
(Daily).
9. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8
hours).
10. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*0*
11. Labetalol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
13. Enoxaparin 60 mg/0.6 mL Syringe Sig: Sixty (60) mg
Subcutaneous Q12H (every 12 hours) for 7 days.
Disp:*840 mg* Refills:*0*
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. Superior vena cava syndrome
2. Pericardial effusion
3. Pleural effusion
4. Pulmonary embolism
5. Pulmonary infection
.
Secondary:
1. Acute myelogenous lymphoma (M5b) s/p allogenic bone marrow
transplant
2. Hypercholesterolemia
3. Hypertension
.
Discharge Condition:
Hemodynamically stable, afebrile
Discharge Instructions:
You were admitted to the hospital with a swollen upper extremity
and swollen face. You were found to have a clot in the superior
vena cava, the vessel which drains venous blood from your upper
extremities and head to your heart. The clot was subsequently
lyzed with TPA (tissue plasminogen activator) and also a
procedure was performed to open the vessel (balloon
angioplasty). Your upper extremity and facial swelling
subsequently resolved. Your course was complicated by a
pulmonary embolism, a clot in the artery which supplies your
lung tissue. You were then placed on anticoagulation with a
heparin drip. Before discharge, your anticoagulation regimen
was switched to oral coumadin. You were also prescribed lovenox
injections twice daily to be continued while you bridge to
therapeutic coumadin levels. You will need close followup for
blood work measuring your INR. Your outpatient oncologist, Dr.
[**Last Name (STitle) 877**], [**First Name3 (LF) **] advise you when to stop lovenox and to be on
coumadin only. You will likely need 6 months of anticoagulation
with coumadin due to your pulmonary embolism.
.
Your hospital course was also complicated by a presumed lung
infection. You completed a 2 week course of antibiotics for
this infection. You also developed a pericardial effusion and
pleural effusion, which is fluid around your heart and lungs
respectively. These effusions were much decreased upon
discharge.
.
**Please consume 3-4 liters per day of liquids.
.
* Please resume home medications except for amlodipine. You
blood pressure will be rechecked in clinic tomorrow morning, and
amlodipine will likely need to be restarted as an outpatient.
.
* New meds :
1. Lovenox 60 mg subcutaneous injection twice daily for 7 days
or as for a period of time as otherwise directed by your
outpatient physician.
2. Warfarin 5 mg by mouth every evening for 6 months total time
period of anticoagulation.
3. Magnesium oxide 400 mg by mouth daily
.
Please keep all followup appointments.
.
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* 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.
* Any serious change in your symptoms, or any new symptoms that
concern you.
Followup Instructions:
1. Followup with PCP: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD in [**12-9**] weeks of
discharge. Phone: [**Telephone/Fax (1) 8129**].
.
2. Please followup at the [**Hospital Ward Name 1826**] 7/outpatient clinic 9:00 AM
on [**2117-2-19**] for blood draw to check your renal function,
electrolytes, coagulation panel, and cyclosporin level. You
blood pressure will also be measured at this time.
.
3. Please followup with Dr. [**First Name (STitle) **] and Dr. [**Last Name (STitle) 877**] at the
following scheduled appointment. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2117-2-22**] 10:30 AM
.
Reminder of previously scheduled appointments:
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2117-3-1**] 11:00
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2117-3-1**] 11:00
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) 2515**] & DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2117-3-1**] 1:30
|
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"427.89",
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"516.8",
"453.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"99.10",
"34.91",
"39.50",
"88.72",
"00.40",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
28319, 28325
|
19526, 26272
|
293, 662
|
28631, 28666
|
5854, 8111
|
31577, 32800
|
5249, 5340
|
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|
28346, 28610
|
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|
28690, 31554
|
5355, 5835
|
8144, 19503
|
238, 255
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690, 4182
|
4204, 4817
|
4833, 5233
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,865
| 138,226
|
45269
|
Discharge summary
|
report
|
Admission Date: [**2190-9-7**] Discharge Date: [**2190-9-14**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 678**]
Chief Complaint:
Melena
Major Surgical or Invasive Procedure:
Endoscopy
Enteroscopy x 2 with thermal ablation of angiectasia
History of Present Illness:
This is an 86 yo male with CAD, severe HOCM, mild AS, and
history of AVM w/ GIB, PUD, diverticular disease, colon cancer
s/p R hemicolectomy, who presnts with melena. He was in his
usual state of health until 1 day prior to admission when he
noted the onset of melena. He reported anorexia and only drank
fluids to keep hydrated. He denies n/v/d. Denies any recent
illness, new foods, or iron supplementation. Denies any
abdominal pain. That night had 3 more episodes of black
"melena" and had his son bring him to the [**Name (NI) **]. He denies LH, CP,
SOB. He states he felt "weak."
Past Medical History:
1. HTN
2. CAD s/p stent to LAD
3. Hypertrophic cardiomyopathy
4. Echo [**4-7**]-[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1914**]. Mod separate symmetric LVH. LV cavity
size normal. LVSF normal (>55%). Severe LV outflow obstruction
c/w HOCM.
1+ AR. AS cant be quantified. 3+ MR. [**First Name (Titles) **] [**Last Name (Titles) **] artery HTN.
5. Multiple AVMs with 15 yrs of recurrent GIB
6. GERD
7. Colon cancer ([**Location (un) 6553**] a) s/p right hemicolectomy in [**2176**]
8. h/o jejunal lipoma in [**2176**]
9. s/p CCY in [**2178**]
10. s/p prostatectomy
11. L inguinal hernia repair [**2179**]
12. Hyperlipidemia
Social History:
married 61 years, lives in [**Location **] with his wife. They have
three sons, two grandchildren, and three greatgrandsons. He and
his wife were [**Name2 (NI) **] in [**Country 3399**], and moved to the US in the 60's. He
previously worked as an accountant, and his wife worked as a
dressmaker. They have been retired for 20 years. He previously
smoked, but quit 40 years ago. Denies any EtOH. His activity at
home is limited by his spinal stenosis and resultant R leg
neuropathic pain.
Family History:
His father died elderly of lung cancer; his mother had
hypertension, and died at age 67 of a CVA.
Physical Exam:
On Admission to ICU:
t 96.5, bp 107/65, hr 70, r 14, 100% ra
Well appearing elderly male in NAD.
PERRL.
OP clr.
JVP 7 cm. no cervical/sm/sc LAD
Irregular s1,s2. IV/VI SEM, inc w/ longer filling time
LCA b/l
+R sided abd scar. +bs. soft. nt. nd.
no le edema.
Pertinent Results:
Admission Labs:
WBC-12.9* RBC-4.07* Hgb-13.7* Hct-39.4* MCV-97 MCH-33.7*
MCHC-34.8 RDW-15.3 Plt Ct-273
PT-12.7 PTT-23.7 INR(PT)-1.1
Glucose-102 UreaN-41* Creat-1.2 Na-135 K-6.5* Cl-96 HCO3-29
AnGap-17
.
Cardiac Enzymes:
[**2190-9-7**] 06:50AM BLOOD CK(CPK)-105 K-MB-2 cTropnT-LESS THAN
[**2190-9-7**] 12:30PM BLOOD CK(CPK)-38 CK-MB-NotDone cTropnT-<0.01
[**2190-9-8**] 12:39AM BLOOD CK(CPK)-131 CK-MB-2 cTropnT-<0.01
[**2190-9-8**] 03:57AM BLOOD CK(CPK)-40 CK-MB-NotDone cTropnT-<0.01
.
Nadir CBC: [**2190-9-10**] 05:20AM BLOOD WBC-8.2 RBC-2.63* Hgb-8.5*
Hct-23.4* MCV-89 MCH-32.4* MCHC-36.5* RDW-17.8* Plt Ct-120*
.
ECG Study Date of [**2190-9-7**] 9:48:06 PM
Sinus rhythm , First degree A-V delay, Left atrial abnormality,
Right bundle branch block, Left anterior fascicular block,
Consider left ventricular hypertrophy, Possible prior
anteroseptal myocardial infarction
Diffuse ST-T wave abnormalities - are present and nonspecific
but clinical
correlation is suggested, Since previous tracing of the same
date, ST-T wave changes less prominent
.
Studies:
PORTABLE ABDOMEN [**2190-9-7**] 9:29 PM
1. Nonspecific bowel gas pattern without evidence of obstruction
or definite free air.
2. Degenerative changes of the lumbar spine and bilateral hips.
.
CHEST (PORTABLE AP) [**2190-9-7**] 9:29 PM
IMPRESSION: Within normal limits.
.
EGD Report [**2190-9-8**]
No source of bleeding seen through mid-jejunum.
.
Small Bowel Enteroscopy Report [**2190-9-9**]
Blood in the stomach; Diverticulum in the second part of the
duodenum; Blood in the duodenum; Blood in the jejunum; Otherwise
normal small bowel enteroscopy to proximal jejunum. No specific
site of bleeding found, though.
.
GI BLEEDING STUDY [**2190-9-9**]
Activity is seen in the stomach and in the epigastric / left
upper quadrant region. The epigastric / left upper quadrant
activity most likely
represents transit of activity from the stomach through the
proximal small
bowel. The pattern of uptake in the stomach suggests the
possibility of free pertechnetate, but gastric bleeding is also
a possibility. No other site of bleeding is identified.
.
Small Bowel Enteroscopy Report [**2190-9-10**]
Angioectasia in the medial aspect of the junction between the
duodenal bulb and the 2nd part of the duodenum (thermal therapy
applied); Diverticulum in the second part of the duodenum; Small
hiatal hernia; Blood in the stomach; Otherwise normal small
bowel enteroscopy to at least 2 ft beyond the ligment of Triez
probably in the distal jejunum
Brief Hospital Course:
In summary, this is an 86 yo m w/ HOCM, CAD, and h/o UGIB,
including PUD, AVMs, colon cancer who presents with melena.
.
In ED, he was initially hemodynamically stable with Hct of 39.
His SBP subsequenlty dropped from 130 to 90, accompanied by
diaphoresis. His BP responded to 250cc NS bolus. He was noted to
have several episodes of black stool in ED which were guaic
positive. Cardiac enzymes were negative and there were no ECG
changes. His BP dropped another time, again responsive to IVF.
In the ED he received a total of 3L IVF and was administered
Protonix IV. He was admitted to the ICU given his active GI
bleed and hypotensive episdoes.
.
##GIB-
In the ICU he received a total of 8 [**Location **], he ruled out by
cardiac enzymes x 3. He underwent one EGD and two
enteroscopies, and one bleeding study. On the second
enteroscopy on [**2190-9-10**] an angioectatic lesion was identified and
cauterized. The GI bleeding study showed possible site in
region of ligament of Trietz, but none was identified on
enteroscopy. He was transferred to the floor on HD #6. He was
discharged to home with a stable Hct x 72 hours, tolerating POs,
and decreased melena; in addition to the prevacid and carafate
he was taking at home, he was started on protonix daily.
.
##HOCM- it is possible this may have contributed to initial
hypotension in ED, as hypotension was rapidly fluid responsive.
He was hemodynamically stable throughout the remainder of his
hospital stay.
.
##HTN: anti-hypertensives and diuretics were initially held
during his ICU stay, then gradually restarted on the medical
floor.
.
##CAD: He was ruled out for MI with negative enzymes.
Medications on Admission:
atenolol 50 mg [**Hospital1 **]
carafate 1 g tid
donnatal 16.2 mg [**Hospital1 **] as needed for cramps
HCTZ 12.5 mg qday
isosorbide DN 10 mg [**Hospital1 **]
lidoderm patch prn
lipitor 20 mg qday
nitro SL prn
prevacid 30 mg qday
docusate Sodium 100 mg [**Hospital1 **]
senna 1 tab [**Hospital1 **]
lorazepam 0.5 mg Q6-8H prn anxiety
aldactone 12.5 mg qday
Discharge Medications:
1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO twice a day.
2. Sucralfate 1 g Tablet Sig: One (1) Tablet PO TID (3 times a
day): take 1-2 hours apart from other medications.
3. Hydrochlorothiazide 25 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
4. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.
8. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
9. Donnatal Tablet Sig: One (1) Tablet PO BID:prn as needed
for cramps: 16.2 mg.
10. Lidoderm 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Topical prn.
11. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)
Sublingual prn as needed for chest pain.
12. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
13. Senna Oral
14. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every [**6-10**]
hours as needed for anxiety.
15. Outpatient Lab Work
Outpatient Laboratory Work to be peformed on [**2190-7-16**] or [**2190-7-17**]
-CBC
-Chem 7
Please cc results to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 216**] at [**Telephone/Fax (1) 250**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnosis
Gastrointestinal Bleed
Angiectasia s/p thermal therapy
.
Secondary Diagnoses:
HOCM
CAD
GERD
history colon cancer s/p R hemicolectomy
history of GI bleed
Discharge Condition:
Good, with stable hematocrit for 72 hours
Discharge Instructions:
You were hospitalized at the [**Hospital1 18**] for a bleed in your
gastrointestinal tract that manifested as melana (dark black
stools). An endoscopy and two enteroscopies were performed and
a bleeding vessel was identified and cauterized. You received
several blood transfusions. At the time of discharge, your
blood counts had been stable for 72 hours and your melana had
improved.
.
Take all medications as prescribed. You have been started on a
new medication, protonix, in addition to your prevacid.
Additionally, your carafate should be taken 1-2 hours apart from
all other medications so it does not interfere with absorption
of other medications.
.
Follow-up as indicated below.
.
You will have home physical therapy.
.
You should contact your doctor or return to the Emergency
Department if you:
-have black stools (melena) or bloody stools
-vomit blood
-become lightheaded/feel like you might pass out
-lose consciousness
-develop chest pain or palpitations (feeling like your heart is
racing)
-develop shortness of breath
-other symptoms that concern you.
Followup Instructions:
You should have your blood drawn in [**2-5**] days for a CBC and Chem
7. A VNA has been requested to perform this blood draw. If,
however, the VNA cannot/will not perform the blood draw, you
have been written a prescription for this bloodwork that can be
taken to an outpatient laboratory facility. The results of
these tests should be communicated to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 216**].
.
You should follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3315**], Gastroenterology,
in [**3-6**] weeks.
.
You should follow-up with Dr. [**First Name (STitle) 216**] as scheduled on [**10-18**]
or earlier if new issues arise.
.
Provider: [**Name10 (NameIs) 9894**],[**Name11 (NameIs) **](B) PAIN MANAGEMENT CENTER
Date/Time:[**2190-9-28**] 10:40
.
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2190-10-18**]
9:10
.
Provider: [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 126**], M.D. Phone:[**Telephone/Fax (1) 127**]
Date/Time:[**2190-11-10**] 10:30
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 684**]
Completed by:[**2190-9-14**]
|
[
"V45.82",
"396.3",
"537.83",
"401.9",
"414.01",
"425.1",
"V10.05",
"530.81",
"416.8",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"99.04",
"44.43"
] |
icd9pcs
|
[
[
[]
]
] |
8607, 8665
|
5059, 6717
|
267, 332
|
8880, 8924
|
2528, 2528
|
10044, 11260
|
2135, 2234
|
7125, 8584
|
8686, 8761
|
6743, 7102
|
8948, 10021
|
2249, 2509
|
8782, 8859
|
2748, 5036
|
221, 229
|
360, 955
|
2544, 2731
|
977, 1614
|
1630, 2119
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,639
| 120,916
|
13818
|
Discharge summary
|
report
|
Admission Date: [**2174-4-14**] Discharge Date: [**2174-4-20**]
Service: CARDIOTHORACIC
HISTORY OF PRESENT ILLNESS: The patient is an 80 year-old
man who was found to have a positive cardiac stress test. He
has a history of borderline diabetes mellitus, asbestosis and
a several month history of increasing chest discomfort.
Catheterization was performed locally, which revealed severe
three vessel coronary artery disease, but preserved left
ventricular function.
PHYSICAL EXAMINATION: Blood pressure 130/80. Heart rate is
72 and regular. No carotid bruits or jugulovenous
distention. Lungs are clear bilaterally. Normal cardiac
examination. Abdomen soft and nontender. No masses are
palpable.
Electrocardiogram shows sinus rhythm, premature atrial
contractions, nonspecific lateral ST T wave changes, possible
old inferior myocardial infarction. Chest x-ray showed
chronic obstructive pulmonary disease and bilateral pleural
calcifications. There was no evidence of congestive heart
failure.
White blood cell count [**Pager number **], hematocrit 37.8%, INR 1.1,
urinalysis normal. Creatinine 1.0, glucose 111, BUN 16,
sodium 141, potassium 3.8, chloride 102.
HOSPITAL COURSE: Mr. [**Known lastname 41507**] was taken to surgery on [**2174-4-15**]. At that time coronary artery bypass grafting times
three was performed. The internal mammary artery was placed
to the left anterior descending artery, saphenous vein grafts
were placed to the obtuse marginal branch circumflex and the
diagonal branch. Postoperatively, he had no major issues.
He was discharged on [**4-21**] in good condition. He should
return to Dr. [**Last Name (STitle) **] on [**5-31**] and to see his local
cardiologist Drs. [**First Name (STitle) **] and [**Name5 (PTitle) 13175**] in three to four weeks.
DISCHARGE DIAGNOSES:
1. Coronary artery disease status post coronary artery
bypass grafting.
2. Diabetes mellitus.
3. Hypertension.
4. Asbestosis.
5. Chronic obstructive pulmonary disease.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 22050**]
MEDQUIST36
D: [**2174-5-31**] 13:25
T: [**2174-6-1**] 07:52
JOB#: [**Job Number 41508**]
|
[
"411.1",
"272.0",
"501",
"428.0",
"427.31",
"414.01",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.15",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
1832, 2286
|
1206, 1811
|
501, 1188
|
127, 478
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,339
| 140,292
|
50587
|
Discharge summary
|
report
|
Admission Date: [**2139-12-7**] Discharge Date: [**2139-12-16**]
Date of Birth: [**2071-3-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Heparin Agents / Percocet / Lisinopril
Attending:[**First Name3 (LF) 281**]
Chief Complaint:
respiratory failure
Major Surgical or Invasive Procedure:
[**2139-12-8**] extubation
[**2139-12-10**] bronchoscopy
History of Present Illness:
68 years old woman with hx of chronic lung disease, CHF, CAD,
tracheal stenosis, previous tracheostomy s/p decannulation
complicated by tracheo cutaneous fistulae s/p repair on 08/[**2138**].
Ms. [**Known lastname 16471**] was admitted to [**Hospital3 13313**] on [**2139-11-20**]. She
had an episode of severe respiratory distress and called EMS, by
the time they arrived she was on respiratory arrest with
pulseless electrical activity, after <1 minute of CPR she went
into sinus rhythm and regained her pulse. She was intubated and
admitted to the ICU for acute respiratory failure and sepsis.
She
was treated with Vancomycin and Ceftriaxone for MRSA pneumonia
and Enterococcus UTI for 2 weeks. She also presented with
pulmonary edema treated with careful diuresis due to hemodynamic
instability. The patient was continued on ventilatory support,
failed multiples extubation trials, had a bronchoscopy done on
[**2139-11-26**] with remove of thick secretions from RLL and LLL
bronchi. She was extubated on [**2139-12-2**] and needed reintubation
after 6 hours for severe respiratory distress. She was
transferred to [**Hospital1 18**] for further management and evaluation for
possible tracheostomy.
Past Medical History:
-Coronary artery disease s/p CABG in [**2118**] and "recent" PCI
-CHF, last TTE [**2138-9-12**] EF 60% with mild LVH and some focal
hypokinesis at base.
-OSA
-Dyslipidemia
-HTN
-Left total hip replacement-[**1-28**], elective. Complicated
postoperative course with post-operative atrial fibrillation
wtih RVR requiring cardioversion, sepsis, Pseudomonas VAP, VRE
UT, and prolonged intubation leading to trach/PEG. Discharged to
chronic wean facility but unable to decannulate. Bronchoscopy
revealed tracheomalacia of subglottic region.
-Supraglottic edema from GERD
-Bipolar disorder
-Depression
-chronic atrial fibrillation, developed postop from THR, not
anticoagulated
-Chronic constipation
-HIT during Fragmin therapy
Social History:
Married. Very supportive husband. When she is not
hospitalized/in rehab, she lives with him. No ETOH or current
smoking. Has 35 pack year smoking history, quit 13 years ago.
Family History:
Depression
Physical Exam:
VS: T 97.1, BP 129/92, HR 96 reg, RR 20, O2 sats 92% 4 LNC
Physical Exam:
Gen: pleasant in NAD
Lungs: wheezes t/o
CV: RRR, S1, S2, no MRG
Abd: soft, NT, ND
Ext: no edema, warm, 2+ pulses intact
Neuro: A and O x 4.
Pertinent Results:
[**2139-12-10**] 04:47AM BLOOD WBC-5.4 RBC-3.97* Hgb-11.6* Hct-34.7*
MCV-87 MCH-29.1 MCHC-33.3 RDW-16.0* Plt Ct-329
[**2139-12-15**] 08:38AM BLOOD K-3.6
[**2139-12-14**] CXR findings: No endotracheal tube is seen. A right
PICC is seen with tip projecting over the mid SVC. Median
sternotomy wires
are intact. Mild cardiomegaly persists. Mediastinal and hilar
contours are
normal and unchanged. The left linear basal atelectasis
persists. Mild
interstitial edema is similar to prior. No pneumothorax. A broad
based thin curvilinear lucency arching adjacent to diaphragm is
not localized on the lateral. Unlear whether this is intra or
extra thoracic and whether this represents free air.
Brief Hospital Course:
The patient was transfered to [**Hospital1 18**] on [**2139-12-7**]. She was
extubated day one, and underwent flexible bronchoscopy revealing
stable tracheal stenosis. The patient was watched, and PT
evaluated her, recommending rehab for gait strengthening.
Lungs: Oxygenation watched, with nightly Bipap, and aggressive
pulmonary toilet with q 6 hours albuterol, mucomyst and chest
PT. Stable on 4L NC with oxygen saturation 90-92% during day.
CV: stable cardiac function without arrythmias. On her home
cardiac medications. Euvolemic. Lytes replaced with lasix. will
need chem panel check periodically and within the week.
Abd: no BM for several days, but has received bisacodyl x 2.
Placed on home stool meds day of discharge. Denies pain. Abdomin
soft
Nutrition: tolerating a regular diet without problems
[**Name (NI) **] 4 person max assist to get OOB
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
5. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours).
6. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
7. Lamotrigine 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
8. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
9. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO AT NIGHT ().
10. Senna 8.6 mg Capsule Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)).
13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
15. Polyethylene Glycol 3350 17 gram Powder in Packet Sig: One
(1) packet PO once a day.
16. Lactulose 20 gram Packet Sig: One (1) packet PO every six
(6) hours.
17. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
18. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
19. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough .
20. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: Three (3) mL Inhalation Q6H (every 6 hours) as
needed for SOB : take with mucomyst
.
21. Acetylcysteine 20 % (200 mg/mL) Solution Sig: Three (3) ML
Miscellaneous Q6H (every 6 hours) as needed for SOB: take with
albuterol around the clock.
22. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
23. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a
day).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 32674**] - [**Location (un) **]
Discharge Diagnosis:
Trachael stenosis intubated s/p extubated
MRSA pneumonia
Congestive heart Failure
Discharge Condition:
deconditioned. awake alert
Discharge Instructions:
Call Dr. [**First Name (STitle) 5586**] office [**Telephone/Fax (1) 10084**] if experience:
-Fever > 101 or chills
-Increased shortness of breath, cough or sputum production
-Continue home oxygen
-Continue BiPAP 12/6 at night or as needed when resting.
Followup Instructions:
Follow-up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 48006**] [**Telephone/Fax (1) 105298**]
Call Dr. [**Last Name (STitle) **] office for a follow-up appointment [**Telephone/Fax (1) 10084**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**]
Completed by:[**2139-12-16**]
|
[
"296.50",
"518.81",
"427.31",
"482.42",
"327.23",
"V15.82",
"272.4",
"V43.64",
"V13.02",
"519.19",
"428.0",
"285.9",
"V45.81",
"V12.54",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.23",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
6575, 6650
|
3547, 4408
|
325, 383
|
6776, 6805
|
2833, 3524
|
7107, 7449
|
2571, 2583
|
4431, 6552
|
6671, 6755
|
6829, 7084
|
2672, 2814
|
266, 287
|
411, 1617
|
1639, 2363
|
2379, 2555
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,668
| 100,486
|
40139
|
Discharge summary
|
report
|
Admission Date: [**2199-12-6**] Discharge Date: [**2199-12-13**]
Date of Birth: [**2120-4-15**] Sex: M
Service: MEDICINE
Allergies:
Pneumococcal Vaccine
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
hemoptysis
Major Surgical or Invasive Procedure:
s/p bronchial artery embolization
History of Present Illness:
79-year-old male with history of NSCLC s/p chemotherapy and
radiation in [**2191**] with local recurrence diagnosed [**4-10**] who
developed hemoptysis and was transferred for bronchial artery
embolization.
.
The patient was doing well until a couple months ago. At that
time he developed intermittent hemoptysis. This was scant and
intermittent until [**5-6**] day ago. At that time he noted increased
hemoptysis totaling a couple teaspoons and he presented to
[**Hospital3 3765**] on [**2199-12-4**]. He was noted to have Hct of 28, had
bronchoscopy with 90% obstructing mass in proximal right
bronchus at the orifice of RML and RLL. Per note, the mass was
fungating and polypoid. Electrocautery coagulation was done with
reduction of the amount of bleeding. He has evidence of mets to
RML and RLL. He was transferred to [**Hospital1 18**] for bronchial artery
embolization.
.
At [**Hospital1 18**] his hct was noted to be 28.2. He was breathing
comfortably with 4L NC. He was monitored on floor until
procedure. He underwent a right bronchial artery embolization
(330-550 microns) which was uncomplicated. After the procedure
the patient was transferred from angio table to stretcher and
developed tachypnea to 40s, desaturation to low 80s on 2L NC and
significant work of breathing. He was switched to 8L simple face
mask with saturation to 90. 15L NRB with saturation to 95. He
was given 1mg morphine and albuterol treatment with some ease in
breathing. CXR was done with no apparent change from prior
description (although no comparison CXR). ABG of 7.42/47/23 with
SaO2 of 95%. Over the next 5-10 minutes the patient became more
comfortable and patient no longer in respiratory distress. NRB
was weaned to simple face mask. Request was made to have patient
observed in MICU overnight.
.
Upon transfer, initial vitals were: BP 154/65, HR 115, RR 35,
SaO2 94% on 50% FM. The patient denies pain, fevers, chills,
nausea, vomiting, diaphoresis, diarrhea, constipation. He
endorses intermittent shortness of breath and notes he
occassionally has productive cough, sometimes with blood clots.
Past Medical History:
1. Stage IIIB NSCLC, s/p radiation and chemotherapy in [**2191**].
Cancer was originally in distal trachea near right bronchus.
Patient in [**4-10**] was noted to have local recurrence during an
admission for pneumonia. Patient was started late [**2199-10-2**] on
palliative chemo with Gemcitabine and has had five cycles.
2. COPD
3. h/o Seizures secondary to brain injury
4. Hyperlipidemia
5. h/o pseudomonas pneumonia
Social History:
Widower, quit smoking in [**2199-4-1**], denies EtOH.
Family History:
Noncontributory.
Physical Exam:
Vitals: T 99.5, BP 135/61, HR 108, RR 26, SaO2 97% 40% FM
General: Alert, oriented, cachectic, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated
Lungs: Decreased breath sounds throughout, more decreased in RLL
and RML. Anterior exam only. No crackles or wheezes appreciated.
Cardiovascular: Decreased heart sounds, difficult to assess. RR,
tachycardia. No murmurs or rubs.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, cyanosis or edema, mild
clubbing, no hematoma/bruit at groin.
Pertinent Results:
Labs:
[**2199-12-6**] 04:53PM BLOOD WBC-7.4 RBC-3.34* Hgb-10.0* Hct-29.1*
MCV-87 MCH-29.8 MCHC-34.2 RDW-20.0* Plt Ct-209
[**2199-12-7**] 05:11PM BLOOD WBC-15.5*# RBC-3.20* Hgb-9.3* Hct-28.0*
MCV-88 MCH-29.1 MCHC-33.3 RDW-20.4* Plt Ct-341
[**2199-12-10**] 04:15AM BLOOD WBC-13.3* RBC-2.98* Hgb-8.9* Hct-26.1*
MCV-88 MCH-29.7 MCHC-33.9 RDW-20.0* Plt Ct-669*
[**2199-12-11**] 04:00AM BLOOD WBC-11.0 RBC-2.84* Hgb-8.2* Hct-24.7*
MCV-87 MCH-28.9 MCHC-33.3 RDW-19.6* Plt Ct-890*
[**2199-12-12**] 04:32AM BLOOD WBC-10.3 RBC-2.68* Hgb-8.0* Hct-23.0*
MCV-86 MCH-29.9 MCHC-34.8 RDW-19.9* Plt Ct-901*
[**2199-12-13**] 03:59AM BLOOD WBC-11.5* RBC-3.15* Hgb-9.0* Hct-27.1*
MCV-86 MCH-28.7 MCHC-33.2 RDW-19.5* Plt Ct-1208*
[**2199-12-6**] 04:53PM BLOOD Glucose-105* UreaN-15 Creat-0.6 Na-136
K-3.5 Cl-99 HCO3-29 AnGap-12
[**2199-12-8**] 04:46AM BLOOD Glucose-127* UreaN-21* Creat-0.9 Na-132*
K-4.0 Cl-99 HCO3-25 AnGap-12
[**2199-12-11**] 04:00AM BLOOD Glucose-147* UreaN-12 Creat-0.7 Na-129*
K-4.1 Cl-95* HCO3-31 AnGap-7*
[**2199-12-12**] 04:32AM BLOOD Glucose-159* UreaN-11 Creat-0.6 Na-132*
K-4.2 Cl-96 HCO3-31 AnGap-9
[**2199-12-13**] 03:59AM BLOOD Glucose-132* UreaN-9 Creat-0.7 Na-127*
K-4.6 Cl-91* HCO3-32 AnGap-9
[**2199-12-6**] 04:54PM BLOOD PT-13.7* PTT-26.4 INR(PT)-1.2*
[**2199-12-12**] 04:32AM BLOOD PT-16.2* PTT-37.9* INR(PT)-1.4*
[**2199-12-6**] 04:53PM BLOOD Calcium-8.2* Phos-2.5* Mg-2.2
[**2199-12-13**] 03:59AM BLOOD Calcium-8.1* Phos-2.4* Mg-2.1
[**2199-12-6**] 11:16PM BLOOD Type-ART pO2-23* pCO2-47* pH-7.42
calTCO2-32* Base XS-3
[**2199-12-7**] 12:45AM BLOOD Type-[**Last Name (un) **] Temp-37.8 pO2-43* pCO2-46*
pH-7.39 calTCO2-29 Base XS-1 Intubat-NOT INTUBA
[**2199-12-10**] 04:15AM BLOOD Vanco-17.0
.
Blood cx [**2198-12-9**] pending, blood cx earlier in admission negative
Urine cx: negative
.
[**2199-12-9**] 8:31 pm SPUTUM Source: Expectorated.
GRAM STAIN (Final [**2199-12-9**]):
<10 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final [**2199-12-9**]):
TEST CANCELLED, PATIENT CREDITED.
.
CXR [**2199-12-11**]:
FINDINGS: Right middle and lower lobe post-obstructive
combination of
collapse and consolidation with volume loss and rightward shift
of midline
structures is unchanged. Increased opacity within the right
upper lobe and
the entire left lung reflects vascular congestion and
mild-to-moderate
pulmonary edema. Cardiac silhouette is significantly obscured.
There is no
pneumothorax or left effusion.
IMPRESSION: Mild-to-moderate pulmonary edema within the left
lung and right upper lobe with unchanged right pleural effusion
and post-obstructive atelectasis and consolidation of the right
middle and lower lobes.
.
LENIs [**2199-12-9**]:
FINDINGS: Grayscale, color and Doppler images were obtained of
bilateral
common femoral, superficial femoral, popliteal and tibial veins.
There is
normal flow, compression and augmentation seen in all the
vessels.
IMPRESSION: No evidence of deep vein thrombosis in either leg.
.
CT chest with contrast [**2199-12-8**]:
CT OF THE CHEST WITH CONTRAST: No pathologically enlarged
supraclavicular, or axillary lymph nodes are present. A small
8-mm left hilar node seen. There is loss of the normal fat plane
along the right mediastinal surface with 2 inferior
paraesophageal nodes measuring 6 and 10 mm in short axis (2:29).
Volume loss is noted involving the right lung with
paramediastinal fibrosis seen bilaterally, but predominantly on
the right in the upper lobe which is poorly enhancing. Some
aerosolized secretions are noted within the distal trachea
extending into the proximal main stem bronchi on the right with
complete occlusion of the bronchus intermedius and proximal
segmental branches of the right middle and right lower lobe by
soft tissue mass. The right upper lobe bronchus has some
secretions within its origin but is patent distally.
The overall size of the right hilar mass is difficult to
delineate in
conjunction with the surrounding post-obstructive collapse of a
large portion of the right lower lobe with the vasculature
remaining patent and coursing through the atelectatic lung. Some
scattered centrilobular nodules are noted within the right upper
lobe in conjunction with regions of bronchiolectasis and
bronchial/bronchiole wall thickening (4:64). The aerated
portions of the right middle and right lower lobe display
bronchiectasis, interstitial septal thickening and surrounding
ground-glass opacities. Mild thickening is noted along the
pleural surface of the right major and minor fissures. Mild
enhancement is noted along the right pleural surface in
conjunction with a moderate-sized pleural effusion with fissural
components.
The left lung displays some apical scarring and paramediastinal
fibrotic
changes as well as a tubular 4 x 6-mm nodule within the lingula
(4:95),
without any other suspicious pulmonary nodules. Underlying
traction
bronchiectasis is noted adjacent to the post-radiation changes
with the
remaining airways appearing otherwise unremarkable. Moderate
background
centrilobular emphysema is better appreciated within the more
normal-appearing left lung.
Mild-to-moderate atherosclerotic calcification is noted
involving the aortic arch, ascending/descending aorta, and
coronary arteries. Atherosclerotic calcification is also noted
involving the aortic valve. Incidentally noted is independent
takeoff of the left vertebral artery from the aortic arch.
Included portions of the upper abdomen display a few scattered
small
cardiophrenic lymph nodes. No suspicious masses within the
liver, spleen,
kidneys, pancreas, or visualized bowel. Both adrenal glands
appear
hypertrophied more prominent on the left side.
BONE WINDOWS: No malignant-appearing osseous lesions are noted.
IMPRESSION:
1. Poorly defined mass in the region of the right hilum with
complete
opacification of the bronchus intermedius and proximal segmental
branches of the right middle and right lower lobe bronchi. The
right upper lobe bronchus is opacified at its orifice but likely
with fluid which is present within the distal right mainstem
bronchus. There are extensive post-obstructive and post
radiation changes involving the right lung with resultant volume
loss. Lymphangitic spread of disease is not excluded.
2. Moderate-sized right pleural effusion with pleural
enhancement suggesting complex fluid. Effusion surrounds the
large portion of the right lower lobe with fissural components.
Left lobe contains single lingular nodule and mild
post-radiation changes
Note: Please note assessment for superimposed pneumonia,
pulmonary
hemorrhage, or worsening post-obstructive changes is not
possible in the
absence of any prior exams available for our review.
[**2199-12-6**] s/p embolization:
PROCEDURE:
1. Right common femoral arterial access.
2. Aortogram.
3. Bronchial artery embolization.
DETAILS: After explaining the risks, benefits, and alternatives
to the
procedure, a written informed consent was obtained. The patient
was brought to the angiographic suite and placed supine on the
table. A timeout and huddle was performed per [**Hospital1 18**] protocol.
The right groin was prepped and draped in a sterile fashion.
Under continuous fluoroscopic and palpatory guidance, the right
common femoral artery access was obtained using a micropuncture
system, which was then exchanged for a 5 French vascular sheath,
the sidearm of which was connected to a continuous heparin
flush. A 5 French pigtail catheter was then advanced into the
aorta over [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 7648**] wire and aortogram was performed. Next,
multiple different catheters over the wire were tried to
cannulate the common bronchial trunk arising from the aorta. Due
to the tortuous and acute orientation of the origin of the
common bronchial trunk, the cannulation and advancement of the
catheter was difficult. However, with extreme care, a Renegade
catheter over an angled Glidewire was advanced further into the
common bronchial trunk. Arteriograms were performed to confirm
the location.
Further advancement of the catheter over the Glidewire was not
possible due to the extreme tortuous anatomy of the vessels.
Hence, it was decided to perform embolization from this
location. 300-500 micron Embospheres were then used to embolize
with intermittent saline flushes. Care was taken to avoid
anyreflux. Intermittent hand angiograms were performed to rule
out filling of the anterior spinal artery. Further embolization
was stopped when stagnancy in antegrade flow was noted. The
catheter and the wires were then removed followed by the
vascular sheath and manual pressure held over the arterial
puncture site for about 15 minutes until good hemostasis was
achieved.
FINDINGS:
1. Aortogram performed demonstrating common bronchial trunk. The
right
bronchial artery is relatively hypertrophied as compared to the
left. No
active extravasation is noted.
2. No contribution to the anterior spinal artery from the
bronchial arteries is noted.
IMPRESSION: Successful Embosphere embolization of the common
bronchial trunk with preferential flow into the right bronchial
artery. Far distal
embolization selectively into the right bronchial artery was not
possible at this stage due to the difficult angle of origin and
tortuousity.
Brief Hospital Course:
This is a 79-year-old male with history of NSCLC s/p chemo and
XRT in [**2191**] now with local recurrence who developed hemoptysis
and s/p right bronchial artery embolization who developed
hypoxic respiratory distress.
.
# Hypoxic respiratory distress: The patient developed hypoxemic
respiratory distress after being turned on right side after
procedure. The differential is broad and includes airway
obstruction from tumor, mucous plugging, intermittent
bronchospasm, and pulmonary embolus. The most likely etiology of
the original hypoxia was secondary to airway obstruction from
tumor or from mucous plugging causing temporary shunt
physiology. This is likely because it occurred after patient was
turned on right side, was temporary, and relieved by coughing.
Interval CXRs showed worsening opacifiation of his right lung
suggesting complete tumor or mucous occlusion of his bronchus
versus a post obstructive pneumonia process. He was started and
continued on IV vanocmycin (day 1 was [**12-7**]) and cefepime (day 1
was [**12-7**]) as all cultures remained negative. He then spiked a
fever and flagyl was started on [**12-9**]. The plan is for a total of
a 14 day course of all antibiotics. The patient was given
nebulizations to ease any possible bronchospastic response. No
peripheral signs of DVT, including negative LENIs although pt is
mildly tachycardic and PE was not entirely excluded as CTA was
not done with PE protocal. However, cancer and PNA can explain
his oxygen requirement and anticoagulation treatment would be
risky given recent arterial access, embolization, and
hemoptysis. He generally requires 4-5L of oxygen to maintain
sats in the low 90s (has h/o hypercarbia and COPD) with
intermittent needs for facemask ventilation in the setting of
coughing fits. He was started on morphine 5mg po prn SOB. He
regularly self suctions. He also has a lot of anxiety which he
receives lorazepam 0.5mg po as needed. He is also on standing
tylenol to suppress fever.
.
# Goals of care: The patient wanted a second opinion from
oncology here at [**Hospital1 18**]. Oncology consult was called and his
previous oncology records were obtained from Dr. [**Last Name (STitle) 87663**] and Dr. [**Name (NI) 88182**]. Oncology suggested a possible 3rd line of chemotherapy,
but the patient said that he would want to "get better" before
trying it. Palliative care was also consulted and his code
status was changed to DNR/DNI. The patient expressed his wishes
to die at home, but the family was not able to organize 24 hour
home care and preferred that the patient be discharged to a [**Hospital1 1501**]
to complete his IV antibiotics course before making a decision
about how to approach his care at home. He has a follow up
appointment with thoracic oncology on [**12-31**] at 10:30 to
discuss further chemo options. There were discussions abbout
home with hospice but that is not being implemented at this
time.
.
# Hemoptysis: The patient has stable hematocrit and is s/p
bronchial artery embolization. The procedure went very well, but
he desatted to the 80s after the procedure when he layed on his
right side as he was being transferred to the stretcher. His
desaturation improved on nonrebreather, resolved within hours
with weaning to nasal cannula, and was likely ssecondary to
mucous plugging. LENIs were checked and were negative for any
DVT. He only had minimal hemoptysis after the procedure and
once or twice in the week following. His heparin sc was stopped
and should remain off given risk of bleeding. HIS HCT did trend
down to 23 from 29 on admission and was 27 on discharged without
transfusion.
.
# Metastatic NSCLC: The patient is undergoing palliative
chemotherapy with Gemcitabine. Will hold on further chemo for
now pending oncology input. See goals of care section above.
.
# Hypothyroidism: Continued levothyroxine
.
# Hyperlipidemia: Continued statin
.
#. Constipation: Pt had constipation while here that he did not
report to us initially. He moved his bowels on senna, colace,
and miralax. He should be monitored for constipation.
.
# h/o Seizures secondary to brain injury: Continue home
phenytoin.
.
# Hypophosphatemia: He repeatedly had a low phos while in
hospital. He should have his phos monitored regularly.
.
#.Hyponatremia: Is SIADH also likely a hypovolemic component
given decreased pos.
Trend hyponatremia.
.
# Thrombocytosis: Likely secondary to suboptimally tx post
obstructive pneumonia
.
# Insomnia in setting of respiratory issues: Pt does well on
trazodone 25mg qhs.
.
# Code: DNR/DNI as outlined above
Medications on Admission:
Simvastatin 20mg daily
Levothyroixine 75mcg daily
Dilantin 100mg QID
Phenobarb 60mg daily
Albuterol neb q4hrs prn
Spiriva 18mcg daily
Temazapam 30mg qHS
Discharge Medications:
1. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
2. levothyroxine 75 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for SOB.
4. phenobarbital 60 mg Tablet Sig: One (1) Tablet PO once a day.
5. phenytoin 100 mg/4 mL Suspension Sig: Two Hundred (200) mg PO
twice a day.
6. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) Puff Inhalation Q4H (every 4 hours) as needed for
shortness of breath or wheezing.
7. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours): day 1 was [**12-9**] for total of 14 day course last day
[**12-23**].
8. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety, discomfort: hold for sedation.
9. lidocaine HCl 2 % Solution Sig: Twenty (20) ML Mucous
membrane TID (3 times a day) as needed for sore throat.
10. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
11. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
12. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
13. morphine concentrate 20 mg/mL Solution Sig: Five (5) mg PO
Q4H (every 4 hours) as needed for shortness of breath.
14. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours).
15. sodium chloride 0.65 % Aerosol, Spray Sig: [**2-2**] Sprays Nasal
QID (4 times a day) as needed for dry nose.
16. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
dose PO DAILY (Daily) as needed for constipation.
17. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day: hold for loose stool.
18. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
19. 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.
20. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
21. CefePIME 2 g IV Q12H
day 1=[**12-7**]
22. vancomycin 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q 12H (Every 12 Hours): day 1 [**12-7**] total 14 day
course last day [**12-21**].
23. Outpatient Lab Work
Chem 10, CBC daily for 1st 3 days and then at discretion of MD
at facility
24. Pneumoboots
Discharge Disposition:
Extended Care
Facility:
the highlands
Discharge Diagnosis:
Primary diagnosis:
1. Stage IIIB NSCLC, s/p radiation and chemotherapy in [**2191**].
Cancer was originally in distal trachea near right bronchus.
Patient in [**4-10**] was noted to have local recurrence during an
admission for pneumonia. Patient was started late [**2199-10-2**] on
palliative chemo with Gemcitabine and has had five cycles.
2. s/p bronchial artery embolization
3. Post obstructive PNA
4. COPD
.
Seondary diagnosis:
1. h/o Seizures secondary to brain injury
2. Hyperlipidemia
3. h/o pseudomonas pneumonia
Discharge Condition:
A & O x3, able to get up to chair with assistance but does not
have oxygen reserve to do more, on 4-5L of oxygen to maintain o2
sats 89-92% occasionally needs fase mask for short periods
Discharge Instructions:
You were admitted for bronchial artery embolization and then had
an increased oxygen requirement. Your lung cancer is worse and
has taken over almost the entire part of your right lung. In
addition you developed fever and have a post obstructive PNA and
you are on cefepime, flagyl, and vancomycin which you will take
for 14 days. You also were started on morphine and you are on
ipratropium and albuterol nebs. You saw oncology here and you
have a follow up appointment with Dr. [**Last Name (STitle) **] on [**12-31**].
Followup Instructions:
Thoracic oncology is working on an appointment for you later
this month. please call ([**2199**] 1-2 days after discharge
to find out the time appointment.
Completed by:[**2199-12-13**]
|
[
"E912",
"162.8",
"253.6",
"934.9",
"799.4",
"486",
"E989",
"V15.3",
"427.31",
"491.21",
"300.00",
"244.9",
"345.90",
"907.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.42",
"88.44",
"99.29"
] |
icd9pcs
|
[
[
[]
]
] |
20400, 20440
|
13152, 17726
|
292, 328
|
21006, 21195
|
3671, 13129
|
21767, 21955
|
2983, 3001
|
17930, 20377
|
20461, 20461
|
17752, 17907
|
21219, 21744
|
3016, 3652
|
242, 254
|
356, 2452
|
20480, 20985
|
2474, 2896
|
2912, 2967
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,762
| 199,302
|
37575
|
Discharge summary
|
report
|
Admission Date: [**2182-10-7**] Discharge Date: [**2182-10-9**]
Date of Birth: [**2159-11-6**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
22yr old female with history of asthma (>3 hospitalized in the
past but never intubated), hashimoto??????s thyroiditis, recently
presented to ED on [**10-4**] w/ cough and subjective fevers x 10
days and represents with cough and shortness of breath. On
initial ED visit, she had peak flow 375 and was discharged home
from the ED w/ prescription for prednisone, but ??????never got
around to filling it??????. Today, she forgot her Albuterol inhaler
when going to class, and subsequently developed worsening
shortness of breath. She was then referred to [**Hospital1 **] via EMS from
her college infirmary, although the patient felt it was
unnecessary at that time. Of note patient is a smoker ([**4-21**]
cigs/week) and last smoked yesterday. She denies any other
precipitants, including emotional stress or exercise.
.
She states she has had at least 3 hospitalizations for asthma
exacerbations in the past (first in high school, last 1 year
ago), but has never been intubated or required an ICU stay.
She has previously done well with Albuterol inhaler, and has
infrequently required oral steroids. She does not recall her
baseline peak flow. She denies aspirin sensitivity.
.
In the ED, VS: 98.3 123 122/46 18 100%. Her initial peak flow
was 460 by EMS then later 250 in ED. She received Albuterol
nebs, 1L NS IV, Solumedrol 125mg IV, Mg Sulfate 4g IV,
Codeine/Guaifenesin 20mg PO, Ativan 1mg, Ipratropium neb x 4.
Episodes of tachypnea to 40??????s, tachycardia to 160??????s that
improved w/ deep breathing.
.
On the floor, the pt noted improvement of shortness of breath,
denied anxiety. She also complained of chest discomfort with
coughing but denied pain.
.
REVIEW OF SYSTEMS: Complete review of systems from the 10-point
questionnaire was reviewed with her today and charted. This was
unremarkable.
Past Medical History:
Hashimoto's thyroiditis: p/w lower extremity weakness,
subclinical hypothyrodism (TSH 9.5) strongly positive
antithyroid antibodies, on levothyroxine.
Social History:
Occupation: Student
Drugs: Denies
Tobacco: Admits to [**4-21**] cigarettes per week
Alcohol: <3 drinks per week
Other: lives in apt, not dorm housing
Family History:
Grandmother with thyroid disease, father, type 1
diabetes.
Physical Exam:
Gen: well-appearing female sitting up in bed, loud
non-productive coughing, speaking in short sentences at a time
but then needs to stop for breath. Somewhat anxious-appearing.
HEENT: PERRL, clear oropharynx
Cor: Tachy, nl S1, S2, no murmurs, rubs or [**Last Name (un) 549**]
Pulm: inspiratory and expiratory wheezes throughout, rhonchi at
the upper lung fields. Not tripoding or using accessory muscles.
Abd: non-tender, non-distended, active bowel sounds. No HSM
Extremites: 2+ pulses, warm, well perfused, no edema
Neuro: AOx3, 5/5 strength throughout, CN II-XII grossly intact
Skin: No rash
Pertinent Results:
[**2182-10-7**] 08:59PM BLOOD WBC-23.7* RBC-4.19* Hgb-11.7*# Hct-36.0
MCV-86 MCH-28.0 MCHC-32.6 RDW-12.3 Plt Ct-322
[**2182-10-9**] 05:22AM BLOOD WBC-22.8* RBC-3.89* Hgb-11.3* Hct-33.7*
MCV-87 MCH-29.1 MCHC-33.6 RDW-13.1 Plt Ct-252
[**2182-10-7**] 08:59PM BLOOD Neuts-91.1* Lymphs-5.9* Monos-2.8 Eos-0.1
Baso-0.1
[**2182-10-8**] 05:04AM BLOOD Neuts-87.4* Lymphs-8.0* Monos-4.3 Eos-0.1
Baso-0.2
[**2182-10-7**] 08:59PM BLOOD PT-13.8* PTT-22.9 INR(PT)-1.2*
[**2182-10-8**] 05:04AM BLOOD PT-13.3 PTT-25.7 INR(PT)-1.1
[**2182-10-7**] 08:59PM BLOOD Glucose-122* UreaN-14 Creat-0.8 Na-141
K-3.7 Cl-110* HCO3-20* AnGap-15
[**2182-10-8**] 05:04AM BLOOD Glucose-122* UreaN-11 Creat-0.6 Na-141
K-4.6 Cl-112* HCO3-23 AnGap-11
[**2182-10-9**] 05:22AM BLOOD Glucose-95 UreaN-8 Creat-0.8 Na-142 K-4.0
Cl-108 HCO3-26 AnGap-12
[**2182-10-8**] 05:04AM BLOOD CK(CPK)-132
[**2182-10-7**] 08:59PM BLOOD Calcium-8.2* Phos-3.2 Mg-2.5
[**2182-10-9**] 05:22AM BLOOD Calcium-9.0 Phos-4.2 Mg-2.0
[**2182-10-8**] 05:04AM BLOOD calTIBC-277 VitB12-476 Folate-10.3
Ferritn-57 TRF-213
[**2182-10-7**] 10:40AM BLOOD TSH-0.31
[**2182-10-7**] 09:07PM BLOOD Glucose-130* Lactate-1.6 Na-144 K-3.7
Cl-109
[**2182-10-7**] 09:07PM BLOOD O2 Sat-98
[**2182-10-7**] 08:59PM BLOOD PERTUSSIS SEROLOGY-PND
IMAGING:
[**2182-10-7**]:
FINDINGS: In comparison with the study of [**10-4**], there is little
interval
change and no evidence of acute cardiopulmonary disease. No
pneumonia,
vascular congestion, or pleural effusion.
Brief Hospital Course:
A/P:
22yr old female with history of asthma (has been hospitalized in
the past but never intubated), subclinical hypothyroidism,
recently presented to ED on [**10-4**] w/ cough and subjective fevers
and represents with cough and sob, reduced peak flow, c/w asthma
exacerbation.
.
#Asthma Exacerbation: Moderate to severe episode w/ PEFR <50%
of expected, . Maintaining good sats currently. No CO2
retention on ABG. Likely precipitant is upper respiratory tract
infection, although additional irritant of smoking likely
contributory. Pt was treated with albuterol nebs, ipratroprium
nebs, Prednisone 60mg PO Daily and ativan 0.5mg IV:PRN for
anxiety. Pt had intermittent coughing spells where she had a
deep, harsh, long cough that was concerning for pertussis.
Pertussis culture/serology, Influenza A/B, Rapid Viral screen
and culture were sent and were pending at the time of discharge.
She steadily improved over the course of her ICU stay and on
day 3 of admission the patient was ready for discharge with
prednisone 60mg PO daily for 4 more days. pt best peak flow
during admission was 350.
.
#Cough: Afebrile, elevated WBC (likely secondary to steroids),
previous clear CXR on prev ED visit. No clear pulmonary
process, but concern for pertussis given severity of cough,
however no known exposures, no recent travel hx, and no true
paroxysms witnessed. More likely cold virus, less likely flu
(given time course), although not vaccinated. Would benefit
from cough suppression due to the violent nature of her cough.
Pt sent home with cough suppresant and medication control for
her asthma. She needs close follow up for better asthma
control.
.
Elevated WBC: pt elevated WBC was elevated on this admission
likely [**12-25**] steroid use. however, pt had elevated WBC on [**10-4**]
and it is unclear whether that level was prior to steroid
administration. Pt would benefit from follow up of her WBC
after she completes her dose of steroids prescribed for this
acute exacerbation.
.
#Smoking Cessation: Pt admits to smoking frequently, but
appears to be minimizing. Discussed smoking cessation. Pt has
no interest in nicotine patch, but has intention to quit in the
future. Pt would greatly benefit from smoking cessation as she
was admitted to the ICU for asthma exacerbation.
.
#Anemia: Pt had normocytic anemia. Anemia labs all normal, but
ferritin on the low side for a patient with an inflammatory
reaction. possible iron deficiency anemia secondary to blood
loss from menstrual periods. This issue was not actively worked
up and seems new as her hg/hct prior to [**10-7**] were normal.
Further work-up for her anemia would be appreciated.
.
#Hypothyroidism: TSH normal. subclinical, dx of Hashimoto??????s
thyroiditis. ? effect on lower extremity weakness, no
significant deficit on exam. we continued her levothyroxine.
TSH was normal. Patient has been seen by endocrine and notes
are in the computer.
.
#Sinus Tachycardia: Anxiety vs Dehydration (pt not eaten all
day). Denies pain. TSH was normal at 0.31. Heart Rate was
well controlled with control of respiratory symptoms as well as
low dose ativan. The patients hear rate slowly trended down as
her symptoms improved and inxiety decreased.
.
Patient had been doing well on day of discharge and ashtma
exacerbation had significantly improved. She was discharged
with close follow up in outpatient clinic as she has no PCP in
[**Name9 (PRE) 86**] and needs better management of her asthma. Also could
benefit from smoking cessation
Medications on Admission:
Levothyroxine 150mg PO
Albuterol inhaler
Discharge Medications:
1. levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO once a
day.
2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puff Inhalation every 4 hours as needed for shortness of
breath or wheezing.
Disp:*1 inhaler* Refills:*2*
3. azithromycin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
4. prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 4 days.
Disp:*12 Tablet(s)* Refills:*0*
5. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 inhaler* Refills:*2*
6. benzonatate 100 mg Capsule Sig: One (1) Capsule PO 3 times a
day as needed for cough.
Disp:*30 Capsule(s)* Refills:*0*
7. Guaifenesin AC 10-100 mg/5 mL Liquid Sig: Five (5) mL PO
every 4-6 hours as needed for cough: Do not drive if you take
this medication as it can potentially cause drowsiness.
Disp:*250 mL* Refills:*0*
8. dextromethorphan poly complex 30 mg/5 mL Suspension,
Sust.Release 12 hr Sig: Five (5) mL PO every twelve (12) hours
as needed for cough.
Disp:*500 mL* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses
- Asthma exacerbation
Secondary diagnoses
- Upper respiratory infection
- Hypothyroidism
- Normacytic anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname **],
You were admitted to [**Hospital1 **] Hospital for
increased cough and shortness of breath. It is likely that you
have a recent infection in your airway that triggered a more
severe asthma attack. While you are in the intensive care unit,
we have been treating you with nebulizers, antibiotics,
prednisone, and inhaled steroid called fluticasone. Many tests
were also sent to evaluate for your cough, including a Pertussis
test, and that result will come back later. Your cough and
asthma exacerbation improved.
While you are in the hospital, it was also noted that you are
anemic. It does not appear to be from low iron at this time.
It will be important for you to have this further evaluated in
the outpatient setting.
Your white blood cell counts, which is a marker of inflammation,
is high. It could be result of your upper airway infection, and
the prednisone can also contribute to it. You should have this
followed up when you see the doctor at the [**Hospital **]
Clinic.
Please note the following changes in your medications.
- Start azithromycin 500 mg, 1 tab, by mouth, once a day, for 2
more days, to be completed on [**10-11**]
- Start prednisone 20 mg, 3 tabs, by mouth, once a day, for 4
more days, to be completed on [**10-13**]
- Start fluticasone, 2 puff, inhaled, twice a day
- Start benzonatate 100 mg, 1 tab, three times a day, as needed
for cough
- Start guaifenesin AC 10-100mg/5mL, take 5 mL, every 4-6 hours,
as needed for cough. Do not drive when you taken this
medication.
- Start dextromethorphan 30 mg/5mL, take 5 mL, every 12 hours,
as needed for cough
You should follow up with doctor in the [**Hospital 1944**] clinic on
[**2182-10-11**] at 10:50AM.
You should follow up with your new primary care doctor [**First Name (Titles) 3**] [**Last Name (Titles) 19379**]d below.
Followup Instructions:
[**Hospital6 733**].
POST [**Hospital 894**] CLINIC
Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2182-10-11**] at 10:50 AM
You are scheduled to meet with your primary care doctor, Pei
[**Doctor Last Name **], on [**2182-12-18**] at 01:45 PM at the [**Hospital Ward Name 23**] Clinical Center [**Location (un) **], in the south suite. You should call [**Telephone/Fax (1) 250**] if you
need to change your appointment time.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"493.92",
"427.89",
"285.9",
"245.2",
"244.9",
"305.1",
"300.00",
"465.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9503, 9509
|
4771, 8301
|
342, 349
|
9681, 9681
|
3266, 4748
|
11707, 12273
|
2566, 2627
|
8392, 9480
|
9530, 9660
|
8327, 8369
|
9832, 11684
|
2642, 3247
|
2079, 2205
|
283, 304
|
377, 2059
|
9696, 9808
|
2227, 2379
|
2395, 2550
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,894
| 135,472
|
32793
|
Discharge summary
|
report
|
Admission Date: [**2186-12-28**] Discharge Date: [**2187-1-31**]
Date of Birth: [**2136-9-22**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Scopolamine
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
Seizures
Major Surgical or Invasive Procedure:
Lumbar puncture
PEG replacement on [**2187-1-8**] per Dr. [**Last Name (STitle) **]
[**Name (STitle) 76356**] shunt placed [**2186-1-25**] by Dr. [**First Name (STitle) **]
History of Present Illness:
The pt is a 50 yo RH man with a PMH of a brain stem mass
pilocytic astrocytoma s/p suboccipital craniotomy with
resection. He was BIBA from a rehab after having a "GTC". This
history is obtained from prior records as well as the patient
via the Spanish interpreter.
Mr. [**Known lastname **] was recently started on antibiotics for a bronchitis
infection. On [**12-27**] he was at rehab when he had a witnessed event
consisting of generalized limb jerking for about 5 minutes. This
was self limited after which he then had another episode lasting
about 1 minute. He was treated with 1gm of dilantin and 1mg of
ativan. He was sent for an MRI in the ED but was unable to
tolerate the study due to too many secretions in his trach. He
has had an LP which showed 19 WBC w/ a lymphocytic predominance
and 1 RBC. There was a normal glucose and protein. He was not
treated with any antibiotics.
Mr. [**Known lastname **] is amnesic to the event and does not recall what
happened today. He also is only oriented to person and believes
that he is living at home. He denies HA, vision changes,
numbness or sensory changes. He also denies dysphagia or
dysarthria. He feels that he legs have "lost power" but is
unable to characterize this further, He also reports abm pain
which is sharp and intermittent, mostly in the RUQ. He denies
changes in bowel or bladder, fevers, chills or cough. He is
unaware of recent bronchitis.
Past Medical History:
1. Medullary Astrocytoma: s/p stereotactic endoscopic
ventriculostomy on [**2186-1-25**] and surgical debulking of the fourth
ventricular exophytic pilocytic astrocytoma on [**2186-11-24**]. His MRI
from [**2187-1-17**] suggests an interval increase in ventricular size
with possible transependymal CSF migration.
2. HTN
Social History:
-EtOH: former
-tobacco: former per records (but states that he is still
smoking
2 PPD)
-drugs: denies
Family History:
-mother: HTN, stroke
-father: died
Physical Exam:
Vitals: T: 98.1 P: 80-95 R: 16 BP: 152/72 SaO2: 99% on trach
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx but limited view, trached with increased clear thick
secretions
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs with transmitted upper airway sounds, decreased
breath sounds @ bases, thick white secretions
Cardiac: nl. S1S2
Abdomen: soft, diffusely tender, worse in the RUQ, no
rebound/guarding, nl bowel sounds, no tympany
Extremities: no edema, no rashes
Neurologic:
-Mental Status: (via Spanish interpreter) Alert, oriented only
to person and hospital but not month ([**Month (only) 462**]), year or day.
Pt does not know the name of the hospital but when told he is
able to identify that he is in [**Location (un) **]. Unable to relate hx,
amnesic to the event and believes he lives at home. Inattentive,
unable to even tell me DOW forwards. His speach is fluent w/
intact repitition per the translator, but he only provides [**2-27**]
word answers. There are no paraphasic errors or dysarthria
however what he says is not always logical (says he doesn't want
to talk because he hasn't washed his mouth). Able to name high
frequency object. Comprehension seems slow and inconsistent at
times,
despite the translator. No neglect but + apraxia bilaterally
CN
I: not tested
II,III: pt does not cooperate with formal VF testing but does
blink to threat bilaterally, pupils 4mm->2mm bilaterally, fundi
normal
III,IV,V: does not bed sclera fully in any direction but this is
symmetrical and he denies diplopia. no ptosis. non-extinguishing
nystagmus in all directions, worse with gaze to the R.
V: sensation intact V1-V3 to pin
VII: R NLF flattening, slow movements of the R side of the face.
VIII: hears voice bilaterally
IX,X: palate elevates symmetrically, unable to visualize the
uvula
[**Doctor First Name 81**]: SCM/trapezeii 5- bilaterally
XII: tongue protrudes midline, tongue movements are slow and
clumsy however
Motor: Normal bulk, increased tone in LE R>L. few beats of
asterixis, + postural tremor. No myoclonus. No pronator drift.
Motor exam limited due to motor impersistence however he appears
to have full strength with maximal impulse testing
Delt [**Hospital1 **] Tri WE FE Grip
C5 C6 C7 C6 C7 C8/T1
L 5- ------------------->
R 5 ------------------->
IP Quad Hamst DF [**Last Name (un) 938**] PF
L2 L3 L4-S1 L4 L5 S1/S2
L 5- ------------------->
R 5 ------------------->
Reflex: No clonus
[**Hospital1 **] Tri Bra Pat An Plantar
C5 C7 C6 L4 S1 CST
L 1------------- 0 Flexor
R 1------------- 0 Flexor
-Sensory: unreliable, no deficits pinprick, but cold sensation,
vibratory sense, proprioception are extremely inconsistent.
Extinction is also unreliable as he states I am touching him on
both sides even when I am not touching him at all.
-Coordination: dysdiadochokinesia w/ [**Name (NI) 11140**], pt does not cooperate
with HSK bilaterally.
Pertinent Results:
[**2186-12-27**] 11:00PM BLOOD WBC-6.7 RBC-3.58* Hgb-10.3* Hct-31.3*
MCV-87 MCH-28.9 MCHC-33.1 RDW-14.3 Plt Ct-390
[**2186-12-27**] 11:00PM BLOOD Glucose-109* UreaN-11 Creat-1.0 Na-138
K-4.8 Cl-101 HCO3-29 AnGap-13
[**2186-12-27**] 11:00PM BLOOD ALT-22 AST-27 AlkPhos-96 Amylase-105*
TotBili-0.2
[**2186-12-28**] 09:40PM BLOOD cTropnT-<0.01
[**2187-1-9**] 08:03PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2187-1-1**] 09:40PM BLOOD HIV Ab-NEGATIVE
[**2186-12-27**] 11:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2186-12-28**] 04:30AM CEREBROSPINAL FLUID (CSF) WBC-52 RBC-1* Polys-0
Lymphs-83 Monos-16 Atyps-1
[**2186-12-28**] 04:30AM CEREBROSPINAL FLUID (CSF) WBC-19 RBC-1* Polys-0
Lymphs-84 Monos-16
[**2186-12-28**] 04:30AM CEREBROSPINAL FLUID (CSF) TotProt-75*
Glucose-63
HSV PCR negative
EEG [**12-28**]: Largely normal EEG for drowsiness. There was minimal
waking background. There were no areas of prominent focal
slowing, and there were no epileptiform features.
[**12-28**] CT head:
1. Status post suboccipital craniectomy with extensive
post-surgical changes and suggestion of possible residual tumor
at the caudal aspect of the fourth ventricle without significant
interval change.
2. Interval resolution of tiny intraventricular hemorrhage. No
new
intracranial hemorrhage is identified.
.
MRI OF THE BRAIN WITHOUT AND WITH GADOLINIUM [**2187-1-17**]
Comparison is made with [**2186-11-25**].
IMPRESSION:
Residual enhancing lesion in the left posterior medulla/fourth
ventricle
suggestive of residual neoplasm.
Interval increase in ventricular size and increase in
periventricular
hyperintensities which could represent transependymal CSF
migration,
ventricular enlargement vs. vasculitis or inflammatory lesions.
Interval enlargement of non-enhancing lesion in the right
frontal lobe of
uncertain etiology. Lack of enhancement argues against
neoplastic etiology.
Recommend attention on follow-up imaging.
No evidence for acute ischemia.
.
[**2187-1-20**] MRI BRAIN with CSF FLOW STUDY:
IMPRESSION:
Flow is noted in the third ventricle, aqueduct, and enlarged
fourth ventricle as well as at the 3rd ventriculostomy.
.
[**2187-1-24**] VIDEO SPEECH AND SWALLOW STUDY:
There was aspiration after the swallow from residual that could
not be passed through the upper esophageal sphincter. The
patient continues to present with severe to profound pharyngeal
dysphagia.
.
12/29/08Lumbar puncture: Openning pressure of 21.5, no evidence
of infection.
.
[**1-26**] CT head: Normal postoperative appearance.
Brief Hospital Course:
Mr. [**Known lastname **] is a 50 year-old RH man with a PMH of a pilocytic
astrocytoma s/p partial surgical resection who presented with a
seizure from an OSH. His neurologic exam on admission revealed
marked encephalopathy, characterized by lack of orientation and
inattention but no paraphasic errors, dysarthria or difficulty
naming. On exam, he had R facial droop with very mild L sided
weakness of UMN pattern. Given unclear precipitation for his
seizure (brain stem tumor is not epileptogenic), he underwent LP
which showed pleocytosis (WBC 19~52) with lymphocytic
predominance. He was initially covered with vancomycin,
ceftriaxone and acyclovir. Given that he remained afebrile,
normal EEG and clearing of mental status with no growth on CSF
culture, his ABX were discontinued on HD #3.
The following other issues were addressed during his stay:
# Medullary Astrocytoma: s/p stereotactic endoscopic
ventriculostomy on [**2186-1-25**] and surgical debulking of the fourth
ventricular exophytic pilocytic astrocytoma on [**2186-11-24**]. His
MRI from [**1-17**] suggests an interval increase in ventricular size
with possible transependymal CSF migration. Neurosurgery was
consulted. A repeat MRI with CSF PULSE SEQUENCE FLOW to assess
the patency of the third ventriculostomy and CSF flow in general
was obtained, this showed patent flow through the
ventriculostomy. He was continued on Keppra [**Hospital1 **]. A series of
family meetings were held, and Palliative care ([**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) 1764**]) was
consulted to assist the family with decision making. Due to
increased ventricular size, Dr. [**First Name (STitle) **] from Neurosurgery was
called to place a VP shunt on [**2187-1-26**] which went well. He was
given 3 days of gentamicin and vancomycin for prophylactic
therapy. He has a right frontal surgical scar which is healing
well. He will follow up with Dr. [**First Name (STitle) **] on [**3-1**] for appt
and head CT.
# Encephalopathy: Multifactorial delirium. Patient was noted to
be confused on admission. LP done and described as above
without evidence of infection. His mental status improved
dramatically from [**1-15**] - [**1-20**]. MR head on [**1-17**] showed
ventricular dilatation and a VP shunt was placed on [**1-26**]. A
follow up CT scan was unremarkable. His encephalopathy
continued to improve. At the time of discharge the patient was
alert and oriented to place and name, year was noted as [**2182**].
He was continued on Zyprexa qhs, given 10 days of thiamine 100mg
IV daily per his Neurononcologist Dr [**Last Name (STitle) 724**]. Lines / tubes / meds
were minimized as able.
# Secretions/bulbar dysfunction: For this patient was treated
with chest PT, suction q2H and PRN. He was also given a
scopalamine patch but developed delirium related to this. This
was discontinued. The team and family considered replaceing his
tracheostomy but it was felt this will not prevent aspiration.
Measures continued to be taken to improve his swallowing
function as his greatest risk was repeated aspiration pneumonia
from this. A video swallow study on [**2187-1-24**] showed aspiration
of nearly everything and patient was kept NPO with tube feeds
via PEG.
# Acute renal failure: Mr. [**Known lastname **] developed ARF with Cr bumping
up to 2.6 likely due to acyclovir +/- vancomycin given FENa 5%.
Cr improved to 1.8-2.0 with hydration and remained stable at
that level.
# Nutrition: On HD#1, while he was still quite encephalopathic,
he pulled his PEG out. Foley was put in to keep tract open but
it went into peritoneum hence removed and Dr. [**Last Name (STitle) **] was
consulted given that he placed the PEG during the prior
admission. Given that he had peritonitis, replacement of the
PEG was deferred for 1 week and in the meantime, he was given
nutrition through NGT which needed to be replaced x3 times given
that he pulled it out during confusion. The PEG was replaced
finally on [**1-8**]. Following PEG placement pt complained of
abdominal pain and CT was done which was not indicative of acute
issues but patient did have bilateral free air likely due to
insufflation during PEG replacement. Patient has been receiving
tube feeds since that time, gradually increasing to a goal of
65cc/hr, currently at 35cc/hr. He is strictly NPO.
# Tracheostomy: On HD#7, he also removed his own trach but
because he had good cough reflex without respiratory distress,
his trach was not replaced. He has been oxygenating well on
room air.
# Aspiration PNA: He completed 8 days of Vancomycin and cefepime
for hospital acquired aspiration pneumonia. Repeat CXRs were
improved.
# Atrial fibrillation: During hospitalization patient went into
Afib with RVR (Pulse into 140's). He was started on diltiazem
QID with good rate control. Patient subsequently converted to
sinus rhythm. It was decided to hold anticoagulation at this
time due to risk of intracranial hemorrage.
# Positive UA: Patient had foley catheter placed for
incontinence on [**2187-1-20**] and d/c'd on [**2187-1-23**]. A Pre-operative
U/A showed 11 WBC and patient spiked fever to 100.7 and so
treated with Bactrim for 7 days, ending the day of discharge.
.
# Anemia: Likely due to chronic disease and serial phlebotomy.
Hematocrit remained stable.
.
#GI/FEN: Patient has G tube, has pulled it out earlier in
hospitalization. Again failed VIDEO SWALLOW STUDY on [**2187-1-24**]
-> needs to remain NPO. PEG replaced and tube feeds continued.
Abdominal binder.
.
# PPX: heparin sc tid cleared by neurosurg, continue [**Hospital1 **] PPI
Medications on Admission:
Colace 100 mg po bid, Famotidine 20 mg po bid,
Diltiazem HCL 60 mg qid, Senna, Scopalamine 1 patch q 3 days,
Bisacodyl 1 [**Last Name (un) **] rectal daily, Metoclopramide 10 mg q 6h,
Lisinopril 20 mg po bid, HCTZ 25 mg q day, Nystatin 5 ml qid,
Albuterol/Ipatropium, Fondaparinux 2.5 mg sc daily, Flagyl 500
mg
tid, Ferrous Sulfate 300 mg [**Hospital1 **], Mupirocin
Per ED records: (pt does not know which medications or doses he
is taking)
Lorazepam 0.5 mg Tab1 Tablet(s) by mouth take one tablet 1hr
prior, one tab right before MRI
Dexamethasone 4 mg Tab 1 Tablet(s)(s) by mouth twice daily
Lisinopril-Hydrochlorothiazide 20 mg-25 mg Tab 1 (One) Tablet(s)
by mouth once a day
Metoprolol 100 mg Tab 1 (One) Tablet(s) by mouth once a day
Amlodipine 10 mg Tab 1 (One) Tablet(s) by mouth once a day
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1)
Injection TID (3 times a day).
2. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed.
3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) Inhalation Q6H (every 6 hours) as
needed.
4. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation
Q6H (every 6 hours) as needed.
5. Acetaminophen 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO q6h as
needed as needed for fever or pain.
6. Levetiracetam 100 mg/mL Solution [**Hospital1 **]: Seven [**Age over 90 1230**]y
(750) mg PO BID (2 times a day).
7. Olanzapine 5 mg Tablet, Rapid Dissolve [**Age over 90 **]: One (1) Tablet,
Rapid Dissolve PO QHS (once a day (at bedtime)).
8. Diltiazem HCl 30 mg Tablet [**Age over 90 **]: One (1) Tablet PO QID (4
times a day).
9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
10. Nystatin 100,000 unit/mL Suspension [**Last Name (STitle) **]: Five (5) ML PO QID
(4 times a day) as needed.
11. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension [**Last Name (STitle) **]:
15-30 MLs PO QID (4 times a day) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Pilocytic astrocytoma in brainstem s/p subtotal resection
Encephalopathy
Seizures
Hypertension
Anemia of chronic disease
Urinary tract infection
Bulbar dysfunction
Paroxysmal atrial fibrillation
Acute renal failure
Discharge Condition:
Stable
Discharge Instructions:
You returned with 2 episodes of witnessed generalized
tonic-clonic seizures while you were at rehab. Upon arrival,
you were further evaluated including lumbar pucture and imaging.
Given pleocytosis, you were initially started on broad-spectrum
antibiotics but upon no growth, your antibiotics were
discontinued and you remained afebrile without seizure activity
during this admission.
.
On the night of your admission, you removed your own PEG. PEG
was replaced per Dr. [**Last Name (STitle) **] on [**1-8**] without complication.
Also, you removed your own trach on [**1-5**] but given that you
were breathing without difficulty with good cough reflex, it was
not replaced.
.
An MRI of your brain and a spinal tap showed increased pressure
in and around your brain. Neurosurgery placed a
ventriculo-peritoneal shunt to help releive this pressure. A
follow up CT was within normal limits.
.
Most of your medications have changed. Please continue your
meds as prescribed. Also, please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**]
as outpatient in addition to following up with your PCP 2~4
weeks after discharge from rehab.
.
You failed a video speech and swallow study. You cannot take
anything by mouth or you are at risk of choking, getting
pneumonia and dying from this. You are getting tube feeds.
If you or your family notice further confusion, if you develop
any chest pain, shortness of breath, abdominal pain or other
concerning symptoms please call your doctor.
Followup Instructions:
You have follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] (neuro-oncology) on
[**2187-2-5**] - please call ([**Telephone/Fax (1) 6574**] if you have questions.
Dr. [**Last Name (STitle) 724**] will help to set you up with Radiation Oncology.
RADIOLOGY MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2187-2-5**] 1:55
Please follow up with your PCP [**Name Initial (PRE) 176**] 2~4 weeks of discharge
from rehab facility.
You should also follow up with Dr. [**First Name (STitle) **] in 3 weeks and have head
CT at that time. The head CT will be done on the [**Hospital Ward Name 517**]
[**Location (un) 470**] at 3PM on [**3-1**]. You will see Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
the same day at 3:30 on LMOB-3A.
|
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icd9cm
|
[
[
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[
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] |
icd9pcs
|
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[]
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2280, 2384
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,223
| 183,972
|
7399
|
Discharge summary
|
report
|
Admission Date: [**2142-6-24**] Discharge Date: [**2142-7-26**]
Date of Birth: [**2090-10-12**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Codeine
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
s/p Fall,admitted for w/u of hypotension. Found to have AS by
echo referred to cardiac surgery.
Major Surgical or Invasive Procedure:
[**2142-7-10**] Cardiac Catheterization
[**2142-7-10**] Aortic Valve Replacement w/ 25mm [**Company 1543**] Mosaic Tissue
Valve
[**7-18**] thoracentesis
[**7-20**] pericardiocentesis in cath lab
[**7-20**] exploratory laparotomy with ligation of L phrenic artery
History of Present Illness:
51 y/o male w/ type 2 DM, peripheral neuropathy, Hep C, HTN, and
recent right TMA who was found to have staph endocarditis and
probable septic brain emboli in [**5-22**]. No plan during that
hospitalization for [**Name (NI) 1291**], pt was discharged on Vanco. Pt d/c'd
from [**Hospital1 18**] on [**6-22**] and presented today ([**6-24**]) after a falling down
stairs with damage to his recently operated right foot. In [**Name (NI) **],
pt was found to be severely anemic, hypotensive, and also with
20lb weight gain since prior hospitalization. Also, noted to be
hyponatremic and in ARF. He was transfused and admitted for
ARF/fluid overload. Pt treated and stabalized by medical service
then on [**8-10**] brought to operating room for Aortic valve
replacement.
Past Medical History:
Aortic Valve Endocarditis (MRSA), Diabetes Mellitus w/
peripheral neuropathy, Seizure Disorder, Hepatitis C, Peripheral
Vascular Disease s/p R foot Metatarsal Amputation, Right foot
osteomyelitis, Degenerative Joint Disorder, Barrett's Esophagus,
s/p Splenectomy, Probable septic emboli to parietal lobe, Torn
rotator cuff, h/o Etoh use/abuse
Social History:
SHx: Drinks EtOH (?am't), h/o past drug use, denies smoking.
Lives at home by self, brother lives above him but is frequently
away. Works as a material handler moving things. Has a 24yo
daughter who he cares for.
Family History:
FHx: mother died of cancer (smoker), o/w NC
Physical Exam:
Admission:
VS: 98 18 106/60 5'(" 99.6kg
HEENT: EOMI, PERRLA, sclera anicteric
Neck: Supple, FROM -JVD
Chest: Mostly CTAB w/ some crackles at bilat bases
Heart: RRR -c/r/m/g
Abd: Soft, NT/ND +BS
Ext: Warm, [**12-18**]+ edema, -varicosities, dressing right foot
Neuro: MAE, non-focal, A&O x 3
Discharge
VS: T89 HR 82SR BP95/57 RR 20 Sat 96% RA
Neuro: A&Ox3, nonfocal
Pulm: CTA bilat
CV: RRR, sternum stable incision CDI
Abdm: Soft/NT/ND/NABS, +BM. Abdm incision, CDI, no erythema or
drainage
Ext [**12-18**]+edema, Rt metatarsal amputation wound clean with VAC in
place
Pertinent Results:
[**2142-6-24**] 10:20AM BLOOD WBC-9.0 RBC-2.26* Hgb-6.9*# Hct-21.3*
MCV-94 MCH-30.7 MCHC-32.7 RDW-16.5* Plt Ct-224
[**2142-7-10**] 03:14AM BLOOD WBC-13.7* RBC-3.81* Hgb-11.3* Hct-35.5*
MCV-93 MCH-29.8 MCHC-32.0 RDW-17.4* Plt Ct-376
[**2142-7-23**] 06:32AM BLOOD WBC-12.4* RBC-3.41* Hgb-10.3* Hct-30.1*
MCV-88 MCH-30.3 MCHC-34.4 RDW-16.3* Plt Ct-293
[**2142-6-24**] 01:35PM BLOOD PT-15.6* PTT-24.8 INR(PT)-1.4*
[**2142-7-12**] 02:41AM BLOOD PT-17.6* PTT-35.8* INR(PT)-1.6*
[**2142-7-22**] 02:42AM BLOOD PT-14.9* PTT-39.8* INR(PT)-1.3*
[**2142-6-24**] 10:20AM BLOOD Glucose-160* UreaN-28* Creat-1.5* Na-132*
K-7.7* Cl-109* HCO3-16* AnGap-15
[**2142-7-12**] 02:41AM BLOOD Glucose-102 UreaN-34* Creat-2.5* Na-135
K-4.1 Cl-101 HCO3-25 AnGap-13
[**2142-7-23**] 06:32AM BLOOD Glucose-94 UreaN-19 Creat-1.5* Na-131*
K-4.4 Cl-99 HCO3-27 AnGap-9
[**2142-7-22**] 10:10AM BLOOD ALT-37 AST-61* AlkPhos-125* Amylase-747*
TotBili-1.1
[**2142-7-23**] 06:32AM BLOOD Calcium-7.5* Phos-3.7 Mg-2.0
[**2142-6-28**] 05:50PM URINE Blood-LG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM
[**2142-6-28**] 05:50PM URINE RBC-[**2-18**]* WBC-[**5-26**]* Bacteri-MANY
Yeast-NONE Epi-[**2-18**]
[**2142-7-26**] 06:36AM BLOOD WBC-11.6* RBC-3.57* Hgb-10.4* Hct-32.0*
MCV-90 MCH-29.3 MCHC-32.6 RDW-16.7* Plt Ct-442*
[**2142-7-26**] 06:36AM BLOOD PT-15.6* PTT-32.2 INR(PT)-1.4*
[**2142-7-26**] 06:36AM BLOOD Glucose-93 UreaN-16 Creat-1.4* Na-134
K-4.6 Cl-101 HCO3-27 AnGap-11
[**2142-7-24**] 06:00AM BLOOD ALT-33 AST-58* AlkPhos-144* Amylase-175*
TotBili-1.2
[**2142-7-24**] 06:00AM BLOOD Lipase-27
[**2142-7-25**] 05:59AM BLOOD Vanco-17.9*
Brief Hospital Course:
Pt was managed on vascular service for Right food wound until
[**6-29**] when he was transferred to medicine. On [**7-7**], pt was
transferred to CCU after having episode of VT vs. SVT w/
aberrancy. Since then, hyypotension resolved, but still in ARF
with intermittent hyperkalemia, as well as fluid overload. Echo
on [**7-3**]-severe AI. Patient seen by neurology noted to have some
lesions in the brain on MRI thought to be septic emboli recent
MRI with improvement. Also seen by dental who recommended tooth
extraction prior to surgery. Renal also following for [**Doctor First Name 48**].
Previously MRSA endocarditis, most recent blood cx positive for
dipthoroides and E. feceium sensitive to vanc, being managed on
vancomcyin dosed by level. Also seen by hepatology given h/o
hep C prior to [**Doctor First Name 1291**]. Cardiology consulted for cath. Cath showed
Sev Aortic insufficiency. Pt treated and stabalized by medical
service then on [**8-10**] brought to operating room for Aortic valve
replacement. Did well in immediate postoperative period,
extubated on POD 1 and transferred from ICU to stepdown floor on
POD 4. Initially postop started on CVVHD which was stopped on
[**7-12**] with resolution of ATN
After transfer to floor noted to have increased cardiac
sillouette by CXR followed by Echo and ultimately a
pericardiocentesis. Pericardial tap c/b laceration of L phrenic
artery which required exploratory laparotomy and repair if
phrenic artery. Pt extubated on POD1 and weaned from vasoctive
medications. PO diet resumed on POD 2 and transferred from ICU
to floor. Patient had uneventful course after ex lap and on POD
16/6 it was decide he was stable and ready for transfer to
rehab.
Medications on Admission:
Aspirin 81mg qd, Protonix 40mg qd, Neurontin 300mg qhs, Keppra
1500mg [**Hospital1 **], Nstatin, Miconazole powder, Vanco 1gm q24, Oxycodone
Discharge Medications:
1. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
Disp:*30 Capsule(s)* Refills:*1*
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*1*
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
Disp:*1 1* Refills:*1*
10. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*0*
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Tablet, Delayed Release (E.C.)(s)
12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
13. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed.
14. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
15. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO Q12H (every 12 hours).
16. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO once a day.
17. Vancomycin 1,000 mg Recon Soln Sig: One (1) gm Intravenous
once a day for 2 weeks.
18. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 10 days: then 40mg QD.
19. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every six (6) hours as needed for breakthrough pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2732**] & Retirement Home - [**Location (un) 55**]
Discharge Diagnosis:
Aortic Insufficiency w/ Aortic Valve Endocarditis s/p Aortic
Valve Replacement
Acute Renal Failure
PMH: Aortic Valve Endocarditis (MRSA), Diabetes Mellitus w/
peripheral neuropathy, Seizure Disorder, Hepatitis C, Peripheral
Vascular Disease s/p R foot Metatarsal Amputation, Right foot
osteomyelitis, Degenerative Joint Disorder, Barrett's Esophagus,
s/p Splenectomy, Probable septic emboli to parietal lobe, Torn
rotator cuff, h/o Etoh use/abuse
Discharge Condition:
Good
Discharge Instructions:
[**Month (only) 116**] take shower. Wash incision and gently pat dry. Do not take
bath.
Do not apply lotions, creams, ointments or powders to incision.
Do no lift more than 10 pounds for 2 months.
Do not drive for 1 month.
If you develop a fever or notice drainage from chest incision,
please contact office.
Please call to schedule all follow-up appointments.
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in 4 weeks.
Dr. [**First Name8 (NamePattern2) 10599**] [**Last Name (NamePattern1) 1968**] in [**12-18**] weeks
Cardiologist(Dr [**Last Name (STitle) 911**]in [**1-19**] weeks
Completed by:[**2142-7-26**]
|
[
"780.39",
"427.41",
"998.2",
"997.69",
"070.70",
"423.9",
"427.1",
"584.9",
"250.60",
"V09.0",
"357.2",
"998.11",
"041.11",
"424.1",
"521.00",
"428.0",
"998.12"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"37.0",
"37.21",
"88.72",
"54.12",
"38.95",
"39.61",
"37.22",
"35.21",
"23.19",
"34.91",
"38.86"
] |
icd9pcs
|
[
[
[]
]
] |
8268, 8358
|
4369, 6083
|
370, 635
|
8848, 8854
|
2699, 4346
|
9263, 9502
|
2047, 2092
|
6274, 8245
|
8379, 8827
|
6109, 6251
|
8878, 9240
|
2107, 2680
|
235, 332
|
663, 1434
|
1456, 1800
|
1816, 2031
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,237
| 150,811
|
16258
|
Discharge summary
|
report
|
Admission Date: [**2150-12-6**] Discharge Date: [**2150-12-18**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**Doctor First Name 2080**]
Chief Complaint:
Patient found unresponsive/confused at home, brought to hospital
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 46366**] is a [**Age over 90 **] M with a medical history notable for COPD on
home oxygen, coronary artery disease, deep vein thrombosis s/p
IVC filter in [**2148**] (not on anticoagultion due to history of GI
bleed). At baseline, he lives independently, he pays his own
bills but he does not drive. He was last seen 1 week prior to
admission by his sister but his neighbors then noticed his
newpapers began collecting in his [**Last Name (un) **] lobby this week.
He was unable to provide further history, including ROS and
other events leading to the admission, due to delirium. This
continued on admission to the medicine service.
He was found at home by EMS on [**12-6**]. On the initial evaluation
by EMS, he was minimally responsive, his temperature was 100.6,
and O2 sats were in the 70s on room air (improved to 90s on non
re-breather).
On arrival to the [**Hospital1 18**] ED he was initially hypertensive but his
blood pressures decreased to SBP 100 in the setting of a
temperature of 100.0. In the ED, he received 5L of normal saline
and had a normal head CT.
In the [**Hospital Unit Name 153**], his evaluation was notable for a left-sided opacity
on CXR of unclear etiology, a [**Name (NI) **] that revealed a dilated RV
with severe pulmonary hypertension (no [**Name (NI) **] available for
comparison), elevated cardiac biomarkers, and a PECT that
revealed no PE and did not reveal a left basilar pneumonia. In
the [**Hospital Unit Name 153**] he received levofloxacin, ceftriaxone, and was started
on Lasix for right heart failure. He was also evaluated by the
geriatrics team and recommended to start on Haldol for
agitation.
On arrival to the floor, he has no complaints. He is confused
and does not answer questions appropriately but is comfortable.
Past Medical History:
- HTN
- COPD - [**2143**] FVC 74% of predicted, FEV1 67% of predicted,
FEV1/FVC 90% of predicted, TLC 111% of predicted, RV 145% of
predicted. Intermitent home supplemental O2 use.
- BPH
- Anemia
- GERD, past +H.pylori
- Gout
- Inguinal hernia
- DVT ([**2148**]) s/p IVC filter
- CAD - stable angina
Social History:
Lives by himself, independent in IDLs, but not all IADLs (see
HPI). No current VNA/HHA. Tobacco - none currently, quit 40+
years ago. EtOH - none. Denies IV, illicit, or herbal drug use.
His wife passed away 2 years PTA, and family notes that he has
been more sad lately.
Family History:
Significant for gout in his father.
Physical Exam:
Physical exam on arrival to the floor:
- Vital signs: T 99.2, P 92, BP 120/60, 96% on 4LNC.
- Gen: Thin, elderly male sleeping when I enter the room. When I
wake him he is pleasant and alert. He does not participate in
the exam though and he is oriented x 1.
- HEENT: Oropharynx is dry.
- Neck: Supple. No nuchal rigidity.
- Chest: Breathing comfortably on 4LNC. I appreciate no wheezes
or rhonchi but he has bilateral rales in mid-lung fields.
- CV: PMI normal size and not displaced. Has PA lift with no
apprecaible RV heave. On my exam he is tachycardic. Regular
rhythm. Regular pulses. Normal S1, S2. III/VI HSM at LSB. JVP 12
cm when sitting upright in bed (90 degrees).
- Abdomen: Normal bowel sounds. Soft, nontender, nondistended.
No pulsatile liver appreciated.
- Extremities: 2+ ankle edema to the mid-calf.
- MSK: Joints with no redness, swelling, warmth, tenderness.
- Skin: Bruising on left side but no open areas of skin.
- Neuro: Alert, oriented x1. CN appear intact but he does no
cooperate with exam. His speech and language appear normal but
answers questions such as "where do you live" with a person's
name. He is smiling and appears comfortable.
Pertinent Results:
- [**12-6**] CXR with left basilar opacity, infection vs. atelectasis
- [**12-6**] PECT with centrilobular moderate emphysema, no PE, and
no evidence of pneumonia
- [**12-6**] Urine culture no growth to date
- [**12-6**] Urinary Legionella negative
- [**12-6**] Blood culture no growth to date
- [**12-7**] Blood culture no growth to date
CT Head:
FINDINGS: The study is severely degraded by motion artifact.
Within this
limitation, there is no evidence of acute intracranial
hemorrhage or acute
major vascular territory infarction. Ventricles and sulci are
prominent
consistent with age-related involutional changes. There is some
low-attenuating regions within the periventricular white matter
consistent
with chronic small vessel ischemic disease. There is evidence of
left
maxillary sinus disease. No acute fractures are identified.
Bilateral
mastoid air cells are clear.
IMPRESSION:
1. No acute intracranial hemorrhage.
2. Left maxillary sinus disease.
CT C spine
IMPRESSION:
1. No evidence of acute fracture. Osseous fragment superior to
the odontoid
process appears well corticated and may represent either old
fracture or
degenerative changes; however, clinical correlation is
recommended.
2. Multilevel degenerative changes noted.
CTA Chest:
The study is extremely limited due to significant motion
artifacts. The
opacification of the pulmonary arteries is satisfactory, and in
the areas that
can be evaluated, no evidence of pulmonary embolism is
demonstrated including
the main pulmonary arteries, the lobar pulmonary arteries, and
the segmental
and subsegmental pulmonary arteries. Heart size is significantly
enlarged.
There is no pericardial effusion but there is bilateral
small-to-moderate
pleural effusion. Aorta is calcified but of normal diameter. No
pericardial
effusion is noted. No mediastinal gross abnormalities have been
demonstrated.
Coronary arteries are significantly calcified.
The imaged portion of the upper abdomen does not reveal any
abnormality.
There are no bone lesions worrisome for infection or neoplasm.
Degenerative
changes are seen throughout the thoracic spine.
Extensive calcifications of the mitral annulus are present.
The airways are patent till the level of subsegmental bronchi
bilaterally.
Centrilobular moderate emphysema affects upper lungs
bilaterally. Subpleural
interstitial changes are noted, diffuse, mostly affecting the
right lung but
extremely limited for evaluation due to motion artifacts, most
likely
representing chronic changes.
IMPRESSION:
Within the limitations of this technically challenging study, no
evidence of
pulmonary embolism is seen. Small bilateral pleural effusions
are present as
well as some degree of emphysema and chronic interstitial
changes with no
evidence of infectious process or other acute abnormalities that
might explain
patient's symptoms.
ECHO:
The left atrium is moderately dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. There is moderate symmetric left ventricular
hypertrophy. The left ventricular cavity is unusually small.
Left ventricular systolic function is hyperdynamic (EF>75%).
There is no ventricular septal defect. The right ventricular
cavity is moderately dilated with moderate global free wall
hypokinesis. There is abnormal septal motion/position consistent
with right ventricular pressure/volume overload. The aortic root
is mildly dilated at the sinus level. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. There is severe pulmonary
artery systolic hypertension. There is a trivial/physiologic
pericardial effusion.
CXR:
Enlargement of the cardiac silhouette is stable. Moderate to
large right and
small to moderate left pleural effusions have increased;
bibasilar opacities
have increased, a combination of increasing pleural effusions
and atelectasis,
superimposed infection cannot be excluded.. There is new mild
vascular
congestion. There is no pneumothorax.
Discharge Labs:
145 / 100 / 17 / 87
3.1 / 35 / 0.9
.
Ca: 9.3 Mg: 1.4 P: 2.4
Brief Hospital Course:
Delirium/Acute Encephalopathy: Likely a combination of
aspiration PNA, atrial fibrillation, and underlying
dementia/decline. He initially required prn Haldol. Geriatrics
was consulted. Over time and with treatment he stabilized. His
baseline on discharge was: NOT requiring haldol, lucid,
pleasant, conversant, occasionally oriented.
Atrial fibrillation with RVR: During hospitalization went into
Afib with RVR to 150s with low blood pressure. He was started
on Diltiazem, requiring increasing doses and IV push. Digoxin
was started as an adjunct. He seemed to settle on diltiazem
90mg QID with Digoxin 0.125mg daily. EKG did not show dig
effect. We recommend continuing this regimen. He may have
intermittent runs of afib with RVR to the 130s, this should
resolve. WOuld allow it to correct on its own unless very
symptomatic.
- Consider transitioning to long acting dilt. Monitor dig level
and adjust appropriately
Aspiration PNA: Treated with full course of Levo/Flagyl. S+S
eval improved during admission. See current diet
recommendations. Would recommend re-evaluation and advance if
tolerates.
Right sided heart failure, Pulm HTN, acute on chronic diastolic
CHF: Confirmed on echo and by exam with elevated JVD and
peripheral edema. Diuresis was limited by low blood pressure
and afib. He diuresed well to lasix 10mg IV and was
transitioned to 10mg daily maintenance, with Kcl supplement
- Adjust lasix, KCL prn based on exam and electrolytes
- rate control with dilt
h/o DVT/afib: Started lovenox. Consider transition to coumadin
based on family wishes
Constipation: Required aggressive bowel regimen
BPH: Held doxasozin given BP issues, oxybutynin given delirium.
Consider restarting at your discretion.
Sister involved in care, and in making medical decisions for
patient. Patient is DNR/DNI, and would discuss with sister if
aggressive care short of resuscitation is needed.
Medications on Admission:
Medications per OMR:
Tylenol prn
Aspirin 81mg PO
Combivent 2 puffs q6 hours prn
Colace 100mg PO BID prn
Doxazosin 2mg PO daily
Fiber laxative PO daily
Golytely prn
Metoprolol 25mg PO BID
Nasal saline
Nitroglycerin prn
Oxybutynin 20mg PO daily
Ranitidine 150mg PO BID
Allergies: Penicillin
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
3. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) ML PO BID (2
times a day).
4. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
5. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. acetaminophen 650 mg Suppository Sig: [**2-7**] Suppositorys Rectal
Q6H (every 6 hours) as needed for pain.
7. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) injection
Subcutaneous QD (): afib, h/o DVT.
8. haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
9. levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) neb Inhalation every 4-6 hours as needed for SOB.
10. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
dose PO once a day as needed for constipation.
12. senna 8.6 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as
needed for Constipation.
13. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
15. potassium chloride 10 mEq Capsule, Sustained Release Sig:
One (1) Capsule, Sustained Release PO once a day: with lasix.
16. Outpatient Lab Work
Please check chem 7, magnesium within the next 3 days
17. medication adjustment
adjust lasix, KCL supplement based on peripheral edema and
potassium level
18. diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Discharge Disposition:
Extended Care
Facility:
[**First Name8 (NamePattern2) 3075**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for Living
Discharge Diagnosis:
Aspiration pneumonia
Delirium, acute encephalopathy
Atrial fibrillation/Flutter
CHF, right-sided, diastolic
Gout flare
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Mr [**Known lastname 46366**],
It was a pleasure to care for you during this admission. You
were admitted when you were sick at home and confused. You were
found to have a pneumonia and this has improved. You also had a
fast heart rate, that needed medicine to slow it down. You got
confused, and this has also been getting better. You were also
given diuretics to eliminate fluid. You were started on Lovenox
as well for blood thinning.
Please take all medications as prescribed and keep all follow up
appointments
Followup Instructions:
Department: [**Hospital1 18**] [**Location (un) 2352**]
When: THURSDAY [**2151-1-14**] at 1:30 PM
With: [**First Name4 (NamePattern1) 1575**] [**Last Name (NamePattern1) 1576**], MD [**Telephone/Fax (1) 1579**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
|
[
"428.0",
"530.81",
"428.33",
"401.9",
"427.32",
"507.0",
"274.01",
"414.01",
"V46.2",
"600.00",
"348.30",
"V12.51",
"V49.86",
"427.31",
"780.09",
"413.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12267, 12408
|
8293, 10205
|
286, 292
|
12571, 12571
|
3987, 4328
|
13367, 13725
|
2747, 2784
|
10546, 12244
|
12429, 12550
|
10231, 10523
|
12824, 13344
|
8208, 8270
|
2799, 3968
|
182, 248
|
320, 2118
|
4337, 8192
|
12586, 12800
|
2140, 2441
|
2457, 2731
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,924
| 137,163
|
18534
|
Discharge summary
|
report
|
Admission Date: [**2169-8-23**] Discharge Date: [**2169-9-2**]
Service:
HISTORY OF PRESENT ILLNESS: Patient is an 86-year-old
gentleman who was leaving his eye doctors when [**Name5 (PTitle) **] [**Name5 (PTitle) 50921**]
over his walker and fell on his head. CT showed a left large
subarachnoid hemorrhage with bifrontal contusions. Patient
was transferred to [**Hospital6 256**] for
further management.
On admission the patient had left medial orbital wall
fracture, left subarachnoid hemorrhage, left orbital
hematoma, small splenic laceration times two, non-filling
left common femoral and ileac veins.
PHYSICAL EXAMINATION: Vital signs: T-max is 97, heart rate
65, BP 133/44, respiratory rate 22, sats 100%. The patient
is intubated. Patient is moving all extremities, agitated
when off sedation. Regular rate and rhythm for his cardiac.
Abdomen is soft, nontender, nondistended. Chest is clear to
auscultation. Head: A 6 cm laceration or abrasion above his
left eye.
DIAGNOSTIC STUDIES: Head CT on admission showed extensive
subarachnoid hemorrhage with parenchymal hemorrhage in the
left occipital lobe in both high frontal lobes. There may be
other areas of contusion that share injury as well, but they
may be masked by diffuse subarachnoid bleed. There are thin
bilateral subdural effusions. There is no ventricular
dilation in the basal cisterns. Spaces are well visualized.
There is a fracture of the left superior medial orbital wall
and adjacent frontal sinus. Fluid is seen within the frontal
sinus, left ethmoid air cells, and left maxillary sinuses.
Mastoid air cells and sphenoid sinuses are normally aerated.
No fractures of the calvarium are appreciated. There is
extensive soft tissue swelling in the left forehead region,
extensive subarachnoid hemorrhage and intraparenchymal
hemorrhages, hematomas.
Repeat scan on [**2169-8-24**] showed intraparenchymal hematoma
involving most of the temporal lobe causing a flattening of
the right lateral ventricle and slight shift of normally
midline structures to the left. There is no herniation, no
hydrocephalus. The blood in the subarachnoid space and the
basal cisterns, contusions in both frontal lobes, and in the
occipital lobe is unchanged. There is swelling of the
cerebral parenchyma and decreased [**Doctor Last Name 352**] white matter
differentiation. Large new intraparenchymal hemorrhage
involving most of the right temporal lobe with a slight shift
that is normally midline.
HOSPITAL COURSE: He was taken to the OR on [**2169-8-24**] for
evacuation of temporal lobe contusion. Head CT at that time
showed a large amount of air within the skull extending from
the right parietal region across the midline and anterior to
the left frontal lobe, extensive high attenuation material is
present in both hemispheres consistent with subarachnoid and
intraparenchymal hemorrhage. There has been interval
evacuation of a large area of hemorrhage in the right
temporal region. Mass effect is still seen with parietal
compression of the right lateral ventricle. There is no
midline shift and no evidence of brain herniation.
Patient opened his eyes to stimulation. Pupils: Left
slightly larger than the right but briskly reactive. Tries
to localize in the arms, moving the left leg to stimulation,
withdraws the right leg. He is neurologically stable.
Patient continued to have poor neuro exams, opening his eyes
slightly two to three times with painful stimulation,
otherwise does not. Right pupil 3 to 4 mm and briskly
reactive. Left pupil 3 to 5 and sluggishly reactive. Left
arm not noted to spontaneously lift and fall a couple of
times, but bilateral lower extremities withdraw to painful
stimulation. Right arm noted to faintly withdraw to nail bed
stimuli. CT yesterday showed no major change when compared
to previous. Patient continued to be monitored closely. The
head CT did show left cortical parietal infarct involving
right parietal cortical infarct as well.
Family meeting was done on [**2169-8-31**]. Family was going to
withdraw care and make patient comfort measures on Sunday.
The patient continued to have progressively worsening CT scan
and progressive decline in neurologic status, becoming less
responsive. He had been made a DNR/DNI. All supportive
measures were to continue until Sunday. On [**2169-8-31**]
patient had no reaction to pain. Pupils were sluggishly
reactive. Patient was informed of the grave prognosis and
did want to continue until Sunday to continue to support the
patient.
On [**2169-9-2**] patient had an episode of hypotension.
Patient's family was notified of his poor prognosis, and the
patient's family made the patient comfort measures only, and
the patient died on [**2169-9-2**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11889**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2169-11-1**] 12:55
T: [**2169-11-4**] 09:30
JOB#: [**Job Number 50922**]
|
[
"453.8",
"800.31",
"458.29",
"518.5",
"997.02",
"E885.9",
"428.0",
"276.0",
"865.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"01.59",
"38.93",
"96.04",
"96.72",
"86.59",
"89.59"
] |
icd9pcs
|
[
[
[]
]
] |
2508, 5035
|
644, 2490
|
110, 621
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,723
| 113,437
|
43969
|
Discharge summary
|
report
|
Admission Date: [**2119-7-4**] Discharge Date: [**2119-7-8**]
Date of Birth: [**2037-1-20**] Sex: M
Service: MEDICINE
Allergies:
Phenytoin / Cefazolin
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
Hypotension, fever, hypoxia
Major Surgical or Invasive Procedure:
[**2119-7-4**] s/p Left Knee Aspiration
.
[has Single lumen PICC, Right AC, placed [**2119-6-27**] @ [**Hospital1 2025**],
placement confirmed by CXR @ [**Hospital1 18**]]
History of Present Illness:
HPI: This is a 82 year-old M with a history of rheumatoid
arthritis S/P bilateral total knee replacements and recent
admission to [**Hospital1 2025**] for left septic knee ([**Date range (2) 94427**],
7/22-29/08)(Coagulase negative Staph) who presents from rehab
with episodes of "staring and unresponsiveness." After
completing a physical therapy session on the day prior to
admission, patient was noted by his wife to be unresponsive
while lying in bed, with a gaze fixed to the left. She denied
witnessing any myoclonic jerks, but does think he may have had
urinary incontinence, without fecal incontinence.
.
Patient was transferred by EMS to [**Hospital3 417**] ED. On arrival
to ED, he was noted to have fever to 103, BP 93/57, HR 98, RR
40, Sat 96% on 2L and he received 750 mg IV levofloxacin. Course
was notable for frequent emesis, subsequent respiratory
distress, and hypotension to 78/57 unresponsive to fluids, so he
was started on Levophed gtt. He was transferred to [**Hospital1 18**] for
further evaluation and management.
.
Of note, patient has had recurrent infectious complications
related to knee hardware, and was most recently discharged on
Vancomycin/Rifampin suppressive therapy, per ID recommendations.
He also had recent episodes of diarrhea, but has been rule-out
for C. difficile at [**Hospital1 2025**], and empiric metronidazole was
discontinued.
Past Medical History:
#. Bilateral hip and knee replacements
-L knee replaced [**2099**] c/b hardware dislocation and infection
?[**2113**], cultures grew coag negative staph and p. acnes, treated
with vancomycin x6weeks followed by levofloxacin/rifampin
suppressive therapy subsequently changed to doxycycline
#. Septic L knee [**5-7**]
- Arthrocentesis showed >35k WBC with 98% polys, s/p I+D and
linear replacement but retained hardware
- Culture grew Staph lugdunesis (Tet R, Ox/Vanc/Clinda/Bactrim
S)
- Initially treated with nafcillin/rifampin
- Represented with diarrhea on [**6-4**] (workup negative), knee said
to have some surround erythema, underwent repeat tap WBC 9700
72%
polys.
- Nafcillin changed to vancomycin [**6-21**] due to concern for ?naf
related AIN
#. Rheumatoid arthritis and OA
#. Hypertension
#. Hypercholesterolemia
#. Prostate cancer s/p prostatectomy
#. Spinal stenosis s/p laminectomy
#. s/p wrist surgery, plate
#. Polyneuropathy
#. s/p TURP
Social History:
The patient is retired and usually lives with his wife although
more recently in rehab. He is now retired, but previously worked
in insurance
Tobacco: None
ETOH: None
Illicits: None
Family History:
Noncontributory
Physical Exam:
D/C Physical Exam:
=================
.
T 98.2, P 72 BP 138/87 RR 18 O2 97% on RA
General: elderly man sitting in [**Female First Name (un) 1634**] chair, alert, flat affect,
somewhat lethargic
HEENT: PERRL, EOMI, sclera white, conjunctiva pale, MMM
Pulm: Bibasilar/posterior fine crackles which do not clear w/
DB&C.
CV: RRR, s1 s2, 2/6 SEM RUSB
Abd: Soft nontender +bowel sounds, no masses or organomegaly
Extremities: bilat LE - warm, slight pitting ~[**11-30**] to knees L>R,
hemesidern noted, DP 2+, cap refill ~ 3 secs, CSM intact,
blanching erythema bilat heels.
L knee with midline well approximatedly surgical wound,
non-tender& non-erythemic but slightly warm to touch, more
swollen compared to the right.
Neuro: Alert, oriented to self (name & DOB), month "[**Month (only) 216**]",
year "08", president "[**Last Name (un) 2450**]"; day "6" (is 9th), location "rehab",
when corrected to hospital, can not say which one. Face
symmetrical @ rest & with movement, tongue midline, resonds
appropriately to requests.
Derm: Erythemic rash in bilat buttocks region, hyperkeratosis
noted bilat feet, skin tear left anterior upper chest w/ dsg
D&I. Bruising noted right lateral flank just superior to illiac
crest.
Access: single lumen PICC, right AC.98.2
Pertinent Results:
ADMISSION LABS:
===============
[**7-4**]: Joint Aspirate ??????left knee ?????? WBC 8000, RBC [**Numeric Identifier 92903**], PMNs 77%,
Lymph 2%, Mono 20%, Eos 0% -c/w inflammatory background but
unlikely septic
[**7-4**]: Gram stain joint fluid prelim ?????? 2+ PMNs, no microorganisms
to date
[**7-4**]: joint crystal analysis pending
[**2119-7-4**] 05:16AM URINE RBC-2 WBC-5 BACTERIA-FEW YEAST-NONE
EPI-0
[**2119-7-4**] 05:16AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-TR
[**2119-7-4**] 05:16AM PT-15.0* PTT-33.7 INR(PT)-1.3*
[**2119-7-4**] 05:16AM GLUCOSE-158* UREA N-23* CREAT-1.7* SODIUM-137
POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-26 ANION GAP-15
[**2119-7-4**] 05:16AM ALT(SGPT)-11 AST(SGOT)-18 LD(LDH)-165 ALK
PHOS-125* TOT BILI-0.5
[**2119-7-4**] 05:16AM proBNP-264
[**2119-7-4**] 05:16AM ALBUMIN-2.7* CALCIUM-9.6 PHOSPHATE-3.8
MAGNESIUM-1.6
[**2119-7-4**] 05:16AM WBC-18.8* RBC-2.91* HGB-8.7* HCT-25.8* MCV-89
MCH-29.9 MCHC-33.8 RDW-15.3
[**2119-7-4**] 05:16AM NEUTS-78.8* BANDS-0 LYMPHS-16.9* MONOS-3.7
EOS-0.3 BASOS-0.3
.
IMAGING:
=======
[**2119-7-5**] PELVIS (AP ONLY) PORT - FINDINGS: The patient is status
post bilateral total hip arthroplasty with revision prosthesis
on the right. There is no major hardware complication seen on
the radiograph. Comparison with prior study will be helpful.
There is severe osteoarthritic changes in the lower lumbar
spine. IMPRESSION: No major hardware complication. Recommend
comparison with prior study.
[**2119-7-5**] CHEST (PORTABLE AP) - Since yesterday, lung volumes
improved and bibasilar atelectasis slightly decreased. Left
lower lobe alveolar opacity also slightly decreased but persists
associated with unchanged patchy alveolar opacity in the right
mid lung, worrisome for multifocal pneumonia which should be
followed up. There is no vascular congestion. Heart size is top
normal and the aorta is moderately tortuous. Right PICC line is
in SVC in unchanged position. Blunting of the left
costodiaphragmatic angle is unchanged.
[**2119-7-4**] KNEE (AP, LAT & OBLIQUE - IMPRESSION: 1) Tibiofemoral
prosthesis;
2) Small lucency in the medial tibial plateau suspicious for
fracture,
comparison to old films would be very useful; 3) Absence of the
patella with dystrophic calcifications seen anteriorly; 4) Large
joint effusion. Joint aspiration would be required if there is
concern for septic joint.
[**2119-7-4**] CHEST (PORTABLE AP) - IMPRESSION: 1. Left lower lobe
pneumonia;
2. Mild pulmonary edema.
.
EEG:
===
[**2119-7-4**] - BACKGROUND: Somewhat unevenly modulated [**8-9**] Hz
posterior background with occasional slower alpha was seen
throughout the later portions of the record with the patient
fully awake. The anterior-posterior voltage gradient was
preserved. No focal, lateralized, or discharging abnormalities
were noted in waking. HYPERVENTILATION: Not performed.
INTERMITTENT PHOTIC STIMULATION: Not performed. SLEEP: The
patient began the tracing in stage II sleep and only gradually,
over time, was able to be aroused to full wakefulness, after
which the patient maintained full wakefulness for the second
half of the record. No abnormalities were noted in stage II
sleep. CARDIAC MONITOR: No arrhythmias noted. IMPRESSION:
Borderline EEG due to some uneven voltage modulation but without
any marked or undue slowing or discharging features. The
clinical significance of the uneven voltage modulation is
uncertain and is of a lesser clinical significance.
.
EEG:
===
[**2119-7-4**] - IMPRESSION: Borderline EEG due to some uneven voltage
modulation but without any marked or undue slowing or
discharging features. The clinical significance of the uneven
voltage modulation is uncertain and is of a lesser clinical
significance.
.
MICROBIOLOGY:
============
[**2119-7-8**] STOOL - CLOSTRIDIUM DIFFICILE TOXIN A & B TEST
(Pending):
[**2119-7-8**] STOOL - OVA + PARASITES (Pending)
[**2119-7-5**] BLOOD CULTURE (Source: Line-PICC) - Pending
[**2119-7-4**] URINE C&S (Catheter) - NO GROWTH
[**2119-7-4**] Blood Cultures x's 3 - pending
[**2119-7-4**] JOINT FLUID (Knee) - GRAM STAIN (Final [**2119-7-4**]): 2+
(1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES; NO
MICROORGANISMS SEEN. FLUID CULTURE (Final [**2119-7-7**]): NO GROWTH.
.
DISCHARGE LABS:
===============
[**2119-7-7**] STOOL - FECAL CULTURE (Pending); CAMPYLOBACTER CULTURE
(Pending); OVA + PARASITES (Pending); CLOSTRIDIUM DIFFICILE
TOXIN A & B TEST (Final [**2119-7-8**]): Feces negative for
C.difficile toxin A & B by EIA.
[**2119-7-7**] 04:59AM BLOOD Vanco-27.9*
[**2119-7-8**] 05:03AM BLOOD WBC-8.1 RBC-3.07* Hgb-9.4* Hct-27.5*
MCV-89 MCH-30.4 MCHC-34.0 RDW-16.6* Plt Ct-297
[**2119-7-8**] 05:03AM BLOOD Neuts-58.7 Lymphs-30.1 Monos-7.1 Eos-3.3
Baso-0.8
[**2119-7-8**] 05:03AM BLOOD Glucose-89 UreaN-14 Creat-1.4* Na-139
K-3.6 Cl-108 HCO3-24 AnGap-11
[**2119-7-8**] 05:03AM BLOOD Calcium-8.7 Phos-3.1 Mg-1.7
Brief Hospital Course:
82 year old male with h/o RA on chronic prednisone, multiple
joint replacements with h/o recent L knee septic joint [**5-7**] on
Vanc/rifampin admitted [**7-4**] with hypotension/hypoxia/MS
changes/fevers/possible seizures. Found to have severe sepsis
[**12-31**] PNA (HAP), placed on zosyn with improvement in above and
admitted to ICU. Transfered to Gen Med [**7-5**] for further
management.
.
Hospital/healthcare Aquired Pneumonia - admitted with fevers,
leukocytosis, MS changes, cough/hypoxia--> severe sepsis/septic
shock (pressors), which has resolved. Patient with LLL and RML
PNA on imaging, ?HAP vs aspiration pneumonitis.
Improved clinical status on Zosyn (10 day course, Day 1 =
[**2119-7-4**], last day = [**2119-7-13**], d/c on [**2119-7-14**]) and Vanc 750mg
q24h (until [**7-11**] for septic joint), currently on RA. Of note,
Vancomycin dose decreased from 1 g -> 750 mg for a Vancomycin
level of 27.9 on [**2119-7-7**] at 0500H.
.
Diarrhea: per wife, this was a [**Last Name 16423**] problem when previously on
nafcilin in [**5-7**], then switched to vanc and placed on imodium
with some improvement but still persistant diarrhea 2-3X/day.
Now, over past day back to having frequent loose stools (not
able to provide more info). No feves, white count is stable. of
note, has also been off imodium while here. not associated with
meals, thus secretory (not osmotic). Stool for C diff negative
x's one & second pending. Given past h/o diarrhea, ID
reccomended NOT starting c. diff rx empirically. Some perirectal
skin rash [**12-31**] stool incot, & need to monitor I/O's & lytes.
.
Acute on chronic renal failure, resolved. Per chart review,
baseline creatinine appears to be around 1.2-1.4. Has improved
with IVF, creatinine 1.4 on [**2119-7-8**]. Would monitor closely given
multiple antibiotics & potential for electrolyte imbalance with
diarrhea.
.
Chronic Septic Arthritis, seen by ID here. Left knee tap this
admission negative cx (inflamm effusion). Continue Vancomycin
and Rifampin (plan to Rx until 8/12 per notes, then bactrim
suppression). Follow up by [**Hospital1 2025**] Ortho and ID clinics: has Ortho
appointment but NEEDS APPOINTMENT WITH [**Hospital1 2025**] ID.
.
Anemia NOS: normocytic, no evidence of bleeding, Fe studies not
suggesting Fe def, T.bili normal so no hemolysis. Most likely
ACD given chronic septic joint. Received 2U PRBC on [**2119-7-6**]. Hct
27.5 on D/C.
.
Altered Mental Status/delirium - multifactorial, but mostly
likely brewing PNA. CT head negative. MS now back to baseline. ?
staring episode concerning for seizure, EEG unremarkable, but
does not rule out (nonepileptiform). [**Month (only) 116**] have been related to
hypotension/[**Month (only) **] cerebral perfusion. Neuro exam nonfocal. If
concern or repeat ? sz like activity, MRI as outpt, but none
indicated currently.
.
Rheumatoid arthritis ?????? chronic prednisone, was placed on stress
dose steroids in ICU X2days, then prednisone X50mg X2doses, then
switched to Prednisone 5mg [**Hospital1 **] and now on Prednisone 5 mg qd.
.
Hyperlipidemia ?????? continue Atorvastatin 20 mg PO QD
.
Hypertension - normotensive currently, re-started on Metoprolol
Tartrate 25 mg PO BID.
.
Decreased appetite & ? Depression - started on Mirtazapine 15 mg
PO QHS on [**2119-7-7**].
.
PPx: Heparin 5000 units SQ TID; Protonix 40 mg po QD
.
Dispo/Code: DNR but not DNI, confirmed with patient.
Medications on Admission:
Rifampin 300 mg [**Hospital1 **]
Bactrim 1 tab daily
Vancomycin 1 gm IV Q 24 hrs
Prednisone 5 mg daily
Omeprazole 20 mg daily
Loperamide 2 mg [**Hospital1 **] PRN
Tylenol 650 mg Q 6 hrs PRN
Oxycodone 5 mg Q 6 hrs PRN
Calcium carbonate 1 tab daily
Lactobacillis 1 packet [**Hospital1 **]
Ferrous sulfate 324 mg daily.
Lovenox 40 mg sub Q daily
Simvastatin 10 mg daily
Multivitamins with minerals 1 tab daily
Lopressor 25 mg [**Hospital1 **]
Nexium 40 mg PO daily
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Atorvastatin 20 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. Rifampin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
7. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. 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.
10. Piperacillin-Tazobactam Na 2.25 g IV Q6H x's 10days, Day
1=[**2119-7-4**], last day = [**2119-7-13**], d/c on [**2119-7-14**]
11. Vancomycin 750 mg IV Q 24H, last day = [**2119-7-11**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] TCU - [**Location (un) 701**]
Discharge Diagnosis:
Primary Diagnosis:
=================
Hospital Aquired Pneumonia, Sepsis
Altered Mental Status
Acute Renal Failure
.
Secondary Diagnosis:
===================
#. s/p Bilateral hip and knee replacements, L knee replacement
([**2099**]) c/b hardware dislocation and infection in ?[**2113**], cultures
grew coag negative staph and p. acnes.
#. Septic L knee [**5-7**], arthrocentesis showed >35k WBC with 98%
polys, s/p I+D and linear replacement but retained hardware,
culture grew Staph lugdunesis (Tet R, Ox/Vanc/Clinda/Bactrim S),
associated diarrhea on [**6-4**] (workup negative)
#. Rheumatoid arthritis and OA
#. Hypertension
#. Hypercholesterolemia
#. Anemia
#. Prostate cancer s/p prostatectomy
#. Spinal stenosis s/p laminectomy
#. s/p wrist surgery, plate
#. Polyneuropathy
#. s/p TURP
Discharge Condition:
Stable: o2 sat 97% RA, no longer hypotensive, taking & retaining
PO's, continues incot loose/liquid brown stools.
Discharge Instructions:
You were admitted to the hospital after experiencing a change in
mental status, low blood pressure, and vomitting. You also
developed a high fever and trouble breathing. Initially you were
sent from Rehab ([**Hospital1 **]) to a local hospital (Caritas
Good Saamaritan)and then transfered to [**Hospital1 **].
You were found to have Pneumonia in several places in your
lungs, probably from aspiration. An aspiration of the fluid in
your left knee did not reveal any bacteria or fungus. Your
breathing and blood pressure has gotten better, so we are
transferring you back to your rehabilitation site.
.
It is important that you take all of your medications as
prescribed and also to follow the instructions of the therapists
at rehabilitation.
.
A new antibiotic called Zosyn was started. You will need to
complete a ten day course of this medication. Your Rifamoin was
continued as was your Vancomycin (but at a lower dose). Your
Bactrim was discontinued.
.
Please let your care givers know if you have any of the
following:
changes in mental status, fever or shaking chills, uncontrolled
vomiting, any blood or "coffee grounds" in any vomit, chest
pain/pressure, trouble breathing, pain in your throat or
abdomen, increased difficulty walking, feel dizzy or
light-headed, blood in your stools, black stools, pain not
adequately controled by medications or other health-related
concerns.
.
Please make and keep all of your follow-up apointments. You
should follow-up with your Primary Care Provider when you are
discharged from the rehabilitation setting.
Followup Instructions:
Please make & keep your follow-up appointments.
.
[**Hospital1 2025**] Orthopaedic Surgery: Dr. [**First Name11 (Name Pattern1) 3613**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 23001**], MD, [**Telephone/Fax (1) 94428**],
for [**2119-8-14**]: 7:30 AM x-rays & 8:00 AM with Otho Fellow and Dr.
[**Last Name (STitle) 23001**].
.
Please call Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 94429**], MD, Infectious Disease at [**Hospital1 2025**],
([**Telephone/Fax (1) 94430**] to schedule a follow-up appointment.
Completed by:[**2119-7-8**]
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,868
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19687+57079
|
Discharge summary
|
report+addendum
|
Admission Date: [**2126-9-27**] Discharge Date: [**2126-10-1**]
Date of Birth: [**2053-4-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Bilateral upper arm and throat discomfort
Major Surgical or Invasive Procedure:
[**9-27**] CABG x4 (LIMA->LAD, SVG->Diag, SVG->OM, SVG->PDA)
History of Present Illness:
73 yo M with h/o CAD s/p multiple MIs and angioplasties, now
with exertional angina, referred for cath and surgical
revascularization.
Past Medical History:
Ischemic cardiomyopathy, CAD, VT s/p ablation, complete heart
block, hypothyroidism, multiple MI's, Diastolic Hrt failure, s/p
AICD [**2122**], Lap appy
Social History:
retired
quit tobacco 30 years ago
no etoh
Family History:
Father with CAD age 59
Physical Exam:
NAD 72 145/70
CV No murmur, distant S1S2
Lungs CTAB ant/lat
Abdomen benign
Extrem warm, no edema 1+ pp
Neuro grossly intact
no carotid bruits
Pertinent Results:
[**2126-9-30**] 07:10AM BLOOD WBC-11.7* RBC-3.26* Hgb-9.7* Hct-28.9*
MCV-89 MCH-29.7 MCHC-33.5 RDW-14.8 Plt Ct-130*
[**2126-9-29**] 09:30PM BLOOD WBC-11.4* RBC-3.47* Hgb-10.3* Hct-30.8*
MCV-89 MCH-29.6 MCHC-33.4 RDW-14.7 Plt Ct-107*
[**2126-9-29**] 02:23AM BLOOD PT-15.5* PTT-34.0 INR(PT)-1.4*
[**2126-9-30**] 07:10AM BLOOD Plt Ct-130*
[**2126-9-30**] 07:10AM BLOOD Glucose-133* UreaN-24* Creat-1.2 Na-141
K-4.9 Cl-104 HCO3-31 AnGap-11
[**9-30**] TWO VIEWS OF THE CHEST: There are small bilateral pleural
effusions (L > R). Although the positioning is different when
compared to semi-upright portable radiograph from the previous
day, the postoperative mediastinal widening demonstrates slight
improvement. No pneumothorax is identified. A dual-lead pacer
remains unchanged in position. A right internal jugular central
line has been removed. No pneumothorax is identified.
IMPRESSION: Small bilateral pleural effusions persist. Slight
improvement in postoperative mediastinal widening.
Brief Hospital Course:
On [**9-27**] Mr. [**Known lastname 53270**] was taken to the operating room where he
underwent CABG x 4. He was transferred to the ICU in critical
but stable condition. He was extuabted on POD #1. He was
transferred to the floor on POD #2. He did well post operatively
and was ready for discharge to rehab on POD #4. His
ACE-inhibitor was held in order to increase his beta blocker,
but should be start in the near future if possible.
Medications on Admission:
Zetia 10', Toprol 100', Diovan 80', Metformin 500",
Levothyroxine 0.25', Simvastatin 40', Advair, Avandia 4', ASA
325', MVi
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
13. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
Colony House Nursing & Rehabilitation Center - [**Location (un) 32775**]
Discharge Diagnosis:
Ischemic cardiomyopathy, CAD, VT s/p ablation, complete heart
block, hypothyroidism, multiple MI's, Diastolic Hrt failure, s/p
AICD [**2122**], Lap appy
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No heavy lifting or driving until follow up with surgeon.
Followup Instructions:
Dr. [**First Name (STitle) **] 1 month
Dr. [**Last Name (STitle) 10543**] 2 weeks
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2126-10-22**]
1:00
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2126-10-1**] Name: [**Known lastname 9926**],[**Known firstname 947**] Unit No: [**Numeric Identifier 9927**]
Admission Date: [**2126-9-27**] Discharge Date: [**2126-10-1**]
Date of Birth: [**2053-4-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 265**]
Addendum:
Addendum to discharge summary:
Mr. [**Known lastname **] is discharged with a diagnosis of chronic diastolic
heart failure.
Discharge Disposition:
Extended Care
Facility:
Colony House Nursing & Rehabilitation Center - [**Location (un) 9928**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**]
Completed by:[**2126-10-8**]
|
[
"412",
"244.9",
"V17.3",
"414.01",
"428.0",
"413.9",
"V45.02",
"250.00",
"V45.82",
"428.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"36.15",
"89.60",
"99.04",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
5186, 5404
|
2013, 2450
|
319, 382
|
4080, 4088
|
1000, 1990
|
4373, 5163
|
798, 822
|
2624, 3762
|
3905, 4059
|
2476, 2601
|
4112, 4350
|
837, 981
|
238, 281
|
410, 546
|
568, 722
|
738, 782
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,712
| 122,878
|
9643
|
Discharge summary
|
report
|
Admission Date: [**2113-4-23**] Discharge Date: [**2113-4-25**]
Date of Birth: [**2053-1-29**] Sex: F
Service: NME
HISTORY OF PRESENT ILLNESS: In summary, this is a 60-year-
old woman with history of pineocytoma diagnosed in [**2108**]
status post removal in [**2109-8-16**], status post removal
of bleeding into the residual tumor and placement of a right
ventriculoperitoneal shunt in [**2109-8-16**], who was
initially diagnosed in [**2108**] after she developed right ear
tinnitus and gait imbalance. She had slowing word finding
difficulties and a change in the quality of her voice.
She eventually had a MRI, which showed a 2 cm by 2 cm by 2 cm
pineal mass and had it resected. Resection was complicated
by hemorrhagic stroke in presumably the right posterior
temporal region as well as a thalamic pain syndrome. This in
turn was complicated by hydrocephalus and a VP shunt was
placed.
She was admitted to Neurosurgery last in [**2112-6-14**] and x-
ray irradiation was offered at that time for the enlarging
tumor. The family declined this and the patient was sent to
the nursing facility for palliative care. She returned in
[**2112-12-15**] for lethargy and was found to have a urinary
tract infection. She was discharged after she was thought to
be back to baseline.
She saw a neuro-oncologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] in followup in
[**Hospital 746**] Clinic, and he communicated to the family that
he does not feel that further radiation, surgery, or
chemotherapy would be helpful at this time. Since then, the
patient had a gradual decline in energy with also the ability
to communicate.
One week prior to this admission she was able to nod yes and
shake her head no appropriately and occasionally to get
single words out. On the Wednesday prior to this admission,
a visiting nurse felt that her lungs sounded "junky" and
levofloxacin was prescribed. There have been no fevers.
Possibly her urine has had ammonia-like smell recently.
Otherwise, she is tolerating her tube feeds via J tube
continuously. Today she was much less responsive and could
not be woken up by her family. They noticed that her pupils
were not reacting. Of note, they have noticed that most
times that her head is turned towards the right and eyes are
turned towards the right. They had noticed occasionally
rhythmic twitching of the right foot. She is doing none of
these currently at the time of admission.
PAST MEDICAL HISTORY:
1. Pineocytoma as above.
2. Hypertension.
3. J tube for feeding.
4. Gastroesophageal reflux disease.
MEDICATIONS:
1. Roxanol for pain.
2. Reglan.
3. Lactulose prn.
ALLERGIES: She has an allergy to Dilantin, which causes a
rash.
SOCIAL HISTORY: She was a nonsmoker, no alcohol or drugs.
She worked formally 20 years for the U.S. Department of Labor
in [**Location (un) 86**]. Has many family members in the area, and her
daughter, [**Name (NI) 32634**] is the healthcare proxy.
PHYSICAL EXAMINATION: On examination, she was afebrile. Her
temperature was actually hypothermic at about 94.5. Her
blood pressures fluctuated from the systolics of 70s to
systolics of 130s. Her heart rate was bradycardic anywhere
from the high 20s to 50s. In general, was ill appearing,
lying in bed with a face mask on. Her mucous membranes were
moist. Her lungs were clear to auscultation bilaterally.
Her heart was regular with no murmurs. Abdomen was soft.
Her J tube site was clean. Extremities showed no pedal edema
or rashes. On mental status, the patient was unarousable to
voice or sternal rub. There was no blink to threat
bilaterally. The pupils are 4 mm and nonreactive. At rest,
the right eye is deviated to the right and the left eye is
midline. The oculocephalic maneuver revealed extraocular
movements that were intact laterally. There were no corneal
reflexes and a gag was depressed, but did elicit a slight
response. She had tone that was normal in all four
extremities. There was slight withdrawal to painful stimulus
in all four extremities and no adventitious movements. Her
coordination could not be tested. Deep tendon reflexes were
present and symmetric. Her sensory exam was intact to
nailbed stimulation in all four extremities. Her gait and
stance could not be tested.
Her imaging CAT scan revealed a very large pineal tumor that
had an enlarging appearance with a resultant edema,
hydrocephalus and effacement of the sulci. The rim of the
hyperdensity surrounding the central portion of the tumor
could represent a rim of hyperdense tumor, which was pushed
outside approximately 5.5 by 5.5 cm in size, which is an
enlargement.
She was initially monitored in the ICU where she was
breathing spontaneously. Her family and daughter mainly said
that she was a full code. She was stable and was transferred
to the floor. After discussions with the Ethics Committee
and the family, it was decided that she could be intubated,
but not to have any resuscitation efforts or CPR. This was
so to allow other family members to arrive.
On hospital day number three, she became very hypoxic and had
agonal breathing. She was intubated and transferred to the
ICU. The Ethics Committee was again consulted who felt that
it was appropriate to be intubated, however, just only until
the family was able to arrive, and then they can say goodbye.
On the evening of [**2113-4-25**] at 9:30 p.m., the patient had
a cerebral blood flow scan done which showed no cerebral
blood flow, which suggested brain death. Her clinical exam
showed that she had lost her extraocular movements. She had
no corneals. Her brain stem function was nil. She had no
withdrawal to pain. She was extubated and the time of death
was 9:30 p.m. on [**2113-4-25**]. Her daughter, [**Name (NI) 32634**] and
family members were at her bedside.
DR.[**Last Name (STitle) **],[**First Name3 (LF) 4267**] 13-282
Dictated By:[**Last Name (NamePattern4) 32635**]
MEDQUIST36
D: [**2113-4-26**] 13:48:59
T: [**2113-4-27**] 08:11:56
Job#: [**Job Number 22655**]
|
[
"V44.4",
"780.01",
"530.81",
"401.9",
"V45.2",
"348.5",
"486",
"237.1",
"438.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.71",
"38.93",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
3016, 6088
|
165, 2485
|
2507, 2741
|
2758, 2993
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,075
| 151,323
|
35341
|
Discharge summary
|
report
|
Admission Date: [**2166-2-12**] Discharge Date: [**2166-2-26**]
Date of Birth: [**2086-2-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
STEMI
Major Surgical or Invasive Procedure:
RIJ
arterial line
History of Present Illness:
This is an 80 year old male with largely unknown PMH who
presented to [**Hospital3 3583**] on [**2166-2-11**] with a chief complaint of
feeling "wobbly" on his feet. By report he had a fall the night
prior to admission to the OSH. He was unable to provide any
additional information regarding his fall. The morning of
admission to the OSH he was found unconscious on the floor by
his son. [**Name (NI) **] was disheveled and the house was unkempt. EMS was
called and he was brought to [**Hospital 46**] Hosp for evaluation. On
admission his FS was 40 and he was given [**1-10**] amp of D50 with
good effect. In initial CXR showed a cavitary lesion in the RUL
and a follow up CT showed a cavitary mass in the RUL with R
hilar and R paratracheal LAD as well as multiple hepatic
densities concerning for a metastatic process. Head CT
reportedly negative. He was given IV fluids for a slightly
elevated CK in the setting of his fall. The following day,
[**2166-2-12**], he developed bradycardia on the floor and was intubated
and coded, ? of CPR being administrated. An ECG showed ST
elevations in II, III, and aVF and ST-D in V1-3. He was treated
given aspiring and a plavix load and was med flighted to [**Hospital1 18**]
on a heparin gtt. There was one note that the patient was given
zosyn at the OSH, reason not documented.
.
Pt med flighted to [**Hospital1 18**], admitted directly to cath lab, prelim
report with small left system, 50% LAD. RCA was occluded
proximally with acute thrombus which was removed. BMS placed.
Right heart cath showed PCWP 15, RA [**10-20**]. Hypotensive after,
transferred to CCU on 5mcg dopamine. Still intubated.
Past Medical History:
1. CARDIAC RISK FACTORS:: Diabetes, Dyslipidemia, Hypertension
UNKNOWN
2. CARDIAC HISTORY: UNKNOWN
-CABG:
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY: UNKNOWN
per report a history of bladder cancer 10 years ago.
Social History:
Lives alone, son [**Name (NI) **] is contact
Family History:
non-contributory
Physical Exam:
VS: 94.5 105/63 73 (SR) 25 100% (AC TV 600 20 100% Fi02)
GENERAL: Elderly man. Intubated. Arousable. Wearing bair
hugger.
HEENT: Right eye constricts to light, surgical left pupil. MM
dry. Intubated.
NECK: IJ (from OSH) left side, bandage on right side, unable to
assess JVP.
CARDIAC: No murmurs, difficult to ascultate over mechanical BS.
LUNGS: Cachectic. Mechanical clear breath sounds.
ABDOMEN: Soft, NTND. + BS
EXTREMITIES: No edema. distal pulses present. femoral sheath
still in place on right.
NEURO: Opens eyes, nods on commands. Withdraws to pain.
Pertinent Results:
[**2166-2-12**] 07:43PM BLOOD WBC-11.3* RBC-3.71* Hgb-10.1* Hct-30.5*
MCV-82 MCH-27.3 MCHC-33.2 RDW-13.8 Plt Ct-366
[**2166-2-12**] 07:43PM BLOOD Neuts-94.7* Lymphs-3.6* Monos-1.2*
Eos-0.1 Baso-0.4
[**2166-2-12**] 07:43PM BLOOD PT-21.3* PTT-38.5* INR(PT)-2.0*
[**2166-2-19**] 10:00AM BLOOD Fibrino-777*
[**2166-2-19**] 10:00AM BLOOD Ret Aut-1.2
[**2166-2-12**] 07:43PM BLOOD Glucose-123* UreaN-41* Creat-1.4* Na-139
K-4.7 Cl-107 HCO3-25 AnGap-12
[**2166-2-12**] 07:43PM BLOOD ALT-42* AST-53* AlkPhos-139*
[**2166-2-12**] 07:43PM BLOOD CK-MB-44* cTropnT-0.23*
[**2166-2-13**] 05:28AM BLOOD CK-MB-48* MB Indx-12.2* cTropnT-0.66*
[**2166-2-14**] 05:49AM BLOOD CK-MB-32* MB Indx-5.4
[**2166-2-15**] 08:23PM BLOOD CK-MB-9 cTropnT-0.42*
[**2166-2-16**] 04:14AM BLOOD CK-MB-13* MB Indx-5.1 cTropnT-0.35*
[**2166-2-12**] 07:43PM BLOOD Calcium-8.6 Phos-5.4* Mg-2.2
[**2166-2-15**] 12:18AM BLOOD calTIBC-94* VitB12-1315* Folate-5.5
Ferritn-1266* TRF-72*
[**2166-2-17**] 04:17AM BLOOD VitB12-1527* Folate-5.3
[**2166-2-20**] 01:55PM BLOOD Hapto-206*
[**2166-2-13**] 05:28AM BLOOD %HbA1c-5.7
[**2166-2-13**] 05:28AM BLOOD Triglyc-50 HDL-24 CHOL/HD-3.0 LDLcalc-39
[**2166-2-17**] 04:17AM BLOOD TSH-0.87
[**2166-2-15**] 06:19AM BLOOD Cortsol-21.5*
[**2166-2-18**] 04:51AM BLOOD Cortsol-16.8
[**2166-2-12**] 05:22PM BLOOD Type-ART pO2-180* pCO2-47* pH-7.32*
calTCO2-25 Base XS--2 Intubat-INTUBATED
[**2166-2-12**] 08:21PM BLOOD Lactate-1.2
.
CTA chest - IMPRESSION:
1. No evidence of pulmonary embolism.
2. Cavitary lesion in the right upper lobe with small air- fluid
level and
contiguous soft tissue density mass extending to the right
hilum.
Differetial diagnosis includes inflammatory and infectious
process, however,
a cavitary neoplasia (squamous cell carcinoma) is also a
consideration.
3. Bilateral large pleural effusions with associated compressive
atelectasis.
4. Hepatic hypodensities, not fully characterized in this study.
Ultrasound
could be performed for further evaluation if clinically
indicated.
5. Ascites and nonspecific soft tissue stranding in the upper
abdomen.
6. T6 lytic lesion. Bone scan is recommended when feasible.
7. Coronary artery calcifications.
.
MRI c-spine - IMPRESSION:
1. Markedly severe spinal canal stenosis at C5-C6 where there is
severe cord compression and extensive cord edema. This is
accompanied by moderate soft tissue edema within the anterior
and posterior soft tissues of the neck centered at this C5-C6
level. There is no acute fracture or subluxation. These findings
in themselves are most suggestive of chronic severe degererative
changes compounded by acute trauma. Note is however made of some
meningeal thickening just posterior to the C6 vertebral body
extending inferiorly from the area of critical stenosis as well
as high T1 signal on delayed post-gadolinium imaging (from prior
MR head). This combination of findings, although probably due to
traumatic etiology, can also be seen with infection or
malignancy.
2. Extensive edema centered at C5-C6 stenosis greater than
typically seen for stenosis, along with possible enhancement
within the cord, raises the possibility of cord infarction
secondary likely to trauma.
.
Echo - There is mild regional left ventricular systolic
dysfunction with mild inferior hypokinesis. The remaining
segments contract normally (LVEF = 45-50%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
.
IMPRESSION: Mild regional left ventricular systolic dysfunction,
c/w CAD. Mild pulmonary hypertension. Limited study.
Brief Hospital Course:
80M with limited known PMH presented from OSH with inferior
STEMI, s/p RCA revascularization. Patient was intubated at the
OSH. Patient initially kept intubated after arrival to the CCU
and was unable to be weaned initially off of the ventilator.
Patient was effectively weaned and extubated for less than 36
hours. Patient with 3 code blue for cardiac arrest with episodes
of only P waves visible on telemetry which improved with
atropine. Patient was found to have significant neurologic
deficits of unclear etiology with lack of movement of bilateral
lower extremities and upper extremity weakness left greater than
right. Patient had extensive neurologic work-up including
evalution by neurology, MRI head and CT spine and was found to
have lesion in the C5/C6 area with edema from either trauma vs.
infection vs. malignancy. Patient had biopsy of cavitary lung
lesion which demonstrated squamous cell cancer with likely
metastasis given lytic lesion seen in thorax. Patient was unable
to be weaned from the ventilator and family was told that long
term prognosis included tracheostomy and PEG with likely
profound permanent neurologic impairment. Family decided to
make patient comfort measures only. Patient was extubated and
expired with family members present.
Medications on Admission:
none
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
STEMI
Discharge Condition:
death
Discharge Instructions:
NA
Followup Instructions:
NA
Completed by:[**2166-2-26**]
|
[
"250.00",
"507.0",
"276.2",
"162.3",
"197.7",
"272.4",
"496",
"198.5",
"518.81",
"427.5",
"289.84",
"410.41",
"414.01",
"584.9",
"578.9",
"458.8",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"37.23",
"36.06",
"96.04",
"96.6",
"99.20",
"33.24",
"96.72",
"00.66",
"88.52",
"00.40",
"88.56",
"96.71",
"00.45",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
8131, 8140
|
6774, 8049
|
320, 339
|
8189, 8196
|
2983, 6751
|
8247, 8280
|
2368, 2386
|
8104, 8108
|
8161, 8168
|
8075, 8081
|
8220, 8224
|
2401, 2964
|
2131, 2197
|
275, 282
|
367, 2018
|
2228, 2290
|
2040, 2111
|
2306, 2352
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,713
| 176,481
|
50307
|
Discharge summary
|
report
|
Admission Date: [**2146-11-27**] Discharge Date: [**2146-12-11**]
Date of Birth: [**2096-10-22**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3151**]
Chief Complaint:
Lethargy
Major Surgical or Invasive Procedure:
None
History of Present Illness:
50 yo F h/o paraplegia, recurrent UTIs with ESBL klebsiella
presents with lethargy. Recently admitted here with urosepsis.
Hospitalized 1 week prior at [**Hospital3 **] with PNA and UTI,
completed course levaquin last Tuesday, remained on 3.5L home O2
(no prior need for home O2).
At home, noted worsening lethargy x2 days, perhaps some
suprapubic abdominal pain, and T 100.9; similar to prior admits
for urosepsis. No real fevers or chills otherwise. Denies cough,
SOB, chest pain. She is also on an extensive home pain regimen,
including methadone 10mg PO TID.
In the ED, vitals: 99.0, 67, SBP 70s, 100% 2L NC. Exam nonfocal
except sleepy but arousable and Ox3, neuro exam unchanged from
baseline. Labs notable for WBC 9.7 without bands, lactate 1.2,
Na 132, BNP 1588. U/A positive. CXR with ?mild edema vs. RLL
infiltrate. Blood and urine Cx sent. Right IJ CVL placed. SBP
improved to high 80s and CVP 10 after 3L NS. CVP 10. Given
vanco/zosyn for presumed early urosepsis. Admit ICU.
ROS: The patient denies any fevers, chills, nausea, vomiting,
diarrhea, constipation, melena, hematochezia, chest pain,
orthopnea, PND, dysuria, lightheadedness, vision changes,
headache, rash or skin changes.
Past Medical History:
T1-T2 paraplegia due to MVA ([**2142**]) s/p trach, s/p ORIF of R
proximal humerus, s/p titanium steel plates in arms
Recurrent UTIs (q 2-3 months) [**3-5**] to atonic bladder with Proteus
and ESBL Klebsiella
Intermittent urinary catheterizations (Q4H) done by PCA or
husband
Depression
HCV with apparent clearing of viremia as of [**5-10**]
h/o pneumonia (including MRSA in [**10-7**])
Anxiety
h/o DVT ([**2142**]) s/p IVC filter
h/o pulmonary nodules
Hypothyroidism
Chronic pain
Anemia of Chronic Disease
Chronic Gastritis
?obstructive lung disease - Possible COPD, also may have
component of restrictive lung dz [**3-5**] chest wall weakness related
to paraplegia. No prior PFTs, yet on home inhaler and
intermittant 2L home O2 since [**8-9**], but until [**11-9**]
hospitalization not requiring home O2
Social History:
Lives at home with her husband. PCA is best friend, [**Name (NI) **].
Occasional EtOH, 35 pack-year tobacco on a nicotine patch; no
drugs.
Family History:
Mother (lung CA)
Physical Exam:
Vitals: T: 95.2 BP: 93/60 HR: 64 RR: 11 O2Sat: 99% on 3L
GEN: Chronically ill-appearing, NAD, speaks slowly, appropriate,
A&Ox3 but occasionally closes eyes, breathing comfortably
without accessory muscle use
HEENT: EOMI, PERRL, sclera anicteric, MM dry, OP Clear
NECK: No JVD, right CVL, carotid pulses brisk, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Bibasilar crackles (R>L), no wheeze or rhonchi
ABD: Soft, NT, ND, +BS, no masses
EXT: Nonpitting bilateral edema, no cyanosis, no palpable cords
NEURO: CN II ?????? XII grossly intact. Moves all upper extremities
with 5/5 strength, no motor tone lowers.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
Labs on discharge:
[**2146-12-10**] 01:45PM BLOOD WBC-5.8 RBC-3.88* Hgb-11.3* Hct-33.4*
MCV-86 MCH-29.1 MCHC-33.7 RDW-14.5 Plt Ct-285
[**2146-12-4**] 12:57AM BLOOD Neuts-74.9* Lymphs-16.2* Monos-7.2
Eos-1.2 Baso-0.5
[**2146-12-10**] 01:45PM BLOOD Plt Ct-285
[**2146-12-10**] 01:45PM BLOOD Glucose-95 UreaN-3* Creat-0.3* Na-140
K-4.3 Cl-97 HCO3-36* AnGap-11
[**2146-12-5**] 05:25AM BLOOD ALT-7 AST-9 LD(LDH)-118 AlkPhos-63
TotBili-0.2
[**2146-12-10**] 01:45PM BLOOD Calcium-9.4 Phos-4.7* Mg-2.2
[**2146-11-29**] 05:45AM BLOOD calTIBC-161* Ferritn-522* TRF-124*
.
Imaging:
Renal US:
FINDINGS: The right kidney measures 13.1 cm and the left kidney
measures 14.5 cm. There is no hydronephrosis, renal masses or
stones. There is probably a left-sided duplicated system, as
discussed on the previous reports. Limited views of the bladder
are unremarkable.
IMPRESSION: No hydronephrosis.
CXR:
IMPRESSION: AP chest compared to [**11-30**] and [**12-3**]: Bibasilar consolidation has grown progressively worse since
[**11-30**] and [**12-3**], concerning for pneumonia. Vascular
congestion and severe
cardiomegaly indicate cardiac decompensation, with probable new
edema in the mid lung zones. Right jugular line ends at the
superior cavoatrial junction. No pneumothorax.
Brief Hospital Course:
50F h/o paraplegia, recurrent UTIs with ESBL klebsiella presents
with likely urosepsis.
# Hypotension: Met SIRS criteria with likely source urine, and
has history of resistant ESBL Klebsiella and Proteus, sensitive
to Zosyn and carbapenems. Also with h/o MRSA. Pulmonary source
also possible although less likely. There was no evidence of a
new infection to date. Her blood pressures were a little lower
than they usually are, likely due to decreased food intake. She
was discharged with instruction to continue to stay hydrated and
increase salt in her diet in order to keep your blood pressures
in her usual range. Discharged on prior Amoxicillin dosing.
# Altered mental status: Likely toxic-metabolic due to combo of
infection and pain medications. Improved without change in
medications or clear infection.
# Chronic pain: Followed by pain clinic at the [**Hospital1 756**] (Dr.
[**Last Name (STitle) **]. Initially held sedating medication but then restarted
prior to discharge as mental status improved.
# Paraplegia s/p MVA: Complicated by atonic bladder requiring
self-catherization, DVT/PE s/p IVC filter, chronic pain
syndrome, post SCI anxiety/depression. Continued oxybutinin for
urinary retention.
# Hepatitis C: Chronic with undetectable viral load as of [**10-9**].
No acute issues.
# Anemia: Anemia of chronic disease, normocytic; currently at
baseline Hct 30-36.
# Hypothyroidism: Continued outpatient levothyroxine.
Medications on Admission:
Baclofen 20mg qam, 10mg lunch, 20mg qhs
Citalopram 20mg daily
Klonopin 1mg qid prn, 2mg qhs prn
Gabapentin 800mg qid
Combivent inh 2 puffs tid
Levothyroxine 75mcg daily
Methadone 10mg tid
Nicotine 21mg patch q24h
Omeprazole 20mg [**Hospital1 **]
Oxybutynin 10mg qam, 5mg lunch, 10mg qhs
Oxycodone 5mg q4-6h prn
Lyrica 150mg tid
Sucralfate 1gm qid
Trazodone 200mg qhs
Calcium 500mg [**Hospital1 **]
Laratadine 10mg daily
Miralax 17gm daily
Discharge Medications:
1. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO QID (4
times a day).
2. Methadone 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
3. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
5. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
6. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Oxybutynin Chloride 5 mg Tablet Sig: 1-2 Tablets PO three
times a day: Please take 2 tabs in the morning; 1 tab at lunch;
2 tabs at nighttime.
9. Miralax 17 gram (100 %) Powder in Packet Sig: One (1) PO
once a day.
10. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation three times a day.
11. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for anxiety.
12. Trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
13. Calcium 500 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO
twice a day.
14. Lyrica 150 mg Capsule Sig: One (1) Capsule PO three times a
day.
15. Loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day.
16. Amoxicillin 500 mg Capsule Sig: One (1) Capsule PO every
eight (8) hours for 11 days: Please take for two weeks total.
Disp:*34 Capsule(s)* Refills:*0*
17. Miconazole Nitrate 2 % Cream Sig: One (1) thin layer to rash
Topical twice a day.
Disp:*30 grams* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1. Sepsis secondary to urinary tract infection
2. Anxiety
3. Restrictive Lung disease
4. Neurogenic Bladder
Secondary Diagnosis:
1. Paraplegia
2. Chronic Pain
3. Anemia
Discharge Condition:
patient is afebrile, with SBPs in the 110s-120s; normal
mentation, feeling well
Discharge Instructions:
You were admitted to the hospital with low blood pressure and
fever, likely related to your urinary tract infection. You were
in the ICU overnight and given several liters of IV fluids and
IV antibiotics. You were then transfered to the medicine floor
where you did well until your antibiotics were changed. You
developed another fever and some moderately low blood pressure
and were brought back to the ICU. Again, you did well. We then
completed your course of IV antibiotics and started you on oral
antibiotics. The bacteria that we grew from your urine culture
showed that it would be killed by this oral antibiotic. You
were doing well and your blood pressure and temperature stayed
normal.
During your hospitalization, you also developed a rash from
yeast in your groin. We took out your foley and returned to
your home regimen of straight catheterizations.
You also had some mild pain in your throat one day that was
likely related to anxiety. It went away with a dose of ativan.
An EKG was normal and it was very unlikely that your heart was
the cause of this pain.
You also started requiring some oxygen through your nasal
canula. You have oxygen at home for comfort. Your oxygen
levels are normal on room air and you should not be worried
about not wearing oxygen, but if it makes you more comfortable,
it is ok to use. In the future you may need further testing of
your lungs, but for now your respiratory status is stable.
When you go home, make sure to complete your course of
antibiotics at home. Also continue using the cream for yeast
infection in your groin. We also stopped the baclofen because
of your low blood pressures. If you are able to tolerate your
pain without it, we would not recommend restarting it at this
time. We did not change any of your other medicines.
Please follow up with Dr. [**Last Name (STitle) 665**] within one to two weeks for
followup.
Please return to the hospital for any confusion, weakness, low
blood pressures, difficulties breathing, fevers, chills, chest
pain, worsening abdominal pain or any other concerns.
Followup Instructions:
Please call Dr.[**Name (NI) 666**] office on Monday morning to make an
appointment for follow up. You should be seen within one to two
weeks. The phone number to the [**Hospital 191**] clinic is [**Telephone/Fax (1) 250**].
|
[
"V12.51",
"300.4",
"038.0",
"486",
"907.2",
"496",
"V45.89",
"276.51",
"E929.0",
"112.89",
"530.81",
"627.9",
"995.91",
"599.0",
"518.89",
"596.4",
"344.1",
"070.54",
"285.29",
"338.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8123, 8129
|
4643, 5315
|
327, 333
|
8362, 8444
|
3354, 3354
|
10577, 10806
|
2566, 2584
|
6582, 8100
|
8150, 8150
|
6119, 6559
|
8468, 10554
|
2599, 3335
|
279, 289
|
3373, 4620
|
361, 1563
|
8299, 8341
|
8169, 8278
|
5330, 6093
|
1585, 2393
|
2409, 2550
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,143
| 188,298
|
29460
|
Discharge summary
|
report
|
Admission Date: [**2182-8-28**] Discharge Date: [**2182-9-2**]
Date of Birth: [**2122-4-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Iodine; Iodine Containing
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
recurrent angina and SOB
Major Surgical or Invasive Procedure:
[**2182-8-28**] MV repair ( 30 mm CE [**Doctor Last Name 405**] annuloplasty band)/ cabg
x4 (LIMA to LAD, SVG to OM1 seq. to OM 2, SVG to PDA)
History of Present Illness:
60 yo male followed for angina/PVD/ mild cerebrovascular dz.
Recently cathed for increasing angina over the past 6 months.
This revealed LM/3 VD. Recently cleared for surgery by Dr. [**Last Name (STitle) 497**]
of hepatology.
Past Medical History:
s/p MVrepair/cabg x4
Hep C ( rx ribavarin/interferon)
Child's A cirrhosis
remote Hep A
remote malaria
[**Last Name (STitle) **]. claudication PVD with right peroneal art. occlusion
neuropathy
remote substance abuse (IVDU/ETOH)
torn right biceps
GERD
hiatal hernia
mild cerebrovascular dz.
Social History:
maintenance worker for the P.O.
lives with wife
smokes 1 ppd for 40 years
sober 24 years
no IVDU in 35 years
Family History:
daughter with cardiomyopathy
brother with MI at 46
father with CABG/CAD/pacer alive at 86
Physical Exam:
5'[**84**]" 192#
HR 61 right 100/59 left 119/59
NAD
? chronic venous stasis changes BLE
PERRLA;EOMI; anicteric sclera, sl. injected, OP unremarkable
neck supple, no JVD or carotid bruits appreciated
CTAB
RRR S1 S2 , no murmur
abd soft, NT, ND, + BS, slightly obese, no HSM/CVA tenderness
extrems warm, well-perfused, no edema, mild BLE spider veins
1+ right fem/ 2+ left fem
1+ [**Name6 (MD) **] DPs
NP PTs
2+ [**Name6 (MD) **] radialsMAE [**6-3**] strengths, nonfocal CN III-XII
Pertinent Results:
PRE-BYPASS:
1. 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 thrombus is seen in the left atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler.
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. There are simple atheroma in the aortic arch. There are
simple atheroma in the descending thoracic aorta.
5. There are three aortic valve leaflets. There is no aortic
valve stenosis. Trace aortic regurgitation is seen.
6. The mitral valve leaflets are mildly thickened. Moderate (2+)
mitral regurgitation is seen.
Dr. [**First Name (STitle) **] was notified in person of the results.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including phenylephrine and is
being A paced.
1. A well-seated mitral annuloplasty ring is seen with normal
leaflet motion and gradients (mean gradient = 3 mmHg). There is
no valvular systolic anterior motion ([**Male First Name (un) **]). Mild mitral
regurgitation is seen.
2. LV function is preserved.
3. Aorta is intact post decannulation
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 928**] [**Name8 (MD) 929**], MD, MD,
Interpreting physician [**Last Name (NamePattern4) **] [**2182-8-28**] 15:02
?????? [**2177**] CareGroup IS. All rights reserved.
Brief Hospital Course:
Admitted [**8-28**] and underwent surgery with Dr. [**First Name (STitle) **]. Transfered
to the CVICU in stable condition on propofol and phenylephrine
drips. Extubated later that day. Remained in the unit for a
couple of days for hypotension requiring continued phenylephrine
drip. Chest tubes removed on POD #2. Pt. was started on
midodrine po for persistent hypotension with good effect. He
was able to be started on lopressor, and has tolerated that
well. (This will be changed back to his pre-op beta blocker,
Toprol XL at 25 mg daily). He should be re-evaluated by Drs.
[**Name5 (PTitle) 5263**] & [**Last Name (un) 32255**] to determine need for continued midodrine. His
epicardial pacing wires were removed on [**9-1**] after he has
tolerated beta blocker. He has remained hemodynamically stable
and was cleared for discharge to home with VNA services on POD
#5. He is to make all follow-up appts. as per discharge
instructions.
Medications on Admission:
ASA 325 mg daily
nexium 40 mg [**Hospital1 **]
metoprolol ER 25 mg daily
chantix
Discharge Medications:
1. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
2. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO once
a day for 7 days.
Disp:*7 Packet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
5. Chantix 0.5 mg Tablet Sig: One (1) Tablet PO once a day:
Resume pre-op regimen for Chantix.
Disp:*30 Tablet(s)* Refills:*2*
6. 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*
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
8. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Midodrine 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day): until re-assessed by Dr. [**Last Name (STitle) 32255**] or Dr. [**Last Name (STitle) 5263**].
Disp:*90 Tablet(s)* Refills:*2*
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company **] and hospice
Discharge Diagnosis:
s/p MVrepair/cabg x4
Hep C ( rx ribavarin/interferon)
Child's A cirrhosis
remote Hep A
remote malaria
[**Company **]. claudication PVD with right peroneal art. occlusion
neuropathy
remote substance abuse (IVDU/ETOH)
torn right biceps
GERD
hiatal hernia
mild cerebrovascular dz.
Discharge Condition:
stable
Discharge Instructions:
no lotions, creams or powders on any incision
no driving for one month
no lifting greater than 10 pounds for 10 weeks
call for fever greater than 100.5, redness, or drainage
Shower daily and pat incisions dry
Followup Instructions:
see Dr. [**Last Name (STitle) 5263**] in [**1-30**] weeks
see Dr. [**Last Name (STitle) 32255**] in [**3-3**] weeks
see Dr. [**First Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2182-9-2**]
|
[
"440.21",
"530.81",
"424.0",
"070.70",
"414.2",
"440.4",
"414.01",
"437.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"39.61",
"36.13",
"35.33"
] |
icd9pcs
|
[
[
[]
]
] |
5945, 6002
|
3460, 4405
|
315, 460
|
6326, 6335
|
1780, 3437
|
6592, 6904
|
1169, 1261
|
4536, 5922
|
6023, 6303
|
4431, 4513
|
6359, 6569
|
1276, 1761
|
251, 277
|
488, 715
|
737, 1027
|
1043, 1153
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,109
| 121,458
|
24637
|
Discharge summary
|
report
|
Admission Date: [**2139-5-5**] Discharge Date: [**2139-5-8**]
Date of Birth: [**2064-8-16**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
garbelled speech
Major Surgical or Invasive Procedure:
Placement of bedside subdural drain.
History of Present Illness:
Mr [**Known lastname 62197**] is a 74 year-old white male with a past medical history
significant for PVD, hypercholesterolemia and CRI who presents
with brief episode of "garbled speech" this am. He states that
he was feeling well this am, and around noon was talking to his
wife and trying to tell her that he was hungry and she couldn't
understand him. The wife says that he was having "garbled
speech" and wasn't making any sense or saying real words. She
finally got the idea that he was hungry and made him a [**Location (un) 6002**]
which he ate without difficulty. He had no problems with
comprehension, no visual changes, no numbness or weakness, and
no headache. By about 12:50pm, he was again speaking normally,
however he would occasionally "not be able to think of words" -
for instance he was talking about landscaping, and could not
think of the word
"crabgrass." The wife then brought him to an OSH [**Name (NI) **] where head
CT revealed a large right subacute SDH. Mr.[**Known lastname 62197**] does not recall
any head trauma. In retrospect, he does recall having a dull,
aching pain in the back of his neck and head on the right side
about 3-4 weeks ago, and he says the he has occasionally had it
since then, but has not bothered him too much. He did call his
PCP about it who said it was "mechanical" and recommended no
further f/u. Pt has not had any weakness or numbness, and no
difficulty with speech up until this brief episode today.
Past Medical History:
1.PVD
2.hypercholesterolemia
3.CRI
4.h/o syncope in past with no identified etiology
5.bilateral hearing loss
Social History:
married and lives with wife. is retired engineer.
occasional EtOH. no smoking or illicit drugs.
Family History:
father had aortic aneurysm, mother had stroke
Physical Exam:
T 97.3; BP 199/88; HR 60; RR 18; O2 sat 99%RA
GENERAL: no acute distress. appears comfortable.
HEENT:tongue midline, no scleral icterus or inFection.
NECK: supple. no lad or carotid bruits appreciated.
CVS: RRRR, S1, S2, No M/G/R
Lungs: CTA A/P bilaterally.
ABD: soft, nt/nd, bowel sound presentx4, nabs
Ext: cool LEs, no edema.
Neuro:
MS: Alert and Oriented x3. Cooperative with exam. Able to say
[**Doctor Last Name 1841**]
backwards. Registration intact to [**3-12**] objects at 30 seconds,
recall intact to [**3-12**] objects at 5 minutes. Repitition and Naming
intact. Speech fluent with normal content and prosody, and
without paraphasic errors or hesitancy. Follows 3-step commands
well. Able to relate coherent and detailed HPI.
No neglect.
CN: PERRL. EOMs intact without nystagmus. Fundi normal with
sharp
disc margins. Visual fields full to confrontation. Facial
sensation and movement intact bilaterally. Hearing intact to
finger rub. Tongue protrudes midline without fasiculations.
Sternocleidomastoids intact bilaterally. Shoulder shrug intact
bilaterally.
Motor: Normal bulk and tone throughout. No fasiculations. No
pronator drift.
Strenght [**5-14**] in all muscle groups upper and lower extremities.
Reflexes: symmetric and intact throughout.
Sensation:
Intact bilaterally to light touch, cold, and pinprick in all
extremities.
Decreased vibration and proprioception at great toes bilaterally
but otherwise intact.
Gait: normal, narrow-based gait with good arm swing. Able heel
and toe walk. Able to tandem. Negative Romberg.
Pertinent Results:
wbc 6.7 hct 37.0 plt 166
pt 12.2 ptt 22.6 inr 0.9
Na 140 ;K 4.0 ;Cl 106 ;CO2 27 ;BUN 31 ;Cr 1.5 ; glucose 117
Brief Hospital Course:
74 year old male admitted with right subdural hematoma.hematoma
managed by subdural drain, patient remained stable. subdural
drain D/C'ed [**5-6**], followed by stroke team.Stroke team
recommeded carotid ultrasound which demonstrated less than 40%
stenosis right internal carotid artery, with 60-69% stenosis,
left internal carotid artery ([**2139-3-8**]). MRA of the head was
negative.
Cervical Spine MR ([**2139-5-8**]) showed no evidence of AVM within the
cervical spine.
Head and Neck MRI obtained showed no vascular malformation. He
was evaluated by PT as was stable in activities.
He remained neurologically intact throughout his stay and by
discharge was ambulating and tolerating a regular diet with ut
difficulty.
Medications on Admission:
aspirin 81mg
lipitor
trental
Discharge Medications:
1. Dilantin 100 mg Capsule Sig: One (1) Capsule PO three times a
day for 7 days.
Disp:*21 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Subdural hematoma
Discharge Condition:
Neurologically stable
Discharge Instructions:
Call for headache or any problems.
Followup Instructions:
Follow up for suture remaval and head CT in 2 weeks. Call Dr.
[**Last Name (STitle) 739**] [**Telephone/Fax (1) 3571**] for appt.
Follow up with neurology and repeat carotid ulrasound in 6
months. Call [**Telephone/Fax (1) 1694**] for appt.
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2139-8-28**]
|
[
"389.9",
"443.9",
"593.9",
"272.0",
"432.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.31"
] |
icd9pcs
|
[
[
[]
]
] |
4850, 4856
|
3908, 4632
|
334, 373
|
4918, 4941
|
3765, 3885
|
5024, 5392
|
2129, 2177
|
4711, 4827
|
4877, 4897
|
4658, 4688
|
4965, 5001
|
2192, 3746
|
278, 296
|
401, 1865
|
1887, 1999
|
2015, 2113
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,092
| 150,954
|
34050
|
Discharge summary
|
report
|
Admission Date: [**2106-10-21**] Discharge Date: [**2106-10-24**]
Date of Birth: [**2022-9-28**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamides) / Codeine
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
84 y/o F with known h/o asc. aortic aneurysm with ? dissection
[**4-16**]. c/o CP this AM, went to OSH ER where CT showed possible
dissection flap in ascending aorta. Remained neuro intact during
transfer to [**Hospital1 18**]. Pt has severe COPD, on home O2 2-3 L/min.
Lives with daughter currently who takes care of her. Able to
walk to restroom. Back in [**4-16**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] was consulted on pt and
did not recommend surgical Rx. Family was not inclined to go for
surgery back then anyway. Pt currently denies seizures, weakness
in extremities or severe SOB.
Reports significant weitgh loss > 30 lbs, denies dysphagia,
hhematemesis. Pt seems to be leaning towards DNR/DNI.
Past Medical History:
- Hypertension
- COPD on home o2 2.5L
- hypothyroidism
- thoracic aortic aneurysm
- multiple hospitalizations for PNA
- hysterectomy [**2071**] for uterine cancer
- anxiety
Cardiac Risk Factors: no Diabetes, Dyslipidemia, + Hypertension
Cardiac History: no CABG
Percutaneous coronary intervention: n/a
Pacemaker/ICD: n/a
.
Social History:
Social history is significant for the absence of current tobacco
use, but long history of smoking quit in [**2093**]. There is no
history of alcohol abuse. Lives alone and is independent with
ADLs in past per family.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
Pulse:67 Resp:33 O2 sat: 98
B/P Right: 100/56 Left: 120/67
Height: Weight:
General: mild distress
Skin: Dry [x] intact []
HEENT: PERRLA [] EOMI [x]
Neck: Supple [x] Full ROM []
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur systolic [**1-15**]
Abdomen: Soft [] non-distended [] non-tender [] bowel sounds +
[]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [-]
Neuro: Grossly intact. moves 4 ext. R handed
Pulses:
Femoral Right:palp Left:palp
DP Right:palp Left:dop
PT [**Name (NI) 167**]: Left:
Radial Right:palp Left:palp
Carotid Bruit Right: - Left:-
Pertinent Results:
[**2106-10-21**] 10:30PM BLOOD WBC-9.9# RBC-4.81# Hgb-13.9# Hct-42.9#
MCV-89 MCH-28.8 MCHC-32.3 RDW-13.7 Plt Ct-308
[**2106-10-21**] 10:30PM BLOOD PT-12.7 PTT-24.3 INR(PT)-1.1
[**2106-10-21**] 10:30PM BLOOD Glucose-84 UreaN-23* Creat-0.8 Na-145
K-3.9 Cl-103 HCO3-34* AnGap-12
Brief Hospital Course:
Ms. [**Known lastname 78587**] was admitted to the [**Hospital1 18**] on [**2106-10-21**] for
management of her aortic dissection. As she was not a good
surgical candidate and was not interested in having a large
operation, surgery was declined. She was admitted to the
intensive care unit for blood pressure management. Her blood
pressure was well maintained on Lopressor and she was
transferred to the floor. She was evaluated by the Palliative
Care service and she and her three daughters decided that she
would be DNR/DNI and be transferred to a [**Hospital1 1501**] closer to home.
She was asymptomatic and was discharged on [**10-24**] in stable
condition.
Medications on Admission:
levothyroxine 25', others are unknown
Discharge Medications:
1. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
3. 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*
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
The [**Hospital **] Nursing Home
Discharge Diagnosis:
- Aortic dissection and aneurysm
- Hypertension
- COPD on home o2 2.5L
- hypothyroidism
- thoracic aortic aneurysm
- multiple hospitalizations for PNA
- hysterectomy [**2071**] for uterine cancer
- anxiety
Discharge Condition:
good
Discharge Instructions:
1) Weigh yourself daily. Report any weight gain of 2 pounds in
24 hours or 5 pounds in 1 week to your cardiologist.
Followup Instructions:
Follow-up with your cardiologist and primary care provider as
instructed.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2106-10-24**]
|
[
"441.01",
"300.00",
"496",
"V10.44",
"401.9",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4226, 4285
|
2752, 3417
|
308, 315
|
4535, 4542
|
2452, 2729
|
4706, 4903
|
1675, 1757
|
3505, 4203
|
4306, 4514
|
3443, 3482
|
4566, 4683
|
1772, 2433
|
259, 270
|
343, 1074
|
1096, 1423
|
1439, 1659
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,332
| 132,575
|
40649
|
Discharge summary
|
report
|
Admission Date: [**2176-6-4**] Discharge Date: [**2176-6-8**]
Date of Birth: [**2106-1-26**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
mild exertional dyspnea and fatigue
Major Surgical or Invasive Procedure:
[**2176-6-4**] Aortic valve replacement (19 mm pericardial)
History of Present Illness:
70 year old hearing impaired female has significant aortic
stenosis. She reports having known about a heart murmur since
early adulthood. Until this past year, she has been
asymptomatic. Now she reports very mild exertional dyspnea
without any other complaints. This will occur with walking
quickly on a flat surface of climbing a flight of stairs. She
did have an isolated episode of transient non exertional chest
pain last year but she has had none since. Echocardiogram on
[**2176-5-6**] revealed severe AS with a peak/mean gradient of
104/63mmHG and a valve area of 0.5 cm2. There was trace AI, mild
concentric LVH
and a normal LVEF. She was referred for cardiac catheterization
to further evaluate her aortic valve. She is now being referred
to cardiac surgery
for aortic valve replacement.
Past Medical History:
Severe aortic stenosis
Osteoporosis
Migraine headaches
Left shoulder impingement syndrome
[**8-/2173**]: left Acromioplasty
s/p Resection of left breast cyst
Remote left arm fracture
Congenital deafness
Hypothyroidism
Social History:
Lives with:husband, who is also deaf
Occupation:retired
Tobacco:denies
ETOH:occasional
Family History:
Grandfather with "heart disease"
Physical Exam:
Pulse:75 Resp:18 O2 sat:100/RA
B/P Right:132/66 Left:135/67
Height:5'3" Weight:127 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur 4/6 SEM
Abdomen: Soft [x] non-distended [x] non-tender [x] +BS [x]
Extremities: Warm [x], well-perfused [x] Edema-1+bilat
Varicosities: None [x]
Neuro: Grossly intact, nonfocal
Pulses:
Femoral Right: Left:
DP Right: Left:
PT [**Name (NI) 167**]: Left:
Radial Right: 2+ Left: 2+
Carotid Bruit: radiated murmur bilat
Pertinent Results:
[**2176-6-4**] 10:23AM BLOOD WBC-6.3 RBC-2.74*# Hgb-8.4*# Hct-25.0*#
MCV-92 MCH-30.8 MCHC-33.6 RDW-13.4 Plt Ct-170
[**2176-6-4**] 10:23AM BLOOD Neuts-68 Bands-0 Lymphs-26 Monos-5 Eos-0
Baso-1 Atyps-0 Metas-0 Myelos-0
[**2176-6-4**] 10:23AM BLOOD Plt Smr-NORMAL Plt Ct-170
[**2176-6-4**] 10:23AM BLOOD PT-15.4* PTT-33.0 INR(PT)-1.3*
[**2176-6-4**] 11:32AM BLOOD UreaN-10 Creat-0.5 Na-143 K-4.2 Cl-113*
HCO3-23 AnGap-11
[**2176-6-5**] 02:02AM BLOOD Calcium-7.9* Phos-3.1 Mg-1.9
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: >= 55% >= 55%
Aorta - Annulus: 2.0 cm <= 3.0 cm
Aortic Valve - Peak Velocity: *4.2 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *70 mm Hg < 20 mm Hg
Aortic Valve - LVOT pk vel: 1.00 m/sec
Aortic Valve - LVOT diam: 1.8 cm
Aortic Valve - Valve Area: *0.7 cm2 >= 3.0 cm2
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV cavity size. Normal regional LV
systolic function. Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending, transverse and descending thoracic
aorta with no atherosclerotic plaque.
AORTIC VALVE: Moderately thickened aortic valve leaflets. Severe
AS (area 0.8-1.0cm2). Moderate (2+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial
MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
Physiologic (normal) PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications.
PREBYPASS
No atrial septal defect is seen by 2D or color Doppler. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The ascending, transverse and
descending thoracic aorta are normal in diameter and free of
atherosclerotic plaque The aortic valve leaflets are moderately
thickened. There is severe aortic valve stenosis (valve area
0.6-0.7cm2). Moderate (2+) aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen.
POSTBYPASS
There is a well seated, well functioning bioprosthesis in the
aortic position. Mild perivalvular AI is visualized. The study
is otherwise unchanged from the prebypass period.
Brief Hospital Course:
Admitted same day surgery and was brought to operating room for
aortic valve replacement. See operative report for further
details. She received Cefazolin for perioperative antibiotics
and was transferred to the intensive care unit for post
operative management. That evening she was weaned from
sedation, awoke neurologically intact and was extubated without
complications. On post operative day one she remained in the
intensive care unit on phenylephrine for blood pressure
management. The evening she developed atrial fibrillation
treated with betablockers and amiodarone, and she converted back
to normal sinus rhythm after a few hours. She continued to
progress and physical therapy worked with her on strength and
mobility. Chest tubes and epicardial wires were removed per
protocol. On POD # 4she was ready for discharge to home with VNA
services.
Medications on Admission:
ALENDRONATE 70 mg once a week (Wednesday)
LEVOTHYROXINE 75 mcg daily
ASPIRIN 81 mg daily
CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 600 + D(3)] twice a day
ERGOCALCIFEROL (VITAMIN D2) 1000 unit daily
MULTIVITAMIN
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day:
400mg for 7 days then decrease to 200mg daily ongoing until you
are told to stop.
Disp:*90 Tablet(s)* Refills:*2*
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. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. alendronate 70 mg Tablet Sig: One (1) Tablet PO QWED (every
Wednesday).
7. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*75 Tablet(s)* Refills:*0*
8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
9. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
Disp:*7 Tablet(s)* Refills:*0*
10. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day for 7 days.
Disp:*14 Tablet Extended Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
aortic stenosis
Osteoporosis
Migraine headaches
Left shoulder impingement syndrome
[**8-/2173**]: left Acromioplasty
s/p Resection of left breast cyst
Remote left arm fracture
Congenital deafness
Hypothyroidism
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with ultram
Incisions:
Sternal - 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 [**6-26**] at 1:30pm [**Hospital **] medical Office building
[**Hospital Unit Name **] [**Telephone/Fax (1) 170**]
Cardiologist: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**6-20**] at 9:15am
Wound check Wednesday [**6-12**] at 10:15am [**Hospital **] medical Office
building [**Hospital Unit Name **] [**Telephone/Fax (1) 170**]
Please call to schedule appointments with your
Primary Care Dr [**Last Name (STitle) **] in [**4-2**] 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:[**2176-6-8**]
|
[
"285.9",
"997.1",
"427.31",
"244.9",
"424.1",
"389.8",
"733.00",
"E878.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
7201, 7259
|
4916, 5780
|
345, 407
|
7514, 7682
|
2289, 4893
|
8606, 9358
|
1597, 1632
|
6038, 7178
|
7280, 7493
|
5806, 6015
|
7706, 8583
|
1647, 2270
|
269, 307
|
435, 1234
|
1256, 1476
|
1492, 1581
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,731
| 129,672
|
1238
|
Discharge summary
|
report
|
Admission Date: [**2182-2-23**] Discharge Date: [**2182-2-28**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7760**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
ERCP [**2182-2-24**]
History of Present Illness:
This patient is a 84 year old woman who initially presented to
[**Hospital 4068**] hospital with 3 day history of abdominal pain. She was
found to have gallstone pancreatitis and received Levo/flagyl.
She was subsequently transferred to the [**Hospital1 18**]. She has had known
gallstones for the last 30-40 year without symptoms.
.
At [**Hospital1 18**], the patient reported epigastric pain radiating to
back, nausea, vomiting, chills but no fever. She denied chest
pain and shortness of breath. She denied jaundice. She had one
bowel movement on the day prior to presentation.
Past Medical History:
PMH: CAD/MI, HTN, h/o gallstones (no prior symptoms), "blood
poisoning" resulting in trach, breast cancer
PSH: CABGx4 '[**67**], appy, hysterectomy, trach, lumpectomy/XRT, B/L
cataracts
Social History:
Quit tobacco 30 years ago
Rarely drinks EtOH
Physical Exam:
102.2 76 97/34 22 93% 3l
NAD, alert and oriented x 3
neck supple
CTAB
RRR
abdomen mildly distended, tender to percussion/palpation in
epigastrium, +[**Doctor Last Name **] with guarding
rectal tone normal, negative guiac at [**Last Name (un) 4068**]
Foley with clear urine
RLE edema (chronic)
Pertinent Results:
ERCP [**2182-2-24**]: Dilated CBD and PD, Multiple CBD stones and
biliary pus, Biliary sphincterotomy, Stone extraction, CBD stent
[**2182-2-23**] 10:50PM WBC-9.0 RBC-3.35* HGB-10.6* HCT-30.0* MCV-90
MCH-31.7 MCHC-35.3* RDW-13.7
[**2182-2-23**] 10:50PM PLT COUNT-159
[**2182-2-23**] 10:50PM NEUTS-90.8* BANDS-0 LYMPHS-6.1* MONOS-2.8
EOS-0.2 BASOS-0.1
[**2182-2-23**] 10:50PM GLUCOSE-140* UREA N-25* CREAT-1.1 SODIUM-137
POTASSIUM-3.9 CHLORIDE-107 TOTAL CO2-21* ANION GAP-13
[**2182-2-23**] 10:50PM ALBUMIN-3.1* CALCIUM-8.1* PHOSPHATE-2.0*
MAGNESIUM-1.6
[**2182-2-23**] 10:50PM ALT(SGPT)-568* AST(SGOT)-537* CK(CPK)-66 ALK
PHOS-581* AMYLASE-553* TOT BILI-2.9*
Brief Hospital Course:
This patient was admitted to the SICU with cholangitis,
pancreatitis and cholecystitis. In the ED, the patient
experienced respiratory distress and was intubated. ERCP was
perfomed at the bedside at which time the findings included:
Dilated CBD and PD, Multiple CBD stones and biliary pus, Biliary
sphincterotomy, Stone extraction, CBD stent. In the unit, the
patient was started on Zosyn, and was supported briefly with
Levophed. On hospital day #2, the patient was successfully
extubated. On hospital day #3, she was transferred to the floor.
Her antibiotics were changed from IV Zosyn to PO
Levaquin/Flagyl. Her diet was advanced gradually which she
tolerated well. On hospital day #5 she was cleared by physical
therapy for discharge to home with services. She was discharged
in stable condition on hospital day #6. She will continue PO
Levaquin/Flagyl for 4 days at home and will follow up with Dr.
[**Last Name (STitle) 6633**] in [**12-31**] weeks for cholecystectomy.
Medications on Admission:
[**Last Name (un) 1724**]: toprol XL 25QD; ASA 325QD; enalapril 10QD; lipitor 5QD;
fluoxetine prn; xanax 0.5prn; MVI; slo niacin 500QD
Discharge Medications:
1. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 4 days.
Disp:*12 Tablet(s)* Refills:*0*
3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Cholangitis
Pancreatitis
Cholecystitis
Discharge Condition:
Stable, tolerating po
Discharge Instructions:
worsening abdominal pain, signs of jaundice or any other
worrisome symptoms.
Please follow-up as directed.
Please resume all medications as taken prior to this
hospitalization. In addition, you should take the antibiotics
and iron tablets as prescribed.
Maintain a low fat diet. For additional nutritional support we
recomment nutritional supplements such as Boost, Ensure, or
Resource at breakfast, lunch, and dinner.
Continue antibiotics.
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2182-4-11**] 9:30
Provider: [**Name Initial (NameIs) **] SUITE GI ROOMS Date/Time:[**2182-4-11**] 9:30
Follow-up with Dr. [**Last Name (STitle) 6633**] in [**12-31**] weeks. Call her office at
[**Telephone/Fax (1) 2998**] to schedule your appointment.
|
[
"518.81",
"V45.81",
"401.9",
"574.31",
"276.2",
"414.00",
"577.0",
"576.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"51.85",
"51.88",
"51.87",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
3749, 3755
|
2206, 3184
|
276, 298
|
3837, 3860
|
1509, 2183
|
4354, 4799
|
3370, 3726
|
3776, 3816
|
3210, 3347
|
3884, 4331
|
1196, 1490
|
222, 238
|
326, 908
|
930, 1119
|
1135, 1181
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,832
| 195,485
|
41818
|
Discharge summary
|
report
|
Admission Date: [**2118-9-4**] Discharge Date: [**2118-9-13**]
Service: MEDICINE
Allergies:
morphine / Protamine / Augmentin / Bactrim DS / Levofloxacin
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
88F with hx of CAD s/p MI and CABG [**2110**], breast CA in [**2101**] s/p
XRT, chemo and LND, osteoporosis, afib s/p pacemaker, and
hemorrhagic stroke (not confirmed)with [**Last Name (un) 19171**] back pain
presenting with back pain to ED who became hypoxic after CTA. Pt
woke up this morning with severe back pain and was also having
diarrhea at that time. Pt is presently on Azithro for PNA,
coughing with minimal phlegm. She has a history of back pain
that began about 1 yr ago, is intermittent, and has recently
been causing her more pain.
Review of systems:
(+) Per HPI
(-) fevers, chills, sweats, dysuria, LE edema (but wears
compression stockings at home), PND (sleeps on one pillow
without difficulty).
Past Medical History:
Coronary artery disease s/p 3 vessel CABG
Sinus note dysfunction s/p dual-chamber pacemaker
Atrial fibrillation
Possible subdural hematoma vs hemorrhagic stroke (not confirmed)
Breast cancer s/p chemoradiation and axillary node dissection
Chronic kidney disease stage III
Fibromyalgia
Cholecysectomy
Tonsilectomy
Total left hip arthroplasty
Social History:
Lives at [**Hospital3 **] center ([**Hospital3 **]). Previously
lived in [**Doctor First Name 5256**], and recieved all of her medical care at
Duke. Denies alcohol and tobacco use. Son [**Doctor First Name 401**] lives in town
with his family
Family History:
Father-lung cancer (died, age 85)
[**Name (NI) 90825**]
[**Name (NI) 90826**]
Physical Exam:
Admission Exam:
VS 97.5, 136/57, 73, 11, 93-100% on 3L NC
General: AAOx person, place, month, and year. tangential thought
process requiring frequent redirection. cachectic
HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: irreg irreg rhythm, no m/r/g, pacer prominently visible in
subcutaneous tissue on right anterior chest wall
Lungs: diffuse crackles bilat, worse in lung bases, no wheezes
or rhonchi
Abdomen: soft, palpable firm bladder, TTP mildly diffusely, NABS
Ext: warm, no edema, cachectic, 2+ pulses
DISCHARGE PHYSICAL EXAM:
Vitals: T 97.5 P 63 BP 118/P O2 sat 95% RA I/O over past 36 h:
840/850+inc
General: Alert, oriented X 3.
HEENT: Sclera anicteric, MMM, oropharynx clear
Lungs: Scattered rhonchi throughout, but few crackles.
CV: Regular rate and rhythm, distant heart sounds
Abd: Soft, NT, ND.
Ext: Trace edema in LEs
Pertinent Results:
Admission labs:
==================
[**2118-9-4**] 12:30PM BLOOD WBC-5.4 RBC-4.76 Hgb-14.8 Hct-47.0
MCV-99* MCH-31.1 MCHC-31.4 RDW-15.8* Plt Ct-200
[**2118-9-4**] 12:30PM BLOOD Neuts-64.3 Lymphs-25.9 Monos-7.2 Eos-1.5
Baso-1.1
[**2118-9-4**] 08:12PM BLOOD PT-13.1* PTT-31.0 INR(PT)-1.2*
[**2118-9-4**] 12:30PM BLOOD Glucose-111* UreaN-23* Creat-1.4* Na-138
K-5.0 Cl-100 HCO3-28 AnGap-15
[**2118-9-4**] 12:30PM BLOOD cTropnT-0.04*
[**2118-9-4**] 08:12PM BLOOD Calcium-9.7 Phos-3.9 Mg-1.6
[**2118-9-4**] 12:30PM BLOOD Digoxin-0.8*
CTA CHEST [**2118-9-4**]:
IMPRESSION:
1. Pulmonary edema, cardiomegaly with marked right atrial
dilatation,
extensive network of venous collaterals in the chest wall, as
well as contrast reflux into the IVC, dilated hepatic veins, and
zygos/hemiazygos system are consistent with right heart failure.
2. Confluent opacification noted in the right lower lung,
possibly
representing asymmetric pulmonary edema, but cannot exclude
superimposed
infectious process including aspiration. Bilateral pleural
effusions, small in the posterior dependent portions; however,
loculated effusions are also noted along the right major fissure
and a large loculated effusion noted anterior to the right upper
lobe.
3. Significant multilevel degenerative change with compression
fractures
noted in T11 and T12. This area was not completely visualized
on prior study, though it appears that the T11 fracture is new
compared to [**2118-8-17**].
RENAL US [**2118-9-7**]:
IMPRESSION: Normal renal son[**Name (NI) **].
CXR [**2118-9-8**]:
FINDINGS: As compared to the previous radiograph, there is
minimally
increased opacity at the left lateral lung bases, likely
atelectatic in
origin. The known bilateral subpleural opacities along with
pre-existing rib changes, are constant in extent and severity.
Also constant in extent is a known right apical area of severe
pleural thickening.
The lung volumes remain low. There is status post CABG,
moderate size of the cardiac silhouette. Right pectoral
pacemaker, clips after left axillary lymph node resection.
[**2118-9-9**]:
IMPRESSION:
Plcement of a dialysis temporary line catheter through the right
internal
jugular vein. The tip is located in the lower SVC, and the
catheter is ready for use.
DISCHARGE LABS:
[**2118-9-13**] 06:40AM BLOOD WBC-5.8 RBC-4.10* Hgb-13.2 Hct-40.7
MCV-99* MCH-32.3* MCHC-32.5 RDW-17.2* Plt Ct-193
[**2118-9-4**] 08:12PM BLOOD Neuts-72.8* Lymphs-20.0 Monos-6.4 Eos-0.2
Baso-0.6
[**2118-9-13**] 06:40AM BLOOD Glucose-89 UreaN-43* Creat-1.6* Na-145
K-5.0 Cl-109* HCO3-26 AnGap-15
[**2118-9-13**] 06:40AM BLOOD Calcium-9.4 Phos-3.2 Mg-1.7
Brief Hospital Course:
88F with hx of CAD s/p MI and CABG [**2110**], breast CA in [**2101**] s/p
XRT, chemo and LND, osteoporosis, pacemaker, and hemorrhagic
stoke with chronic back pain, presented with back pain.
Hospital course: Pt presented w/ back pain, VS 96.2 94 138/87 16
98% RA. Exam was notable for thoracic kyphosis with tenderness
to palpation at approx T6-8 on the right side. There was no
obvious CVA tenderness. Pulmonary exam was mostly clear. Cardiac
exam was unremarkable. Abdominal exam was benign. Labs
significant for CBC and CHEM-7 at baseline with Cr. 1.4. U/A was
negative for infection. Chest X-ra showed small bilateral
pleural effusions, slightly worse than on previous exam, patchy
opacity in the right lung base. CTA chest was obtained for
concern for aortic dissection, showed no dissection, no PE, but
possible new vertebral compression fx. After returning from CTA,
patient had O2 saturation in the 80s with drowsiness, rales on
exam. She was started on O2, and portable chest x-ray showed
mild increase in pulm vasc congestion. Pt was started on CPAP,
given 20mg IV lasix 1mg of dilaudid, and admitted to intenstive
care unit. VS on transfer 72 115/72 16 94%; she was arousable to
voice.
In the MICU, pt became more alert, VS 97.5, 136/57, 73, 11,
93-100% on 3L NC. Her sudden decline in respiratory status was
judged to be likely [**2-24**] an aspiration event while supine in CT
scanner, as patient did not demonstrate any signs of infection
(no leukocytosis, no fever). Speech and swallow was consulted,
who recommended nectar prethickened liquids.
Pt was noted to be in acute renal failure, likely [**2-24**] IV
contrast for CTA. Pt was oliguric but stable, transferred to the
floors for further management. She remained stable, with O2 sats
trending low when taken on the finger but increasing to mid-90s
when taken on forehead.
Cr trended up over first 48 hours on floor, peaking at 4.3 on
[**2118-9-9**]. She was given gentle IV fluids for question of
hypovolemia (reporting thirst, had low PO intake), became more
hypoxic w/ concern for heart failure, fluids d/c'd. Renal
consulted, who recommended diuresis at 80 mg IV lasix, and HD
line placement if no response w/in a few hours. Pt remained
oliguric, IR placed temporary nontunneled HD line on [**2118-9-9**].
Pt's creatinine trended down at next chem draw, however, and
urine output increased from 10cc/hour to 20 cc/hour, reassuring
for renal recovery. Her creatinine continued to trend downward
w/ improvine urine output, and on [**9-11**] her HD line was pulled,
as well as her Foley catheter. By day of discharge she was near
her baseline creatinine of 1.4, with Cr measured at 1.6. She had
one episode of large urinary incontinence on the night before
discharge, judged likely [**2-24**] post-ATN diuresis.
Re: aspiration, patient was followed by speech and swallow over
her stay, and two video swallows were performed to optimize her
plan for safe nutritional intake. One last study was planned for
day of discharge, but was declined by family as it was unlikely
to change management. Family and patient acknowledged risk of
aspiration, and expressed desire to maintain safest possible
intake according to plan outlined by S&S, but also trying to
maximize patient enjoyment and comfort, which may include some
slight increase in risk at times. Pt was advised to maintain a
soft diet, with nectar-thickened liquids, and to sit up as
perpendicularly as possible during mealtimes.
Regarding compression fractures, patient was started on higher
dose of calcium and vitamin D at discharge, with f/u including
bone scan in one month. Home tramadol for pain control was held
during pt's period of acute kidney injury, but was reinstated on
discharge. During [**Name (NI) **], pt treated with low doses of codeine to
treat both pain and cough, with good results and little sedative
effect; however, pt complained of itch on day of discharge and
medication was discontinued.
Regarding code status, intern on team had extensive conversation
with patient and health care proxy. [**Name (NI) 6419**] understood the
unlikelihood of weaning from the vent in the event of
intubation. They clearly expressed valuing pt's quality of life
over extending her life if she could not return to good
functional status. The decision was made to make her DNR/DNI.
Pt was discharged in stable condition to rehab.
TRANSITIONAL ISSUES:
# Loculated Pleural Effusion: seen on CT. Duration and
significance is unknown. Difficult to access due to presence of
pacemaker. Judged possibly chronic changes from recurrent
aspiration or from prior breast cancer surgery/radiation. MICU
team discussed results with the patient and her son. They are
not eager to pursue aggressive interventions to work this up.
Given clinical stability there is little evidence for closed
space infection (i.e infection related to effusion). Consider
repeat CT scan in 6 weeks as outpatient to monitor for interval
change
# Digoxin: Pt's digoxin for A-fin was discontinued as inpatient,
can be reinstated as an outpatient by PCP.
# Aspiration: Patient had aspiration seen on video swallow.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Pharmacy.
1. Acetaminophen 650 mg PO TID
2. Aspirin 325 mg PO DAILY
3. Atorvastatin 10 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Nadolol 40 mg PO DAILY
6. Ranitidine 150 mg PO DAILY
7. Furosemide 10 mg PO DAILY
8. cranberry extract *NF* 0 mg ORAL DAILY
9. Os-Cal 500 + D *NF* (calcium carbonate-vitamin D3) 500mg
(1,250mg) -600 unit Oral daily
10. TraMADOL (Ultram) 25 mg PO Q6H:PRN back pain
11. Digoxin 0.0625 mg PO EVERY OTHER DAY
12. estradiol *NF* 0.01 % (0.1 mg/g) Vaginal daily
13. Lidocaine 5% Patch 1 PTCH TD DAILY back pain
Patient can refuse if she does not have pain.
14. Acidophilus Probiotic *NF* (acidophilus-pectin, citrus) 100
million-10 cell-mg Oral Daily
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Atorvastatin 10 mg PO DAILY
3. Lidocaine 5% Patch 1 PTCH TD DAILY back pain
Patient can refuse if she does not have pain.
4. Multivitamins 1 TAB PO DAILY
5. Nadolol 40 mg PO DAILY
6. Ranitidine 150 mg PO DAILY
7. Acidophilus Probiotic *NF* (acidophilus-pectin, citrus) 100
million-10 cell-mg Oral Daily
8. Aspirin 325 mg PO DAILY
9. cranberry extract *NF* 0 mg ORAL DAILY
10. estradiol *NF* 0.01 % (0.1 mg/g) Vaginal daily
11. Furosemide 10 mg PO DAILY
12. TraMADOL (Ultram) 25 mg PO Q6H:PRN back pain
13. Citracal Regular *NF* (calcium citrate-vitamin D3) 500 mg
400 Oral [**Hospital1 **]
RX *calcium citrate-vitamin D3 [Citrus Calcium] 200 mg
calcium-250 unit [**Unit Number **] tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**]
Discharge Diagnosis:
Primary:
Osteoporotic vertebral compression fracture
Dysphagia
Aspiration pneumonitis
Acute diastolic heart failure
Loculated pleural effusion NOS
Acute renal failure
Secondary:
Coronary artery disease s/p 3 vessel CABG
Sinus note dysfunction s/p dual-chamber pacemaker
Atrial fibrillation
Possible subdural hematoma vs hemorrhagic stroke (not confirmed)
Breast cancer s/p chemoradiation and axillary node dissection
Chronic kidney disease stage III
Fibromyalgia
Cholecysectomy
Tonsilectomy
Total left hip arthroplasty
Discharge Condition:
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname **], It was a pleasure taking care of you here at
[**Hospital1 69**]. You were admitted for back
pain, and shortness of breath after getting a CT scan. Your back
pain may be caused by a worsening compression fracture. You were
treated with tylenol, which seemed to help your pain. You
probably got short of breath from aspirating some of your
secretions, which irritated your lungs. You were treated with
fluids, and given thickened liquids to reduce aspiration. You
were also advised to eat sitting upright to reduce aspiration
events.
Followup Instructions:
Department: NEUROLOGY
When: THURSDAY [**2118-10-6**] at 10:30 AM
With: [**Name6 (MD) 4677**] [**Name8 (MD) 4678**], MD [**Telephone/Fax (1) 3506**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: TUESDAY [**2118-10-11**] at 2:00 PM
With: BONE DENSITY TESTING [**Telephone/Fax (1) 4586**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: TUESDAY [**2118-10-11**] at 4:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2164**], MD [**Telephone/Fax (1) 1803**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2118-9-13**]
|
[
"V15.3",
"414.00",
"787.91",
"724.5",
"403.90",
"737.10",
"585.3",
"V45.81",
"511.89",
"428.0",
"787.20",
"427.31",
"584.5",
"733.00",
"780.09",
"428.31",
"338.29",
"V43.64",
"V87.41",
"E947.8",
"V45.02",
"729.1",
"V10.3",
"733.13",
"412",
"788.5",
"507.0",
"V49.86"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90",
"38.95"
] |
icd9pcs
|
[
[
[]
]
] |
12084, 12178
|
5342, 5535
|
276, 282
|
12742, 12789
|
2682, 2682
|
13513, 14409
|
1671, 1751
|
11285, 12061
|
12199, 12721
|
10493, 11262
|
5552, 9716
|
12925, 13490
|
4965, 5319
|
1766, 2336
|
9737, 10467
|
876, 1026
|
226, 238
|
310, 857
|
2698, 4949
|
12804, 12901
|
1048, 1391
|
1407, 1655
|
2361, 2663
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,430
| 150,546
|
31253+57740
|
Discharge summary
|
report+addendum
|
Admission Date: [**2136-11-26**] Discharge Date: [**2136-12-10**]
Date of Birth: [**2058-12-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Known firstname 2969**]
Chief Complaint:
Esophageal cancer
Major Surgical or Invasive Procedure:
Flexible bronchoscopy, EGD, transthoracic esophagectomy
History of Present Illness:
Mr. [**Known lastname 2973**] is a 77 year-old male with a history of
Adenocarcinoma esophageal cancer T3N1 s/p chemo and radiation
therapy. His most recent PET scan showed persistent FDG
avidity, minimally less than baseline in the distal esophagus,
but no other areas of abnormality. He is being admitted for
transthoracic esophagectomy.
Past Medical History:
Esophageal carcinoma s/p Chemotherapy
Mild neuropathy
Hypertension
Diabetes - type II
Hard-of-hearing
BPH
PSH:
[**2136-8-14**]: Right cephalic vein cut-down for placement of a double
lumen Port-a-Cath, placement of a jejunostomy tube
Social History:
He is a former but light cigar smoker when he was in his 30s.
No cigarettes or alcohol infrequently. He denies a history of
heartburn. He has been married twice and currently with a
woman, he has been with 20+ years. He himself has 4 children
with whom he is certainly in contact, but 2 of the 4 live out of
state.
Family History:
His father died in his older ages of heart disease. The only
cancer he has is one brother died of lung cancer. Three other
brothers are alive and without cancer. He was in the concrete
cement business for 40 years.
Physical Exam:
General: 77 year-old male in no apparent distress
HEENT: normocephalic, mucus membranes moist, voice hoarse
Neck: supple, no lymphadenopathy
Card: normal S1,S2, regular, rate & rhythm, no murmur/gallop or
rub
Resp: decreased breath sounds otherwise clear bilaterally
GI: bowel sounds positive, abdomen soft non-tender/non-distended
Ext; warm no edema
Incision: Neck clean dry intact with steri-strips, mid-abdomen
well healed
Neck wound: clean, small serous discharge, mild erythema
Neuro: non-focal
Pertinent Results:
[**2136-11-26**]: Pathology
Tissue: pleural mass, pleural mass - not finalized
Chest radiograph of [**2136-11-28**].
PA AND LATERAL CHEST RADIOGRAPHS: There has been interval
removal of a right chest tube and an NG tube. Currently a right
Port-A-Cath remain with its tip in the mid SVC. No pneumothorax
or right pleural effusion is present.
[**2136-11-29**] Echocardiogram:
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. LV systolic function appears depressed, although in the
presence of atrial fibrillation the left ventricular ejection
fraction (at least moderately reduced) cannot be quantitated
with certainty. There is no ventricular septal defect. Right
ventricular chamber size is normal. Right ventricular systolic
function is borderline normal. The aortic root is moderately
dilated at the sinus level. The ascending aorta is mildly
dilated. The number of aortic valve leaflets cannot be
determined. The aortic valve leaflets are mildly thickened. The
study is inadequate to exclude significant aortic valve
stenosis. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
[**2136-12-3**] IR/SBFT & Video Oropharyngeal Swallow
FINDINGS: Optiray contrast media passes freely through the
esophagus with a small amount of aspiration into the airway.
There is no evidence for anastomotic leak. Ingestion of thick
barium also shows small amount of aspiration with no anastomotic
leak. Please see the video oropharyngeal component of the
examination for further details.
IMPRESSION: The two studies taken together, both the partial
barium esophagram and video oropharyngeal swallow, show no
anastomotic leak, mild aspiration improved with chin tuck, and
vocal cord paresis.
LABS:
[**2136-11-29**] TSH-2.2
[**2136-12-3**] WBC-6.6 Hgb-10.4* Hct-30.9 Plt Ct-187
[**2136-12-3**] Glucose-206* UreaN-23* Creat-0.8 Na-134 K-4.1 Cl-102
HCO3-25
[**2136-12-10**] WBC-6.8 Hgb-9.2* Hct-28.3 Plt Ct-484*
[**2136-12-7**] Glucose-222* UreaN-31* Creat-1.0 Na-133 K-4.9 Cl-97
HCO3-29
[**2136-12-7**] ALT-31 AST-17 AlkPhos-117 TotBili-0.4
Brief Hospital Course:
Mr. [**Known lastname 2973**] was admitted on [**2136-11-26**] and taken to the operating
for an uneventful
flexible bronchoscopy, EGD and transthoracic esophagectomy. He
was transferred to the intensive care unit. Immediate
postoperatively he was hypotensive and responded well to fluid
boluses. He was transfused with 1 unit of packed-red-blood
cells. On postoperative day #1 he was extubated without
difficulty. He was found to have tachycardia with a heart rate
in the 160's and his beta-blocker was restarted with a good
response. The chest-tube was placed on water-seal with
moderated serosanguinous output. He had good pain control with
an epidural and PCA managed by the acute pain service. Nutrition
was consulted and he was started on trophic feeds of Probalance
at 30cc/hr with a goal of 65cc/hours. On postoperative day #2
he was transferred to the floor. He had an episode of rapid
atrial fibrillation and cardiology was consulted who recommended
an echocardiogram, TSH, a diltiazem drip and metoprolol
intravenous which was implemented. He remained hemodynamically
stable with burst of sinus rhythm and atrial flutter. His
potassium and magnesium were repleted to maintain a Mg of 2.0
and K+ > 4.5. On postoperative day #4 the chest tube was removed
and a chest x-ray revealed no pneumothorax. The pain service
removed the epidural and his pain was controlled with a PCA.
His foley was removed and he voided without difficulty. He was
seen by physical therapy. On postoperative day #6 his voice was
hoarse and ENT was consulted. He was found to have a left vocal
cord immobility. He was seen by speech for a video swallow
which revealed mild oral and pharyngeal dysphagia characterized
by reduced oral control. They recommended aspiration
precautions and a PO diet of thin liquids and soft consistency
solids. On postoperative day #8 the JP and abdominal staples
were removed. He remained in sinus rhythm and was converted to
PO diltiazem and metoprolol. On POD#9 patient became hypotensive
with SBP in the 80's and went into atrial fibrillation with
heart rate in the 150s, he was bolused and had his medications
staggered. A CTA was also performed to rule out a pulmonary
embolus which was negative, however a LLL effusion was noted.
The IP service tapped the effusion on POD#10 removing 2 liters
of fluid. The patient continued to have periodic episodes of
atrial fibrillation and was started on Coumadin to decrease risk
of stroke. He was also switched from the Diltiazem to PO
Amiodarone. On POD#11 his neck wound was found to a small amount
of drainage it was opened and packed with iodophone. He
remained afebrile and had no leukocytosis. He continued to make
steady progress and was discharged to rehab on postoperative day
#14. He will follow up with Dr. [**Last Name (STitle) **] and ENT as an
outpatient. He is to follow-up with his PCP for Coumadin
management after discharge from rehab.
Medications on Admission:
Flomax 0.4mg once daily
Metformin 1000mg twice daily
Glipizide 5mg twice daily
Lisinopril 5mg once daily
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed.
2. Heparin Flush Port (10 units/mL) 5 ml IV DAILY:PRN
10 ml NS followed by 5 ml of 10 Units/ml heparin (50 units
heparin) each lumen Daily and PRN. Inspect site every shift.
3. regular insulin
regular insulin per sliding scale
based on QID fingersticks.
4. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
[**Hospital1 **] (2 times a day) as needed.
8. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice
a day: hold HR < 60, SBP 100.
10. Warfarin 5 mg Tablet Sig: One (1) Tablet PO as directed to
maintain INR 2.0-2.5.
11. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 6 days: [**12-13**] decrease to 200mg once daily .
12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q4H (every 4 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 701**]
Discharge Diagnosis:
Esophageal Cancer s/p chemotherapy
Parosymal Atrial Fibrillation
Left Vocal Cord Immobility
Hypertension
Diabetes Mellitus Type 2
Hiatal Hernia
BPH
J-Tube/Porta Cath placement [**7-28**]
Discharge Condition:
Stable
Discharge Instructions:
Please call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 73743**] if experience:
-Fevers > 101 or chills
-Increased cough, sputum production or shortness of breath
-Chest Pain
-Incision begins to drain
Steri-strips will fall off in time
J-Tube site keep clean- wash with soap and water and pat dry and
cover with DSD daily.
Do not put any medications in your feeding tube unless they are
in liquid form.
you may eat a soft solid diet- no tough meats.
continue your tube feeding until Dr. [**Last Name (STitle) **] advises you
otherwise.
Neck wound dressing: change twice a day.
Coumadin for atrial fibrillation: INR Goal 2.0-2.5
Coumadin follow-up with Dr. [**Last Name (STitle) 17025**] after discharge from
rehab
Decrease amiodarone 200 mg once daily starting [**12-13**].
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] on [**12-20**] at 9:00am on the [**Hospital Ward Name 516**]
[**Hospital Ward Name 23**] Clinical Center, [**Location (un) **]
Report to the [**Location (un) 861**] Radiology Department 45 minutes before
your appointment for a Chest X-Ray
Follow-up with ENT Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 2349**] for Left Vocal Cord
Immobility
Follow-up with Dr. [**Last Name (STitle) 73**] cardiology in [**4-27**] weeks.
[**Telephone/Fax (1) 902**] call for an appointment.
Call Dr. [**Last Name (STitle) 17025**] for coumadin dosing after discharge from
rehab.
Completed by:[**2136-12-10**] Name: [**Known lastname 12232**],[**Known firstname 3549**] Unit No: [**Numeric Identifier 12233**]
Admission Date: [**2136-11-26**] Discharge Date: [**2136-12-10**]
Date of Birth: [**2058-12-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Known firstname 9814**]
Addendum:
Please see discharge instructions regarding Stage III sacral
decubitus care.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2215**] Northeast - [**Location (un) 50**]
Discharge Instructions:
Please call Dr.[**Doctor Last Name **] office [**Telephone/Fax (1) 12234**] if experience:
-Fevers > 101 or chills
-Increased cough, sputum production or shortness of breath
-Chest Pain
-Incision begins to drain
Steri-strips will fall off in time
J-Tube site keep clean- wash with soap and water and pat dry and
cover with DSD daily.
Do not put any medications in your feeding tube unless they are
in liquid form.
you may eat a soft solid diet- no tough meats.
continue your tube feeding until Dr. [**Last Name (STitle) 9341**] advises you
otherwise.
Neck wound dressing: change twice a day.
Coumadin for atrial fibrillation: INR Goal 2.0-2.5
Coumadin follow-up with Dr. [**Last Name (STitle) 2031**] after discharge from
rehab
Decrease amiodarone 200 mg once daily starting [**12-13**].
Coccyx wound: change every 3 days: stage III decubitus clean
with normal saline, pat dry then apply protective barrier, then
apply a thin layer of wound gel (Duoderm Gel) to the open wound.
Cover with Allevyn Foam adhesive.
Chair cushion and Air mattress: reposition every 1-2 hrs.
[**Known firstname 3549**] [**Last Name (NamePattern1) 9816**] MD [**MD Number(2) 9817**]
Completed by:[**2136-12-10**]
|
[
"458.29",
"427.31",
"787.22",
"389.9",
"600.00",
"V15.3",
"150.5",
"250.00",
"356.9",
"478.31",
"553.3",
"V15.82",
"707.03",
"401.9",
"511.9",
"997.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.22",
"34.91",
"45.13",
"96.6",
"43.5",
"42.41",
"99.04",
"42.62"
] |
icd9pcs
|
[
[
[]
]
] |
11256, 11338
|
4523, 7457
|
341, 399
|
9266, 9275
|
2134, 4500
|
10112, 11233
|
1379, 1598
|
7612, 8930
|
9056, 9245
|
7483, 7589
|
11362, 12582
|
1613, 2115
|
284, 303
|
427, 770
|
792, 1028
|
1044, 1363
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,780
| 117,266
|
48410
|
Discharge summary
|
report
|
Admission Date: [**2180-2-17**] Discharge Date: [**2180-2-24**]
Date of Birth: [**2100-3-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2234**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
EGD
Colonoscopy
History of Present Illness:
This 79 year old man was at his physical therapist's office
today when he was found to be hypotensive with SBPs in the 90s,
and was sent to the [**Hospital1 18**] where he was found to be guiaic
positive.
.
His wife reports that he has been increasingly fatigued and
lethargic for the last three days. She noticed that he has also
had loose stools for the last three or four days but does not
know if they were bloody or melanotic. Yesterday he was
noticeably out of breath when climbing up stairs; she thought
this might be because he had missed several sessions of his
exercise/physical therapy class at [**Hospital 100**] Rehab. He attended a
session of this class today, and the physical therapist noticed
that he seemed weak and tired; and on taking his blood pressure
found him to be lower than usual (he is generally somewhat
hypertensive) and declining. The PT called an ambulance and he
was brought to the [**Hospital1 18**].
.
In the emergency department, his initial vitals were T 97.6, HR
86, BP 108/57, RR 20, O2 sat 100% RA. He was found to have
grossly melanotic stool in his rectal vault, which was guiaic
positive; an NG lavage was negative. He was given IV
pantoprazole and cross-matched for 2 units of PRBCs. The GI
service saw him in the ED and plans colonoscopy either later
this evening or tomorrow. In the emergency department he was
hemodynamically stable with blood pressures in the 120s/80s.
Past Medical History:
Per OMR:
* hypertension
* dementia
* mild chronic renal insufficiency: Cr 1.4-1.6 at baseline
* MGUS with detailed evaluation in [**2178**]
* remote history of testicular cancer
* prostate cancer, more recently evaluation is negative for
prostate cancer
* chronic leg pain, EMG suggesting radiculopathy, degenerative
lumbar changes seen on skeletal survey
* regular debridement of toenails/foot lesions by podiatry
* psoriasis
Social History:
Former smoker, quit 15 years ago; EtOH: drinks one drink a night
most nights, sometimes two drinks when out with friends
(1x/2weeks). [**Name2 (NI) **]d; wife accompanying him here.
Family History:
Non-contributory
Physical Exam:
T 98.8
HR 90
BP 143/84
RR 19
O2 100
.
GEN: Well-appearing elderly man sitting in bed with blankets
gathered around him, NAD
HEENT: no OP lesions; MMM; anicteric; EOMI
NECK:
HEART: RRR, low-pitched systolic murmur heard best at base, no
r/g
CHEST: Good air movement bilaterally, slight crackles at bases,
no wheezes or rhonchi
ABDOMEN: Soft, non-distended, non-tender to palpation and to
taps; no hepatosplenomegaly
EXTREMITIES: Cool feet with faint pulses; radial pulses ++/++;
SKIN: Healed ovoid lesions throughout c/w healed psoriasis
lesions
NEURO: Strength 4+ and symmetrical in all extremity directions;
.
.
Pertinent Results:
.
[**2180-2-17**] 01:54PM WBC-11.7*# RBC-3.19*# HGB-9.6*# HCT-28.7*#
MCV-90 MCH-30.3 MCHC-33.6 RDW-14.2
[**2180-2-17**] 01:54PM NEUTS-84.5* LYMPHS-11.5* MONOS-3.4 EOS-0.5
BASOS-0.1
[**2180-2-17**] 01:54PM PLT COUNT-273
[**2180-2-17**] 01:54PM GLUCOSE-106* UREA N-75* CREAT-1.6* SODIUM-143
POTASSIUM-5.2* CHLORIDE-110* TOTAL CO2-22 ANION GAP-16
[**2180-2-17**] 01:54PM CK(CPK)-116
[**2180-2-17**] 01:54PM CK-MB-6 cTropnT-0.03*
.
.
.
CHEST X-RAY, [**2-17**]
INDICATION: 79-year-old man with cough and slight shortness of
breath. Evaluate for pneumonia.
.
CHEST, TWO VIEWS: Comparison is made to prior examination of
[**2175-9-21**]. The heart is normal in size. The mediastinal and hilar
contours are unremarkable. The pulmonary vasculature is normal.
The lungs are clear. There is no consolidation. There are no
pleural effusions. There is haziness overlying the right
hemithorax that extends into the soft tissue and is felt to be
technical in nature due to malalignment of the x-ray tube.
.
IMPRESSION: No acute intrathoracic process. No evidence of
pneumonia.
.
Brief Hospital Course:
ASSESSMENT AND PLAN:
.
79 year old man with vascular dementia, past prostate and
testicular cancer, past MGUS, coming to us with a 16 point Hct
drop in the past week, with a history of [**3-28**] days of increasing
lethargy and fatigue as well as loose stools.
.
GI BLEED
Pt has grossly melanotic guiaic-positive stool and a relatively
acute Hct drop. All BP meds, NSAIDs held on admission. 2 large
bore IVs placed, started on IV PPI [**Hospital1 **], and transfused 1 unit
pRBC in MICU. GI consulted and EGD showed gastritis and
duodenitis with contact bleeding. [**Name2 (NI) **] was then called out to the
floor for further management. Patient's crit remained stable
and he underwent colonoscopy demonstrating diverticulosis.
.
LEG PAIN
Per discussion with PCP ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]), likely c/w sciatica, calf
and foot pain is new manifestation of [**Last Name 73683**] problem. Exam
not c/w DVT; no asymmetry, no swelling, no pain to palpation;
not c/w arterial clot: pain not worse w activity. Continued on
gabapentin.
DEMENTIA
Per wife, pt has vascular dementia. Memory not formally tested
but based on pt's need to repeat questions and inability to
provide history, short-term memory deficit is reasonably
significant. No treatment needed at this point, and patient
appears to have the capacity to consent.
HYPER/HYPOTENSION
Pt has past hx of hypertension. Normotensive throughout hospital
course in spite of GI bleed. Initially held BP meds in setting
of GI bleed, gradually re-added usual outpatient regimen.
ACUTE RENAL FAILURE AND CHRONIC KIDNEY DISEASE
Some renal insufficiency at baseline. Creatinine around 1.3.
To 1.6 on admit. WIth blood and fluids, to 1.1 by discharge.
Medications on Admission:
Captopril 25 mg [**Hospital1 **]
Clonidine 0.2 mg [**Hospital1 **]
Norvasc 5 mg daily
Gabapentin 300 mg tid
Motrin 600 mg daily
ASA 325 mg daily
Vitamin A [**Numeric Identifier 961**] unit daily
Testosterone 5 mg/24hr patch weekly
Discharge Medications:
1. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Norvasc 5 mg Tablet Sig: One (1) Tablet PO once a day.
3. Captopril 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
Disp:*60 Capsule(s)* Refills:*0*
5. Vitamin A 10,000 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. Testosterone 5 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. Triamcinolone Acetonide 0.1 % Ointment Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day).
9. White Petrolatum-Mineral Oil Cream Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
1. Acute Blood Loss Anemia
2. GI bleeding
3. Gastritis
4. Duodenitis
5. Dementia
6. Hypertension
7. Sciatica
Discharge Condition:
Stable, hematocrit stable and HD stable for days.
Discharge Instructions:
Follow up as below.
Contact your doctor or go to the emergency room if you notice
any recurrence of bleeding in your stool, shortness of breath,
chest pain, light-headedness, fevers or any other new concerning
symptoms.
Take all medications as prescribed. We have made the following
changes:
1)Protonix is new and is for your gastritis
2)We have increased your neurontin, also known as gabapentin.
Take the increased dose until you see Dr. [**Last Name (STitle) **]. This
medication is for your leg pain
3)Do not take aspirin or any "NSAIDS" such as ibuprofen, motrin,
advil, alleve until you are seen by Dr. [**Last Name (STitle) **] and she instructs
otherwise.
Otherwise, we have made no changes.
You had a small polyp or piece of stool seen in the end of your
colon seen on the CAT scan of your colon. The doctors did not
[**Name5 (PTitle) 788**] this on the colonoscopy. They have recommended you have a
repeat colonoscopy in one years time.
Followup Instructions:
follow up with your primary care doctor or one of her colleagues
within the next 1-2 weeks. Call [**Telephone/Fax (1) 1247**] to schedule an
appointment.
You also have the followign previously scheduled appointments:
Provider: [**Name10 (NameIs) **] [**First Name8 (NamePattern2) 1243**] [**Name8 (MD) **], M.D. Date/Time:[**2180-5-22**] 9:20
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 1142**]
Date/Time:[**2180-5-8**] 9:45
Colonoscopy in one year's time.
|
[
"403.90",
"729.5",
"562.10",
"584.9",
"338.29",
"437.0",
"578.1",
"722.52",
"535.40",
"E935.9",
"V12.54",
"696.1",
"285.1",
"V10.46",
"290.40",
"585.3",
"796.3",
"535.60",
"E849.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"45.16",
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
7118, 7176
|
4220, 5960
|
323, 340
|
7329, 7380
|
3119, 4197
|
8383, 8923
|
2453, 2471
|
6241, 7095
|
7197, 7308
|
5986, 6218
|
7404, 8360
|
2486, 3100
|
275, 285
|
368, 1787
|
1809, 2238
|
2254, 2437
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,334
| 127,603
|
53603
|
Discharge summary
|
report
|
Admission Date: [**2120-4-23**] Discharge Date: [**2120-5-1**]
Date of Birth: [**2063-9-29**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Tetracycline
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Coronary artery disease
Major Surgical or Invasive Procedure:
[**2120-4-26**]: Coronary artery bypass grafting x4, with the
left internal mammary artery to the left anterior descending
artery, and reverse saphenous vein grafts to the second
obtuse marginal artery, and sequential reverse saphenous vein
graft to the posterior descending artery and the posterior
left ventricular branch artery.
History of Present Illness:
53 year old male with reports of chest burning associated with
shortness of breath relieved with rest. This has been ongoing
for the past six months. He completed a Persantine stress test
on [**2120-4-2**]. There were no chest
pain symptoms or ischemic ECG changes with the Persantine
infusion. Imaging revealed a previous large infarct or scar in
the inferior and inferolateral wall extending from the base to
the mid LV with a small amount of peri-infarct ischemia at the
base of the inferolateral wall. There was mild hypokinesis of
the basal inferior wall and the LVEF was 46%. He was referred
for cardiac catheterization. He was found to have coronary
artery disease and is now being referred to cardiac surgery for
revascularization.
Past Medical History:
Hypertension
Hyperlipidemia
LV [**Year (4 digits) 16631**] dysfunction
Coronary artery disease
Perpherial vascular disease
Gout
? Sleep apnea
Past Surgical History:
[**9-/2117**] Stents x 3 Left internal iliac and common femoral
[**9-/2117**] Stents x 2 Right LE
Social History:
Lives with:Wife Contact:[**Name (NI) **] (wife)Phone
#[**Telephone/Fax (1) 110132**](home),[**Telephone/Fax (1) 110132**]
(cell)
Occupation:propane truck driver
Cigarettes: Smoked no [] yes [x] current smoker, 1-1.5 ppd x30
years
Other Tobacco use:denies
ETOH: < 1 drink/week [x] [**3-12**] drinks/week [] >8 drinks/week []
Illicit drug use:denies
Family History:
Premature coronary artery disease- Father died from MI at 72
Physical Exam:
Pulse:18 Resp:53 O2 sat:18
Admission
B/P Right:132/79 Left:130/75
Height:6'5" Weight:107 kgs
General: NAD, AAOx3
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 [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x]
Extremities: Warm [x], well-perfused [x] Edema []
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: palp Left: palp
DP Right: palp Left: palp
PT [**Name (NI) 167**]: palp Left: palp
Radial Right: palp Left: palp
Carotid Bruit Right: none Left: none
Pertinent Results:
Echocardiogram [**2120-4-26**]
LEFT ATRIUM: Normal LA and RA cavity sizes.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal
interatrial septum.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Normal LV wall thickness and cavity
size.
LV WALL MOTION: Regional left ventricular wall motion findings
as shown below; remaining LV segments contract normally.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal diameter of aorta at the sinus, ascending and arch
levels. Focal calcifications in descending aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Moderate to severe (3+) MR. [**Name13 (STitle) 15110**] to the eccentric
MR jet, its severity may be underestimated (Coanda effect).
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
REGIONAL LEFT VENTRICULAR WALL MOTION:
Conclusions
PREBYASS. Large (4.9 by 2.1 cm basal inferior aneurysm
consistent with prior inferior MI. The posteromedial papillary
muscle is restrictive and this is the mechanism for the
posteriorly directed MR jet which hugs the wall of the LA
(Coanda effect) and appears to be consistent with moderate to
severe MR with a vena contracta of 5.5cm which potentially
underestimates the degree of MR. [**First Name (Titles) **] [**Last Name (Titles) 16631**] pulm venous flow
reversal. Other valves are essentially normal and no other
segmental wall motion abnormalities. The left atrium and right
atrium are normal in cavity size. Left ventricular wall
thicknesses and cavity size are normal. The remaining left
ventricular segments contract normally. LVEF = 40-45%. Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis or aortic
regurgitation. Moderate to severe (3+) mitral regurgitation is
seen. Due to the eccentric nature of the regurgitant jet, its
severity may be significantly underestimated (Coanda effect).
There is no pericardial effusion. Lateral mitral annular tissue
Doppler of 8.5 cm/sec consistent with normal diastolic function.
Mild descending thoracic aortic atherosclerotic plaque. Intact
IAS. No clot in LAA. Normal coronary sinus
Cardiac Catheterization: Date:[**2120-4-23**] Place:[**Hospital1 18**]
LMCA: normal
LAD: mid 90% stenosis, D2 ostial 80% stenosis
LCX: OM1 mid 40% stenosis, OM2 mid 60-70% stenosis, OM3 mid
60-70% stenosis
RCA: ostial 100% stenosis
[**2120-4-30**] 09:43AM BLOOD WBC-7.0 RBC-3.61* Hgb-9.9* Hct-30.3*
MCV-84 MCH-27.5 MCHC-32.8 RDW-14.8 Plt Ct-245#
[**2120-4-28**] 06:40AM BLOOD WBC-9.2 RBC-4.01* Hgb-10.8* Hct-33.0*
MCV-82 MCH-27.0 MCHC-32.9 RDW-15.3 Plt Ct-147*
[**2120-4-27**] 04:29AM BLOOD WBC-14.4* RBC-4.33* Hgb-11.2* Hct-36.6*
MCV-85 MCH-26.0* MCHC-30.7* RDW-15.1 Plt Ct-185
[**2120-5-1**] 05:20AM BLOOD PT-16.8* INR(PT)-1.6*
[**2120-4-30**] 07:50AM BLOOD PT-13.6* INR(PT)-1.3*
[**2120-4-29**] 06:32AM BLOOD PT-12.5 INR(PT)-1.2*
[**2120-4-27**] 04:29AM BLOOD PT-12.2 PTT-30.5 INR(PT)-1.1
[**2120-5-1**] 05:20AM BLOOD Glucose-105* UreaN-23* Creat-1.1 Na-135
K-4.0 Cl-96 HCO3-27 AnGap-16
[**2120-4-30**] 07:50AM BLOOD Na-135 K-4.1 Cl-97
[**2120-4-29**] 06:32AM BLOOD Na-133 K-4.2 Cl-97
[**2120-4-28**] 06:40AM BLOOD Glucose-141* UreaN-23* Creat-1.0 Na-134
K-4.3 Cl-100 HCO3-26 AnGap-12
Brief Hospital Course:
The patient was brought to the operating room on [**2120-4-26**] where
the patient underwent Coronary artery bypass grafting x4, with
the left internal mammary artery to the left anterior descending
artery, and reverse saphenous vein grafts to the second obtuse
marginal artery, and sequential reverse saphenous vein graft to
the posterior descending artery and the posterior left
ventricular branch artery.
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. Beta blocker and statin were initiated.
The patient was transferred to the telemetry floor for further
recovery. Chest tubes and pacing wires were discontinued
without complication. POD2 he had an episode of rapid atrial
fibrillation and converted to sinus rhythm with amiodarone. He
remained hemodynamically stable. His ACE was restarted.
Respiratory he was titrated off oxygen with aggressive pulmonary
toilet and nebs. He was gently diuresed with a normal renal
function and good urine output. He was evaluated by the physical
therapy service for assistance with strength and mobility. By
the time of discharge on POD 5 the patient was ambulating
freely, the wound was healing and pain was controlled with oral
analgesics. The patient was discharged home with VNA services in
good condition with appropriate follow up instructions.
Medications on Admission:
ATENOLOL 50 mg daily
HYDROCHLOROTHIAZIDE 12.5 mg daily
INDOMETHACIN 50 mg [**Hospital1 **]
LISINOPRIL 30 mg daily
NITROGLYCERIN 0.4 mg Tablet, 1-3 Tablets sublingually PRN
SIMVASTATIN 40 mg daily
ASPIRIN 325 mg daily
MULTIVITAMIN one Tablet daily
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day for 2 weeks.
Disp:*28 Tablet Extended Release(s)* Refills:*0*
5. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily) for 2 weeks.
Disp:*14 Patch 24 hr(s)* Refills:*0*
6. bupropion HCl 75 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day) for 2 weeks.
Disp:*56 Tablet(s)* Refills:*0*
7. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
8. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 2 tabs [**Hospital1 **] x 5days the 2tabs QD x7days then 1 tab QD.
Disp:*60 Tablet(s)* Refills:*1*
9. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
10. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*1*
11. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
12. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
13. warfarin 2 mg Tablet Sig: as directed Tablet PO once a day:
5mg on [**5-1**] then as directed by Dr.[**Last Name (STitle) 83355**] [**Name (STitle) 77919**] .
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Coronary artery disease
LV [**Company 16631**] dysfunction
Hypertension
Hyperlipidemia
Perpherial vascular disease, s/p Stents x 3 Left internal iliac
and common femoral, Right LE x 2 [**9-/2117**]
Gout
Sleep apnea
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Dilaudid
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage. Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
WOUND CARE NURSE Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2120-5-7**] 10:30 in
the [**Last Name (un) 2577**] Building [**Last Name (NamePattern1) **] [**Hospital Unit Name **]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8583**], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2120-5-30**] 1:00 in
the [**Hospital Unit Name **] [**Last Name (NamePattern1) **] [**Hospital Unit Name **]
Follow-up with Dr. [**Last Name (STitle) **]/Dr.[**Last Name (STitle) 83355**] [**Name (STitle) 77919**] ([**Telephone/Fax (1) 110133**]
[**2120-5-6**] at 1:30 at 112A [**Last Name (NamePattern1) 110134**], [**Numeric Identifier 12023**]
Please call your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Known firstname **] [**Last Name (NamePattern1) 110135**] [**Telephone/Fax (1) 75712**] for a
follow-up appointment in [**5-9**] weeks.
INR check on [**5-2**] and [**5-4**] results called to:
Dr. [**Last Name (STitle) 83355**] [**Name (STitle) 77919**] [**Telephone/Fax (1) 110136**]
Completed by:[**2120-5-1**]
|
[
"443.9",
"414.10",
"327.23",
"305.1",
"272.4",
"V70.7",
"414.01",
"428.20",
"274.9",
"413.9",
"427.31",
"424.0",
"401.9",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"39.61",
"88.53",
"36.13",
"37.22",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
9940, 9989
|
6410, 8013
|
303, 637
|
10248, 10468
|
2836, 3809
|
11238, 12300
|
2078, 2141
|
8311, 9917
|
10010, 10227
|
8039, 8288
|
10492, 11215
|
1595, 1695
|
3848, 6387
|
2156, 2817
|
239, 265
|
665, 1407
|
1429, 1572
|
1711, 2062
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,805
| 168,079
|
45858
|
Discharge summary
|
report
|
Admission Date: [**2183-3-6**] Discharge Date: [**2183-3-18**]
Date of Birth: [**2116-12-11**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
R femoral line
R IJ
R A-line
History of Present Illness:
66 year old man with history of CAD s/p STEMI and stenting, with
severe ischemic CMP (EF 15-20%) on home milrinone +
pseudoephedrine, DM, PVD, COPD who presents from rehab with
hypotension and hypothermia.
.
Pt with worsening renal fxn at rehab. Received kayexelate,
insulin and D50 on [**3-5**] for hyperkalemia. Then found to have BP
50s-70s systolics with WBC of [**Numeric Identifier 5863**] and 7% bands sent to ED.
.
Of note, had recent prolonged hospitalization from [**1-28**] to [**2-17**]
with RSV and MRSA PNA infections and subsequent volume overload.
Pt was again admitted from [**2-28**] to [**3-1**] for atypical CP relieved
by GI cocktail. Course c/b acute on chronic CHF.
.
In the ED, his VS were T96.2, 73, 66/45, 22, 92% NRB. WBC of 26
with left shift. Lactate of 5.2 -> 4.1. ARF with Cr of 3.7 and
hyperkalemic. INR of 22. CXR with mild pulmonary edema and
unchanged old L lung opacification (s/p pneumonectomy). R fem
line placed b/o INR of 22. Pt was intubated for respiratory
distress with succ, etomidate and versed. 1L IVF, then started
on dopa gtt with MAP remaining abovee 60. Pt received vanc and
zosyn. Vit K 10 IV and 2 bags of FFP for INR of 22. Also 1 amp
bicarb, 5U insulin and [**11-27**] amp D50 for hyperkalemia. Pt being
admitted for sepsis to ICU.
.
On arrival to the MICU, he was nonresponsive, intubated on
100%FiO2.
Past Medical History:
1) CAD: most recent cath with BMS stents to RCA/OM1
- anterior STEMI in [**11-2**] with stents x 2 to LAD, course c/b
cardiogenic shock requiring balloon pump.
- h/o BMS to proximal and distal LAD in [**2174**]
2) CHF, severe regional left ventricular systolic dysfunction,
EF 15-20% on home milrinone
3) COPD: On 2L NC at home. PFT's [**10-3**]: Marked obstructive
ventilatory defect. The reduced FVC is likely due to gas
trapping but a coexisting restrictive defect cannot be excluded.
Suggest lung volume measurements if clinically indicated. FVC
62% predicted, FEV1 39% predicted, FEV1/FVC 63% predicted.
4) Hypercholesterolemia
5) Gout
6) PVD s/p left iliac artery stent in [**2174**].
7) Diabetes mellitus
8) Non-small-cell lung carcinoma, status post left pneumonectomy
9) Gastroesophageal reflux disease
10) Paroxysmal atrial fibrillation, chronically anticoagulated
on coumadin
11) Hypertension
Social History:
h/o prior tobacco abuse x 60 pack years; quit in [**2173**]. There is
no history of alcohol abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Father had CAD in old age. Sister with MVP.
Physical Exam:
VS: T 96.9, BP 82/54 (on dopa), HR 85, RR 17, O2 82% on AC
500x16, FiO2 0.5, PEEP 5 -> O2 100% on FiO2 1.0
Gen: WDWN middle aged male, intubated, sedated.
HEENT: NCAT. PERRL. ETT in place.
Neck: Supple. JVD difficult to assess.
CV: RR, normal S1, S2. Systolic murmur, best heard over apex.
Chest: No BS over L lung. R lung CTA anteriorly.
Abd: Obese, soft, NTND, R femoral line in place
Ext: faint peripheral pulses, cool, no significant edema
Skin: Abdominal wall hematomas, no rash.
Neuro: nonresponsive, sedated.
Pertinent Results:
On admission:
116 83 74
=========== 132
6.4 17 3.7
.
CK: 25 MB: Notdone
Ca: 9.1 Mg: 2.3
ALT: 81 AP: Tbili: 2.4 Alb:
AST: 89 LDH: Dbili: TProt:
[**Doctor First Name **]: Lip: 15
.
WBC 26.2, Hct 31.4, Plt 335
.
Lactate 5.2
INR 22
.
CXR in ED: Post-left pneumonectomy changes are again evident.
Consistent with the given history, PICC line has been placed
from a left upper extremity approach. The distal tip overlies
the mediastinum. It is approximately at the superior cavoatrial
junction. Please note the extreme right costophrenic angle has
been excluded from view as it has been on prior exams. There is
mild prominence of the pulmonary vasculature likely indicative
of mild edema. No definite large effusion is seen. There is no
pneumothorax. IMPRESSION: PICC line as above. Mild volume
overload.
.
Echo in ED: The left atrium is markedly dilated. The right
ventricular cavity is moderately dilated with moderate global
free wall hypokinesis. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. The mitral valve
leaflets are moderately thickened. Moderate (2+) mitral
regurgitation is seen. Severe [4+] tricuspid regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
IMPRESSION: Severely depressed left systolic function with EF of
10%- slightly less than on prior study. Moderate MR and severe
TR. Mild pulmonary hypertension. PRELIMINARY REPORT developed by
a Cardiology Fellow. Not reviewed/approved by the Attending Echo
Physician.
.
Echo [**3-7**]: The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
There is moderate regional left ventricular systolic dysfunction
with near akinesis of the inferior wall and the distal half of
the anterior septum and anterior wall, distal lateral wall. The
apex is mildly aneurysmal and akinetic. The remaining segments
are moderately hypokinetic. No masses or thrombi are seen in the
left ventricle. The right ventricle is mildly dilated with
moderate global free wall hypokinesis. The aortic valve leaflets
(3) are mildly thickened. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Normal left ventricular cavity size with extensive
regional systolic dysfunction c/w multivessel CAD. Mild mitral
regurgitation. Moderate pulmonary artery systolic hypertension.
Compared with the fellow study of earlier in the day, an
inferior aneurysm is not appreciated on the current study. It
likely represented and off-axis apical view.
.
Renal U/S: no obstruction or hydro
.
Previous studies:
.
Cardiac Cath on [**2182-11-28**]
1. Two vessel coronary artery disease.
2. Successful stenting of the OM and RCA with bare metal stents.
.
Cardiac Catheterization [**2182-11-14**]
1. Three vessel coronary artery disease.
2. Cardiogenic shock.
3. Acute anterior myocardial infarction
4. Successful PTCA and stenting of the proximal-mid left
anterior descending artery with two overlapping bare metal
stents.
5. Successful placement of an IABP via the right common femoral
artery.
.
Echo [**2182-12-19**]
IMPRESSION: Severe regional left ventricular systolic
dysfunction, c/w CAD. Moderate right ventricular systolic
dysfunction. Moderate mitral and triscuspid regurgitation.
Moderate pulmonary hypertension.
Brief Hospital Course:
66 year old man with history of CAD s/p STEMI and stenting
([**11-2**]), with severe ischemic CMP (EF 15-20%) on home milrinone
+ pseudoephedrine, DM, PVD, COPD who presents from rehab with
hypotension and hypothermia, found to in septic shock, pressor
dependent, with MRSA bacteremia (from PICC line) and ESBL
Klebsiella in urine and sputum. Made CMO on [**3-18**]. Pt died
minutes after extubation on [**3-18**] at 1:40PM.
.
# Septic shock: IVF-refractory hypotension from sepsis, worse
[**2-14**] with oliguria again, cardiomyopathy contributing. Initial
lactate 6.0, repeat [**2-14**] 1.9. Initially MRSA bacteremia from
PICC line and ESBL Klebsiella in urine + sputum. One day of
stress dose steroids on admit. Transiently on dopa and
vasopressin, currently on levophed, vasopressin and milrinone
drips, with escalation of pressor requirement [**2-13**]. On
Vanc/Zosyn until [**3-10**], switched to Vanc/[**Last Name (un) **] on [**3-11**] b/o ESBL
Klebsiella from urine + sputum. Developed worsening VAP [**2-14**]
with increased sputum with GNR's, low-grade fever, worse
hypotension, increased WBC, infiltrate. Pt was continued on
levophed, milrinone gtt, Vasopressin, eventually also epinephrin
gtt. He was continued on Vanc and [**Last Name (un) **]. Sputum [**3-10**] with sparse
Acinetobacter [**Last Name (un) 36**] to Bactrim, started iv bactrim. Also empiric
hydrocortizone 50mg iv q6. Made CMO on [**3-18**]. Pt died minutes
after extubation on [**3-18**] at 1:40PM.
.
# Respiratory failure: Intubated in ED for respiratory distress.
Known COPD, also with sepsis. Pt has only one lung after
resection for lung cancer. Failed PSV trial on [**3-9**] but could be
extubated on [**3-10**]. Required more O2 on BiPAP, Lasix 40 IV w/o
effect. Frank blood from NGT, reintubated at 5AM on [**3-11**].
Started lasix gtt on [**3-11**], not effective at 10/hr, added on [**3-13**]
diuril 500 IV bid with good response, stopped [**2-12**] as
autodiuresing. Made CMO on [**3-18**]. Pt died minutes after
extubation on [**3-18**] at 1:40PM.
.
# AMS: Likely toxic-metabolic (infxn, sedation, hypoxia).
.
# ARF: On admission with creatinine 3.7 up from baseline of 1.2
-1.4. Renal U/S w/o obstruction. Likely prerenal etiology +/-
ATN. Monitor UOP closely with sepsis. Holding dig. Treat
hyperkalemia as needed. Appreciate renal recs. Hyaline casts in
urine c/w pre-renal or poor forward flow. Cr nadir at 1.5 ([**2-14**])
but UOP decreasing, likely additional insult from worsening
hypotension.
.
# Supratherapeutic INR: INR of 22 on admission in setting of ARF
on coumadin. Received Vitamin K 10 IV and 4 bags of FFP, INR
came down to 2.0 eventually but is trending up intermittently
requiring more Vit K and FFP during active bleeds. Coumadin was
held as well as isolated doses of ASA/plavix during severe
bleeding (held twice total). Pt received FFP and PRBC as needed
([**3-11**], [**3-13**])with INR goal < 2.0 and Hct >25 during active
bleeding episodes.
.
# Thrombocytopenia: Improved. Plt of 113 on [**3-12**], down from 335
on admission. Heparin products were transiently held but HIT Ab
came back negative. DIC labs were unremarkable.
.
# CMP: EF 15%. On home milrinone and pseudoephedrine. CXR with
mild pulmonary edema on admission. Pt received IVF boluses for
hypotension as needed. Diuretics initially held then diuresed as
above. Continued milrinone drip as above. Outpatient cards attg
was following.
.
# CAD: s/p STEMI c/b by cardiogenic shock requiring balloon
pump. Trop 0.09 -> 0.07 in ED. Held intermittently isolated
doses of ASA/plavix as needed for active bleeding. Cardiac
enzymes remained not significantly elevated and were not
followed further.
.
# PAF: the patient has a h/o PAF. Holding dig b/o ARF. No
coumadin or heparin gtt per cards. Pt was continued on amio.
.
# Anemia: baseline Hct 27-32. Intermittent bleeding from ETT and
BRBPR from likely hemorrhoids. Received PRBC as needed with Hct
goal > 25 during active bleeds. Also Vit K and FFP as needed as
above. PRBC on [**5-21**], [**3-14**].
.
# LFT elevations: likely from shock liver. Trended down. Were
monitored.
.
#.DM2: FS qid, transiently on insulin gtt, then RISS.
.
# Hypothyroidism: TSH wnl. Continued L-thyroxin.
.
#.FEN: NPO. TFs. Held as needed if high residuals. Repleted
electrolytes as needed.
.
#.PPx: PPI, P-boots, supratherapeutic INR, bowel regimen
.
# Access: R femoral line [**Date range (1) 42063**], R IJ (trauma line) placed
[**3-8**], R A-line placed [**3-7**], PICC removed
Medications on Admission:
Lasix 40 [**Hospital1 **]
Milrinone infusion 0.6 mcg/kg/min
Hydrocodone/tylenol q6h prn
Lidocaine patch daily
Tiotropium inhal daily
Calium/Vit D daily
Mylanta 30ml daily
Bowel regimen
Dig 0.125 qod
Warfarin 1.5mg daily
Colesevelam 1875 q12h
ISS
Amio 200 daily
Pseudoephedrine 30mg qid
Levothyroxine 0.125 daily
Iron 325 daily
ASA 325 daily
PPI 40 daily
Plavix 75 daily
Colechaciferol daily
MVI daily
Spironolactone 25 daily
Tylenol prn
Discharge Medications:
Made CMO on [**3-18**]. Pt died minutes after extubation on [**3-18**] at
1:40PM.
Discharge Disposition:
Expired
Discharge Diagnosis:
Made CMO on [**3-18**]. Pt died minutes after extubation on [**3-18**] at
1:40PM.
Discharge Condition:
.
Discharge Instructions:
.
Followup Instructions:
.
|
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"414.01",
"276.7",
"570",
"287.5",
"518.81",
"244.9",
"599.0",
"V10.11",
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icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04",
"96.72",
"96.6",
"38.93",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
12120, 12129
|
7036, 11525
|
327, 357
|
12255, 12258
|
3483, 3483
|
12308, 12312
|
2805, 2932
|
12013, 12097
|
12150, 12234
|
11551, 11990
|
12282, 12285
|
2947, 3464
|
276, 289
|
385, 1743
|
3498, 7013
|
1765, 2673
|
2689, 2789
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,728
| 177,681
|
5469
|
Discharge summary
|
report
|
Admission Date: [**2160-10-9**] Discharge Date: [**2160-10-26**]
Date of Birth: [**2120-4-8**] Sex: F
Service: Medicine
HISTORY OF PRESENT ILLNESS: The patient is a 40 year old
woman with a history of hypoparathyroidism secondary to a
parathyroid adenoma and papillary thyroid cancer, status post
total thyroidectomy and right superior parathyroidectomy on
[**2160-9-30**], who recovered well but whose course was
complicated by parathyroid studding with hypocalcemia. She
was admitted to [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] shortly
after her surgery, with symptomatic hypocalcemia. Her
calcium was repleted and she was discharged home on Rocaltrol
and Tums E-X calcium supplementation every day.
The patient presented to the Emergency Room the night prior
to admission with nausea, vomiting, dizziness, inability to
tolerate oral intake and a calcium level of 18.2. Her
electrocardiogram showed sinus bradycardia but was otherwise
normal. She was given fluids, calcitonin and pamidronate,
with a resultant decrease in her calcium level to 11.9. She
was admitted for close monitoring of her calcium level and
monitoring by telemetry. She now feels much better, with
some residual nausea, dizziness and fatigue. She also
complained of abdominal soreness from frequent emesis. Her
review of systems was otherwise negative.
PAST MEDICAL HISTORY: 1. Type 2 diabetes mellitus for the
past five years, well controlled on oral hypoglycemics with
no complications. 2. Depression for the past four years,
controlled on Celexa. 3. Anxiety for the past four years,
controlled on Klonopin as needed. 4. Right knee
osteoarthritis, status post arthroscopy times two. 5.
Status post breast biopsy that was negative. 6. Status post
polypectomy during colonoscopy with a repeat colonoscopy that
was negative. 7. Hypoparathyroidism due to parathyroid
adenoma, status post right superior parathyroidectomy. 8.
Papillary thyroid cancer, status post total thyroidectomy,
now on Cytomel.
MEDICATIONS ON ADMISSION: Glucophage 1,000 mg p.o.b.i.d.,
Celexa 20 mg p.o.q.d., Avandia 4 mg p.o.b.i.d., Klonopin 0.5
mg p.o.q.h.s.p.r.n., Cytomel 25 mcg p.o.q.d., Tums E-X 4 gm
six times per day, magnesium oxide 400 mg p.o.q.d., Rocaltrol
0.25 mg p.o.q.d.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient lives with her husband. She
does not use tobacco, alcohol or drugs.
FAMILY HISTORY: The patient's family history is negative for
thyroid cancer or hypoparathyroidism, positive for diabetes
mellitus and hypertension.
REVIEW OF SYSTEMS: Negative.
PHYSICAL EXAMINATION: On physical examination, the patient
was a mildly anxious, relatively fatigued woman who was
afebrile with a blood pressure of 100/60, pulse 76,
respiratory rate 20 and oxygen saturation 93% in room air.
Head, eyes, ears, nose and throat: Mucous membranes dry,
otherwise unremarkable. Neck: Well healed incision, clean,
dry and intact without erythema. Lungs: Clear to
auscultation bilaterally. Cardiovascular: Regular rate and
rhythm, no murmur, rub or gallop. Abdomen: Diffusely tender
but otherwise soft and nondistended with no rebound or
guarding, positive bowel sounds. Extremities: Without
edema, 2+ peripheral pulses. Neurologic: Nonfocal, 5/5
strength, normal sensation to light touch, intact cranial
nerves, negative Chvostek's and negative Trousseau's signs.
LABORATORY DATA: Admission white blood cell count was 10.6
with normal differential, hematocrit 33.8, platelet count
383,000, sodium 143, potassium 4.2, chloride 107, bicarbonate
25, BUN 12, creatinine 0.8, glucose 164, albumin 4, TSH 2.5
and parathyroid hormone 6.8 (low). Initial calcium was 18.2,
which dropped to 11.9 with fluids in the Emergency Room.
Initial ionized calcium was 2.36, which was high. Initial
magnesium was 1.4.
HOSPITAL COURSE: The patient came to the floor after
receiving fluids, calcitonin and pamidronate in the Emergency
Room. Her calcium levels were initially followed three times
a day. She was initially hypocalcemic and required frequent
intravenous infusions of calcium gluconate. Given her
frequent need for intravenous electrolyte replacement and
three times a day blood draws, a left subclavian line was
placed. Her magnesium was also followed three times a day
and she often required intravenous magnesium repletion. She
was started on higher doses of oral Tums and magnesium oxide
than she had been on at home.
In the middle of her hospital course, the patient required
such frequent infusions of intravenous electrolytes that she
was transferred to the Medical Intensive Care Unit for
monitoring. Once she was on a better oral regimen with a
decreased need for intravenous infusions, she was transferred
back to the floor. She eventually achieved a dose of
calcium, magnesium oxide and Rocaltrol that maintained her at
stable blood levels of these electrolytes.
Hypophosphatemia secondary to the intravenous calcium
infusions was a complication that was treated initially with
phosphorous repletion and then by having her take her Tums
not at meals in order to prevent it from acting as a
phosphorous binder. She briefly had hypokalemia during her
first few days in the hospital, that resolved quickly with
only a few days of repletion.
The cause of the patient's hypomagnesemia was unclear,
although her urinary fraction excretion of magnesium was
high. A renal consult was obtained and they suggested that
she should be followed over time, mainly weeks to months, for
improvement in her magnesium levels, and continue oral
supplementation in the meantime. Her magnesium doses that
she received did induce diarrhea but it was not significantly
uncomfortable for the patient.
During her hospital stay, the patient was changed from
Cytomel to Synthroid. The initial plan after her thyroid
resection had been to keep her on Cytomel in preparation for
discontinuation of hormone to look for any remaining thyroid
tissue that might require removal. However, given her more
pressing problem of electrolyte imbalances, she was changed
to Synthroid for better control of her hypothyroidism. At
some point in the future, she will be switched back to
Cytomel and a search for residual thyroid tissue will be
done.
Cardiovascular: The patient was kept on telemetry. She
initially had a long QT but, as her hypocalcemia resolved,
her QT shortened. Once her calcium levels were stable, she
was taken off telemetry as she had no further signs of
electrocardiographic abnormalities.
From a hematologic standpoint, the patient had a baseline
hematocrit of 33 on admission, which was post surgical. She
developed a dilutional anemia, after receiving the fluids in
the Emergency Room, that was slowly resolving, although her
hematocrit did not completely correct due to frequent, namely
three times a day, laboratory draws. She was guaiac negative
throughout her stay and was started on iron tablets to
support her during the time of blood loss from phlebotomy.
Infectious disease: The patient tolerated her left
subclavian line well but spiked a temperature to 100.6 on day
13 after the line was placed. The line was removed and she
had no further fever spikes. At that point, she was no
longer requiring intravenous electrolyte infusions and was
down to blood draws twice a day, so removing the line was an
acceptable course of action.
CONDITION AT DISCHARGE: Improved.
DISCHARGE DIAGNOSES:
Hypocalcemia secondary to parathyroid studding.
Hypothyroidism.
Diabetes mellitus.
Depression.
Anxiety.
Right knee osteoarthritis.
DISCHARGE MEDICATIONS:
Glucophage 1,000 mg p.o.b.i.d.
Celexa 20 mg p.o.q.d.
Avandia 4 mg p.o.b.i.d.
Klonopin 0.5 mg p.o.q.h.s.p.r.n.
Synthroid 175 mcg p.o.q.d.
Iron sulfate 325 mg p.o.b.i.d.
Tums E-X 4 tablets p.o.t.i.d., not with meals; this would
give the patient a total of 800 mg of elemental calcium three
times a day or 2.4 grams of elemental calcium every day.
Magnesium oxide 1 gm p.o.t.i.d.
Rocaltrol 0.25 mg p.o.q.d.
DISCHARGE STATUS: To home to follow up with primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5361**], for daily blood draws beginning the
day after discharged. As the patient's levels stabilize
further, she will be able to have fewer blood draws. The
patient will also follow up with Dr. [**Last Name (STitle) 9287**], her
endocrinologist, in four days after discharge. On discharge,
her calcium level was 8.4 and stable. Her magnesium was 1.7
and stable. Her phosphorous level was 2.2. Her parathyroid
hormone was 9.3, which was still low.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 22132**]
Dictated By:[**Name8 (MD) 1552**]
MEDQUIST36
D: [**2160-11-9**] 20:33
T: [**2160-11-11**] 12:24
JOB#: [**Job Number 22133**]
|
[
"427.89",
"588.8",
"252.1",
"V10.87",
"250.00",
"275.3",
"275.2",
"300.01",
"311"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
2526, 2659
|
7548, 7680
|
7703, 8946
|
2123, 2410
|
3953, 7501
|
2713, 3935
|
7516, 7527
|
2679, 2690
|
166, 1436
|
1459, 2096
|
2427, 2509
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,218
| 124,980
|
53290
|
Discharge summary
|
report
|
Admission Date: [**2137-9-28**] Discharge Date: [**2137-10-5**]
Date of Birth: [**2078-4-12**] Sex: F
Service: MEDICINE
Allergies:
Propoxyphene / Seasonale / Demerol
Attending:[**First Name3 (LF) 3256**]
Chief Complaint:
dyspnea and cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
59 yo F w/ PMH of gastric bypass and known DVT/PE >10 years ago
in post-op course presents with worsening dyspnea and cough. Pt
reports over the past many months that she has had worsening
cough which is productive of sputum leading to coughin fits and
she has been worked up by her PCP and allergist. Two days prior
she noted acute worsening of her dyspnea on exertion as she
walked up a slight incline and then the day of admission noted
to have dyspnea just alking around the kitchen and was concerned
re: reoccurance of a PE. Pt reports no family history of
PE/DVT, denies any recent hospitalizations or prolonged
immobilizations. She reports being worked up by a hematologist
after her last DVT/PE but does not know what the workup
consisted of. She reports being up to date on her colonoscopy
and mamaograms which have all been negative. She reports
chronic right sided knee pain from her OA s/p TKR and recently
has developed worsening groin pain that is uncomfortable to sit
at times.
In the ED she initially triggered for tachycardia and was found
to be in sinus tach on her EKG, her exam was notable for a
normal lung exam and CXR that per report was unchanged compared
to prior. She had a d-dimer checked that was eelvated and CTPA
showed massive bilateral Pulmonary emboli. She was given one
dose of lovenox 90mg (1mg/kg dosing) and admitted to the MICU
for monitoring given her persistent tachycardia. She had some
ST depressions in the lateral leads of her EKG and her troponin
was 0.02. She denied any chest pain.
On arrival to the MICU she complained of cough but denied chest
pain, reported some chest discomfort. Denied fevers, chills,
sick contacts.
Past Medical History:
Past Medical History:
history of DVT and PE
Obesity
osteoarthritis
asthma
depression
anxiety
Past Surgical History:
Gastric bypass, left inguinal hernia repair, right femoral
hernia repair, right knee arthroscopy and then right knee total
replacement, ventral incisional hernia repair.
Social History:
She lives in [**Location **]. She is employed. history of smoking, but
does not currently smoke. drinks alcohol rarely.
Family History:
No family history of DVT/PE, any sudden unexplained deaths
Physical Exam:
Admission Physical Exam:
Vitals: 99.3, 133, 120/75, 23, 94%3L
General: Alert, oriented, no acute distress, having coughing
fits that are productive
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Trachycardic and regular, no MRG appreciated however very
tachycardic
Lungs: Moving good air to the bases and Clear to auscultation
bilaterally, no wheezes, rales, rhonchi
Abdomen: Obese, soft, non-tender, non-distended, normoactive
bowel sounds
GU: no foley
Ext: Warm, well perfused, spider veins present. Right knee scar
well approximated. 2+ pulses, no clubbing, cyanosis or edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
Pertinent Results:
Admission Labs:
[**2137-9-28**] 06:15PM BLOOD WBC-7.5 RBC-4.17* Hgb-9.8* Hct-31.7*
MCV-76*# MCH-23.6*# MCHC-31.0 RDW-18.1* Plt Ct-463*
[**2137-9-28**] 06:15PM BLOOD Neuts-64.2 Lymphs-25.7 Monos-8.6 Eos-1.2
Baso-0.3
[**2137-9-28**] 07:00PM BLOOD PT-11.2 PTT-25.6 INR(PT)-1.0
[**2137-9-28**] 06:15PM BLOOD Glucose-104* UreaN-11 Creat-0.4 Na-143
K-4.4 Cl-104 HCO3-25 AnGap-18
[**2137-9-29**] 03:45AM BLOOD Calcium-8.6 Phos-4.4# Mg-2.1
[**2137-9-28**] 07:00PM BLOOD D-Dimer-6009*
[**2137-9-28**] 06:15PM BLOOD cTropnT-0.02*
[**2137-9-28**] 06:24PM BLOOD Lactate-1.7
[**2137-10-2**] 06:25AM BLOOD Calcium-9.1 Phos-4.7* Mg-1.9 Iron-17*
[**2137-10-2**] 06:25AM BLOOD calTIBC-365 Ferritn-13 TRF-281
[**2137-9-28**] 10:50PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.021
[**2137-9-28**] 10:50PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-MOD
[**2137-9-28**] 10:50PM URINE RBC-1 WBC-5 Bacteri-FEW Yeast-NONE Epi-<1
CXR - FINDINGS: Frontal and lateral views of the chest were
obtained. Posterior left diaphragmatic hernia is again seen
with mild overlying atelectasis. No focal consolidation,
pleural effusion, or evidence of pneumothorax is seen. The
cardiac and mediastinal silhouettes are stable, as are the hilar
contours.
IMPRESSION: No acute cardiopulmonary process.
CTA Chest - IMPRESSION:
1. Extensive bilateral pulmonary embolus, without evidence of
pulmonary infarction. Mild dilatation of the right ventricle as
compared to the left may be an early sign of right heart strain.
Findings could be correlated with echocardiogram.
2. Chronic elevation of the left hemidiaphragm. Previously
fat-containing left Bochdalek hernia now contains colon
TTE
The left atrium and right atrium are normal in cavity size.
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity is unusually small. Left ventricular systolic
function is hyperdynamic (EF>75%). The right ventricular cavity
is mildly dilated with mild global free wall hypokinesis. There
is abnormal septal motion/position consistent with right
ventricular pressure/volume overload. 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. The tricuspid valve leaflets are mildly
thickened. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2135-9-2**],
the right ventricle is dilated and hypokinetic with evidence of
pressure/volume overload. The left ventricle is smaller and
hyperdynamic, likely due to interventricular dependence.
Pulmonary pressures are now elevated. Findings suggestive of
acute right heart strain from pulmonary embolism.
LENI's -IMPRESSION:
1. Focal DVT in the left popliteal vein of indeterminate age. No
other sites of DVT within the left lower extremity.
2. No evidence of DVT in the right lower extremity.
Brief Hospital Course:
59 yo F w/ pmh of PE presenting with worsening dyspnea,
tachycardia found to have bilateral PEs on CTPA.
ACTIVE ISSUES:
#Bilateral Pulmonary Emboli: Patient presented with nonspecific
respiratory symptoms and worsening dyspnea with 3L oxygen
requirement and was found to have elevated Ddimer with CTPA
consistent with bilateral pulmonary emboli. EKG showed sinus
tachycardia and only TW flattening in lead III. She was started
on lovenox 1mg/kg (100mg) [**Hospital1 **]. The patient's risk factors for PE
are previous DVT/PE in the post-op setting following orthopedic
surgery. Age appropriate cancer screening including mamogram and
colonoscopy had been negative per patient. Ultrasound of lower
extremities were ordered to assess for clot burden and revealed
LLE popliteal DVT. TTE showed evidence of moderate right heart
strain. On lovenox, the patient's respiratory status improved.
She was started on coumadin. On discharge she understood plans
for bridging and was planning to have INR checked on [**10-7**] at
PCP's office.
#Cough: Patient had cough with worsening dyspnea on admission.
While it may relate to her known PEs, she also had productive
sputum and a history of cough over the previous several months.
She remained afebrile and without leukocytosis while in the ICU.
She was treated symptomatically with guaifenasin and albuterol
nebs.
#Tachycardia: Patient was in sinus tachycardia 110s-120s most
likely due to her pulmonary emboli. Her blood pressure remained
stable with SBP 120s-130s.
INACTIVE ISSUES:
#Anemia: Hct remained stable and close to baseline of 29 from
[**5-/2136**] throughout ICU stay. Given her history of gastric bypass,
is likely due to malabsorption. Iron studies showed evidence of
[**Doctor First Name **].
#Depression/Anxiety: Continued home cymbalta and wellbutrin.
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from Patient.
1. BuPROPion (Sustained Release) 300 mg PO QAM
2. Duloxetine 20 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
Discharge Medications:
1. BuPROPion (Sustained Release) 300 mg PO QAM
2. Duloxetine 20 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Enoxaparin Sodium 80 mg SC Q12H
5. Guaifenesin ER 1200 mg PO Q12H
RX *guaifenesin 200 mg 1 tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
6. Warfarin 5 mg PO DAILY16
RX *warfarin [Coumadin] 5 mg 1 tablet(s) by mouth daily Disp
#*10 Tablet Refills:*0
7. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
- Pulmonary Embolism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to [**Hospital1 18**] with shortness of breath and were
found to have a large clot in your lungs. You were placed on
blood thinners and your breathing slowly improved. You will be
discharged on coumadin and will need to follow-up closely with
your primary care physician to make sure that your INR levels
are within the goal range.
Of note, you reported that it has been some time since your last
mammogram. You will need to have a mammogram soon and should
discuss this with your PCP at your initial follow-up
appointment.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] C.
Location: [**Hospital1 **] HEALTHCARE-[**Location (un) 8596**]
Address: [**Location (un) 8597**], [**Location (un) **],[**Numeric Identifier 3862**]
Phone: [**Telephone/Fax (1) 8598**]
Appt: [**Last Name (LF) 766**], [**10-7**] at 11:45am
Name: [**Last Name (LF) 3060**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: DIVISION OF HEMOSTASIS AND THROMBOSIS
Address: [**Location (un) **], E/TCC-9, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3062**]
***The office is working on a follow up appt for you and will
call you at home with the appt. IF you dont hear from the office
by Tuesday morning, please call directly to book.
|
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4,869
| 122,893
|
22436
|
Discharge summary
|
report
|
Admission Date: [**2196-11-19**] Discharge Date: [**2196-11-26**]
Date of Birth: [**2157-11-6**] Sex: M
Service: MED
Allergies:
Sulfa (Sulfonamides) / Dapsone
Attending:[**First Name3 (LF) 6114**]
Chief Complaint:
Hyperkalemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 174**] is a 39 y.o. man with HIV (diagnosed [**2179**]) with a
history of ESRD (on hemodialysis) HTN, Diabetes Mellitus,
Hepatitis C, DVT, neuropathy, pancreatitis secondary to ddI,
polysubstance abuse and non-compliance to medications. He
presented to the ED [**2196-11-19**] with a change in mental status. On
presentation, his potassium 6.8, glucose 5, Calcium 6.2, BP
226/134, HR 71. He was given insulin and glucose in the ED, and
was reported to have a seizure. Glucose measured post-seizure
was 5. He was transferred from the MICU to the floor today. In
the week preceeding this admission, the patient did not show up
to 3 scheduled hemodialysis appointments because he felt
lethargic and "couldn't move" his legs. He also states that he
has not been compliant with his medication. He reports that
although he remembers to take his medication, he chooses not to
because he "gets a feeling that says not to take it"; other
times, he finds it inconvenient to bring his medications when he
stays with friends, and will miss doses in this setting.
Mr. [**Known lastname 206**] past medical history is significant for a previous
admission to the [**Hospital1 **] on [**2196-10-8**], a week after discharging himself
AMA from [**Hospital1 **]. He presented intoxicated (EtOH 40), Hct 18
and with right thigh pain and swelling and reported that he had
not received dialysis 4 days prior to admission. During this
hospital stay, he admitted to cocaine use 2 months prior. A
right lower extremity ultrasound showed a partially reclusive
thrombus in the right femoral vein secondary to placement of an
indwelling cathater. He was treated with IV Heparin and
discharged on Coumadin 3mg PO. He states that he was compliant
with his medications for a week following discharge.
Past Medical History:
HIV (diagnosed [**2179**]; current CD4 is 6)
h/o DVT (right femoral vein)
ESRD (secondary to HIV nephropathy on HD)
Diabetes Mellitus
Hepatitis C (never been on treatment)
HTN
Neuropathy
Pancreatitis (secondary to ddI)
Polysubstance abuse (Alcohol, cocaine)
Social History:
Currently lives in [**Location 669**] with his mother. She is in the
process of moving house, and has stated that Mr. [**Known lastname 174**] will be
able to stay with her indefinately post-discharge from the [**Hospital1 **].
He did not complete high school, and went on to the job corps
where he trained to be a mechanic and a chef. He reports that
"it's been a while since [I've] had a job". He states that he
spends his time lying on the couch and spending time with
friends.
Diet/Exercise: Sedentary lifestyle; eats foods high in fats and
salt.
Smoking: "A couple of cigarettes a day" since he was 21.
Alcohol: Reports that he drinks socially; a "couple of bottles"
a day. Does not admit to previous alcoholic intoxication.
Drugs: States that he has never used recreational IV drugs. ?
track marks on antecubital fossa on right side.
Sexual history: Has not been sexually active for many years.
Reports that the only STD he has is HIV.
Family History:
Hypertension, CAD, Diabetes Mellitus
Physical Exam:
Vitals: Tmax 98.7, BP 130/70. HR 84, RR 20, O2sat 100% RA
Gen- Mr. [**Known lastname 174**] is lying in bed receiving dialysis and does not
appear to be in any distress. He is itching himself on his arms
and face. He appears his stated age.
Skin- Skin on feet feels warm to touch; no sores, bruises
present on feet. Pigmentation on calves.
Head- Normocephalic, atraumatic.
Eyes- Scleral icterus. Conjunctivae clear, no lid-lag. No
nystagmus. EOM full.
Ears- Canal clear. Hears rub bilaterally.
Nose- Septum midline, intact. Membranes normal, no discharge.
Mouth- Lips and membranes slightly moist. No ulcers. 4 front
teeth missing on upper row.
Neck- Supple. ROM deferred secondary to dialysis.. Could not
palpate thyroid. Trachea midline. No buffalo hump. No carotid
bruit.
Nodes- No palpable cervical, supraclavicular, axillary nodes.
Cor- RRR. No thrills, rocks, lifts. S2 > S1 in intensity. A2>P2
physiologically split. No murmurs, S3, click, rub.
Resp- No cough. Diaphragmatic excursions ~4cm bilaterally. No
dullness to percussion, no decreased fremitus in any lung
fields. On auscultation, normal breath sounds in all fields
except for crackles in right lower lung field. I:E ratio is 1:1.
No use of accessory muscles to breathe.
Abd- Hyperactive bowel sounds. Rebound tenderness in right
middle quadrant. No HSM, masses. Abdominal aorta could not be
palpated. No bruit.
Ext- Pulses
Strong Radial, Femoral, DP palpable on R and L
No cyanosis, clubbing, varicosities, edema.
Neuro- CNS
I not tested
II acuity good
III, IV, VI EOM full
V facial sensation and corneal reflex intact, jaw strength good
VII symmetrical expression
VIII Negative Rinne, hears whisper bilaterally
IX, X uvula midline; phonation normal
[**Doctor First Name 81**] shrug (trapezius), SCM good
XII tongue midline
Sensory: LT, PT, vibration all intact bilaterally.
Motor: Upper extremity extensors [**5-16**], otherwise [**6-15**] all muscle
groups.
Negative Babinski.
Pronator drift deferred due to dialysis.
Cerebellar tests: Finger-nose-finger intact, rapid alternating
movements performed well. Romberg deferred.
Mental status: Alert, oriented to name, date and hospital.
Appropriate, normal affect. Could spell WORLD backwards. Memory
[**4-13**] without prompting. Could not do serial 7??????s. Knew name of
current president and could name the democratic nominee ([**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **]). No L/R confusion or neglect.
DTRs
Could not elicit ankle reflexes. R Triceps deferred due to IV
placement.
L/R Patellar, L/RBiceps, L Triceps, L/R Brachioradialis 2+
MSK Good range of passive and active range of motion for all
joints.
Pertinent Results:
Radiology:
CXR [**2196-11-19**]: No acute infiltrates are seen.
CXR [**2196-11-20**]: Findings concerning for early right lower lobe
pneumonia.
Mild volume overload.
Labs:
[**2196-11-19**] 09:21PM PH-7.26* COMMENTS-SERUM
[**2196-11-19**] 09:21PM freeCa-0.89*
[**2196-11-19**] 08:30PM GLUCOSE-103 UREA N-122* CREAT-19.8*#
SODIUM-141 POTASSIUM-5.5* CHLORIDE-100 TOTAL CO2-15* ANION
GAP-32*
[**2196-11-19**] 08:30PM CALCIUM-7.3* PHOSPHATE-12.8*# MAGNESIUM-2.7*
[**2196-11-19**] 08:30PM WBC-2.1* RBC-2.39* HGB-8.4* HCT-24.2*
MCV-102* MCH-35.2* MCHC-34.7 RDW-20.4*
[**2196-11-19**] 08:30PM NEUTS-72.0* LYMPHS-22.6 MONOS-2.9 EOS-2.2
BASOS-0.3
[**2196-11-19**] 08:30PM ANISOCYT-2+ MACROCYT-3+
[**2196-11-19**] 08:30PM PLT COUNT-75*
[**2196-11-19**] 06:20PM GLUCOSE-22* UREA N-136* CREAT-21.4*#
SODIUM-142 POTASSIUM-5.8* CHLORIDE-100 TOTAL CO2-12* ANION
GAP-36*
[**2196-11-19**] 06:20PM ALT(SGPT)-32 AST(SGOT)-27 CK(CPK)-274* ALK
PHOS-93 AMYLASE-191* TOT BILI-0.4
[**2196-11-19**] 06:20PM LIPASE-33
[**2196-11-19**] 06:20PM cTropnT-0.07*
[**2196-11-19**] 06:20PM ALBUMIN-4.1 CALCIUM-6.2*
[**2196-11-19**] 06:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2196-11-19**] 06:20PM WBC-3.2* RBC-2.44* HGB-8.8* HCT-25.0*
MCV-102* MCH-36.1* MCHC-35.3* RDW-20.3*
[**2196-11-19**] 06:20PM NEUTS-68.7 LYMPHS-24.1 MONOS-5.1 EOS-1.7
BASOS-0.5
[**2196-11-19**] 06:20PM ANISOCYT-2+ MACROCYT-3+
[**2196-11-19**] 06:20PM PLT SMR-VERY LOW PLT COUNT-72*
[**2196-11-19**] 06:20PM PT-13.6 PTT-25.9 INR(PT)-1.2
[**2196-11-19**] 06:09PM K+-6.9*
Brief Hospital Course:
Following dialysis in the MICU, Mr. [**Known lastname 174**] was transferred to
[**Hospital1 **] [**Doctor Last Name 22583**], under Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 58311**] on [**2196-11-20**] for further
care.
1. Seizure
Likely a tonic-clonic seizure (pt reports symptoms consistent
with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]??????s paralysis and tongue biting) with loss of
consciousness in the setting of hypoglycemia. The hypoglycemia
resulted from the administration of insulin followed by glucose
in the ED while attempting to resolve the hyperkalemia. The
hypoglycemia resolved with 2 amps D5, and there have been no
seizures since.
2. Acute on ESRD causing hyperkalemia
ESRD likely due to HIV nephropathy; acute flair secondary to
missed dialysis insult. Upon admission, patient Creatinine was
19.8, BUN 122, Phosphate 7.26. Patient received 5 sessions of
Hemodialysis throughout this admission. Hyperkalemia, BUN and
Creatinine normalized over course following each subsequent
dialysis session, with Cr noted at 8.9 the day before discharge.
Uremia caused pruritis (improved on benadryl and sarna lotion)
which resolved with dialysis. Phosphate trended down with
Calcium carbonate and Renagel. Patient was put on Nephrocaps
throughout stay.
3. Anemia
Increased MCV most likely secondary to poor Epo production from
ESRD, and poor medication compliance (he is prescribed Epogen at
home but had been unreliable in taking it); alternatively it is
consistent with a picture of alcohol use or also characteristic
of being on a HAART regimen. Hct was 25 on admission (which
appears to be the patient's baseline) and it has remained
stable. Hct 27 at discharge.
4. HTN
BP in ED 226/134. BP poorly controlled due to patient
non-compliance with medications. He was intially continued on
his home medications (Labetolol 600mg TID, Hydralazine 10mg TID,
Enapril 10mg QD). This regimen was changed to Labetolol 600mg
TID, Amlodipine 10mg QD, Enapril 10mg QD. Labetolol was
discontinued [**2196-11-24**] in favor of reducing the number of
medications, and Atenolol 50mg QD was begun. The patient did
very well, maintaining blood pressures ~120-130/70-80 at time of
discharge. We discuss with him the importance of taking BP
medications as prescribed; he has expressed a committment to
improving his medication adherence following discharge.
5. GI
Diarrhea on admission, resolved after 1 day. Following the
diarrhea patient did not have a bowel movement while in house.
Cultures for C.diff, MAC, microsporidiosis, parasite ordered to
rule out infectious colitis. Discharged on stool softeners.
6. Pancytopenia, chronic
Likely HIV-associated. CMV viral load negative; CMV IgG was
positive, CMV IgM negative indicating past CMV infection. Bone
marrow biopsy done prior to admission as an outpatient;
recommend follow up on these results with PCP.
7. Immunocompromised status
HIV/AIDS (dz [**2179**])
CD4 count is 90; patient is not HAART compliant. Held HAART
while in house. Will consider restarting HAART regimen when
patient can demonstrate capability in drug adherence with his
other medication. Continue outpatient regimen of inhaled
Pentamidine once monthly (last given [**2196-11-4**]) for PCP
[**Name Initial (PRE) 1102**]. Azithromycin for MAC prophylaxis was given once,
but discontinued after concerns of a rising eosinophil count
(range was 6.2-20). The most likely etiology of his eosinophilia
is HIV-related vs. a drug reaction and does not warrent further
work-up (Skiest et [**Doctor Last Name **]., Clinical Significance of Eosinophilia in
HIV-infected individuals. The American Journal of Medicine,
[**2189**]) but we recommend that the eosinophil count be followed as
an outpatient given that the patient complains of pruritis.
Patient positive for Hepatitis C, likely secondary to IV drug
use. Never been on treatment. Recommend outpatient follow up
with US Abdomen to rule out hepatomas and visualize portal vein
every 6months to 1 year; alpha-fetoprotein levels to rule out
Hepatocellular carcinoma; viral load and genotype to determine
best treatment.
8. Polysubstance abuse
Hx cocaine and alcohol use, although tox screen [**2196-11-19**] was
negative. Issues stable throughout hospital course by
empirically treating him with MVI, B12, Folate. Patient met with
social work re. drug non-compliance, substance abuse and housing
post-discharge. Social work discussed joining addiction program,
which patient is amenable to. Patient has been asked to contact
the program post-discharge to set up a date for admission.
9. h/o DVTs
Per previous admission, patient was found to have right femoral
DVT secondary to placement of indwelling line. (He has no risk
factors for hypercoaguability).
He was treated with IV Heparin and started on PO Coumadin 3mg,
which was increased over 2 days to Coumadin 10mg with a goal PTT
60-80 and goal INR [**3-15**]. Once therapeutic, dose was reduced to
5mg daily of Coumadin. Pt INR was found to be therapeutic on day
of discharge, the Heparin IV was d/c'd with anticipation of INR
f/u at the [**Hospital1 **].
10. Diabetes Mellitus
Likely Type II. While in house, we put him of an insulin sliding
scale, however he only needed one dose of Humolog on [**2196-11-20**]
when his blood glucose was 184. For the remainder of his
hospital stay, his range of blood glucose varied from 99-142.
Nutrition came to discuss diabetic diet options.
11. Neuropathy
HIV-associated peripheral neuropathy vs. Diabetic neuropathy. He
was started on Neurontin 100mg PO HS and transitioned to 100mg
TID plus 125mg supplemental post hemodialysis.
Medications on Admission:
Renagel 800 tid
Nephrocaps
Coumadin 3mg qd
Gabapentin 300 mg [**Hospital1 **]
Labetalol HCl 600 mg tid
Hydralazine 60 mg
Diltiazem HCl 120 mg qd
Enalapril 20 mg [**Hospital1 **]
Losartan Potassium 50 mg qd
Abacavir Sulfate 300 mg [**Hospital1 **]
Lopinavir-Ritonavir
Tenofovir 300 mg qwk
Discharge Medications:
1. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
Disp:*90 Tablet, Chewable(s)* Refills:*0*
2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO QD (once a day).
Disp:*30 Cap(s)* Refills:*0*
3. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
twice a day as needed.
Disp:*1 tube* Refills:*0*
4. Enalapril Maleate 10 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
5. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO QD
(once a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Atenolol 50 mg Tablet Sig: One (1) Tablet PO QD (once a day).
Disp:*30 Tablet(s)* Refills:*2*
7. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*30 Tablet(s)* Refills:*0*
8. Gabapentin 100 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Hyperkalemia
2. ESRD
3. HTN
4. HIV/AIDS
Discharge Condition:
Fair
Discharge Instructions:
Return to emergency department if you experience chest pain,
shortness of breath, abdominal pain, fevers, chills, or night
sweats.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] within 1 week of discharge.
Completed by:[**2196-11-25**]
|
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6121, 7714
|
14907, 15012
|
3392, 3430
|
13722, 14606
|
14656, 14701
|
13409, 13699
|
14752, 14884
|
3445, 5542
|
249, 263
|
335, 2132
|
5557, 6102
|
2154, 2413
|
2429, 3376
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,509
| 184,380
|
30947
|
Discharge summary
|
report
|
Admission Date: [**2199-6-13**] Discharge Date: [**2199-6-19**]
Date of Birth: [**2173-6-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] at [**Hospital3 **] Community Clinic
CC:[**CC Contact Info 73158**]
Major Surgical or Invasive Procedure:
intubation
History of Present Illness:
26M with no significant past medical history presented [**2199-6-12**]
to [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] with two days of sore throat. He noted
progressive sore throat associated with dysphagia, odynophagia,
and difficulty speaking. A CT of his neck revealed
oropharyngeal, hypopharyngeal, aryepiglottic, and epiglottic
edema with airway narrowing. He was treated with dexamethasone
and ceftriaxone and transferred to [**Hospital1 18**] ED for advanced airway
management.
On [**2199-6-13**] he underwent an awake nasaltracheal intubation for
airway protection. Treated with Vanc/Unasyn and dexamethasone.
Repeat ENT exam showed resolution of edema and he was extubated
uneventfully on [**6-16**]. ICU course complicated by mild
hyperglycemia and hypertension treated with HCTZ, lasix, and
hydralazine.
ROS: no previous episodes of HTN per patient. No previous
infections. Otherwise healthy 26 M.
Past Medical History:
PMH:
(1) MVC with left foot fractures requiring fixation ([**2195**])
Social History:
Occasional alcohol use, smokes [**12-1**] ppd. Denies illicit drug use.
Family History:
Reports no family history of hypertension or early heart
disease.
Physical Exam:
Vital Signs: T 97.6, BP 152/82 (symmetric in both arms, unable
to find a cuff large enough for his legs but pulses are equal
throughout), 95% on RA
Physical examination:
- Gen: Obese male, well-appearing in NAD.
- HEENT: Has dysarthria but unable to appreciate any
oropharyngeal swelling. No stridor.
- Chest: Normal respirations and breathing comfortably on room
air. Lungs clear to auscultation bilaterally.
- CV: Regular rhythm. Normal S1, S2. No murmurs or gallops. 2+
carotids w/out bruits. No ankle edema.
- Abdomen: Normal bowel sounds. Soft, nontender, nondistended.
- Neuro: Alert, oriented x3. Good fund of knowledge. CN 2-12
intact.
Pertinent Results:
Chemistries:
- [**2199-6-17**] 03:30 glucose 146, BUN, 25, Cr 0.6, Na 136, K 4.1,
Cl 99, HCO3 30
Hematology:
- CBC: 9.1>40<243
Micro History:
- [**6-13**] BCx negative x 2
- [**6-13**] MRSA swab negative
Brief Hospital Course:
26 M with supraglottitis/epiglottitis. He required intubation
for airway protection, and he was initially managed in the ICU.
ENT followed throughout the hospitalization. He was treated
with IV antibiotics (vanc and Unasyn) and IV Decadron, and his
pharyngeal swelling improved. He was extubated on [**6-16**] and now
doing well. He developed hypertension in the ICU, likely due to
the IV steroids, which was treated with hydrochlorothiazide.
All cultures returned negative, thus there was no culture data
to guide therapy. Vancomycin and decadron were discontinued,
and pt's Unasyn was changed to oral augmentin at the time of
discharge.
At the time of discharge, he was feeling well without
complaints. He will follow up with his PCP and with ENT as an
outpatient.
Medications on Admission:
none
Discharge Medications:
1. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours for 5 days.
Disp:*15 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
# Supraglottitis/epiglottitis
# Hypertension, due to steroids
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with difficulty breathing, and you were found
to have significant supraglottitis and epiglotitis. You were
treated with intubation to protect your airway, steroids, and
antibiotics. Your symptoms improved, you were extubated, and you
will complete a course of antibiotics as an outpatient.
Followup Instructions:
You will be contact[**Name (NI) **] with a follow up appointment with your
primary care physician.
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) 10827**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] (ENT)
Location: [**Doctor Last Name **] & [**Doctor Last Name 3880**] LLC
Address: [**Location (un) 3881**], [**Apartment Address(1) 3882**], [**Location (un) **],[**Numeric Identifier 3883**]
Phone: [**Telephone/Fax (1) 2349**]
Appointment: Wednesday, [**7-3**], 2:15PM
|
[
"478.6",
"790.29",
"V15.51",
"E932.0",
"464.51",
"464.31",
"401.9",
"564.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
3578, 3584
|
2603, 3378
|
446, 459
|
3690, 3690
|
2368, 2580
|
4173, 4678
|
1621, 1688
|
3433, 3555
|
3605, 3669
|
3404, 3410
|
3841, 4150
|
1703, 1852
|
1874, 2349
|
275, 408
|
487, 1421
|
3705, 3817
|
1443, 1515
|
1531, 1605
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,055
| 173,096
|
7955
|
Discharge summary
|
report
|
Admission Date: [**2158-4-12**] Discharge Date: [**2158-5-18**]
Date of Birth: [**2086-6-12**] Sex: F
Service: CARDIOTHORACIC SURGERY
HISTORY OF PRESENT ILLNESS: This is a 71 year old female
patient of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11493**], who has previously had two stents
to the right coronary artery, who was admitted to [**Hospital1 346**] initially for an outpatient cardiac
catheterization as a result of a recent positive exercise
tolerance test.
PAST MEDICAL HISTORY:
1. Cardiomyopathy.
2. Congestive heart failure.
3. Previous right coronary artery interventions, one in
[**2155**], and one in [**2156**], recent positive exercise tolerance
test on [**2158-3-24**].
4. Hypertension.
5. Hypercholesterolemia.
6. Noninsulin dependent diabetes mellitus.
7. Anxiety disorder.
8. Obesity.
9. Status post appendectomy.
10. Status post cholecystectomy.
11. Status post bilateral oophorectomy.
MEDICATIONS ON ADMISSION:
1. Aspirin 325 mg q.d.
2. Potassium Chloride 20 meq q.d.
3. Bumex 1 mg q.d.
4. Norvasc 5 mg q.d.
5. Hydralazine 50 mg q.i.d.
6. Imdur 30 mg q.d.
7. Atenolol 50 mg q.d.
8. Digoxin 0.125 mg q.d.
9. Ativan 0.5 mg p.r.n.
10. DiaBeta 5 mg p.o. q.d.
11. Zaroxolyn 5 mg p.r.n.
12. Multivitamin one q.d.
LABORATORY DATA: On admission were essentially unremarkable.
HOSPITAL COURSE: The patient was taken to the Cardiac
Catheterization Laboratory on [**2158-4-12**]. Catheterization
revealed two vessel coronary artery disease, significantly
decreased left ventricular function and pulmonary
hypertension.
On [**2158-4-13**], the patient underwent a diagnostic angiogram
secondary to 100 millimeter gradient and systolic blood
pressure from the right to the left arm and she was found to
have a totally occluded left subclavian artery. Attempt to
open the artery with angioplasty was unsuccessful. They were
not able to pass the wire across the lesion.
On [**2158-4-14**], the patient was taken to the operating room with
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] where she underwent coronary artery bypass
graft times two with saphenous vein to the left anterior
descending and saphenous vein to the diagonal.
Postoperatively, she was transported to the cardiac surgery
recovery room from the operating room in stable condition on
intravenous Milrinone, Nipride and insulin drip. She was
atrially paced. On postoperative day one, the patient was
weaned from mechanical ventilator and was extubated, however,
over the course of the next two days, the patient was noted
to have decreasing urine output, decreasing cardiac output
and requirement for inotropic support.
On [**2158-4-17**], postoperative day three, an echocardiogram was
obtained which revealed a left ventricular ejection fraction
of 20%, decreased right ventricular function, 2+ mitral
regurgitation and mild pulmonary hypertension. The following
day the patient was taken to the Cardiac Catheterization
Laboratory to evaluate coronary artery disease and patency of
saphenous vein grafts due to her continued need for inotropic
support.
Catheterization revealed low cardiac output, revealed a 90%
occlusion of her saphenous vein to the diagonal coronary
artery graft as well as 80% left anterior descending lesion.
There was an attempt made to stent the saphenous vein to the
diagonal graft, however, this resulted in dehiscence of the
anastomosis as well as a free perforation into the left
ventricle and pericardium. An intra-aortic balloon pump was
placed at that time due to hemodynamic instability.
The patient was transported emergently to the operating room
with Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] where she underwent repair of the
anastomosis. Postoperatively, the patient was transported
from the operating room to the Cardiac Surgery recovery room
with intravenous Milrinone and Dobutamine as well as an
intra-aortic balloon pump for support. The patient was kept
sedated and mechanically ventilated over the next two to
three days where she stabilized hemodynamically.
On [**2158-4-21**], the intra-aortic balloon pump was weaned and
discontinued as were her inotropics at that time. However,
the following 24 to 48 hours resulted in worsening cardiac
function requiring intra-aortic balloon pump to be replaced
and inotropic support to be resumed. The patient over the
next week or so underwent a very slow wean of inotropic
support. Her intra-aortic balloon pump was discontinued a
few days later.
On [**2158-4-24**], the patient went to the Electrophysiology
Laboratory for placement of a DDD permanent pacemaker due to
continued need for pacemaker support and need to suppress
atrial fibrillation which was resulting in bradycardic
rhythms.
Over the next week or so, the patient remained on low dose
Milrinone and Dobutamine. She required continued ventilatory
support. On [**2158-5-10**], the patient had a PICC line for
continued intravenous access placed due to finding of a
positive catheter tip culture of her central line which
revealed E. coli as well as Enterococcus which were
pansensitive. The patient has had no subsequent positive
blood cultures and that line was discontinued.
The patient was transferred on [**2158-5-10**], to the Surgical
Intensive Care Unit/Critical Care Service due to continued
need for intensive care support. On [**2158-5-11**], the patient
underwent tracheostomy and percutaneous endoscopic
gastrostomy placement by Dr. [**First Name4 (NamePattern1) 951**] [**Last Name (NamePattern1) 952**]. The patient
tolerated this procedure well and continued very slow wean
from ventilator support over the next week or so.
On [**2158-5-15**], the patient received a neurology consultation
due to generalized lethargy, decreased movement of all her
extremities and her decreased responsiveness mentally. It
was their thought that the patient had generalized neuropathy
and myopathy and the recommendation was to obtain an EMG
which is scheduled to be done tomorrow, [**2158-5-18**]. The
patient also underwent a left upper extremity ultrasound due
to swelling of the left arm and this resulted in a negative
study for deep vein thrombosis.
Most recent laboratory values on the patient are as follows,
from [**2158-5-17**], white blood cell count 7.7, hematocrit 30.2,
platelet count 167,000. Sodium 144, potassium 4.8, chloride
109, CO2 26, blood urea nitrogen 53, creatinine 0.8, glucose
164. Most recent Digoxin level is from [**2158-5-16**], which
revealed a level of 1.8. This is down from previous levels
of as high as 3.7 approximately four days prior to this.
Procainamide level on [**2158-5-16**], was 4.7 with NAPA of 17.8 at
that time.
Most recent culture data are as follows: On [**2158-5-13**], the
patient had a stool culture sent for C. difficile which was
negative. Central line which was discontinued on [**2158-5-9**],
was positive for E. coli as well as Enterococcus. All
subsequent blood cultures have been negative with the
exception of yeast in her sputum and urine from [**2158-5-2**].
MEDICATIONS ON DISCHARGE:
1. Sliding scale with regular insulin coverage q6hours as
she is continuous tube feeds. Coverage is as follows: For
blood glucose of 120 to 140 two units subcutaneous regular
insulin, 141 to 160 four units, 161 to 180 six units, 181 to
200 eight units, 201 to 220 ten units, 221 to 240 twelve
units, 241 to 260 fourteen units, 261 to 280 sixteen units,
281 to 300 eighteen units, greater than 300 twenty units.
2. Vioxx 25 mg per gastrostomy tube q.d.
3. Digoxin which is on hold currently due to elevated
Digoxin level. This should be resumed at 0.125 mg q.d.
beginning on [**2158-5-18**], with levels to be followed until a
stable dose is achieved.
4. Hydrochlorothiazide 25 mg per gastrostomy tube b.i.d.
5. Glutamine 5 mg per gastrostomy tube b.i.d.
6. NPH insulin 20 units subcutaneous q12hours.
7. Zinc 200 mg per gastrostomy tube q.d.
8. Aspirin 325 mg per gastrostomy tube q.d.
9. Plavix 75 mg per gastrostomy tube q.d.
10. Norvasc 5 mg per gastrostomy tube q.d.
11. Lasix 40 mg per gastrostomy tube b.i.d.
12. Nystatin swish and swallow 5 ml q.i.d.
13. Procainamide 500 mg per gastrostomy tube q4hours.
14. Hydralazine 50 mg per gastrostomy tube q6hours.
15. Colace 100 mg per gastrostomy tube b.i.d.
16. Vitamin C 500 mg per gastrostomy tube b.i.d.
17. Albuterol meter dose inhaler four puffs q4hours and
p.r.n.
18. Potassium Chloride p.r.n. potassium less than 4.4.
19. Magnesium Sulfate p.r.n. magnesium less than 2.0.
20. Current tube feeding is Promote with Fiber at 50 ml per
hour. The patient is at her goal rate and tolerating it well.
21. She also receives Collagenase Ointment with dressings
applied to her sacral decubitus b.i.d. and a dry sterile
dressing to the left leg p.r.n.
The patient's operative staples were removed today and
Steri-Strips applied. Her incision is clean, dry and intake
to her sternum.
Her physical examination today is as follows: The patient is
afebrile with stable vital signs. She is AV paced at 90.
She previously has had atrial fibrillation which has been
suppressed with Procainamide and Digoxin. Neurologically,
the patient is awake and oriented. She follows commands.
She moves her right arm freely and spontaneously. Her left
arm she does move to command. She is not moving her legs.
The patient is lethargic at times. Cardiovascular
examination is regular rate and rhythm, AV paced at 90 beats
per minute. Her Digoxin is on hold currently, and the
patient has significant blood pressure discrepancy. Her left
arm is significantly lower than her right arm due to
subclavian artery stenosis on the left. Pulmonary
examination - Her breath sounds are coarse bilaterally. She
is presently on pressure support ventilation which was turned
down from 12 yesterday to 10 today, 50% FIO2 which are given
her spontaneous tidal volumes of between 300 and 400
milliliters. She has thick tan secretions although not large
amounts. She has tolerated use of the Passimere valve
intermittently over the past two days well. Her abdomen is
obese and benign. The patient also has a left antecubital
PICC line in place. Her extremities are edematous.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSES:
1. Coronary artery disease, status post coronary artery
bypass graft, status post stent to the graft with perforation
and resultant emergency operation to repair the anastomosis.
2. Respiratory failure.
3. Diabetes mellitus.
4. Generalized neuropathy and myopathy from prolonged
hospitalization.
5. Atrial fibrillation with treatment resulting in
bradycardia requiring DDD permanent pacemaker placement.
FOLLOW-UP: The patient is to follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
in the office upon discharge from rehabilitation facility.
Office telephone number is [**Telephone/Fax (1) 28544**]. Please direct any
surgery related questions to his office number.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Name8 (MD) 964**]
MEDQUIST36
D: [**2158-5-17**] 20:18
T: [**2158-5-17**] 21:01
JOB#: [**Job Number 28545**]
|
[
"414.02",
"518.81",
"997.1",
"785.51",
"428.0",
"414.01",
"997.3",
"998.2",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.06",
"39.61",
"36.01",
"37.4",
"37.23",
"31.1",
"37.61",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
10299, 11273
|
7128, 10244
|
992, 1361
|
1379, 7102
|
184, 515
|
537, 966
|
10269, 10278
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,900
| 153,556
|
51342
|
Discharge summary
|
report
|
Admission Date: [**2168-12-7**] Discharge Date: [**2168-12-15**]
Date of Birth: [**2084-9-8**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 633**]
Chief Complaint:
light-headedness
Major Surgical or Invasive Procedure:
central line placement
History of Present Illness:
EAST HOSPITAL MEDICINE ATTENDING ADMISSION NOTE
Date: [**2168-12-12**]
Time: 23:30
PCP: [**Name10 (NameIs) 665**], [**Name11 (NameIs) **] [**Name Initial (NameIs) **]. MD: [**Telephone/Fax (1) 250**];
[**University/College 96450**]
The patient is an 84 year-old man with a PMH significant for
ischemic cardiomyopathy EF 25%, CAD, DVT/A Fib on coumadin,
bladder cancer s/p transurethral resection requiring straight
cath who presents to the ED following episode of lightheadness.
Today wife was straight cathing the patient (typically done
every 1-2 days) and a large amount of blood returned. During
this time patient became lightheaded/presyncopal and
consequently presented to the ED. Denies recent fever, chills,
cough. Denies recent hematuria (other than todays episode) or
blood in the stool. Denies recent chest pain. Denies increase in
lower extremity edema. Has baseline orthopnea and PND - but no
recent increase. Patient had one transient episode of shortness
of breath last week but resolved without intervention. Overall
patient has been feeling his usual state of health.
.
In the ED, VS 97.8 HR 72 BP 74/47 RR 20 O2 97%. Labs notable for
HCT 31.9, WBC 11.6 (89% N, 2% bands), creatinine 2.6, lactate
4.7 (improved to 3 with 3 L NS) and positive Ua with large
blood. Patient was broadly covered with Vancomycin/Zosyn. Upon
placement of foley a blood clot returned but urine turned clear
with continuous irrigation. Patient's blood pressure improved to
100-110 with 3 L NS but prior to ICU transfer became hypotensive
(SBP 80s) requiring central line placement and started on
Levophed.
.
ROS: The patient denies any fevers, chills, weight change,
nausea, vomiting, abdominal pain, diarrhea, constipation,
melena, hematochezia. Denies increase in cloudy urine. Denies
rash.
.
Past Medical History:
-Two-vessel Coronary artery disease s/p stent to the LCx [**10/2156**]
-Ischemic cardiomyopathy, TTE [**7-3**] with EF 20-30%, 3+MR, 2+TR
-Hypertension
-s/p Implantable cardioverter-defibrillator
-Atrial fibrillation, on coumadin (INR goal [**12-29**])
-Dyslipidemia
-Chronic kidney disease, baseline Cr 1.6-1.8
-High-grade papillary TCC, non-invasive, s/p transurethral
resection ([**2165-11-28**]) and 6 cycles of BCG (last on [**2166-2-13**]), s/p
urethral stricture
-Hypothyroidism
-Sigmoid diverticulosis, internal hemorrhoids on [**2160**]
colonoscopy
-Iron deficiency anemia
-History of deep venous thrombosis x3 ([**2101**], [**2135**], [**2139**])
-s/p left carotid endarterectomy [**2153**]
-History of syncope
-Left lower extremity stasis dermatitis
-s/p inguinal herniorrhaphy
Social History:
Lives with wife. Retired, former banker. Independent of ADLs,
wife does the cooking. Still works in the garden. Former
smoker, quit at least 10 years ago. Has not drank EtOH for 20-25
years.
Family History:
Father died of emphysema. Mother died at age [**Age over 90 **]. There is no
known history of kidney or GU tract disorders; there likewise is
no known history of platelet disorders.
Physical Exam:
VS: 97.8 84 20 124/80 94% 2L (90% on RA)
GEN: Well-appearing, no acute distress
HEENT: dry mucosa, EOMI, PERRL, sclera anicteric, no epistaxis
or petechia
CV: RRR, distant heart sounds, displaced PMI. no M/G/R.
PULM: Bibasilar crackles
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E
NEURO: alert, oriented to person, place, and time. Symmetric
DTRs.
SKIN: [**Name2 (NI) **] jaundice, cyanosis, or gross dermatitis. No ecchymoses.
R central line in place
Pertinent Results:
Labs:
[**2168-12-7**] 06:00PM WBC-11.6* RBC-3.29* HGB-10.3* HCT-31.9*
MCV-97 MCH-31.3 MCHC-32.2 RDW-15.1
[**2168-12-7**] 06:00PM NEUTS-89* BANDS-2 LYMPHS-5* MONOS-4 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2168-12-7**] 06:00PM PLT COUNT-158
[**2168-12-7**] 06:00PM HYPOCHROM-1+ ANISOCYT-OCCASIONAL
POIKILOCY-NORMAL MACROCYT-OCCASIONAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2168-12-7**] 06:00PM PT-40.9* PTT-29.7 INR(PT)-4.3*
[**2168-12-7**] 06:00PM GLUCOSE-93 UREA N-57* CREAT-2.6* SODIUM-138
POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-19* ANION GAP-19
[**2168-12-7**] 06:13PM LACTATE-4.7*
[**2168-12-7**] 06:20PM URINE COLOR-Red APPEAR-Cloudy SP [**Last Name (un) 155**]-1.022
[**2168-12-7**] 06:20PM URINE BLOOD-LG NITRITE-NEG PROTEIN-75
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-MOD
[**2168-12-7**] 06:20PM URINE RBC->50 WBC->50 BACTERIA-MANY YEAST-NONE
EPI-0
.
Micro:
GRAM STAIN (Final [**2168-12-9**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2168-12-12**]):
DUE TO LABORATORY ACCIDENT CULTURE PLANTED ON [**2168-11-30**].
FASTIDIOUS ORGANISMS [**Month (only) **] NOT GROW.
INTERPRET RESULTS WITH CAUTION.
.
SPARSE GROWTH Commensal Respiratory Flora.
C. Diff: negative x3
.
URINE CULTURE (Final [**2168-12-10**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. SECOND
MORPHOLOGY.
Piperacillin/tazobactam sensitivity testing available
on request.
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ESCHERICHIA COLI
| | KLEBSIELLA
PNEUMONIAE
| | |
AMPICILLIN------------ <=2 S <=2 S
AMPICILLIN/SULBACTAM-- 4 S <=2 S 4 S
CEFAZOLIN------------- <=4 S <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S <=0.25 S
NITROFURANTOIN-------- 32 S <=16 S 64 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S <=1 S
Blood cx: Negative
Imaging:
CT Abd:
Pt is a 22 y.o male with h.o Crohns disease (followed by Dr.
[**Last Name (STitle) 3708**] on Cimzia as has failed prior tx (pentasa, budesonide,
infliximab), recently admitted with symptoms of Crohns flare and
SBO, who now presents with abdominal pain and vomiting.
IMPRESSION:
TECHNIQUE: Axial MDCT images were acquired through the pelvis
following
injection of contrast via the Foley catheter. Approximately 300
cc of diluted Cysto-Conray was administered via gravity to the
Foley. Coronal and sagittal reformats were produced and
reviewed.
FINDINGS: The bladder is moderately well distended with
contrast. There is a small amount of free air in the bladder and
a Foley catheter in situ. There is prominent trabeculation at
the right lateral wall of the bladder with bladder diverticula
seen postero-laterally on the right. There is mild residual
thickening of the bladder wall seen at the left side
posteriorly, near but not at the left ureteral orifice. There is
reflux of contrast into the left distal ureter. No bladder leak
is seen. There is a small amount of free fluid in the pelvis
most seen in the right iliac fossa. No cause for this is
identified on the current study. There is extensive vascular
calcification noted. No pelvic lymphadenopathy is seen.
BONY STRUCTURES: There is moderate-to-severe degenerative
changes noted in
both hips. No destructive lytic or sclerotic bony lesions are
seen.
.
1. No bladder leak.
2. Multiple small bladder diverticula seen.
3. Mild thickening of the bladder wall, seen in the left
posterior location.
4. Reflux of contrast into the distal left ureter.
CXR [**12-7**]-FINDINGS: Again seen, is a left-sided cardiac
pacer/defibrillator with leads in the right atrium and right
ventricle. The cardiomediastinal and hilar contours are normal.
EKG clips and wires overly the chest and somewhat limit
evaluation. There is subtle opacity in the left lower lung which
appears stable from prior and likely represents chronic
scarring. However, there is a new ill-defined opacity in the
lateral aspect of the right mid-lung which could represent
pneumonia versus mass. There is no pleural effusion or
pneumothorax. Heart and mediastinal contour appear stable. The
osseous structures are intact.
IMPRESSION: New opacity in the right mid-lung may represent
infection or mass
- dedicated PA and lateral views or a chest CT recommended -
discussed with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 49784**] at 19:53 on [**2168-12-7**].
.
CXR [**12-9**]-The position of the right internal jugular line and
pacemaker leads is stable. There is overall slight interval
increase in the right upper lobe diffuse opacity that might
represent minimal gradual progression of infection, but there is
no evidence of worsening of moderate interstitial engorgement
since the prior study. Chronic changes in the lung bases can be
partially addressed on this non-dedicated study. Left basal
atelectasis and small amount of left pleural effusion are
redemonstrated.
If patient is short of breath, it might be attributed actually
to diffuse
interstitial lung disease and correlation with dedicated chest
CT may be
considered.
.
CXR [**12-11**]-Comparison films [**12-9**].
The position of the various support lines and tubes is
unchanged. The overall appearance of the chest and in particular
lung fields is also unchanged.
IMPRESSION:
Chronic lung changes, no failure.
.
CXR [**12-12**]
CHEST AP
.
Some movement artifact is present. There has been no significant
change since the prior chest x-rays. The position of the various
lines and tubes is unchanged. No gross failure is present.
IMPRESSION: No change.
.
EKG [**12-11**]-Ventricular pacing with pseudofusion. The
irregularities suggest the atrial rhythm is atrial fibrillation.
Since the previous tracing of [**2168-12-8**] pacing with variable
fusion is now present. On the prior tracing there was atrial
pacing. Clinical correlation is suggested.
EKG [**12-8**]-Ventricularly paced rhythm at 70 beats per minute.
Compared to tracing #1 no
diagnostic change.
TRACING #2
.
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2168-12-15**] 08:56 7.4 2.90* 9.0* 27.9* 96 31.0 32.3 17.0* 66*1
[**2168-12-14**] 06:00 8.5 2.89* 9.0* 27.6* 95 31.2 32.7 17.1* 55*2
Source: Line-Right IJ
[**2168-12-13**] 03:50 6.8 2.86* 8.8* 27.0* 95 30.8 32.5 17.2* 57*1
Source: Line-IJ
[**2168-12-12**] 04:09 7.7 2.85* 8.7* 26.5* 93 30.5 32.9 16.8* 51*
Source: Line-rij
[**2168-12-11**] 15:25 26.5*
Source: Line-central
[**2168-12-11**] 03:55 8.0 2.90* 9.1* 26.9* 93 31.4 33.8 16.6* 54*
Source: Line-CVL
[**2168-12-10**] 14:46 30.8*
Source: Line-CVL
[**2168-12-10**] 02:43 10.3 3.08* 9.5* 28.8* 94 30.9 33.0 16.9*
59*3
[**2168-12-9**] 15:23 28.9*
Source: Line-cental line
[**2168-12-9**] 02:58 20.0* 3.02* 9.4* 28.2* 93 31.2 33.5 17.0*
86*1
[**2168-12-8**] 22:36 28.2*
[**2168-12-8**] 14:56 26.3* 2.83* 8.9* 27.1* 96 31.3 32.7 15.5
105*
Source: Line-central ine
[**2168-12-8**] 02:50 37.4* 2.73* 8.6* 26.2* 96 31.6 33.0 14.9 172
ADDED DIFF @ 0601 ON [**2168-12-8**]
[**2168-12-7**] 18:00 11.6* 3.29* 10.3* 31.9* 97 31.3 32.2 15.1
158
.
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct
INR(PT)
[**2168-12-15**] 08:56 66*1
[**2168-12-15**] 08:56 25.6* 86.9* 2.5*
[**2168-12-14**] 06:00 55*2
Source: Line-Right IJ
[**2168-12-14**] 06:00 19.9* 62.0* 1.8*
Source: Line-Right IJ
[**2168-12-13**] 03:50 VERY LOW3 57*1
Source: Line-IJ
[**2168-12-13**] 03:50 17.0* 81.3* 1.5*
Source: Line-IJ
[**2168-12-12**] 04:09 51*
Source: Line-rij
[**2168-12-12**] 04:09 15.5* 84.1* 1.4*
Source: Line-rij
[**2168-12-11**] 03:55 54*
Source: Line-CVL
[**2168-12-11**] 03:55 14.6* 91.4* 1.3*
Source: Line-CVL
[**2168-12-10**] 23:00 14.6* 90.9* 1.3*
Source: Line-CVl
[**2168-12-10**] 14:46 14.4* 150*4 1.3*
Source: Line-CVL; heparin dose: 1250
[**2168-12-10**] 02:43 VERY LOW 59*5
[**2168-12-10**] 02:43 14.9* 29.6 1.3*
[**2168-12-9**] 02:58 LOW 86*1
[**2168-12-9**] 02:58 33.0* 42.4* 3.3*
[**2168-12-8**] 14:56 105*
Source: Line-central ine
[**2168-12-8**] 14:56 56.4* 51.7* 6.3*6
Source: Line-central ine
[**2168-12-8**] 02:50 172
ADDED DIFF @ 0601 ON [**2168-12-8**]
[**2168-12-8**] 02:50 46.3*7 43.7* 5.0*7
[**2168-12-7**] 18:00 158
[**2168-12-7**] 18:00 40.9* 29.7 4.3*
.
[**2168-12-15**] 08:56 981 39* 1.7* 140 3.9 108 24 12
[**2168-12-14**] 06:00 105*1 36* 1.9* 141 3.7 108 24 13
Source: Line-Right IJ
[**2168-12-13**] 03:50 105*1 30* 1.8* 1382 3.72 110*2 232 9
Source: Line-IJ
[**2168-12-12**] 18:44 118*1 26* 1.7* 141 4.0 108 23 14
[**2168-12-12**] 04:09 116*1 24* 1.9* 142 3.4 113* 22 10
Source: Line-rij
[**2168-12-11**] 15:25 109*1 26* 1.7* 140 4.0 112* 21* 11
Source: Line-central
[**2168-12-11**] 03:55 991 28* 1.7* 142 4.3 112* 22 12
Source: Line-CVL
[**2168-12-10**] 23:00 30* 1.8* 142 3.4 112*
Source: Line-CVl
[**2168-12-10**] 14:46 118*1 33* 1.8* 143 4.0 113* 17* 17
Source: Line-CVL
[**2168-12-10**] 02:43 961 38* 1.8* 142 4.0 116* 19* 11
[**2168-12-9**] 02:58 122*1 48* 2.3* 138 4.3 111* 19* 12
[**2168-12-8**] 14:56 157*1 47* 2.3* 138 4.8 111* 16* 16
Source: Line-central ine
[**2168-12-8**] 02:50 157*1 49* 2.3* 139 4.2 111* 17* 15
[**2168-12-7**] 18:00 931 57* 2.6* 138 4.2 104 19* 19
ADDED TE8-TE11 AT [**Telephone/Fax (2) 106487**]
.
Brief Hospital Course:
Assessment/Plan:
Pt is an 84 y.o male with h.o ischemic CMP EF 25%, CAD, DVT/afib
on coumadin as outpt, bladder cancer s/p transurethral resection
requiring straight cath who presented with hematuria and was
initially admitted to ICU with urosepsis requiring pressors. Pt
now improved and transferred to medical floor. While in the ICU,
pt developed new thrombocytopenia.
.
#Urinary tract infection (s/p shock and urosepsis)-Pt's urine
culture grew pan-sensitve E.coli and Klebsiella. Initially, pt
required pressors and IVF to maintain SBP. Pressors weaned [**12-9**].
Initially covered broadly with vanco/zosyn, tailored to IV
ceftriaxone on [**12-10**]. CT pelvis ruled out bladder perforation or
abscess formation. PO cipro begun [**12-14**] and pt should continue
this medication for 14 day course abx (day 1 [**12-7**])-last day [**12-21**]
for complicated UTI. Discussed foley catether with urology. Pt
is to have foley catheter in place until his f/u with Dr.
[**Last Name (STitle) 3748**]. [**Name (NI) 1094**] wife typically self-caths him at home 3xdaily.
.
#hematuria-present at home prior to admit during self-cath.
Resolved and did not reoccur this admission. Urology follow-up
for h.o bladder cancer arranged with Dr. [**Last Name (STitle) 3748**].
.
#Thrombocytopenia-plts Dropped from 158->52 during admit. Likely
related to sepsis +/- antibiotic use. Pt had not been receiving
heparin products prior to this fall in counts. CVL flush was
ordered as saline. Pt was started on heparin gtt after the plt
fall as a bridge to coumadin an counts remained stable on this
medication. Heparin DC'd [**12-15**]. Pt did not display signs of
bleeding. Platelet count should be monitored after discharge to
ensure continued recovery. If recovery does not occur, pt should
follow up with a hematologist.
.
#normocytic anemia-baseline appears to be 31-39. NO signs of
active bleeding were present after initial hematuria. Likely
related to recent hematuria, infection and hemodilution. INR
also supratherapeutic on admit. Stable. Currently 27.9 upon
discharge. HCt can be monitored at rehab. Iron studies/B12 and
folate can be performed if persisent. Pt should discuss whether
a colonoscopy is needed for routine screening.
.
#acute systolic CHF- EF 25%/ ICD in place Last TTE 5/[**2167**]. s/p
aggressive volume resuscitation due to sepsis in the ICU.
Intermittent lasix gtt during ICU. Transitioned to IV lasix on
[**12-12**]. Fluid balance +800cc at time of transfer to medical floor.
Pt was given daily doses of 40mg IV daily with good effect. He
was started on his home dose of 40mg PO lasix on day of
discharge. (In addition to 40mg IV lasix given). Pt is sating
90-91% on RA and weight on discharge was recorded as 159lbs. Pt
on asa/BB/ACEI. For increased SOB/hypoxia would consider 40mg IV
lasix x1.
.
#hypoxia-Pt's oxygen requirment vascillated between 90-91% on RA
and occasionally mid 90's on 2-3L. Suspect that this was due to
acute systolic heart failure. Pt did not display other clinical
signs to suggest PNA and this did improve with diuresis. In
addition, pt with CXR findings suggestive of basilar scaring and
possible interstitial lung disease. So it is possible that
89-91% is patient's true baseline. Pt should continue to follow
up and can consider imaging with CT scan or pulmonary eval in
the outpatient setting. Sats 90-91% on RA at time of discharge.
.
#CAD-no active chest pain. 1 episode of SOB [**12-11**]. EKG without
signs of ischemia. Continued statin, asa 81mg. BB and ACEi had
been initially held given hypotension but restarted BB
(carvedilol 3.125mg [**Hospital1 **] and ACEI lisinopril 2.5mg) on [**12-15**] with
good effect.
.
#CKD-baseline 1.7-2.3. Elevated to 2.6 on admit. Currently 1.7
at baseline. Restarted home dose ACEI [**12-14**].
.
#DVT-coumadin held on admit as supratherapeutic at 6.3. Reversed
with 5mg PO vitamin K. INR trended down and [**12-11**] subtherapeutic.
Heparin gtt started on [**12-10**] and bridge with coumadin begun. Pt
now therapeutic INR 2.5. Heparin gtt stopped. Pt should coumadin
regimen upon discharge. 2.5mg mon/wed/fri/sun and 3.5mg
tue/[**Last Name (un) **]/sat. Pt's INR should be followed at rehab.
.
#afib-as above regarding coumadin. INR elevated, given vit K,
then heparin/coumadin started. 5mg coumadin daily during admit.
Pt should resume home dosing tonight. (home dosing 3.5mg/2.5mg
alternating) see above. Amiodarone started [**12-12**]. Carvedilol
3.125mg [**Hospital1 **] restarted [**12-14**] with good effect.
.
#b/l medial toe erythema-symmetric on toes, appears to be from
pressure or sleep position rather than an acute gouty flare.
Areas are not warm and pt has full range of motion. Area of pain
is localized to these specific areas and not the joints or the
joints of the great toe.If signs of gout were to develop or
occur, could consider renally dosed colchicine x1 and/or
prednisone. Would avoid NSAIDs in this patient.
.
#bladder cancer s/p transurethral resection-followed by Dr.
[**Last Name (STitle) 3748**]. Hopefully, will be able to DC foley and allow pt to
return to straight cath after rehab stay and f/u with Dr.
[**Last Name (STitle) 3748**]. FOley catheter should remain in place until schedule
urology f/u with Dr. [**Last Name (STitle) 3748**].
.
#incidential radiographic findings-CXR found subtle opacity in
left lower lung that appears stable and likely represents
scarring. However, CXR reports new ill-defined opacity in
lateral aspect of R.mid lung that could be PNA vs. mass. Repeat
CXR shows lung base chronic findings that could be suggestive of
interstitial lung disease. Pt did not have fever or other
clincal signs of PNA. Pt should follow up with his PCP to
discuss need for further imaging and workup. Chest CT could be
performed in the outpatient setting for further evaluation.
.
#dyslipidemia-continued atorvastatin at home dose
.
#hypothyroidism-continued levothyroxine at home dose
.
FEN: cardiac diet
.
DVT PPx: coumadin
.
Precautions for: falls
.
Lines: PIV
.
CODE: FULL
.
[**Hospital 106488**] rehab facility.
Medications on Admission:
AMIODARONE [PACERONE] - 200 mg Tablet - 1 Tablet(s) by mouth
once
a day
ATORVASTATIN - 10 mg Tablet - one Tablet(s) by mouth every day
CARVEDILOL [COREG] - 3.125 mg Tablet - 1 Tablet(s) by mouth
twice
a day
FUROSEMIDE - 40 mg Tablet - 1 Tablet(s) by mouth daily
LEVOTHYROXINE [LEVOXYL] - 100 mcg Tablet - 1 Tablet(s) by mouth
once per day
LIDOCAINE HCL - 2 % Gel - inject into urethra every third day
before catheterization. - No Substitution
LISINOPRIL - 2.5 mg Tablet - 1 Tablet(s) by mouth once a day
every evening
NITROGLYCERIN - 400 MCG (1/150 GR) TABLET - PLACE ONE TABLET
UNDER TONGUE Q5 MIN X 3 AS NEEDED FOR JAW OR CHEST PAIN
WARFARIN - (Prescribed by Other Provider) - 5 mg Tablet - 0.5
(One half) Tablet(s) by mouth daily as directed by coumadin
clinic.
WARFARIN - (Prescribed by Other Provider) - 1 mg Tablet - 1
Tablet(s) by mouth as directed. Patient normally takes3.5mg
Tues/Thurs/Saturday, 2.5mg all other days
Discharge Medications:
1. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
7. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO q
mon/wed/fri/sun.
8. Coumadin 1 mg Tablet Sig: 3.5 Tablets PO q tue/[**Last Name (un) **]/sat:
3.5mg tue/[**Last Name (un) **]/sun.
2.5mg mon/wed/fri/sun.
9. ciprofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 6 days.
Disp:*6 Tablet(s)* Refills:*0*
10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
shock due to urosepsis
acute renal failure
thrombocytopenia
coagulopathy
acute systolic CHF
toe erythema
.
CAD
afib
h.o DVT
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital with blood in your urine and
feeling lightheaded. Your blood pressure was initally low and
you were found to have sepsis (a severe infection) from your
urinary tract. For this, you were initally monitored in the ICU.
You improved and you were transferred to the regular medical
floor. You were given antibiotics for this infection and will
continue this upon discharge. Your foley catheter should also
remain in place until your follow up appointment with Dr.
[**Last Name (STitle) 3748**]. Your coumadin was held initially as your numbers were
elevated. This was restarted and you should continue to have
your INR checked regularly.
.
You some extra fluid outside of your lungs and were given Lasix
with good effect.
.
Medication changes:
1.Continue Cipro 750mg daily for 6 more days
.
Please take all of your medications as prescribed and follow up
with the appointments below.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Please have your rehab facility schedule you an appointment with
your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Name (STitle) 665**] at [**Telephone/Fax (1) 250**] after discharge.
Department: SURGICAL SPECIALTIES
When: [**2168-12-29**] at 9:00 AM
With: DR. [**First Name (STitle) **] [**Doctor Last Name **] [**Telephone/Fax (1) 3752**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: CARDIAC SERVICES
When: TUESDAY [**2169-3-21**] 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: TUESDAY [**2169-3-21**] at 1:30 PM
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
Department: SURGICAL SPECIALTIES
When: THURSDAY [**2169-3-30**] at 10:15 AM
With: DR. [**First Name (STitle) **] [**Doctor Last Name **] [**Telephone/Fax (1) 3752**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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"V10.51",
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"V58.61",
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] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
22567, 22664
|
14424, 20476
|
320, 345
|
22832, 22832
|
3888, 14401
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373, 2165
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2187, 2977
|
2993, 3187
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,310
| 140,316
|
45225
|
Discharge summary
|
report
|
Admission Date: [**2137-1-16**] [**Month/Day/Year **] Date: [**2137-2-11**]
Date of Birth: [**2063-3-11**] Sex: M
Service: NEUROLOGY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 5868**]
Chief Complaint:
73 year-old man with a history of proximal basilar artery
stenosis on coumadin, previous strokes, HTN, DM, CAD s/p [**Hospital **]
transferred from OSH with left-sided weakness, dysarthria and
right-sided intracranial bleed.
Major Surgical or Invasive Procedure:
PEG
Tracheostomy
arterial line
Endotracheal intubation x2
History of Present Illness:
Per EMS records, at ~4:15 this AM, wife awoke to find pt
slightly confused, weak on left side, unable to ambulate and
incontinent of urine and called 911. Pt was well last night when
he went to sleep. EMS found pt in bed, alert and oriented,
speaking full sentences, but with dysarthria, left facial droop
and arm/leg weakness, and complaining of headache. Blood
pressure
was 180/100, pulse 82.
At OSH, blood pressure remained elevated. Initial labs showed
glucose of 230, INR 3.4, WBC 11.4, otherwise normal including
negative cardiac enzymes. Head CT revealed a right mostly medial
temporal bleed with extension into lateral ventricle. Pt given
10 mg vitamin K, 1 mg morphine and transferred here. On arrival,
SBP 200/103 and pt was started on labetalol drip and given
proplex (clotting factors 2, 7, 9 and 10).
ROS: Still c/o mild headache. Denies chest pain, trouble
breathing
Past Medical History:
1. Proximal basilar artery stenosis, on coumadin, followed by
Dr. [**First Name (STitle) **] [**Name (STitle) **] here. On MRI, also has evidence of old
left cerebellar, right thalamus/basal ganglia and right parietal
infarcts in addition to small vessel disease.
2. CAD, s/p CABG [**2126**]
3. HTN
4. DM type II, followed by [**Last Name (un) **]
5. GERD
6. Hypothyroidism
7. s/p CCK
Social History:
Lives with wife, retired teacher. No tobacco, EtOH
Family History:
+DM, sister with [**Name2 (NI) 500**] cancer
Physical Exam:
Exam on admission:
PE: T 100.8 BP 200/103 HR 14 RR 96% 2L NC
General: Appears young for age, in no acute distress
HEENT: NC/AT Sclera anicteric.
Neck: Supple.
Lungs: Clear to auscultation bilaterally
CV: somewhat irregular, nl S1, S2, 2/6 systolic murmur. 2+
carotids without bruit
Abd: Soft, nontender, normoactive bowel sounds
Extr: No edema
Neurologic Examination:
Mental Status: Somewhat sleepy, arousable but tended to fall
back
to sleep. Oriented to person, place
Attention: Can count backward from 10, could not say days of
week
backward
Language: Fluent, significant dysarthria, no paraphasic errors,
repetition intact. Can follow complex 2-step commands,
distinguish right/left
No obvious neglect
Cranial Nerves: Unable to assess visual fields given
inattention.
Pupils equally round and minimally reactive to light. Right gaze
preference, though can move eyes briefly across midline. No
nystagmus. Intact to light touch. Left facial droop. Hearing
intact to finger rub bilaterally. Tongue midline, no
fasciculations.
Motor: Normal bulk. Somewhat decr tone L arm. Fasiculations
absent in upper and lower extremities. No tremor.
Strength seems full on right. Unable to lift left arm or leg in
air, but can provide some resistance to pull, esp finger
flexion,
biceps, quadriceps. Can wiggle toes, move hands to command.
Sensation was grossly intact to light touch. Withdraws
purposefully on left arm, leg.
Reflexes: DTRs slightly [**Name2 (NI) 19912**] throughout, though perhaps L>R.
Toes down on right, up on left.
Unable to assess coordination and gait due to mental status.
Pertinent Results:
Labs on admission:
WBC 11 (81N, 14L, 4M, 1E) Hct 42.6 Plt 188
PT 23.2* PTT 38.1 INR 3.4**
Na 141 K 3.9 Cl 106 HCO3 25 BUN 20 Cr 1.2 Gluc 226
Ca 9.1 Mg 1.7 PO4 2.2
CK 77 TnT <0.01
OSH: LFTs nl
UA: Lg bld, 30 prot, 1000 glu, 15 ket, LE neg, nitr neg. >50
RBC,
[**4-13**] WBC, few bact
[**2137-1-29**] 04:26AM BLOOD ALT-45* AST-38 AlkPhos-63 Amylase-126*
TotBili-0.3
[**2137-1-18**] 03:42PM BLOOD CK-MB-5 cTropnT-<0.01
[**2137-1-16**] 10:47PM BLOOD CK-MB-3 cTropnT-<0.01
[**2137-1-16**] 04:54PM BLOOD cTropnT-<0.01
[**2137-1-17**] 03:10AM BLOOD %HbA1c-6.3*
[**2137-1-17**] 03:10AM BLOOD Triglyc-115 HDL-37 CHOL/HD-3.5 LDLcalc-68
[**2137-1-25**] 10:08AM BLOOD Ammonia-38
[**2137-2-5**] 03:17AM BLOOD Valproa-89
Head CT (OSH): Right medial temporal bleed with some basal
ganglia involvement with extension into lateral ventricles. No
subarachnoid blood seen.
EEG([**1-18**])
(PLEDs) seen over the right hemisphere. These discharges suggest
cortical dysfunction involving the right hemisphere and
represent an increased risk for seizure activity. No clear
seizure activity was seen during this recording.
MRI:
1. A punctate area of restricted diffusion involving the
posterior left frontal lobe, suggestive of a tiny area of acute
infarction.
2. High signal surrounding the right basal ganglia hemorrhage
seen in the diffusion images, is more likely due to artifact
from T2 shine-through.
3. No change in the size of the right basal ganglia hemorrhage
in its intra- ventricular extent.
4. Blood products seen most likely within the left sylvian
fissure indicate it is bordering sulci. When reviewing a prior
CT, this is most likely due to subarachnoid blood in these
locations.
ECHO:
Mild symmetric left ventricular hypertrophy with mild global
biventricular hypokinesis (?related to tachycardia). Mild mitral
regurgitation. Mild pulmonary artery systolic hypertension
CT Chest (with contrast) [**1-29**]:
1) No evidence of pneumonia. Bibasilar atelectasis with small
bilateral pleural effusions.
2) Findings consistent with resolving CHF.
3) Cholelithiasis.
Duplex Left UE:
Long segment of occlusive thrombus within the left cephalic
vein.
Brief Hospital Course:
Pt initially admitted to the neuro ICU for management of right
temporal and basal ganglia hemorrhage. He was transferred to
the Step Down unit on [**2-1**].
Neuro: His INR was reversed and he was admitted to the ICU for
neurologic and BP monitoring. He became more somnolent, had
decreased movement on the left side and had episodes of extensor
posturing [**1-18**]. EEG was done and showed PLEDS. He was started
on dilantin. Dilantin was later changed to depakote b/c of
suspected drug fever from dilantin. Repeat head CT showed stable
appearance of bleed. MRI showed several areas of hypointensity
on susceptibility sequences suggesting possiblity of
microbleeds/amyloid. Subsequent CTs have shown stable appearance
of bleed. After transfer to the floor, his neuro exam remained
stable. He is awake, follows simple commands, moves his right
side spontaneously and is able to move his left toes and
slightly pull left leg proximally.
RESP: Pt developed aspiration PNA early in hospital course. On
[**1-19**], pt had increasing respiratory distress requiring
intubation. He failed extubation on [**1-29**] and required
re-intubation and subsequent tracheostomy ([**2137-1-31**]). Chest CT
done [**1-29**] showed no evidence of infiltrate, resolving CHF,
bilateral pleural effusions and atelectasis. Since transfer to
the floor, he has had difficulty managing trach secretions and
required frequent suctioning. Rpt CXR have been without change.
Secretions improved, suctioning frequency improved as well to q
2-3 hours.
CV: BP initially controlled with labetalol drip-then switched to
dilt. On [**1-19**], pt had new onset Afib. Cardiology was consulted
and recommended initial rate control with dilt drip and beta
blocker. TEE was negative for clot. He was started on amiodarone
for rhythm control since we are unable to anticoagulate him at
this time. After transfer to floor, ACEI was added to his
regimen for BP control. He is currently taking lisinopril,
metoprolol, diltiazem for BP control. Amiodarone for Afib-has
been in and out of afib (rate well controlled). He will need
followup with cardiology to determine duration of amiodarone
therapy.
** restart coumadin on [**2-17**] at 2.5mg qHS with goal INR 2-2.5
for afib. **
HEME: Pt was on Coumadin on admission for tx of basilar artery
stenosis. His INR on admission was 3.4. Given proplex in ED and
FFP. INR normalized.
FEN/GI: Pt had PEG placed [**1-31**], now on tube feeds.
ID: Pt became febrile, was found to have UTI and initially was
started on Levoflox. He also developed a PNA and was started on
Flagyl for possible aspiration PNA. He remained febrile with
rising WBC. C. diff negative. Blood and sputum cultures were
positive for MRSA ([**1-24**]). He was started on Vancomycin for
suspected line infection, all line Cultures were negative. He
will continue Vanco for 14 day course (after a-line
removed)-last day will be [**2137-2-10**].
ENDO: Pt was continued on synthroid. Required inuslin drip in
the ICU for glycemic control. On transfer to the floor, he was
started on NPH and RISS. We will monitor his glucose levels and
adjust NPH as needed. TSH will need to be monitored while on
amiodarone.
Medications on Admission:
Glucophage 100 [**Hospital1 **], lantus unk dose, prandin 4mg qam and
2mg qnoon and qpm, zantac 300, synthroid 50, [**Doctor First Name 130**] prn,
lipitor 20, atenolol 50, coumadin 4.5, methazolamide 25,
glaucoma drops, ?mavik
[**Doctor First Name **] Medications:
1. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q4-6H (every 4 to 6 hours) as needed.
2. Brimonidine Tartrate 0.2 % Drops Sig: One (1) Drop Ophthalmic
Q8H (every 8 hours): OU.
3. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime): OU.
4. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
6. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML
Miscell. Q4-6H (every 4 to 6 hours) as needed.
7. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
9. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
10. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
11. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day): hold for SBP<110, HR<55.
12. Valproate Sodium 250 mg/5 mL Syrup Sig: Three (3) PO Q8H
(every 8 hours).
13. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
14. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Pramoxine-Zinc Oxide in MO 1-12.5 % Ointment Sig: One (1)
Appl Rectal TID (3 times a day) as needed.
16. Levothyroxine Sodium 25 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
17. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
18. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. Vancomycin HCl 10 g Recon Soln Sig: 1000 (1000) mg
Intravenous Q12H (every 12 hours): last day of antibiotics is
[**2137-2-10**] to complete a 14 day course.
20. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN
10ml NS followed by 1ml of 100 units/ml heparin (100 units
heparin) each lumen QD and PRN. Inspect site every shift
21. Insulin
NPH 20 units qAM, 15 units q HS. RISS. Please adjust NPH doses
according to finger sticks QID.
[**Year (4 digits) **] Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
[**Location (un) **] Diagnosis:
Right temporal lobe/basal ganglia hemorrhage
Atrial Fibrillation
Basilar artery stenosis
Pneumonia (MRSA in blood and sputum)
DM
[**Location (un) **] Condition:
Improved
[**Location (un) **] Instructions:
Please keep your follow up appointments. If you should develop
new weakness, numbness, speech difficulty or other concerning
symptoms, please come to the ER for evaluation.
Followup Instructions:
1. Follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] from
rehab
2. Please call [**Telephone/Fax (1) 2574**] for an appointment with Dr. [**Last Name (STitle) **]
after [**Last Name (STitle) **] from rehab. Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D.
Where: [**Hospital6 29**] NEUROLOGY Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2137-6-25**] 4:00
3. Please follow-up with cardiology in 2 months - ([**Telephone/Fax (1) 3942**].
4. If possible, should have pulmonary function testing done in
the future as an outpatient (as you are on amiodarone). THis
may be difficult given tracheostomy.
|
[
"482.41",
"250.80",
"349.82",
"V09.0",
"453.8",
"433.00",
"414.01",
"331.4",
"790.92",
"511.9",
"244.9",
"V45.81",
"428.0",
"038.11",
"507.0",
"431",
"574.20",
"038.0",
"995.91",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.1",
"96.72",
"38.93",
"43.11",
"38.91",
"96.04",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
5826, 9028
|
511, 571
|
3655, 3660
|
11905, 12593
|
1981, 2027
|
9054, 11467
|
2042, 2047
|
11499, 11630
|
246, 473
|
11662, 11672
|
11707, 11882
|
599, 1487
|
2766, 3636
|
3674, 5803
|
2426, 2750
|
2411, 2411
|
1509, 1897
|
1913, 1965
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,555
| 161,550
|
51430
|
Discharge summary
|
report
|
Admission Date: [**2110-5-30**] Discharge Date: [**2110-6-10**]
Date of Birth: [**2037-2-8**] Sex: M
Service: NEUROSURGERY
Allergies:
Penicillins / Bactrim
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Left sided subdural hematoma
Major Surgical or Invasive Procedure:
Left sided craniotomy
History of Present Illness:
73 yo man s/p fall whom has fallen 3-4 times the past couple
months. He was sitting on the chair, took a nap then slid from
chair and found himself on the floor, hit his head and right
shoulder. Patient denies any seizure, CP, SOB, visual changes,
bowel or bladder incontinence. Patient suffers from multiple
sclerosis and uses walker.
Past Medical History:
1. Multiple sclerosis for > 20 years followed by Dr. [**Last Name (STitle) 106638**] at
[**Hospital1 2025**].
2. CLL/NHL
3. Hypertension
4. Pancytopenia
5. Depression
6. Chronic LE edema
7. Chronic GU tract obstruction (bilateral hydronephrosis and
bilateral hydroureter to the level of the ureterovesicular
junctions)
Social History:
Lives alone.
He denies smoking, denies alcohol abuse.
He uses a walker to ambulate.
He is a retired taxi driver.
Has grown son and daughter.
Family History:
Father deceased from a myocardial infarction.
Mother deceased from [**Name (NI) 2481**] disease.
Physical Exam:
T:98.4 BP:133/71 HR:80 R:15 O2Sats:975RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils:equal, reactive EOMs intact
Neck: Supple, no tenderness on cervical spine.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. 2+ edema on the right lower
extremity with ertyhema, warm.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**1-31**] objects at 5 minutes.
Language: Speech somewhat slurred 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, 2.5 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 [**4-4**] throughout except right
deltoid,
right IP/Quad 4+/5. Right pronator drift.
Sensation: Intact to light touch, proprioception, pinprick and
vibration bilaterally.
Reflexes: B T Br Pa Ac
Right 1 1 1 3 2
Left 2 2 2 3 2
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
Pertinent Results:
[**2110-5-30**] 08:31PM TYPE-ART PO2-74* PCO2-36 PH-7.47* TOTAL
CO2-27 BASE XS-2
[**2110-5-30**] 08:31PM GLUCOSE-131* LACTATE-1.7 NA+-137 K+-4.2
[**2110-5-30**] 08:31PM O2 SAT-95
[**2110-5-30**] 08:31PM freeCa-1.15
[**2110-5-30**] 03:58PM TYPE-ART PO2-135* PCO2-33* PH-7.42 TOTAL
CO2-22 BASE XS--1
[**2110-5-30**] 03:58PM GLUCOSE-155* LACTATE-2.0 K+-3.1*
[**2110-5-30**] 03:58PM freeCa-0.91*
[**2110-5-30**] 12:10PM freeCa-1.12
[**2110-5-30**] 11:51AM GLUCOSE-214* UREA N-12 CREAT-1.0 SODIUM-137
POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-24 ANION GAP-12
[**2110-5-30**] 11:51AM CALCIUM-7.5* PHOSPHATE-3.1 MAGNESIUM-1.7
[**2110-5-30**] 11:51AM WBC-4.8 RBC-3.45* HGB-10.8* HCT-30.8* MCV-89
MCH-31.5 MCHC-35.2* RDW-16.1*
[**2110-5-30**] 11:51AM PT-12.5 PTT-22.2 INR(PT)-1.1
.
.
Head CT [**5-29**]: Left subdural hematoma involving the entire left
convexity and left middle cranial fossa, with subfalcine
herniation to the right of [**2-2**] mm. Apparent effacement of the
left suprasellar cistern may be due to oblique patient
positioning but is concerning for early uncal herniation.
.
B/L LENIs [**5-29**]: neg
PCXR [**5-29**]: Clear lungs. No rib fractures.
EKG: Normal sinus rhythm. Occasional PACs.
CT C-spine [**5-30**]: Severe degenerative changes of the cervical
spine. Loss of the normal cervical lordosis. Anterolisthesis of
C4 on C5 is likely secondary to degenerative changes
.
EEG [**6-1**]: This is an abnormal portable EEG due to the presence of
bursts of sharp slowing and delta frequency slowing over the
entire left
hemisphere and increased voltage gradient over the left
hemisphere
throughout the recording. Additionally, the background over the
right
hemisphere is mildly slow and disorganized. The first
abnormality
suggests subcortical and possible cortical dysfunction diffusely
affecting the left hemisphere, predominantly over the left
fronto-central region. The second abnormality suggests a
widespread
mild encephalopathy with subcortical and cortical dysfunction.
There
were no clear epileptiform discharges recorded.
.
MRI [**6-2**]: No acute infarcts. Stable small left subdural hematoma
and pneumocephalus after recent subdural hematoma evacuation.
Small vessel ischemic changes.
.
Carotids [**6-2**]: No evidence of hemodynamically significant
stenosis in the carotid arteries bilaterally. Nonvisualization
of the left vertebral artery.
.
KUB [**6-4**]: 1. Marked dilatation of large bowel with the cecum
measuring 12 cm. This may represent colonic ileus, although, a
low rectal obstruction cannot be excluded. Continued interval
followup is recommended.
.
ECHO [**6-4**]: The left atrium is mildly dilated. No atrial septal
defect is seen by 2D or color Doppler. Right ventricular chamber
size and free wall motion are normal. The aortic root is mildly
dilated. The ascending aorta is mildly dilated. The aortic arch
is mildly dilated. 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 to moderate
([**12-2**]+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
.
CTA [**6-5**]: 1. Multiple small subsegmental pulmonary emboli within
the right upper and right lower lobes.
2. Right lower lobe pulmonary nodules are unchanged from the
PET/CT of [**2109-9-18**].
.
Head CT [**6-6**]: No change since the prior examination in the size
of the small left subdural collection, status post evacuation of
a subdural hematoma. No midline shift. No new hemorrhage.
.
KUB [**6-6**]: Nonspecific bowel gas pattern with nondilated loops of
air-filled small and large bowel.
.
Head CT [**6-9**]: Stable appearance of a small left subdural
collection status post evacuation of a subdural hematoma. No
midline shift or evidence of new hemorrhage
Brief Hospital Course:
Mr [**Known lastname **] was admitted to the NeuroICU for Q1 Neurochecks, he
was prepared for surgery on HD#2. Due to his significant
pronator drift and cofounding MS which could impaired his exam
he was consented for a left sided craniotomy for subdural
evacuation. Post operatively he was awake, alert and orientated
X3 with right sided weakness, his dressing was dry and intact. A
head CT postoperatively showed subdural removed with air in the
space. On POD#1 he was found to have right sided weakness and a
repeat head CT showed some reaccumulation of blood in the
subdural space he was transferred to the neurological floor.
.
On POD#2 he was found to have garbled speech and significant
right sided hemi-paresis, he was brought for an emergent head CT
which showed stable amount of blood. He was transferred to the
Neurostep down unit for closer neurological exam. An MRI done
was of poor quality but did not show stroke. An EKG showed
normal sinus rhythm. A chest Xray was done and showed right
infrahilar mass that on a followup CT was shown to be
insignificant stable findings from previous studies. An EEG was
done and showed no epileptiform focus. His vital signs remained
stable. On POD#3 the neuro exam improved in the morning to
a&ox3, but again fluctuated to disoriented and aphasic aphasic
during the day. His temperature spiked to 101.7 and he had a
fever workup that was negative for a source of infection. He
also had two brief episodes of bradycardia and the medicine
service was consulted. He had caroted duplex studies that showed
no significant stenosis. An echo showed no cardiac
abnormalities. A chest CT report came back that suggested a
possibility of PE, although motion artifact limited the study.
On POD#4 his neuro exam again improved and stayed stable during
the day. He was found to have abdominal distension and had a
fleets enema which resulted in minimal stool. He was transfered
to the regular floor.
.
On POD#5 His neuro exam and vitals remained stable. KUB was
ordered to assess bowel obstruction which showed a 12cm dilated
cecum and dilated loops of large bowel. General surgery was
consulted. A rectal tube was placed resulting in a large bowel
movement and a decrease in his abdominal distention. On POD#6 A
CTA was ordered and he was premedicated with mucomist for renal
protection. CTA showed multiple subsegmental pulmonary emboli.
Patient was started on IV heparin with adjusted therepeutic goal
PTT 40-60. His neuro exam and vitals remained stable. POD#7 head
CT unchanged from prior. POD#8 repeat KUB improved and rectal
tube was removed. Advanced diet as tolerated. Started coumadin.
POD#9 continued coumadin, INR was still subtherapeutic. Patient
had one large bowel movement, abdomen no longer distended.
POD#10 am INR still subtherapeutic, but early afternoon it was
at 3.5. Coumadin dose held. Patient with intermittent
expressive aphasia which resolved spontaneously. Repeat head CT
was unchaged. POD#11 am INR 3.1, patient discharged to rehab.
Plan to continued to hold warfarin and follow INR downtrend.
Likely resume on pm [**6-11**] with goal INR 2.0 (lower end of
therapuetic range). Patient continues to have intermittent
expressive aphasia. Would benefit from speech therapy as well as
aggressive physical/occupational therapy.
Medications on Admission:
Keppra 500mg am, 1000mg pm
Baclofen 30mg [**Hospital1 **]
Flomax 0.4 [**Hospital1 **]
Cranberry extract 2 [**Hospital1 **]
vit C one [**Hospital1 **]
senna 2 qhs
Colace 100 [**Hospital1 **]
Ranitidine 150 [**Hospital1 **].
Discharge Medications:
1. Baclofen 10 mg Tablet Sig: Three (3) Tablet PO BID (2 times a
day).
2. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: Two (2)
Capsule, Sust. Release 24HR PO HS (at bedtime).
3. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
4. Folic Acid 1 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 Q12H (every 12 hours) as
needed for GI prophy.
6. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day). Tablet(s)
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
8. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
10. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed. Tablet(s)
12. Warfarin 2 mg Tablet Sig: One (1) Tablet PO at bedtime:
Start [**6-11**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
- Left sided subdural hematoma
- Multiple small subsegmental pulmonary emboli within the right
upper and right lower lobes
- Colonic ileus
Discharge Condition:
Neurologically stable
Discharge Instructions:
You have been started on a new medication called warfarin.
Please have your INR check at least twice weekly with GOAL INR
2.0. Please have your doctor adjust the dose accordingly.
.
Please take medications as prescribed.
.
Please keep follow-up appointments.
.
Keep incision dry until staples come out. Watch incision for
redness, drainage, bleeding, swelling or fever greater than
101.5
Followup Instructions:
Follow up in 6 weeks with a head CT and appointment with Dr.
[**Last Name (STitle) 106639**] [**Name (STitle) **] in [**Hospital 4695**] clinic.
Phone: [**Telephone/Fax (1) 1669**]
Location: [**Hospital Unit Name 31391**]
Completed by:[**2110-6-10**]
|
[
"202.80",
"E888.1",
"997.1",
"852.21",
"204.10",
"340",
"784.3",
"560.1",
"427.89",
"293.9",
"415.11",
"401.9",
"780.39",
"997.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.31",
"96.09"
] |
icd9pcs
|
[
[
[]
]
] |
11539, 11609
|
6883, 10179
|
314, 338
|
11792, 11816
|
2893, 6860
|
12252, 12505
|
1221, 1320
|
10453, 11516
|
11630, 11771
|
10205, 10430
|
11840, 12229
|
1335, 1658
|
246, 276
|
366, 703
|
1961, 2874
|
1673, 1945
|
725, 1046
|
1062, 1205
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,044
| 164,313
|
726
|
Discharge summary
|
report
|
Admission Date: [**2173-9-3**] Discharge Date: [**2173-9-22**]
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
Cold foot
Major Surgical or Invasive Procedure:
Angiography/stent left Superficial Femoral Artery
History of Present Illness:
86 y/o male with a hx of 3V CAD, CHF - EF 35%, chronic afib,
DM2, PVD s/p bypass L [**Doctor Last Name **]-->DP in [**2168**], recent dx of colon CA
s/p R colectomy on [**2173-8-19**] at [**Hospital1 336**] with post-op complications
including confusion, MS changes that resolved with time. Patient
was sent to rehab post-op where he had a fall on L leg, with ?
trauma to L leg. Pt was noticed to have a cold L foot, and he
was transferred to [**Hospital1 **] for continued evaluation on [**9-3**].
Pt had angiography on HD 1 which showed 1. Total occlusion of
the left SFA, Total occlusion of the left SFA to DP graft, 3.
Successful stenting of the left SFA, 4. Failed intervention on
the SFA to DP graft, 5. Successful Angioseal. Pt with successful
stent placement, and post-procedure, pt had warm foot to
palpation. On HD3, per notes, patient was noted to be
"pleasantly confused, not oriented to place" with low UOP that
responded to fluid boluses. Pt was also noted to be in mild CHF,
with 2+ edema noted. Over the next 2 days, pt with decreased
appetite, poor PO intake, and continued confusion, with
decreased spontaneous movement, requiring restraints to prevent
removal of Foley.
On HD 6, gerontology was consulted for delirium, noting cause
likely multifactorial from environment, stress post-procedure,
and med effect. Recommended zyprexa prn, trazadone 25mg qhs,
d/cing cipro, haldol and foley. Patient continued to have waxing
and [**Doctor Last Name 688**] changes in his MS, with occasional clearing of
sensorium. Patient was being diuresed for his CHF, when on
HD10-12, was noted to have worsening somnolence, lack of
spontaneous movement, poor PO intake, and depression. Pt was
transferred to the medicine for continued care so that he may be
transferred to a [**Hospital1 1501**] for continued rehab.
Currently, denies any complaints of CP, SOB, DOE, or orthopnea.
Does have a wet cough that has persisted over the past 2 weeks
despite attempts at aggressive diuresis. No HA/LH/dizziness. Pt
admits to decreased appetite, but denies any deconditioning or
generalized weakness, saying PT never comes on his schedule.
Otherwise no complaints today.
Past Medical History:
PMHx:
1. CAD, 3V, no hx of CABG.
2. Systolic CHF, EF35%
3. Chronic Afib
4. DM2, x12 years.
5. PVD, s/p bypass L [**Doctor Last Name **]->DP in [**2168**], s/p angioplasty, SFA stent
on [**9-3**].
6. Recent dx of colon CA s/p R colectomy on [**2173-8-19**] at OSH.
Social History:
quit tobaco and etoh approximatedly 25 years ago
Family History:
non contributory
Physical Exam:
VS: Tc 95.4 Tm98.3 BP 90-130/50-60 HR64-84 RR18-20 Sat94-100%RA
Is/Os [**0-0-**]
GEN: Male, appears stated age, lying comfortably in bed, with
occasional episodes of wet cough.
HEENT: O/P clear. MMM. Anicteric sclera
NECK: JVD +4-5cm.
CV: Distant heart sounds. Irregular rhythmn. Nml s1,s2. No s3 or
murmur could be appreciated.
RESP: Difficult to ascertain due to patient noncompliance.
Decreased BS at bases bilat.
ABD: Soft. NTND. +BS. No TTP. No HSM
EXT: [**1-24**]+ edema to mid-shin bilat. Pulses 2+ bilat.
NEURO: AAOx1, to person only. Able to follow commands,
conversation, but not able to recall well. CN II-XII intact, UE
strength 5/5. LE strength 5/5 bilat, although limited by
restraints.
Pertinent Results:
[**2173-9-3**] 07:52PM BLOOD WBC-12.7*# RBC-4.03* Hgb-9.9*# Hct-32.1*#
MCV-80*# MCH-24.7*# MCHC-31.0 RDW-15.0 Plt Ct-423#
[**2173-9-21**] 01:05PM BLOOD WBC-6.5 RBC-4.17* Hgb-10.5* Hct-33.4*
MCV-80* MCH-25.1* MCHC-31.3 RDW-16.2* Plt Ct-371
[**2173-9-3**] 09:15AM BLOOD PT-21.4* INR(PT)-3.0
[**2173-9-21**] 01:05PM BLOOD Plt Ct-371
[**2173-9-3**] 07:52PM BLOOD Glucose-124* UreaN-20 Creat-0.9 Na-139
K-4.0 Cl-101 HCO3-28 AnGap-14
[**2173-9-21**] 01:05PM BLOOD Glucose-213* UreaN-27* Creat-1.3* Na-138
K-4.3 Cl-98 HCO3-35* AnGap-9
[**2173-9-3**] 07:52PM BLOOD Calcium-8.7 Phos-3.2 Mg-1.5*
[**2173-9-21**] 01:05PM BLOOD Calcium-8.1* Phos-3.1 Mg-2.3
[**2173-9-7**] 09:30AM BLOOD VitB12-1161* Folate-14.5
[**2173-9-4**] 02:34AM BLOOD Type-ART pO2-132* pCO2-38 pH-7.47*
calHCO3-28 Base XS-4
[**2173-9-4**] 02:34AM BLOOD Glucose-148* Lactate-1.3
C cath-- FINAL DIAGNOSIS:
1. Total occlusion of the left SFA,
2. Total occlusion of the left SFA to DP graft.
3. Successful stenting of the left SFA.
4. Failed intervention on the SFA to DP graft.
5. Successful Angioseal.
ART DUP EXT LO UNI;F/U: IMPRESSION: Patent bypass graft left
lower extremity. The increased velocity in the native vessel
distal to the graft could indicate some arterial disease in the
native vessel.
Noncontrast head CT: IMPRESSION:
1. No intracranial hemorrhage or mass effect.
2. Chronic small vessel ischemic changes and left parietal
infarct.
EKG: [**9-3**]
Atrial fibrillation with a moderate ventricular response.
Diffuse ST-T wave abnormalities - cannot rule out myocardial
ischemia. Low QRS voltage in the limb leads. No previous.
CXR [**9-10**]
1. Slight improvement in patchy bibasilar opacities, which could
be due to improving atelectasis or aspiration. Underlying
infectious pneumonia not fully excluded in the appropriate
clinical setting.
2. Persistent bilateral pleural effusions, left greater than
right
Brief Hospital Course:
A/P: 86 y/o male with a hx of 3V CAD, CHF - EF 35%, chronic
afib, DM2, PVD s/p bypass L [**Doctor Last Name **]-->DP in [**2168**], recent dx of colon
CA s/p R colectomy on [**2173-8-19**] at [**Hospital1 336**] with post-op complications
including confusion, MS changes that resolved with time, s/p
angiography and stent for cold L foot, with post-procedure
confusion, waxing MS.
1. Mental status change:
Patient with decreased memory with intact attentiveness. His
orientation waxed and waned throughout the day since he was
transfered to the medicine team. Aparently patient had a post op
delerium since his colon resection. It was felt that there was
also an elemtne of dementia present that coupled with
environment and meds lead to confusion. All psychoactive meds
were held. Patient was given Ziprexa as needed for agitation
episodes. Mental status partially improved.
2. CHF
Patient with decreased systolic fxn, last EF 35%. On transfer to
medicine team, patient had continued symptoms of poorly
controlled CHF with stable/normal vitals. Patient was gently
diuresed and he was make euvolemic. Creatinine remained stable.
Patient was continued on BB blocker, ace inhibitor and laxis.
3. A-fib
Patient with chronic a-fib. Patient was continued on coumadin to
maintained INR around 2.0 (prevent bleeding). On day of
discharged INR was 2.0. Patient ventricular rate was well
controlled during hospital stay.
4. Peripheral vascular disease
Patient had angioplasty/stent to SFA during hospitalization.
Favorable course. Patient was folled by the vascular surgery
team during his stay on medicine team. NO complications. Good
pulses and [**Last Name (un) 5355**] was warm. Patient was continued on plavix and
aspirin
5. DM2 - Patient was controlled with insulin sliding scale
during hospital stay
-Cont Insulin SS.
6. ID
Patient had a U/A with WBCs, mod bacteria on urine, but negative
urine cx x2. Since patient remained afebrile, WBC stable and no
symptoms abx were held. Subsequent U/A was sent and was negative
for leuks or nitrates.
7. F/E/N
Patient with decreased PO intake during hospital stayed.
Nutrition recomendations were followed. Electrolytes were
repleated PRN.
8. Mechanical Fall: In the morning on day of discharged patient
was found on the floor. Neurological exam did not show any focal
deifict. CT scan done- negative for acute intracraneal pathology
Medications on Admission:
Furosemide 80 mg IV QPM
Furosemide 100 mg IV QAM
Cephalexin 500 mg PO Q8H Day 4
Miconazole Powder 2% 1 Appl TP QID:PRN
Captopril 6.25 mg PO TID
Pantoprazole 40 mg PO Q24H
Metoprolol 25 mg PO BID
insulin SS
Clopidogrel 75 mg PO DAILY
Aspirin EC 325 mg PO DAILY
Coumadin 2.5mg po qd (held [**Date range (1) 5356**] d/t INR>3.0)
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain.
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*1*
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
9. Warfarin Sodium 2.5 mg Tablet Sig: One (1) Tablet PO at
bedtime: Please have your INR checked on [**9-23**] and adjust
accordingly.
Disp:*30 Tablet(s)* Refills:*0*
10. Atorvastatin Calcium 10 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
11. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
12. Lasix 40 mg Tablet Sig: as directed Tablet PO twice a day: 2
tablets each morning (80mg), 1 tablet each afternoon (40mg).
Disp:*90 Tablet(s)* Refills:*1*
13. Glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day:
Check BS at least twice each day and keep a log.
Disp:*30 Tablet(s)* Refills:*1*
14. Hospital Bed
15. APP Matress
16. transport chair
86y/o male with slowly resolving delirium, s/p angiography and
stent for cold left food.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 701**] VNA
Discharge Diagnosis:
1. Delirium
2. s/p angiography and stent of left SFA
3. Cardiac heart failure
4. Colon Cancer s/p recent resection
5. Hypertension
6. Diabetes Mellitus type II
Discharge Condition:
Fair, Tolerating POs, afebrile, hemodynamically stable. Delirium
slowly improving.
Discharge Instructions:
-continue with medications as prescribed
-please have a daily weight recorded
-please follow-up with appts as scheduled
-low-salt diet
- Please check your INR level on [**2173-9-23**] by VNA services.
- If fever, shortness of breath, chest pain or any other
symptoms that concern you , call your PCP or visit the ED.
Followup Instructions:
-patient will see Dr. [**Last Name (STitle) **] in [**2173-10-6**] at 9 am [**Telephone/Fax (1) 5357**]
Completed by:[**2173-12-28**]
|
[
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icd9cm
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[
[
[]
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[
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icd9pcs
|
[
[
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10037, 10095
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5522, 7902
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237, 289
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10299, 10384
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3610, 4458
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,293
| 161,416
|
23918
|
Discharge summary
|
report
|
Admission Date: [**2189-12-27**] Discharge Date: [**2190-1-1**]
Date of Birth: [**2108-2-4**] Sex: M
Service: NEUROSURGERY
Allergies:
[**Last Name (un) **]-Dur
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Elective admission for left temporal lobectomy
Major Surgical or Invasive Procedure:
L craniotomy for resection of mass
L Temporal lobectomy
History of Present Illness:
81M with hx of left parotid cancer treated with radiation in
[**2178**]
who now presents with increased confusion and concern for
progression of radiation necrosis. In [**2182**], the patient had an
MRI that showed a left temporal lobe lesion. This was felt to be
most consistent with radiation necrosis on review by Neuro here
at [**Hospital1 18**] and the patient was started on steroids at that time.
He
had improvement and had no further issues until recently his
family noted new behavioral changes. The family noticed the
confusion 1 year ago with occasional combativeness. However, the
patient was still able to be very independent, including
driving.
He had been seen by his PCP and Neurologist over this past year
who started him on anti-depressant medications (initially
citalopram, then switched to fluoxetine). 2 months ago, the
patient had a more rapid decline with respect to confusion and
behavior and family stopped letting him drive. He was seen back
in [**Hospital **] clinic with Dr. [**Last Name (STitle) 6570**] on [**11-24**] - he recommended
repeat imaging with PET-CT and MRI. The repeat MRI showed a new
complex [**Month/Day (1) 6279**] mass in the temporal lobe with the read saying
most consistent with persistent radiation necrosis. He was
started on high dose steroids at that time with dexamethasone
12mg daily although became quite combative at that dose. His
dose
was then tapered to 4mg which helped with the combativeness
however he was still very confused and weak and was admitted by
Dr [**Last Name (STitle) 724**] for further workup. While in house he was started on
insulin and ultimately discharged home with plans for follow-up
with us.
Today he presents to the clinic to discuss possible surgical
intervention. Since discharge he has had issues with his blood
sugars and also had a fall on New Years Eve after which he had a
laceration on his right eye brow requiring stitches.
Past Medical History:
PAST ONCOLOGIC HISTORY:
[**2178**] [**2179-5-10**] Left facial nerve palsy and left cheek lesion
[**2179-5-4**] MRI showed left parotid mass
[**2179-6-4**] Left total parotidectomy, left facial nerve resection
and
greater auricular nerve graft, SCM flap, gold weight impland to
left upper lid, tarsal strip blepharoplasty of the left lower
lid
by Dr. [**Last Name (STitle) 1024**] at [**Hospital3 2358**]
Pathology: high grade muco-epidermoid carcinoma with perineural
invasion, level 2 LN negative
[**2179-5-29**] FNA of neck LN, suspicious for carcinoma
[**2179-6-29**] - [**2189-8-19**] XRT in 35 fr. by Dr. [**First Name (STitle) **]
[**12/2182**] Neck MRI showed left temporal brain lesion
[**2183-1-3**] Brain MRI showed left temporal lesion
[**2183-2-10**] Brain MRI showed left temporal lesion, considered to be
treatment effect, treated with dexamethasone
[**2183-7-7**] Brain MRI shows stable left temporal lesion
.
.
PAST MEDICAL HISTORY:
1. Parotid gland cancer, left
2. Left facial paralysis
3. Left hearing loss
4. Dyslipidemia
5. Asthma, COPD
6. Tremor of the hands, primidone since [**2182**]
7. Depression
8. Borderline diabetes
9. Polyps of the colon, [**2168**]
10. Hernia surgery
[**88**]. Rotator cuff pinning
12. Excision of skin lesions
13. Viral hepatitis
14. Chronic left otitis externa following radiation
15. CAD, Positive stress test [**2175**]
16. Degenerative joint disease
17. Memory problems considered multi-infarct dementia [**2182**]
18. Low vitamin B12
19. Prostatism
Social History:
He is widowed and lives alone, but his daughter lives upstairs
in
the same building. His parents are deceased. He has no siblings.
He had five children, one died in a motorcycle accident. Among
his children, [**Doctor First Name **] is the health care proxy. [**Name (NI) **] is a retired
machinist. He smoked for 20 years.
Family History:
Uncle with parotid CA.
Physical Exam:
Gen: WD/WN, comfortable, NAD.
HEENT: stitches over right eyebrow from fall Pupils: PERRL
EOMs intact
Neck: Supple.
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 and place
Language: Speech fluent with moderately good comprehension
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4mm to
3mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Left facial droop, decreased sensation of left cheek
secondary to radiation.
VIII: Hearing decreased on left
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 [**4-24**] throughout. No pronator drift
Sensation: decreased left side of face
Toes downgoing bilaterally
Coordination: right dysmetria
Pertinent Results:
CT HEAD W/O CONTRAST [**2189-12-29**]
1.Immediately status post left temporparietal craniotomy and
resection of
[**Year/Month/Day 6279**] mass in the left temporal lobe, with expected
post-surgical change
2. Hyperdensity in the extra-axial space overlying the left
frontal lobe,
new, likely small subdural hemorrhage.
3. Extensive vasogenic edema with leftward shift of
normally-midline
structures, slightly more pronounced compared to the [**2189-12-16**]
examination
MRI Brain with and without contrast [**2189-12-30**]:
FINDINGS: The patient is status post left temporoparietal
craniotomy with
expected post-surgical changes in the form of pneumocephalus,
left frontal
extra-axial fluid collection (measuring 6 mm in maximal
thickness) and large fluid-filled resection cavity at the tip of
the left temporal lobe with sedimentation and fluid-fluid level.
A considerable amount of blood product is lining the posterior
and medial aspect of the resection cavity. Enhancement is noted
along the dura and is likely reactive in nature. On
diffusion-weighted images, there is gyriform hyperintensity on
the DWI (images # 12,13,14, series #9), involving the posterior
aspect of the resection cavity and extending along the primary
auditory associative cortex, concerning for acute/subacute areas
of ischemia.
The previously reported vasogenic edema, involving the left
temporal and the left parietal lobe is unchanged, there is
stable mass effect with distortion of the lateral ventricles,
compression of the left cerebral peduncle and midline shift.
Flow voids of the major intracranial vessels are preserved. The
paranasal
sinuses are clear. Opacification of the left mastoid air cell is
largely
unchanged.
IMPRESSION:
1. Status post resection of right temporal lesion with
postoperative changes in the form of dural enhancement
extra-axial fluid (6 mm in maximal thickness), pneumocephalus,
and moderate hemorrhage at the resection site.
2. Gyriform hyperintensity on the DWI (images # 12,13,14, series
#9),
involving the posterior aspect of the resection cavity and
extending along the primary auditory associative cortex,
concerning for acute/subacute areas of ischemia.
Head CT w/o contrast [**2189-12-31**]:
FINDINGS: Status post left temporoparietal craniotomy, resection
of the left temporal complex lesion with persistent extensive
vasogenic edema with effacement of the left lateral ventricle.
However, there is a new large hemorrhage in the resection site
spanning over area of 5.5 x 4.7 cm. There is also increase in
the subdural hemorrhage along the falx (2:17) and tracking along
the left convexity. There is increase in the rightward shift of
midline structures from 4.5-8 mm in keeping with increased mass
effect from the new hemorrhage. There are areas of attenuation
in the subcortical and periventricular white matter, likely
chronic small vessel ischemic changes. There is residual
post-surgical left pneumocephalus.
IMPRESSION: Status post left temporoparietal craniotomy and
resection of left temporal lobe lesion with a new large
intraparenchymal hemorrhage at the resection site and interval
increase in size of left extra-axial subdural hematoma. Interval
increase in mass effect and shift of midline structures from
4.5-8 mm.
Head CT w/o contrast [**2189-12-31**]:
Status post left temporoparietal craniotomy and resection of
left temporal
lobe lesion with interval increase in large intraparenchymal
hemorrhage at
the resection site and interval increase in laryering bld in
right ventricle. Again noted is left extra-axial subdural
hematoma. Interval increase in mass effect and max rightward
shift of midline structures measured as 11.2mm compared to 8mm.
Brief Hospital Course:
81 y/o M with history of parotid CA presents with increased
confusion. MRI head revealed a L temporal lobe lesion. Patient
was admitted on [**12-27**] for elective resection and temporal
lobectomy for tumor necrosis. On [**12-29**], patient was taken to the
OR with an uncomplicated course. He was taken to the ICU for
close monitoring post operatively. Post op head CT revealed some
pneumocephalus and stable midline shift. On examination, patient
remained at baseline. On [**12-30**], he was stable and encourgaed to
be OOB with assistance. He is scheduled for an MRI of the head
and then will be transferred to the floor. His dexamethasone was
also weaned to a QOD taper. On [**12-31**] he was grossly stable in the
stepdown unit while awaiting evaluation by PT and OT for
disposition planning. In the afternoon, it was noted that he had
a mental status change- nonverbal, lethargic, asymmetric pupils.
A STAT head CT was done which showed hemorrhage into the
surgical cavity with midline shift. He was transferred to the
ICU. A repeat head CT showed worsening midline shift. A meeting
was had with the family and it was decided to not pursue
aggressive intervention. He was made DNR/DNI/CMO. All
medications were discontinued except for those promoting
comfort.
On [**2190-1-1**] at 4:40 PM the patient expired and was pronounced
by Dr. [**Last Name (STitle) 60974**] (note in OMR).
Medications on Admission:
1. ALPRAZOLAM 0.25 mg by mouth once a day
2. BACLOFEN 5 mg by mouth 3 times per day for hiccups
3. CLOPIDOGREL 75 mg by mouth once a day
4. DEXAMETHASONE 6 mg by mouth twice a day
5. FEXOFENADINE 60 mg by mouth as needed
6. FLUOXETINE 20 mg by mouth once a day
7. LORAZEPAM 1 mg by mouth at bedtime
8. OMEPRAZOLE 20 mg by mouth daily
9. PRIMIDONE 50 mg by mouth twice a day
10. SIMVASTATIN 20 mg by mouth at bedtime
11. TAMSULOSIN 0.4 mg by mouth at bedtime
12. CHOLECALCIFEROL 2,000 unit by mouth once a day
Discharge Disposition:
Expired
Discharge Diagnosis:
L temporal lobe lesion/tumor necrosis
L temporal ICH with midline shift
Cerebral edema
Discharge Condition:
xx
Discharge Instructions:
xx
xx
Followup Instructions:
xx
Completed by:[**2190-1-12**]
|
[
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
[
[
[]
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11088, 11097
|
9139, 10528
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336, 393
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11228, 11233
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5423, 9116
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3888, 4214
|
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