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40,883
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46287
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Discharge summary
|
report
|
Admission Date: [**2146-8-3**] Discharge Date: [**2146-8-9**]
Service: MEDICINE
Allergies:
Trazodone / Vicodin
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Hypotension, Acute Renal Failure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname 24828**] is an 85 year old female with past medical history
significant for CAD, atrial fibrillation, HTN, chronic low back
pain and dementia with hallucination component who presented to
ED this afternoon after altered mental status from usual
baseline, slurred speech and a fall this morning. She was noted
to have markedly low blood pressure with arrival BP of 69/42.
Patient arrived to ED with her daughter who claimed that patient
had altered mental status since 8pm last night and slurred
speech was noticed this morning. Early this morning the patient
felt "dizzy" and fell to her knees despite walking with her
daughter and suffered a small knee abrasion but did not hit her
head. Patient denies any associated nausea, vomiting, chest
pains, palpitations or dyspnea during event. Daughter states
that patient was given her usual oxycodone, amiodarone and
metoprolol this morning but reports that they have been holding
her HCTZ due to low BPs. At baseline she usually walks with a
walker. Initial EMS BS 125 mg/dl on scene.
.
Of note the patient is followed by a geriatrics and she had her
risperdal dose doubled at recent [**7-20**] visit. Blood pressure just
2 weeks ago at 112/60s range. Patient had also been advised to
stop her HCTZ as of [**7-12**] due to concern for low blood pressures.
.
In the ED, initial vs were: T [**Age over 90 **]F, HR 62, BP 69/42, RR 18, O2
sat 100% RA. While in the ED, she continued to seem delerius on
exam. She was given over 4L IVFs and blood pressures still
remained labile with systolic readings in 70-90s range. She had
no leukocytosis and UA negative, CXR clear. Still given
CTX/Vancomycin for empiric coverage of possible infection. Head
CT also negative. She self d/c'd her EJ line. C-spine negative
film negative. Labs showed K 5.8 so she recieved kayexalate for
hyperkalemia. EKG unchanged from previous ; NSR with slight
upsloping ST v3-v5, <1/2mm , not elevated. No TWI or ST
depressions and initial troponin negative. INR elevated at 6.9.
.
On arival to the [**Hospital Unit Name 153**], initial vital signs were: 95.2F,
BP127/48, HR 66, RR10 and O2 sat 98% RA. Mrs. [**Known lastname 24828**] has no
complaints. Her health care proxy is present for the interview.
Past Medical History:
-Afib on coumadin
-VTE disease
-GERD
-HTN
-HL
-CAD with angina
-L1 compression fracture/osteoporosis
-Mitral regurgitation
-Osteoarthritis/DJD
-Right Hip Bursitis
-Spinal stenosis
-Status post pubic ramus fracture - [**12/2142**]
-Status post falls - [**8-/2144**] and [**11/2145**]
-Dementia- Most likely vascular with possible Alzheimer's
component
Social History:
Living situation: Lives in house with daughter downstairs
[**Name2 (NI) **] relationships: Daughter [**Name (NI) 11556**]
Habits: denies Smoking, EtOH
Family History:
Per OMR: Father and mother both deceased (father, 70, influenza;
mother, 65, congestive heart failure). She has 8 siblings with
multiple medical problems (brother, coronary artery disease, MI
age 62; brother, coronary artery disease, MI age 65; brother,
pulmonary embolism in his 60s; sister brain aneurysm, deceased
in 50s; sister with renal failure and on hemodialysis, deceased
in 70s, and brother with leukemia deceased in his 50s).
Physical Exam:
General: Frail appearing elderly female, alert and oriented x2,
no acute distress at rest
HEENT: PERRL, EOMI. Sclera anicteric, very dry MM, oropharynx
clear, nares clear.
Neck: supple, JVP flattened, no LAD, no thyromegaly
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: small well healed abd scar, soft, non-tender,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
GU: foley in place
NEURO: CNs [**3-4**] in tact, sensation light touch WNL, [**5-25**] UE
strength and [**4-25**] lower extremity strength.
Ext: warm and very thin extremities, small scrape over left
knee, well perfused, 2+ pulses, no clubbing, cyanosis or edema
Pertinent Results:
[**2146-8-3**] 07:40AM BLOOD WBC-8.6 RBC-3.75* Hgb-11.4* Hct-36.8
MCV-98 MCH-30.3 MCHC-30.9* RDW-16.6* Plt Ct-323
[**2146-8-7**] 05:50AM BLOOD WBC-12.9* RBC-3.22* Hgb-9.7* Hct-30.8*
MCV-96 MCH-30.2 MCHC-31.6 RDW-15.2 Plt Ct-232
[**2146-8-8**] 06:55AM BLOOD WBC-11.1* RBC-3.07* Hgb-9.6* Hct-29.7*
MCV-97 MCH-31.3 MCHC-32.4 RDW-15.6* Plt Ct-235
.
[**2146-8-4**] 03:35AM BLOOD PT-64.2* PTT-49.7* INR(PT)-7.4*
[**2146-8-5**] 08:15AM BLOOD PT-18.6* PTT-31.5 INR(PT)-1.7*
[**2146-8-6**] 06:15AM BLOOD PT-16.1* PTT-29.7 INR(PT)-1.4*
[**2146-8-7**] 05:50AM BLOOD PT-16.1* PTT-36.6* INR(PT)-1.4*
[**2146-8-8**] 06:55AM BLOOD PT-16.3* PTT-31.6 INR(PT)-1.4*
.
[**2146-8-3**] 07:40AM BLOOD Glucose-113* UreaN-53* Creat-2.5*# Na-134
K-5.8* Cl-110* HCO3-16* AnGap-14
[**2146-8-8**] 06:55AM BLOOD Glucose-80 UreaN-12 Creat-1.1 Na-140
K-3.6 Cl-103 HCO3-28 AnGap-13
.
[**2146-8-3**] 07:40AM BLOOD ALT-17 AST-23 CK(CPK)-73 AlkPhos-87
TotBili-0.2
[**2146-8-3**] 03:09PM BLOOD ALT-12 AST-16 CK(CPK)-56 AlkPhos-73
TotBili-0.2
[**2146-8-4**] 03:35AM BLOOD CK(CPK)-70
[**2146-8-3**] 07:40AM BLOOD CK-MB-4
[**2146-8-3**] 07:40AM BLOOD cTropnT-LESS THAN
[**2146-8-3**] 03:09PM BLOOD CK-MB-4 cTropnT-<0.01
[**2146-8-4**] 03:35AM BLOOD CK-MB-4 cTropnT-<0.01
.
[**2146-8-8**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-Negative
[**2146-8-5**] Blood Culture, Routine-PENDING INPATIENT
[**2146-8-5**] Blood Culture, Routine-PENDING INPATIENT
[**2146-8-5**] URINE CULTURE-Negative
[**2146-8-3**] MRSA SCREEN-Negative
[**2146-8-3**] URINE CULTURE-Negative
[**2146-8-3**] URINE CULTURE-Negative
[**2146-8-3**] Blood Culture, Routine-Negative
[**2146-8-3**] Blood Culture, Routine-Negative
.
CT HEAD W/O CONTRAST IMPRESSION:
1. No evidence of acute intracranial process.
2. Global atrophy, consistent with patient's age. Patchy white
matter
hypodensity consistent with chronic small vessel ischemic
change.
.
CT C-SPINE W/O CONTRAST IMPRESSION:
1. No evidence of acute cervical spine injury.
2. Multilevel spinal degenerative change.
3. Heterogeneous appearance to the right thyroid lobe.
.
CHEST (PORTABLE AP) IMPRESSION: No acute cardiopulmonary
abnormality.
Brief Hospital Course:
In summary, Ms. [**Known lastname 24828**] is an 85 year old female with history of
dementia with hallucinations, CAD, afib, HTN, and hypothyroidism
who presents now with hypotension and new acute renal failure.
.
#Hypotension: Pt was initially hypotensive to 69/42 in ED. This
was thought to be secondary to decreased oral intake. Her
pressures improved with fluid resuscitation. She remained normo
to hypertensive in the ICU and her BP meds were restarted. Her
dizziness was likely secondary to medication SE and her
risperdal was held. Blood cultures were drawn to rule out sepsis
and the patient was never febrile nor did she have an elevated
white count. Cardiac enzymes were trended and returned negative.
Her Urine cultures returned negative.
.
#ARF: Initially the patient's creatinine was elevated to 2.5,
well above her baseline of 1.4-1.5. Her creatinine improved with
fluid resuscitation and returned to baseline. Her urine output
also improved with fluids. Her lisinopril was held pending
improvement of her kidney function, but was resumed and
tolerated after her renal failure resolved.
.
#Dementia: The patient's family reported that her dementia had
worsened recently though she does have a long-standing history
of dementia with hallucinogenic features. Recently her risperdal
was increased for this reason. The patient did display evidence
of active hallucinations. Her risperdal was initially held out
of concern for her worsening confusion, but this is continuing
to be held for concern for possible contribution to hypotensive
episode. Patient should follow up with her PCP for further
evaluation and management.
.
# Atrial fibrillation: For the patient's history of Afib, she
was maintained on her home amiodarone. Her coumadin was held
once her INR returned in the supratherapeutic range. She was
also given a dose of Vitamin K for her elevated INR (max 7.4).
CHADS2 score 2. INR now subtherapeutic, and she was resumed on
her home warfarin dosing schedule. There is no need for heparin
bridge.
Her metoprolol and amiodarone were continued
She will need INR check after discharged, and she was instructed
to follow up with her coumadin clinic within the next 2 days.
Her INR at the time of discharge was 1.4.
.
#CAD: The patient was monitored with telemetry. Cardiac enzymes
were also drawn and returned negative. She was continued on her
home medications simvastatin and aspirin.
.
# Hypophosphatemia
- resolved with IV potassium phospate
.
# Hypomagnesemia
- resolved with IV Magnesium sulfate
.
#Hypothyroidism: The patient was continued on her home regimen
of levothyroxine.
.
#GERD: The patient was continued on her home medication
omeprazole.
.
.
# Disp: pt was evaluated by PT who recommended either [**Hospital 3058**]
rehab vs home with 24 hr supervision. Family stated that they
are able to provide 24 hr care, and pt discharged to pt's
daughter's house under care of family.
Medications on Admission:
AMIODARONE - 200 mg 3xweek on Mon, Wed, Fri
CITALOPRAM - 40 mg Tablet - 1.5 Tablet daily
CITALOPRAM - 20 mg Tablet - 1 Tablet(s) by mouth daily
GABAPENTIN - 200 mg at bedtime
HYDROCHLOROTHIAZIDE -(On Hold from [**2146-7-12**] to unknown for
Low BP/orthostasis) - 12.5 mg Capsule - 1 Capsule(s) by mouth
once a day
LEVOTHYROXINE - 25 mcg Tablet by mouth every other
day Alternating with 50 mcg QOD
LIDOCAINE - 5 % (700 mg/patch) Adhesive Patch, Medicated - 1
patch daily On for 12 hours and off for 12 hours.
LISINOPRIL - 10 mg Tablet - 1 (One) Tablet(s) by mouth at
bedtime
METOPROLOL SUCCINATE - (Dose adjustment - no new Rx) - 50 mg
Tablet Sustained Release 24 hr - One-half Tablet by mouth daily
in the evening
NITROGLYCERIN - 0.3 mg Tablet, Sublingual - 1 Tablet(s)
sublingually daily PRN
OMEPRAZOLE - 40 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)
by mouth daily
OXYCODONE - 5 mg Tablet - 1 Tablet(s) by mouth TID PRN To be
filled [**2146-7-7**]
RISPERIDONE - 0.5 mg Tablet - 1 Tablet(s) by mouth at bedtime as
needed for hallucinations
SIMVASTATIN - 20 mg Tablet - 1 Tablet(s) by mouth daily
WARFARIN [COUMADIN] - 1 mg Tablet - 1 Tablet(s) by mouth at
bedtime 1 mg Mon-Wed-Fri and 2 mg the other days of the week
Discharge Medications:
1. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) as needed for back pain .
3. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO 3X/WEEK
(MO,WE,FR).
5. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
8. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO once a day.
9. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO twice a
day.
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
11. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
12. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
13. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
15. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO 4X/WEEK
([**Doctor First Name **],TU,TH,SA).
16. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO 3X/WEEK
(MO,WE,FR).
17. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAYS (MO,WE,FR).
18. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAYS
([**Doctor First Name **],TU,TH,SA).
19. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain back : on 12 hours/off 12 hours.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
# Hypotension; unclear etiology. Possibly due to poor po intake
and medication effect
# Acute renal failure
# Diarrhea, nos
# Dementia/Acute delerium
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted with confusion, low blood pressure and acute
kidney failure. You were treated with IV fluids and admitted to
the ICU. You were taken off of your rispiridal, in case this
contributed to your episode of low blood pressure. The kidney
function has returned to [**Location 213**].
Please have your INR checked with your coumadin clinic within
the next 2 days.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Department: GERONTOLOGY
When: WEDNESDAY [**2146-8-17**] at 11:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RNC [**Telephone/Fax (1) 719**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"276.2",
"733.00",
"413.9",
"424.0",
"276.7",
"244.9",
"275.2",
"724.2",
"584.9",
"787.91",
"715.90",
"272.4",
"276.51",
"293.0",
"401.9",
"458.9",
"294.8",
"530.81",
"427.31",
"414.01",
"275.3"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12401, 12458
|
6509, 9422
|
258, 265
|
12652, 12652
|
4352, 6486
|
13324, 13624
|
3109, 3547
|
10698, 12378
|
12479, 12631
|
9448, 10675
|
12834, 13301
|
3562, 4333
|
186, 220
|
293, 2550
|
12667, 12810
|
2572, 2924
|
2940, 3093
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,641
| 180,277
|
7261
|
Discharge summary
|
report
|
Admission Date: [**2117-5-12**] Discharge Date: [**2117-5-26**]
Date of Birth: [**2071-9-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2117-5-17**] Coronary Artery Bypass Graft x 4 (Left internal mammary
artery to left anterior descending, saphenous vein graft to
diagonal, saphenous vein graft to obtuse marginal, saphenous
vein graft to posterior descending artery)
History of Present Illness:
This 45 year old male with a long cardiac history inclulding
multiple myocardial infarctions (1st at age 33) and 7 coronary
stents, presented to another hospital with chest pain. He ruled
in for NSTEMI and cardiac cathetreization revealed 3 vessel
disease. He was transferred for surgical evaluation.
Past Medical History:
coronary artery disease
s/p 7 coronary stents
diabetes mellitus
h/o multiple MIs
Hyperlipidemia
Hypertension
Social History:
Lives with: wife
Occupation: mechanical technician
Tobacco: none
ETOH: none
Family History:
mom with MI in her 40s s/p CABG twice
brother with MI at 28yo
Physical Exam:
admission:
Pulse:58SR Resp: 18 O2 sat: 100%RA
B/P Right: Left: 108/70
Height: Weight: 86.9kg
General: NAD, slightly anxious
Skin: Dry [x] intact [x] no rash
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [] no edema or varicosities
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: no bruits appreciated
Pertinent Results:
[**2117-5-17**] Echo: Pre-CPB: No spontaneous echo contrast is seen in
the left atrial appendage. Overall left ventricular systolic
function is mildly depressed (LVEF= 40 - 45 %). Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the descending thoracic [**Month/Day/Year 5236**]. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no
pericardial effusion. Post-CPB: The patient is AV-Paced, on low
dose phenylephrine. Left ventricular systolic fxn remains mildly
depressed. RV systolic fxn is normal. No AI, no MR. [**First Name (Titles) **] [**Last Name (Titles) 18350**]t.
[**2117-5-14**] Carotid U/S: Right ICA with no stenosis. Left ICA with no
stenosis.
[**2117-5-25**] 10:20AM BLOOD WBC-10.9 RBC-4.83 Hgb-14.2 Hct-42.1
MCV-87 MCH-29.3 MCHC-33.6 RDW-12.5 Plt Ct-478*
[**2117-5-24**] 06:20AM BLOOD WBC-9.6 RBC-4.20* Hgb-12.6* Hct-36.2*
MCV-86 MCH-30.0 MCHC-34.7 RDW-13.0 Plt Ct-378
[**2117-5-22**] 04:50AM BLOOD WBC-11.1* RBC-4.06* Hgb-12.2* Hct-35.1*
MCV-87 MCH-30.1 MCHC-34.9 RDW-12.8 Plt Ct-311
[**2117-5-25**] 10:20AM BLOOD K-4.8
[**2117-5-24**] 06:20AM BLOOD Glucose-155* UreaN-12 Creat-0.6 K-4.5
[**2117-5-23**] 04:40AM BLOOD Glucose-139* UreaN-11 Creat-0.6 Na-134
K-4.2 Cl-97 HCO3-26 AnGap-15
[**2117-5-17**] 07:10AM BLOOD Glucose-164* UreaN-15 Creat-0.8 Na-134
K-4.7 Cl-99 HCO3-27 AnGap-13
Brief Hospital Course:
Mr. [**Known lastname 1557**] was transferred from an outside hospital after being
ruled in for myocardial infarction and catheterization which
revealed severe three vessel coronary artery disease. He was
appropriately worked up for surgery and awaited complete Plavix
washout.
On [**5-17**] he was brought to the Operating Room where he underwent
coronary artery bypass graft x 4. Please see operative report
for surgical details.He easily weaned from bypass, not requiring
any pressors. 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
extubated.
On post-op day one he was doing well and was transferred to the
telemetry floor for further care. Beta blockers and diuretics
were started and he was diuresed towards his pre-op weight. On
post-op day two his chest tubes were removed. On post-op day
three epicardial pacing wires were removed. He was noted to have
a moderate amount of serosanguinous dtr[**Name (NI) 26858**] from the distal
[**1-10**] of his sternal incision. He was without fever or
leukocytosis. He was started on Keflex. The drainage gradually
decreased and stopped. The sternum was stable and without
erythema. He was evaluated by Physical Therapy for strength and
mobility and was cleared for discharge to home.
His HgA1c on admission was 11 and he required insulin therapy
was instituted during his admission. He was instructed on
glucose testing and administarion of both morning Lantus and
sliding scale coverage with HumaLog insulin as well.
He was discharged on oral antibiotics for a week and a wound
check will be performed in 5 days. He was given full
instructions about medications, wound care and follow up.
Medications on Admission:
Crestor 20mg daily
Atenolol 100mg daily
Plavix 75 mg daily
Niaspan 1000mg qhs
Metformin 1000mg daily
Zetia 10mg daily
Actos 15mg daily
ASA 325mg daily
Tricor 145mg daily
Diovan 80mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
3. Rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
daily ().
Disp:*30 Tablet(s)* Refills:*2*
5. Niacin 500 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO BID (2 times a day).
Disp:*60 Capsule, Sustained Release(s)* Refills:*2*
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice
a day.
Disp:*60 Tablet(s)* Refills:*2*
7. Insulin Glargine 100 unit/mL Solution Sig: Thirty (30) units
Subcutaneous once a day.
Disp:*1 pen* Refills:*2*
8. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 7 days.
Disp:*28 Capsule(s)* Refills:*0*
9. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
11. Humalog Pen 100 unit/mL Insulin Pen Sig: per sliding scale
Subcutaneous four times a day: 120-159-2units B/L/D
160-199-4units B/L/D/2units HS
200-239-6 units B/L/D,4units HS
240-279-8units B/L/D,6units HS
280-319-10units B/L/D,8units HS
320-360-12units B/L/D, 10units HS
B-bkfst,L-lunch,D-dinner,HS-bedtime.
Disp:*2 * Refills:*2*
12. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
VNA of [**Doctor Last Name **]
Discharge Diagnosis:
Coronary Artery Disease
s/p Coronary Artery Bypass Graft x [**Street Address(2) 26859**] elevation Myocardial Infartcion
s/p 7 coronary stents
insulin dependent diabetes mellitus
Hypertension
Hyperlipidemia
TIA [**2113**]
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema and minimal serosanguinous
drainage
Leg Right - healing well, no erythema or drainage
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.Please shower daily including washing incisions
gently with mild soap, no baths or swimming until cleared by
surgeon. Look at your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon:
Dr. [**Last Name (STitle) **] on [**6-24**] @ 1:30 PM ([**Telephone/Fax (1) 170**])
Please call to schedule appointments with:
Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11679**] ([**Telephone/Fax (1) 26860**]in [**1-9**] weeks
Cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 7960**]in [**1-9**] weeks
[**Hospital Ward Name 121**] 6 wound clinic check on [**Last Name (LF) 766**], [**5-31**] at 10am
**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:[**2117-5-26**]
|
[
"V45.82",
"250.02",
"414.01",
"V58.67",
"V17.3",
"410.71",
"401.9",
"V12.54",
"272.4",
"412"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.13",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
7083, 7144
|
3386, 5157
|
331, 568
|
7410, 7643
|
1943, 3363
|
8485, 9231
|
1141, 1204
|
5395, 7060
|
7165, 7389
|
5183, 5372
|
7667, 8462
|
1219, 1924
|
281, 293
|
596, 899
|
921, 1032
|
1048, 1125
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,949
| 132,974
|
28901
|
Discharge summary
|
report
|
Admission Date: [**2161-11-5**] Discharge Date: [**2161-11-17**]
Date of Birth: [**2109-12-27**] Sex: M
Service: SURGERY
Allergies:
Percocet / Aldactone
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
HCV cirrhosis/HCC
Major Surgical or Invasive Procedure:
[**2161-11-6**] Liver [**Month/Day/Year **]
History of Present Illness:
Patient is a 51-year-old male with hepatitis C cirrhosis,
HCC s/p RFA and chemoembolization with success, recently
admitted
([**Date range (1) 69725**]) for evaluation of dizziness and unsteadiness
as well potential liver [**Date range (1) **] that never occurred. He is
now
here for another potential liver [**Date range (1) **]. Yesterday, he had
an
episode of epistaxis after staying up late, lasted a couple of
minutes but stopped with direct pressure. He denied any trauma
and said that this has happened in the past when he stays up
later than usual
Past Medical History:
#. Hepatitis C - Genotype 1. Recently undectable viral load
([**2161-8-27**]).
Dr. [**Last Name (STitle) 497**] is his hepatologist, on [**Last Name (STitle) **] list
#. HCC diagnosed in 2/[**2155**]. Underwent radiofrequency ablation at
[**Hospital1 2177**] [**12-26**]. His cancer progressed s/p radiofrequency ablation at
[**Hospital1 2177**]. [**9-27**]: CT w/ 2 nodules each 1.1cm in segment VI were more
conspicuous concerning for recurrence. 1.5-cm subcapsular nodule
in VII unchanged, 6mm foci in II and VII unchanged. Had
attempted but incomplete Transcatheter Arterial
Chemoembolization . Started on Sorafenib. [**10-27**]: TACE completed
successfully at [**Hospital1 18**]. [**5-28**]: No evidence of disease recurrence
on CT. AFP 1.6 ([**2161-8-26**])
#. Hypertension.
#. Cirrhosis.
#. Portal hypertensive gastropathy. ([**10-27**] EGD)
#. Anemia (BL HCT~29-33)
OLT [**2161-11-6**]
Social History:
Lives w/ father of a cousin currently. Previously incarcerated
for arms trafficking / sales. Tobacco: ~35 years, 1 pack / [**2-22**]
days. Quite smoking [**2155**]. He does not drink alcohol or use any
drugs currently. Reports remote intranasal cocaine use. Per
clinic records ([**Doctor Last Name 497**]) also used IV drugs previously.
Family History:
He had a grandmother who died of lung cancer in her 80s. His
mother died of heart disease in her 70s and his father is still
alive. Brother and sister with DM. Brother with Hep C and
cirrhosis.
Physical Exam:
VS: Wt 104.9 kg, T 99.2, HR 87, BP 155/87, RR 20, SpO2 94%RA
General: Alert, oriented, no acute distress
HEENT: Mild sclera icterus
Neck: Supple, no elevated JVP
CV: RRR, normal S1/S2, no murmurs/rubs/gallops
Resp: CTAB, no crackles or wheezes
Abdomen: Soft, non-tender, non-distended, no rebound tenderness
or guarding, no organomegaly, +BS
Ext: Warm, well perfused, 2+ pulses distally
Pertinent Results:
[**2161-11-17**] 05:00AM BLOOD WBC-6.1 RBC-3.22* Hgb-10.0* Hct-28.6*
MCV-89 MCH-31.3 MCHC-35.2* RDW-16.8* Plt Ct-103*
[**2161-11-13**] 03:51AM BLOOD PT-15.8* PTT-27.1 INR(PT)-1.4*
[**2161-11-17**] 05:00AM BLOOD Glucose-78 UreaN-32* Creat-1.4* Na-140
K-4.4 Cl-102 HCO3-36* AnGap-6*
[**2161-11-17**] 05:00AM BLOOD ALT-42* AST-13 AlkPhos-58 TotBili-0.5
[**2161-11-16**] 06:10AM BLOOD Albumin-2.5* Calcium-8.1* Phos-3.2
Mg-1.5*
[**2161-11-17**] 05:00AM BLOOD tacroFK-11.2
Brief Hospital Course:
On [**2161-11-6**] he underwent liver [**Date Range **]. Surgeon was Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **]. Please see operative report for details. He had an
uncomplicated OR course. Two 19 [**Doctor Last Name 406**] drains were placed into
the retroperitoneum, one was placed around the right lobe of the
liver. The second behind the hilum. He received standard
induction immunosuppression. He was transferred to the SICU
postop where he was extubated on pod 1. He required FFP for
elevated INR. [**Doctor Last Name 406**] drains had high outputs of sanguinous fluid.
Hct dropped and PRBCs were given. A duplex US showed a small
perihepatic collection with normal vasculature. Hematocrit
stabilized.
Creatinine improved including LFTs with downward trend. Prograf
was started on pod 1 and adjusted daily per level. Solumedrol
was tapered per protocol to prednisone 20mg qd.
Diet was advanced and tolerated. He experienced some
hyperglycemia requiring sliding scale insulin. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consult
was obtained and NPH insulin was started in addition to the
sliding scale with improved control of blood sugars.
He was quite edematous and required IV lasix initially then
daily lasix with great diuresis. Lasix was stopped on [**11-17**]. The
lateral [**Doctor Last Name 406**] drain was removed and the medial [**Doctor Last Name 406**] drainage
decreased to ~ 500cc/day of serous fluid. This was left in place
at time of discharge.
An abdominal CT was done on [**11-13**] to assess for a perihepatic
hematoma. This revealed no significant perihilar fluid
collection identified. Small posterior
perihepatic collection abutting the diaphragm. Small bilateral
pleural effusions. Expected induration of the mesentery and
perihilar region. Moderate anasarca and mild periportal edema
and persistent splenic varices and splenomegaly.
PT was consulted and recommended rehab for deconditioning. He
was screen and accepted to [**Hospital **] Rehab Hospital. Vital signs
were stable and he was tolerating a regular diet at time of
discharge.
Medications on Admission:
Lasix 80mg PO daily
Amiloride 15mg PO daily
Lactulose 30mL PO TID
Rifaximin 400mg PO TID
Coumadin 3mg (M,Th), 4mg (Sun,Tu,Wed,Fri,Sat)
Ciprofloxacin 250mg PO daily
Omeprazole 20mg PO daily
Clotrimazole 10mg troche PO 5 times daily
Albuterol 1-2 puffs q6 prn
Combivent inhaler prn
Aspirin 81mg PO daily (has not started yet)
Allergies: Percocet, Aldactone
Discharge Medications:
1. Prednisone 5 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for Pain.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
5. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**1-21**]
Puffs Inhalation Q6H (every 6 hours) as needed.
6. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
13. Insulin NPH Human Recomb 100 unit/mL Suspension Sig:
Eighteen (18) units
units Subcutaneous once a day.
14. Insulin Lispro 100 unit/mL Solution Sig: follow sliding
scale Subcutaneous four times a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
HCV cirrhosis
HCC
s/p liver [**Hospital1 **]
hyperglycemia
Discharge Condition:
good
Discharge Instructions:
Please call the [**Hospital1 1326**] Office [**Telephone/Fax (1) 673**] if fever, chills,
nausea, vomiting, inability to take any of your medications,
abdominal pain, incision redness/bleeding/drainage or increased
output of JP drain fluid
Labs every Monday and Thursday with results fax'd to [**Telephone/Fax (1) 1326**]
Office [**Telephone/Fax (1) 697**]
Empty and record JP drain outputs and bring record to next
[**Telephone/Fax (1) 1326**] Office visit
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2161-11-26**] 2:50
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] CENTER (NHB)
Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2161-11-26**] 3:30
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2161-12-2**] 11:30
Completed by:[**2161-11-17**]
|
[
"276.2",
"456.8",
"070.54",
"E932.0",
"401.9",
"572.3",
"285.9",
"155.0",
"574.10",
"571.5",
"249.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.93",
"50.59"
] |
icd9pcs
|
[
[
[]
]
] |
7129, 7208
|
3329, 5452
|
299, 345
|
7311, 7318
|
2837, 3306
|
7824, 8320
|
2218, 2414
|
5859, 7106
|
7229, 7290
|
5478, 5836
|
7342, 7801
|
2429, 2818
|
242, 261
|
373, 930
|
952, 1847
|
1863, 2202
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,106
| 118,701
|
35652
|
Discharge summary
|
report
|
Admission Date: [**2186-2-14**] Discharge Date: [**2186-3-9**]
Date of Birth: [**2164-9-1**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1936**]
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
intraabdominal drain placed
History of Present Illness:
21 yr old female with very complicated PMHx including SLE with
nephritis, myopericarditis, embolic CVA, and recent disseminated
zoster who presents with seizure like activity today and
vomiting. Her course and presenting symptoms are as follows.
.
Admission [**Date range (2) 81121**] with 2 seizures characterized as
floating vision, left eye deviation, neck stiffening, and
rhythmic shaking. MRI infarct involving the right parietal,
occipital, and temporal lobes. Thought potentially
thromboembolic in the setting of lupus. Keppra initiated. During
this admission she had bacteremia, infected pleural effusion and
lupus myocarditis. She was given steroids, initiated on ASA and
coumadin.
.
Admission [**Date range (1) 81122**] with disseminated zoster and abdominal
abscesses with treatment with Acyclovir then to valacyclovir.
She was also found to have an intrabdominal fluid collection
with 212,000 WBCs, 98% PMNs treated with metronidazole and
ceftriaxone. Upper GI bleed during this admission likely due to
[**Doctor First Name **]-[**Doctor Last Name **] tear and an esophageal ulcer. Bactrim, cellcept,
aspirin and coumadin held.
.
Mother reports nausea with emesis after po intake since
discharge with increasing temperature to 99 at home. She did not
take her medications Friday and potentially the rest of the
weekend as she felt these were worsening her nausea and emesis.
Emesis was food products and then greenish bilious, no
hematemesis, no coffee ground. Mild cough and general malaise
and patient was sleeping throughout saturday. Around 7 pm mother
noticed daughter opening mouth with clenched jaw drooling. This
then resolved within seconds and repeatedly occured several more
times. No bowel or bladder incontinence and mother and daughter
report this was unlike her previous seizures.
.
In ED temp o 99.4, BP 128/102. 2 mg Ativan, 1 mg dilaudid given
after episode of what appeared to be a seizure with arm flexion.
Neurology [**Doctor Last Name 4221**] and recommended Keppra loading patient and
MRI/MRA/MRV to assess lesions in brain. No LP was ordered. On
floor temp to 101.
.
ROS: + mild nausea, mild headache, general malaise, cough, loose
stools and jaw clencing as above with jaw pain post.
Past Medical History:
-SLE diagnosed at age 15, multiple ICU admissions, 1st
pericardial effusion [**10-24**], has had previous tamponade, s/p
pericardial window x2
-Lupus nephritis: [**Month (only) **] biopsy - mixed membranous
glomerulonephritis stage 5
-Lupus induced myopericarditis
-History of pleural effusion
-Stroke: right parietal, occipital, and temporal lobes, left
cerebellum and vermis
-Generalized tonic clonic seizures
-Recent admission to [**Hospital1 18**] for disseminated zoster and abdominal
abscess, also found to have non-bleeding [**Doctor First Name **]-[**Doctor Last Name **] tear and
esophageal ulcer with upper gastrointestinal bleed
Social History:
The patient previously was in college in [**State 5887**], but since
[**10-24**] has generally been hospitalized for this lupus flare. She
has lived with her mother since the recent discharge, and has
been receiving [**Year (2 digits) 269**] services. She denies cigarette, EtOH, or
illicit drug use.
Family History:
There is no family history of lupus, strokes, or seizures.
Physical Exam:
VS: 101, 117/78, 107, 18, 96% RA, 38.1 kg
GEN: chronically ill appearing cachectic female laying in bed
HEENT: EOMI, PERRL, sclera anicteric, MM dry
NECK: Supple, no neck stiffness
CV: Reg rate, III/VI Systolic EM left upper sternal border
CHEST: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABD: Soft, tender to deep palpation
EXT: 3+ edema at the ankle. Dry excoriated skin. pulses intact
SKIN: on examining buttock region 2 inch x 2 inch excoriated
circumferential lesion with adjacent hyperpigmented lesions.
NEURO: please see neuro note for detailed examination. In brief
sleepy but awakens to Alert, oriented x 3. Able to relate
history with some probing. Intermittently falls asleep(difficult
as patient given ativan and dilaudid) No dysarthria. Strength
[**2-19**] bilaterally. Sensation intact. No dysarthria. Unclear
[**Name2 (NI) 6954**]. Did not assess gait.
Pertinent Results:
[**2186-2-13**] 09:37PM BLOOD WBC-8.3# RBC-2.60* Hgb-7.5* Hct-21.7*
MCV-84 MCH-28.9 MCHC-34.6 RDW-17.3* Plt Ct-201
[**2186-2-14**] 05:02PM BLOOD WBC-19.5*# RBC-2.48* Hgb-7.0* Hct-20.7*
MCV-83 MCH-28.4 MCHC-34.0 RDW-17.5* Plt Ct-173
[**2186-2-15**] 02:16PM BLOOD WBC-20.5* RBC-3.89* Hgb-11.3* Hct-32.1*
MCV-82 MCH-29.0 MCHC-35.2* RDW-17.4* Plt Ct-100*
[**2186-2-16**] 03:31AM BLOOD WBC-28.6* RBC-4.19* Hgb-12.3 Hct-34.4*
MCV-82 MCH-29.3 MCHC-35.7* RDW-17.7* Plt Ct-103*
[**2186-2-20**] 06:15AM BLOOD WBC-7.5 RBC-2.99* Hgb-8.7* Hct-24.6*
MCV-82 MCH-29.1 MCHC-35.5* RDW-18.1* Plt Ct-43*
[**2186-2-25**] 06:29AM BLOOD WBC-10.8 RBC-3.60* Hgb-10.5* Hct-28.4*
MCV-79* MCH-29.1 MCHC-36.9* RDW-18.0* Plt Ct-86*
[**2186-3-3**] 05:07AM BLOOD WBC-10.6 RBC-3.25* Hgb-9.8* Hct-26.1*
MCV-80* MCH-30.1 MCHC-37.4* RDW-17.4* Plt Ct-78*
[**2186-3-5**] 06:16AM BLOOD WBC-9.4 RBC-2.97* Hgb-8.6* Hct-24.3*
MCV-82 MCH-29.1 MCHC-35.5* RDW-18.2* Plt Ct-95*
[**2186-2-13**] 09:37PM BLOOD Neuts-73.2* Bands-0 Lymphs-22.6 Monos-2.9
Eos-0.7 Baso-0.7
[**2186-2-15**] 02:50AM BLOOD Neuts-96.4* Lymphs-2.2* Monos-1.1*
Eos-0.1 Baso-0.2
[**2186-2-13**] 09:37PM BLOOD Plt Ct-201
[**2186-2-14**] 05:30AM BLOOD PT-13.8* PTT-43.0* INR(PT)-1.2*
[**2186-2-16**] 03:31AM BLOOD Plt Smr-LOW Plt Ct-103*
[**2186-2-18**] 06:50AM BLOOD PT-14.5* PTT-45.6* INR(PT)-1.3*
[**2186-2-25**] 06:29AM BLOOD Plt Ct-86*
[**2186-3-3**] 05:07AM BLOOD Plt Ct-78*
[**2186-3-4**] 05:37AM BLOOD Plt Ct-98*
[**2186-2-14**] 06:18PM BLOOD Thrombn-13.9*
[**2186-2-14**] 06:18PM BLOOD Fibrino-237#
[**2186-2-15**] 02:50AM BLOOD Fibrino-264
[**2186-2-14**] 05:30AM BLOOD Ret Aut-3.0
[**2186-2-21**] 06:27AM BLOOD Ret Aut-1.0*
[**2186-2-24**] 05:29AM BLOOD Ret Aut-0.6*
[**2186-2-14**] 06:18PM BLOOD ACA IgG-9.6 ACA IgM-11.2
[**2186-2-14**] 06:18PM BLOOD Inh Scr-NEG
[**2186-2-13**] 09:37PM BLOOD Glucose-74 UreaN-6 Creat-0.6 Na-132*
K-3.4 Cl-102 HCO3-23 AnGap-10
[**2186-2-20**] 06:15AM BLOOD Glucose-62* UreaN-20 Creat-0.9 Na-137
K-3.0* Cl-114* HCO3-19* AnGap-7
[**2186-3-5**] 06:16AM BLOOD Glucose-94 UreaN-14 Creat-0.5 Na-136
K-4.2 Cl-112* HCO3-19* AnGap-9
[**2186-2-19**] 06:17AM BLOOD Lipase-40 GGT-278*
[**2186-2-20**] 06:15AM BLOOD Lipase-47 GGT-238*
[**2186-2-13**] 09:37PM BLOOD Calcium-7.1* Phos-3.9# Mg-1.5*
[**2186-3-5**] 06:16AM BLOOD Calcium-7.8* Phos-2.5* Mg-1.7
[**2186-2-14**] 05:30AM BLOOD Hapto-170
[**2186-2-14**] 05:30AM BLOOD D-Dimer-[**2136**]*
[**2186-2-14**] 06:18PM BLOOD Cryoglb-NEGATIVE
[**2186-2-20**] 03:18PM BLOOD Hapto-59
[**2186-2-21**] 06:27AM BLOOD Hapto-41
[**2186-2-24**] 05:29AM BLOOD Hapto-<20*
[**2186-2-25**] 06:29AM BLOOD calTIBC-83* VitB12-919* Folate-8.5
Ferritn-GREATER TH TRF-64*
[**2186-2-14**] 06:18PM BLOOD C3-LESS THAN C4-14
[**2186-2-22**] 06:35AM BLOOD C3-21* C4-12
[**2186-3-1**] 09:21AM BLOOD C3-23* C4-10
[**2186-2-14**] 05:02PM BLOOD B-GLUCAN-Test
[**2186-2-14**] 05:02PM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-
TEST
[**2186-3-2**] 12:02PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2186-2-14**] 11:32AM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-SM
[**2186-2-14**] 11:32AM URINE RBC-0-2 WBC-[**1-19**] Bacteri-FEW Yeast-MOD
Epi-0
[**2186-3-2**] 12:02PM URINE RBC-16* WBC-1 Bacteri-NONE Yeast-MANY
Epi-0
[**2186-2-14**] 11:32AM URINE Hours-RANDOM Creat-62 TotProt-201
Prot/Cr-3.2*
[**2186-2-25**] 09:48PM URINE Hours-RANDOM Creat-30 TotProt-567
Prot/Cr-18.9*
[**2186-2-16**] 07:57AM ASCITES WBC-[**Numeric Identifier 81123**]* RBC-[**Numeric Identifier 81124**]* Polys-94*
Lymphs-1* Monos-1* Macroph-4*
Culture data
[**2-14**] Blood cultures x3 negative
[**2-14**] CSF culture
[**2186-2-14**] 9:00 am CSF;SPINAL FLUID TUBE 3.
GRAM STAIN (Final [**2186-2-14**]):
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..
FLUID CULTURE (Final [**2186-2-17**]): NO GROWTH.
VIRAL CULTURE (Preliminary): No Virus isolated so far.
[**2-14**] Urine culture
[**2186-2-14**] 11:32 am URINE Source: CVS.
**FINAL REPORT [**2186-2-16**]**
URINE CULTURE (Final [**2186-2-16**]):
PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 2 S
CIPROFLOXACIN--------- 1 S
GENTAMICIN------------ <=1 S
MEROPENEM------------- 4 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
[**2-15**] Blood culture negative. Mycolytic bottle negative.
[**2-23**], [**2-24**] blood cultures negative
[**2-16**] Peritoneal fluid
[**2186-2-16**] 7:57 am PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final [**2186-2-16**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2186-2-19**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2186-2-22**]): NO GROWTH.
FUNGAL CULTURE (Final [**2186-3-3**]): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2186-2-17**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
[**2-13**] EKG
Baseline artifact. Predominantly regular rhythm. Borderline low
voltage.
Since the previous tracing of [**2186-1-17**] precordial leads may be
unchanged.
Suggest repeat tracing and clinical correlation.
Read by: [**Last Name (LF) **],[**First Name3 (LF) 900**] A.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
91 176 74 374/428 10 4 38
[**2-14**] Echo
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Left ventricular systolic
function is hyperdynamic (EF>75%). The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. The pulmonary artery systolic pressure
could not be determined. There is a small to moderate sized
pericardial effusion. The effusion appears circumferential. The
effusion is echo dense, consistent with blood, inflammation or
other cellular elements. There are no echocardiographic signs of
tamponade. No right atrial or right ventricular diastolic
collapse is seen.
Compared with the findings of the prior study (images reviewed)
of [**2186-1-18**], the pericardial effusion appears somewhat
smaller.
[**2-15**] CT Chest/Abdomen/Pelvis
IMPRESSION:
1. Reaccumulation of U-shaped abdominal fluid collection with an
enhancing
rim. Given the prior sterile aspirations of this collection,
this collection
may relate to the patient's lupus. The rim-enhancement is
non-specific given
the history of drainage catheters within the collection. If
aspiration is
performed, the fluid could be sent for autoimmune markers.
2. No evidence of pulmonary embolism.
3. Large pericardial effusion, most of which has not been
previously imaged
making comparison difficult. New severe anasarca and mesenteric
fluid.
3. Left lower lobe atelectasis, though infection cannot be
excluded.
4. Marked submucosal edema within the stomach, which may be
secondary to
lupus vasculitis or third spacing.
5. Newly developed gallbladder sludge.
[**2-15**] MR head/ MRA/MRV
IMPRESSION:
1. Compared to prior exam from [**2185-12-8**], there is new
uniform
pachymeningeal thickening and enhancement which is a nonspecific
finding and
can be seen with lumbar puncture. Recommend clinical
correlation. No
hemorrhage or new infarct.
2. Subcutaneous fluid collection at the vertex, for which
correlation with
physical exam is recommended.
3. Normal MRA and MRV.
Peritoneal fluid cytology:
NEGATIVE FOR MALIGNANT CELLS.
[**2-16**] CT guided drainage of intraabdominal fluid collection
IMPRESSION:
1. Successful CT-guided percutaneous abdominal collection
drainage with
catheter placement.
2. Extensive anasarca.
[**2-17**] CT L-spine
IMPRESSION:
1. Limited examination, with no evidence of epidural or subdural
hematoma in
the lumbar spine.
2. Evidence of both delayed and vicarious excretion of contrast
material,
likely related to [**Month/Day (4) **] insufficiency, which should be
correlated clinically.
[**2-18**] CXR
IMPRESSION: Effusions bilaterally, atelectasis on the left and
possible early
pneumonia at the right lower lobe; followup recommended.
[**2-19**] EKG
Sinus bradycardia. The Q-T interval is prolonged. Generalized
low voltage.
Non-specific ST-T wave changes. There is a late transition
consistent with
possible prior anterior myocardial infarction. Compared to the
previous
tracing the rate is slower, the Q-T interval is longer and
abnormal transition
is new.
Read by: [**Last Name (LF) 2194**],[**First Name3 (LF) **] H.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
46 166 76 558/533 -3 -22 69
[**2-23**] CT head
IMPRESSION:
1. No acute intracranial hemorrhage or mass effect.
2. Hypodense areas, noted in bifrontal white matter,
parasagiital cortex
at vertex, left parietal lobe (series 3, image 17) are of
uncertain nature.
Further evaluation, with MR can be considered for better
assessment, as there
is no prior CT study to assess the significance of these
findings. No
abnormality on the prior MRI was noted in these locations.
3. Punctate calcifications in the parotid/ adjacent soft
tissues-
incompletely imaged.
[**2-24**] Echo
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF 60%). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
The estimated pulmonary artery systolic pressure is normal.
There is a moderate to large sized pericardial effusion.
Stranding is visualized within the pericardial space c/w
organization. There are no echocardiographic signs of tamponade.
No right atrial or right ventricular diastolic collapse is seen.
Compared with the findings of the prior study (images reviewed)
of [**2186-2-14**], the pericardial effusion is significantly more
voluminous.
[**2-24**] MR head, MRA, MRV
IMPRESSION:
Findings most suggestive of PRES bilaterally. Less likely these
findings
could be post ictal.
No evidence for acute ischemia.
No evidence for dural venous sinus thrombosis.
Mild vascular irregularity on the MRA, which is unchanged, may
be related to
Lupus .
[**2-28**] EKG
Cardiology Report ECG Study Date of [**2186-2-28**] 12:28:04 AM
Sinus bradycardia
Low precordial lead QRS voltages
Prolonged Q-Tc interval
Diffuse T abnormalities
These findings are nonspecific but clinical correlation is
suggested
Since previous tracing of [**2186-2-22**], sinus bradycardia and further
ST-T wave
changes are now present
Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
48 150 68 536/515 24 -13 158
[**2-28**] Echo
IMPRESSION: Moderate pericardial effusion with stranding.
Preserved biventricular regional and global systolic function.
Mild mitral and trivial aortic regurgitation.
Compared with the prior study (images reviewed) of [**2186-2-24**],
the effusion is slightly smaller in size. Aortic regurgitation
was present on the prior study but not commented upon.
Brief Hospital Course:
21 yo F with SLE complicated by myopericarditis, tamponade,
nephritis, CVA, pleural effusions, intraperitoneal hemorrhage
who was recently admitted [**Date range (1) 81125**] with disseminated zoster,
intraabdominal abscess, Upper GI bleed secondary to esophageal
ulcer who presented [**2-13**] with jaw clenching and right arm
twitching concerning for seizure activity. In the ER was
admitted after Keppra load. Was febrile on the floor and an LP
was done which showed WBC 1. She was tachycardic to 150s on the
floor, febrile to 101 and BP 90s systolic. Given concern for
hemodynamic stability she was transferred to the ICU.
In the ICU, had echo which showed recurrent effusion but no
tamponade. Treated with vancomycin, zosyn, and flagyl and given
IV solumedrol for question of adrenal insufficiency. CT torso
showed recurrence of abdominal fluid collection, which had been
drained on prior admit. IR drain placed [**2-16**]. She responded well
to IVF resuscitation with resolution of her tachycardia.
1. Sepsis
Suspected intrabdominal source given recurrent intrabdominal
fluid collection seen on CT, now s/p IR drainage. Urinary
source possible given Pseudomonas, but she did not have any
significant pyuria arguing against a cystitis. Infectious
disease was [**Month/Day (2) 4221**]. The patient was maintained on Vancomycin
and Zosyn. After 2 weeks of Vancomycin this was discontinued,
and Zosyn was continued. Repeat CT showed resolving
intraabdominal fluid collection. All cultures negative to date.
Infectious disease recommends continuing Zosyn for 14 day course
after intraabdominal drain is removed.
Radiology recommended keeping the drain in place for one month
(until [**3-18**]). Then it will need to be clamped. A repeat
abdominal CT will be needed at that time to assess the fluid
collection. Only after this CT is evaluated will the drain be
removed.
2. SLE: Rheumatology was [**Month (only) 4221**]. The patient was maintained
on IV solumedrol 30mg IV bid and hydroxychloroquine. She
received one dose of cytoxan on [**3-3**] and tolerated this well.
Given prolonged immunosuppression, she was started on Bactrim
for PCP [**Name Initial (PRE) 1102**].
.
3. Seizures: Patient had GTC seizure [**2-23**], while on keppra.
Neurology was reconsulted. Keppra dose was increased to 1g IV
q12h. Patient has history of stroke. Not anticoagulated [**12-19**]
upper GI bleed. MRI concerning for PRES. Given that patient is
without further seizures, neuro exam nonfocal, plan for repeat
MRI in 4 weeks (mid-[**Month (only) 116**]) to eval resolution of PRES, per
neurology recommendations.
.
4. Anemia with history of upper GI Bleed: HCT was checked daily,
and the patient was transfused to keep HCT > 24. She was
continued on [**Hospital1 **] PPI. She had CT abdomen done to ensure that
she was not bleeding around her abdominal drain, which she was
not.
.
5. Thrombocytopenia: - Platelets down >50% from admission,
likely due to consumption in setting of infection or SLE. PF4
negative [**11-25**]. No active signs of bleeding. Heparin was held
even after repeat PF4 was negative. Patient received IVIG on [**2-19**]
and [**2-20**], per rheumatology recommendations given that this may
have been ITP. Platelets were monitored daily.
.
6. Rash: Erythematous, desquamating rash over face, trunk, and
extremities. Dermatology was [**Month/Day (4) 4221**]. Thought to be drug
reaction, potentially secondary to Zosyn. No eosinophilia. No
mucous membrane involvement. Given that she's asymptomatic,
without pain or itchiness, she was not treated for this.
.
.
7. Pericardial effusion: Echo from [**2-24**] shows large pericardial
effusion with organization. Patient was always hemodynamically
stable. Repeat echo showed persistent, organizing effusion.
Cardiothoracic surgery was [**Month/Year (2) 4221**]. They are considering
pericardial stripping as an outpatient after SLE flair better
controlled. Cardiology has recommended repeat echo in 4 weeks
and outpatient cardiology follow up. Pulsus was checked daily,
and was never widened.
.
8. Severe back pain: Patient complained of lower back pain, and
attributed this to post-LP. CT spine showed no evidence of
hematoma. MRI showed no signs of cord compression. Neuro exam
non focal. Pain was controlled with PRN morphine. Pain resolved
on its own.
.
FEN regular. Encourage po with supplemental shakes.
Access PICC line placed [**3-5**]
PPX PPI, pneumoboots.
Medications on Admission:
1.Levetiracetam 250 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
2.Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3.Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4.Metoprolol Tartrate 25 mg Tablet Sig: 0.5 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).
6.Citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
7.Prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day
8.Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9.Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
10.Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain: [**Month (only) 116**] cause drowsiness, please do not
operate any vehicles or heavy machinery.
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.Citracal + D 315-200 mg-unit Tablet Sig: Two (2) Tablet PO
twice a day: Please take at a different time to your
Hydroxychloroquine
Discharge Medications:
1. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
3. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
4. Clobetasol 0.05 % Ointment Sig: One (1) Appl Topical PRN (as
needed) as needed for itching.
5. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for anxiety.
9. LeVETiracetam 1,000 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours).
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
12. Prochlorperazine Edisylate 5 mg/5 mL Syrup Sig: One (1)
teaspoon PO Q6H (every 6 hours) as needed for nausea.
13. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
14. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback
Sig: One (1) piggyback Intravenous Q8H (every 8 hours): Continue
until 2 weeks after abdominal drain is removed.
15. Insulin Lispro 100 unit/mL Solution Sig: see below units
Subcutaneous ASDIR (AS DIRECTED): Please follow sliding scale.
16. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
17. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary diagnosis:
1. Lupus exacerbation
2. Sepsis secondary to intraabdominal fluid collection
3. Pericardial effusion
4. Posterior reversible encephalopathy syndrome
5. Decubitus ulcer
6. Microcytic anemia
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with seizures. You were transferred to the
ICU because your blood pressure was low, and your heart rate was
high. You were found to have an intraabdominal fluid collection,
that was drained. You will need to have this drain in place
atleast until early [**Month (only) 116**]. You were treated will antibiotics for
potential infection in your abdomen.
We treated your lupus with IV and po steroids. You also received
a dose of cytoxan.
You had seizures while you were in the hospital, and kept on
anti-seizure medications. You will need to follow up with
neurology.
Your blood counts were persistently low. You received some blood
transfusions for this.
You have fluid around your heart. You will need to follow up
with Cardiology and Cardiac surgery.
If you develop fevers, lightheadedness, chest pain, shortness of
breath, abdominal pain, or any other symptoms that concern you
please call your primary care doctor or go to the emergency
department.
Followup Instructions:
You have the following appointments scheduled:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2186-3-10**] 9:00
MD: Dr. [**First Name (STitle) 20862**] [**Name (STitle) 20863**]
Specialty: Rheumatology
Date and time: Thursday, [**3-23**]@ 11:30AM
Location: [**Last Name (NamePattern1) 439**], [**Hospital Ward Name **] Office Medical Bldg., [**Hospital Unit Name **]
Phone number: [**Telephone/Fax (1) 2226**]
Appointment #2
MD: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 914**]
Specialty: Cardiac Surgery
Date and time: Tuesday, [**3-21**] @ 1pm
Location: [**Last Name (NamePattern1) 439**], [**Hospital Ward Name **] Office Medical Bldg., [**Hospital Unit Name **]
Phone number: [**Telephone/Fax (1) 170**]
Appointment #3
MD: Dr. [**First Name4 (NamePattern1) 8516**] [**Last Name (NamePattern1) **]
Specialty: Cardiology
Date and time: Tuesday, [**3-23**] @ 9AM
Location: [**Hospital Ward Name 23**] Bldg. 7th [**Last Name (un) 5355**]
Phone number: [**Telephone/Fax (1) 62**]
MD: Dr. [**First Name (STitle) **] [**Name (STitle) **]
Specialty: Infectious Disease
Date and time: Wednesday, [**3-29**] @1:30PM
Location: [**Last Name (NamePattern1) 439**], [**Hospital Ward Name **] Office Medical Bldg., [**Apartment Address(1) **] GB
Phone number: [**Telephone/Fax (1) 457**]
Please make an appointment to see your primary care doctor after
you are discharged from rehab.
Completed by:[**2186-3-9**]
|
[
"112.0",
"785.52",
"567.22",
"300.4",
"041.7",
"285.29",
"585.9",
"707.03",
"583.81",
"423.9",
"710.0",
"338.19",
"287.31",
"345.10",
"348.39",
"599.0",
"038.9",
"707.22",
"995.92",
"276.2",
"707.04",
"693.0",
"053.9",
"V58.65",
"287.4",
"403.90",
"276.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"38.93",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
23544, 23616
|
16225, 20675
|
321, 350
|
23868, 23877
|
4606, 10040
|
24898, 26425
|
3599, 3659
|
21881, 23521
|
23637, 23637
|
20701, 21858
|
23901, 24875
|
3674, 4587
|
10074, 16202
|
274, 283
|
378, 2601
|
23656, 23847
|
2623, 3265
|
3281, 3583
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,130
| 114,902
|
55080
|
Discharge summary
|
report
|
Admission Date: [**2194-9-22**] Discharge Date: [**2194-10-8**]
Date of Birth: [**2149-12-3**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Neck pain with upper and lower extremity weakness
Major Surgical or Invasive Procedure:
Anterior fusion C4-7 with C5 and C6 corpectomy
PEG and Tracheotomy
History of Present Illness:
44F status post diving accident found to have C4,5,6 fracture.
Patient dove into a shallow sand bar hitting her head. Patient
was unable to move extremities at the scene. +EtOH
Past Medical History:
PMH: GERD, anxiety
PSH: L5 discectomy? [**2192**]
Social History:
+ EtOH
Family History:
N/C
Physical Exam:
T98 HR 70 BP 80/60 RR14 Sat 98%
A&O x 3. Calm and comfortable.
BUE skin clean and intact. No tenderness, deformity, erythema,
edema, induration or ecchymosis. 1+ radial pulses
Midline Tenderness over cervical spine.
RUE:
elbow flex [**4-24**]
elbow extension [**3-24**]
wrist flexion [**1-23**]
wrist extension [**1-23**]
finger abduction [**1-23**]
finger flexion [**1-23**]
LUE:
elbow flex [**4-24**]
elbow extension [**3-24**]
wrist flexion [**1-23**]
wrist extension [**1-23**]
finger abduction [**1-23**]
finger flexion [**1-23**]
RLE:
hip flexion 0/5
knee flexion 0/5
knee extension 0/5
Toe extension [**1-23**]
plantar flexion [**1-23**]
LLE
hip flexion 0/5
knee flexion 0/5
knee extension 0/5
Toe extension [**1-23**]
plantar flexion [**1-23**]
No rectal tone.
C4 Sensory level: No light touch sensation below clavicle
Pertinent Results:
[**2194-9-23**] 05:00AM BLOOD WBC-16.5* RBC-3.72* Hgb-10.9* Hct-32.7*
MCV-88 MCH-29.2 MCHC-33.2 RDW-14.1 Plt Ct-227
[**2194-9-22**] 10:45PM BLOOD WBC-12.0* RBC-3.99* Hgb-11.9* Hct-35.2*
MCV-88 MCH-29.8 MCHC-33.8 RDW-14.0 Plt Ct-240
[**2194-9-22**] 03:20PM BLOOD WBC-10.7 RBC-4.32 Hgb-12.6 Hct-37.6
MCV-87 MCH-29.2 MCHC-33.5 RDW-14.1 Plt Ct-236
[**2194-9-23**] 05:00AM BLOOD Glucose-152* UreaN-9 Creat-0.5 Na-135
K-4.6 Cl-105 HCO3-22 AnGap-13
[**2194-9-25**] 11:20PM BLOOD WBC-13.4* RBC-2.91* Hgb-8.6* Hct-25.5*
MCV-88 MCH-29.5 MCHC-33.7 RDW-13.9 Plt Ct-279
[**2194-9-25**] 11:20PM BLOOD Glucose-126* UreaN-7 Creat-0.5 Na-138
K-3.9 Cl-100 HCO3-30 AnGap-12
Brief Hospital Course:
The patient was admitted to the [**Hospital1 18**] Spine Surgery Service on
[**2194-9-22**] and taken to the Operating Room for an anterior cervical
fusion C4-7 with C5 and C6 corpectomy. The surgery was without
complication and the patient was transferred to the TICU in a
stable condition. TEDs/pnemoboots were used for postoperative
DVT prophylaxis. Intravenous antibiotics were given per standard
protocol. Initial postop pain was controlled with a PCA. On HD#2
she returned to the operating room for a scheduled C3-7
decompression and fusion as part of a staged 2-part procedure.
Please refer to the dictated operative note for further details.
The second surgery was also without complication and the patient
was transferred to the PACU in a stable condition. Postoperative
HCT was stable. She was kept NPO until bowel function returned
then diet was advanced as tolerated. The patient was
transitioned to oral pain medication when tolerating PO diet.
Foley was removed on POD#2 from the second procedure. She was
fitted with a hard collar for ambulation. Physical therapy was
consulted for mobilization out of bed.
Unfortunately, her respiratory status worsened on the evening of
[**9-25**] and she required. She underwent a PEG and Tracheotomy [**10-2**].
An IVC filter was placed for pulmonary embolic prophylaxis on
[**10-4**]. She remained on mechanical ventilation with pressure
support through the tracheostomy. A passy-muir valve trial was
attempted, but the patient was unable to tolerate it. Social
Work was consulted and provided personal and family support
throughout her hospital stay. Hospital course was otherwise
unremarkable. On the day of discharge the patient was afebrile
with stable vital signs. She will be transported by ambulance to
[**Hospital3 **] center in [**Location (un) 86**]. Fnal neurological
diagnosis is C5 [**First Name7 (NamePattern1) 8489**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] cord injury with resulting
tetraparesis. Prior to discharge, slight fasiculations were
noted in the toes. Social Work and attending physicians answered
all questions and the patient and family expressed readiness for
discharge.
Medications on Admission:
1. Ranitidine 75 mg PO DAILY
2. Sertraline 50 mg PO DAILY
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain/fever
2. Acetylcysteine 20% 200-400 mg TT Q2H:PRN
3. Bisacodyl 10 mg PR DAILY constipation
4. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL [**Hospital1 **]
Use only if patient is on mechanical ventilation.
5. Docusate Sodium (Liquid) 100 mg PO BID constipation
6. Enoxaparin Sodium 30 mg SC Q12H
7. Guaifenesin [**5-29**] mL PO Q6H:PRN secretions
8. 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.
9. HYDROmorphone (Dilaudid) 2-4 mg PO Q3H:PRN pain
10. Lorazepam 0.5-1 mg IV Q4H:PRN anxiety
11. Midodrine 5 mg PO TID
12. Milk of Magnesia 30 mL PO Q6H:PRN constipation
13. Nystatin 500,000 UNIT PO Q8H
14. Senna 1 TAB PO BID constipation
15. 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.
16. 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.
17. Pantoprazole 40 mg PO Q24H
18. Sertraline 50 mg PO DAILY
19. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
C4/C5/C6 fractures
Partial paraplegia
Discharge Condition:
Good
Discharge Instructions:
You have undergone the following operation: ANTERIOR/POSTERIOR
Lumbar Decompression With Fusion
Immediately after the operation:
-Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit or stand
more than ~45 minutes without getting up and walking around.
-Rehabilitation/ Physical Therapy:
o2-3 times a day you should go for a walk for 15-30 minutes as
part of your recovery. You can walk as much as you can tolerate.
oLimit any kind of lifting.
-Diet: Eat a normal healthy diet. You may have some constipation
after surgery. You have been given medication to help with this
issue.
-Brace: You have been given a collar. This is to be worn when
you are walking. You may take it off when sitting in a chair or
while lying in bed.
-Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry then
you can leave the incision open to the air. Once the incision is
completely dry (usually 2-3 days after the operation) you may
take a shower. Do not soak the incision in a bath or pool. If
the incision starts draining at anytime after surgery, do not
get the incision wet. Cover it with a sterile dressing. Call the
office.
-You should resume taking your normal home medications. No
NSAIDs.
-You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
[**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
Activity: as tolerated
Cervical collar: when out of bed
Treatments Frequency:
Please continue to change the dressing daily.
Followup Instructions:
With Dr. [**Last Name (STitle) 363**] in 10 days
Completed by:[**2194-10-8**]
|
[
"E883.0",
"806.09",
"806.04",
"530.81",
"300.00",
"305.00",
"518.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.1",
"81.63",
"77.79",
"80.99",
"43.11",
"96.04",
"81.03",
"96.72",
"84.52",
"03.09",
"84.51",
"81.02",
"38.97",
"03.53",
"38.7"
] |
icd9pcs
|
[
[
[]
]
] |
5757, 5827
|
2264, 4444
|
326, 394
|
5909, 5916
|
1584, 2241
|
8039, 8119
|
715, 720
|
4553, 5734
|
5848, 5888
|
4470, 4530
|
5940, 6039
|
735, 1565
|
7884, 7947
|
7969, 8016
|
6075, 6268
|
237, 288
|
6304, 6754
|
6766, 7866
|
423, 601
|
623, 675
|
691, 699
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,969
| 174,918
|
40955
|
Discharge summary
|
report
|
Admission Date: [**2106-6-18**] Discharge Date: [**2106-8-12**]
Date of Birth: [**2026-6-18**] Sex: M
Service: MEDICINE
Allergies:
Iodine / Crestor / lisinopril
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
New metastatic cancer to spine found on outside MRI
Major Surgical or Invasive Procedure:
Ortho Surgery #1 [**6-21**]:
1. L3 bilateral hemilaminectomy.
2. L4 laminectomy for biopsy of neoplasm.
3. Open treatment lumbar fracture, posterior.
4. Posterolateral fusion L3-L4, L4-L5.
5. Posterior spinal instrumentation L3-L5.
6. Iliac crest bone graft harvest for fusion augmentation.
7. Allograft for fusion augmentation.
8. Deep muscle open biopsy.
9. Open biopsy deep bone.
Ortho Surgery #2 [**7-20**]:
1. L4 corpectomy.
2. L3 partial vertebral body resection for lesion.
3. Application of interbody device L3-L5.
4. L3-L4 anterior fusion.
5. L4-L5 anterior fusion.
6. Allograft for fusion augmentation.
NGT placement x 3
Chest Tube Placement
EGD with balloon dilation of duodenal stricture
PICC placement
Anoscopy
History of Present Illness:
80 yo m with hx MVR bioprosthetic, AF on coumadin, 1 month hx of
left shoulder and side pain, presents after MRI today noted what
looked like mets cancer at T1, T2, and T3. He was called by his
physician who asked him to come to ED at [**Hospital1 18**] for specialty
evaluation. Pt reports being in usoh when he began to have L
upper chest pain with coughing about 4 weeks ago. 2 weeks ago
noticed left shoulder and scapula pain, as well as left
arm/elbow pain. In context of all of this he had recent surgery
in [**11/2105**] for MVR, and had 30 lbs weight loss and early satiety
since. He has undergoing several EGDs which have demonstrated a
short duodenal stricture. This has been dilated x 2 and
biopsied with results c/w peptic stricture; benign w/o
malignancy. EUS performed end of [**2106-4-23**] by Dr. [**Last Name (STitle) 26064**] at
[**Hospital1 112**] showed benign stricture. He also had Abd CT w/o contrast
[**2106-4-1**] which showed narrowing of post-bulbar duodenum
(stricture as above), with cystic lesion at L4. Because of the
latter, he underwent bone scan [**2106-4-1**] which was negative. MRI
cervical spine was reportedly performed today in [**Location (un) 1411**] w/o
gadolinium and showed Thoracic lesions above. However, we do
not have report nor images of this.
Pt denies fevers, abd pain, diarrhea, or night sweats. No
problems with urination. He reports colonoscopy 4 months ago at
[**Hospital1 882**], which was normal. We do not have this report. He
reports yearly prostate exam which has been normal. No other
localizing complaints. He did have a past basal cell carcinoma
which was removed 20 years ago and has not been a problem since.
Past Medical History:
ESOPHAGEAL REFLUX
OBESITY
SLEEP APNEA
ISCHEMIC HEART DISEASE - OTHER CHRONIC
AMNESIA/MEMORY DISORDER [**2102-6-21**]
BACK PAIN
HYPERLIPIDEMIA
PULMONARY NODULE/LESION, SOLITARY [**2104-7-16**]
MACROCYTOSIS WITHOUT ANEMIA [**2105-4-20**]
S/P MITRAL VALVE REPLACEMENT [**2106-2-26**]
ATRIAL FIBRILLATION [**2106-3-30**]
ANTICOAGULANT LONG-TERM USE [**2106-3-30**]
Past Surgical History:
Pilonidal cyst surgery x 2 [Other] [**2048**],[**2050**]
Left shoulder, right elbow,right wrist x2; rig*
TONSILLECTOMY & ADENOIDECTOMY
Lumbar rhizotomy [Other] [**2099**]
right shoulder surgery [Other] [**2078**]
right carpal tunnel surgery [Other] [**2092**]
both thumb surgery [Other] 99 - [**2096**]
VASECTOMY [**2072**]
RT SHOULDR ACRIOMPLASTY [Other] [**2102-11-28**]
right tennnis elbow surgery [Other] [**2073**]
left shoulder surgery [Other] [**2091**]
mitral valve replacement [Other] [**11/2105**]
Dr [**Last Name (STitle) 1537**] - B/W - bovine valve
Social History:
Pt is married with 2 children. Past pipe smoker, but quit in
[**2062**]. Three [**1-24**] glasses of wine per week. No drug use.
Family History:
Father - progressive supranuclear palsy. Mother - CHF. [**Name2 (NI) **]
cancers.
Physical Exam:
Admission Exam:
Vitals: 96.5, 124/72, 93, 18, 99% RA
Gen: Pleasant, NAD.
HEENT: No OP erythema or exudate. No scleral icterus.
Pulm: CTA B.
Heart: RRR. No m/r/g.
Abd: +BS. NTND. No HSM.
Rectal: Prostate without clear mass, although there did seem to
be some slight irregularity of unclear significance.
Ext: No c/c/e.
Discharge Exam:
Vitals: 99.2 122/70 88 22 96%
Gen: fatigued, no acute distress
HEENT: MMM, anicteric, no lymphadenopathy
CV: RRR, 3/6 systolic murmur
Lungs: Clear bilaterally
Abd: soft, non-tender, non-distend, hyperactive bowel sounds,
midline incision well-healing
Ext: no CCE, rash on lower legs c/w tinea
Back: deep tissue injury to left buttock
Pertinent Results:
Admission Labs:
138 103 14 105 AGap=10
---------------
4.1 29 0.7
Ca: 8.9 Mg: 2.0 P: 3.7
6.1 > 38.6 < 238
N:64.3 L:27.3 M:4.3 E:3.1 Bas:0.9
On discharge:
[**2106-8-12**] 05:27AM BLOOD WBC-7.4 RBC-2.73* Hgb-9.1* Hct-27.1*
MCV-99* MCH-33.3* MCHC-33.5 RDW-20.6* Plt Ct-176
[**2106-8-2**] 03:13AM BLOOD PT-15.5* INR(PT)-1.4*
[**2106-8-12**] 05:27AM BLOOD Glucose-101* UreaN-16 Creat-0.6 Na-140
K-3.7 Cl-107 HCO3-28 AnGap-9
[**2106-7-28**] 07:55AM BLOOD ALT-7 AST-42* AlkPhos-134* TotBili-0.5
[**2106-8-11**] 05:31AM BLOOD Calcium-7.1* Phos-3.0 Mg-1.8
[**2106-8-8**] 04:38PM BLOOD freeCa-1.21
Video Swallow Evaluation [**2106-8-10**]:
Mr. [**Known lastname **] presented with a moderate oropharyngeal dysphagia
as
characterized above with penetration of thin liquids,
nectar-thick liquids, and ground solid. Pt also had trace
aspiration of thin and nectar-thick liquids with one episode of
significant aspiration with large consecutive sips of thin
liquids. Pt had a spontaneous throat clear in response to
penetration which was moderately effective for clearing the
airway, more so with nectar-thick liquids than with thin
liquids.
RECOMMENDATIONS:
1. PO diet: nectar-thick liquids, pureed solids.
2. PO meds crushed with applesauce.
3. 1:1 supervision to maintain strict aspiration precautions
4. Small sips, ONE sip at a time.
5. TID oral care.
6. Agree with keeping NG tube in place until pt demonstrates
sufficient PO intake.
7. We will f/u later this week to evaluate for further upgrades.
Brief Hospital Course:
In Summary (please see below for more details):
80 yo m with hx MVR bioprosthetic, AF on coumadin, 1 month hx of
left shoulder and side pain, presents after MRI noted what
looked like mets cancer at T1, T2, and T3. Biopsy of the spine
identified multiple myeloma as the cause of the lytic lesions.
His hospital course has included:
- posterior lumbar fusions on [**2106-6-21**]
- Anterior lumbar fusion [**2106-7-20**]
- ileus and gastric outlet obstruction, requiring dilation
- acalculous cholecystitis and infectious pericholecystic fluid
- C difficile diarrhea
- right sided exudative pleural effusion s/p chest tube and
removal
- health care associate pneumonia (treated with
vanc/cefe/flagyl)
- sacral decubitus ulcer
On discharge, his condition has significantly improved. His
active problem list now includes:
- multiple myeloma: untreated, will likely start chemo soon
- nutrition: tolerating pureed and nectar diet, advance as
tolerated
- duodenal stricture: tolerating diet, GI will followup if
having difficulty with PO
- afib: in NSR during hospitalization, holding warfarin given
comorbidities
- sacral decub: needs wound care
- physical therapy
.
.
Hospital Course:
#) Multiple Myeloma: Pt presented initially with concern for
metastatic disease seen on outside MRI. He was found to have a
pathologic L4 fracture in need of stabilization and his multiple
myeloma was diagnosed via tissue pathology from posterior spine
stabilization on [**2106-6-21**]. Heme/Onc and Rad/Onc were aware of
patient but put further treatment or evaluation for multiple
myeloma on hold until more acute hospital issues are resolved
(see below). From the beginning family expressed desire to
pursue treatment of myeloma once patient able. Given his
improved medical status, he was transferred to rehab with
followup by the oncology there to consider therapy with decadron
and velcade. The family also opted for Dr. [**Last Name (STitle) **] [**Name (STitle) 2405**] as
their oncologist, and he can be reached at [**Telephone/Fax (1) 17667**]. Will
need pamidronate q4wks (1st dose was [**8-8**]).
.
#) Pathologic Spine Fracture:
Pt had lumbar instability due to L4 lytic lesion found
incidentally on initial MRI. Pt had no symptoms at time of this
discovery. Pt underwent L3-L4 bilateral hemilaminectomy with
posterolateral fusion of L3-L5 with iliac crest bone graft
harvest for fursion augmentation. Due to extent of metastatic
destruction, also needed second surgery for anterior spine
stabilization. On [**7-20**] patient went to OR and underwent anterior
fusion of L3-L5. He was transferred to the MICU post-op then
called out to the floor. On the floor he was helped out of bed
to chair without use of the brace.
.
#) Gastric Outlet Obstruction/Ileus:
Post operative ileus was present from date of initial spine
stabilization surgery. Pt also had known benign duodenal
stricture dilated x 4 at OSH ([**Hospital1 882**]/[**Hospital1 112**] - see Atrius records)
in [**Month (only) 547**]/[**Month (only) 116**]. He became acutely obstructed on [**2106-6-25**] with AXR
showing severe dilation of his stomach. An NGT placement yielded
1L bilious fluid. ERCP took to EGD later that day and performed
another balloon dilation of stricture. Afterward pt had some
improvement but over the next 10 days twice become more
distended and had NGTs placed twice with some bilious output
from the NGT and abdominal relief each time. Possible that the
2nd two events were due to total bowel distension and ileus [**2-24**]
to narcotics, Cdiff, immobility, and limited diet as much as a
problem with the duodenal stricture as they were not completely
relieved with NGT placement and abdominal imaging showed
persistently dilated bowel loops. After his anterior fusion,
abdomen remained distended possibly from gastric
obstruction/post-operative ileus/narcotic use. KUB showed no
signs of SBO. On POD4 he had 2BMs and he was started on clears
for diet. On the [**Hospital1 **], he was tolerating clear diet, moving
bowels reguarly. However there was concern for aspiration
pneumonia and patient was transferred to MICU for respiratory
distress. He was started on TPN in the MICU, and then
transitioned to tube feeds. He was transferred back to the floor
and TPN was discontinued. He continued on continuous tube feeds
until his mental status was improved, and then underwent another
video swallow eval. Recommendations from speech/swallow were to
start him on a pureed and nectar diet. He tolerated this well
without further abdominal distention, and the NG tube and tube
feeds were discontinued. He was discharged to rehab on the
pureed diet, which he was tolerating well.
.
#) Cdiff Infection:
Pt started developing leukocytosis with low grade temps on
[**2106-6-29**]. Was having very little stool but it was liquid and Cdiff
toxin sent on [**2106-6-30**] came back positive on [**2106-7-1**]. Pt had
already been started on metronidazole on [**6-30**] (along with CTX)
for emperic coverage of gallbladder. Initially WBC and exam
improved with this therapy but when WBC worsened again PO vanco
was added to metronidazole on [**2106-7-5**]. Bowel distension slowly
improved with this treatment and abdominal pain slowly resolved.
However, continued to have persistently dilated bowel loops as
noted above. Since pt was started on Cefepime/Vanco for HAP
coverage when transfered to the ICU initially and completed a 8
day course of this therapy, decision was made to extend PO
Vanco/IV metronidazole coverage to end [**7-27**]. PO Vanco was
restarted because of the high likelihood of recurrence. He
continued prophylactic PO vanco coverage until [**8-12**].
.
#) Poor respiratory status:
This was not present on hospital admission and CXR on [**2106-6-29**] had
no effusion but PICC confirmation CXR on [**7-2**] showed large
unilateral (right) effusion which had developed in the 3 day
interval. Pt had worsening of breathing status a day or two
before this was observed as well as discomfort in R side which
presumably was due to effusion although initially had been
attributed to either Cdiff or Choleystitis as both were being
evaluated at that time. Pt was doing okay on 2-3L NC but fluid
was not responding well to lasix when on the evening of [**7-5**] he
became acutely tachypnic and was transfered to the ICU where he
was briefly on BIPAP and CT surgery placed a chest tube with >1L
of output. Fluid studies boarderline exudate vs transudate and
cultures pending. Abx were broadened to cefepime and vancomycin
at time of unit transfer. Pt now with stabilized respiratory
status and has largely resolved effusion on f/u CXRs. Chest tube
removed today and pt doing well enough to call out to floor on
[**7-7**]. After arrival to the floor, stayed comfortable on RA-2L NC
with only minimal reaccumulation of R pleural effusion noted on
f/u CXRs. Completed 8 day course of Cefepime/IV Vancomycin as
noted above for presumed hospital acquired pneumonia and WBC
which had spiked up on day of hospital transfer trended down to
the normal range with these treatments. Pt returned to the OR on
[**7-20**] and remained intubated post-op. He was extubated on [**7-22**].
Since transfer to the [**Hospital1 **] on 06/31, he has remained tachypneic,
with RR rising upto 50. He was also tachycardic with HR up to
120. EKG was unchanged from previous, ABG shows alkolosis,
Multiple CXRs and MRI with contrast ([**7-29**]) showed only stable
atelectasis and stable right-sided pleural effusion, with no
evidence of pneumonia or PE. Started therapeutic heparin to
treat presumptive PE on [**7-28**]; He was not fluid overloaded and
did not improve w/ lasix. Given aspiration risk, pleural
effusion and previous HCAP, restarted IV vancomycin and cefipime
on [**7-29**] for 1 week. He was transferred out of the MICU on [**8-6**]
and continued to be tachypnic to high 20s, but respiratory
status was otherwise stable. His respiratory status continued
to improve and he was discharged with a RR ~20 on room air with
a normal oxygen saturation.
.
#) Question of Cholecystitis:
During time when pt initially developed leukocytosis, low grade
temps, and abd distension, concern developed about possible
gallbladder process. Abdominal CT had showed GB enlargement but
picture muddied by fluid around gallbladder from small amount of
ascites due to low albumin. Gallbladder U/S was non-diagnostic
so HIDA scan was obtained. This showed evidence of acute
cholecystitis with caveat that some question if could be falsely
positive in setting of NPO status. Due to concerns for risk of
perc cholecystostomy tube recommended by surgical service,
decision was made to initially treat with IV abx and pt had some
improvement. Development of R pleural effusion raised concern
again for GB process and resulting sympathetic effusion in right
lung. However, pt improved again with drainage of pleural
effusion and empiric treatment for hospital acquired pneumonia
and GI consulting service agreed that less likely pt had
cholecystitis in current setting although pt continued to remain
at very high risk for acalculous cholecystitis due to his
overall level of poor health.
.
#) Delirium:
Pt was intermittently delirious for 4-5 days after initial
ortho/spine surgery. This largely resolved in the following 10
days with pt only requiring a couple of doses of haldol (which
had only limited effect). Pt again started to become somewhat
confused on AM of [**2106-7-13**] which was attributed to multifactorial
delerium in an elderly, very sick patient who had been in the
hospital for almost 4 weeks. Family actually thought patient
looked better than he had the entire hospitalization that day
but the next day delirium seemed further worsened and that night
patient again required ICU transfer due to 2 blood containing
bowel movements and a small Hct drop.
In the MICU patient had visual hallucinations and required
restraints because started pulling at lines. On POD2 after
anterior spinal fusion pt became slightly agitated. On transfer
to the [**Hospital1 **], delirium continued to wax and wane. On discharge,
he is alert and oriented to name, sometimes to date, sometimes
to location.
.
#) GI Bleed:
Although patient had multiple above GI issues, no GI bleeding
had been noted during first 3 weeks of hospitalization. Pt had
history of bleeding hemorrhoids and was on [**Hospital1 **] omeprazole for
GERD/GI prophylaxis considering his level of sickness. On the
afternoon of [**2106-7-13**], pt was reported to have a blood bowel
movement while working with physical therapy. On physician exam
of the stool, it was brown with some blood streaking and patient
had notable hemorrhoid protruding externally on physical exam.
In light of stool appearance with very little total blood,
hemorrhoid, and pt report of past bleeding hemorrhoids, this
bleed was attributed to hemorrhoidal source. However, later that
evening pt had a large maroon bowel movement in the setting of
low grade new tachycardia and mild respiratory distress. Stat
Hct showed drop from 28.7 to 24.5 which was slightly outside the
range of lab error and in the setting of this and other clinic
changes (HR and RR), pt was transferred to the MICU and IV PPI
initiated. Of note, this occurred in setting of patient being
advanced from liquids to regular diet in the last 24hrs. In the
MICU, pt was transfused 1u prbc. Anoscopy performed by GI. No
lesion was visualized. Sigmoidoscopy was performed on [**7-16**] which
suggested bleeding was likely an internal hemmorhoid. Hct were
stable afterwards. There was concern on a subsequent MICU
admission for bleeding given a downtrending H/H. Upper endoscopy
by GI demonstrated a non-bleeding duodenal ulcer. On discharge,
H/H was stable. He was converted to pantoprazole 40 [**Hospital1 **] PO at
discharge.
.
#) Atrial Fibrillation:
Pt had history of atrial fibrillation for which he had been on
warfarin. This was stopped on admission due to need for spinal
surgery and relatively low day to day risk of embolic stroke
compared to high risk of spinal bleeding on therapeutic
anticoagulation. Also has prosthetic mitral valve but it since
it was a tissue valve, it did not need anticoagulation. Pt was
actually sinus most of admission and midly tachycardic when was
febrile/developing infection. On low dose metoprolol as an
outpatient which was held for the concern of GI bleed. Warfarin
was held on discharge given multiple comorbidities and
relatively low embolic risk. This was discussed with the PCP at
discharge. His metoprolol was not re-started during the
hospitalization but should be restarted at rehab and was
included in his medication list.
.
# Nutrition Status:
Mr. [**Known lastname **] was intermittently on TPN, tube feeds, and diets
throughout his hospitalization. Most recently he was
transitioned from TPN to tube feeds. A video swallow eval
recommended nectars and pureed food. He tolerated this diet well
over the last 24 to 48 hours. His tube feeds were stopped and
his NG tube was removed prior to discharge.
.
# Adrenal Insufficiency
There was a question of adrenal insufficiency raised while the
patient was hypotensive in the MICU. He was started on steroids
with relief of his hypotension. He was then tapered down from
the stress dose to a maintenance dose of 10mg AM and 5mg PM of
hydrocortisone. On [**8-11**] he underwent a cortisol stim test, and
his cortisol level at 1hr and 15min was 17.8. It was felt that
this was nearly a normal response and that his steroids could be
tapered. It was likely that the poor adrenal response was
related to his signficantly troubled hospital stay. He received
10mg hydrocortisone in the hospital prior to discharge, and then
will receive 5mg hydrocortisone at rehab and then will stop.
.
Medications on Admission:
Simvastatin 20 qd
Xalatan 0.005% 1 drop each eye daily
Warfarin 5 mg Sun/Mon/Wed/Fri; 2.5 mg Tue/Thurs/Sat
Omeprazole 40 mg [**Hospital1 **]
Metoprolol 25 qd
MVI
Citracal + D.
Tylenol
Oxycodone 5 mg prn
Baclofen 10 prn
Erythromycin eye ointment tid (for 7 days for eye infection).
Discharge Medications:
1. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
3. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
4. clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times
a day).
5. 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.
6. 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.
7. hydrocortisone 5 mg Tablet Sig: One (1) Tablet PO once a day
for 1 doses: finishing steroid taper, give one dose friday
morning, then discontinue.
8. Pantoprazole 40 mg IV Q12H
9. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO three times a
day as needed for pain.
10. Zyprexa 2.5 mg Tablet Sig: 1-2 Tablets PO at bedtime as
needed for insomnia or agitation.
11. zoledronic acid 4 mg/5 mL Solution Sig: One (1) dose
Intravenous once a month: last dose [**2106-8-8**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital-[**Hospital1 8**]
Discharge Diagnosis:
Multiple myeloma
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Mr. [**Known lastname **], you were originally admitted almost two months ago
with back pain, and spinal surgery revealed this was called by
multiple myeloma lesions. Your hospital stay has since been
prolonged by multiple complications including many transfers to
the MICU. You are being transferred to a rehabilitation hospital
for further therapy.
Followup Instructions:
---Follow-up with PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) 7842**] ([**Telephone/Fax (1) **] after
rehab.
---Hem/onc at [**Hospital1 **] will follow multiple myeloma. Can
contact Dr. [**Last Name (STitle) **] [**Name (STitle) 2405**] at [**Telephone/Fax (1) 17667**] to coordinate care
---Follow-up with [**Hospital1 18**] GI after rehab regarding duodenal
stricture
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32,425
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Discharge summary
|
report
|
Admission Date: [**2160-8-13**] Discharge Date: [**2160-8-24**]
Date of Birth: [**2109-1-23**] Sex: F
Service: MEDICINE
Allergies:
Shellfish / Flexeril / Tricyclic Compounds
Attending:[**First Name3 (LF) 13256**]
Chief Complaint:
Hyponatremia, hypokalemia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: This is a 51 y/o F c/ a significant past medical history of
Hep C/cirrhosis, removal of prosthetic right hip for hardware
infection, recent hospitalization for sepsis (pseudomonas +
blood
cultures), was admitted to the hepatology service yesterday
afternoon for hyponatremia and [**First Name3 (LF) **] (Na of 120 and a K
of
6.2). The patient's lactulose was stopped one week ago for
diarrhea. In addition, the patient was recently seen at an
outside hospital where a CT showed possible osteomyelitis of the
right sternoclavicular joint. Based on nursing assessment, the
patient was obtunded on admission. Overnight, she was hypoxic
(O2
sat 87% RA), hypoglycemic, and hypothermic (T 93.4). Her O2 sats
improved with 2L FM. Her BP remained normal the entire evening
(SBP 100-130s). While her O2 saturations improved, the patient
continued with an altered mental status. The patient was
transferred to the SICU and the [**First Name3 (LF) **] surgery service.
Past Medical History:
PMH: HCV Cirrhosis ('[**51**], nonresponder to interferon/
ribavirin, no varices on EGD [**5-15**] c/b encephalopathy,
thrombocytopenia, ascites, and hydrothorax), Hyponatremia
baseline 128-133, Secondary adrenal insufficiency, Asthma,
Diabetes mellitus, GERD, Anxiety, UTIs, MRSA bacteremia and
septic arthritis([**10-14**], [**12-16**]), LE Cellulitis, Hypercalcemia
.
PSH: TIPS [**11-8**] for ascites, R hip fracture and ORIF in [**11/2157**],
(c/b polymicrobial septic hip: E. Coli, enterococcus, coag neg
Staph, Klebisiella), s/p washout [**6-/2158**], hardware removal
[**9-/2158**]
Social History:
Lives currently with her mother. [**Name (NI) **] 1 daughter and a
granddaughter. Smoking d/c in [**2154**], smoked 1/2ppd for several
years. Sober since [**2148**], h/o iv-heroin (d/c in [**2148**]).
Family History:
Father - COPD, alcohol cirrhosis
Mother - diabetes, HTN, HL
Daughter - congenital heart dz
Physical Exam:
On admission:
VS: T 97.9 BP 120/80 P 85 RR 18 O2 sat 100% on RA
General: thin, chronically ill appearing woman tremulous, but in
NAD
HEENT: EOMI, sclera mildly icteric, MMM
Neck: no JVD
Lungs: CTAB; no wheezes, rhonchi, rales
CV: RRR, nl S1 and S2, II/VI systolic murmur over RUSB; no rubs
or gallops; 2-3 cm area of swelling and erythema over right
sterno-clavicular junction; not warm to touch, tender to deep
palpation
Abdomen: +BS, soft, non distended, non tender, no hepatomegaly
Ext: WWP, 1+ brawny and pitting LE edema, ecchymoses of UEs; 2+
DPs and PTs
Neuro: AAOx3, tremor but no asterixis; CNII-XII intact. motor
and sensation grossly intact, decreased ROM in right UE.
In ICU:
VS: T 97.5 HR 105 BP 104/64 RR 26 96% 2L
GEN: eyes closed, answers questions in one word answers,
withdraws from sternal rub
HEENT: dry mucous membranes, no scleral icterus
CHEST: CTA B/L, slightly tachypneic with shallow breaths,
decreased BS at bases B/L
HEART: S1, S2, tachycardic
ABD: soft, slightly distended, did not ellicit withdrawal or
grimacing on deep palpation
EXT: warm, 1+ edema, warm, B/L calf cellulitis (warm,
blanching),
right hip VAC dressing intact with no erythema and minimal
drainage
On discharge:
VS 97.2, 93/47, 96, 18, 97RA
General: thin, chronically ill appearing woman, tremulous, NAD
HEENT: EOMI, sclera mildly icteric
Lungs: CTAB; no rhonchi, rales, or wheezes
CV: RRR, nl S1 and S2, III/VI systolic murmur loudest along
LUSB, no rubs, or gallops
Abdomen: +BS, soft, non distended, non tender
Ext: WWP, no edema; 2+ DPs and PTs
Neuro: A&O x3; appropriate, motor and sensation grossly intact;
+ fine tremor, slight asterixis
Pertinent Results:
Admission Labs:
[**2160-8-13**] 05:30PM PT-15.2* INR(PT)-1.3*
[**2160-8-13**] 05:30PM PLT COUNT-145*#
[**2160-8-13**] 05:30PM NEUTS-85.2* LYMPHS-8.8* MONOS-5.4 EOS-0.4
BASOS-0.3
[**2160-8-13**] 05:30PM WBC-14.8*# RBC-3.77*# HGB-11.7*# HCT-35.8*#
MCV-95 MCH-31.0 MCHC-32.6 RDW-20.4*
[**2160-8-13**] 05:30PM ALBUMIN-2.5* CALCIUM-9.3 PHOSPHATE-4.3#
MAGNESIUM-2.1
[**2160-8-13**] 05:30PM ALT(SGPT)-30 AST(SGOT)-77* ALK PHOS-250* TOT
BILI-1.4
[**2160-8-13**] 05:30PM GLUCOSE-124* UREA N-46* CREAT-0.9 SODIUM-120*
POTASSIUM-6.4* CHLORIDE-93* TOTAL CO2-21* ANION GAP-12
[**2160-8-13**] 07:38PM URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE
EPI-0-2
[**2160-8-13**] 07:38PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2160-8-13**] 07:38PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2160-8-13**] 07:38PM URINE OSMOLAL-328
Micro:
[**8-13**] Urine Cx- enteroccocus (VRE)
[**8-13**] Blood Cx- No growth
[**8-14**] Blood Cx- No growth
[**8-15**] Urine legionella- negative
[**8-16**] C. diff- negative
[**8-18**] Joint fluid (sternoclavicular jt)- GS negative; 1 PMN; cx -
no growth
[**8-22**] Urine cx- no growth
[**8-23**] Blood cx- NGTD
[**8-23**] C. diff- negative
Studies:
[**8-13**] CXR: 1. Although lower lobe opacities have improved from the
prior radiograph, the possibility of residual or recurrent
infection should be considered in the appropriate clinical
setting. 2. Dilated loops of bowel in upper abdomen are
incompletely evaluated on this chest radiograph. Dedicated
abdominal radiographs may be helpful to exclude an obstructive
process.
[**8-14**] CXR: 1. NG tube in appropriate position. 2. Small bilateral
pleural effusions, left greater than right, slightly increased.
3. Increased retrocardiac opacity concerning for worsening
atelectasis or infection.
[**8-14**] Duplex Doppler Abd U/S: Decline in MPV velocity and high
distalTIPS velocities concerning for distal stenosis at the
TIPS/HV junction. Further evaluation recommended.
[**8-14**] CT Head: 1. No acute intracranial process. 2. Aerosolized
secretions and mucosal thickening within the right sphenoid
sinus.
[**8-14**] LENI: No DVT of either lower extremity.
[**8-15**] CT R clavicle: 1) Destruction of medial right clavicle with
exuberant adjacent callus formation. The appearance may be
post-traumatic, but infection cannot be excluded. If clinical
concern for infection remains, biopsy/aspiration could be
performed with CT guidance. 2) Patchy opacification
predominantly in right lower lobe incompletely assessed on this
examination however appears similar to findings of [**2160-7-4**]
and may represent chronic atelectasis with possible
infectious/inflammatory process.
Discharge Labs:
[**2160-8-24**] 06:00AM BLOOD WBC-4.8 RBC-2.28* Hgb-7.6* Hct-21.2*
MCV-93 MCH-33.5* MCHC-36.0* RDW-19.5* Plt Ct-23*
[**2160-8-24**] 06:00AM BLOOD PT-15.7* INR(PT)-1.4*
[**2160-8-24**] 06:00AM BLOOD Glucose-159* UreaN-99* Creat-1.1 Na-135
K-5.3* Cl-100 HCO3-30 AnGap-10
[**2160-8-24**] 06:00AM BLOOD ALT-18 AST-42* AlkPhos-89 TotBili-2.5*
[**2160-8-24**] 06:00AM BLOOD Calcium-9.3 Phos-3.6 Mg-3.0*
[**2160-8-14**] 03:27PM BLOOD CRP-24.4*
Brief Hospital Course:
51 yo woman with h/o HCV cirrhosis (c/b encephalopathy, ascites,
s/p TIPS) and septic hip, with recent admission for pseudomonas
bacteremia, admitted with hyponatremia, [**Month/Day/Year **] and
subsequent decompensation with hepatic encephelopathy in the
setting of pneumonia and UTI. Her hospital course by problem was
as follows:
.
# Hyponatremia- Likely secondary to poor PO intake superimposed
on chronic hyponatremia in setting of cirrhosis. Patient's
baseline sodium is 128-133. She was given albumin with gradual
improvement of her sodium levels.
.
# [**Month/Day/Year **]- On admission, patient with K of 6.4. Had peaked
T waves on EKG and is complaining of myalgias for the past week.
She was treated with insulin, calcium gluconate, albuterol, and
kayexelate. Her [**Month/Day/Year **] was attributed to her recent
decrease in lasix dose from 120 to 80 mg. Lasix was increased
during this hospitalization to 80 mg [**Hospital1 **] and spironolactone was
decreased to 100 mg daily. Patient was monitored on telemetry
with no cardiac events.
.
# HCV cirrhosis (c/b ascites, thrombocytopenia, encephelopathy,
coagulopathy, s/p TIPS). Pt is currently not a [**Hospital1 **]
candidate due to recurrent infections. During this
hospitalization, patient decompensated and became
encephelopathic in the setting of infection (UTI and pneumonia,
see below) with a possible contribution from distal stenosis of
her TIPS diagnosed on duplex doppler U/S. She required
aggressive lactulose therapy (which she had stopped at home for
one week prior to admission) and was transferred to the SICU for
management of hypoxia and hypothermia in the setting of
encephelopathy. She was transferred back to the floor after a
couple of days, stable and lucid with her aggressive lactulose
regimen. In addition to lactulose, she was continued on her home
rifaximin. Lasix was uptitrated to 80 mg [**Hospital1 **] and spironolactone
was downtitrated to 100 mg daily given her [**Hospital1 **] on
presentation. A Dobhoff was placed in the post-pyloric position
for tube feeds as the patient exhibited poor PO intake. She was
discharged with instructions to continue her tubefeeds.
.
# UTI- Patient grew out VRE in urine and completed a 8 day
course of linezolid.
.
# Pneumonia- Patient became hypoxic and hypothermic one day
after admission, though she remained hemodynamically stable.
Leukocytosis to 14.8 with 85% polys. She was transferred to the
SICU where she was empirically treated with zosyn for a possible
pneumonia seen on CXR. Her blood cultures were negative to date.
She completed 8 days of treatment with zosyn and was given
albuterol, ipratroprium nebs PRN. She was breathing comfortably
on room air with oxygen saturations in the high 90s on room air
at the time of discharge.
.
# R clavicle fracture- There was some concern for osteomyelitis
given the patient's recurrent hip infections. She was seen by
orthopedics and per their recs CT scan was performed which
showed a traumatic injury but was inconclusive for infection.
Patient underwent CT guided sternoclavicular joint aspiration
which showed a negative GS negative and cx. ESR was 18 and CRP
24.4. Infectious disease consultants recommended holding
treatment for osteomyelitis given the negative biopsy results
and low likelihood of osteo.
.
# Acute renal insufficiency- Patient experienced a short-lived
bump in her creatinine to 1.2 from her baseline of 0.8-0.9. This
was attributed to a pre-renal etiology in the setting of poor PO
intake despite tube feeds. Patient was given albumin and
encouraged to increase PO intake. At the time of discharge,
creatinine was trending down.
.
# Thrombocytopenia- On admission, platelets were 145, which
trended down to a low of 23. Her thrombocytopenia was attributed
to baseline poor hepatic function in the setting of cirrhosis
with superimposed linezolid related toxicity. Linezolid was
discontinued after 8 days of treatment. Patient was
hemodynamically stable without any bleeding during this
hospitalization. Would advise monitoring and follow up in the
outpatient setting.
.
# Adrenal insufficiency: Patient was continued on her home
prednisone 5 mg daily. She was on stress dose steriods briefly
during the time of her SICU transfer, but these were promptly
discontinued as her condition quickly stabilized.
.
# Hip wound: s/p R hip ORIF in [**2156**], c/b multiple joint/hardware
infections and sepsis, spacer inside, wound vac in place. No
signs of active infection. The wound was evaluated by wound care
nursing along with Dr. [**Last Name (STitle) **]. They recommended discontinuing
the wound vac due to concern for premature closure of the wound
with atypical granulation tissue (cauliflower tissue) which
could potentially cause collection or abscess formation. Daily
dressing changes with AMD were performed per wound care recs and
patient was discharged with instructions to continue this care
plan. She was continued on her oxycodone for pain control during
this hospitalization.
.
# Depression- Patient reported saddened mood, without SI/HI. Her
venlafaxine dose was increased from 75 to 150 mg PO BID.
.
# Nutrition- Patient with poor PO intake for past 2-3 weeks
prior to admission. Nutrition consulted and recommended Dobhoff
placement with tubefeeds (isosource 1.5 tube feeds at 45 cc/hr).
She was continued on a diabetic diet and her home vitamins.
.
# Diabetes- Patients sugars were up and down given her acute
infections. On discharge she had achieved good glucose control
with glargine 20 units qHS and ISS.
.
# Asthma: Stable. Patient was continued on her home albuterol,
ipratroprium, and fluticasone.
.
Pending on Discharge:
[**8-23**] Blood cultures
Agree with plan above. Patient d/c to home with the
understanding that she will return to this medical center for
further hosptial care should her condition deteriorate.
Medications on Admission:
Albuterol Inhaler 2 PUFF IH [**Hospital1 **]
Ipratropium Bromide MDI 2 PUFF IH [**Hospital1 **]:PRN wheezing
Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **]
Montelukast Sodium 10 mg PO/NG DAILY
Lasix 80 mg qd
SPIRONOLACTONE - 150mg qd
Rifaximin 550 mg PO/NG [**Hospital1 **]
Glargine 22 qHS
Lispro SS
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - 50,000 unit MWF
Calcitriol 0.25 mcg PO EVERY OTHER DAY
Oxycodone SR (OxyconTIN) 10 mg PO Q12H
OxycoDONE (Immediate Release) 5 mg PO/NG Q6H:PRN pain
KETOCONAZOLE - 2 % Cream - apply to the area twice daily
NYSTATIN - 100,000 unit/gram Powder - TID
PREDNISONE - 5 mg Tablet - One Tablet(s) by mouth daily
CALCIUM CARBONATE - 2 x 500 mg Tablet TID
MAGNESIUM OXIDE - 400 mg Tablet 2-3 times MULTIVITAMIN
FoLIC Acid 1 mg PO/NG DAILY
Gabapentin 100 mg PO/NG Q12H
Venlafaxine 75 mg PO BID
Doxycycline 100 mg b.i.d.
Multivitamin 1 tab daily
Discharge Medications:
1. Tube feeds
Please give Isosource 1.5 Cal Full strength (or equivalent);
Starting rate: 20 ml/hr; Advance rate by 10 ml q6h Goal rate: 45
ml/hr
Residual Check: q4h Hold feeding for residual >= : 200 ml
Flush w/ 50 ml water q6h
2. Tube feed pump and supplies
Please provide tube feed pump and supplies.
3. Outpatient Lab Work
Please check CBC, chem 7, bilirubin, albumin and INR weekly. Fax
results to results to [**First Name8 (NamePattern2) 1022**] [**Last Name (NamePattern1) **] ([**Last Name (NamePattern1) 1326**] Coordinator),
[**Hospital1 18**] Liver Center at [**Telephone/Fax (1) 697**].
4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): Please take additional lactulose if you are
feeling confused, sleepy, or otherwise not yourself.
5. Rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
8. Venlafaxine 75 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
9. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY
OTHER DAY (Every Other Day).
12. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO QMOWEFR (Monday -Wednesday-Friday).
13. Calcium Carbonate 200 mg (500 mg) Tablet, Chewable Sig: Two
(2) Tablet, Chewable PO TID (3 times a day).
14. Spironolactone 25 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
15. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous at bedtime.
16. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation twice a day as needed for shortness of
breath or wheezing.
17. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) puff Inhalation twice a day.
18. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler
Sig: Two (2) puffs Inhalation twice a day as needed for
shortness of breath or wheezing.
19. Doxycycline Hyclate 100 mg Tablet Sig: One (1) Tablet PO
twice a day.
20. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO every
twelve (12) hours.
21. OxyContin 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO every twelve (12) hours as
needed for pain: Do not drink or drive while taking this
medication.
22. Oxycodone 5 mg Capsule Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
23. Montelukast 10 mg Tablet Sig: One (1) Tablet PO once a day.
24. Ketoconazole Topical
25. Wound Care
For Right Hip Wound:
Daily dressing changes to hip site with AMD (anti-microbial
dressing) packing strips into the depth of the wound - this is
best achieved with 90 or greater degree flexion of pt's right
leg. Cover top with dry gauze and ABD pad.
[**Location (un) **] straps to decrease the need for adhesive
placement and removal which can strip pt skin and cause pain.
26. Insulin Sliding Scale
Please resume lispro sliding scale as previously taking
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 6138**] Home Care Services
Discharge Diagnosis:
Primary:
Hepatitis C virus cirrhosis complicated by hepatic
encephelopathy
Pneumonia
Urinary tract infection
Secondary:
Secondary adrenal insufficiency
Asthma
Diabetes mellitus
GERD
Depression/Anxiety
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 68459**],
It was a pleasure taking care of you at the [**Hospital1 18**]. You were
admitted to the hospital because of some abnormalities in your
blood chemistries related to your liver disease. You were
continued on your home medications and restarted on your
lactulose and improved.
While you were here, you were also diagnosed with a pneumonia
and urinary tract infection for which you were treated with
antibiotics. You required a short stay in the intensive care
unit because your oxygen levels were low, but you improved. We
also performed a biopsy of your sternoclavicular joint to see if
there was any infection- these results showed no infection.
While you were in the hospital you had a poor appetite and were
unable to eat very much food. In order to ensure you received
adequate nutrition, we placed a feeding tube and started giving
you tubefeeds. It is important that you continue the tube feeds
at home to increase your calorie intake and build your strength.
While you were in the hospital you were seen by wound care
specialists for your right hip wound- they felt that the wound
vac was not appropriate for your wound and advised daily
dressing changes - we advise that you continue to do this at
home.
We have made the following changes to your medications:
- RESTART taking your lactulose as indicated
- CHANGE your dose of venlafaxine to 150 mg twice daily
- CHANGE your dose of insulin glargine at night and change your
sliding scale to regular insulin
- CHANGE your dose of furosemide to 80 mg twice daily
- CHANGE your dose of spironolactone to 100 mg daily
- STOP taking magnesium
You may continue to take your other medications as you were
previously.
Please follow up at the appointments below.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2160-9-3**] 11:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2164**], MD Phone:[**Telephone/Fax (1) 1803**]
Date/Time:[**2160-9-8**] 11:20
Completed by:[**2160-8-24**]
|
[
"V09.80",
"789.59",
"300.00",
"V58.67",
"571.5",
"255.41",
"486",
"250.80",
"E849.7",
"682.6",
"998.83",
"530.81",
"V54.19",
"070.44",
"E928.8",
"599.0",
"493.90",
"E932.3",
"041.04",
"E878.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"00.14",
"80.39"
] |
icd9pcs
|
[
[
[]
]
] |
17072, 17146
|
7193, 12833
|
330, 336
|
17392, 17392
|
3953, 3953
|
19348, 19654
|
2177, 2270
|
13988, 17049
|
17167, 17371
|
13071, 13965
|
17568, 18848
|
6732, 7170
|
2285, 2285
|
12847, 13045
|
18877, 19325
|
265, 292
|
364, 1329
|
6028, 6715
|
3969, 6019
|
2299, 3486
|
17407, 17544
|
1351, 1942
|
1958, 2161
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,299
| 119,606
|
31225
|
Discharge summary
|
report
|
Admission Date: [**2113-7-6**] Discharge Date: [**2113-7-6**]
Service: SURGERY
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
Ruptered AAA
Major Surgical or Invasive Procedure:
Attempted repair of ruptured abdominal aortic aneurysm.
History of Present Illness:
This was a woman in her 80s transferred from an outside hospital
with a ruptured abdominal aortic aneurysm. At the initial
arrival, her blood pressure was 160. Her CT demonstrated she
was not a candidate for an Endograft given
it was a juxtarenal aneurysm. This also demonstrated rupture
into the right retroperitoneum. She was taken emergently to the
operating room for open AAA repair.
Past Medical History:
CABG ('[**08**]), femur fx, h/o ankle fracture, wheelchair
Social History:
not known
Family History:
not known
Physical Exam:
AF / tachycardic / blood pressure was 160
resp distress
palp mass midline
fem [**Doctor Last Name **]
distal not assessed
emergently take to the OR
Pertinent Results:
[**2113-7-6**] 08:34AM BLOOD
WBC-6.0 RBC-2.51* Hgb-7.8* Hct-22.8* MCV-91 MCH-31.0 MCHC-34.1
RDW-15.1 Plt Ct-18*
[**2113-7-6**] 08:35AM BLOOD
Type-ART pO2-325* pCO2-30* pH-7.32* calTCO2-16* Base XS--9
[**2113-7-6**] 08:35AM BLOOD
Glucose-234* Lactate-9.6* Na-145 K-3.4* Cl-125*
[**2113-7-6**] 08:35AM BLOOD
Hgb-7.4* calcHCT-22
RADIOLOGY Final Report
CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS
COMPARISONS: None.
TECHNIQUE: Axial MDCT images were obtained from the lung bases
through the symphysis pubis before and after administration of
nonionic Optiray contrast.
CT OF THE ABDOMEN WITH AND WITHOUT IV CONTRAST: There is a tiny
right-sided pleural effusion with dependent atelectasis. There
is a moderate-sized hiatal hernia. The patient is status post
median sternotomy.
There are multiple calcified granulomas within the spleen.
Calcified stones are seen within the gallbladder. The liver,
pancreas and kidneys are unremarkable. The adrenal glands are
slightly hyperenhancing which may represent component of
hypoperfusion complex. The adrenal glands are otherwise
unremarkable.
There is a large infrarenal abdominal aortic aneurysm measuring
up to 7.7 cm in maximal axial dimension with mural thrombus
which shows evidence of rupture and active extravasation. Active
extravasation of contrast is seen into the right side of the
retroperitoneum and there is a large retroperitoneal hematoma,
predominantly involving the right side but extending into the
anterior and posterior pararenal space and right pericolic
gutter. The infrarenal abdominal aortic aneurysm extends down to
the iliac bifurcation which are ectatic but not aneurysmal.
CT OF THE PELVIS WITH IV CONTRAST: A Foley catheter is within
the bladder. The patient is status post hysterectomy. There is
diverticulosis of the sigmoid and descending colon. The
appearance of the bowel is unremarkable on this arterial phase
study.
CT RECONSTRUCTIONS: Extensive degenerative changes are seen
within the lower thoracic and lumbar spine.
IMPRESSION: Large, up to 7.7 cm leaking infrarenal abdominal
aortic aneurysm with active extravasation with associated
moderate-sized right-sided retroperitoneal hematoma
Brief Hospital Course:
This was a woman in her 80s transferred from an outside hospital
with a ruptured abdominal aortic aneurysm. At the initial
arrival, her blood pressure was 160. Her CT demonstrated she
was not a candidate for an Endograft given it was a juxtarenal
aneurysm. This also demonstrated rupture into the right
retroperitoneum. She was taken emergently to the operating room
for open AAA repair.
The patient arrived in the OR with a blood pressure of 70. She
was placed supine on the OR table. The abdomen and groins were
sterilely prepped and draped.
Anesthesia attempted to place arterial and venous access lines.
We assisted with a femoral venous line placement through which
resuscitation fluids were given. The patient was intubated.
The abdomen was entered through a midline incision. The
supraceliac aorta was clamped manually and then using blunt
dissection, the aorta was dissected out. A TE probe was felt
within the esophagus. A clamp was placed on the supraceliac
aorta with improvement in blood pressure. We then exposed the
retroperitoneum. There was a very large amount of blood coming
from the right retroperitoneum. We opened the aneurysm and took
it up to the level of the renal arteries. We visualized and
avoided the right renal vein. A 16 mm tube graft was then
sutured in place just below the renal arteries. After
completing this anastomosis, two pledgeted repair sutures were
placed with subsequent hemostasis at the suture line.
However, with release of the supraceliac clamp, the blood
pressure dropped substantially and replacement of the clamp was
required. Several attempts were made at this during this time.
We proceeded to perform the distal anastomosis with the proximal
clamp in position with intermittant attempts at clamp release
none of which were tolerated. No heparin
was given through the procedure. I should note that upon
entering into the abdomen, there was a foul smell suggestive of
dead bowel. Nearing completion of the distal anastomosis, we
flushed the proximal aorta. There was extensive clot noted. We
backbled and again there was fairly significant clot. We
flushed these extensively and then flushed with heparinized
saline before completing the anastomosis. At one
point just prior to the completion, the patient became
hypertensive without receiving any pressors. It was felt that
the proximal aorta had clotted. We loosened the suture line and
expressed clot and again flushed until there was good bleeding;
but once again, the patient did not tolerate release of the
supraceliac clamp. There was no evidence of major hemorrhage
coming from the suture lines nor from the supraceliac aorta at
the clamp point. It was felt that the blood pressure
intolerance was likely due to visceral and renal reperfusion.
The patient's heart rate became agonal despite multiple doses of
epinephrine and atropine. CPR was performed several times
without improvement. The cardiac function was minimal on TEE.
The patient was then declared dead, and further
resuscitation attempts were aborted.
The abdomen was closed with a running suture through the skin.
Medications on Admission:
deceased
Discharge Medications:
deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
deceased
Discharge Condition:
deceased
Discharge Instructions:
deceased
Followup Instructions:
deceased
Completed by:[**2114-3-1**]
|
[
"998.11",
"444.0",
"568.81",
"401.9",
"V10.42",
"V45.81",
"286.9",
"441.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"38.44",
"99.04",
"99.07",
"99.05",
"99.60"
] |
icd9pcs
|
[
[
[]
]
] |
6483, 6492
|
3270, 6391
|
253, 310
|
6544, 6554
|
1051, 3247
|
6611, 6649
|
856, 867
|
6450, 6460
|
6513, 6523
|
6417, 6427
|
6578, 6588
|
882, 1032
|
201, 215
|
338, 731
|
753, 813
|
829, 840
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,765
| 196,798
|
30749
|
Discharge summary
|
report
|
Admission Date: [**2167-4-28**] Discharge Date: [**2167-7-2**]
Date of Birth: [**2114-1-22**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Transferred from OSH with hypoxic respiratory failure
Major Surgical or Invasive Procedure:
Intubation
Tunneled HD line placement
hemodialysis
PICC placement, PICC removal
History of Present Illness:
This is a 53 year-old woman with history of CAD, CHF, copd on
home oxygen, pulm hypertension, polysubstance abuse who
presented to OSH earlier today ([**4-28**]) with altered mental
status. As per records, patient presented after her VNA noted
medical non-compliance and apparent overuse of sedating
medications and summoned EMS. When patient arrived at OSH, the
patient was somewhat confused and hypoxic to high 80's on 3
liters. (Unclear baseline requirement but on home oxygen). Also
tachycardic to 100, tachypneic to mid 20's and hypertensive to
160's. She had low grade fevers to 99. She was felt to be in
congestive heart failure, was noted to have hyperkalemia, and
apparently new renal failure with creatinine in 6's. A central
line was placed but then the patient became agitated,
self-extracted the femoral line. Serial haldol, benadryl and
ativan x3 were not effective in sedating her and therefore the
patient was intubated for airway protection. The femoral line
was replaced. The patient had a NG tube placed, was given
kayxelate, calcium gluconate, bicarb, insulin, and glucose for
hyperkalemia, las well as lasix for CHF. She was given a dose of
levoquin for UTI/possible pneumonia. The patient had an anion
gap acidosis and there was concern for ethylene glycol because
"urate crystals" were noted in the urine.
.
She was noted to have coffee grounds by NGT.
.
The patient was transferred to [**Hospital1 18**] ER. In our ER, received a
tox consult, renal consult, GI consult and CXR. The CXR
confirmed CHF. Flomipazole was given for possible ethylene
glycol intoxication. Renal recommended: no dialysis, give
bicarb. GI recommended: protonix, ffp and vitamin K. Tox: no
other reccs.
.
Vitamin K 10 subcut, 2 units FFP, protonix, insulin, dextrose,
calcium gluconate, Kaexelate and bicarb given.
.
Past Medical History:
(per OSH records)
1. COPD-on 4L O2 by NC at home
2. Pulmonary Hypertension
3. CAD
4. CHF--diastolic dysfunction
5. Anxiety
6. Polysubstance Abuse
7. PVD s/p L AKA
Social History:
Lives alone in [**Doctor Last Name **], has a visiting nurse.
Family History:
unknown
Physical Exam:
ADMISSION EXAM
VS: Temp: 97.5 BP:154/65 HR:89 RR:24 100%O2sat
VENT: AC 550x24, fio2 of 1, peep of 10.
I/O: 150/400 in our emergency department
general: intubated, sedated
HEENT: Pupils equal, minimally responsive, anicteric, MMM, op
without lesions, no supraclavicular or cervical lymphadenopathy
lungs: Crackles [**12-9**] way up
heart: RR, S1 and S2 wnl, no murmurs, rubs or gallops
appreciated but difficult to appreciate
abdomen: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
extremities: no cyanosis, clubbing or edema. Left AKA
skin/nails: no rashes/no jaundice/
neuro: intubated, sedated
Pertinent Results:
[**2167-4-28**] 08:30PM BLOOD
-WBC-19.5* RBC-4.94 HGB-13.1 HCT-41.0 MCV-83 MCH-26.5* MCHC-31.9
RDW-18.5* NEUTS-83.7* BANDS-0 LYMPHS-10.3* MONOS-5.7 EOS-0.2
BASOS-0.1
PT-28.5* PTT-30.6 INR(PT)-3.0* PLT SMR-HIGH PLT COUNT-449*;
HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-NORMAL MACROCYT-NORMAL
MICROCYT-NORMAL POLYCHROM-1+
-ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG
tricyclic-POS OSMOLAL-313*
cTropnT-0.08*
CK(CPK)-231*
GLUCOSE-101 UREA N-105* CREAT-6.5* SODIUM-130* POTASSIUM-6.8*
CHLORIDE-98 TOTAL CO2-16* ANION GAP-23*
[**2167-4-28**] 08:39PM GLUCOSE-92 LACTATE-1.3 K+-6.3*
.
[**2167-4-28**] 09:00PM URINE
EOS-NEGATIVE; RBC-[**5-17**]* WBC-21-50* BACTERIA-MANY YEAST-NONE
EPI-[**5-17**]; BLOOD-MOD NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-TR
BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-SM; COLOR-Yellow
APPEAR-Hazy SP [**Last Name (un) 155**]-1.020
[**2167-4-28**] 09:00PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG; OSMOLAL-376
[**2167-4-28**] 09:35PM TYPE-ART PO2-60* PCO2-45 PH-7.23* TOTAL
CO2-20* BASE XS--8
[**2167-4-28**] 10:55PM UREA N-109* CREAT-6.5* SODIUM-135
POTASSIUM-6.2* CHLORIDE-102 TOTAL CO2-17* ANION GAP-22*
.
[**2167-5-30**] WBC-9.3 Hgb-11.0* Hct-34.3* MCV-86 MCH-27.6 MCHC-32.0
RDW-23.8* Plt Ct-314
[**2167-6-10**] WBC-13.1* Hgb-9.3* Hct-30.1* MCV-93 MCH-28.5
MCHC-30.8* RDW-24.0* Plt Ct-425
[**2167-6-23**] WBC-19.0* Hgb-10.7* Hct-34.2* MCV-91 MCH-28.2
MCHC-31.1 RDW-22.1* Plt Ct-640*
[**2167-6-24**] WBC-18.0*Hgb-10.7* Hct-32.8* MCV-87 MCH-28.5 MCHC-32.6
RDW-21.6* Plt Ct-578*
[**2167-6-27**] WBC-16.7* Hgb-11.0* Hct-35.7* MCV-91 MCH-28.2
MCHC-30.9* RDW-21.2* Plt Ct-482*
[**2167-6-28**] WBC-19.0* Hgb-11.4* Hct-36.3 MCV-91 MCH-28.5
MCHC-31.4 RDW-20.9* Plt Ct-503*
.
MICRO:
-Urine cultures ([**4-28**], [**5-1**], [**5-6**]): No growth.
.
-Sputum ([**4-29**]): 3+ gram positive cocci in pairs and clusters.
-Sputum ([**5-1**]): 1+ yeast.
.
-Blood ([**4-30**], [**5-1**], [**5-6**], [**5-15**], [**5-18**], [**6-22**]): Negative.
-Blood ([**6-24**], off antibx): no growth to date.
-Blood ([**5-14**]): One bottle with staph coagulase negative.
.
-Catheter tip ([**5-6**]): No growth.
-Catheter tip ([**5-13**]): No growth.
-Catheter tip ([**5-22**], [**5-26**], [**6-20**]): No growth.
.
-Hemodialysis catheter blood cx ([**6-18**]): No growth.
.
-Stool ([**5-8**], [**5-10**], [**5-11**], [**5-31**], [**6-27**]): C. diff. negative.
.
-Blood ([**5-22**]): RPR Negative.
.
[**4-30**] ECHO
The left atrium is normal in size. The right atrium is
moderately dilated.
There is mild symmetric left ventricular hypertrophy. The left
ventricular
cavity size is normal. Overall left ventricular systolic
function is normal
(LVEF>55%). The aortic valve leaflets (3) are mildly thickened.
There is no
aortic valve stenosis. Mild (1+) aortic regurgitation is seen.
The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. There is
moderate pulmonary
artery systolic hypertension. There is a trivial/physiologic
pericardial
effusion.
.
[**5-1**] CT TORSO
IMPRESSION:
1. No bowel obstruction is identified. Small bowel and large
bowel loops appear unremarkable.
2. Bilateral increased interstitial markings and septal
thickening is suggestive of presence of the heart failure. The
heart is also mildly enlarged.
3. Small bilateral pleural effusions and dependent atelectatic
changes are noted at both lung bases. Infiltrate/infection
cannot be ruled out. Small pericardial effusion is also noted.
4. A 4-mm nodule is noted within the anterior portion of the
right middle lobe. Pathologically enlarged right paratracheal
node measures 13 mm in the short axis.
5. Diverticulosis with no evidence of diverticulitis.
6. The aorta demonstrates severe stenosis below the renal
arteries. No aneurysmal dilatation is noted.
7. Small right kidney with normal sized left kidney. No
hydronephrosis or stones are identified.
.
[**5-1**] CT HEAD
1. No acute intracranial abnormality.
2. Chronic infarcts in the right cerebellum and centrum
semiovale.
3. Sinus disease involving left maxillary and sphenoid sinuses.
.
[**5-2**] EEG
IMPRESSION: This is an abnormal EEG due to the presence of
probable
periodic lateralizing epileptiform discharges (i.e., PLEDs)
involving
the right hemisphere which could indicate a subcortical
abnormality
involving this area. The presence of a diffusely slow background
and
disorganized background is consistent with a mild to moderate
encephalopathy of toxic, anoxic, or metabolic etiology. The
occasional
sharp waves can be a sign of cortical irritability, but clinical
correlation would need to be provided. No evidence for ongoing
seizures
is seen.
.
[**5-19**] ECHO/Bubble study:
Focused study to assess for patent foramen ovale. Images were
obtained at
rest, with cough and post-valsalva release with injection of
agitated saline.
No evidence for an atrial septal defect or patent foramen ovale
was
identified. There is symmetric left ventricular hypertrophy with
preserved
global systolic function. No pericardial effusion is seen.
.
[**5-25**] MR spine: 1. Multilevel degenerative changes of the lower
lumbar spine, most pronounced at the L4-5 and the L5-S1 levels
respectively.2. Type [**First Name9 (NamePattern2) **] [**Last Name (un) 13425**] changes of the L4 and L5 vertebral
bodies respectively. 3. No evidence of epidural abscess.
.
[**6-10**] Chest CTA:1. No definite evidence of pulmonary embolus. 2.
Cardiomegaly, pleural effusions, and pulmonary edema, all
consistent with congestive heart failure.3. Right upper and
right middle lobe pulmonary nodules, little change since [**2167-5-1**]. Six-month followup chest CT is recommended to assess
stability.4. Mediastinal lymphadenopathy, likely reactive.
.
[**6-15**] ECHO bubble: Saline contrast study performed to assess for
intracardiac shunt. No passage of agitated saline is seen into
the left heart is identified. The left ventricular cavity is
normal in size. There appears to be global hypokinesis that is
more pronounced/worse that the study of [**2167-5-19**].
.
[**6-19**] ECHO: The left atrium is elongated. The right atrium is
moderately dilated. The estimated right atrial pressure is [**4-16**]
mmHg. Left ventricular wall thicknesses and cavity size are
normal. There is moderate to severe global left ventricular
hypokinesis (LVEF = 30 %). Systolic function of apical segments
is relatively preserved. No masses or thrombi are seen in the
left ventricle. The right ventricular cavity is moderately
dilated with mild globalfree wall hypokinesis. The aortic valve
leaflets are mildly thickened. Mild to moderate ([**12-9**]+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion. Compared with the
prior study (images reviewed) of [**2167-4-30**], global left
ventricular systolic function is more depressed and the right
ventricular cavity is mildly dilated and hypokinetic. The
estimated pulmonary artery systolic pressure is higher.
.
[**6-22**] CT OF THE CHEST WITHOUT IV CONTRAST: There is no axillary
lymphadenopathy. There is pretracheal lymphadenopathy measuring
up to 1.5 cm. This is unchanged. There are small bilateral
effusions. These are stable. Again noted is an ovoid nodule in
the apex of the right lung measuring 1.2 x 0.5 cm. This is
stable in appearance. There are tiny nodules in the right lung.
These are again stable. There is diffuse septal thickening which
is unchanged. In the presence of cardiomegaly this is consistent
with CHF.
CT OF THE ABDOMEN WITHOUT IV CONTRAST: The liver is without
focal lesions. The gallbladder has been removed. Spleen,
pancreas, adrenal glands are unremarkable. The right kidney is
atrophic. The left kidney has some bulging of the contour at mid
pole measuring about 1.6 cm. This is difficult to evaluate on
the prior study as there is significant artifact from the
patient's body touching the gantry but is likely present. There
is no retroperitoneal lymphadenopathy. Small and large bowel are
normal.
CT OF THE PELVIS WITHOUT IV CONTRAST: The uterus is normal in
size and contains some calcified fibroids. There is
diverticulosis of the sigmoid colon. There is no adjacent
inflammatory fat stranding. There is no free fluid in the
pelvis. No pelvic adenopathy is noted. On bone windows, there
are degenerative changes involving the lumbar spine. IMPRESSION:
1. No findings to explain the patient's symptoms. The
examination is essentially unchanged in comparison to prior
studies.
2. Interstitial prominence and small bilateral pleural effusions
with cardiomegaly are consistent with CHF. Again this is stable.
3. Mediastinal adenopathy unchanged.
.
[**6-23**] RUQ US:1. No focal fluid collections. 2. Atrophic right
kidney consistent with chronic renal failure.
.
[**2167-6-30**]
4:18p
Other Blood Chemistry:
HBsAg: Negative
HBs-Ab: Negative
HBc-Ab: Negative
[**2167-4-29**] 05:41PM
Report Comment:
Source: Line-hemodialysis
HEPATITIS
Hepatitis B Surface Antigen NEGATIVE
Hepatitis B Surface Antibody POSITIVE
Hepatitis B Virus Core Antibody NEGATIVE
HEPATITIS C SEROLOGY
Hepatitis C Virus Antibody POSITIVE
Brief Hospital Course:
DISCHARGE SUMMARY (as of [**2167-5-27**])
Assessment and Plan:
This is a 53 year old woman with coronary artery disease,
congestive heart failure, copd, pulmonary hypertension, s/p L
AKA who is oxygen dependent on nasal canula 4 liters at home,
and polysubstance abuse who presented to [**Hospital3 35813**] Center
in [**State 792**]with altered mental status, hypoxia, and
agitation. She was intubated for airway protection and
transferred to [**Hospital1 18**]. Course complicated by anuric renal
failure requiring dialysis.
.
1)Mental Status change:
Most likely multifactorial, as patient with previous
polysubstance abuse. Chronic small vessel disease noted on head
CT. EEG negative for seizure activity. Per family, patient
lives alone and able to care for herself and perform activities
of daily living.
On admission, toxicology screen revealed opiates and tricyclics,
and by medical notes on transfer, patient had been using more
sedating medications than normal. Neurology evaluated patient
and vitamin B12 and folate levels were normal. She received
thiamine. TSH level was elevated to 8 and her T4 was only very
slightly below normal. Thus, thyroid function was not
attributed to altered mental status. An EEG revealed
encephalopathy, but no seizures. CT head revealed chronic small
vessel disease. LP and MRI were deferred.
-Upon extubation, patient slowly became more alert, first with
purposeful eye tracking and then by following simple commands.
She received Haldol and Ativan, which sedated her profoundly for
several days. Then, after extubation, she began to have
conversations but with frequent outbursts with cursing at times,
poor attention and short term memory. She became febrile on
[**2167-5-7**], which was concerning for a line infection, and was
treated initially with Vanco/Zosyn changed to Vanco/Meropenem
plan for 3 day course complete [**2167-5-9**]. C. diff negative x3. Her
head CT was unchanged.
On [**5-13**], patient had her PICC line and tunneled HD line placed
and developed fevers within 12 hours. Only one blood culture
from [**5-14**] revealed one bottle of staph coagulase negative
organisms. Treated with ten day course of vancomycin (per HD
protocol) through [**5-23**].
-Lexapro was restarted on [**2167-5-12**], but held on [**5-22**].
Psychiatry continued to follow patient and for continued
outbursts recommended haldol 0.5mg PO/IV three times daily. As
above, concern that heavy sedatives with ativan and haldol cause
profound sedation. She required soft wrist restraints for
prevention of line removal. Pt was transferred to the MICU on
[**6-2**] for respiratory compromise (see below).
-Upon arriving at the floor on [**6-5**] the patient was AOx3, but
with residual confusion, impulse control issues, and aggitation.
Her course was complicated by recurrent episodes of aggitation
and anxiety which were hard to control. She perseverated on her
medications, her course, and her dietary restrictions. Psych
was consulted and attempted to help control these outbursts
without using benzodiazepems. She often complained of dyspnea,
but requested ativan as treatment. She was transferred to the
MICU for low O2 saturation, where she was diuresed for
congestive heart failure/volume overload. She was transferred
back to the floor on [**6-15**], where she continued to be anxious and
take off her O2 mask. Psych recommended continuing standing
haldol as well as 100mg neurontin qhs. Benzodiazepines were
avoided. This combination had a calming effect and the patient
was significantly less agitated without being over-sedated,
thought to be back to her baseline mental status. Remained at
baseline mental status for the rest of the hospitalization
.
2) Respiratory Compromise:
At outside hospital, patient was hypoxic to high 80's on 3L. At
home, she requires 4L nasal canula. Patient has history of
COPD, CHF, and pulmonary hypertension per outside notes.
Intubated on transfer and thought that congestive heart failure
contributed to hypoxemic event. No clear pneumonia. Patient
was aggressively diuresed via hemodialysis. She was extubated
on [**5-7**]. Hypoxia seems out of proportion to edema
demonstrated on imaging. TTE was negative for patent foramen
ovale.
.
On [**2167-6-1**], the patient triggered for hypoxia 68% on 6 liters
(the patient formerly had been 90-92% on 6 liters. On recheck,
the O2 sat was 88% and then 90-91% on 6 liters without
intervention. The patient was scheduled to have HD as scheduled
on [**2167-6-2**].
.
At HD, the HD catheter was noted to be nonfunctioning. TPA was
tried without success. Then, the patient was found to be hypoxic
to 75% at HD with ABG 7.53/26/44 0on a 40% venti mask. On a
NRB, the patient's saturations improved to 97% and a repeat gas
was 7/53/27/58.
.
The patient denied any chest pain and says the shortness of
breath was not acute in onset but had been developing over the
past few days. However, her SBP was noted to be 188-216 during
HD and the patient was given her am BP meds as a result. CXR
indicated volume overload and pt. was thought to have had acute
pulmonary edema [**1-9**] hypertension and inability to dialyze. Pt
was transferred to MICU and had temporary femoral HD line
initially placed, then tunneled HD line placed by IR [**6-3**]. She
had 7L removed during MICU course with improvement of
oxygenation and was sent back to floor [**6-5**].
.
While on the floor she was maintained on 6L of NC. She did
occasionally complain of dyspnea and anxiety, however it was
hard to differentiate this from her psychiatric issues, as she
was often breathing at a normal rate and sat'ing in the mid 90s
while complaining. She generally maintained saturations from
88-95%. She did have at least two desat's into the low 80s at
night, but responded within minutes to reassurance and haldol
without changing any pulmonary medications or oxygen. On [**6-9**]
she had an episode of somlenence and increased confusion after
her Haldol had been increased to 2mg/dose and her NC O2 dropped
to 4L. SHe was somlenent but arousable, and still oriented to
self She recovered mental status quickly after a 50% venti mask
was placed, and was then seen by the MICU staff. She was
transferred again to the MICU at that point, and again was
diuresed aggressively with good result. Repeat TTE again showed
no patent foramen ovale/shunt. CTA was negative for PE.
.
She was transferred back to the floor on [**6-15**], where she
continued to required 6-8 L O2 and occasionally desat'd in
setting of anxiety. An echo [**6-19**] showed evidence of worsening
CHF (EF 30% now, was >55% in [**Month (only) **]), which would explain
continued increased oxygen requirement and SOB, with evidence of
pulmonary edema on CXR. In conjunction with the renal team, the
patient required almost daily HD or ultrafiltration to draw off
fluid. Attempts were made with medications to balance the need
for afterload reduction with supporting a blood pressure which
could tolerate volume loss through dialysis. This primarily
involved decreasing the patient's betablocker and verapamil dose
significantly, while maintaining isosorbide nitrate. The patient
was witnessed several times eating high salty foods, and being
non-compliant with the fluid restriction which complicated
attempts to manage her volume status. With aggressive HD, as
well as improved management of her anxiety and aggitation
(above) the patient gradually was weaned down to her baseline
requirement of 4L O2 on nasal cannula.
.
3) Anuric renal failure: ATN likely from TCA/opiate overdose.
Outside hospital records revealed creatinine of 4.0 in [**Month (only) 958**]
[**2166**]. On admission, anuric. She was hyperkalemic, so initially
received kayxelate, calcium gluconate, insulin, and
bicarbonated. No ECG changes. Renal ultrasound negative for
obstruction. Received aggressive hemodialysis sessions. There
was concern that tunneled dialysis line infected, but as she was
not rigoring and did not ever develop fever or hypotension
except when on dialysis, believed that filter on hemodialysis
machine may have caused adverse reaction. Asaghi filter used on
[**5-22**] with good effect.
.
Management of the patient's volume status was complicated by
dietary noncompliance and aggitation. After requiring 2 MICU
transfers from the floor due to decreased oxygen saturation from
pulmonary edema, we were finally able to dialyze her
sufficiently to bring her back to baseline oxygen requirement.
We monitored her intake carefully and impressed upon her the
importance of dietary compliance. Adding neurontin to her
anxiety regimen helped calm her and she became more compliant
with our management strategy and was less likely to take off her
oxygen support. Renal recommends performing a 24 hour urine
collection after one month to re-evaluate her renal status.
.
4) Cardiovascular:
--Ischemia: History of coronary artery disease. As outpatient,
on aspirin but no beta blocker or ace-inhibitor. ECG without
ischemic changes and initial cardiac enzymes negative. Continued
aspirin and added beta blocker.
--Pump: Evidence of pulmonary edema and congestive heart failure
on admission. As anuric, removed excess fluid with
hemodialysis.
--Rhythm: Remained in sinus rhythm. Started on beta blockade.
--Hypertension: Severely elevated blood pressures. Started
amlodipine, metoprolol, and isorbide. Goal blood pressure <170,
but due to longstanding hypertension, developed worsened mental
status when blood pressures less than 140. Most likely due to
hypoperfusion. In setting of hypotensive episodes during
dialysis, held antihypertensives on mornings of dialysis. Over
the course of hospitalization, we adjusted her bp medications
according to what was tolerated during dialysis. On discharge,
she is taking isosorbide mononitrate 30mg SR and toprol XL 100mg
q day.
.
5) GI:
On admission, apparent UGI bleeding. Coffee grounds in NGT but
this was in setting of supratherapeutic INR. Subsequently
resolved status post reversal of INR. Treated with IV (and then
po) protonix. Her serial hematocrits remained stable.
Abdominal CT on [**5-1**] unremarkable. Diverticulosis was noted on
subsequent abdominal CT (as above).
.
6) Infectious Disease:
On admission, received levofloxacin, but then broadened to zosyn
and vancomycin for UTI. Completed seven day course on [**5-5**].
Shortly after discontinuation of antibiotics, was transiently
febrile, so started meropenem and vancomycin on [**5-7**] for 3 day
course.
PICC line was placed and tunneled HD line placed on [**5-13**].
Febrile shortly after line placed (1/4 bottles with staph
coagulase negative), so started ten day course of vancomycin
that was completed on [**5-23**]. New PICC placed [**6-3**] for
antibiotics and question of infection.
On [**6-17**] ID was consulted for rising leukocytosis. Bacillus
species grew from [**6-19**] PICC blood cx, pt was started on cefepime
for bacteremia on [**6-20**] (initial culture result said GNR) and
PICC was d/c'd. Was discovered on [**6-23**] that bacillus likely was
a contaminant. Pt has been afebrile, but given persistently high
WBC, there was concern for infection or other etiology. [**6-18**]
culture from HD catheter had no growtn. C. Diff was negative.
Antibiotics were discontinued on [**6-23**] given no organism isolated
and patient being afebrile. Subsequent culture from [**6-24**] showed
no growth to date. Can consider other cause of leukocytosis:
patient was not on systemic steroids so that is unlikely to be a
cause. Patient had mediastinal lymphadenopathy and lung nodules,
which could suggest a malignant cause. Recommend working up
malignancy as outpatient given that patient is clinically stable
and would benefit from rehab placement.
.
7) Depression:
On outpatient lexapro. Restarted during hospitalization, but
discontinued, per psychiatry, on [**5-22**].
.
8) Prophylaxis:
Patient on SC heparin (was on coumadin as outpatient, but
unclear reason), lansoprazole, bowel regimen, and thiamine.
.
9) Access:
PICC placed on [**5-13**], but removed [**5-22**]. Tunneled
hemodialysis catheter placed on [**5-13**]. PICC placed [**6-3**],
removed [**6-21**].
.
10) FEN:
Initially on tubefeeds. Speech and swallow evaluation on [**5-18**] cleared patient for thin liquids and pureed solids.
Aspiration precautions. Eventually advanced to regular renal
diet. Occasionally was hyponatremic, thought due to excess free
water ingestion. Was kept on fluid restriction 1L/day, with
varying effect as patient would sometimes obtain water/fluids
when the nurse was not looking.
.
11) Rash:
Patient noted to have morbilliform rash on trunk and flank on
evening of [**5-25**]. Most likely result of drug reaction.
Potentially vancomycin. Started on hydrocortisone cream, sarna
lotion, and triamcinolone cream. Resolved. Pt also noted to have
intragluteal irritation with sattelite lesions, likely yeast
infection. Started on miconazole powder.
.
12) Code:
Full. Confirmed with daughter. (in the past patient had said
she wanted to be DNR/DNI but then reversed this).
.
Communication:
Daughter, [**Name (NI) **] - [**Telephone/Fax (1) 72819**].
.
Dispo:
To . Has outpatient HD slot at [**Location (un) 37361**] for MWF.
Medications on Admission:
Unsure of doses--from [**Hospital1 **] records
1.Aspirin
2.Hydralazine
3.Imdur
4.Amytriptyline
5.Lexapro
6.Ativan
7.Advair
8.Combivent
9.Albuterol
10. Lasix
11. Coumadin
12. Cardizem
Discharge Medications:
1. Aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
2. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [**Hospital1 **]: [**12-9**]
Drops Ophthalmic PRN (as needed).
3. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
4. Docusate Sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID (2
times a day) as needed: hold for diarrhea.
5. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day) as needed: hold for diarrhea.
6. Lactulose 10 g/15 mL Syrup [**Last Name (STitle) **]: Thirty (30) ML PO Q8H (every
8 hours) as needed: hold for diarrhea.
7. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Last Name (STitle) **]: One (1)
Inhalation Q4H (every 4 hours) as needed for wheezing.
8. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
9. Thiamine HCl 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
10. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Last Name (STitle) **]: One (1) Cap
PO DAILY (Daily).
12. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device [**Last Name (STitle) **]:
One (1) inh, Disk with Device Inhalation [**Hospital1 **] (2 times a day).
13. Budesonide 0.25 mg/2 mL Solution for Nebulization [**Hospital1 **]: One
(1) neb Inhalation [**Hospital1 **] (2 times a day).
14. Nystatin 100,000 unit/mL Suspension [**Hospital1 **]: Five (5) ML PO QID
(4 times a day).
15. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
[**Hospital1 **]: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
16. Haloperidol 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q4-6H (every
4 to 6 hours) as needed for anxiety or aggitation.
17. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Hospital1 **]: One (1)
neb ih Inhalation Q6H (every 6 hours) as needed.
18. Tramadol 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q12H (every 12
hours) as needed.
19. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital1 **]:
One (1) Adhesive Patch, Medicated Topical Q24H (every 24 hours).
20. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
21. Haloperidol 2 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times
a day).
22. Zolpidem 5 mg Tablet [**Hospital1 **]: 1-2 Tablets PO HS (at bedtime).
23. Miconazole Nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical QID
(4 times a day) as needed.
24. Sevelamer 400 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID W/MEALS
(3 TIMES A DAY WITH MEALS).
25. Gabapentin 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO HS (at
bedtime): hold for oversedation.
26. Toprol XL 100mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day
Discharge Disposition:
Extended Care
Facility:
Banister House
Discharge Diagnosis:
congestive heart failure , acute on chronic renal failure
Discharge Condition:
Discharge to Banister house in [**Hospital1 789**], RI, stable,
afebrile, good po intake, wheelchair bound [**1-9**] amputation
Discharge Instructions:
please seek medical attention for shortness of breath, chest
pain, dizzyness, headache
Please take your medications as prescribed.
Followup Instructions:
Please get a repeat chest CT in 6 months to monitor the R upper
and middle pulmonary nodules.
.
Please get a 24 hour urine test to evaluate your kidney in one
month
Completed by:[**2167-7-2**]
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icd9cm
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,436
| 188,560
|
28644
|
Discharge summary
|
report
|
Admission Date: [**2176-1-23**] Discharge Date: [**2176-2-2**]
Date of Birth: [**2094-3-30**] Sex: F
Service: SURGERY
Allergies:
Morphine Sulfate / Digoxin / Metoprolol
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
nonhealing left foot injury
Major Surgical or Invasive Procedure:
diagnostic angiogram with left leg runoff via left femoral
artery
History of Present Illness:
81y/o female with known PVd s/p Rt. BKA [**6-7**] for
nonreconstructable disease present now with nonhealing left 3rd
toe ulceration x 3 months secondary to trama.patient seen in
clinic last week returns now for diagnositic angiogram.
Past Medical History:
Dm2,neuropathy
coronary artery disease, history of myocardial infract,s/p
coronary artery bypass grafting x3 [**2168**],s/p angioplasty [**7-8**]
history of hypertension
history of osteoarthritis
history of osteoporesis
history of left wrist fx,ORIF w pins [**2128**]
history of appendicitis s/p appendectomy
history of hystrectomy [**2128**]'s
history of anemia of chronic disease ,transfused
history of chronic renal insuffiency
history of gastric reflux disease
history of bladder prolapse s/p suspensiion
Social History:
Lives with son
Family History:
unknown
Physical Exam:
gen: no acute distress
CV: RRR nl S1S2
Lungs: clear to auscultation with mild expiratory wheezing
Abd: soft nontender nondistended
ext/pulses: rt. BKA, incision well healed.left foot cold with
ulcerations of toes 2,3 without drainage.2+ pitting edemaleft
foot pulses palpable at, dopperable DP/Pt, palpable popliteal.
Neuro: Ox3, nonfocal
Pertinent Results:
[**2176-1-24**] 12:00AM DIGOXIN-1.3
[**2176-1-23**] 06:40PM GLUCOSE-181* UREA N-53* CREAT-1.2* SODIUM-138
POTASSIUM-4.5 CHLORIDE-99 TOTAL CO2-28 ANION GAP-16
[**2176-1-23**] 06:40PM estGFR-Using this
[**2176-1-23**] 06:40PM CALCIUM-9.7 PHOSPHATE-4.0 MAGNESIUM-2.5
[**2176-1-23**] 06:40PM %HbA1c-6.1* [Hgb]-DONE [A1c]-DONE
[**2176-1-23**] 06:40PM DIGOXIN-1.6
[**2176-1-23**] 06:40PM WBC-6.5 RBC-4.41# HGB-13.1 HCT-38.3# MCV-87
MCH-29.8 MCHC-34.4 RDW-15.9*
[**2176-1-23**] 06:40PM PLT COUNT-214
[**2176-1-23**] 04:42PM URINE HOURS-RANDOM
[**2176-1-23**] 04:42PM URINE GR HOLD-HOLD
[**2176-1-23**] 04:42PM URINE COLOR-Yellow APPEAR-SlHazy SP [**Last Name (un) 155**]-1.015
[**2176-1-23**] 04:42PM URINE RBC-18* WBC-34* BACTERIA-RARE YEAST-FEW
EPI-<1
Brief Hospital Course:
[**2176-1-23**] admitted. Iv hydration for anticipated angio
[**2176-1-24**] mental status changes and profound bradycardia in cath
lab holding area. EPS consulted.Transfered to cardology service
for continued care and possible pacemaker.
angio cancelled.
[**2176-1-25**] heart rate remained in the 50's overnight. lopressor and
dig were held.Patient stableized and transfered back to Vascular
service.No pacemaker at this time since heart rate
recovered.cardiac enzymes stable no acute EKg changes.
[**2176-1-26**] ubderwent diagnostic angiogram and left leg runoff.
[**2176-1-27**] Acute pulmonary edema. Patient transfered to VICu for
continued care. EKG with ?? changes but difficult to determine
secondary to LBBB. Troponins 0.07.Cardology reconsulted. gives
ASA,diuresed with lasix and IV NTG gtt and heparin Gtt
began.Bedside Echo obtianed.regional wall motion abnormalities
noted. EF 25-30%(base line )
[**2176-1-28**] lisinopril and imdur increased for afterload reduction
and SBP control.lasix was began at 80mgm [**Hospital1 **] and titrated to
volumne status.hold beta blockers but may use intraop if need
control b/p. Should not require a pacemaker at this popint per
EPS service.
[**2176-1-29**] continue toadjust diuretics and antihypertensives. Imdur
and lisiopril dosing increased, norvqsc suggested to be added to
medical regiment if SBP not under 140, lqsix readjusted to 60mgm
[**Hospital1 **]. On [**2-1**] pt underwent L fem-AK [**Doctor Last Name **] BPG; postoperatively, pt
was hypotensive in the PACU; a PA catheter was placed,
cardiology was consulted, and a swann was placed. IVFs were
increased to 120cc/hr, and pt was transfused blood as well, but
she continued to have labile BP and an increasing base excess.
Patient's lactate increased from [**1-8**] at this point, the pt went
into rapid v-tach, and ACLS protocol was started. Despite
exhaustive efforts, after 40 minutes pt was unresponsive and she
was pronounced dead @ 2:15AM on [**2176-2-2**].
Medications on Admission:
Aricept 10qhs, Lasix 40'', Lopressor 50'', Isosorbide 30',
Lisinopril 10', Digoxin .125mg', Tramadol 50mg prn, Fentanyl
patch 25 q 72 hours, depakote 125 qhs, gabapentin 300", lantus
10u qhs, lipitor 40 qhs, omeprazole 20',
Discharge Medications:
none
Discharge Disposition:
Extended Care
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Completed by:[**2176-4-5**]
|
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9,144
| 178,473
|
51462
|
Discharge summary
|
report
|
Admission Date: [**2141-12-27**] Discharge Date: [**2142-1-4**]
Date of Birth: [**2071-3-7**] Sex: M
Service: MEDICINE
Allergies:
Percocet / Ciprofloxacin
Attending:[**First Name3 (LF) 2972**]
Chief Complaint:
chest pain & shortness of breath
Major Surgical or Invasive Procedure:
Cardiac catheterization with Drug eluting stents x2 to ostial
and mid RCA.
History of Present Illness:
Mr. [**Known lastname **] is a 70 year old man with a complicated history
including CAD s/p CABG in [**2130**], PVD, systolic CHF (EF 45-50% in
[**11-15**]) w/ diastolic dysfunction, severe COPD, severe AS (0.8cm2)
& AI who presents as a transfer from [**Hospital6 **] for
respiratory failure. Mr. [**Known lastname **] has been hospitalized multiple
times in the last several months for respiratory failure and has
been intubated 3 times over the past 3 months most recently in
early [**Month (only) 404**] at [**Hospital1 34**]. Following his most recent discharge, he
was seen by his PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) 216**] on [**2141-12-13**] for persistent upper
respiratory symptoms and placed on a Z-pack. His symptoms
improved, but the patient's wife called the patient's PCP 3 days
prior to this admission stating that the patient had developed
worsening cough productive of thick yellow-green sputum and
worsening shortness of breath on his home 2L O2, as well as
chest tightness that resolved after SL NTG x 2. At that time,
his wife reported that he had no chest pain, nausea, sweating,
[**Date Range **], chills, vomiting or dizziness and he was directed to
[**Hospital6 33**] for further evaluation.
.
For unclear reasons, he did not seek care until the day prior to
admission when his breathing and chest pain symptoms worsened.
He was taken to [**Hospital6 33**] by ambulance and found to
be non-verbal in the ED. CXR was negative and pBNP was 3969. He
was initially treated for presumed systolic CHF exacerbation and
COPD with CPAP, IV Solumedrol, nebulizers, Lasix, and Nitrates.
He was also given a dose of IV Levaquin out of concern for
infection but his respiratory rate declined and his ABG's
demonstrated severe respiratory acidosis so he was intubated in
the [**Hospital3 **] ED. In the ICU, EKG's demonstrated sinus
tachycardia with left anterior fascicular block and ST
depressions in II, V3, V4. CE's rose with CK's peaking at 229
and Troponin levels peaking at 0.45. He was placed on a Heparin
gtt, ASA, beta-blocker, and a statin. The following morning, his
respiratory status improved and he was extubated and placed on
BIPAP before being transferred to the [**Hospital1 18**] at family request.
.
On arrival to the CCU, the patient was noted to be on BIPAP, but
not in respiratory distress. He was able to speak with the
health care team, but demonstrated a visible left hand tremor
and was relative immobile.
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.
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:CABG '[**30**] (LIMA -> LAD, SVG -> D2, OM2, RCA; stent to RCA
graft '[**32**]). Has three vessel coronary disease
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
3. OTHER PMH:
- severe AORTIC STENOSIS (mean gradient 47 mmHg)
- h/o [**Name (NI) **] [**Doctor Last Name 27089**] (unclear when)
- Hyperlipidemia
- Obstructive sleep apnea
- GERD
- Anxiety
- Colon cancer s/p sigmoid colectomy w/ colorectal anastomosis
'[**37**] and adjuvant Xeloda therapy
- PVD
- B12 deficiency anemia
- Ascending aortic aneurysm (4.2x4.2 in [**4-13**])
- Anterior wall abdominal hernia
- COPD
- HTN
- Asthma
Social History:
Tobacco: 150 pk-year smoker (currently smokes 1ppd and more in
the past), still smoking.
EtOH: Greater than 50 years of significant EtOH (previously
reported 4 tumblers of vodka/day, recently reporting 2-4 beers
per day).
Illicits: None
Used to work in security and at a mattress factory, has not
worked for several years.
Walks without assistance at baseline.
Family History:
Dad died of MI at 57. 2 brother had MI. One brother had
emphysema. One other brother with brain tumor.
Physical Exam:
VS on admission: T 97.3 BP 128/73 HR 89 RR 8 O2 sat 98% on BIPAP
at 30% FiO2
GENERAL: Well-developed elderly man in NAD. Oriented x3. Mood,
affect appropriate.
HEENT: NC/AT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: JVD not able to be assessed [**1-9**] soft tissue obscuring
anatomy
CARDIAC: RRR, normal S1, S2. No murmurs audible. No thrills,
lifts. No S3 or S4.
LUNGS: No chest wall deformities. CTAB, no crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NT/ND, large ventral hernia with multiple
abdominal scars throughout the abdomen. No HSM. Abdominal aorta
not enlarged by palpation. No abdominal bruits. Positive bowel
sounds.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 1+
Left: DP 1+
NEURO: CNII-CXII intact, able to follow commands, easily
conversant, moving all extremities
Pertinent Results:
2D-ECHOCARDIOGRAM [**2141-11-27**]: OSH, EF 45-50%, with aortic valve
area of 0.8cm2 and [**1-10**]+ aortic insufficiency.
.
[**10/2141**]: The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
There is mild global left ventricular hypokinesis (LVEF =
45-50%). Right ventricular chamber size and free wall motion are
normal. The ascending aorta is mildly dilated. The aortic valve
leaflets are moderately thickened. There is severe aortic valve
stenosis (valve area 0.8cm2). An eccentric jet of mild (1+)
aortic regurgitation is seen. The mitral valve leaflets and
supporting structures are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is an anterior space which most likely
represents a fat pad.
IMPRESSION: Severe aortic valve stenosis. Mild symmetric left
ventricular hypertrophy with mild global hypokinesis. Mild
pulmonary artery systolic hypertension. Mild aortic
regurgitation.
Compared with the report of the prior study (images unavailable
for review) of [**2136-5-18**], the severity of aortic stenosis has
progressed, mild aortic regurgitation is now seen, left
ventricular systolic function is less vigorous, and the
estimated pulmonary artery systolic pressure is higher.
.
CARDIAC CATH [**2139-10-3**]:
RIGHT ATRIUM {a/v/m} -/[**5-12**]
RIGHT VENTRICLE {s/ed} 33/7
PULMONARY ARTERY {s/d/m} 33/10/20
PULMONARY WEDGE {a/v/m} -/[**10-17**]
LEFT VENTRICLE {s/ed} 143/11
AORTA {s/d/m} 128/53/80
SYSTEMIC VASC. RESISTANCE 1604
PULMONARY VASC. RESISTANCE 214
.
PROXIMAL LAD 40% stenosis
MID-LAD 100% stenosis
DIAGONAL-1 100% stenosis
DIAGONAL-2 DIFFUSELY DISEASED
OM-2 90% stenosis
.
Impressions:
1. Three vessel native coronary artery disease.
2. Known occlusion of all SVGs.
3. Patent LIMA-LAD graft.
4. Mild pulmonary arterial hypertension.
5. Severe, but noncritical aortic stenosis.
6. Normal biventricular diastolic function.
CT Abd/pelvis Noncon [**12-31**]
CT ABDOMEN WITHOUT IV CONTRAST: Lung bases are clear without
consolidation or pleural effusion. The heart size is normal
without pericardial effusion. Dense calcification of the
coronary arteries is noted.
In the abdomen, assessment of solid organs is limited in the
absence of IV
contrast. However, the liver is grossly unremarkable. A focal
hypodensity
anteriorly is unchanged and likely represents focal fatty
infiltration. A
small gallstone is present in a decompressed gallbladder. The
pancreas,
spleen, adrenal glands and kidneys are grossly unremarkable.
There is no
hydronephrosis in either kidney. Perinephric stranding size is
unchanged.
The stomach and duodenum are distended with fluid and small
amount of ingested material. The esophagus also contains fluid.
There is no free air or free fluid in the abdomen. The abdominal
aorta
demonstrates atherosclerotic calcification, but is normal in
caliber. There is no mesenteric or retroperitoneal
lymphadenopathy by size criteria.
CT PELVIS WITHOUT IV CONTRAST: Large bowel demonstrates residual
oral
contrast material, possibly from the CT of [**2141-12-13**] or
from an outside hospital study. Loops of small bowel are
distended, extending to the distal small bowel. Both small and
large bowel extends into a large, wide-based ventral hernia. A
transition in small bowel caliber is noted just adjacent to the
ventral hernia, with a small segment of fecalization of contents
of the dilated small bowel, measuring up to 4 cm. Distally,
there is marked decompression of the distal and terminal ileum.
The colon is relatively decompressed, although still retained a
small amount of stool and contrast material. There is no
extraluminal fluid or air. The sigmoid colon demonstrates
scattered diverticulosis without diverticulitis. There is no
free fluid layering dependently in the pelvis. The urinary
bladder contains excrete contrast material. There is no pelvic
or inguinal lymphadenopathy by size criteria. A fem-fem bypass
graft is in place. The patient has undergone prior low anterior
resection and surgical material is present at the rectosigmoid
junction.
OSSEOUS STRUCTURES: Degenerative changes are present throughout
the lower
spine, with no interval change. There is no new fracture.
IMPRESSION:
1. High-grade small-bowel obstruction, with dilatation of
proximal loops up to 4 cm, and complete decompression of the
distal and terminal ileum.
Obstruction may be early, as there is residual oral contrast and
stool within the colon, which is minimally decompressed. No
evidence of perforation. Obstruction occurs adjacent to the
mouth of the large ventral hernia. However, both dilated and
decompressed loops pass into and out of the hernia sac.
Obstruction may be related to adhesions.
2. Cholelithiasis without cholecystitis.
3. Diverticulosis without diverticulitis.
4. No evidence of obstruction at the rectosigmoid anastomosis.
5. Atherosclerotic disease.
[**1-1**] abd x-ray
Single supine portable abdomen radiograph was obtained. The
radiograph
demonstrates focal mild dilatation of small bowel loops in the
epigastric
region measuring 3.2 cm, consistent with the small bowel loops
seen within the ventral hernia on the prior CT scan. Air is seen
within the descending colon and the rectum. The relative lack of
air in the distal small bowel suggests likely partial or early
small bowel obstruction. There is no intraperitoneal free air.
The NG tube terminates at the gastroesophageal junction, and the
sideholes
likely are at the distal esophagus. Recommended advancement of
the NG tube.
IMPRESSION:
1. Findings suggestive of early/partial small bowel obstruction.
2. Recommended further advancement of the NG tube.
Labs at admission:
9>31.8<142
(WBC peaked at 15.3 on [**12-31**] in the context of steroids)
N 90, L7.1, M2.2, E0.6, B0.2
PT 12, PTT 116, INR 1.0 (normalized at discharge)
137/3.8/99/30/25/1.3<171
(Cr peaked at 2.6 on [**12-31**] and was 1.2 at discharge)
ALT 46, AST 45, LD 262, CK 124, Alk Phos 48, TB 0.4
(this was peak CK), other LFTS normalized before discharge
Brief Hospital Course:
70 year old man with a complicated history including CAD s/p
CABG, PAD, systolic CHF (EF 45-50% in [**10-16**]) w/ diastolic
dysfunction, severe COPD, severe AS (0.8cm2) & AI and a severe
ventral hernia who presents as a transfer from [**Hospital3 **] for respiratory failure. After rapid stabilization of
his respiratory status, he went for a cath with PCI with DESx2
to the RCA on [**12-29**]. He had intermittent abdominal pain that
progressed to an SBO on [**12-31**]. Patient made progressively less
urine and was transferred to MICU through [**1-1**]. He was sent to
the cardiology service on [**1-1**] and the SBO subsequently
resolved.
# Small bowel obstruction
Patient has history of severe ventral hernia s/p laparotomy for
colon resection and intermittent abdominal pain, last on
[**2141-12-13**]. He received a CT ABD with contrast that was negative
for SBO at that time. On [**12-28**] he complained of abdominal pain
that passed with ativan and simethicone. On [**12-30**] he had
constipation, [**12-31**] he had obstipation, bilious emesis and acute
renal failure. A NGT was placed. Surgery was consulted. All PO
only medications were held except for Plavix which was given
down the NGT. Surgery followed and his NGT drainage decreased
and he started to have BMs on [**1-2**]. On [**1-2**] the NGT was pulled.
Mr. [**Known lastname 9907**] then had intermittent nausea without vomiting which
resolved with Ranitidine. He continue to have BMs and flatus.
# ARF: On [**12-30**] he developed ARF in the setting of SBO. Patient
made very little urine and was therefore transfered to a MICU
for management of fluid status given ARF and Aortic stenosis.
IVF were started and a foley catheter was placed which was
subsequently removed with voiding prior to discharge. His
creatinine at d/c was 1.2, at his baseline.
# Respiratory failure/ COPD
Patient with known history of COPD, Asthma, and OSA as well as
an extensive smoking history. He is on 2L of continuous O2 as
well as Albuterol, Advair, and Tiotropium at home and over the
past 3 months has required multiple intubations for respiratory
distress despite repeated courses of Prednisone & antibiotics,
most recently approximately 2 weeks PTA. He was intubated on
[**12-26**] at [**Hospital1 34**] for an ABG of 7.12/91/62/32 and was extubated on
[**12-27**] AM to CPAP prior to transfer after improved respiratory
status. Etiology likely obstructive lung disease with systolic
CHF as patient did not demonstrate e/o infection. In the CCU,
the patient was placed on BIPAP and eventually weaned to 2L of
NC over approximately 24 hours. He received 40 mg of Prednisone
daily and a course of levaquin. By [**12-31**], he was on 2 litres,
saturating at 97%. He was able to tolerate room air with good
saturations on day of discharge. He was discharged with a slow
steroid taper.
# Systolic Heart Failure
Diasolic Heart Failure
Aortic Stenosis, Severe
Aortic Insufficiency
Patient with known systolic heart failure, last EF in [**11-15**]
demonstrated EF 45-50% with severe AS (mean gradient 47 mm Hg
and area 0.8cm^2) and [**1-10**]+ AR. His EF is unchanged from
echocardiograms, but as his AR has progressed significantly
since his last echo one month prior, his true forward flow is
likely more compromised than his EF would suggest. CXR's from
OSH have not demonstrated e/o congestion or effusions and
clinical exam does not support fluid overload, but pBNP was
elevated at 3969. Patient possibly a candidate for
percucanteous valve replacement vs valvuloplasty however this
decision will be deferred to the outpatient setting.
# CORONARIES: Patient s/p CABG '[**30**] (LIMA -> LAD, SVG -> D2, OM2,
RCA; stent to RCA graft '[**32**]). His last cardiac catheterization
in [**2138**] demonstrated three vessel coronary disease with a patent
LIMA, but occlusion of all vein grafts. Patient with possible
old inferior MI based on micro-Q waves in II, III, AvF, but EKG
on admission does not demonstrate new ST changes. CE's trended
down from OSH levels (peak CK 229) and patient was CP free.
Patient initially on Heparin gtt, ASA, statin, beta-blocker. He
did not receive Plavix at OSH as he has a history of GI bleed
and thrombocytopenia while on Plavix. He was discharged with the
addition of Plavix and high-dose statin with high-dose aspirin.
# RHYTHM: Patient without known history of arrythmia, but
micro-Q waves in II, III, and AvF suggest prior inferior infarct
not seen on ECG from 11/[**2140**].
# Hypertension: Patient takes Imdur SR 120 mg daily & Metoprolol
Tartrate 25mg TID at home. Blood pressures at OSH and in CCU
were well-controlled. Given h/o AS, patient likely pre-load
dependent. Imdur and Metoprolol were restarted before discharge.
# Hyperlipidemia: Patient takes Simvastatin 20mg qHS at home.
Given question of ACS, high dose statin warranted. Fish oil was
also continued.
# Alcohol abuse: Patient with extensive EtOH history and an
episode of DT in [**11/2141**] requiring intubation. His EtOH screen
on [**12-26**] at [**Hospital1 34**] was negative and his wife reported that his last
drink was on [**12-25**]. Patient was maintained on a CIWA scale and
continued to get his home q8H prn Ativan for anxiety.
# Anxiety: Patient with h/o anxiety, on Celexa 80mg daily,
Lorazepam 1mg TID:PRN, and Seroquel 12.5mg [**Hospital1 **] at home. Per OMR
records, patient preferred not to take Seroquel out of concern
for side effects, so it is unlikely to be an active medication.
Home medications were continued.
# Peripheral vascular disease: Patient with known PAD s/p [**Hospital1 **]
Fem-[**Doctor Last Name **] bypass (unclear when). He also has a known ascending
aortic aneurysm last measured at 4.2cm x 4.2cm in 5/[**2138**]. ASA
325 and Pentoxyfylline SR 400mg TID were continued.
# Anemia: Patient with known Vitamin B-12 deficiency anemia for
which he receives daily supplementation. Iron studies during
this hospitalization were normal and he was continud on his home
B-12 1,000 mcg daily.
# GERD: Patient was continued on his home Omeprazole 20mg daily
and then was switched to an H2B before discharge. Ranitidine
worked better than Famotidine.
# H/o recurrent C. difficile colitis: Patient has failed
multiple Flagyl regimens in the past in the context of EtOH use,
and was ultimately successfully treated with an extended course
of Vancomycin. He did have an episode of diarrhea and abdominal
pain during this hospitalization which resolved. He had multiple
bowel movements after resolution of his SBO, likely thought to
be due to just improved motility.
# H/o Colon cancer: s/p sigmoid colectomy w/ colorectal
anastomosis
'[**37**] and adjuvant Xeloda therapy with resulting post-surgical
anterior wall abdominal hernia. Patient uses belt for hernia
control, but this has exacerbated SOB in the past, so it was not
utilized during this hospitalization.
# Active smoking habit: Patient smokes ~ 1ppd with >150 pack
year history. He was given a Nicotine TD during this
hospitalization and provided an Rx and counseling prior to
discharge.
CODE: FULL CODE (confirmed with patient's wife)
COMM: [**Name (NI) **] & patient's wife [**Doctor First Name **] [**Telephone/Fax (1) 106696**](h),
[**Telephone/Fax (1) 106697**](c))
Medications on Admission:
ALBUTEROL SULFATE 90 mcg HFA Inhaler 1-2 puffs q4-6H:PRN
AMITRIPTYLINE 50 mg qHS
CITALOPRAM 80mg daily
FLUTICASONE-SALMETEROL 500 mcg-50 mcg [**Hospital1 **]
HYDROCODONE-ACETAMINOPHEN 5 mg-500 mg [**Hospital1 **]:PRN
IPRATROPIUM-ALBUTEROL 2.5-0.5 mg/3 mL NEB QID
ISOSORBIDE MONONITRATE SR 60 mg daily
LORAZEPAM 1 mg TID:PRN anxiety
METOPROLOL TARTRATE 25mg [**Hospital1 **]
NITROGLYCERIN 0.4 mg SL PRN:chest pain
OMEPRAZOLE EC 20 mg daily
PENTOXIFYLLINE SR 400 mg TID
PREDNISONE taper (taper unknown)
QUETIAPINE 12.5 mg Tablet [**Hospital1 **]
SIMVASTATIN 20 mg qHS
TIOTROPIUM BROMIDE 18 mcg, 1 puff daily
ASPIRIN 81 mg Tablet [**Hospital1 **]
CYANOCOBALAMIN 1,000 mcg daily
OMEGA-3 FATTY ACIDS 1,000 mg daily
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Take every day for one year, do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] or
stop taking. .
Disp:*30 Tablet(s)* Refills:*11*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*28 Tablet(s)* Refills:*2*
3. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO at bedtime.
5. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) puff Inhalation twice a day.
6. Pentoxifylline 400 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO TID (3 times a day).
7. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO twice a day.
8. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) puff Inhalation once a day.
9. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO
DAILY (Daily).
11. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*28 Patch 24 hr(s)* Refills:*2*
12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six
(6) hours as needed for pain: do not take more than 4 grams in
24 hours.
13. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: [**12-9**] Inhalation Q4H (every 4 hours) as needed
for shortness of breath, wheezing.
14. Citalopram 40 mg Tablet Sig: One (1) Tablet PO twice a day.
15. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for anxiety.
16. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
17. Prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day.
18. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
19. Isosorbide Mononitrate 120 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
20. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
21. Prednisone 5 mg Tablet Sig: 1-2 Tablets PO once a day: take
2 tablets (with your 20mg tablets to equal 30mg) through [**1-6**];
on [**1-7**] start taking one tablet (with your 20mg tablets to equal
25mg).
Disp:*30 Tablet(s)* Refills:*2*
22. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for shortness
of breath or wheezing: use in place of your nebulizer.
Disp:*1 INH* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] [**Hospital3 269**]
Discharge Diagnosis:
Acute on Chronic Systolic and Diastolic congestive Heart Failure
Chronic Kidney Disease, Stage 2
Chronic Obstructive Pulmonary Disease Exacerbation
Aortic Valve Stenosis
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
You had trouble breathing and needed to be intubated at [**Hospital 7912**]. You were extubated and transferred to [**Hospital1 **] [**First Name (Titles) **] [**Last Name (Titles) 4656**] your heart.
You were treated with antibiotics for COPD (emphysema) and given
prednisone and nebulizer treatments to help your oxygen level.
A Cardiac catheterization showed blockages in your arteries
which may have made your breathing worse. You had 2 stents
placed in an artery in your heart. You will need to be on Plavix
for one year and possibly longer. It is extremely important that
you take Plavix and aspirin every day and not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**].
Missing [**Last Name (Titles) 4319**] could cause your stents to clot off and cause a
heart attack or death
While you were here some of your medications were changed.
You should CONTINUE taking:
-Imdur 120mg daily
-Metoprolol 25mg three times a day
-Tylenol 325-650mg every 6 hours as needed for pain
-Albuterol nebs four times a day and every 2 hours as needed for
shortness of breath or wheezing
- Amitriptyline 25mg nightly
- Celexa 20 mg twice a dy
- Advair 500/50 twice a day
- multivitamin daily
- trental 400mg three times a day
- Seroquel 12.5mg twice a day
- Spiriva 18 mcg daily
- Fish oil
- Vitamin B1 and B12
- Ativan 1mg every 8 hours as needed for anxiety. You should not
drive with this medication.
You should START taking:
- Plavix 75 mg daily
- take bactrim for PCP pneumonia prevention because of your
steroids until your doctor tells you to stop it
- You should stop smoking. Use the nicotine patch once a day to
help. DO NOT smoke while using the patch since it can be even
more dangerous for your heart.
You should CHANGE:
- INSTEAD of Aspirin 81 mg daily START spirin 325mg and your
cardiologist will let you know when to come down to 81mg
- Increase your Simvastatin to 80 mg daily
- STOP Prilosec and INSTEAD START Ranitidine for reflux since
Prilosec an interfere with your new heart stents.
- You should increase your Prednisone to 30mg daily (one 20mg
pill plus two 5mg pills) through [**1-6**]. On [**1-7**], start taking a
total of 25mg daily (one 20mg pill plus one 5mg pill)
.
Weigh yourself every morning, call Dr. [**Last Name (STitle) **] if weight goes up
more than 3 lbs in 1 day or 6 pounds in 3 days.
Followup Instructions:
You have the following appointments:
Appointment #1
MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Specialty: Cardiology
Date/ Time: [**Last Name (NamePattern1) 2974**], [**1-12**], 1:30
Location: [**Street Address(2) **], [**Location (un) **]
Phone number: [**0-0-**]
Special instructions for patient:
Appointment #2
MD: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 216**]
Specialty: Internal Medicine/ PCP
Date/ Time: Wednesday, [**2143-1-10**]:10am
Location: [**Hospital Ward Name 23**] building, [**Location (un) 453**], Atrium Suite
Phone number: [**Telephone/Fax (1) 250**]
|
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67,887
| 151,061
|
44036
|
Discharge summary
|
report
|
Admission Date: [**2184-12-3**] Discharge Date: [**2184-12-13**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
fever, hypoxia
Major Surgical or Invasive Procedure:
Central venous catheterization
History of Present Illness:
[**Age over 90 **] yo Russian speaking male with sCHF (~ 36% on echo [**3-/2184**]),
CAD, critical AS < 0.8 cm^2, COPD on 2L NC (FEV1 121% in [**2179**])
presents from [**Hospital1 100**] Senior Life with fever up to 103,
tachycardia to 110s, and reported hypoxia down to 66% on RA.
Per report, patient was given Tylenol 650 mg at 9PM and then
brought in by EMS for further evaluation. He was placed on NRB.
Upon arrival to the ED, VS 102.5 110 107/53 32 98% 10L NRB.
Apparently patient was oriented and denied any complaints, such
as fever, chest pain, SOB, any other pain. He was noted to be
drowsy on exam. There was concern for PNA although CXR was per
report without obvious infiltrate. He was tried on
non-invasives, but it did not improve his respiratory status,
had poor seal, and in fact, patient constantly tried to take the
mask off. He was given vancomycin and zosyn for presumed
pneumonia. Then, UA was found to be grossly positive. He was
also noted to be hypotensive to SBP in the 70s. LIJ was placed
and he received 1 L of IVF. Upon transfer, VS 94 92/48 35 97%
NRB
On the floor, patient was awake. He denied any pain. He stated
to the daughter over the phone that he was comfortable.
Review of systems:
(+) Per HPI
(-) Denies night sweats, recent weight loss or gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denies
cough, shortness of breath, or wheezing. Denies chest pain,
chest pressure, palpitations, or weakness. Denies nausea,
vomiting, diarrhea, constipation, abdominal pain, or changes in
bowel habits. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
- Critical AS w/ valve area of < 0.8cm2 on echo [**3-/2184**]; followed
by
Dr. [**Last Name (STitle) **]
- CAD s/p MIx2 in the distant past; last P-MIBI in 04/[**2178**].
Catheterization was deferred given chronic renal failure and
potential risks.
- sCHF, last EF 36% ([**3-/2184**])
- Mild LVH
- Mild (1+) mitral regurgitation
- Mild (1+) aortic regurgitation
- History of PE s/p hip surgery, with right atrial thrombus s/p
right atrial thrombectomy in [**2165**]. He is also s/p IVC filter
placement
- hypertension
- hyperlipidemia
- peripheral vascular disease
- Type II DM
- Osteoarthritis, s/p L hip arthroplasty in [**2165**]
- Chronic LE edema
- tremor
- COPD on home O2
- Parkinsonism
- H/o left proximal femoral periprosthetic intertrochanteric
fracture [**3-/2184**]
Social History:
- Patient was an aeronautical engineer in [**Country 532**].
- Currently living at [**Hospital1 100**] Senior Life.
- Tobacco use 100 pack years but quit several years ago
- Denies ETOH, IVDU.
Family History:
Father with history of early sudden cardiac death. Brother with
stomach cancer. Brother with [**Name (NI) 5895**] disease.
Physical Exam:
ADMISSION EXAM
VS 98.2, HR 84, BP 85/45, RR 22, O2Sat 98% 50% standby
General: comfortable, opens eyes to voice, no acute distress
HEENT: sclera anicteric, mucous membrane moist, oropharynx clear
Neck: supple, JVD to the [**1-12**] of the neck, no LAD
Lung: + crackles up to [**1-12**] of the lung on the left and slightly
better on the right, no wheeze or rhonchi
CV: RRR, + 4/6 SEM, no rub or gallop
Abd: obese, soft, NT, ND, BS+
Extremities: 2+ pitting edema up to the thighs, 2+ DP pulses R
and 1+ DP on the L
GU: + Foley with sediments
.
DISCHARGE EXAM
VS: 98.0, 69, 98/51, 26, 92% on 3L
GEN: NAD
HEENT: PERRL, MMM, OP clear
NECK: supple, JVP at mid neck
HEART: RRR, 4/6 SEM with radiation to carotids
LUNG: CTA BL
ABD: soft, NT/ND, +BS
EXT: 1+ pitting edema to thigh, 1+ sacral edema
Pertinent Results:
ADMISSION LABS
CBC
[**2184-12-3**] 10:35PM BLOOD WBC-6.1 RBC-4.56* Hgb-13.2* Hct-39.4*
MCV-86 MCH-29.0 MCHC-33.5 RDW-13.9 Plt Ct-158#
[**2184-12-3**] 10:35PM BLOOD Neuts-92.3* Lymphs-3.9* Monos-1.3*
Eos-2.0 Baso-0.4
[**2184-12-3**] 10:35PM BLOOD Glucose-223* UreaN-33* Creat-1.3* Na-141
K-3.3 Cl-105 HCO3-24 AnGap-15
[**2184-12-3**] 10:35PM BLOOD PT-28.9* PTT-30.9 INR(PT)-2.8*
.
DISCHARGE LABS
[**2184-12-13**] 06:20AM BLOOD WBC-10.5 RBC-3.82* Hgb-11.0* Hct-32.9*
MCV-86 MCH-28.7 MCHC-33.4 RDW-13.6 Plt Ct-333
[**2184-12-13**] 06:20AM BLOOD PT-13.8* PTT-29.5 INR(PT)-1.3*
[**2184-12-13**] 06:20AM BLOOD Glucose-143* UreaN-24* Creat-1.2 Na-142
K-3.3 Cl-99 HCO3-36* AnGap-10
[**2184-12-13**] 06:20AM BLOOD Calcium-8.3* Phos-3.8 Mg-2.5
[**2184-12-13**] 04:28PM BLOOD Glucose-118* UreaN-26* Creat-1.2 Na-136
K-3.9 Cl-94* HCO3-32 AnGap-14
.
CARDIAC ENZYMES
[**2184-12-3**] 10:35PM BLOOD CK(CPK)-80
[**2184-12-3**] 10:35PM BLOOD CK-MB-5 cTropnT-0.12* proBNP-2871*
[**2184-12-4**] 05:20AM BLOOD CK-MB-13* MB Indx-6.0 cTropnT-0.55*
[**2184-12-4**] 02:51PM BLOOD CK-MB-8 cTropnT-0.46*
.
LACTATE
[**2184-12-3**] 10:43PM BLOOD Lactate-3.2*
[**2184-12-4**] 05:41AM BLOOD Lactate-2.6*
.
URINE STUDIES
[**2184-12-3**] 11:25PM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.012
[**2184-12-3**] 11:25PM URINE Blood-LG Nitrite-POS Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG
[**2184-12-3**] 11:25PM URINE RBC-155* WBC->182* Bacteri-MOD Yeast-NONE
Epi-0
[**2184-12-3**] 11:25PM URINE WBC Clm-MANY
.
MICROBIOLOGY
Legionella Urinary Antigen (Final [**2184-12-4**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other L.
pneumophila serogroups or other Legionella species. Furthermore,
in infected patients the excretion of antigen in urine may vary.
.
Urine [**12-3**] - positive for pansensitive E.coli
Blood Cx [**12-3**], [**12-4**] X2, [**12-6**], [**12-8**] all no growth
MRSA screening pos
Sputum - Commensal Respiratory Flora
.
CXR [**12-3**]
FINDINGS: Single AP upright portable view of the chest was
obtained. The patient is status post median sternotomy. There
are low lung volumes. Blunting of the right costophrenic angle
may be due to a trace effusion. Subtle bilateral patchy
opacities may relate to infection versus mild volume overload.
Cardiac and mediastinal silhouettes are stable. No pneumothorax.
.
CXR [**12-10**]
In comparison with the study of [**11-7**], there is again
enlargement of the cardiac silhouette with substantial pulmonary
edema and bilateral pleural effusions with compressive
atelectasis at the bases.
.
ECHO [**12-7**]
The left atrium is moderately dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity is moderately dilated.
There is mild to moderate global left ventricular hypokinesis
(LVEF = 35-40%). Right ventricular chamber size is normal with
mild global free wall hypokinesis. The aortic valve leaflets are
severely thickened/deformed. There is critical aortic valve
stenosis (valve area <0.8cm2). Mild (1+) aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Mild (1+) mitral regurgitation is
seen. There is no pericardial effusion.
.
IMPRESSION: Dilated left ventricle with mild to moderate global
systolic dysfunction. Mild right ventricular systolic
dysfunction. Critical calcific aortic stenosis. Mild aortic
regurgitation. Mild mitral regurgitation.
Brief Hospital Course:
[**Age over 90 **] yo Russian speaking male with critical aortic stenosis and
systolic CHF as well as COPD on 2L O2 by nasal cannula at
baseline presenting from [**Hospital1 100**] Senior Life with rigors, fever
to 103, tachycardia and hypoxia in the setting of UTI.
1) Acute on chronic systolic heart failure/chronic AS: The
patient has known critical AS and is not an operative candidate
due to age and recent comorbid conditions (percutaneous valve
was considered at one time but likely not feasible at this time
given multiple recent medical issues). On admission he was
hypotensive, likely due to peripheral vasodilation in the
context of sepsis and capillary leak. The patient was bolused
and developed massive lower extremity edema and crackles over
both lung fields with pulmonary edema seen on chest radiograph.
He was diuresed successfully in the MICU and later on the floor.
He was initially treated with oral lasix and later with lasix
gtt, which he tolerated well. However he remains fluid
overloaded on exam with pitting edema up to his sacrum. He was
already on 12mg of lasix and we added Melolazone 2.5mg to his
current regimen. He has responded well and has remained
hemodynamically stable. His BP at baseline in the 90s-100s/50s
which is thought to be due to his critical AS. Of note, the
patient is not on beta blocker or ACEi due to low blood
pressure.
- cont on lasix drip at 12mg/hour (please titrate to UO
>100cc/hour) as BP tolerates
- Monitor electrolytes and creatine [**Hospital1 **] while pt is on lasix
drip (last checked this PM. He was given 20mEq of Kcl PO).
Please keep K> 4 and Mg >2
- I would switch back to oral Lasix 40 mg [**Hospital1 **] (or higher
depending on how pt responds) once sacral and thigh edema has
improved
- Cont on Metolazone 2.5mg [**Hospital1 **] as pt tolerates
- He has appointment with cardiologist in early [**Month (only) **], but trying
to schedule earlier appointment within 1-2 weeks
2) Sepsis: On presentation patient noted to be hypotensive with
SBP in the 70s and febrile in the ED with rigors and marked
leukocytosis. Pt had positive UA and urine culture positive for
pansensitive E.coli. Patient received vancomycin and
piperacillin/tazobactam in the ED for presumed infection with
pulmonary source (given marked hypoxia). On final read of
initial chest radiograph and MICU review pulmonary infection was
felt less likely. He was then treated for an UTI and antibiotic
was switched to Cipro which he had the last dose this evening.
Pt's BP improved to low 100s after three liters of IV fluid.
Septic physiology improved thereafter and patient remained
afebrile and with falling WBC count. Further minor hypotension
(SBP's in 90's which is his baseline). He is currently
hemodynamically stable.
.
3) COPD: The patient has a history of COPD diagnosed in the
[**2163**]. However, his PFT in [**2179**] showed FEV1/FVC at 121%.
During much of his hospitalization, crackles and signs of volume
overload predominated suggesting pulmonary edema, NOT COPD
exacerbation was the primary driver of his hypoxemia. He was
treated with duoneb prn.
.
4) ARF: Patient baseline creatinine is 0.9-1.0. This was
elevated at 1.3 on admission but quickly improved and stabilized
near 1.2.
.
5) Pneumonia: On presentation radiographs with no clear
infiltrate and patient had no signs or symptoms of pneumonia so
this was not thought a causative factor of his illness. Pt had
respiratory distress multiple times in the setting of volume
overload. Pneumonia was on the differential several times, and
pt was empirically covered with levofloxacin and vanco/zosyn at
times. However, his response to diuresis is consistent with
pulmonary edema. Pt remained afebrile and no leukocytosis and
not on treatment for pneumonia at the time of discharge.
.
CHRONIC ISSUES
# H/o CAD/HTN/HLD: On admission patient had elevated trop EKG
without significant changes felt to be reflective of demand
ischemia. Troponin was noted to trend downward. He was
continued on his home paravastatin and aspirin.
.
# Anticoagulation: Patient was on warfarin at presentation. The
indication was somewhat unclear. [**Name2 (NI) **] record, coumadin was
started during his hip surgery in [**2184-3-9**]. He had remote
history of DVT/PE in the setting of hip surgery. After patient
left MICU attending hospitalist discussed this with attending
physician at [**Hospital1 100**] [**Name9 (PRE) 13089**] Life who was also unable to declare
exact reason, simply reporting patient was on this medicine at
transition to long term care. By [**Hospital1 18**] records patient appears
to have been started on recent period of anticoagulation in
[**Month (only) 958**] of this year for prophylaxis after he sustained a hip
fracture. Given patient remains largely immobile and has a
history of venous thromboembolism with no history of bleeding
complications it seems reasonable to continue anticoagulation
for now with a low threshold to stop for problems. His current
INR is 1.3 (he was supratherapeutic on Sat and coumadin was
held. He was also given one dose of Vit K in the ICU last week).
Continue to monitor INR and titrate as needed
.
# T2DM- He was continued on insulin sliding scale while
admitted.
.
TRANSITIONAL ISSUES
# CODE STATUS: DNR/DNI (confirmed with daughter/HCP)
# Communication: Patient, daughter [**Name (NI) **] [**Telephone/Fax (1) 94555**] home,
[**Telephone/Fax (1) 94502**] cell
# MEDICATION CHANGES
- START lasix gtt (see below for details)
- START metalozone 2.5 mg [**Hospital1 **]
- START aspirin 325
- START aggressive bowel regimen given critical aortic
stenosis (Colace 100 mg [**Hospital1 **], Senna qd prn, MOM q6 prn, bisacodyl
po/pr prn)
# FOLLOW UP PLAN
- Recommend lasix gtt as pt has sacral and LE pitting edema,
likely [**5-18**] liter positive. Will target [**1-11**] liter negative as
BP and renal function tolerates. Will hold for SBP < 85 or DBP
< 45 or evidence of poor perfusion (baseline BP 90s/50s)
- Please check lytes at least [**Hospital1 **] given aggressive diuresis
- Recommend insulin sliding scale
- Follow up appointment with Dr. [**Last Name (STitle) **], [**Name8 (MD) **] MD (Phone:
[**Telephone/Fax (1) 62**]
Fax: [**Telephone/Fax (1) 9672**]). Currently scheduled on [**1-18**]. Will recommend
arrange an earlier appointment.
Medications on Admission:
- warfarin 3 mg Tues/Thurs/Sat
- warfarin 2.5 mg Sun/Mon/Wed/Fri
- warfarin 1 mg
- pravastatin 10 mg
- trazodone 100 mg qHS
- aspirin 81 mg daily
- cyanocobalamin 1000 mcg
- KCl 20 Meq
- Omeprazole 40 mg
- Miralax 17 g
- furosemide 40 mg [**Hospital1 **]
- furosemide 20 mg
- ammonium lactate qHS
Discharge Medications:
1. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
2. pravastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Q16 ON TUE,
THR, SAT ().
4. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Q16 ON SUN,
MON, WED, FRI ().
5. metolazone 2.5 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. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as
needed for constipation.
8. furosemide 10 mg/mL Solution Sig: titrate to neg [**1-11**] liter
fluid balance while pt still edematous as BP and kidney function
tolerate Injection INFUSION (continuous infusion): 5-15mg per
hour- titrate to UO> 100cc/hour. Hold or decrease rate for
SBP<90 .
9. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation: Please
hold for diarrhea.
10. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation: Please hold for loose BM/diarrhea.
11. insulin lispro 100 unit/mL Solution Sig: sliding scale
Subcutaneous ASDIR (AS DIRECTED).
12. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for
Nebulization Sig: One (1) neb treatment Inhalation every [**4-14**]
hours as needed for shortness of breath or wheezing.
13. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
14. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
15. Miralax 17 gram Powder in Packet Sig: One (1) PO once a day
as needed for constipation: Please hold for loose BM/diarrhea.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary Diagnoses:
- UTI with sepsis
- critical AS
- Acute on Chronic CHF
Secondary Diagnoses:
- Parkinsonism
- DM 2
- Peripheral Vascular Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname 94553**],
You were admitted at our hospital for urinary tract infection
that caused low blood pressure in the context of your very tight
valve in your heart. You were treated with antibiotics and
fluid initially to support your blood pressure. This necessary
treatment in the emergent setting on admission caused a lot of
burden to your already weakened heart. You were then given iv
medications to remove the fluid from your lungs. You improved
significantly and are being discharged back to the facility
where you lived previously.
.
Please note that the following medication has changed:
- Please START to take aspirin 325 mg tablet by mouth daily
- Please START to take Colace 100 mg tablet by mouth twice a
day, please hold for loose stool
- Please START to take senna 8.6 mg tablet daily as needed for
constipation
- Please START to take magnesium hydroxide suspension 30 cc
every 6 hours as needed for constipation
- Please START to take bisacodyl 5 mg tablet, 2 tablets daily by
mouth or through the rectum as needed for constipation
- Please START the furosemide iv drip titrate to daily fluid
balance negative (currently at 12mg/hour) [**1-11**] liter as your
blood pressure tolerates until your sacral and thigh edema
resolves.
- START Metolazone 2.5 mg PO BID until this is further Please
hold for SBP < 85
- There are no further changes to your medication
.
You have an appointment with Dr. [**Last Name (STitle) **] on [**1-18**] (see below for
details), however we are trying to get you an appointment in the
next 1-2 weeks. [**Hospital3 **] will help you take your
medications and titrate these as needed.
.
It has been a great pleasure taking care of you here at [**Hospital1 18**].
We wish you a speedy recovery.
Followup Instructions:
Department: CARDIAC SERVICES
When: MONDAY [**2185-1-17**] at 11:20 AM
With: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
- We will try placing an appointment with Dr. [**Last Name (STitle) 2052**] within
the next 1-2 weeks.
|
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|
2821, 3015
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,336
| 179,518
|
49474
|
Discharge summary
|
report
|
Admission Date: [**2102-12-6**] Discharge Date: [**2102-12-21**]
Service: GREEN [**Doctor First Name 147**]
HISTORY OF PRESENT ILLNESS: The patient was an 81 year old
woman at the time of admission, 82 years old at discharge who
presented with diffuse abdominal pain times one week,
increasing in intensity in the 24 hours prior to
presentation. It was associated with two episodes of coffee
ground emesis the evening prior to admission. No fever,
chills, shortness of breath, chest pain, bright red blood per
rectum or change in bowel or flatus habits. Patient had been
using increasing nonsteroidal anti-inflammatories over the
past three months for osteoarthritis. No history of ETOH
use.
PAST MEDICAL HISTORY: Arrhythmia (sick sinus syndrome with
intermittent/complete heart block) with pacemaker,
hypertension, mild aortic stenosis, CAD,
hypercholesterolemia, history of cardiovascular accident,
urinary incontinence, Diabetes mellitus Type II,
hypothyroidism, dementia of Alzheimer's type,
anxiety/depression.
PAST SURGICAL HISTORY: History of right hip fracture with
compression screw in [**2101-4-6**].
SOCIAL HISTORY: Resident of [**Hospital3 **] and Care
for the Aged.
FAMILY HISTORY: Noncontributory.
ALLERGIES: No known drug allergies.
MEDICATIONS AT [**Hospital1 5595**]: Zyprexa 5 qhs, Paxil 20 qd, Simethicone
80 qid, Detrol 1 mg [**Hospital1 **], Trazodone 50 qhs, Naproxen 500 [**Hospital1 **],
Glucotrol 2.5 qd, Synthroid 50 qd, Ativan 0.5 [**Hospital1 **],
Pilocarpine 5 tid.
PHYSICAL EXAMINATION: Vitals Pulse 80, blood pressure 90/49,
respirations 24, 02 sat 100% NRB. This is an uncomfortable
female with distended, tympanitic abdomen with diffuse
guarding, greatest in the epigastric area. Coffee ground NGT
aspirate. Guaiac positive stool. No bright red blood per
rectum. Of note: Umbilical hernia.
LABORATORY DATA: CBC: WBC 4.5, hematocrit 33.2, platelets
455, N44, Bd29, L24, Chem: Na 134, Cl 96, BUN 41, potassium
5.0, C02 23, creatinine 3.3. ABG: Metabolic acidosis.
Cardiac enzymes: Within normal limits x 1 on admission.
Liver enzymes: Within normal limits except for amylase 246
and lipase 1320.
Chest x-ray: Significant for free intraperitoneal air. EKG:
Normal paced rhythm.
HOSPITAL COURSE: Initial course, patient given fluid
resuscitation, started on broad-spectrum antibiotics and
taken to the OR for emergent exploratory laparotomy.
Intraoperatively, the abdomen was found to be filled with
purulent material. A 1 cm perforation in the anterior
duodenum was identified and was repaired with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **].
A 7 cm exophytic mass was also found to be emanating from the
left hepatic lobe. An intraoperative consult was obtained
and the mass was removed by Dr. [**Last Name (STitle) **]. Of note: On
pathology, the liver mass was determined to be a hemangioma.
Postoperatively, the patient was transferred to the SICU and
was discharged fro the SICU to the General Floor on POD#3.
Respiratory: The patient was initially kept intubated
postoperatively in order to protect airway until metabolic
acidosis corrected. She was extubated on POD #1. Patient
experienced wheezing which was improved by albuterol
nebulizer. Cardiology: Rhythm - Pacemaker interrogated on
HD#1, POD#0 and found to be functioning normally. Pump:
Patient experienced some increased difficulty breathing on
POD#5 and was found to have evidence of worsening CHF. The
patient was started on Lasix. Cardiac enzymes/EKG were
checked on POD#8 and there was no evidence of myocardial
infarction as precipitant for worsening CHF. Patient managed
on Lasix and was eventually able to be taken off Lasix prior
to discharge. Patient was placed on a perioperative beta
blocker. ID: Patient was initially on Ampicillin,
Levofloxacin, Flagyl and Fluconazole for broad-spectrum
coverage. Peritoneal swabs grew micrococcus/Stomatococcus.
Above antibiotics were continued. On POD#7, patient spiked a
temperature to 101.8. Cultures were done and CT was done to
rule out abscess. Central line culture was initially
reported as positive for gram positive cocci so patient was
changed from ampicillin to Vancomycin to cover possible MRSA
however further reporting described mixed flora and
Vancomycin was discontinued. Broad-spectrum antibiotics were
discontinued on POD#11. Patient found to have H. pylori.
Treatment for this was begun with Clarithromycin and
amoxicillin when patient was able to take PO on HD#11.
Patient should continue this until [**2102-12-26**] along with
ongoing proton pump inhibitor. Endocrinology: NIDDM:
Patient's oral hypoglycemics held during the admission and
fingersticks were monitored. Patient was given coverage by
regular insulin sliding scale. FEN: Patient initially
presented in acute renal failure, most likely secondary to
decreased intravascular volume. Renal function normalized
following fluid resuscitation. Patient initially kept NPO.
Started on TPN POD#3. Patient began to tolerate sips of
clears on POD#11 and was advanced, tolerating diabetic diet
at discharge. Musculoskeletal: Patient continued to
complain of arthritis pain, but given history of duodenal
perforation decision was made to avoid further NSAID use.
Patient noted control of pain with acetaminophen and Ultram
around the clock. Psych: Patient placed on outpatient
medications when able to tolerate.
LINES: RIJ triple lumen, Foley.
DISCHARGE MEDICATIONS: As admission except Metoprolol 25 [**Hospital1 **]
added. Tramadol 50 mg PO q 6 hrs for arthritis pain. All
NSAIDs discontinued.
DISPOSITION: To [**Hospital 100**] Rehab.
DISCHARGE STATUS: Alert and oriented to person. Not
agitated. Able to hold logical and intelligent conversation
and follow commands. Unable to ambulate and requiring [**Doctor Last Name 2598**]
lift for out of bed. Tolerating full diabetic diet.
DISCHARGE DIAGNOSIS: Perforated duodenal ulcer, liver
hemangioma, acute renal failure, congestive heart failure,
diabetes mellitus Type II, depression, anxiety, dementia of
Alzheimer's type, arrhythmia, gastritis, hypotension,
osteoarthritis. Code status: DNR/DNI at [**Hospital1 5595**]. DNR/DNI
withheld for surgery. Discharge follow up with Dr. [**Last Name (STitle) **]
in [**1-9**] weeks. Follow up with [**First Name8 (NamePattern2) **] [**Doctor First Name **], cardiologist
after discharge.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9325**], M.D. [**MD Number(1) 10637**]
Dictated By:[**Last Name (NamePattern1) 47939**]
MEDQUIST36
D:
T: [**2103-2-20**] 14:26
JOB#:
|
[
"250.00",
"427.31",
"584.9",
"424.1",
"E935.9",
"532.20",
"428.0",
"228.04",
"715.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"50.29",
"44.42",
"96.07",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
1218, 1523
|
5517, 5944
|
5966, 6681
|
2272, 5493
|
1058, 1131
|
1546, 2035
|
2053, 2254
|
147, 708
|
731, 1034
|
1148, 1201
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,734
| 195,488
|
19364
|
Discharge summary
|
report
|
Admission Date: [**2115-6-29**] Discharge Date: [**2115-7-12**]
Date of Birth: [**2067-10-16**] Sex: M
Service: MEDICINE
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
transferred from HD, hypoglycemic, febrile, delta-MS
Major Surgical or Invasive Procedure:
Hemodialysis
CVVH
History of Present Illness:
47yoM with h/o type I diabetes mellitus, ESRD on hemodialysis,
Addison's disease, chronic LLE ulcer transferred from dialysis
to with fever, hypoglycemia, and somnolence.
.
Patient was discharged from [**Hospital1 18**] [**2115-6-7**] after admission for
work-up of his LLE ulcer. He was discharged initially to
[**Hospital3 2558**] and then to home on continued iv oxacillin for
treatment of MSSA osteomyelitis. He has also continued on
weekly vancomycin dosed at dialysis. At dialysis today he was
noted to be more lethargic and was found to be hypoglycemic. He
was then transferred to [**Hospital1 18**] ED. On presentation to the ED T
101.8rectal, HR 94 BP 180/100, RR 18 97%RA with FS=19. He was
treated with 2amps D50 and then started on D5NS gtt. FS's
remain in 70s, and patient continued to be somnolent, and
insulin infusion was changed to D10 with improvement in FS to
116.
.
In the ED, head CT was negative for acute intracranial process.
LP was unremarkable. He received 2gm CTX empirically for
treatment of meningitis. Urinalysis and CXR were unremarkable;
blood and urine cultures are pending. ECG 75bpm, NSR, left-axis
and LVH, nml intervals, no ST/T changes.
.
On presentation he is arousable to voice, follows some commands,
and answers orientation questions appropriately, then
immediately falls back asleep.
Past Medical History:
1. Addison??????s Disease, dx [**2099**], on Hydrocortisone and florinef
2. IDDM- dx age 29, brittle diabetic h/o DKA and hyperglycemic
Sz
3. ESRD on HD , awaiting transplant from his sister (but not
with infxn)
4. AOCD, on procrit at dialysis
5. Peripheral Neuropathy
6. Peripheral Edema -chronic LE edema
7. CAD: s/p NSTEMI, echo [**5-20**] nl EF 1+ TR
8. ETT MIBI (-) at RPP of 18,000 in [**4-20**]. s/p right retinal hemorrhage repair
10. Hypothyroidism
11. Hypercholesterolemia
12. htn- poorly controlled
13. medicine non compliance [**12-19**] insurance issues?
14. recent non displaced left distal radial fracture s/p fall on
ice, in cast since [**2115-1-27**]
Social History:
No tob, Etoh, illicits, He is single w/ no kids and lives in
[**Location 3146**]. He was a former clerk/supervisor but is currently on
disability.
Family History:
Family History:
Father died age 50 due to cancer
Mother died age 60 due to breast cancer
4 brothers, 3 sisters: 2 siblings w/ DM
Physical Exam:
T 101.8 HR 67 BP 180/100 -> 126/80 -> 148/78 RR 18 97%RA
Gen: somnolent but arousable
HEENT: PERRL/sluggish reaction, anicteric, MMM
Neck: supple, no LAD, no thyromegaly, JVP nondistended
CV: RRR, no mrg, nml s1s2
Resp: CTAB
Abd: +BS, soft, NT, ND, no masses, no HSM
Ext: LLE w/ 2+ pitting edema, venous stasis changes, heal ulcer
without drainage, RLE muscle wasting
Neuro: PERRL, arousable to voice and pain, MAEW
Pertinent Results:
[**2115-6-29**] 12:20PM BLOOD WBC-7.9 RBC-4.96# Hgb-14.9# Hct-43.3#
MCV-87 MCH-30.0 MCHC-34.4 RDW-18.7* Plt Ct-167#
[**2115-6-30**] 04:14AM BLOOD WBC-12.4*# RBC-4.66 Hgb-13.6* Hct-41.9
MCV-90 MCH-29.3 MCHC-32.5 RDW-18.8* Plt Ct-172
[**2115-7-1**] 04:50AM BLOOD WBC-20.0*# RBC-4.06* Hgb-11.8* Hct-36.1*
MCV-89 MCH-29.0 MCHC-32.6 RDW-18.8* Plt Ct-194
[**2115-7-2**] 05:09AM BLOOD WBC-23.4* RBC-4.14* Hgb-12.2* Hct-36.9*
MCV-89 MCH-29.4 MCHC-33.0 RDW-19.1* Plt Ct-223
[**2115-7-3**] 04:29AM BLOOD WBC-19.0* RBC-4.10* Hgb-12.0* Hct-37.3*
MCV-91 MCH-29.3 MCHC-32.3 RDW-19.2* Plt Ct-219
[**2115-7-4**] 05:10AM BLOOD WBC-14.4* RBC-3.80* Hgb-11.2* Hct-34.6*
MCV-91 MCH-29.6 MCHC-32.5 RDW-19.4* Plt Ct-187
[**2115-7-7**] 05:44AM BLOOD WBC-13.6*# RBC-3.63* Hgb-10.8* Hct-33.1*
MCV-91 MCH-29.7 MCHC-32.5 RDW-19.7* Plt Ct-192
[**2115-7-9**] 02:55AM BLOOD WBC-7.4 RBC-3.46* Hgb-10.2* Hct-31.9*
MCV-92 MCH-29.4 MCHC-31.9 RDW-19.1* Plt Ct-217
[**2115-6-29**] 12:20PM BLOOD Neuts-68.3 Bands-0 Lymphs-15.4*
Monos-1.3* Eos-14.5* Baso-0.5
[**2115-7-2**] 05:09AM BLOOD Neuts-43* Bands-0 Lymphs-8* Monos-2
Eos-47* Baso-0 Atyps-0 Metas-0 Myelos-0
[**2115-7-3**] 04:29AM BLOOD Neuts-37* Bands-0 Lymphs-7* Monos-0
Eos-54* Baso-2 Atyps-0 Metas-0 Myelos-0
[**2115-7-4**] 05:10AM BLOOD Neuts-30* Bands-0 Lymphs-8* Monos-1*
Eos-61* Baso-0 Atyps-0 Metas-0 Myelos-0
[**2115-7-5**] 04:37AM BLOOD Neuts-49* Bands-0 Lymphs-6* Monos-3
Eos-41* Baso-0 Atyps-1* Metas-0 Myelos-0
[**2115-7-6**] 05:36AM BLOOD Neuts-74.4* Lymphs-12.3* Monos-2.9
Eos-10.1* Baso-0.3
[**2115-7-7**] 05:44AM BLOOD Neuts-67.6 Bands-0 Lymphs-10.5*
Monos-1.7* Eos-20.0* Baso-0.3
[**2115-7-9**] 02:55AM BLOOD Neuts-79.3* Lymphs-14.7* Monos-5.5
Eos-0.3 Baso-0.1
[**2115-6-30**] 04:14AM BLOOD PT-15.3* PTT-35.5* INR(PT)-1.6
[**2115-6-29**] 12:20PM BLOOD Glucose-23* UreaN-13 Creat-2.8* Na-141
K-3.2* Cl-99 HCO3-29 AnGap-16
[**2115-6-30**] 11:50PM BLOOD Glucose-533* UreaN-33* Creat-4.8* Na-127*
K-4.5 Cl-88* HCO3-21* AnGap-23
[**2115-7-1**] 09:00PM BLOOD Glucose-506* UreaN-47* Creat-5.7* Na-124*
K-4.3 Cl-87* HCO3-18* AnGap-23*
[**2115-7-2**] 12:25AM BLOOD Glucose-355* UreaN-48* Creat-5.8* Na-127*
K-3.6 Cl-90* HCO3-21* AnGap-20
[**2115-7-6**] 05:36AM BLOOD Glucose-403* UreaN-44* Creat-5.2* Na-135
K-4.0 Cl-99 HCO3-21* AnGap-19
[**2115-7-7**] 05:09AM BLOOD Glucose-48* UreaN-30* Creat-3.6* Na-141
K-3.6 Cl-103
[**2115-7-9**] 02:55AM BLOOD Glucose-24* UreaN-42* Creat-3.6* Na-134
K-4.0 Cl-94* HCO3-27 AnGap-17
[**2115-6-29**] 12:20PM BLOOD ALT-38 AST-30 LD(LDH)-229 AlkPhos-626*
Amylase-24 TotBili-0.9
[**2115-7-2**] 08:10AM BLOOD ALT-24 AST-21 AlkPhos-439* TotBili-0.3
DirBili-0.2 IndBili-0.1
[**2115-7-2**] 02:10PM BLOOD ALT-23 AST-19 CK(CPK)-26* AlkPhos-423*
TotBili-0.3
[**2115-7-5**] 04:37AM BLOOD ALT-28 AST-26 AlkPhos-449* TotBili-0.3
DirBili-0.2 IndBili-0.1
[**2115-7-7**] 05:09AM BLOOD ALT-28 AST-28 AlkPhos-427* TotBili-0.6
[**2115-7-7**] 05:44AM BLOOD ALT-29 AST-30 AlkPhos-427* TotBili-0.6
[**2115-6-29**] 07:00AM BLOOD Calcium-3.8* Phos-2.1*#
[**2115-6-29**] 12:20PM BLOOD Albumin-3.9 Calcium-10.5* Phos-2.4*
Mg-1.5*
[**2115-6-29**] 09:23PM BLOOD Calcium-8.5 Phos-3.8# Mg-1.3*
[**2115-6-29**] 12:20PM BLOOD TSH-1.6
[**2115-7-4**] 05:10AM BLOOD TSH-2.4
[**2115-7-6**] 12:04AM BLOOD ANCA-NEGATIVE B
CT HEAD W/O CONTRAST [**2115-6-29**]
INDICATION: Altered mental status.
FINDINGS: No hydrocephalus, shift of normally midline
structures, intra- or extraaxial hemorrhage, or acute major
vascular territorial infarct is identified. Surrounding osseous
and soft tissue structures are unremarkable. Imaged sinuses are
clear.
IMPRESSION: No acute intracranial pathology identified. Findings
were relayed to the ED dashboard at approximately 2 p.m., [**6-29**], [**2114**].
LIVER OR GALLBLADDER US (SINGLE ORGAN) [**2115-7-4**]
RIGHT UPPER QUADRANT ULTRASOUND: The liver is free of any focal
or textural abnormalities. The gallbladder is slightly distended
with areas of wall edema. There are multiple, echogenic and
shadowing stones within the gallbladder. There is no evidence of
pericholecystic fluid. There is no evidence of ascites. The flow
within the portal vein is hepatopetal. Incidental note is made
of an echogenic right kidney, compatible with the patient's
history of end-stage renal disease. The common bile duct is not
dilated at 4 mm.
IMPRESSION:
1. Cholelithiasis.
2. Equivocal for acute cholecystitis. The gallbladder is
slightly distended with wall edema, but there is no evidence of
pericholecystic fluid. This may be seen in third spacing of
fluid of end-stage renal disease.
CHEST (PA & LAT) [**2115-7-8**]
A large bore dialysis catheter remains in place, terminating in
the right atrium. There has been interval decrease in the heart
size and decreased caliber of the pulmonary vascularity.
Previously present diffuse perihilar haziness as well as
numerous thickened septal lines show interval improvement. No
confluent areas of consolidation are seen in either lung. There
are small bilateral pleural effusions, left greater than right.
IMPRESSION: 1) Resolving pulmonary edema, most likely due to
fluid overload. 2) No evidence of pneumonia.
Brief Hospital Course:
47yoM with h/o type I diabetes mellitus, ESRD on HD, HTN,
chronic LLE ulcer presenting with fever, hypoglycemia, and
change in mental status and admitted to the MICU
.
- Syncope during HD: Pt's original syncopal episode at
presentation was attributed to hypoglycemia (see below).
However, during the first week of the pt's MICU stay, 3 HD
attempts resulted in 2 syncopal and 1 pre-syncopal episodes
within 10-15 min from initiating dialysis. During those
episodes, the pt was not hypoglycemic. He did not spike fever
during or after these episodes. Blood cultures were drawn and
are negative to date. Various explanations were considered for
these episodes, including transient bacteremia-infected HD or
PICC line (but blood Cxs negative), allergic reaction to the HD
membrane and volume shift (but the episodes occurred very early
during HD, before significant volume was removed from the pt).
.
As the pt was not able to tolerate HD, he was started on CVVH,
which he tolerated w/o incident for 1 day, until, in the am of
the 2nd day of CVVH ([**2115-7-7**]), the pt reported feeling cold,
rigoring with recalcitrant hypoglycemia (FSBS = 48 @ 5:00 am)
despite 4 amps of D50. Finally settled out around BS = 100,
stopped CVVH @ 12:00 noon, then spiked a temp of 100.8 at 13:00.
Was pan-cultured, CXR ?RLL PNA/atelectasis and fluid overload
(official read: fluid overload). PICC line pulled and tip sent
for culture. Started on stress dose steroids of 100 mg IV q8 and
po steroids d/c'ed. Given one dose of gent + levofloxacin. By
5:00 pm pt looked much better, afebrile, no longer rigoring. The
next day, Monday [**2115-7-8**], pt was able to tolerate HD (low
filtration rate), but while on stress steroids and Abx
(levoflox-Vanc). Continued to do well on HD [**7-9**] and [**2115-7-10**], on
levofloxacin, Vanc (dosed per levels) and stress steroids.
Currently tapering stress steroids.
.
- Diabetes control/Hyperglycemia/Hypoglycemia: Patient has had
repeated episodes of hypoglycemia measured at dialysis in the
past. He p/w hypoglycemia, and he had additional hypoglycemic
episodes as mentioned above. This hypoglycemia was most likely
due to supratherapeutic insulin use in setting of changing
insulin requirements - ? possible (undocumented) infection.
Additionally, patient may have been adrenally insufficient on
presentation, as his baseline steroid dose (20 mg qam - 5 mg qpm
hydrocortisone) was changed to 5mg qHS after his last
hospitalization(unclear why). However, for most of his MICU
stay, the pt was hyperglycemic, occasionally necessitating
insulin gtt. Endocrine consult was called and helped manage the
pt's diabetes.
.
- Fever: etiology unknown; CXR, LP and UA nondiagnostic.
Originally on oxacillin + Vanc dosed at HD for treatment of LLE
osteomyelitis, but oxacillin stopped [**12-19**] concern re:
eosinophilia (see below). Continued on Vanc dosed for levels
<15, added levofloxacin as mentioned above for ? PNA. Fever
resolved and patient discharged to finish a course of Levo and
Vanc (dosed with HD).
.
- Addison's disease: After his last hospitalization in [**Month (only) 205**], the
pt's baseline steroid replacement dose (20 mg qam - 5 mg qpm
hydrocortisone) was changed to 5mg qHS -unclear why. The pt was
on inadequate dose on admission, but received 100 mg
hydrocortisone IVX1 originally and started on his correct dose.
So, presumably, from that point on he was on adequate
replacement dose. However, it is possible that the pt's baseline
steroid requirements have increased. Pt remained stable and was
discharged home on previous dose.
.
- Eosinophilia: Pt noted to have significant and persistent
eosinophilia during this hospitalization, despite being on
presumably adequate steroid replacement doses for his Addison's.
(Please note, after his last hospitalization in [**Month (only) 205**], the pt's
baseline steroid replacement dose (20 mg qam - 5 mg qpm
hydrocortisone) was changed to 5mg qHS -unclear why. The pt was
on inadequate dose on admission, but received 100 mg
hydrocortisone IVX1 originally and started on his correct dose.
So, presumably, from that point on he was on adequate
replacement dose). Consulted Allergy and Endo, who both agreed
that it would be unlikely to have persistent eosinophilia >1wk
after re-initiation of adequate steroid replacement doses.
Unclear cause of eosinophilia, especially given concerns re:
allergic reaction to HD filter. Also, checked O+P (negative).
Eosinophilia improved on stress dose steroids (100 mg
hydrocortisone IV tid). Stopped oxacillin (? drug reaction), but
continued Vanc. Resolved
.
- Elevated alk phosphatase: Had been noted several months ago
and persisted during this hospitalization. GGT also elevated,
suggesting liver source. Liver U/S negative for parenchymal
lesions. Recommended outpt f/u at time of discharge.
.
- Mental status: Somnolence on presentation likely due to
hypoglycemia. Head CT and LP were nondiagnostic. Tox screens
negative. Mental status improved to baseline
.
- CAD: no acute issues; continued ASA, Lipitor, Labetolol for
secondary prevention
.
- HTN: continued labetalol, amlodipine for now. if patient is
unarousable and can not take po's, can give iv labetolol and
hydralazine prn
.
- LLE ulcer: continued [**Hospital1 **] wet-to-dry dressings and obtained
podiatry/wound care consult.
.
- Hypothyroid: checked TSH given change in MS, continued
levothyroxine at outpt dose.
.
- GERD: continued Protonix
Medications on Admission:
Lantus- 30 U
Neurontin 600mg tid
Hydrocortisone 5mg qHS (the correct dose was supposed to be 20
mg qam - 5 mg qpm).
Fludrocortisone 0.1mg [**Hospital1 **]
Protonix 40mg daily
Levothyroxine 50mcg daily
Lipitor 20mg daily
Sevelamer 400mg tid
Labetolol 600mg QID
Amlodipine 10mg daily
Oxacillin 2g iv Q6hr
Vanco (dosed during HD)
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Levothyroxine Sodium 25 mcg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
4. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
6. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Labetalol 200 mg Tablet Sig: Three (3) Tablet PO QID (4 times
a day).
8. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every
48 hours) for 4 doses.
Disp:*4 Tablet(s)* Refills:*0*
9. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*120 Tablet(s)* Refills:*2*
10. Hydrocortisone 20 mg Tablet Sig: One (1) Tablet PO qam.
Disp:*30 Tablet(s)* Refills:*2*
11. Hydrocortisone 5 mg Tablet Sig: 5-1 Tablets PO at night:
please take:
5 tabs [**7-12**]
5 tabs [**7-13**]
4 tabs [**7-14**]
3 tabs [**7-15**]
2 tabs [**7-16**]
1 tab [**7-17**] and onward.
Disp:*50 Tablet(s)* Refills:*2*
12. Insulin Glargine 100 unit/mL Solution Sig: Sixteen (16)
units Subcutaneous at breakfast.
13. Insulin Lispro (Human) 100 unit/mL Solution Sig: 1-15 units
Subcutaneous qachs: ASDIR by sliding scale.
Disp:*qs qs* Refills:*2*
14. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
gram Intravenous as dosed by dialysis for 6 weeks.
Disp:*qs gram* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1468**] VNA
Discharge Diagnosis:
Primary:
Addison's Disease
DM1
ESRD
HTN
syncope
osteomyelitis
Secondary:
CAD
hypothyroidism
gerd
anemia
Discharge Condition:
stable on HD
Discharge Instructions:
please take all medications as prescribed.
please follow all discharge instructions.
please make all followup appointments as instructed.
please attend hemodialysis at [**Location (un) 4265**] as instructed.
Call your PCP or return to ED if you have fever>101.4, chest
pain, shortness of breath, inability to tolerate food or liquid,
persistent nausea or vomitting, evidence of blood in [**Doctor Last Name 3945**] or
vomit, or any other concerns.
Followup Instructions:
1) please call your PCP, [**Name10 (NameIs) **] [**Last Name (STitle) **] ([**Telephone/Fax (1) 1144**]) and make a
follow up appointment to be seen next week.
2) please call Dr [**Last Name (STitle) **] of the [**Hospital **] Clinic ([**Telephone/Fax (1) 2378**])
and make an appointment to be seen in [**11-18**] weeks.
3) please call Dr [**Last Name (STitle) **], podiatry, ([**Telephone/Fax (1) 543**]) and make an
appointment to be seen next week.
4) please call your nephrologist, Dr [**Known firstname 805**], and make an
appointment to be seen in [**11-18**] weeks.
Appointment Reminders:
Provider: [**First Name11 (Name Pattern1) 354**] [**Last Name (NamePattern4) 3013**], M.D. Where: [**Hospital6 29**]
[**Hospital3 1935**] CENTER Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2115-8-5**] 1:45
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 32281**],[**MD Number(3) 41034**]: KS [**Hospital Ward Name **] BUILDING
([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX) BEHAVIORAL NEUROLOGY UNIT
Phone:[**Telephone/Fax (1) 1690**] Date/Time:[**2115-8-12**] 1:00
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
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"707.15",
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"272.0",
"530.81",
"731.8",
"250.83",
"244.9",
"730.27",
"682.7",
"414.01",
"780.2",
"285.21",
"288.3",
"250.73",
"412",
"458.21",
"276.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"38.93",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
15657, 15716
|
8316, 13145
|
324, 343
|
15865, 15880
|
3178, 8293
|
16380, 17588
|
2599, 2714
|
14149, 15634
|
15737, 15844
|
13798, 14126
|
15904, 16357
|
2729, 3159
|
232, 286
|
371, 1711
|
13161, 13772
|
1733, 2402
|
2418, 2567
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
801
| 195,211
|
50408
|
Discharge summary
|
report
|
Admission Date: [**2197-8-9**] Discharge Date: [**2197-9-15**]
Date of Birth: [**2151-2-17**] Sex: F
Service: MEDICINE
Allergies:
Tetracyclines / Demerol / Penicillins / Cefepime
Attending:[**First Name3 (LF) 1148**]
Chief Complaint:
Acute renal failure, fever, hypotension
Major Surgical or Invasive Procedure:
Central venous catheter
History of Present Illness:
Pt is a 46y/o WF w/ an extensive PMH including ESRD s/p renal
transplant who was recently hospitalized at [**Hospital1 18**] from [**Date range (1) 105047**]
and presents now as a transfer from an OSH where she went with
fever, diarrhea, and hypotension. Her last admission at [**Hospital1 18**]
was marked by ARF found to be [**1-5**] chronic allograft rejection.
She developed TRALI after a transfusion and was intubated
leading to a MSSA VAP. Her ICU course was further complicated
by a staph epi UTI and AIN [**1-5**] nafcillin treatment of her VAP.
She eventually failed extubation attempts and received a
PEG/trach prior to being transferred to [**Hospital1 19286**]
Rehab. At her rehab, she developed fever to 102 and hypotension
to 92 systolic.
.
She was sent to the [**Location (un) 1121**] ICU for these complaints and was
found to have BCX + for coag - staph, GPC/GNR in her sputum, and
a UCX c/w contamination. She received a CT torso showing, per
report, bibasilar lung consolidation, questionable
nephrolithiasis, and pancolitis. She was treated broadly with
PO vanco/flagyl (for ? cdiff; cx negative to date), levaquin
(for ? UTI; cx c/w contamination), and vancomycin (for GPC in
blood/sputum; cx w/ staph epi). She was fluid repleted to a CVP
of 12 but saw no change in her ARF (1.6 on [**Hospital1 18**] d/c -> 3.3 on
readmission). She was transferred to [**Hospital1 18**] for further
managment of her multiple problems and unresolved ARF.
.
On arrival, the patient was normotensive and afebrile. Her
trach was noted to have scant tan sputum. She denied any pain
or SOB. She was not vocal which limited the history available
but did respond appropriately to questions by shaking her head
Y/N. She had access with a R IJ triple lumen and 3 PIV.
Past Medical History:
1. ESRD s/p living related renal transplant in [**2182**] [**1-5**] single
left kidney and focal glomerulosclerosis; c/b ureteral
stricture, s/p ureteral stent placement, last exchanged [**3-9**]. On
CSA and prednisone for immunosuppression.
2. HTN
3. Depression
4. Hyperlipidemia
5. Endometriosis
6. severe gastroparesis on [**2193**] gastric emptying study
Social History:
Significant for a 20 pack per year history of tobacco. Denies
alcohol or IVDU. She lives with her husband and son although
most recently living at [**Hospital **] Rehab.
Family History:
NC
Physical Exam:
98.0, 135/50, 67, 18, 97%
Vent: TC, AC 60% FIO2, 600 TV, 18 RR, 5 PEEP, 21 plateau
Gen: Obese WF lying in bed, not talking but nods head to
questions and responds to commands, mild horizontal head tremor
at rest
HEENT: EOMI, MMM, O/P w/ white exudate on hard and soft palate
c/w thrush
CV: RRR, no M/R/G
Lungs: CTA anteriorly, posterior exam limited by positioning but
mild bibasilar crackles appreciated
Abd: Obese, soft, non-tender, PEG site C/D/I
Ext: No C/C/E
Skin: No skin breakdown/rash, triple lumen and peripheral IV
from OSH w/out signs of erythema/exudate/tenderness
Neuro: Fine tremor worsened by motion in both UE and LE, able to
move fingers and toes to command, patellar reflexes intact
bilaterally, smile symmetrical, EOMI, PERRLA
Pertinent Results:
[**2197-8-9**] 09:47PM URINE URIC ACID-MOD
[**2197-8-9**] 09:47PM URINE HYALINE-1*
[**2197-8-9**] 09:47PM URINE RBC-[**10-23**]* WBC-0-2 BACTERIA-FEW
YEAST-NONE EPI-1
[**2197-8-9**] 09:47PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2197-8-9**] 09:47PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2197-8-9**] 10:04PM PT-12.6 PTT-28.3 INR(PT)-1.1
[**2197-8-9**] 10:04PM PLT COUNT-299
[**2197-8-9**] 10:04PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-2+
MACROCYT-2+ MICROCYT-1+ POLYCHROM-OCCASIONAL OVALOCYT-OCCASIONAL
BURR-2+ TEARDROP-OCCASIONAL
[**2197-8-9**] 10:04PM NEUTS-89.1* BANDS-0 LYMPHS-7.8* MONOS-2.8
EOS-0.2 BASOS-0.1
[**2197-8-9**] 10:04PM WBC-14.9*# RBC-2.91* HGB-8.5* HCT-26.1*
MCV-90 MCH-29.3 MCHC-32.7 RDW-19.0*
[**2197-8-9**] 10:04PM CALCIUM-8.4 PHOSPHATE-5.8*# MAGNESIUM-1.9
[**2197-8-9**] 10:04PM GLUCOSE-95 UREA N-52* CREAT-2.9*# SODIUM-144
POTASSIUM-3.0* CHLORIDE-114* TOTAL CO2-16* ANION GAP-17
CT head [**9-1**]: There is a subtle area of low attenuation and
asymmetry within the region of the superior right internal
capsule which may represent chronic change. No intracranial
hemorrhage or mass effect is seen.
.
CXR [**8-29**]: This is improved. Moderate cardiomegaly and vascular
engorgement of the hila, lungs and mediastinum are unchanged.
Tracheostomy tube in standard placement. Tip of the right PICC
line projects over the junction of the brachiocephalic veins,
and that of the right subclavian line projects over the superior
cavoatrial junction. No pneumothorax.
.
video swallow [**9-4**]: An oral and pharyngeal swallowing video
fluoroscopy study was performed in collaboration with the speech
and swallow department. Varying consistencies of barium were
administered under constant fluoroscopic video guidance. Without
the speaking valve in place, patient was seen to aspirate nectar
thin liquids. With the speaking valve, patient demonstrated
penetration, but no definite evidence of aspiration. The patient
demonstrated poor oral control throughout the study.
.
CT chest [**9-5**]: 1) Airway obstruction proximal to tracheostomy
tube insertion site. Fluid attenuation of airway lumen suggests
retained secretions and edema as the primary factors, although
underlying granulation tissue is not fully excluded. Edematous
changes extend proximally to the glottic region.
2) Overdistended tracheostomy tube cuff.
3) Collapse of right middle and both lower lobes with impaction
of the airways probably due to areas of retained secretions.
High attenuation material within right lower lobe segmental
airways, likely due to aspiration of oral contrast media.
4) Persistent pericardial and small pleural effusions.
5) Multifocal infectious small airways disease process, slightly
improved since [**2197-8-10**].
.
CXR [**9-7**]: Since prior examination, no significant interval
changes. Persistent bibasilar opacity may represent aspiration
pneumonia, less likely atelectasis. Unchanged retrocardiac
opacity represents atelectasis. Stable right PICC line with its
tip projecting over the brachiocephalic vein junction. No
evidence of pneumothorax.
.
[**2197-9-15**]: CBC: 9.5> 10.9/33.3< 370
[**2197-9-15**]: Chem: X1.6* 144 4.1 108 30 20 1.6
Brief Hospital Course:
46 y/o WF w/ a hx of ESRD s/p xplant and recent admission for
ARF/TRALI/VAP/UTI/AIN readmitted w/ ARF, hypotension, and fever.
Managed at NSMC ICU for several days prior to transfer and HD
stable and afebrile on transfer. Transferred to [**Hospital1 18**] from ICU
on HD #30 for witnessed aspiration and pneumonia where she
rapidly improved and was discharged directly from the unit.
.
1. ARF: Pt w/ acute elevation of creatinine compared to her d/c
level. Unclear etiology but likely [**1-5**] transplant rejection
versus ATN ([**1-5**] hypovolemia) versus AIN ([**1-5**] Rx). No evidence of
obstruction on CT but non-obstructive renal stone seen. Uric
acid crystals on UA. Cellcept was stopped and only high dose
steroids where continued for immunosuppresssion. Creatinine
improved with hydration. Baseline Cr 1.9-2.0 since last
admission. Pt continued on Prednisone, Cellcept was restarted
by Renal after her creatinine began to trend down. Pt once
again had an episode of elevated Cr while septic from aspiration
Pneumonia. Her Cr trended down back toward baseline while being
treated with broad spectrum Abx. Abx were renally dosed. By
time of discharge, Cr had returned to baseline levels.
.
2. Fever: Afebrile initially but multiple possible sources at
OSH for fever. Treated with vancomycin for MSSE bacteremia (cx
data from OSH) for a course of 14 days (last day [**8-20**]). Sputum
cx here with Acinetobacter baumanni, highly resistent. BAL Gram
stain demonstrated GNR and GPC. Initially treated with Bactrim,
but subsequent resistence development to Bactrim, therefore
changed to Tobramycin on [**8-16**] for a course of 14 days. Re:
diarrhea, C. diff A & B toxin was negative x3. Stool O & P
negative. Aspiration event on HD #30 and patient returned to the
MICU with elevated temps. Infection resolved on Meropenem and
Vancomycin. Cultures grew acinetobacter sensitive to
Unasyn/Tobra; intermediate to meropenem. Vanc D/C b/c no gram +
organisms on culture. Meropenem continued [**1-5**] clinical
improvement and she was discharged on day 7 of a 14 day course.
.
3. Respiratory distress: When first hospitalized, respiratory
status improved with treatment for acinetobacter + MSSE
pneumonia. On [**2197-9-8**], pt transferred to MICU after witnessed
aspiration event and consequent desaturation to the 70%s.
Subsequent imaging and bronchoscopy ruled out tracheal stenosis,
but demonstrated findings c/w aspiration PNA. Pt treated for
aspiration PNA with vancomycin and meropenum, MDI, ventilatory
support with clinical improvement. Pt on pressure support
alternating w/ trach collar trials on d/c had been on trach
collar for > 24 hours.
.
4. Tremor, dysphagia, weakness: After [**Hospital **] transfer from the
MICU to the floor, patient had dysphagia, diffuse weakness, and
tremor. A head CT showed an abnormality in the Internal Capsule
that was thought to be unrelated to current symptoms according
to Neuro. Patient passed swallow evaluation and is eating well.
Weakness and tremor improving daily. Per Neurology, did not need
an MRI as an inpatient to further evaluate IC abnormality. She
ws scheduled for an outpatient MRI and has follow up with
Neurology following the MRI.
.
5. Anemia: Given pt's history of renal failure, Hct was followed
throughout hospitalization. Pt was transfused at Hct < 21. Epo
and Fe therapy were continued during hospitalization.
.
6. UTI: Pt during course of hospitalization had UA suggestive of
UTI. Meropenum for treatment of aspiration PNA provided
cross-coverage for UTI microbes. UTI resolved as final
surveillence cultures were (-).
.
7. Hypotension: Reportedly hypotensive at OSH. Resolved on
admission.
.
8. FEN: Electrolytes repleted prn. Renal tube feeds. Speech and
swallow evaluation.
.
9. Prophylaxis: Heparin SC. PPI. Pneumoboots.
.
10. Full code.
Medications on Admission:
1. Albuterol 2 puffs qid
2. Atrovent 2 puffs qid
3. Trazodone 50mg qhs
4. Hydrocortisone 60mg q6h
5. Vancomycin 250mg NG q6h
6. Vitamin A/D
7. Tylenol 650mg q4h
8. Haldol 5mg qhs
9. HSQ
10. Calcium 500mg tid
11. Reglan 500mg q6h
12. Triamcinolone cream [**Hospital1 **]
13. Prednisone 5mg [**Hospital1 **]
14. Mycophenolate 250mg [**Hospital1 **]
15. Metoprolol 25mg [**Hospital1 **]
16. Nexium 20mg
17. Celexa 20mg
18. Amlodipine 5mg
19. Dibucaine cream prn
20. Balmex prn
21. EPO 12k units qM/W/F
22. Xanax 1mg tid
23. Flagyl 500mg tid
24. Levaquin 500mg (d3)
Discharge Medications:
1. Albuterol Sulfate 0.083 % Solution Sig: [**12-5**] NEB Inhalation
Q6H (every 6 hours) as needed.
2. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Acetaminophen 160 mg/5 mL Solution Sig: 325-650 mg PO Q4-6H
(every 4 to 6 hours) as needed.
4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation
Q4-6H (every 4 to 6 hours) as needed.
6. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q6H (every 6 hours).
7. Epoetin Alfa 10,000 unit/mL Solution Sig: [**Numeric Identifier 961**] ([**Numeric Identifier 961**]) units
Injection QMOWEFR (Monday -Wednesday-Friday).
8. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
9. Azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
12. Ipratropium Bromide 0.02 % Solution Sig: [**12-5**] NEB Inhalation
Q6H (every 6 hours) as needed.
13. Psyllium Packet Sig: One (1) Packet PO TID (3 times a
day) as needed.
14. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
15. Pantoprazole 40 mg IV Q12H
16. Meropenem 500 mg Recon Soln Sig: Five Hundred (500) MG
Intravenous Q8H (every 8 hours) for 10 days.
17. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
19. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection TID (3 times a day).
20. Ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO twice
a day.
21. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
injection Injection ASDIR (AS DIRECTED): Give 2 units for BG
150-200. Give 4 units for BG 201-250. Give 6 units for BG
251-300. Give 8 units for BG 301-350. Give 10 units for BG
351-400. Give 12 units for BG>400 and notify MD.
22. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): hold for SBP<120, HR<60. Tablet(s)
23. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two
(2) ML Intravenous DAILY (Daily) as needed.
24. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
25. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] Rehabilitation & Nursing Center - [**Location (un) 538**]
Discharge Diagnosis:
Primary:
1. Acute Renal Failure
2. Pneumonia
3. Urinary Tract Infection
.
Secondary:
1. end stage renal disease
2. hypertension
3. depression
4. hyperlipidemia
5. transfusion related acute lung injury
Discharge Condition:
Good
Discharge Instructions:
You were admitted to the hospital for Respiratory Distress and
Acute Renal Failure.
.
Please continue to take all medications as prescribed. You will
need to take 7 more days of Meropenem antibiotic for a
pneumonia.
.
You should follow up with your Nephrologist Dr. [**Last Name (STitle) 3271**], the
[**Hospital1 18**] Neurology department as below.
.
You should call your doctor or return to the ER should you
experience any of the following:
Fever > 101
Severe Difficulty Breathing
Numbness/Tingling/Paralysis
Severe Dizziness
Nausea/Vomiting
Difficulty with Urination
Severe Chest Pain/SOB
Any other symptoms that worry you.
Followup Instructions:
Please follow-up with your primary care [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
on [**2197-9-27**] 2:45 pm. Phone: [**Telephone/Fax (1) 105048**].
.
Please follow up with Nephrology as below:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7198**], M.D. Date/Time:[**2197-9-20**] 4:00
.
Please follow up with Neurology as below:
Provider: [**Name Initial (NameIs) 540**]/[**Doctor Last Name **] Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2197-12-20**] 2:30
.
You will need to have an MRI obtained prior to your neurology
appointment. XMR WEST 2 RADIOLOGY Phone:[**Telephone/Fax (1) 327**]
Date/Time:[**2197-9-21**] 6:30. Basement of [**Hospital Ward Name **] clinical
center.
.
Please continue medical care with treatment team at your
rehabilitation facility.
|
[
"428.0",
"577.0",
"486",
"996.81",
"288.50",
"599.0",
"038.9",
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"995.92",
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] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"38.93",
"33.21",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
13730, 13884
|
6851, 10676
|
349, 374
|
14129, 14136
|
3551, 6828
|
14814, 15666
|
2765, 2769
|
11288, 13707
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13905, 14108
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10702, 11265
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14160, 14791
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2784, 3532
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269, 311
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402, 2178
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2200, 2560
|
2576, 2749
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
226
| 108,072
|
20861
|
Discharge summary
|
report
|
Admission Date: [**2196-12-15**] Discharge Date: [**2196-12-20**]
Date of Birth: [**2169-10-4**] Sex: F
Service: MEDICINE
Allergies:
Bactrim / Dilaudid
Attending:[**First Name3 (LF) 949**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
lumbar puncture
History of Present Illness:
Ms. [**Known lastname 55537**] is a 27yo woman with h/o HCV, liver transplant x
2 in [**2177**] (rejected first liver), (?Wilson's disease per
records) and 3rd OLT in [**2189**] who was in her USOH until yesterday
afternoon when she began to have RUQ pain that radiated like a
band across her stomach. She had chills and diaphoresis at that
time, and a headache (which she frequently gets per records), N
but no V. Noted that she "just din't feel good" and was sleeping
a lot yesterday. She also noted a few hours later she had some
chest pain, not pleuritic, sharp pain "like needles", no cough,
+SOB along with abd and CP. Yesterday, she presented to [**Hospital 1281**]
Hospital in [**Location (un) **], MA, where she had an abdominal CT scan that
was unremarkable. She was found to have an elevated bilirubin
over 4 (baseline 2.0). She remained there overnight and went
home today, when she went to see Dr. [**Last Name (STitle) 497**]. In his office she
was febrile to >101. He sent her immediately to be admitted to
the hospital.
.
ROS: HA as above (per records complained of this over last few
weeks), facial tingling "all over in a circle." otherwise
unremarkable.
Past Medical History:
liver transplant x 2 in [**2177**] at [**Hospital **] [**Hospital1 11900**](rejected first liver); ?3rd transplant in [**2189**]
- does not recall CMV infections, but did have HSV esophagitis
in 2/87
- possible cholangitis [**2187**]
- recurrent UTIs
- HCV: past interferon treatment suppressed VL from 6mill to
79,000 but had to stop [**3-10**] depression/disorientation. Recently
restarted ribaviron and pegylated interferon on [**11-30**].
- incarcerated hernia repair
- s/p ccy with liver transplantation
.
Meds:
prednisone 10mg po qother day (took today)
cyclosporin 125 mg po qday
ribavirin 400mg po bid
interferon 120mcg (0.3mL) SQ QFri
trazodone 10mg po qhs prn
.
All: bactrim --> hives; dilaudid
Social History:
lives at home with her daughter and her brother's family (his
wife and 4 children). Does not work. Denies tobacco, alcohol, or
other drugs including intravenous drugs.
Family History:
mother with DM, HTN, breast ca.
Physical Exam:
HR 96, BP 95/59 RR 19 O2 98% RA
Gen: sleepy but answers questions with poor concentration
HEENT: NCAT, PERRL, sclerae mildly icteric, OP not injected, MM
dry, no sinus tenderness, no photophobia
Neck: supple, no JVD, no LAD
Cor: RRR, II/VI systolic flow murmur heard throughout precordium
non radiating, s1s2
Pulm: CTAB
Abd: well-healed transverse surgical scar, RUQ tenderness, +
[**Doctor Last Name 515**] sign, + rebound tenderness over upper but not lower
abdomen, + diffuse abdominal tenderness to moderate palpation,
+BS, soft, ND
Ext: no c/c/e, w/w/p, pulses 2+ radial and PT pulses bilat
Neuro: moves all four to command, strength 4/5 bilateral quads,
[**6-10**] bilateral hands and feet at ankles, rest of neuro exam not
performed given sleepiness of pt
Pertinent Results:
CT abd from OSH [**2196-12-14**]: film reviewed by trauma [**Doctor First Name **] here with
radiology and was basically negative (pneumobilia only, with
mild intrahepatic dilation, no free air or abscesses)
.
RUQ U/S:Normal hepatic vessels in this patient post transplant.
No other commentary.
.
CXR: no acute CP process.
CT abd [**2196-12-15**]:
IMPRESSION:
1. Decrease pneumobilia status post hepaticojejunostomy.
2. Splenomegaly.
3. Increasing bibasilar atelectasis compared to same day study
from outside hospital. Possible consolidation cannot be
excluded.
.
MRCP: negative for obstruction
.
CMV/EBV negative
[**12-15**] bld cx + pan-[**Last Name (un) 36**] E coli; + Urine cx from OSH + for E coli
repeat bld cx neg
.
HSV DFA +
.
Lumbar Puncture: 0 rbc, 0 wbc
.
[**2196-12-16**] 04:04AM BLOOD WBC-5.7 RBC-3.16* Hgb-9.7* Hct-27.5*
MCV-87 MCH-30.8 MCHC-35.4* RDW-15.7* Plt Ct-74*
[**2196-12-20**] 04:50AM BLOOD WBC-4.3 RBC-3.66* Hgb-11.6* Hct-31.3*
MCV-86 MCH-31.8 MCHC-37.2* RDW-15.9* Plt Ct-184
[**2196-12-15**] 02:30PM BLOOD Glucose-78 UreaN-12 Creat-0.8 Na-139
K-3.9 Cl-108 HCO3-22 AnGap-13
[**2196-12-15**] 02:30PM BLOOD ALT-29 AST-27 LD(LDH)-244 AlkPhos-145*
Amylase-42 TotBili-4.2* DirBili-0.8* IndBili-3.4
[**2196-12-20**] 04:50AM BLOOD ALT-27 AST-27 TotBili-1.1
[**2196-12-15**] 09:21PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE
.
Bld Cx + for E coli
Brief Hospital Course:
Ms [**Known lastname 55537**] is a 27F with h/o liver transplant x 3 (last in
[**2189**]) who presented with fever and abdominal pain and direct
hyperbilirubinemia who was presumed to have cholangitis but was
subsuquently found to have E coli urosepsis.
.
Upon admission to the floor Ms [**Known lastname 55537**] was found to be
tachycardic to the 120s, hypotensive with sbp in the 90s fever
to 104. She was given 3LNS boluses, started on Zosyn and Flagyl
to empirically cover for cholangitis, and was transferred to the
ICU for further management. She received another 2LNS boluses in
the ICU and did not need pressors for BP support. Ms [**Known lastname 55537**]
had a stat CT abdomen and Abdominal ultrasound which did not
reveal any signs of cholangitis. She was subsuquently found to
have E coli bacteremia and urine culture from an outside
hospital revealed E. coli UTI. She was changed to IV
ciprofloxacin when sensitivities returned and was discharged
with a 14 day course of oral cipro. Her fevers gradually
resolved as did her hypotension and her abdominal pain was
completely resolved by discharge. Repeat blood cultures were
negative. UA and urine cultures repeated at [**Hospital1 18**] were negative
and CT-abdomen showed no evidence of pyelonephritis.
.
# Immunosuppression: Ms [**Known lastname 55538**] post transplant
immunosuppressive regimen was cyclosporine 150bid + prednisone
10 QOD. She was admitted with supra-therapeutic cyclosporine
levels above 300. Her CSA doses were adjusted with wide
fluctuation in her level. Her dose was decreased to 100mg po
bid prior to discharged because the concern is her sepsis was
likely induced by her overimmunosuppression. Her CSA level on
the morning of discharge was 344, but this was not reported
until after the patient's discharge. She was contact[**Name (NI) **] via
telephone to have another level drawn the next day.
.
During Ms. [**Known lastname 55538**] stay she developed oral lesions that
were + for herpes virus by direct antigen testing. She had also
been reporting headache and photophobia so a lumbar puncture was
performed that showed no RBC or WBC. She was treated briefly
with IV acyclovir and then transitioned to a 10-day course of
valacyclovir 500mg po bid. She has been instructed to cover her
lesions when she interacts with her 18month-old daughter. She
also had signs of bacterial superinfection of one of the lesions
for which she is being treated with bactroban.
.
#. Hyperbilirubinemia: There was concern on admission that Ms
[**Known lastname 55538**] tbili was 4.4 and she had RUQ pain. Abd US and CT
abdomen were negative for obstruction. She had an MRCP that was
negative for obstruction. The hyperbilirubinemia resolved with
antibiotic treatment making sepsis the likely source.
.
# HCV: Ms [**Known lastname 55537**] received her 4th treatment of pegylated IFN
+ ribaviring several days PTA. Her interferon was held x 1 dose
due to her sepsis and her ribavirin was briefly held due to
concern over her anemia. Her last viral load had shown good
response to IFN/ribavirin so the ribavirin was restarted with
plans to resume IFN in 1 week.
.
# anemia/thrombocytopenia: Ms [**Known lastname 55537**] presented with anemia
and thrombocytopenia that improved with treatment of her sepsis.
Hemolysis labs were negative making ribavirin a less likely
culprit. Her hct on discharge was 30, which does not merit epo
treatment.
.
# Immunization: Ms [**Known lastname 55537**] was found to be negative for HAV
and HBV antibodies. She was therefore vaccinated with #1 of the
HAV and HBV series. These series should be completed in liver
clinic. She also received pneumococcal vaccine and influenza
vaccine.
Medications on Admission:
prednisone 10mg po qother day (took today)
cyclosporin 125 mg po qday
ribavirin 400mg po bid
interferon 120mcg (0.3mL) SQ QFri
trazodone 10mg po qhs prn
Discharge Medications:
1. Prednisone 10 mg Tablet Sig: One (1) Tablet PO QOTHER DAY ().
2. Ribavirin 200 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily).
3. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day): apply to lesions on upper lip until resolved.
Disp:*1 tube* Refills:*2*
4. Cipro 750 mg Tablet Sig: One (1) Tablet PO twice a day for 8
days.
Disp:*16 Tablet(s)* Refills:*0*
5. Valtrex 500 mg Tablet Sig: One (1) Tablet PO twice a day for
9 days.
Disp:*18 Tablet(s)* Refills:*0*
6. Cyclosporine 100 mg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
Disp:*60 Capsule(s)* Refills:*2*
7. Peg-Intron 120 mcg/0.5 mL Kit Sig: 0.3 ml Subcutaneous once a
week.
8. Outpatient Lab Work
cyclosporine trough
please draw in approximately 1 week
Discharge Disposition:
Home
Discharge Diagnosis:
E coli bacteremia
Urosepsis
hepatitis C
s/p orthotopic liver transplantation
herpes labalis
Discharge Condition:
good: afebrile, VSS
Discharge Instructions:
You should continue to take all medications as prescribed. You
were admitted with a blood infection and need to finish a 14-day
course of an antibiotic called ciprofloxacin (you have 9 more
days to take this). We are also giving you a medicine called
valtrex for your mouth sores to take for 8 days. Until the
lesions on your lips are crusted over, they are potentially
ifectious. You need to be careful around your daughter and not
[**Doctor Last Name **] her. You should continue to take your interferon and
ribavirin as scheduled.
.
Dr [**Last Name (STitle) 497**] wants you to decrease your cyclosporine dose to 100mg
twice per day. You should have your trough level drawn in about
a week (it should be drawn 1 hour before your next dose is due).
.
You should follow-up in clinic with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] as below.
.
Please seek immediate medical attention if you have abdominal
pain, fevers, chills, jaundice, eye pain, worsening headache, or
for any other concerns.
.
You were also given a hepatitis A vaccine, influenza vaccine,
pneumonia vaccine, and the first in the hepatitis B vaccine
series. You will need to finish the hepatitis B vaccine series
with 2 other shots. We will convey this to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 674**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 13146**], [**MD Number(3) 3261**]:[**Telephone/Fax (1) 673**]
Date/Time:[**2196-12-27**] 2:20
|
[
"287.5",
"996.82",
"599.0",
"038.42",
"285.9",
"E878.0",
"054.9",
"070.54"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
9427, 9433
|
4710, 8432
|
295, 313
|
9569, 9591
|
3278, 4687
|
10962, 11166
|
2446, 2479
|
8636, 9404
|
9454, 9548
|
8458, 8613
|
9615, 10939
|
2495, 3259
|
241, 257
|
341, 1515
|
1538, 2244
|
2260, 2430
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,196
| 196,560
|
50913
|
Discharge summary
|
report
|
Admission Date: [**2152-10-17**] Discharge Date: [**2152-10-26**]
Date of Birth: [**2086-7-27**] Sex: M
Service: [**Location (un) 259**]
HISTORY OF PRESENT ILLNESS: The patient is a 66 year old
male with cardiac risk factors of age, sex, hypertension,
hypercholesterolemia, and smoking history, who was initially
admitted on [**10-17**] after a fall and head injury. The
patient was at a football game on [**2152-10-16**], when he
fell down an embankment about 15 feet and hit his head
without loss of consciousness. The patient was taken to
[**Hospital **] Hospital Emergency Room where he was found to have a
subarachnoid hemorrhage and an interparenchymal hemorrhage on
CT scan without any midline shift and with normal ventricles.
The patient had no focal deficits but complained of left
orbital pain, headache and back pain. He was diagnosed there
with Type 2 odontoid fracture on neck x-ray and he was
transferred to the Neurosurgery service at the [**Hospital1 346**] in a hard cervical collar.
At [**Hospital1 69**], a chest x-ray and
pelvis CT scan were all normal. Head CT scan showed
multi-focal hemorrhage, both cortical and subarachnoid, nasal
bone fracture as well as an air fluid level in the left
maxillary sinus. There is also low density subdural fluid
collection, probably chronic. There was no evidence of C2
fracture on MRI. The patient was kept in the cervical collar
due to the diagnosis given at the outside hospital while
awaiting further imaging. He was kept in the Intensive Care
Unit for 24 hours for observation. A repeat head CT scan the
following day showed no change.
On [**10-18**], after eating dinner, the patient reported
substernal chest pain associated with bilateral lower arm
numb but no shortness of breath, diaphoresis, nausea,
vomiting, lightheadedness or palpitations. He reports the
chest pain lasting one hour. He thought that it was
indigestion and was given some Tums with some relief. The
patient was seen by Cardiology consultation at that time.
The EKG showed no changes at the time but CK were in the 300s
with increased CK MB of 23 and troponin of 31.7, which
subsequently increased to 47.3.
The patient was given aspirin, beta blocker, his
Hydrochlorothiazide was discontinued and a repeat EKG showed
biphasic T waves with no other significant changes.
An echocardiogram showed an ejection fraction of 60% but the
apex was not well visualized, which could be hypokinetic.
The echocardiogram was otherwise normal and the patient was
transferred to the Medicine Service for management. The
patient was not anti-coagulated secondary to the subarachnoid
hemorrhage and the interparenchymal hemorrhage.
PAST MEDICAL HISTORY:
1. Hypertension.
2. High cholesterol.
3. No history of coronary artery disease.
4. Colon cancer in [**2144**] with positive nodes on status post
transverse colectomy and 5-FU and levamisole treatment. He
has had routine colonoscopies which have been normal.
5. He has a history of prostate cancer diagnosed in [**Month (only) 956**]
of this year by biopsy. He had the biopsy due to a PSA of
5.2 in late [**Month (only) 404**] of this year; biopsy showed [**Doctor Last Name **] 8.
Negative bone scan, MRI or other metastatic work-up. He has
gotten Lupron and is awaiting to get radioactive seed implant
and external beam radiation therapy.
6. History of hiatal hernia and dyspepsia.
SOCIAL HISTORY: Real estate appraiser. He has a 120 pack
year tobacco history but quit 25 years ago. He drinks about
two alcoholic drinks per weekend.
FAMILY HISTORY: Significant for coronary artery disease;
father died of myocardial infarction at age 64; he had two
brothers in good health. His mother died of unknown cause.
No history of cancer.
MEDICATION AS OUTPATIENT:
1. Univasc.
2. Lescol.
3. Lupron.
4. Aspirin.
5. Vitamin E.
6. Question of a diuretic.
PHYSICAL EXAMINATION: The patient was afebrile with a
temperature of 98.6 F.; heart rate of 80; blood pressure of
112/60; respiratory rate was 14; 96% on room air. He was in
no acute distress. Pupils equally round and reactive to
light. Extraocular movements are intact. Mucous membranes
were moist. His neck was in a cervical collar. Chest was
clear bilaterally. Heart was regular rate and rhythm, S1 and
S2. He had an S4. No murmurs or rubs. Abdomen was soft,
nontender, nondistended. Liver span of about 10 cm.
Extremities with no cyanosis, clubbing or edema. Two plus
pulses globally. He was alert and oriented times three. His
cranial nerves II through VII as well as IX and XII were
intact. Other cranial nerves were difficult to assess due to
neck immobilization.
LABORATORY: On admission, his CK had been in the 300s, 311,
367, and 348. CK MB 23, 26 and 19. Troponin were 31.7 and
47.3. He had a white count of 10.7, hematocrit of 39,
platelets of 192, INR 1.1, normal PTT. Chem-7 was
essentially normal. He had a creatinine of 1.0 and a
phosphorus of 3.7, magnesium of 2.0.
HOSPITAL COURSE: The patient remained stable. He was put on
Nitroglycerin paste and Nitroglycerin as well as beta blocker
and aspirin. He was kept on his statin. He was not
anti-coagulated again due to the intracranial bleed. The
patient remained stable and a repeat head CT scan on
[**10-20**] showed no change. Neurosurgery cleared him for
anti-coagulation as well as cardiac catheterization.
On [**10-20**], the patient received flexion and extension
cervical x-rays which showed no cervical fracture. The
cervical collar was discontinued on the night of [**10-20**].
The patient continued to have a few mild brief episodes of
chest discomfort lasting three to five seconds. He did not
receive his sublingual Nitroglycerin because it resolved
spontaneously before he had a chance to call the nurse. The
patient was taken to cardiac catheterization on [**2152-10-25**]. The cardiac catheterization showed mildly elevated
left side filling pressures, infero-apical severe hypokinesis
with no mitral regurgitation, left ventricular ejection
fraction is about 50%.
Coronary angiography showed left dominant anatomy and a 99%
mid-occlusion with extensive thrombus in the left anterior
descending; otherwise normal. The thrombus was removed with
Angioject and the left anterior descending was dilated with
2.5 by 3 balloon and a stent was placed. The patient
remained stable and did well without any post-catheterization
chest pain, groin pain or neurologic symptoms. The sheath
was removed that same evening. The patient's labs remained
stable and his hematocrit remained stable. His CK continued
to drift down to 58 on the day of discharge.
The patient was started on Plavix post catheterization.
Heparin and 2B3A blocker were not given due to the
intracranial bleed and the patient was discharged in good
condition on [**10-26**], to be followed up by Dr. [**Last Name (STitle) **] and
Dr. [**Last Name (STitle) 1327**], the Neurosurgeon.
DISCHARGE MEDICATIONS:
1. Plavix 75 mg p.o. q. day.
2. Aspirin 325 mg p.o. q. day.
3. Metoprolol 12.5 mg p.o. twice a day.
4. Nitroglycerin sublingual one to two tablets p.r.n. chest
pain.
5. Lescol 40 mg p.o. q. h.s.
6. Univasc 15 mg p.o. q. day.
DISCHARGE DIAGNOSES:
1. Head trauma; intracranial bleed.
2. Non-Q wave myocardial infarction.
[**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern1) 24503**], M.D. [**MD Number(1) 24504**]
Dictated By:[**Name8 (MD) 6371**]
MEDQUIST36
D: [**2152-10-26**] 11:23
T: [**2152-10-26**] 12:06
JOB#: [**Job Number **]
|
[
"410.71",
"E884.9",
"802.0",
"851.81",
"185",
"401.9",
"272.0",
"V10.05"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"37.22",
"36.06",
"36.02",
"88.53"
] |
icd9pcs
|
[
[
[]
]
] |
3579, 3882
|
7224, 7566
|
6971, 7203
|
5007, 6948
|
3905, 4989
|
187, 2692
|
2714, 3407
|
3424, 3562
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,725
| 171,533
|
17300
|
Discharge summary
|
report
|
Admission Date: [**2146-4-24**] Discharge Date: [**2146-4-29**]
Date of Birth: [**2080-3-9**] Sex: M
Service: Medicine, [**Location (un) **] Firm
CHIEF COMPLAINT: Fever and hyperglycemia.
HISTORY OF PRESENT ILLNESS: The patient is a 66-year-old
male with a history of coronary artery disease (status post
coronary artery bypass graft), type 2 diabetes, hypertension,
and paroxysmal atrial fibrillation who presented with fever,
weakness, and hyperglycemia.
The patient was at [**Hospital1 69**] from
[**Doctor Last Name 792**]visiting his daughter who is currently an
inpatient when he developed increased fatigue and weakness.
On checking his blood sugars, they were in the 400s, at which
time he presented to the Emergency Department with a fever of
103. He denied any chest pain, shortness of breath, nausea,
vomiting, diarrhea, melena, or bright red blood per rectum.
He was initially hemodynamically stable in the Emergency
Department, but his blood pressure subsequently fell to the
70s and 80s. He was volume resuscitated with 6 liters of
normal saline without affect. A right internal jugular
triple lumen catheter was placed in the Emergency Department,
and Levophed and Neo-Synephrine were initiated for blood
pressure support. The patient was admitted to the Medical
Intensive Care Unit for further management.
PAST MEDICAL HISTORY:
1. Coronary artery disease; status post myocardial
infarction in [**2133**] treated at that time with percutaneous
transluminal coronary angioplasty, followed by a 4-vessel
coronary artery bypass graft in [**2142**].
2. Diabetes; on insulin.
3. Hypertension.
4. Paroxysmal atrial fibrillation; treated with Coumadin.
5. Congestive heart failure (with an ejection fraction of
30%).
6. Beta-thalassemia trait.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Aspirin, Coumadin, lisinopril,
Pravachol, Pletal, Lasix, Zaroxolyn, 70/30 insulin,
Neurontin, and allopurinol.
SOCIAL HISTORY: The patient is married. He denies the use
of tobacco. He drinks alcohol only occasionally.
PHYSICAL EXAMINATION ON PRESENTATION: Examination on
admission revealed temperature was 103, heart rate was 124,
blood pressure was 88/40, respiratory rate was 18, and oxygen
saturation was 96% on room air. In general, he was
lethargic. Oriented times three. He appeared acutely ill.
Pertinent physical findings revealed that his oropharynx was
dry. His neck was supple with jugular venous pulsation
approximately 10 cm. His lungs sounded clear to auscultation
bilaterally (by report). His heart examination was regular
with normal first heart sounds and second heart sounds. A
2/6 systolic ejection murmur at the left upper sternal
border. His abdominal examination was unremarkable. His
extremities revealed trace pedal edema with chronic venous
stasis dermatitis bilaterally and erythema of the left lower
extremity around the medial malleolus which was also warmer
than surrounding skin. Neurologic examination revealed that
he was alert and oriented times three. Cranial nerves II
through XII were intact. Otherwise, neurologic examination
was nonfocal.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories on
admission revealed white blood cell count was 21.7 (with a
differential of 77 polys, 6 bands, 8 lymphocytes, and 7
monocytes), hematocrit was 31.7, and platelets were 210.
Chemistry-7 was remarkable for a blood urea nitrogen of 59
and creatinine of 1.6. Blood sugar was 314 on admission.
Liver function tests were checked and were within normal
limits. Initial set of cardiac enzymes done in the Emergency
Department revealed creatine kinase was 250, with a MB
fraction of 7, and a troponin of 2.4. Coagulations revealed
prothrombin time was 19.7 and an INR of 2.6. Urinalysis on
admission revealed a specific gravity of 1.017, with a small
amount of blood, and a glucose measurement of 1000.
PERTINENT RADIOLOGY/IMAGING: Electrocardiogram on admission
revealed a sinus rhythm with a right bundle-branch block at a
rate of 108, with ST depressions in V4 through V6.
A chest x-ray on admission showed cardiomegaly without
infiltrate or signs of congestive heart failure.
HOSPITAL COURSE BY ISSUE/SYSTEM:
1. INFECTIOUS DISEASE ISSUES: Presumably septic, the
patient was admitted to the Medical Intensive Care Unit where
he was initially treated with vancomycin and levofloxacin
after having been started on oxacillin in the Emergency
Department for presumed cellulitis of the left lower
extremity. His hemodynamic instability improved rather
quickly, and his antibiotics were changed to Unasyn; although
a source of his sepsis was still unknown.
With the patient afebrile without any signs of hemodynamic
instability or obvious source of infection, the Unasyn was
discontinued; allowing any present infection to present
itself. After the discontinuation of the antibiotics, the
patient remained afebrile with no signs of obvious infection,
and antibiotics were not re-initiated.
Blood cultures throughout this admission were negative to
date at the time of this dictation.
2. HYPOTENSION ISSUES: Hypotension again presumed to be
sepsis. The patient was treated initially with Levophed and
Neo-Synephrine. Further volume resuscitation was held given
his high likelihood of the complication of congestive heart
failure.
Pressors were weaned over the subsequent 24 hours, and by the
second hospital day the patient was off all pressors and was
maintaining his blood pressure.
3. CARDIOVASCULAR SYSTEM: In the setting of the patient's
hypotension, he developed electrocardiogram changes and had
cardiac enzymes measured with a peak troponin of 49.3 and a
creatine kinase of 334. Ultimately, the electrocardiogram
did not develop T waves, and the patient was diagnosed and
treated medically for a non-Q-wave myocardial infarction.
He was not treated with heparin because he was fully
anticoagulated with Coumadin; however, he was continued on
aspirin. Once his blood pressure tolerated, his ACE
inhibitor was restarted. He was also begun on Lopressor when
his blood pressure allowed.
With the aggressive volume resuscitation upon admission, the
patient did experience congestive heart failure which was
treated with his outpatient doses of Lasix and Zaroxolyn once
his blood pressure was able to tolerate this.
A full set of lipids was checked which revealed a total
cholesterol of 127, high-density lipoprotein was 56,
low-density lipoprotein was 56, and triglycerides were 77.
Therefore, his Pravachol dosing was not changed.
For his atrial fibrillation, his Coumadin was continued at
his outpatient dose at 7 mg daily with his INR maintained
appropriately. With diuresis, the patient's heart failure
improved to his baseline
4. RENAL INSUFFICIENCY ISSUES: Upon admission, the
patient's creatinine was 1.6. This was felt to be due to
prerenal azotemia. With hydration upon the initial
resuscitation, his creatinine improved to 1.4. Subsequently,
with the complication of his congestive heart failure, his
creatinine worsened again to 1.7. However, with diuresis his
creatinine got as low as 1.2; which was likely his baseline.
5. LEFT KNEE PAIN ISSUES: On hospital day three, the
patient developed the acute onset of left knee pain with
focal tenderness on the lateral side of the knee with an
apparent effusion within the knee.
Concern was raised for a septic joint given the likelihood of
his recent bacteremia. However, on further probing of the
patient's past medical history it was found that he has a
history of gout in that knee and had been on allopurinol
prior to admission. The patient was treated empirically for
gout with colchicine, and Rheumatology was consulted
regarding the possibility of an arthrocentesis in the setting
of an elevated INR to rule out a septic joint. Rheumatology
did tap the left knee and aspirated 0.5 cc of joint fluid
which was sent for culture; on which there was no growth at
the time of this dictation.
Following 24 hours of treatment with colchicine, the
patient's symptoms improved dramatically, and his walking
improved. The patient was to be treated with colchicine 0.6
mg p.o. three times per day for a total of three days
followed by 0.6 mg p.o. once per day for approximately four
weeks; at which time he was to follow up with his
orthopaedist in [**State 792**]and likely restart his
allopurinol at that time.
6. ENDOCRINE SYSTEM: The patient was continued on 70/30
insulin with the addition of a regular insulin sliding-scale.
Initially, due to decreased oral intake as well as a strict
diabetic diet, he was requiring less insulin than he did at
home. However, ultimately because of continuing elevated
fingersticks his insulin was returned to his outpatient
doses.
DISCHARGE DIAGNOSES:
1. Sepsis of unknown etiology.
2. Non-Q-wave myocardial infarction.
3. Chronic renal insufficiency with acute renal azotemia.
4. Gout.
5. Congestive heart failure.
MEDICATIONS ON DISCHARGE:
1. Aspirin 325 mg p.o. once per day.
2. Pravachol 40 mg p.o. q.h.s.
3. Lisinopril 20 mg p.o. once per day.
4. Coumadin 7 mg p.o. once per day.
5. Lasix 80 mg p.o. once per day.
6. Zaroxolyn 2.5 mg p.o. once per day (to be taken one half
hour prior to Lasix).
7. Toprol-XL 50 mg p.o. once per day.
8. Neurontin 300 mg p.o. three times per day.
9. Colchicine 0.6 mg p.o. three times per day (through [**2146-4-30**]) followed by 0.6 mg p.o. once per day (for four
weeks).
10. Pletal 100 mg p.o. twice per day.
11. 70/30 insulin 50 units subcutaneously q.a.m. and 30
units subcutaneously q.p.m.
12. Tylenol p.o. as needed.
13. Multivitamin one tablet p.o. once per day.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was instructed to follow up with Dr. [**Last Name (STitle) **]
(his orthopaedist) in three to four weeks regarding further
treatment of his gout.
2. In addition, the patient was to follow up with his
primary care physician in the next one to two weeks.
DISCHARGE STATUS: The patient was discharged with plans for
home physical therapy upon return to [**Doctor Last Name 792**]in
approximately to days.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 24755**]
Dictated By:[**Name8 (MD) 6166**]
MEDQUIST36
D: [**2146-4-29**] 13:43
T: [**2146-5-2**] 08:49
JOB#: [**Job Number 48431**]
|
[
"250.00",
"274.0",
"038.9",
"785.59",
"682.6",
"410.71",
"428.0",
"593.9",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"81.91"
] |
icd9pcs
|
[
[
[]
]
] |
8796, 8966
|
8993, 9692
|
1851, 1963
|
9776, 10459
|
4221, 8775
|
9707, 9743
|
181, 207
|
236, 1349
|
1371, 1824
|
1980, 4187
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,560
| 124,581
|
23395
|
Discharge summary
|
report
|
Admission Date: [**2148-11-21**] Discharge Date: [**2148-11-21**]
Date of Birth: [**2122-4-23**] Sex: M
Service: SURGERY
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
Fulminant liver failure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 50215**] transferred to [**Hospital1 18**] from St.[**Hospital 6783**] Hospital in
[**Last Name (un) 17679**], MA with fulminant liver failure. The preceding
history is somewhat unclear. It appears that he overdosed on an
unknown substance.
Past Medical History:
Unknown.
Social History:
Unknown.
Family History:
Unknown.
Brief Hospital Course:
At admission, the patient was hemodynamically unstable and
unconscious on 2 pressors. His liver enzymes were massively
elevated with an INR of 3.7. He was listed for liver
transplantation. Over the course of the day, he was heavily
resuscitated with blood products and 3 pressors as well as
fluid. A bolt was placed to monitor intracerebral pressure. He
was treated for elevated ICPs and was placed on CVVHD for renal
failure. Despite maximizing efforts, he went into multi-system
organ failure. His heart arrested in the evening of [**11-21**]. A code was called and he was resuscitated after the ACLS
protocol. His heart returned to a pressure producing rythm. But
he arrested again 30min later. This time all efforts were
without success. He was pronounced dead at 6:35pm [**2148-11-21**].
Discharge Disposition:
Expired
Discharge Diagnosis:
Fulminant liver failure with fatal outcome.
Discharge Condition:
See above.
Discharge Instructions:
None.
Followup Instructions:
None.
Completed by:[**2148-11-22**]
|
[
"572.2",
"311",
"577.0",
"584.9",
"570"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"01.18"
] |
icd9pcs
|
[
[
[]
]
] |
1543, 1552
|
726, 1520
|
321, 327
|
1639, 1651
|
1705, 1742
|
693, 703
|
1573, 1618
|
1675, 1682
|
258, 283
|
355, 619
|
641, 651
|
667, 677
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,193
| 145,148
|
50150
|
Discharge summary
|
report
|
Admission Date: [**2188-9-23**] Discharge Date: [**2188-9-25**]
Date of Birth: [**2134-4-12**] Sex: F
Service: MEDICINE
Allergies:
Amoxicillin / Erythromycin Base / [**Hospital1 **] Advil Allergy Sinus
/ Codeine / Tetracycline
Attending:[**First Name3 (LF) 4095**]
Chief Complaint:
Melena, hematemesis
Major Surgical or Invasive Procedure:
EGD
Blood Transfusion
History of Present Illness:
54 yo F w/ h/o ETOH abuse (seizure per report in setting of ETOH
withdrawal), duodenotis/gastritis, anxiety p/w emesis and melena
x 1 day.
.
Pt reports drinking 1pint of vodka daily over the weekend
(usually drinks 5 drinks of vodka daily). Monday morning she
developed nausea and abdominal pain. She had an episode of
melena. She reports trying to hydrate w/ po fluids, but then
developing emesis that looked "black." While walking to the
kitchen she had an episode of syncope, where she felt
diaphoretic and lightheaded, then "blacked out" and woke up on
the ground. Of note, she recently was admitted for hematemesis
and melena, s/p EGD that showed duodonitis/gastritis, no
varices.
.
On presentation to the ED: VS were: HR 133, BP 117/81, RR 22,
100% RA. She was orthostatic by symptoms. On exam she had
diffuse abdominal tenderness. She was NG lavage with dark red
blood that cleared w 500 cc lavage. She had abd CT that did not
show free air and ECG notable for sinus tach. Labs notable for
hct 36, lactate 7.8, wbc 12, inr 1.1, ast 50s (otherwise LFTs
wnl). Received 3L NS, 1mg iv lorazepam, 80mg iv pantoprazole and
started on pantoprazole drip. She has 2 pivs (16/18) and is T&C
for 2 units. Her HR improved to 90s-100s.
Past Medical History:
- Gastritis
- Duodenitis
- Alcohol abuse
- GERD
- Internal and external hemorrhoids
- Chronic back pain/chronic neck pain/chronic ankle pain
- Pancreatic cystic lesion
- Asthma
- Osteopenia
- History of perirectal abscess
- Anxiety
- vitamin D deficiency
- S/p partial colectomy and appendectomy
Social History:
Lives off [**Social Security Number 104675**]Social Security. She is currently "in between
apartments" so she is staying at friends' [**Name2 (NI) **]. Her mother and
six siblings live in the area. Patient smokes [**12-16**] ppd, has since
the age of 12. She states that she drinks "socially," (ie about
3 drinks/day a few times per week) but prior notes state she has
been drinking approximately 1 pint of vodka every other day. Has
thought about cutting down and does get annoyed when people ask
about her drinking. Denies illicit drug use.
Family History:
Significant for diabetes on both sides of the family. Also,
breast cancer in her female cousins on her mother's side of the
family but no immediate relatives. She also has an uncle on her
dad's side with pancreatic cancer. Father and uncle died of MIs
in their 60s.
Physical Exam:
Discharge Physical Exam:
Physical Exam:
Vitals: T: 97.9 BP: 109/72 P: 81 R: 13-24 O2: 100% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
CV: tachy, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, TTP diffusely, non-distended, bowel sounds
present, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2188-9-24**] 02:16AM BLOOD WBC-5.7 RBC-3.40* Hgb-9.7* Hct-30.7*
MCV-90 MCH-28.7 MCHC-31.7 RDW-16.0* Plt Ct-83*
[**2188-9-23**] 09:10AM BLOOD WBC-12.0*# RBC-4.16* Hgb-11.3* Hct-36.0
MCV-87 MCH-27.1 MCHC-31.3 RDW-16.5* Plt Ct-150#
[**2188-9-23**] 09:10AM BLOOD Neuts-75* Bands-2 Lymphs-16* Monos-4
Eos-2 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2188-9-24**] 02:16AM BLOOD Plt Ct-83*
[**2188-9-23**] 09:10AM BLOOD PT-12.8 PTT-21.1* INR(PT)-1.1
[**2188-9-24**] 02:16AM BLOOD Glucose-88 UreaN-7 Creat-0.5 Na-136 K-4.0
Cl-104 HCO3-19* AnGap-17
[**2188-9-24**] 02:16AM BLOOD ALT-18 AST-54* LD(LDH)-311* AlkPhos-54
TotBili-0.5
[**2188-9-24**] 02:16AM BLOOD Calcium-8.0* Phos-3.5 Mg-1.2*
[**2188-9-23**] 09:10AM BLOOD Albumin-5.4*
[**2188-9-24**] 02:16AM BLOOD Hapto-106
[**2188-9-23**] 11:25AM BLOOD Ethanol-97*
[**2188-9-23**] 02:04PM BLOOD Lactate-3.0* [**2188-9-23**] 11:26AM BLOOD
Lactate-4.4*
[**2188-9-23**] 09:20AM BLOOD Lactate-7.8* K-3.7
CT Abd/Pel [**2188-9-23**]
IMPRESSION:
1. Stomach is partially collapsed and poorly evaluated; however,
there are
foci of hyperdensity which may represent ingested content, but
hemorrhage is not excluded.
2. Stable appearance of previously documented pancreatic cystic
lesion.
Hepatic steatosis.
3. No evidence of perforation. No free fluid or free air.
EGD: Tear of the mucosa in the gastroesophageal junction -
healing MW tear
Erythema, granularity, friability and congestion in the whole
stomach compatible with gastritis
Erythema and congestion in the duodenal bulb compatible with
duodenitis
Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
54 yo F w/ h/o ETOH abuse, duodenotis/gastritis, anxiety
presents with emesis and melena x 1 day.
.
# Upper GIB: Pt placed on a PPI drip. Hct was 23 s/p 2 U pRBC.
GI was consulted and they performed an EGD on [**9-23**] which
showed: "Tear of the mucosa in the gastroesophageal junction -
healing MW tear. Erythema, granularity, friability and
congestion in the whole stomach compatible with gastritis.
Erythema and congestion in the duodenal bulb compatible with
duodenitis. Otherwise normal EGD to third part of the duodenum."
Her pm stabilized in the low 30s and she was hemodynamically
stable. Her PPI was changed to PO.
.
# ETOH withdrawal: Given history of seizure, she was placed on
a q2 CIWA scale and she was given folate/thiamine. Social work
was consulted.
.
# Elevated lactate: no leukocytosis or fevers. Etiology likely
due to dehydration w/ volume loss. Lactate down trending w/
ivfs and she remained hemodynamically stable.
.
# Asthma: Continue albuterol
.
# Anxiety: Continue venlafaxine
Medications on Admission:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation every 4-6 hours as needed for wheeze.
2. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
3. gabapentin 400 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO DAILY (Daily).
5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Vitamin D-3 2,000 unit Tablet Sig: One (1) Tablet PO once a
day.
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
8. Calcium 500 500 mg calcium (1,250 mg) Tablet Sig: Three (3)
Tablet PO once a day.
9. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
Discharge Medications:
1. gabapentin 400 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO DAILY (Daily).
Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*2*
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
Disp:*1 inhaler* Refills:*0*
7. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
Disp:*30 Tablet(s)* Refills:*0*
8. fluticasone 50 mcg/Actuation Spray, Suspension Sig: [**12-16**]
Nasal once a day.
Disp:*1 bottle* Refills:*2*
9. Vitamin D-3 2,000 unit Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
10. Calcium 500 500 mg calcium (1,250 mg) Tablet Sig: Three (3)
Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*2*
11. multivitamin Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Tear
Gastritis
Duodenitis
Melena
Hematemesis
Thrombocytopenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came into the hospital because of bleeding from your
stomach. The tests that we did (incluidng the EGD, which is a
camera that takes video pictures of your esophagus, stomach, and
small intestine) show that you had a tear in the lining of your
stomach and esophagus that caused you to bleed. This tear
formed because your were vomiting. This is why you vomited
blood and why you passed blood in your stool. The EGD also
showed that you have serious inflammation of your stomach and
upper part of the intestine. This is caused by alcohol use and
it is strongly recommedned that you stop using alcohol. You
have also been prescribed medications to help control the
inflammation and you should take these as directed.
Followup Instructions:
Please see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] who works with your primary care
physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], at the scheduled time next week. You
should also go on Monday to the clinic to get your blood drawn.
You need to get a test of your blood called a CBC, which will
evaluate the number of cells in your blood. We would like to
make sure the platelets in your blood are of normal number. It
is also recommended that you seek assistance to stop drinking
alcohol.
Department: [**Hospital3 249**]
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
When: THURSDAY [**2188-10-2**] at 9:10 AM
With: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
This appointment is with a hospital based physician as part of
your transition from the hospital back to your primary care
provider [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. After this visit you will be seen by Dr.
[**First Name (STitle) **].
Completed by:[**2188-9-28**]
|
[
"287.5",
"305.01",
"535.61",
"276.51",
"305.1",
"530.7",
"276.2",
"300.00",
"535.31",
"493.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
8241, 8247
|
4983, 5993
|
376, 400
|
8419, 8419
|
3371, 4960
|
9319, 10612
|
2556, 2824
|
6857, 8218
|
8268, 8398
|
6019, 6834
|
8570, 9296
|
2879, 3352
|
317, 338
|
428, 1660
|
8434, 8546
|
1682, 1980
|
1996, 2540
|
2864, 2864
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,248
| 199,311
|
21414
|
Discharge summary
|
report
|
Admission Date: [**2174-8-27**] Discharge Date: [**2174-9-2**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4975**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization
History of Present Illness:
82 y/o M with h/o HTN, PVD, COPD, recently discovered SDH in
[**4-19**], ESRD on HD, as well as CAD s/p kissing stents to LAD/LCx
in [**5-19**], followed by ISR of LAD in [**11-19**] and recent repeat cath
in [**6-21**] for refractory chest pain with taxus stents to 80% LAD
(distal to prior stent and 70% proximal LCx), med-flighted from
[**Hospital6 8283**] with recurrent chest pain. He was
seen in clinic by Dr. [**Last Name (STitle) **] 3 days ago at which time ([**8-24**]) he was
hypotensive by report and somewhat confused. Sent to the ED
where he received IVF and was sent home. He returned for
dialysis on [**8-25**] (the following day) where he was again found to
be hypotensive and complained at that time of multiple episodes
of CP on the day prior for which he had taken 6 ntg. He was
again referred to the ED, where his vitals were HR 68, BP 84/60.
An EKG demonstrated AF with LVH and ST depressions with TWI in
inferolateral leads, unchanged from prior EKG. His hypotension
was presumed secondary to intravascular volume depletion and
plans were made for careful IVF (given history of intubation
secondary to CHF), while holding BP meds for low blood pressure.
Cardiac enzymes were CK 22/25/22, top I =.04/.04/.03. While
there, he had a number of episodes of CP that were poorly
responsive to ntg, requiring multiple doses of MSO4 for relief.
He was started on a heparin gtt on the night of [**8-26**]. On [**8-27**],
just after dialysis, he again developed left sided CP which he
describes as radiating to left shoulder with SOB, relieved with
nitropaste 1". He was continued on [**Month/Year (2) **], Plavix, and received
metoprolol 25 mg as tolerated by blood pressure while at OSH. It
was decided, given recurrent CP, to transfer patient to [**Hospital1 18**]
for urgent cath rather than waiting until Monday, and he was
transferred on heparin drip and 3 L NC oxygen. Of note,
patient's INR today 2.2 and had been given coumadin for AF at
[**Hospital3 4298**]. Of note, patient with SDH in [**4-19**]. CT at MVH
showed stability. Patient is inactive physically at baseline.
.
PMH:
1) PVD
2) AAA-5x5 cm ([**4-21**])
3) PAF
4) CVA-longstanding history of head complaints including
intermittent vision loss and headache with many CT/MRAs
demonstrating chronic changes.
5) COPD
6) Depression
7) ESRD on HD
8) HTN
9) diastolic chf with 2 intubations for respiratory failure in
setting of fluid overload
10) CAD: Since last cath, had outpatient persantine thallium
stress test performed in [**Hospital1 1562**]--septal ischemia with good
ejection fraction
.
OP Medications:
Metoprolol 25 PO BID
Advair 250-50 mcg [**Hospital1 **]
[**Hospital1 **] 325 qd
Lisinopril 5 mg qd
folate ca acetate 667mg-3 capsules TID
Clopidogrel 75 qd
atorvastatin 80 qd
coumadin 2 mg qd
zoloft 100 mg qd
protonix 40 mg qd
trileptal 150 mg [**Hospital1 **] (recently discontinued)
B12 1000mcg qd
lasix 40 mg [**Hospital1 **]
imdur 30 mg qd
Vit E 400 u qd
ambien 10 mg qhs
Procrit with dialysis
.
Fam Hx: NC
.
Social history: retired marine, living in senior home, has been
2 ppd smoker for 30 yrs but stopped 2 years ago, EtOH denied.
.
PE:
Vitals 97.1/90 irreg/122/56/17/98%on 2L
Gen: nad
HEENT: arcus, mmm
Neck: JVD elevated 12 cm
CV: No carotid bruits, lat displaced PMI, 3/6 systolic crescendo
decrescendo murmur at LUSB. 1-2/6 systolic murmur, blowing, at
apex
Lungs: rales [**3-19**] way up posterior lung fields
Abd: Soft, NT, NABS
Extremities: cool skin, no le edema, distal pulses
non-dopplerable
Labs: see below
EKG: atral fibrillation at 90 bpm, nl axis, nl intervals, 1mm ST
depressions in v4-v6, I
TWI in I, aVl, v5-V6, II avF--inferolateral (old)
J-point elevation in V2-V3.
.
CT Head OSH: No change in subdural hematoma.
.
Echocardiogram [**4-21**]:
Findings:
LEFT ATRIUM: Mild LA enlargement. All four pulmonary veins
identified and enter the left atrium.
LEFT VENTRICLE: Moderate symmetric LVH. Mildly dilated LV
cavity. Normal regional LV systolic function. Overall normal
LVEF (>55%). No resting LVOT gradient. No LV mass/thrombus.
LV WALL MOTION: basal anterior - normal; mid anterior - normal;
basal anteroseptal - normal; mid anteroseptal - normal; basal
inferoseptal - normal; mid inferoseptal - normal; basal inferior
- normal; mid inferior - normal; basal inferolateral - normal;
mid inferolateral - normal; basal anterolateral - normal; mid
anterolateral - normal; anterior apex - normal; septal apex -
normal; inferior apex - normal; lateral apex - normal; apex -
normal;
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Focal calcifications in
ascending aorta. Mildly dilated descending aorta. Focal
calcifications in descending aorta.
AORTIC VALVE: Severely thickened/deformed aortic valve leaflets.
No masses or vegetations on aortic valve. Mild AS.
MITRAL VALVE: Moderately thickened mitral valve leaflets.
Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: The TEE probe was passed with assistance from
the
anesthesioology staff using a laryngoscope. The patient was
under general anesthesia throughout the procedure.
Conclusions:
The left atrium is mildly dilated. There is moderate symmetric
left
ventricular hypertrophy. The left ventricular cavity is mildly
dilated. Regional left ventricular wall motion is normal.
Overall left ventricular systolic function is normal (LVEF>55%).
No masses or thrombi are seen in the left ventricle. Right
ventricular chamber size and free wall motion are normal. The
descending thoracic aorta is mildly dilated. The aortic valve
leaflets are severely thickened/deformed. No masses or
vegetations are seen on the aortic valve. There is mild aortic
valve stenosis. The mitral valve leaflets are moderately
thickened. Trivial mitral regurgitation is seen. There
is no pericardial effusion.
.
C.Cath [**6-21**]
COMMENTS:
1 Selective coronary angiography of this right dominant system
demonstrated two vessel CAD. The LMCA was calcified with minimal
disease. The LAD had ostial 50% prior to the old stent and an
80% focal lesion at the septals. The LCX had a 70% proximal
stenosis. The RCA was small with non-critical diffuse disease.
2 Resting hemodynamics demonstrated elevated right and left
sided
filling pressure with RVEDP=16 mmHg and LVEDP=20 mmHg. The
cardiac
output was preserved with CI=3.8 L/min/m2.
3 Interrogation of the aortic valve demonstrated minimal aortic
stenosis with a mean gradient of 17 mmHg and a calculated
[**Location (un) 109**]=2.1 cm2.
4 The LAD lesion was predilated with a 2.5 X 15mm NC Ranger
balloon and stented with a 3.0 X 16mm Taxus stent with lesion
reduction from 80% to 0%. The final angiogram showed TIMI III
flow with no residual stenosis, no dissection and no
embolisation. (see PTCA comments)
5. The LCX lesion was directly stented with a 3.5 X 12mm Taxus
stent
with lesion reduction from 70 percent to 0 percent. The final
angiogram showed TIMI III flow with no dissection or
embolisation. (See PTCA comments)
FINAL DIAGNOSIS:
1. Two vessel CAD.
2. Mild left ventricular systolic dysfunction.
3. Minimal aortic stenosis.
4. Successful stenting of the LAD (Drug eluting)
5. Successful stenting of the CX (Drug eluting)
.
82 yo M with HTN, hypercholesterolemia, PVD, CAD s/p stents to
LAD/LCx as recently as [**6-21**], with recent SDH in [**4-20**] (small),
presents with chest pain at rest with intentions for
catherterization. Patient currently CP free.
1. Chest pain- Not convincingly cardiac given EKG relatively
unchanged from prior (possibly increased ST depression in
lateral leads) and no increase in cardac enzymes despite
numeraous episodes of CP over last few days. Possibly some
volume related hypoperfusion in the setting of fixed stenoses
and dialysis. Will continue heparin drip and give Vitamin K for
INR reversal with plans for possible cath monday. If CP recurs
and is difficult to control, may consider more urgently. Could
also be demand in setting of AF. Will consder ablation only if
unable to decrease HR with meds
- continue heparin gtt with frequent neuro evals given subdural
hemorrhage. Hold integrillin
-[**Month/Day (1) **], Plavix
-metoprolol 25 mg PO BID as tolerated, restart ACE-I next if BP
tolerates
-echo tomorrow, possibly cath monday at dr[**Last Name (STitle) 5452**] discretion
-gave one dose of vit K.
- obtain CTA to r/o PE, dissection as source of chest pain
- will need op GI appointment for EGD (r/o PUD).
.
2. Afib: currently not in RVR. On BB, heparin for
anticoagulation, holding coumadin.
- will hold coumadin due to h/o GI Bleed
.
2. Hypotension/Presyncope: Unclear etiology now. Difficult due
to poor historian. Because patient appears total body fluid
overloaded, unclear that due to hypovolemia.
.
3. Shortness of breath: responded well to atrovent nebs.
-continue COPD meds
-Component of volume overload. Increase to 40 mg IV BID, up from
outpatient dose of 40 [**Hospital1 **] PO. Fluid restriction. Gave Imdur 30
mg (outpatient dose)
.
4. ESRD-Will make renal aware in am. Patient significantly
volume overloaded currently but does make urine.
-Scheduled for next HD on Tuesday
-plan for HD Tuesday
- started nephrocaps
.
5. Subdural hematoma-stable CT at OSH
.
6. FEN-Cardiac healthy, diabetic healthy
.
Proph: PPI, on heparin
Past Medical History:
1.)HTN
2.)CAD -- Taxus stent to LAD/LCX ostia in [**6-19**], Cypher for LAD
instent restenosis [**11-19**]
3.)Diastolic chf with 2 intubations for overload-related
respiratory failure EF 60%
4.)Paroxysmal afib
5.)PVD
6.)AAA s/p repair [**4-21**]
7.)CVA -- Episode of aphasia in [**2172**], MRI/MRA with chronic small
vessel changes, no acute infarct, totally occluded right ICA
8.)COPD
9.)CRF -- steadily climbing from 1's in [**2172**], 4's in [**6-20**]'s
in [**10-20**]
10.)Depression
11.)PTSD
12.)Query etoh abuse with possible withdrawal at [**2172**] admission
Family History:
Unknown, as he did not know his parents.
Pertinent Results:
[**2174-8-27**] 06:14PM GLUCOSE-90 UREA N-35* CREAT-5.3* SODIUM-137
POTASSIUM-4.5 CHLORIDE-99 TOTAL CO2-26 ANION GAP-17
[**2174-8-27**] 06:14PM ALT(SGPT)-10 AST(SGOT)-20 LD(LDH)-274*
CK(CPK)-35* ALK PHOS-84 TOT BILI-0.2
[**2174-8-27**] 06:14PM WBC-5.4 RBC-3.71* HGB-12.0* HCT-36.9*
MCV-100* MCH-32.3* MCHC-32.4 RDW-16.9*
[**2174-8-27**] 06:14PM PT-25.9* PTT-52.1* INR(PT)-2.6*
.
Trop: .16
CK<100 x 3 cycles.
EKG [**8-27**]
Atrial fibrillation with a slow ventricular response. Probable
left ventricular
hypertrophy with repolarization change. Compared to the previous
tracing
of [**2174-7-9**] the rhythm has changed.
CTA CHEST W&W/O C &RECONS [**2174-8-29**] 4:58 PM
CTA CHEST W&W/O C &RECONS
Reason: rule out PE or dissection
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
82 year old man with PVD, CAD, COPD, p/w CP, s/p clean cath
REASON FOR THIS EXAMINATION:
rule out PE or dissection
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 82-year-old man with PVD, CAD, COPD presenting with
chest pain status post spleen catheterization. Rule out PE or
dissection.
TECHNIQUE: MDCT-acquired axial images of the chest were obtained
without IV contrast. IV contrast-enhanced images of the chest
were then performed. Coronal and sagittal reformations were
obtained.
CT CHEST WITHOUT AND WITH IV CONTRAST: There are bilateral large
pleural effusions, right greater than left. There are few focal
areas of ground-glass opacity within the right upper lobe. There
is associated dependent atelectasis. There are multiple enlarged
lymph nodes within the mediastinum, the majority of which are
calcified, the largest measuring 11 mm in diameter within the
precarinal space. There is also calcified hilar lymphadenopathy,
measuring 18 mm in diameter on the right. There are calcified
granulomas within left atelectatic lower lobe. Bilateral pleural
effusion. Atelectasis.
CTA CHEST: There is no evidence of pulmonary embolism or aortic
aneurysmal dilatation within the visualized thoracic aorta.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Large bilateral pleural effusions, right greater than left.
3. Calcified mediastinal and hilar lymphadenopathy along with
calcified lung granulomas consistent with chronic granulomatous
disease such as tuberculosis or sarciodosis
CT HEAD W/O CONTRAST [**2174-8-30**] 11:49 AM
CT HEAD W/O CONTRAST
Reason: please evaluate for SDH, other process.
[**Hospital 93**] MEDICAL CONDITION:
82 year old man with CAD, PVD, COPD, with h/o SDH
REASON FOR THIS EXAMINATION:
please evaluate for SDH, other process.
CONTRAINDICATIONS for IV CONTRAST: None.
NON-CONTRAST HEAD CT SCAN
HISTORY: Coronary artery disease, peripheral vascular disease
and chronic obstructive pulmonary disease with history of a
subdural hematoma. Evaluate for status of subdural hemorrhage.
TECHNIQUE: Non-contrast head CT scan.
COMPARISON STUDY: CT scan of [**2174-5-8**] interpreted by Drs.
[**First Name (STitle) 1022**] and [**Name5 (PTitle) **] as showing "no evidence of hemorrhage or mass
effect."
FINDINGS: There is no sign of an intracranial hemorrhage, mass
effect, or shift of normally midline structures, or visible
major vascular territorial infarction. Two probable chronic
lacunar infarctions are noted within the head of the right
caudate nucleus with redemonstration of a mild degree of chronic
small vessel infarction in the periventricular white matter of
both cerebral hemispheres. There is prominent atherosclerotic
calcification involving both distal vertebral arteries as well
as the basilar artery, and to a marked extent involving the
cavernous portions of both internal carotid arteries.
The surrounding osseous and soft tissue structures are notable
for interval development of moderate, slightly polypoid shaped
mucosal thickening involving the right maxillary antrum. The
incompletely visualized remaining paranasal sinuses appear
normally aerated.
CONCLUSION: No intracranial hemorrhage. Other findings as noted
above.
.
[**Hospital 93**] MEDICAL CONDITION:
82 year old man with ESRD, COPD and pleural effusion
REASON FOR THIS EXAMINATION:
Right decubitus to evaluate pleural effusion.
PA LATERAL AND DECUBITUS VIEWS OF THE CHEST, [**8-31**]
HISTORY: End-stage renal disease, COPD. Pleural effusions.
Decubitus views to assess size.
IMPRESSION: PA, lateral and decubitus views compared to [**7-9**] through [**8-28**].
Moderate volume mobile bilateral pleural effusion, stable on the
left and increased on the right since [**7-9**] and [**8-28**].
Interstitial edema has almost entirely cleared since [**8-28**].
Severe left lower lobe atelectasis has worsened since [**8-28**].
Heart size top normal. No pneumothorax
Upper endoscopy:
Stomach:
Mucosa: Diffuse continuous hypertrophy of the mucosa with no
bleeding was noted in the whole stomach. These findings are
compatible with hypertrophic gastritis. Cold forceps biopsies
were performed for histology at the stomach .
Impression: Hypertrophy in the whole stomach compatible with
hypertrophic gastritis (biopsy)
Otherwise normal EGD to second part of the duodenum
Recommendations: Follow-up biopsy results
The symptoms may be explained by the findings.
Additional notes: The procedure was done by the attending
physician and GI fellow.
Tissue biopsy [**8-31**]:
DIAGNOSIS:
Stomach, mucosal biopsy:
Mild chronic inactive gastritis.
HELICOBACTER PYLORI ANTIBODY TEST (Final [**2174-9-2**]):
POSITIVE BY EIA.
Reference Range: Negative.
Brief Hospital Course:
1. Chest pain: The patient was admitted with chest pain with EKG
demonstrating possibly increased ST depression in lateral leads
and troponin of .16 with no elevation in CK. The differential
diagnosis for his chest pain included cardiac ischemia due to
coronary blockage vs. increased demand due to atrial
fibrillation vs. volume related hypoperfusion in the setting of
fixed stenoses and dialysis vs non cardiac cause. He was
continued on a heparin drip and underwent cardiac
catheterization, which demonstrated no flow limiting CAD. CTA
was also performed, which ruled out pulmonary embolism or aortic
dissection. He was continued on his outpatient dose of aspirin,
plavix and metoprolol, while his ACE inhibitor was held.
Non-cardiac causes for the patient's chest pain were explored
and he underwent a EGD, which demonstrated hypertrophic
gastritis.
.
2. Anticoagulation: The patient was restarted on coumadin after
a CT of his brain was performed to rule out expansion of
previously noted subdural hematoma.
.
3. Hypotension/Presyncope: Unclear etiology now. It is likely
that when the patient experienced chest pain previously, he self
medicated with nitroglycerin leading to some hypotension.
.
4. Respiratory: The patient is chronically oxygen dependent at
home. His chest x-ray demonstrated some degree of atelectasis
and volume overload. His dyspnea responded well to atrovent
nebulizers.
.
5. Chronic renal insufficiency: The patient underwent renal
dialysis according to his normal outpatient schedule while in
the hospital, with removal of fluid to assist in relieving his
pulmonary congestion.
Medications on Admission:
Metoprolol 25 PO BID
Advair 250-50 mcg [**Hospital1 **]
[**Hospital1 **] 325 qd
Lisinopril 5 mg qd
folate ca acetate 667mg-3 capsules TID
Clopidogrel 75 qd
atorvastatin 80 qd
coumadin 2 mg qd
zoloft 100 mg qd
protonix 40 mg qd
trileptal 150 mg [**Hospital1 **] (recently discontinued)
B12 1000mcg qd
lasix 40 mg [**Hospital1 **]
imdur 30 mg qd
Vit E 400 u qd
ambien 10 mg qhs
Procrit with dialysis
Discharge Medications:
1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
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. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
8. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily).
10. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily).
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
13. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
14. Outpatient [**Hospital1 **] Work
INR check
15. Outpatient [**Hospital1 **] Work
INR check
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Nursing Association
Discharge Diagnosis:
Primary:
hypertrophic gastritis
CHF with diastolic dysfunction
Secondary:
CAD
Paroxysmal Atrial fibrillation
COPD
ESRD
HTN
Discharge Condition:
stable, on nasal cannula oxygen, tolerating normal diet.
Discharge Instructions:
You underwent a cardiac catheterization while in the hospital to
evaluate your chest pain. You were found to have NO new blockage
in your coronary arteries.
.
You should not continue to take sublingual nitrates for chest
pain. If you have chest pain, you should call your primary care
physician to discuss appropriate action.
.
You had an endoscopy while in the hospital which showed
hypertrophic gastritis. You should could continue to take a PPI
medication, as you have in the past for treatment of this.
.
Please seek immediate medical attention if you experience chest
pain, shortness of breath, dizziness/lightheadedness, bloody
bowel movements or any other worrisome symptoms.
.
Please take all medications as directed. Your Aspirin has been
changed to 81 mg daily. There have been no other changes to your
medication regimen.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet.
.
You are on a blood thinner called coumadin. This requires that
you have your INR checked regularly and may require that you
decrease or increase your dose.
Followup Instructions:
Please visit with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
(phone number: [**Telephone/Fax (1) 36558**]) on Tuesday, [**9-6**], after your
dialysis visit.
.
Please have your INR level checked at your dialysis visit on
Saturday, [**9-3**]. Your results should be faxed to Dr.[**Name (NI) 29821**]
office at [**Telephone/Fax (1) 55375**].
.
Continue your normal dialysis schedule.
Completed by:[**2174-9-13**]
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94
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7687
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Discharge summary
|
report
|
Admission Date: [**2176-2-25**] Discharge Date: [**2176-2-29**]
Date of Birth: [**2101-9-20**] Sex: M
Service: MEDICINE
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
1. endotracheal intubation
2. central venous catheter placement
History of Present Illness:
74 y/o M w/past hx of HTN and cervical radiculopathy, who
presented today c/o weakness. He stated that he thought he had
the flu over the past few days, with a nonproductive cough,
headache, and general weakness. Very poor PO intake. He was
recently prescribed effexor, and took his first dose this AM.
Approximately one hour after that, he felt much weaker. EMS was
called and on arrival his bp was 80/60. He received 1 L NS and
his bp responded to 120s.
On arrival to the ED, his bp was 110s-120s/60s with a pulse in
the 60s. He was awake, alert, and answering questions. His only
complaints were of a headache, and he felt like he had to
urinate but was unable to. He denied any chest pain, shortness
of breath, abdominal pain. Mild nausea but no vomiting. While
examining him, he became bradycardic to 42 and hypotensive to
60/40. He was febrile to 101.2 and diaphoretic. He received 2L
NS wide open with a mild response in his bp to 70s/50s. He was
put on peripheral dopamine. Bedside echo revealed no pericardial
effusion, possibly depressed EF, no visible aortic aneurysm, and
a dilated IVC. He was taken urgently to CT scan to r/o PE and
dissection.
In the CT scanner, he vomited. no aspiration observed and CXR no
infiltrate. No blood in vomit. He then became tachycardic to the
130s (narrow complex) which appeared to be SVT per ED resident
no ECG confirmation in CT. Dopamine stopped with normalization
of HR. He then again became tachycardic in the 130s, and this
time broke with carotid massage back down to 70. Still
hypotensive in 70s and so started on neo. CT showed no PE or
dissection.
When he returned, intubated for airway protection given vomiting
and hemodynamic instability. Never hypoxic or with resp
distress. Good mentation per family. vanc/levoflox/flagyl and
decadron. Lactate was 1.6 and he had 1600 cc UOP. His SBP came
back up to the 160s and the neo was weaned off. Multiple
attempts at right subclavian caused 2 arterial sticks. CXR
showed no pneumo/hemothorax.
Subsequently became hypotensive again, and placed back on neo
and dopa. Right IJ placed. Sent to CCU. Given total of 3
liters NS.
Recently had epidural steroid inject ion [**2-23**]. No worsening of
back pain since that time.
Past Medical History:
1. HTN
2. Cervical radiculopathy
3. Low back pain s/p lumbar epidural steroid injection [**1-8**]
Social History:
never smoked, no alcohol. lives with son. uses [**Name2 (NI) **] at
baseline. Has normal mental status. has home PT.
Family History:
non-contributory
Physical Exam:
Tm 101.2, Tm 99.8, bp 114/63, map 80, p 80 NSR
Vent: AC 600/5/r12/40%, rr (obs) 17, PIP 15
ABG: 7.34/44/371
I/O: UOP>30cc/hr
drips: neo 0.19, dopa 3
gen: well, nontoxic
lungs: CTAb
CV: s1/s2, rrr
abd: soft, nttp, nabs, nd
ext: no edema, warm, dry, dp2+
neuro: pupils 3mm equal, MAE, cantonese speaking only,
intubated.
skin: no rash or skin breakdown anteriorly
Pertinent Results:
Laboratory:
labs at discharge:
wbc 4.7, hct 41.2, plt 148
Na 134, K 3.6, Cl 110, HCO3 22, BUN 11, Cr 0.8, glucose 95, Ca
8.6, Mg 1.8, Ph 2.9.
.
Microbiology:
[**2-25**] Blood culture: pending.
[**2-25**] Urine culuture: negative.
[**2-26**] DFA for influenza: negative.
.
Imaging:
[**2-25**] CXR:
Clear lungs.
[**2-25**] CT chest/abdomen/pelvis:
1. No evidence for pulmonary embolus or aortic dissection.
2. Focal mesenteric region of increased attenuation which most
likely represents inflammation secondary to mesenteric
panniculitis, or less likely trauma, edema, or tumor (lymphoma).
There is no evidence of mesenteric vasculature or bowel
compromise. A biopsy or CT scan in the future may provide
further diagnostic information.
3. Fluid within the esophagus which increases this patient's
risk of aspiration.
4. Multiple low-attenuation lesions throughout the liver which
most likely represent simple liver cysts; however, an ultrasound
examination could be performed for confirmation when the patient
is clinically stabilized.
[**2-27**] TTE:
Conclusions:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and systolic function are normal
(LVEF>55%). Regional left ventricular wall motion is normal.
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. The mitral
valve leaflets are structurally normal. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Mild mitral regurgitation with normal valve
morphology. Preserved global and regional biventricular systolic
function.
Brief Hospital Course:
74 M with fever and hypotension intubated electively for airway
protection.
.
# Hypotension:
He was hypotensive in the emergency department which was of
unclear etiology. This was thought most likely to be due to
hypovolemia due to dehydration as his blood pressure normalized
with IV fluids. By the end of his hospitalization he had
actually started to become hypertensive and was started on
lisinopril 10 mg daily. His HCTZ was not restarted as it was
thought this may have been contributing to his hyponatremia.
.
Fever:
This was of unclear etiology and was attributed to a likely
viral syndrome. He had no localizing signs or symptoms of
infection. A test for influenza was negative as was a urine
culture. Blood cultures were pending at discharge. He was
initially treated with broad spectrum antibiotics including
vancomycin, levofloxacin, and metronidazole. Once his culture
data was negative he was switched to po levofloxacin and he was
discharged to complete a seven day course.
.
# Resp Failure:
He was intubated in the ED for airway protection but he was
successfully extubated shortly after arriving to the MICU and
maintained a normal O2 saturation throughout the rest of his
hospital course.
.
# Hyponatremia:
On admission he was initially hyponatremic with a sodium of 129.
This was thought to be due to a combination of hypovolemia from
dehydration as well as HCTX effect. With hydration and stopping
his HCTZ his sodium normalized and at discharge it was 134.
.
# Cervical radiculopathy:
He has a history of this and was last seen in neurology clinic
in [**2169**]. He intermittently complained of neck pain during his
admission and was set up with a follow-up appointment in
neurology with Dr. [**First Name (STitle) **] on [**4-8**] at 3:00.
.
# Lower back pain:
He has a history of chronic lower back pain and spinal stenosis
and has been followed in the pain management center. He was
kept on his gabapentin and has a follow-up appointment with the
pain clinic.
.
# Urinary hesitancy:
This is also a chronic issue for him and he was started on
tamsulosin during his hospitalization with some effect. He has
a follow-up appointment in the urology clinic.
.
# Focal mesenteric thickening on CT scan:
His abdominal exam was benign and he did not complain of
abdominal pain. The general surgery service was consulted and
did not recommend any intervention.
.
# Dispo:
He was discharged to home with plans for home physical therapy
as he had previously had. He was also set up for appointments
with his PCP, [**Name10 (NameIs) **] pain clinic, urology, and neurology.
Medications on Admission:
Gabapentin 300 mg qd
Spectravite Senior
Super B-complex
Omega3/Omega6 Fish Oil
HCTZ 25 mg qd
Xalatan 0.005% eye drop
Timolol 0.5% opthalmic solution
Effexor - started day of admission.
Discharge Medications:
1. Gabapentin 600 mg Tablet Sig: One (1) Tablet PO three times a
day.
2. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
3. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
4. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
5. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2*
6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 1952**], [**Location (un) 86**]
Discharge Diagnosis:
1. Viral syndrome.
Discharge Condition:
Stable.
Discharge Instructions:
1. You are being discharged to home.
2. Please take your medications as prescribed.
--We started lisinopril for your blood pressure. Please take
this until you see Dr. [**First Name (STitle) **] next week and you can have your blood
pressure checked.
--We started tamsulosin for your urinary frequency.
--You should continue to take levofloxacin (an antibiotic) for
three more days.
3. Please come to your follow-up appointments (see below).
4. If you experience any fevers, chills, sweats, dizziness, or
other concerning symptoms, please seek medical attention.
Followup Instructions:
1. You have an appointemnt with Dr. [**First Name (STitle) **] on Wednesday [**3-6**]
at 2:00 pm. Please call his office at [**Telephone/Fax (1) 27950**] if you need
to reschedule this appointment.
2. Provider: [**Name10 (NameIs) 9894**],[**Name11 (NameIs) **](A) PAIN MANAGEMENT CENTER
Date/Time:[**2176-3-8**] 1:30
3. Provider: [**Name10 (NameIs) 161**] [**Name8 (MD) 6476**], MD Phone:[**Telephone/Fax (1) 921**]
Date/Time:[**2176-3-20**] 3:30 - urology appointment.
4. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4406**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 44**]
Date/Time:[**2176-4-8**] 3:00 - neurology appointment.
Completed by:[**2176-3-1**]
|
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[
[]
]
] |
[
"88.72",
"96.04",
"38.93",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
8667, 8742
|
5111, 7713
|
305, 370
|
8805, 8815
|
3319, 3331
|
9427, 10126
|
2903, 2921
|
7948, 8644
|
8763, 8784
|
7739, 7925
|
8839, 9404
|
2936, 3300
|
257, 267
|
3350, 5088
|
398, 2629
|
2651, 2750
|
2766, 2887
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,705
| 155,006
|
21934
|
Discharge summary
|
report
|
Admission Date: [**2171-10-22**] Discharge Date: [**2171-11-6**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
GI bleeding
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Age over 90 **] yo female with a history of CHF, ?UC, and CRI who was
intially admitted to [**Hospital6 8283**] [**2171-10-11**] after
she passed out after a sudden episode of large black stool at
Windamere NH where she resides. At MVH, she received 5U PRBC's
over 10 days in response to Hct on admission at 30. She had a
Hct nadir at 20 over her hospitalization, now hct stable @ 30 x
3 days (baseline hct 30). She had a negative EGD and a
colonoscopy on [**2171-10-16**] up to 60cm only (secondary inadequate
prep). She had no hematemesis during her hospitalization and
had a "minimal" amount of black stool since admission. She was
transferred to [**Hospital1 18**] intensive care on [**10-22**] for further work
up. In the intensive care unit, the patient was treated for
H.pylori, transfused 2 units PRBCs on [**10-23**] and [**10-24**], yet was
unable to have colonoscopy because the patient refusing prep.
The patient was also hypernatremic on admission, which resolved
after free water repletion. The patient was occasionally
bradycardic with episodes of pauses, but she was never
symptomatic and often sleeping. Most notably, the patient had
intermittent melena (small amts, at most 50 cc)but managed to
stay hemodynamically stable with stable Hct 32. The patient
communicates only via writing since she is deaf. The patient
was transferred to a regular medicine floor for further
management.
Past Medical History:
* AS valve area 0.9cm^2
* CRI creat 1.8 at baseline, diagnosed in [**7-5**] w/ creat 2.3;
* report of Ulcerative Colitis diagnosed by c-scope, s/p
polypectomy;
* CHF
* s/p hip fx [**7-5**]
* b/l cataracts
* b/l OA of knees
* deafness - communicates via writing
Social History:
widowed, lives @ Windamere's NH ([**Hospital3 4298**]); no hx
tobacco use; no ethanol use.
Family History:
unknown
Physical Exam:
On discharge,
T 96.6 BP 130/72 P 66 R 16 Sat 98% RA
Gen: thin cauc female lying comfortably, NAD
HEENT: PERLLA, EOMI, sclara anicteric, no conjuctival injection,
mucous membranes slightly dry, no lymphadenopathy, no thryroid
nodules or masses, no supraclavicular lymph nodes, no posterior
lymphadenopathy, neck supple, full ROM, neg JVD, no carotid
bruits
COR: RRR, S1 and S2 wnl, no murmurs/rubs/gallops
[**Last Name (un) **]: CTA bilateally anteriorly,
ABD: +BS/S/NT/ND/no masses
EXT: no edema peripherally, no sacral edema, no rash, no
posterior tend
NEURO: II-XII intact, deaf bilaterally
Pertinent Results:
Labs:
@OSH; [**2171-10-11**] admission creat 1.8 BUN 53; glu 155 alk phos 180
[**Doctor First Name **] 127; LDH/CPK wnl; hct 30;
[**2171-10-15**] hct 20
[**2171-10-18**] hct 25; o/w hct ranging 20-34, stable at 30-31 since
[**2171-10-18**]
wts [**2171-10-11**] 124# [**2171-10-11**] 119# [**2171-10-14**] 121# [**2171-10-16**] 107#
.
ON transfer [**2171-10-22**]: Na 153 K 3.0 hct 35 (s/p 1 U PRBC's in
transit on [**Location (un) **], 30 @ OSH prior to transfer)
Now:
[**2171-11-5**] 09:55AM BLOOD WBC-6.6 RBC-4.00* Hgb-12.1 Hct-35.0*
MCV-88 MCH-30.2 MCHC-34.5 RDW-14.8 Plt Ct-245
[**2171-11-5**] 09:55AM BLOOD Plt Ct-245
[**2171-11-4**] 03:45PM BLOOD Glucose-96 UreaN-17 Creat-0.9 Na-142
K-4.5 Cl-108 HCO3-26 AnGap-13
[**2171-11-3**] 06:11AM BLOOD Calcium-8.3* Phos-2.5* Mg-1.5*
EGD gastric antrum Bx at OSH:
[**2171-10-18**] - chronic gastritis involving antral type mucosa;
helicobacter species focally present;
~
Rad:
@ OSH:
[**2171-10-16**] CT Abd to r/o AAA - no IV or PO contrast; no AAA, max
dia 2.4cm; L 2cm renal cyst; atelectasis or infiltrate @ LL
base; liver, pancreas, spleen and adrenals, wnl;
[**2171-10-11**] CXR:mild cardiomegaly, no pulm edema, no pna;
~
Here at [**Hospital1 18**]:
[**2171-10-22**] CXR: RIJ in place, no CHF, no pna;
~
EKG: NSR @ 60 bpm, nl axis, nl intervals, no ST changes
~
Tagged Red Cell Study ([**2171-10-29**])
IMPRESSION: Focal area of increased tracer uptake in the
anterior right pelvis which does not appear to be within the GI
tract. It is unclear what the etiology of this is, but
possibilities include a fistula, hemangioma or pelvic kidney.
Brief Hospital Course:
1. GI bleed: After the patient's initial presentation with
melena, she still had small amts of melena (averaging 1 episode
of approx 30-50 cc/2-3days). She received a total of 5U PRBC's
over 10 days at OSH and an additional 6 units at [**Hospital1 18**].
Transfusion criterion was to main Hct above 27. Etiology of the
patient's GI bleed remained cryptic after EGD which revealed
mild gastritis. Despite being H.pylori positive, no ulcers were
noted. Nonetheless, the patient was treated with pantoprazole
twice daily. Clarithromycin and amoxicillin were given for a 14
day course. Colonoscopy at MVH up to 60cm was also unrevealing.
Repeat colonscopy at [**Hospital1 18**] showed a polyp in the proximal
ascending colon, diverticulosis of the sigmoid colon, blood in
the entire colon and terminal ileum. Thus a source of bleeding
was not identified. Repeat EGD at [**Hospital1 18**] showed large hiatal
hernia, in the upper potion of the hiatal hernia a healed linear
erosion, in the antrum a partially healed linear ulcer. The
colonoscope was inserted to the mid-jejunum and no lesions were
found in careful examination of the small bowel. It was
recommended that the patient continue on proton pump inhibitors
and the general impression was that the bleeding site was either
of the two abnormalities seen because they were healing. Of
note, the [**Hospital 228**] medical records specified a history of UC,
but the patient denies this history and colonoscopy was not
consistent with that diagnosis. A tagged red cell GI bleeding
was also performed which showed a focal area of increased tracer
uptake in the anterior right pelvis which did not appear to be
within the GI tract. It was unclear what the etiology of this
is, but possibilities include a fistula, hemangioma or pelvic
kidney. Hematocrits were checked serially 2-3 times per day and
the patient was able to hold stable values around 30 for three
days at a time. The patient was sent for a small bowel follow
through to evaluate for possible strictures or Crohn's, but the
study was normal, without any evidence of strictures,
dilatation, or mucosal abnormality. Despite the above full
series of studies, it was difficult to unequivocally identify
source of the patient's bleeding. It was believed that source
was related to healing erosions seen on EGD, but definitive
diagnosis would only be possible with open surgery. After
discussions with the patient, her niece, and the GI service, it
was thought that the morbidity of exploratory laparotomy to find
source of bleeding would carry too much of a risk for the
patient. Empiric hormonal therapy with estrogen could be tried
next if the GI bleeding continues. Antibiotic course for H.
pylori has been completed.
2. CHF - From her outside record, the patient was on standing
lasix. She never appeared to be in failure throughout her floor
admission and consistently appeared euvolemic to slightly
hypovolemic on exam. Lasix was held given hypovolemia and
likely pre-load dependence given moderate AS.
3. Hypernatremia - Na 153 on admission was likely secondary to
hypovolemic hypernatremia. Sodium levels improved to normal
limits after free water repletion. Daily monitoring revealed no
repeat episodes of hyponatremia.
4. CRI - The patient carried a diagnosis of chronic renal
insufficiency with baseline creat of 1.8, but this value
improved to 0.8 on iv fluids.
5. Bradycardia - The patient had rare episodes of sinus
bradycardia with occasional pauses and junctional escape rhythm.
One episode was associated with hypotension but on iv fluid
resuscitation, blood pressure were within normal limits. She
was never symptomatic. The patient was evaluated by cardiology
and bradycardia as well as syncopal episode at [**Hospital3 4298**]
were felt to be likely vasovagal and did not recommend a
temporary pacemaker. The patient will need outpatient followup
with Holter monitor.
6. Code: Full Code
Medications on Admission:
All: NKDA
~
Meds on transfer from OSH:
protonix 40mg po bid
lasix 20mg po qd
carafate 1gm qid
tylenol 325mf po q6h prn
~
Meds currently on in MICU:
Clarithromycin 250 PO BID
Amoxicillin 500 PO BID
Protonix 40 mg PO BID
RISS
Protonix 40 IV BID
Vitamin K 10 mg PO x 3 days
Zofran prn
~
Outpt Meds:
Zantac
lasix 20mg po qd
azithromycin for presumed pna prior to admission
flonase [**Hospital1 **]
tylenol prn
Discharge Medications:
1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
2. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
3. Menthol-Cetylpyridinium Cl 2 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed) as needed for dry throat,
cough.
Discharge Disposition:
Extended Care
Facility:
Windemere Nursing & Rehabilitation Center - [**Location (un) **]
Discharge Diagnosis:
GI bleed of undetermined source
Discharge Condition:
Fair
Discharge Instructions:
1. Please take all of your medications.
2. Please seek medical attention should you experience any of
the following: shortness of breath, chest pain, palpitations,
sudden weakness, lightheadedness, dizziness, loss of
consciousness, fainting, nausea, vomiting, fever, chills
3. Please weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3
lbs.
4. Adhere to 2 gm sodium diet
Followup Instructions:
Please follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] within 1-2 weeks,
particularly if you experience bloody or dark stools or feel
lightheaded, have chest pain, or shortness of breath, or
increased fatigue
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
[
"428.0",
"276.0",
"424.1",
"593.9",
"556.9",
"427.89",
"285.1",
"211.3",
"578.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
9184, 9275
|
4393, 8346
|
274, 280
|
9350, 9356
|
2772, 4370
|
9794, 10162
|
2131, 2140
|
8803, 9161
|
9296, 9329
|
8372, 8780
|
9380, 9771
|
2155, 2753
|
223, 236
|
308, 1723
|
1745, 2007
|
2023, 2115
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,912
| 147,116
|
47296
|
Discharge summary
|
report
|
Admission Date: [**2112-4-9**] Discharge Date: [**2112-4-15**]
Date of Birth: [**2057-8-27**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
54 yo M s/p CABG x 3 on [**3-16**] with prolonged post op hospital
course, discharged to rehab. At rehab c/o preogressive SOB, o2
sats decreased to 84%. Sent to [**Hospital1 **] er where CTA showed bilateral
PE. Started on heparin IV.
Past Medical History:
CABG x 3
Dyslipidemia, Hypertension, Percutaneous coronary intervention,
in [**2102**] w/ stent to LAD at [**Hospital6 **].
Social History:
Denies any tobacco, EtOH or illicit drug use. Works as a nurse
for an insurance company for the last year.
Family History:
His father and brother both died of MIs at age 48.
Physical Exam:
98.7 98 91/58 18
101 kg 71"
NAD
Lungs decreased bretah sounds at both bases
Heart RRR without murmur
Abdomen Benign
Extrem with palpable pulses t/o
Pertinent Results:
[**2112-4-12**] 05:40AM BLOOD WBC-9.5 RBC-4.60 Hgb-13.3* Hct-41.7
MCV-91 MCH-29.0 MCHC-32.0 RDW-14.3 Plt Ct-398
[**2112-4-12**] 05:40AM BLOOD PT-27.8* PTT-93.3* INR(PT)-2.8*
[**2112-4-11**] 04:32AM BLOOD PT-20.3* PTT-80.7* INR(PT)-1.9*
[**2112-4-10**] 07:03PM BLOOD PT-19.4* PTT-75.9* INR(PT)-1.8*
[**2112-4-10**] 08:15AM BLOOD PT-16.7* PTT-70.7* INR(PT)-1.5*
[**2112-4-9**] 09:30AM BLOOD PT-15.3* PTT-30.5 INR(PT)-1.4*
[**2112-4-12**] 05:40AM BLOOD Glucose-105 UreaN-13 Creat-0.9 Na-137
K-4.3 Cl-99 HCO3-21* AnGap-21*
[**2112-4-15**] INR 3.1
BILAT LOWER EXT VEINS [**2112-4-10**] 8:03 AM
BILAT LOWER EXT VEINS
Reason: pt. with PE r/o DVT
[**Hospital 93**] MEDICAL CONDITION:
54 year old man with dyspnea s/p cabg
REASON FOR THIS EXAMINATION:
pt. with PE r/o DVT
STUDY: Bilateral lower extremity venous ultrasound.
INDICATION: 54-year-old male presenting with dyspnea. Status
post CABG. Assess for DVT.
CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2112-4-9**] 10:25 AM
CTA CHEST W&W/O C&RECONS, NON-
Reason: ? PE
[**Hospital 93**] MEDICAL CONDITION:
54 year old man with pmh of CABG, recently discharged for the
same, presents from rehab w/ acute onset SOB and desats to 80s
on RA (prior normal). Not clinically in CHF.
REASON FOR THIS EXAMINATION:
? PE
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 54-year-old with recent CABG and acute-onset
shortness of breath. Evaluate for PE.
COMPARISON: Chest radiograph, [**2112-3-27**] and [**2112-4-9**].
TECHNIQUE: Multidetector helical scanning of the chest was
performed following administration of 70 cc of IV Optiray
contrast. Coronal, sagittal and multiple oblique MIP reformats
were displayed.
CTA OF THE CHEST: There are multiple segmental and subsegmental
pulmonary emboli involving all lobes of the lung. Clot burden is
extensive. There is mild enlargement of the right atrium,
suggesting right heart strain. The aorta is of normal caliber
with no evidence of dissection. Heart size is normal with
minimal pericardial fluid. There is a fluid collection extending
retrosternally along the anterior mediastinum, measuring
approximately 5.7 TRV x 1.3 AP x 6.0 CC in dimension which may
simply be postoperative fluid, though infection cannot be
excluded. The sternal wires are intact and there is no evidence
of sternal dehiscence. There is a clear fat plane between this
fluid collection and the great vessels. Extensive coronary
artery calcifications and multiple CABG grafts are noted. There
is a moderate left-sided non- loculated pleural effusion with
associated atelectasis, within normal limits given the patient's
post-cardiac surgery status. There are peripheral ground- glass
opacities within the anterior right upper lobe which are
nonspecific but may represent infectious or inflammatory
etiology. No pathologically enlarged mediastinal, axillary, or
hilar lymph nodes.
This exam is not tailored for subdiaphragmatic assessment. The
visualized portions of the liver, spleen, and adrenal glands are
normal.
There are no suspicious lytic or sclerotic lesions. Prominent
confluent anterior osteophytosis of the mid-thoracic spine is
noted.
IMPRESSION:
1. Extensive bilateral pulmonary emboli with suggestion of right
heart strain. Findings were posted to the ED dashboard at the
time of the exam.
2. Retrosternal fluid collection, which may simply be
postoperative fluid, though infection cannot be excluded. No
evidence of sternal dehiscence.
3. Moderate-sized left pleural effusion with associated
atelectasis.
COMPARISONS: None.
FINDINGS: Grayscale and Doppler assessment of the right and left
common femoral, superficial femoral and popliteal veins was
performed. Normal flow, augmentation and compressibility is
demonstrated of the right and left common femoral, right and
left superficial femoral and left popliteal veins. Echogenic
material is seen to expand the right popliteal vein above the
knee and is consistent in appearance with acute thrombus.
Echogenic material is seen to extend in to the right posterior
tibial and peroneal veins also consistent in appearance with
thrombosis. Doppler assessment of the calf veins of the left leg
demonstrates echogenic material within the left peroneal vein
consistent with acute thrombus.
IMPRESSION: Findings consistent with deep vein thrombosis
involving the right popliteal vein. Acute thrombis extends into
the posterior tibial and peroneal veins as well as the left
peroneal vein.
Brief Hospital Course:
He was admitted to cardiac surgery [**4-9**] and started on IV heparin
and coumadin. He was diuresed for a moderate left effusion.
Lower extremity dopplers showed a right DVT. He was transferred
to the ICU for increased work of breathing. He was seen by
vascular surgery and there was no indication for an IVC filter.
His breathing improved and he was transferred back to the floor.
His INR was therapeutic and he was ready for discharge home on
hospital day #5. Target INR is 2.0-3.0 for PE/DVT.
First blood draw [**4-16**] with results to be called to PCP [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 5936**] for coumadin dosing/INR followup. Pt. is to make all
followup appts. as directed in discharge instructions.
Medications on Admission:
ASA 325', Niacin SR 500', Atenolol 50', Lisinopril 20', Lipitor
10'
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Niacin 500 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO QAM (once a day (in the morning)).
Disp:*30 Capsule, Sustained Release(s)* Refills:*1*
3. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*1*
4. Thiamine HCl 100 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) for 1 weeks.
Disp:*14 Capsule(s)* Refills:*0*
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
7. 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*
8. Atenolol 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Disp:*45 Tablet(s)* Refills:*1*
9. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO twice a day
as needed.
Disp:*20 Tablet(s)* Refills:*0*
10. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 1 doses: 2 mg today only [**4-15**];then daily dosing per Dr.
[**First Name (STitle) 5936**].
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
PE/DVT
s/p CABG [**2112-3-16**].
CAD s/p stent-LAD, HTN, ^chol, obesity,gout,CHF,anemia,Pilonidal
cyst removal, Tonsillectomy
Discharge Condition:
Stable.
Discharge Instructions:
Coumadin for pulmonary embolus to be followed by PCP [**Name9 (PRE) **] [**Name Initial (PRE) **].
[**First Name4 (NamePattern1) 5936**]
[**Last Name (NamePattern1) **] 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 lifting more than 10 pounds for 10 weeks from surgery.
No driving until follow up with surgeon.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2112-4-19**] 1:00
Dr. [**First Name (STitle) 5936**] in 2 weeks
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**] ( cardiology) appt. [**5-2**] Monday 2:00PM [**Hospital Ward Name 23**]
7 [**Hospital Ward Name **]
Dr. [**Last Name (STitle) **] (vascular) appt. Monday [**4-25**] 3:30 PM [**Hospital Ward Name **] [**Hospital Unit Name **]
First blood draw SAT [**4-16**], with results to be called to Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] office at [**Telephone/Fax (1) 42923**] and faxed to him also at
[**Telephone/Fax (1) 77681**]
Completed by:[**2112-4-15**]
|
[
"401.9",
"V45.81",
"428.42",
"E878.2",
"428.0",
"272.4",
"997.2",
"453.42",
"511.9",
"274.9",
"415.11"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7699, 7762
|
5573, 6311
|
324, 332
|
7932, 7942
|
1122, 1766
|
8433, 9163
|
885, 937
|
6429, 7676
|
2180, 2350
|
7783, 7911
|
6337, 6406
|
7966, 8410
|
952, 1103
|
281, 286
|
2379, 5550
|
360, 596
|
618, 743
|
759, 869
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,244
| 165,629
|
48634+49004
|
Discharge summary
|
report+report
|
Admission Date: [**2128-5-24**] Discharge Date: [**2128-5-31**]
Date of Birth: [**2053-1-19**] Sex: F
Service:
ADDENDUM: This is an addendum to a previously dictated
discharge summary for the above dates of admission. On [**5-28**] I had performed debridement of a necrotic right calf
wound. This was an excisional debridement completely using
sharp dissection with scissors and a blade. Only skin was
removed. The total surface area was 40 sq cm.
[**First Name11 (Name Pattern1) 518**] [**Last Name (NamePattern4) **], [**MD Number(1) 17554**]
Dictated By:[**Last Name (NamePattern4) 17555**]
MEDQUIST36
D: [**2128-9-15**] 15:40:27
T: [**2128-9-16**] 19:43:48
Job#: [**Job Number 102301**]
Admission Date: [**2128-5-24**] Discharge Date: [**2128-5-31**]
Date of Birth: [**2053-1-19**] Sex: F
Service: MEDICINE
Allergies:
Demerol / Motrin / ProAir HFA / Gluten / Ace Inhibitors / Diovan
/ Dilaudid / vancomycin
Attending:[**First Name3 (LF) 4588**]
Chief Complaint:
left lower extremity pain, swelling
Major Surgical or Invasive Procedure:
[**2128-5-26**] - Debridement and evacuation of right lower extremity
hematoma
[**2128-5-28**] - Bedside debridement of right lower extremity wound
History of Present Illness:
This is a 75 year-old Female with a PMH significant for chronic
A.fib (on Coumadin), chronic lower extremity edema, celiac
enteropathy, hypothyroidism, obstructive sleep apnea (on BiPAP),
non-insulin diabetes mellitus who presents following left lower
extremity trauma 4-days prior, now with concern for erythema and
swelling.
.
The patient was in her usual state of health 4-days ago when she
hit the medial part of her left shin on a chair leg. The area
immediately became ecchymotic, painful and swollen. She called
her PCP and she recommended a plain radiograph, but the patient
felt she couldn't make it the radiology suite. Over the next day
or so she noted increased swelling and the development of a
hematoma on her lower extremity. She denies fevers or chills; no
changes in extremity sensation or strength. She denies chest
pain or trouble breathing.
.
In the ED, initial VS: 97.6 103 141/75 22 96% RA. Exam was
notable for irregularly irregular rate and rhythm with an area
of 5-cm of ecchymosis on the lateral part of her shin with some
induration and blanching erythema. Laboratory data notable for
WBC 6.2, hematocrit 39.7%, platelets 321. Creatinine 0.6. [**Month/Day/Year 263**]
5.8. Left lower extremity U/S demonstrated an evolving hematoma
on the lateral aspect of the distal calf without clot burden.
She was admitted with the plan to initiate IV Unasyn for
presumed soft tissue infection (she received a single dose).
Past Medical History:
PAST MEDICAL & SURGICAL HISTORY:
1. Chronic atrial fibrillation, currently managed with rate
control as well as warfarin for anticoagulation
2. Chronic lower extremity edema
3. Celiac disease
4. Hypothyroidism
5. Obstructive sleep apnea (on BiPAP)
6. Diabetes mellitus, type 2
Social History:
Patient lives at home on the [**Location (un) 470**]. She ascends 3 flights of
7 stairs without issue. Independent in her ADLs and ambulates
with a cane at baseline. Denies tobacco use or alcohol use; no
recreational substance use.
Family History:
Father died on lung cancer. Mother died of complications related
to mitral stenosis.
Physical Exam:
ADMISSION EXAM:
.
VITALS: 97.8 138/80 88 18 97% RA
GENERAL: Appears in no acute distress. Alert and interactive.
Obese-appearing female.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes moist.
NECK: supple without lymphadenopathy. JVD difficult to assess
given body habitus.
CVS: Regular rate and rhythm, without murmurs, rubs or gallops.
S1 and S2 normal.
RESP: Decreased breath sound at bases only without adventitious
sounds. No wheezing, rhonchi or crackles. Stable inspiratory
effort.
ABD: soft, obese, non-tender, non-distended, with normoactive
bowel sounds. No palpable masses or peritoneal signs.
EXTR: no cyanosis, clubbing; chronic lymphedema changes to the
thighs bilaterally with overlying lymphedematous changes and
swelling, 2+ peripheral pulses on right and doppler signals on
left; left lower extremity with lateral shin raised and
indurated hematoma with mild surrounding blanching erythema;
some medial shin ecchymoses; some vesicular-appearing lesions.
NEURO: CN II-XII intact throughout. Alert and oriented x 3.
Strength 5/5 bilaterally, sensation grossly intact. Gait
deferred.
.
DISCHARGE EXAM:
.
VITALS: 100.3 98.1 108/60 98 21 96% 2L NC FS: 138-176
I/Os: 840 / - | 1000
GENERAL: Appears in no acute distress. Alert and interactive.
Obese-appearing female.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes moist.
NECK: supple without lymphadenopathy. JVD difficult to assess
given body habitus.
CVS: Irregularly irregular rate and rhythm, without murmurs,
rubs or gallops. S1 and S2 normal.
RESP: Decreased breath sound at bases only with faint
inspiratory crackles at left base. No wheezing, rhonchi. Stable
inspiratory effort.
ABD: soft, obese, non-tender, non-distended, with normoactive
bowel sounds. No palpable masses or peritoneal signs.
EXTR: no cyanosis, clubbing; chronic lymphedema changes to the
thighs bilaterally with overlying lymphedematous changes and
swelling, 2+ peripheral pulses on right and doppler signals on
left; right lower extremity and shin with lateral hematoma edges
that are ecchymotic; base of prior hematoma with subcutaneous
fascia exposed but no active bleeding or necrotic debris.
NEURO: CN II-XII intact throughout. Alert and oriented x 3.
Strength 5/5 bilaterally (limited in RLE by pain only),
sensation grossly intact. Gait deferred.
Pertinent Results:
ADMISSION LABS:
.
[**2128-5-24**] 12:10PM BLOOD WBC-6.2 RBC-4.26 Hgb-12.2 Hct-39.7 MCV-93
MCH-28.7 MCHC-30.8* RDW-15.0 Plt Ct-321
[**2128-5-24**] 12:10PM BLOOD Neuts-77.5* Lymphs-16.8* Monos-3.1
Eos-2.1 Baso-0.5
[**2128-5-24**] 12:10PM BLOOD PT-57.8* PTT-62.0* [**Month/Day/Year 263**](PT)-5.8*
[**2128-5-24**] 12:10PM BLOOD Glucose-122* UreaN-10 Creat-0.6 Na-142
K-3.3 Cl-104 HCO3-26 AnGap-15
[**2128-5-24**] 12:10PM BLOOD Calcium-9.0 Phos-2.8 Mg-1.8
.
DISCHARGE LABS:
.
[**2128-5-31**] 05:40AM BLOOD WBC-5.5 RBC-2.96* Hgb-8.9* Hct-28.0*
MCV-94 MCH-30.0 MCHC-31.8 RDW-15.5 Plt Ct-358
[**2128-5-31**] 05:40AM BLOOD PT-12.4 PTT-28.5 [**Month/Day/Year 263**](PT)-1.1
[**2128-5-31**] 05:40AM BLOOD Glucose-122* UreaN-14 Creat-0.6 Na-138
K-3.7 Cl-98 HCO3-29 AnGap-15
[**2128-5-31**] 05:40AM BLOOD Calcium-8.7 Phos-3.2 Mg-1.9
.
MICROBIOLOGY DATA:
[**2128-5-24**] Blood cultures (x 2) - no growth
[**2128-5-26**] MRSA screen - negative
[**2128-5-27**] Urine culture - no growth
[**2128-5-27**] Blood culture - pending
.
IMAGING:
[**2128-5-24**] UNILAT LOWER EXT VEINS - Duplex Doppler examination was
performed on the right lower extremity. This study is limited as
the patient could not tolerate compression. There is normal
augmentation seen in the common femoral, superficial femoral and
popliteal veins. The distal calf veins are patent. A hypoechoic
lesion seen on the lateral aspect of the distal calf measures 3
x 2.9 x 1.2 cm demonstrates no increase in vascularity. There
are no findings to suggest deep vein thrombosis.
.
[**2128-5-27**] CHEST (PORTABLE AP) - As compared to the previous
radiograph, the patient has developed mild pulmonary edema.
There is no evidence of pneumonia. Blunting of the costophrenic
sinus on the left could suggest the presence of a small left
pleural effusion. Normal hilar and mediastinal structures.
Brief Hospital Course:
IMPRESSION: 75F with a PMH significant for chronic A.fib (on
Coumadin), chronic lower extremity edema, celiac enteropathy,
hypothyroidism, obstructive sleep apnea (on BiPAP), non-insulin
diabetes mellitus who presented following right lower extremity
trauma with development of a rapidly-expanding hematoma that
auto-released on [**2128-5-25**], who is s/p debridment and evacuation
([**2128-5-26**]) and who remained hemodynamically stable.
.
# AUTO-RELEASED RIGHT LOWER EXTREMITY HEMATOMA - The patient
presented with evidence of traumatic right lower extremity
injury with swelling, mild erythema and ultrasound showing an
evolving hematoma without DVT or clot burden. She initially
remained afebrile without leukocytosis. Her hematoma appeared
stable, but given some concern for surrounding infection, she
received Unasyn IV x 1 in the ED and Doxycycline with
Ciprofloxacin in the MICU, despite an exam without purulent
cellulitis. Overnight on [**2128-5-25**], the hematoma auto-released and
she required urgent operative intervention for evacuation. She
was transferred to the MICU post-operatively given some
hypotension and acute blood loss anemia that responded to IV
fluids and blood products. Overall, she required 5 units of
fresh frozen plasma (and vitamin K PO for a supratherapeutic [**Date Range 263**]
to [**6-17**]) and 3 units of packed red cells. Her hematocrit nadir
was in the 24% range and responded to blood products; on
discharge her hematocrit was 28%. She required bedisde
re-debridement on [**2128-5-28**] to remove necrotic debris. Following
operative intervention, her hematocrit stabilized and she
required no further transfusions. She did require intermittent
IV Lasix given her blood product requirements, likely this was
mild acute pulmonary edema in the setting of possible diastolic
dysfunction; these issues resolved with IV Lasix. Her wound was
managed with wet-to-dry dressings (per General Surgery) and
began to show improvement. Prior to discharge, Plastic Surgery
evaluated her wound and felt reconstructive options were
feasible in the future. They recommended Zinc and vitamin C
supplementation to promote healing, and we performed daily
dressing changes with Xeroform and dry gauze overtop to promote
granulation. She was able to ambulate with physical therapy
prior to discharge.
.
# SUPRATHERAPEUTIC [**Date Range 263**] - Long-standing A.fib on Coumadin as an
outpatient. Home dose of Coumadin remains between 2.5 and 5 mg
daily. [**Date Range 263**] on admission supratherapeutic in the setting of
recent poor PO intake and antibiotic dosing. Coumadin was held
given these concerns, and given her hematoma concerns. The
patient received a total of 5 units of FFP and vitamin K for
reversal, following admission. In discussion with her outpatient
Cardiologist and PCP, [**Name10 (NameIs) **] resumed her Aspirin and her Coumadin at
the time of discharge.
.
# ATRIAL FIBRILLATION - Long-standing and chronic atrial
fibrillation. Rate controlled with Diltiazem and Digoxin.
CHADs-2 score of 3 and has been anticoagulated with Coumadin.
[**Name10 (NameIs) 263**] on adission supratherapeutic and with hematoma concerns (see
above). Continued rate control with Diltiazem. Coumadin was
resumed at the time of discharge; her lower extremity should be
monitored closely.
.
# DIABETES MELLITUS, TYPE 2 - Last HbA1c 7.6% and
well-controlled on no oral hypoglycemic regimen or insulin.
Fingersticks in the mid-100s. She was maintained on an insulin
sliding scale while hospitalized.
.
# OBSTRUCTIVE SLEEP APNEA - Remained on BiPAP and home oxygen
via nasal cannula.
.
# HYPOTHRYOIDISM - Continued Levothyroxine 150 mcg PO daily.
.
# HYPERLIPIDEMIA - Continued Pravastatin 10 mg PO QHS. Will
continue Ezetimibe 5 mg PO daily.
.
TRANSITION OF CARE ISSUES:
1. Assistance with medication administration.
2. Resume Coumadin (cautious given recent leg hematoma), in
discussion with PCP. [**Name10 (NameIs) 263**] goal was [**2-13**]. Previous Coumadin dosing
was 2.5 to 5 mg PO daily; resume at 2 mg PO daily with daily [**Month/Day (3) 263**]
check.
3. Will need physical therapy and assistance with ambulation
(walker or cane device). Heart rate occassionally in the 130-140
bpm range when ambulating (given deconditioning). Continue rate
control with calcium-channel blocker.
4. Wean supplemental oxygen as tolerated; no home oxygen
requirement.
5. Monitor fingerstick glucose.
6. Dressing changes to right lower extremity daily: place
Xeroform over wound base. Then apply 4 x 4 dry gauze and ABD
gauze overtop. Then wrap RLE with kerlex and elevate.
7. At the time of discharge, the patient had blood cultures
pending, but these were no growth to-date.
Medications on Admission:
HOME MEDICATIONS (confirmed with patient)
1. Albuterol sulfate 2.5 mg/3 mL soln Q6H PRN shortness of
breath
2. BiPAP 13 cm/9 cm for nighttime use
3. Digoxin 125 mcg PO daily (250 mcg every other day)
4. Diltiazem 180 mg ER PO BID
5. Ergocalciferol-D2 50,000 units PO monthly
6. Ezetimibe 5 mg PO daily
7. Furosemide 20 mg PO every other day
8. Levothyroxine 150 mcg PO daily
9. Oxygen 3 liters at nighttime with BiPAP
10. Potassium chloride 40 mEq PO daily (on Lasix days)
11. Pravastatin 10 mg PO QHS
12. Triamcinolone 0.1% cream applied twice daily for eczema
13. Triamcinolone 0.1% ointment applied to psoriatic lesions on
legs and arms daily
14. Coumadin 5 mg PO daily ([**Month/Day (3) 263**] goal [**2-13**]; Monday through
Thursday 2.5 mg; and Friday through Sunday 5 mg)
15. Acetaminophen 650 mg PO TID PRN pain
16. Aspirin 81 mg PO daily
Discharge Medications:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation Q6H (every 6
hours) as needed for wheezing, dyspnea.
2. BiPAP
BiPAP settings: 13 cm/9 cm for nighttime use with 3L of
supplemental oxygen via nasal cannula
3. digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
4. digoxin 125 mcg Tablet Sig: Two (2) Tablet PO EVERY OTHER DAY
(Every Other Day).
5. diltiazem HCl 180 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO BID (2 times a day).
6. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO once a month.
7. ezetimibe 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
8. furosemide 20 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
9. levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
Two (2) Tablet, ER Particles/Crystals PO every other day: on
Lasix days.
11. pravastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. triamcinolone acetonide 0.1 % Cream Sig: One (1) application
Topical twice a day as needed for rash.
13. triamcinolone acetonide 0.1 % Ointment Sig: One (1)
application Topical twice a day as needed for rash: applied to
psoriatic lesions on legs and arms daily .
14. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO three
times a day as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
15. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
16. senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
17. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily).
18. zinc sulfate 220 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
20. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day: [**Month/Day (3) 263**]
goal [**2-13**].
21. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 10 days: started [**2128-5-25**], ending [**2128-6-3**].
22. doxycycline hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours) for 10 days: started [**2128-5-25**], ending
[**2128-6-3**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] rehab
Discharge Diagnosis:
Primary Diagnoses:
1. Acute, traumatic right lower extremity hematoma
.
Secondary Diagnoses:
1. Chronic atrial fibrillation
2. Chronic lower extremity lymphedema
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:
Patient Discharge Instructions:
.
You were admitted to the Internal Medicine service at [**Hospital1 1535**] on CC7 regarding management of
your left lower extremity injury and hematoma. You injured your
right leg after hitting it on the chair. An ultrasound showed no
clot burden, only a large and evolving hematoma. This appeared
to be stable on serial exams. We initially dosed you with IV
antibiotics and switched to oral antibiotics to prevent the
hematoma from becoming infected. You had an elevated [**Hospital1 263**] this
admission and we held your Coumadin for anticoagulation. You
ambulated with the physical therapist and were feeling improved
at the time of discharge.
.
Please call your doctor or go to the emergency department if:
* You experience new chest pain, pressure, squeezing or
tightness.
* You develop new or worsening cough, shortness of breath, or
wheezing.
* You are vomiting and cannot keep down fluids, or your
medications.
* If you are getting dehydrated due to continued vomiting,
diarrhea, or other reasons. Signs of dehydration include: dry
mouth, rapid heartbeat, or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit, or have a
bowel movement.
* You experience burning when you urinate, have blood in your
urine, or experience an unusual discharge.
* You have pain that is not improving within 12 hours or is not
under control within 24 hours.
* Your pain worsens or changes location.
* You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
* You develop any other concerning symptoms.
.
CHANGES IN YOUR MEDICATION RECONCILIATION:
.
* Upon admission, we ADDED:
START: Senna 8.6 mg (2 tablets) by mouth twice daily for
constipation
START: Miralax 17 gram powder by mouth daily for constipation
START: Acetaminophen 1000 mg by mouth three times daily for leg
pain
START: Zinc sulfate 220 mg by mouth daily for wound healing
START: Ascorbic acid 500 mg by mouth twice daily for wound
healing
START: Ciprofloxacin 500 mg by mouth twice daily for 10-days
total (started [**2128-5-25**], ending [**2128-6-3**])
START: Doxycycline 100 mg by mouth twice daily for 10-days total
(started [**2128-5-25**], ending [**2128-6-3**])
.
* This admission, we CHANGED:
DECREASE: Resume Coumadin at 2 mg by mouth daily, starting this
evening ([**Month/Day/Year 263**] goal [**2-13**])
.
* The following medications were DISCONTINUED on admission and
you should NOT resume: NONE
.
* You should continue all of your other home medications as
prescribed, unless otherwise directed above.
Followup Instructions:
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: THURSDAY [**2128-6-10**] at 3:00 PM
With: ACUTE CARE CLINIC with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Phone:[**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
* You will be called by Dr. [**First Name (STitle) **] Lee's office in Plastic
Surgery in regards to scheduling your follow-up appointment.
|
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60,515
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28686
|
Discharge summary
|
report
|
Admission Date: [**2114-11-3**] Discharge Date: [**2114-11-7**]
Date of Birth: [**2092-9-5**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3200**]
Chief Complaint:
Nausea and vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
22 year old female who is s/p open Roux-en-Y gastric bypass on
[**2114-10-16**] who was readmitted on [**10-24**] for nausea and dehydration,
who presents to the ED again with 3 days of nausea and vomiting.
She was advanced to a stage IV diet on [**10-29**], however has been
unable to keep anything down over the past 3 days. She has
attempted water and popsicles today and was unsuccessful. She
denies fevers, chills, constipation, diarrhea, urinary symptoms,
or any pain. She had an UGI on [**10-25**] that showed no evidence of
gastric outlet obstruction or leak.
Past Medical History:
PMH: None
PSH: Cesarean section '[**13**], Laparoscopic Roux-en-Y gastric bypass
'[**14**]
Social History:
Pt has a h/o smoking. Pt stopped this before gastric bypass
surgery, and it has been emphasized that she must not resume
smoking, tobacco or otherwise.
The patinet consumes alcohol occassionally. The patient does
not work and live with her son at her mother's place
Family History:
Obesity, Mother s/p RYGB with successful outcome.
Physical Exam:
Vital signs: Temperature 97.8, Heart rate 72, Blood pressure
118/74, Respirations 18, oxygen saturation 100% room air
Constitutional: no acute distress, normal affect
Neuro: alert and oriented to person, place and time; gait steady
Cardiac: regular rate and rhythm, normal S1 and S2, no murmurs/
rubs/ gallops
Lungs: clear to auscultation, bilaterally; breathing even,
spontaneous, non-labored
Abdomen: obese, soft, non-distended, no rebound tenderness or
guarding
Wounds: well healed mid-line surgical incision
Extremities: no clubbing, cyanosis or edema
Pertinent Results:
[**2114-11-4**] 07:04PM BLOOD Type-ART Temp-36.4 pO2-191* pCO2-26*
pH-7.41 calTCO2-17* Base XS--5 Intubat-NOT INTUBA
[**2114-11-5**] 12:31PM BLOOD calTIBC-252* VitB12-1297* Folate-12.9
Ferritn-220* TRF-194*
[**2114-11-3**] 11:00AM BLOOD Calcium-9.7 Phos-3.1 Mg-1.6
[**2114-11-3**] 05:25PM BLOOD Calcium-8.9 Phos-3.1 Mg-1.4*
[**2114-11-4**] 08:15AM BLOOD Calcium-8.6 Phos-2.6* Mg-1.8
[**2114-11-4**] 12:50PM BLOOD Calcium-8.7 Phos-2.1* Mg-1.7
[**2114-11-5**] 05:43AM BLOOD Calcium-8.6 Phos-2.8 Mg-1.8
[**2114-11-7**] 07:38AM BLOOD Calcium-8.5 Phos-3.5 Mg-1.4*
[**2114-11-3**] 11:00AM BLOOD Glucose-93 UreaN-7 Creat-0.8 Na-138 K-4.8
Cl-102 HCO3-18* AnGap-23*
[**2114-11-3**] 05:25PM BLOOD Glucose-75 UreaN-5* Creat-0.7 Na-140
K-4.1 Cl-108 HCO3-18* AnGap-18
[**2114-11-4**] 08:15AM BLOOD Glucose-78 UreaN-4* Creat-0.6 Na-140
K-4.2 Cl-110* HCO3-15* AnGap-19
[**2114-11-4**] 12:50PM BLOOD Glucose-77 UreaN-3* Creat-0.6 Na-138
K-3.9 Cl-106 HCO3-17* AnGap-19
[**2114-11-5**] 05:43AM BLOOD Glucose-89 UreaN-4* Creat-0.6 Na-141
K-3.2* Cl-109* HCO3-22 AnGap-13
[**2114-11-7**] 07:38AM BLOOD Glucose-74 UreaN-5* Creat-0.5 Na-139
K-3.5 Cl-106 HCO3-22 AnGap-15
[**2114-11-5**] 12:31PM BLOOD Ret Aut-1.9
[**2114-11-3**] 11:00AM BLOOD Plt Ct-381
[**2114-11-4**] 12:50PM BLOOD Plt Ct-321
[**2114-11-4**] 03:15PM BLOOD PT-15.4* PTT-32.9 INR(PT)-1.3*
[**2114-11-4**] 09:05PM BLOOD PTT-150*
[**2114-11-5**] 05:43AM BLOOD PTT-150*
[**2114-11-5**] 05:43AM BLOOD Plt Ct-313
[**2114-11-5**] 05:43AM BLOOD Plt Ct-313
[**2114-11-5**] 12:30PM BLOOD PTT->150*
[**2114-11-5**] 06:31PM BLOOD PTT-UNABLE TO
[**2114-11-5**] 08:45PM BLOOD PTT-34.1
[**2114-11-6**] 04:15AM BLOOD PTT-78.2*
[**2114-11-6**] 11:10AM BLOOD PTT-77.6*
[**2114-11-7**] 07:38AM BLOOD PT-15.9* PTT-44.4* INR(PT)-1.4*
[**2114-11-3**] 11:00AM BLOOD Neuts-65.9 Lymphs-24.5 Monos-5.7 Eos-3.1
Baso-0.7
[**2114-11-3**] 11:00AM BLOOD WBC-7.2 RBC-4.91 Hgb-12.6 Hct-39.1
MCV-80* MCH-25.6* MCHC-32.1 RDW-15.2 Plt Ct-381
[**2114-11-4**] 12:50PM BLOOD WBC-7.6 RBC-4.40 Hgb-11.3* Hct-35.7*
MCV-81* MCH-25.7* MCHC-31.6 RDW-15.2 Plt Ct-321
[**2114-11-5**] 05:43AM BLOOD WBC-5.9 RBC-4.00* Hgb-10.5* Hct-32.3*
MCV-81* MCH-26.2* MCHC-32.5 RDW-15.4 Plt Ct-313
Brief Hospital Course:
Ms. [**Known lastname **] presented to the Emergency Department on [**2114-11-3**] with complaints of nausea and vomiting with inability to
tolerate oral intake for 2 days. She was given intravenous
fluids for hydration and intravenous antiemetics for nausea.
Once stabilized, she was transferred to the general surgical
[**Hospital1 **] for further observation.
On hospital day #1 the patient was without nausea or vomiting,
however, an abdominal/ pelvic CTA scan was obtained to evaluate
for an anastamotic stricture and bowel ischemia due to low serum
bicarbonate on laboratory data. The CTA results were negative
for an intra-abdominal process, however, there was an incidental
finding of a right lower lobe pulmonary embolism. The patient
was subsequently transferred to the medical intensive care unit
for initiation of a heparin gtt with close monitoring.
Additionally, lower extremity non-invasive studies were
performed to evaluate for the presence of a deep vein
thrombosis, of which there were none. Hematology was consulted
regarding anticoagulation in this patient with recommnendations
for bridging the patient to coumadin therapy with heparin or
enoxaparin.
On hospital day #3, the patient continued on the heparin gtt
which was titrated based upon the results of PTT results which
were obtained every six hours. Also, as she remained stable
without signs or symptoms of respiratory distress, she was
transferred to back to the general surgical [**Hospital1 **].
On hospital day #4, the diet was advanced to stage 4, which the
patient tolerated well. The heparin gtt was discontinued and
the decision was made to begin a 3-month course of lovenox
therapy given the unknown effect of gastric bypass surgery on
coumadin absorption. The patient was taught to self-administer
the lovenox medication and was also taught to report any head
injuries or signs of uncontrolled bleeding by the nursing staff
prior to discharge.
At the time of discharge on hospital day #5, the patient was
doing well, afebrile with stable vital signs. The patient was
tolerating a Stage 4 diet, ambulating, voiding independently,
and without pain. She will follow-up in one month, but will
report any return of nausea and vomiting for which she would
require and esophagogastroduodenoscopy.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
Medications on Admission:
Ursodiol 300 mg Capsule [**Hospital1 **]: One (1) Capsule PO twice a day.
Multivitamin Tablet, Chewable [**Hospital1 **]: Two (2) Tablet, Chewable PO
once a day.
Lansoprazole 30 mg Tablet,Rapid Dissolve, 1 Tablet, PO once a
day.
Iron dose unknown
Discharge Medications:
1. enoxaparin 150 mg/mL Syringe [**Hospital1 **]: One (1) Syringe
Subcutaneous [**Hospital1 **] (2 times a day) for 3 months.
Disp:*14 Syringe* Refills:*12*
2. ursodiol 300 mg Capsule [**Hospital1 **]: One (1) Capsule PO twice a day.
3. multivitamin Tablet, Chewable [**Hospital1 **]: Two (2) Tablet,
Chewable PO once a day.
4. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day.
5. iron Oral
Discharge Disposition:
Home
Discharge Diagnosis:
Pulmonary embolism; Nausea; Dehydration
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Discharge Instructions: Please call your surgeon or return to
the emergency department if you develop a fever greater than
101.5, chest pain, shortness of breath, severe abdominal pain,
pain unrelieved by your pain medication, severe nausea or
vomiting, severe abdominal bloating, inability to eat or drink,
foul smelling or colorful drainage from your incisions, redness
or swelling around your incisions, or any other symptoms which
are concerning to you.
Diet: Stay on Stage 4 diet until your follow up appointment. Do
not self advance
diet, do not drink out of a straw or chew gum.
Medication Instructions:
Resume your home medications, CRUSH ALL PILLS.
You will be starting some new medications:
1. You are being discharged on medications to treat the pain
from your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST refrain from such activities while
taking these medications.
2. You should begin taking a chewable complete multivitamin with
minerals. No gummy vitamins.
3. You will be taking Zantac liquid 150 mg twice daily for one
month. This medicine prevents gastric reflux.
4. You will be taking Actigall 300 mg twice daily for 6 months.
This medicine prevents you from having problems with your
gallbladder.
5. You should take a stool softener, Colace, twice daily for
constipation as needed, or until you resume a normal bowel
pattern.
6. You must not use NSAIDS (non-steroidal anti-inflammatory
drugs) Examples are Ibuprofen, Motrin, Aleve, Nuprin and
Naproxen. These agents will cause bleeding and ulcers in your
digestive system.
Activity:
No heavy lifting of items [**10-19**] pounds for 6 weeks. You may
resume moderate
exercise at your discretion, no abdominal exercises.
Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
Please call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 305**] to make a follow-up
appointment within 4 weeks.
Completed by:[**2114-11-8**]
|
[
"280.9",
"787.01",
"276.51",
"278.01",
"415.19",
"V45.86"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7448, 7454
|
4204, 6635
|
333, 340
|
7538, 7538
|
1998, 4181
|
9842, 9994
|
1353, 1405
|
6932, 7425
|
7475, 7517
|
6661, 6909
|
7713, 8277
|
1420, 1979
|
274, 295
|
9485, 9819
|
368, 937
|
8302, 9473
|
7553, 7665
|
959, 1052
|
1068, 1337
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,610
| 198,638
|
17482
|
Discharge summary
|
report
|
Admission Date: [**2196-3-31**] Discharge Date: [**2196-4-5**]
Date of Birth: [**2133-10-29**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2196-3-31**]- 1. Coronary artery bypass graft x2; left internal
mammary artery to the left anterior descending artery and
saphenous vein graft to diagonal artery.2. Endoscopic harvesting
of the long saphenous vein.3. Complex mitral valve repair with
[**Doctor Last Name 4726**]-Tex suture and size 28 [**Doctor Last Name **] annuloplasty ring.
History of Present Illness:
As you recall, he is a 62-year-old gentleman with known mitral
regurgitation. Approximately one year ago, he required
hospitalization for an acute episode of congestive heart failure
secondary to community-acquired pneumonia. Since that time, he
has been doing relatively well on medical therapy. However,
recently, he admits to worsening shortness of breath on
exertion. He denies chest pain or orthopnea as well as lower
extremity edema. However, his shortness of breath does limit
his routine ADLs at this time. His most recent echocardiogram is
from [**2196-1-21**], which showed an ejection fraction of 60-65%
with 4+ mitral regurgitation. There was of note a small
vegetation on the mitral valve. The aortic valve was normal.
There was 1+ tricuspid regurgitation and his right-sided heart
pressures were elevated. His PASP was estimated at 38 mmHg.
Given that his serial echocardiograms have shown worsening MR
and increasing PA pressures, he was referred to me for cardiac
surgical evaluation.
Past Medical History:
mitral regurgitation, history of acute congestive heart failure,
hypertension, dyslipidemia, history of non-ST elevation
myocardial infarction in [**2195-2-20**], and history of pneumonia
in [**2195-2-20**], hypertension, hyperlipidemia.
Social History:
Lives at home w/ his wife. [**Name (NI) 1403**] in retail. Denies tobacco
ever, no drug use. Currently drinks 1 beer/night but does have
history of ETOH abuse.
Family History:
Denies early heart disease.
Physical Exam:
Physical examination in my office today revealed a pulse of 58,
respirations of 14, and blood pressure of 158/79, saturation 97%
on room air. In general, he was a well-developed and
well-nourished male in no acute distress. His skin was
unremarkable. Oropharynx was benign. His teeth were in poor
repair. Neck was supple with full range of motion. There was
no JVD. Lungs were clear to auscultation bilaterally. Heart
had a regular rate and rhythm, normal S1 and S2 with a III/VI
systolic murmur best heard at the left lower sternal border.
Abdomen was benign. Extremities were warm and well perfused
without edema. He had no varicosities of the greater saphenous
vein. Neurologically, he was alert and oriented x3. Cranial
nerves II through XII were grossly intact. He had 5 out 5
strength and no focal deficits were appreciated. He had 2+
distal pulses and there was a question of a right-sided carotid
bruit.
Pertinent Results:
[**2196-4-1**] ECHOPRE-BYPASS: The left atrium is moderately dilated.
No atrial septal defect is seen by 2D or color Doppler. Regional
left ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%), although the LVEF may be
overestimated in the face of severe MR. There is moderate
symmetric LVH. Right ventricular chamber size and free wall
motion are normal. There are simple atheroma in the aortic arch.
There are simple atheroma in the descending thoracic aorta. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. An eccentric,
posteriorly directed jet of severe (4+) mitral regurgitation is
seen. There is prolapse of the anterior mitral leaflet and a
chordal remnant is visible in the left atrium during systole.,
and it appears to be the A3 segment. There is no pericardial
effusion. POST-BYPASS: The patient is AV paced and on an
infusion of phenylephrine. Biventricular function is preserved.
The aorta is intact. The Swan Ganz catheter is in the proximal
right PA. The mitral valve has been repaired and an annuloplasty
ring placed. No chordal remnant is visible , although a long
suture is visible along the sewing ring near the anterior
portion of the left atrium. There is no MR and no paravalvular
leak. No mitral stenosis is evident. The remainder of the
examination is unchanged.
[**2196-4-3**] 06:35AM BLOOD WBC-17.8* RBC-2.35* Hgb-7.4* Hct-21.7*
MCV-93 MCH-31.7 MCHC-34.2 RDW-12.8 Plt Ct-168
[**2196-4-4**] 07:15AM BLOOD WBC-11.9* RBC-2.55* Hgb-7.8* Hct-23.1*
MCV-91 MCH-30.8 MCHC-33.9 RDW-14.8 Plt Ct-205
[**2196-4-5**] 06:50AM BLOOD WBC-8.6 RBC-2.46* Hgb-7.7* Hct-22.4*
MCV-91 MCH-31.2 MCHC-34.2 RDW-14.1 Plt Ct-259
[**2196-4-3**] 06:35AM BLOOD Glucose-125* UreaN-28* Creat-1.0 Na-135
K-4.1 Cl-101 HCO3-26 AnGap-12
[**2196-4-5**] 06:50AM BLOOD Glucose-103 UreaN-16 Creat-0.9 Na-134
K-4.0 Cl-101 HCO3-28 AnGap-9
[**2196-4-5**] 06:50AM BLOOD Mg-2.2
Brief Hospital Course:
Mr. [**Known lastname 48828**] was admitted to the [**Hospital1 18**] on [**2196-3-31**] for elective
surgical management of his mitral regurgitation and coronary
artery disease. He was taken to the operating room where he
underwent coronary artery bypass grafting and a complex mitral
valve repair. Please see operative note for surgical details.
Postoperatively he was taken to the intensive care unit for
invasive monitoring. Within 24 hours, he awoke neurologically
intact and was extubated without incident. Beta blockade was
initially withheld for transient complete heart block. Pacing
wires were kept in and his rhythm was observed. Over several
days, his heart rate and rhythm improved. Low dose beta blockade
was slowly introduced, and no further heart block was noted.
Given NSTEMI and postoperative hypertension, ACE inhibitor was
resumed. Also received several units of packed red blood cells
for a postoperative anemia. Also started on a 3 day course of
Ciprofloxacin for a positive urinalysis. His ICU course was
otherwise uneventful and he transferred to the SDU on
postoperative day two. Beta blockade was slowly advanced and
anti-hypertensives were titrated accordingly. Given persistent
hypertension, he was eventually started on Clonidine patch. He
remained in a normal sinus rhythm and no further heart block was
noted on telemetry. Given prior history of ETOH, he was started
on multivitamins and anxiolytics. The remainder of his hospital
course was uneventful and he was discharged to home on
postoperative day five.
Medications on Admission:
Aspirin 81 mg daily, Aldactazide 50/50 tablets one daily,
Amlodipine 10 mg daily, Lisinopril 40 mg twice daily,
Simvastatin 20 mg daily, Catapres patch 0.3 mg over 24 hours
every weekly, Toprol XL 100 mg daily.
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
7. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QTUES (every Tuesday).
Disp:*30 Patch Weekly(s)* Refills:*2*
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every [**6-27**]
hours as needed for anxiety.
Disp:*30 Tablet(s)* Refills:*0*
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days: take 1 tab(40mg) for 7 days then discontinue -
please take with KCL.
Disp:*7 Tablet(s)* Refills:*0*
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for
7 days: take 1 tab(20meq) for 7 days then discontinue - please
take with Lasix.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Mitral regurgitation/Coronary artery disease - s/p CABG/MV
Repair
History of acute congestive heart failure
Non-ST elevation myocardial infarction
Transient Postop Complete Heart Block
Postop Anemia
Postop Urinary Tract Infection
Hyperlipidemia
Hypertension
History of ETOH Abuse
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks from date of
surgery.
6) No driving for 1 month or while taking narcotics for pain.
7) Call with any questions or concerns.
Followup Instructions:
Please follow-up with Dr. [**First Name (STitle) **] in 1 month ([**Telephone/Fax (1) 1504**]
Please follow-up with Dr. [**Last Name (STitle) 171**] in 2 weeks. [**Telephone/Fax (1) 62**]
Please follow-up with Dr. [**Last Name (STitle) 6924**] in [**2-23**] weeks. [**Telephone/Fax (1) 608**]
Scheduled appointments:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2196-5-30**]
9:20
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2196-4-5**]
|
[
"414.01",
"272.4",
"997.1",
"428.0",
"285.9",
"426.0",
"305.00",
"429.5",
"401.9",
"424.0",
"E878.2",
"412",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.11",
"36.15",
"35.12",
"39.61",
"35.32"
] |
icd9pcs
|
[
[
[]
]
] |
8488, 8546
|
5171, 6713
|
340, 688
|
8870, 8877
|
3176, 5148
|
9675, 10258
|
2185, 2215
|
6975, 8465
|
8567, 8849
|
6739, 6952
|
8901, 9652
|
2230, 3157
|
281, 302
|
716, 1727
|
1749, 1989
|
2005, 2169
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,344
| 173,721
|
47405
|
Discharge summary
|
report
|
Admission Date: [**2188-12-19**] Discharge Date: [**2188-12-23**]
Date of Birth: [**2109-3-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1654**]
Chief Complaint:
Respiratory Failure
Major Surgical or Invasive Procedure:
intubation
laryngoscopy
flexible bronchoscopy
History of Present Illness:
This is a 79 yo M with a past medical history of , who was
brought to the [**Hospital1 18**] ED after being noted to be dyspneic at
[**Hospital 100**] Rehab. In the ED, despite having inspiratory and
expiratory stridor and using accessory muscles with increased
work of breathing, the patient denied shortness of breath. In
evaluation of his airway, there was some concern that he may
have epiglottitis. ENT was consulted and although they noted an
omega-epiglottis, there was no sign of infection. They
recommended 12mg decadron IV Q8h x 3 and bronchoscopy.
.
He was kept in the ED for several hours, and he began to look
tired, with some agitation and the decision was made to intubate
him. He was a difficult intubation, and thick secretions were
noted in his throat, raising the suspicion that he is unable to
clear his airway and that perhaps he had a mucous plug
contributing to his increased work of breathing.
.
Of note, he has had a dry cough for about 3 weeks pta. He had a
CXR which was notable for a lack of an acute intrathoracic
process. He was afebrile and hemodynamically stable while in the
ED.
Past Medical History:
DM2
asthma
dyslipidemia
gait disorder
vertigo
CRI (baseline 1.1-1.3)
Mild dementia- ?[**Last Name (un) 309**] Body Dementia
s/p recent mechanical fall
s/p CCY
s/p hernia repair
s/p b/l blepharoplasty
Social History:
Tob 40 pack yrs, smokes a cigarette now only occasionally
ETOH rare IVDA none Pt lives in an [**Hospital3 **] facility. He
has a daughter who lives in the area. His wife recently died in
[**Month (only) 359**], since that time, patient has been seen several times by
his gerontologist for confusion and hallucinations.
Family History:
non-contributory
Physical Exam:
VS: Temp: BP: 118/60 HR:79 RR: O2sat 98% on PS 5/5
GEN: sedated, NAD
HEENT: Right pupil small and fixed. Left RRL. Right sided
fullness in the throat, two small mobile LN's. No thyromegaly.
RESP: CTAB no w/r/r
CV: RRR (distant) no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e, warm, good pulses
NEURO: unable to perform complete neuro exam [**2-1**]
intubation/sedation
downgoing Babinski b/l
Pertinent Results:
[**2188-12-19**] 09:10PM WBC-7.9 RBC-4.17* HGB-13.4* HCT-40.5 MCV-97
MCH-32.2* MCHC-33.1 RDW-14.4
[**2188-12-19**] 09:10PM NEUTS-89* BANDS-0 LYMPHS-2* MONOS-6 EOS-0
BASOS-0 ATYPS-3* METAS-0 MYELOS-0
[**2188-12-19**] 09:10PM GLUCOSE-238* UREA N-30* CREAT-1.1 SODIUM-144
POTASSIUM-3.9 CHLORIDE-110* TOTAL CO2-25 ANION GAP-13
[**2188-12-19**] 09:10PM CALCIUM-8.7 PHOSPHATE-2.4* MAGNESIUM-2.1
[**2188-12-19**] 11:13AM TYPE-ART O2-100 PO2-97 PCO2-46* PH-7.40 TOTAL
CO2-30 BASE XS-2 AADO2-595 REQ O2-94 INTUBATED-NOT INTUBA
[**2188-12-19**] 10:00AM cTropnT-0.09*
.
EKG: poor baseline. NSR@ 83. No acute ST-T wave changes.
.
INITIAL CXR [**12-19**]: FINDINGS:AP upright portable chest
radiograph is obtained. Evaluation somewhat limited by low
lung volumes. The lungs are clear bilaterally,
demonstrating no evidence of pneumonia or CHF. The
cardiomediastinal silhouette is unremarkable. There is no
pneumothorax. No evidence of foreign body. Bowel gas
pattern appears unremarkable. Visualized osseous structures
are intact. Degenerative changes are noted in the spine.
IMPRESSION: No acute intrathoracic process.
.
MRI [**12-19**] Neck Soft Tissues: FINDINGS: When compared with prior
MRI dated [**2187-12-5**], there is prominence of the epiglottis.
Multilevel degenerative changes are again noted in the cervical
spine with prominent anterior osteophytes at multiple levels.
IMPRESSION: 1. Prominence of the epiglottis. Clinical
correlation
is advised. 2. Degenerative changes in the cervical spine, not
significantly changed from prior study.
Brief Hospital Course:
.
# Respiratory Failure - Chest xray did not show pneumonia, but
viral infection was suspected in the setting of cough and thick
airway secretions. If exacerbated by dehydration, these could
become thick enough to cause difficulty clearing past an
enlarged omega-shaped epiglottis which was identified on
laryngoscopy. The increased work of breathing could have been
caused either by a mucous plug caught at the epiglottis, or a
bronchial plug resulting in transient lobar collapse. He
underwent bronchoscopy by Interventional Pulmonary which showed
thick secretions but no airway lesions. It does not seem that
this is a lower airway issue as he did very well on minimal
pressure support and was extubated shortly. He received 3 doses
of Decadron. He was maintained on chest PT. HOB was elevated
at all times and he was maintained on aspiration precautions.
He underwent swallow evaluation which showed aspiration with
thin liquids and difficulty with regular solids. He should also
have strict supervision with eating and reevaluation of
swallowing function if shows any sign of aspiration. The
possibility of bulbar dysfunction was considered given his
neurologic deterioration over the last couple of months. As his
respiratory function rapidly returned to [**Location 213**], neurologic
evaluation was deferred to the outpatient setting. On
discharge, he was requiring daily Physical Therapy and
occasional oral suctioning to assist him in clearing his
secretions. He oxygen saturation was 97 to 100% on room air.
.
# Dementia/Vertigo - Concern over last few months that this
patient may have [**Last Name (un) 309**] body dementia as he has had progressive
decline with hallucinations with a history of a gait disorder.
Neurologic evaluation deferred as above. He had occasional
agitation with redirectability at night which did not require
medication.
.
# DM2 - His Actos and glipizide were initially held in the
setting of being NPO. They were restarted when he began taking
regular po. He was maintained on [**First Name8 (NamePattern2) **] [**Doctor First Name **] diet and his
fingersticks were under reasonable control.
.
# Hypernatremia - He developed hypernatremia on the floor, which
was thought secondary to hypovolemia from poor po intake after
extubation. He was given gentle fluid resuscitation after which
his sodium normalized. He should be encouraged to take po
(nectar thickened) fluids and have his sodium level rechecked on
[**2188-12-24**].
.
Medications on Admission:
RISS
Vit D
colace
Zetia
Actos
tylenol PRN
albuterol
Dulcolax PRN
Milk of Magnesia
ASA 81
Ca Carbonate
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Omega-shaped epiglottis
Respiratory failure of unclear etiology
Hypernatremia
Dementia
Discharge Condition:
good, stable on room air
Discharge Instructions:
You were admitted with respiratory distress. You were
temporarily intubated and placed on ventilator. You were
evaluated by ENT who found some edema in your larynx, but no
signs of infection. You underwent bronchoscopy and were found
to have lots of respiratory secretions that were likely from a
viral syndrome. Your chest xray showed no pneumonia. After
extubation, you had excellent respiratory status with no oxygen
requirement. You were evaluated by the Speech therapists who
have modified your diet to prevent aspiration.
.
Please take all of your medications as prescribed. Please
attend all of your follow up appointments.
.
If you experience difficulty breathing, chest pain, fever, or
other concerning symptoms, please call your doctor or go to the
ER.
Followup Instructions:
Please call your primary care doctor, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
([**Telephone/Fax (1) 24024**], to schedule a follow up appointment within the
next 1-2 weeks. Please discuss Neurology evaluation with Dr.
[**Last Name (STitle) **].
Completed by:[**2188-12-23**]
|
[
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"518.81",
"465.9",
"781.2",
"478.29",
"331.82",
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"294.11",
"478.6"
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icd9cm
|
[
[
[]
]
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[
"96.04",
"31.42",
"33.22",
"96.71"
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icd9pcs
|
[
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[]
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6844, 6910
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4206, 6692
|
338, 386
|
7041, 7068
|
2584, 4183
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7886, 8194
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2137, 2565
|
278, 300
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414, 1527
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1549, 1750
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1766, 2088
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,449
| 106,369
|
2316
|
Discharge summary
|
report
|
Admission Date: [**2192-9-23**] Discharge Date: [**2192-9-28**]
Date of Birth: [**2140-7-8**] Sex: M
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Diarrhea for 6 weeks, anuric x3 days.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt's history and hospital course reviewed. Briefly, this is a
52M w/ h/o HIV who p/w 3 days of anuria and general malaise. He
had been having diarrhea for the past 6 weeks and on
presentation to the ED for his anuria, he was found to be
hypotensive to 84/60 and in ARF with Cr 5.7 (baseline 1.0). He
also complained of left-sided chest discomfort, a substernal
pressure radiating across his chest that had been ongoing for
2-3 weeks. Sepsis protocol was initiated and RSC CVL was placed.
BP improved to SBP of 100 with 4L IVF and IV heparin was started
for troponin leak of 0.11. He was transferred to the MICU.
.
While in the MICU, the patient's ARF responded well to IVF, with
his Cr decreasing to 1.8 on transfer to the floor. TnT decreased
from 0.11 to 0.02. However, TTE showed a markedly dilated RV
cavity and moderate global RV free wall hypokinesis consistent
with RV pressure/volume overload. The patient's pretest
probability for PE was considered high given his HIV status,
chest pain, and TTE results, but a V/Q scan showed low
probability. Given his post-test estimated probability of PE was
20%, he was continued on anticoagulation. Hct drop from 33.8 on
admission to 26.1 after fluid resuscitation with guaiac positive
stool, hypovolemia, likely demand ischemia, and h/o abnormal EGD
raised strong suspicion for GIB, but his Hct returned to 33.3 by
time of transfer to floor. His platelets dropped from 160 on
admission to 97, and HIT antibody test was positive [**9-25**], so he
was switched to argatroban. On the day of transfer, the pt
spiked a low-grade temperature to 100.7. He was pan-cultured but
no antibiotics were started as there was no clear infectious
source.
Past Medical History:
HIV - dx [**2179**], CD4 <100 on [**2192-9-11**], on HAART
HIV neuropathy
Vacuolar Myelopathy - impaired sensation from neck down
Spastic Bladder
Muscle Spasticity of Leg
CAD s/p cypher times 3 (mid-RCA, prox-RCA, and mid-LAD)
+PPD but negative CXR and sputum
s/p Appy
Social History:
Lives with wife, son, and father, smokes 1.5 ppd x 35 years, occ
etoh, no drugs, previously worked as manager, now on disability
Family History:
Father alive at 86 and healthy, mother deceased at age 85 from
breast cancer, one sister and one brother both healthy
Physical Exam:
VS: 100.6, 139/95, 85, 20, 100% RA, 83.3kg
Gen - sitting comfortably in bed, NAD
HEENT - PERRL, EOMI, sl thrush, MMM
NECK - supple, LAD (old), no JVD
Lungs: CTAB
CV - RRR, nl S1S2, no m/r/g
Abd - soft, ND, NT, no reb/gaurd, NABS
Ext - no c/c/e, dry skin over lower extremities
Neuro - CN II-XII intact, spastic lower extremities with 3/5
weakness, nl strength in upper ext. AAO X3, no focal deficits
Pertinent Results:
[**2192-9-23**] 12:35PM GLUCOSE-98 UREA N-41* CREAT-5.7*# SODIUM-135
POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-19* ANION GAP-20
[**2192-9-23**] 12:35PM WBC-8.1# RBC-3.91* HGB-11.9* HCT-33.8* MCV-87
MCH-30.3 MCHC-35.1* RDW-17.9*
[**2192-9-23**] 12:35PM ALT(SGPT)-16 AST(SGOT)-37 CK(CPK)-264* ALK
PHOS-115 TOT BILI-0.5
[**2192-9-23**] 12:35PM LIPASE-180*
[**2192-9-23**] 08:13PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2192-9-23**] 08:13PM URINE RBC-[**5-12**]* WBC-[**2-5**] BACTERIA-OCC
YEAST-NONE EPI-0-2
[**2192-9-23**] 10:58PM CORTISOL-3.6
[**2192-9-23**] 10:58PM CORTISOL-24.5*
[**2192-9-23**] 10:58PM CALCIUM-6.4* PHOSPHATE-3.7 MAGNESIUM-1.9 URIC
ACID-7.4*
.
[**9-23**] CXR: PORTABLE AP CHEST RADIOGRAPH: The right subclavian
venous line is terminating in mid SVC. There is no evidence of
pneumothorax. Cardiac and mediastinal contours are within normal
limits, and there is no consolidation or effusion.
.
[**9-23**] CT OF THE ABDOMEN WITHOUT IV CONTRAST. Dependent changes
are seen at the lung bases. Allowing for limitations of a
non-contrast study, the liver, gallbladder, pancreas, spleen,
and kidneys appear unremarkable. Again seen is a rounded
hypodensity in the right adrenal likely representing adrenal
adenoma, not significantly changed in appearance from prior
study. Visualized portions of bowel appear unremarkable. There
is no evidence of free air or free fluid within the abdomen.
Scattered lymph nodes are seenthroughout the mesentery and
retroperitoneum, however, none appear to meet CT criteria for
pathological enlargement.
.
-CT OF THE PELVIS WITHOUT IV CONTRAST: The rectum, sigmoid
appear
unremarkable. Air is seen within the bladder, likely secondary
to Foley catheterization. No evidence of free air or free fluid
within the pelvis.
.
-ECHO ([**5-8**]): EF 55% , no regional wall abnormaliites, mild
pulmonary HTN.
.
-ECHO [**2192-9-24**]: The left atrium is normal in size. Left
ventricular wall thickness, cavity size, and systolic function
are normal (LVEF>55%). Regional left ventricular wall motion is
normal. The right ventricular cavity is markedly dilated with
moderate 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. There is minimal mitral regurgitation. There is
moderate pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
.
[**2192-9-24**] LENIs: no DVT
.
[**2192-9-24**] V/Q scan: low probability for PE
Brief Hospital Course:
This is a 52 y.o. HIV positive male ([**2192-9-11**]: CD4 72,
VL>100,000) with a 6 week history of diarrhea and low-grade temp
who was initially admitted to the MICU for hypotension and ARF,
improved after volume resuscitation.
.
# Diarrhea. Likely the patient was hypotensive and in renal
failure secondary to hypovolemia precipitating ARF. The patient
had a small amount of outpatient work-up for this, negative to
date, including: Stool C. Diff, culture and CMV viral load
undetectable. The patient was given symptomatic treatment,
including imodium and his diarrhea improved dramatically. He was
unable to provide a stool sample while on the floor. The patient
was given a prescription for an outpatient stool sample for
repeat stool culture (including viral and bacterial), DFA for
crytosporidium and giardia, ova & parasites, microsporidium. The
GI team was consulted on the patient. It was their
recommendation that the patient have an infectious work-up. If
negative and diarrhea persists, the patient should have a
colonoscopy at a later date when aspirin and plavix can be held
(at least 9 months from the time of drug eluting stent
placement. At the time of discharge, the patient's diarrhea was
well-controlled with loperamide and the patient was tolerating
fluids PO. He was encouraged to have aggressive PO fluid intake
whenever diarrhea occurs.
.
# Fevers. The patient had a low-grade (100) fever after coming
to the floor from the MICU. This may be secondary to the same
process as the diarrhea. However, the patient has poorly
controlled HIV and therefore is at risk for numerous sources.
Empiric antibiotics were deferred as no source of infection was
found.
.
# Hypotension. Likely secondary to persistent diarrhea. The
patient was aggressively hydrated with IV NS in the MICU. He
came to the floor normotensive and maintained this volume status
for the remainder of his time in the hospital.
.
# Acute renal failure. Likely pre-renal secondary to persistent
diarrhea and volume depletion. The patient's Cr improved to
normal range after volume resuscitation.
.
# Chest pain. The patient had a CTA that was negative for PE. He
had a slight troponin elevation thought consistent with demand
ischemia in the setting of hypotension and poor troponin
excretion in the setting of renal failure. The patient's
troponin trended downward throughout his admission and he never
showed CK elevations.
.
# CAD. No signs of acute ischemia. Troponin leak with normal CK
likely secondary to demand ischemia and ARF. The patient was
continued on ASA, plavix, beta blocker, statin. His ACEi was
held for renal failure and then restarted prior to discharge. On
echo, the patient had new mechanical dysfunction. The patient
should have outpatient p-MIBI to assess for perfusion deficits.
.
# HIV. On [**2192-9-11**], CD4 72, VL>100,000. The patient's HAART has
been held while in the MICU for renal failure. These medications
were restarted prior to discharge. The patient's PCP will
consider initiating prophylactic antibiotics as an outpatient.
.
# Anemia. Patient's baseline appears 29-30. Patient with drop in
Hct likely in part secondary to dilution. The patient had guaiac
positive stool with known abnormal colonoscopy and EGD in past
is concerning for GI bleed. The patient had multiple units of
blood transfusion while in the MICU. His Hct normalized prior to
discharge.
.
# Thrombocytopenia. The patient's platelets declined to 90 while
in the MICU and he was found to be HIT antibody positive.
Heparin products were held and the patient's platelet count
stabilized.
Medications on Admission:
Ritonavir 100 qd
3TC 300 mg qd
DDI 400 mg qd
Atazanavir 300 mg qd
Lisinopril 5 mg qd
ASA 325 qd
Plavix 75 qd
Atenolol 25 mg qd
Lipitor 20 qd
Famotidine 20 mg [**Hospital1 **]
Gabapentin 300 mg qhs
Sucralfate 1 g qid
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
5. Didanosine 400 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
6. Lamivudine 150 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. Atazanavir 100 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily).
Disp:*90 Capsule(s)* Refills:*2*
8. Loperamide 2 mg Capsule Sig: One (1) Capsule PO Q4-6H (every
4 to 6 hours) as needed.
Disp:*30 Capsule(s)* Refills:*1*
9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
10. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
11. Famotidine 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
12. Gabapentin 300 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
13. Sucralfate 1 g Tablet Sig: One (1) Tablet PO four times a
day.
Disp:*120 Tablet(s)* Refills:*2*
14. Outpatient Lab Work
Stool sample: Please send for C. Diff toxin assay, DFA for
Cryptosporidium/Giardia, routine stool cx, Microsporidium,
Yersinia, Vibrio, Ova and Parasites.
Give this sample at Dr. [**Last Name (STitle) 12103**] office.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Diarrhea
.
Secondary: HIV
Discharge Condition:
Good
Discharge Instructions:
Take all medications as prescribed.
.
Attend all follow-up appointment.
.
You must give a stool sample for analysis at your primary care
physician's office.
.
It is recommmended that you have an outpatient colonoscopy.
Please have your primary care physician help you schedule this
study.
.
If you have recurrent diarrhea you must drink a large amount of
water to replace what is lost in your stool.
.
If you develop nausea, vomiting, fevers, chest pain, shortness
of breath or decreased urine output please call your doctor or
return to the hospital.
Followup Instructions:
Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 3308**]), Monday [**2192-10-8**] 10:30AM. Give a
stool sample at this office visit to look for possible causes of
your diarrhea. Please make Dr. [**Last Name (STitle) **] aware that it is recommended
for you to have a colonoscopy when it is safe to hold your
aspirin plavix (9 months after your coronary stent was placed).
|
[
"042",
"276.52",
"414.01",
"355.8",
"V45.82",
"E934.2",
"287.4",
"584.9",
"285.9",
"787.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
11268, 11274
|
5793, 9372
|
311, 318
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11353, 11360
|
3049, 5770
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346, 2036
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|
2345, 2477
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,185
| 145,824
|
10694
|
Discharge summary
|
report
|
Admission Date: [**2112-2-24**] Discharge Date: [**2112-2-27**]
Date of Birth: [**2057-8-8**] Sex: F
Service: MEDICINE
Allergies:
Latex / Codeine / Erythromycin Base / Augmentin / Sulfa
(Sulfonamide Antibiotics) / Methadone / IV Dye, Iodine
Containing / Lidocaine / MS Contin / Lyrica / Depo-Medrol /
OxyContin
Attending:[**First Name3 (LF) 2279**]
Chief Complaint:
CC: [**Hospital **]
Transfer to MICU for UGI bleed
Major Surgical or Invasive Procedure:
s/p EGD [**2112-2-25**]
History of Present Illness:
HPI:
Ms [**Known lastname 8271**] is a 54 yo female with hx of COPD, htn, and chronic
pain who presented to [**Hospital1 **] [**Location (un) 620**] today with acute dyspnea in
the setting of runing out of her inhalers.
.
She has felt worsening dypsnea since Saturday, but her dyspnea
acutely worsened yesterday. She also reports that for the last
two days she has had nausea and has vomiting several times dark
black material. She denies blood in her stool or dark stool,
but has been having diarrhea. She also admits to fever and
sweats since yesterday.
.
At [**Hospital1 **] Neehdam she was found to be tachycardic to the 130s and
hypoxic in the low 90's on RA. She was given IVF and
levofloxacin (CXR was reportedly normal, but she reported fever
and had a WBC). EKG was without ischemic changes. Labs
revealed a cr of 1.2 and trop of 0.115 so she was given ASA and
started on a heparin gtt with a bolus and transferred to [**Hospital1 18**]
ED for cardiology evaluation. She was reportedly guaiac
negative on exam. She was also given nebs.
.
In the ED, initial VS: T 98.1 HR 92 BP 116/70 RR 16 SAt 100%
on 2LNC. On arrival to our ED she reported that her dyspnea had
resolved. She was initially continued on the heparin gtt which
was later stopped when she reported hematemesis and her Hct came
back at 24.6 (when it had been 33.5 at BINeeham). EKG again
showed no ischemic changes. Besides the hematemesis for the
last two days she also admitted to melena and had guaiac
positive melanotic stools on exam in our ED. She was started on
a protonix gtt with 80 mg IV boluses and given 5 mg diazepam, 4
mg morphine x 2, and 4 mg zofran. She was also ordered for 2
units PRBC (but had not received them yet). She refused NG
lavage. GI was consulted and recommended medically stabilizing
overnight with plan for an EGD in the morning. She was
transferred up to the floor with 2 PIV.
.
Currently she has had no further episodes of hematemesis.
.
On ROS she admits to recent URI symptoms, headache, and
dizziness. She denies abdominal pain or chest pain. She also
has had her chronic back pain.
Past Medical History:
Past Medical History:
# COPD/asthma (history of multiple admissions for exacerbations
but no prior h/o intubation)
# Hypertension
# Fibromyalgia
# chronic fatigue
# OA
# TMJ
# Eczema
Social History:
She lives with her husband. She is not currently working. She
quit smoking about 1 month ago. She denies alcohol or drug use.
Family History:
Her father died of lung cancer and who mother has heart disease.
Physical Exam:
GEN: Middle-aged female sitting in bed in NAD
HEENT: PERRL, anicteric, unable to fully open her mouth
secondary to pain, no supraclavicular or cervical
lymphadenopathy
RESP: Breathing comfortably. Prolonged expiratory phase with
wheezing bilaterally.
CV: RRR, no MRG
ABD: +BS, soft NTND
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: Alert and anxious. Grossly nonfocal.
Pertinent Results:
[**2112-2-24**] 09:40PM BLOOD WBC-14.4* RBC-3.13*# Hgb-8.5*# Hct-24.6*#
MCV-79* MCH-27.0 MCHC-34.4 RDW-14.8 Plt Ct-361
[**2112-2-24**] 10:35PM BLOOD Hgb-8.8* Hct-25.0*
[**2112-2-25**] 09:53AM BLOOD WBC-8.4 RBC-3.29* Hgb-9.4* Hct-27.0*
MCV-82 MCH-28.6 MCHC-34.8 RDW-15.5 Plt Ct-269
[**2112-2-24**] 09:40PM BLOOD Neuts-86.2* Lymphs-11.5* Monos-2.0
Eos-0.1 Baso-0.1
[**2112-2-24**] 09:40PM BLOOD PT-16.2* PTT-131.0* INR(PT)-1.4*
[**2112-2-25**] 09:53AM BLOOD PT-15.1* PTT-24.0 INR(PT)-1.3*
[**2112-2-24**] 09:40PM BLOOD Glucose-101* UreaN-57* Creat-0.9 Na-136
K-4.3 Cl-104 HCO3-20* AnGap-16
[**2112-2-25**] 09:53AM BLOOD Glucose-103* UreaN-32* Creat-0.8 Na-140
K-4.1 Cl-108 HCO3-23 AnGap-13
[**2112-2-24**] 09:40PM BLOOD ALT-14 AST-20 AlkPhos-43 TotBili-0.2
[**2112-2-25**] 09:53AM BLOOD CK(CPK)-70
[**2112-2-24**] 09:40PM BLOOD cTropnT-0.11*
[**2112-2-24**] 09:40PM BLOOD Lipase-52
[**2112-2-25**] 09:53AM BLOOD Calcium-7.6* Phos-2.9 Mg-1.7
.
Chest Radiograph ([**2112-2-24**]): IMPRESSION: Within limitations, no
acute pulmonary process.
Brief Hospital Course:
54 yo female with COPD, htn, and chronic pain who presented to
[**Hospital1 **] [**Location (un) 620**] today with a COPD exacerbation complicated by demand
ischemia, additionally with an upper GI bleed.
.
# UGIB, acute blood loss anemia: The patient has a baseline Hct
in the low 40's. Hct on presentation to the OSH was 33 and
dropped to 25 here in the setting of IVF. She reported
hematemesis and had melena on rectal exam here consistent with
an upper GI bleed. She had been taking celebrex [**Hospital1 **] recently.
No further episodes of vomiting in house. Patient
hemodynamically stable. She received a total of 4 units of
blood while in-house with stabilization of her Hct at 31. She
underwent an EGD with MAC on [**2-25**] which demonstrated PUD and
gastritis. She is advised to avoid all ASA, NSAIDs, and
celebrex. She was maintained on a PPI [**Hospital1 **] and her diet was
advanced as tolerated. An H pylori was sent and PENDING upon
discharge. She will need a repeat EGD in [**7-13**] weeks.
.
# Demand ischemia: Patient asymptomatic with no ischemic
changes on EKG, but sustained a significant troponin leak,
secondary to demand ischemia from anemia. Given absence of
symptoms, she likely would not benefit from a stress. ASA is
contraindicated at this point.
.
# CPD exacerbation: The patient presented with acute dyspnea
after running out of her inhalers at home. She received neb
treatments in the OSH ED with improvement in her acute dyspnea.
CXR showed no PNA, however she was with wheezing consistent with
a COPD exacerbation. She was treated with nebulizers,
hydrocortisone, and azithromycin with stabilization of
respiratory status. She was changed to oral prednisone for 3
more days to complete a 5-day course, once her Hct was
stabilized and she was taking po's.
.
# Hypertension: Stable, home lisinopril and hctz were held in
the setting of GI bleed, but restarted the day prior to
discharge.
.
# Chronic fatigue syndrome/fibromyalgia/TMJ: Patient is on a
narcotics contract as an outpatient and her home regimen was
restarted once she was tolerating po's.
Medications on Admission:
Albuterol inhaler 2 puffs qid
Celebrex 200 mg po bid prn
Clonazepam 2 mg po daily prn
Diazepam 5 mg po q6h prn
Flovent 220 mcg inhaler 2 puffs [**Hospital1 **]
Hctz 25 mg po daily
Hydrocodone 100 mg po 4-5 times daily prn
Lisinopril 5 mg po daily
Zolpidem 10 mg po qhs
Calcium
Discharge Medications:
1. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
3. diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
4. fluticasone 220 mcg/Actuation Aerosol Sig: Two (2) inh
Inhalation twice a day: rinse mouth after use.
5. azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 1 days: last day [**2112-2-28**].
Disp:*1 Tablet(s)* Refills:*0*
6. Proventil HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two
(2) puffs Inhalation four times a day.
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. prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 3 days: last day [**2112-3-1**].
Disp:*9 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Upper GIB
Peptic ulcer disease
Gastritis
Anemia, acute blood loss
Demand ischemia
COPD exacerbation, acute
HTN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Tolerating po's, no GI symptoms, Hct stable
Discharge Instructions:
You were admitted for an upper GI bleed, secondary to peptic
ulcer disease and gastritis. This resolved and was stabilized
with several blood transfusions. PLEASE DO NOT TAKE ANY NSAIDS,
ASPIRIN, or CELEBREX. Please take protonix twice daily until
further follow-up with GI. An H. pylori blood test was sent and
was PENDING upon discharge - this will be followed up by the [**Company 191**]
doctor next week.
You also had an acute COPD exacerbation, for which you were
started on a short course of steroids. Please complete this
course.
It is very important you follow-up in [**Company 191**] this week for a repeat
blood count and assessment of your symptoms - please call [**Company 191**] on
Monday to schedule an appointment.
You will need to see GI in [**5-11**] and will need a repeat endoscopy
in [**7-13**] weeks.
MEDICATION CHANGES:
1. STOP Celebrex
2. START Protonix 40 mg twice daily
3. START Prednisone 60 mg daily x 3 more days (last day [**2112-3-1**])
4. START Azithromycin 250 mg daily x 1 more day (last day
[**2112-2-28**])
5. DO NOT take any aspirin, motrin, ibuprofen, aleve, or other
anti-inflammatories.
No other medication changes were made.
Followup Instructions:
**Please call [**Company 191**] on Monday to schedule an appointment:
[**Telephone/Fax (1) 250**].
**Please call the GI department to schedule an appointment in 1
month.
.
Department: PAIN MANAGEMENT CENTER
When: FRIDAY [**2112-3-11**] at 8:50 AM
With: [**Name6 (MD) 8673**] [**Last Name (NamePattern4) 8674**], MD [**Telephone/Fax (1) 1652**]
Building: One [**Location (un) **] Place ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Parking on Site
Department: [**Hospital3 249**]
When: THURSDAY [**2112-3-17**] at 8:40 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**]
Completed by:[**2112-2-28**]
|
[
"493.22",
"729.1",
"780.71",
"524.60",
"285.1",
"715.90",
"338.29",
"533.40",
"535.41",
"288.60",
"410.71",
"414.01",
"692.9",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.16"
] |
icd9pcs
|
[
[
[]
]
] |
7930, 7936
|
4584, 6691
|
491, 517
|
8091, 8091
|
3522, 4561
|
9482, 10417
|
3032, 3098
|
7018, 7907
|
7957, 8070
|
6717, 6995
|
8286, 9114
|
3113, 3503
|
9134, 9459
|
401, 453
|
545, 2662
|
8106, 8262
|
2706, 2869
|
2885, 3016
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,710
| 153,687
|
39481
|
Discharge summary
|
report
|
Admission Date: [**2182-8-12**] Discharge Date: [**2182-8-15**]
Date of Birth: [**2110-10-9**] Sex: M
Service: MEDICINE
Allergies:
trazodone
Attending:[**First Name3 (LF) 594**]
Chief Complaint:
Chief Complaint: Dyspnea
Reason for MICU transfer: Hypoxia
Major Surgical or Invasive Procedure:
Arterial Line Placement
History of Present Illness:
71 year-old male with a history of squamous cell carcinoma of
lung [**2172**] s/p R VATs and RLL basilar segmentectomy, organizing
pneumonitis and follicular bronchiolitis, COPD (FEV1 81%, on 4L
NC at home) who presents for respiratory distress. Awakened
overnight with severe dyspnea, which had been worsening
thoughout the day. EMS called and found patient in resp distress
with O2 sats in the 60's. He was placed on NRB w/ only slight
increase in O2 sat then placed on CPAP w/ O2 sats into the low
80s (poor fitting [**Last Name (LF) **], [**First Name3 (LF) **] report).
On arrival patient O2 sat 45% on CPAP with severe dyspnea.
First completed vitals 0400: T 97, HR 120, RR 35, BP 162/83, O2
sat 56% on non-rebreather. Immediately placed onto BIPAP and
started on nebs w/ increase O2 sats to 100% and decreased work
of breathing. Patient was given 125mg methylprednisolone, 750mg
IV levofloxacin and 3 albuterol nebulizers and 3 ipratropium
nebulizers.
On arrival to the MICU, patient is breathing comfortably on [**8-25**]
of bipap with saturations in the high 90s. He denies any acute
complaints. Patient denies any changes in his baseline cough
and states that he is not having more sputum production than
usual. He also denies changes in his 2 pillow orthopnea, or any
PND. Patient also denies any recent fevers/ chills.
Review of systems:
(+) Per HPI including dysuria.
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, or wheezing. Denies chest pain, chest
pressure, palpitations, or weakness. Denies nausea, vomiting,
diarrhea, constipation, abdominal pain, or changes in bowel
habits. Denies frequency, or urgency. Denies arthralgias or
myalgias. Denies rashes or skin changes
Past Medical History:
- Diffuse parenchymal lung disease-biopsy showed organizing
pneumonitis and follicular bronchiolitis- [**2179**] bx showed
follicular bronchiolitis. Trial of high dose steroids (pred 60mg
daily) helped, then had hypoxemia to 70s when stopped. Had trial
of rituximab infusion, both on [**2181-6-11**] and [**2181-6-26**]
- H/o lung CA (scc): incidental nodule on cxr, s/p R VATS and
RLL basilar segmentectomy on [**2172-3-23**], neg margins. f/b Dr.
[**Last Name (STitle) 87213**], serial chest CT (stable 11mm RLL nodule and 6mm L
hilar nodule)
- COPD on 4L home O2 (FEV1 67%: >5 hospitalization and ~ED
vistis since [**2181**] for COPD exacerbation. No history of
intubation.
- Hypertension
- Benign prostatic hypertrophy: Elev PSA : 7.1 ([**1-26**]) --> 9.5
([**7-27**]). has been up to 11 in past ([**4-26**]). prostate bx neg x3.
now on flomax, avodart
- H/O colonic polyps : A-colon: [**2173**] scope sessile polyps,
[**7-/2177**] repeat hyperplastic polyps.
- Gout
Social History:
Patient reports being a county clerk and he retired during
[**2160**]. Reports a 100 pack year history of smoking. Quit in
[**2172**] after lung cancer discovered. Denies alcohol and drug use.
Denies any recent sick contacts. Denies TB or asbestos
exposure.No ETOH now.
Family History:
Brother had problem with SOB and required pacemaker placement.
No family history of lung cancer or autoimmune diseases.
Physical Exam:
Admission Physical Exam:
General: On NIPPV but interactive, talking
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Bibasilar crackles ~1/2 up his lung fields bilaterally
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Discharge Physical Exam:
General: alert & oriented x3, NAD
HEENT: PEERL, EOMI, oropharynx clear, MMM
Neck: supple, no LAD, no JVD
CV: RRR, no murmurs, rubs or gallops
Pulm: bilateral rhonchi and expiratory wheeze L>R
Abd: soft, NT/ND, +BS, no HSM
GU: Foley in place
Ext: warm, 2+ pulses
Neuro: CNII-XII grossly intact, gait deferred, 5/5 strength in
all extremities
Pertinent Results:
Admission Labs:
[**2182-8-12**] 04:02AM BLOOD WBC-16.7*# RBC-5.18 Hgb-15.9 Hct-49.6
MCV-96 MCH-30.8 MCHC-32.1 RDW-15.1 Plt Ct-318
[**2182-8-12**] 04:02AM BLOOD PT-10.9 PTT-28.8 INR(PT)-1.0
[**2182-8-12**] 04:02AM BLOOD Glucose-208* UreaN-19 Creat-0.7 Na-135
K-3.8 Cl-98 HCO3-22 AnGap-19
Discharge Labs:
[**2182-8-14**] 03:03AM BLOOD WBC-14.5* RBC-4.24* Hgb-13.1* Hct-39.7*
MCV-94 MCH-30.9 MCHC-33.0 RDW-15.3 Plt Ct-274
[**2182-8-14**] 03:03AM BLOOD PT-10.9 PTT-33.2 INR(PT)-1.0
[**2182-8-14**] 03:03AM BLOOD Glucose-126* UreaN-27* Creat-0.6 Na-143
K-4.3 Cl-109* HCO3-25 AnGap-13
Imaging:
[**8-12**] CXR
FINDINGS: Single frontal view of the chest demonstrates normal
cardiomediastinal silhouette. Rightward tracheal deviation
appears
longstanding. There is worsening bilateral widespread reticular
opacities can be explained by progressive pulmonary fibrosis,
but concurrent pulmonary edema is certainly possible. There is
no pleural effusion
IMPRESSION: Progressive pulmonary fibrosis and severe
centrilobular emphysema.
Concurrent pulmonary edema is possible.
Brief Hospital Course:
71 year-old male with a history of squamous cell carcinoma of
lung [**2172**] s/p R VATs and RLL basilar segmentectomy, organizing
pneumonitis and follicular bronchiolitis, COPD (FEV1 67%, on 4L
NC at home) who presents for respiratory distress.
# Hypoxia: Pt has an extensive history of lung pathology
including COPD, organizing pneumonitis/follicular bronchiolitis
using 4L NC at home. There was concern that this might be acute
exacerbation of interstitial lung disease versus possible
infectious process given leukocytosis. Specifically, patient
denied recent illness and denied any changes in cough/orthopnea.
He did not meet criteria for HCAP as he was discharged >3
months ago. Pt's recent PET/CT showed concerning signs of
infectious/ inflammatory process in lungs. The pt received a
three day course of IV methylprednisolone 80mg and was then
transitioned to prednisone 60mg PO. Patient will need a 2 week
taper that is outlined below. Fungal markers were negative. Pt
also received a 7 day course of ceftriaxone and a five day
course of azithromycin. Pt was slowly weaned down on FiO2 with
supplementation with albuterol and ipratropium with the goal of
having pt back on home O2 requirement of 4-5L. Upon discharge,
pt was still on facemask humidifier 35% in addition to 5L NC. Pt
is to finish 5 day course of azithromycin and will switch from
ceftriaxone to cefpodoxime and finish a 7 day course at rehab.
# Chronic steroid use: Received burst therapy for inflammation.
Will have taper as below. Pt has been on oral steroids on
chronic basis and was initially on Bactrim SS. We switched pt to
Bactrim DS and continued Vitamin D and calcium supplementation.
Pt is to continue once weekly Vit D 50,000 U for two months and
then transition to daily Vit D 1000 U.
# Hypertension: Patient was on metoprolol as an outpatient.
Metoprolol Tartrate 25 mg PO/NG [**Hospital1 **] was started and BP remained
in 120-130s.
# History of depression/ anxiety: Pt was euthymic throughout
hospital course and was continued on citalopram, mirtazepine,
and lorazepam.
# History of restless legs: Pt was continued on Ropinirole 0.25
mg PO/NG QPM 1 hour before bedtime.
# BPH: continued Tamsulosin 0.4 mg PO HS
# Gout: Not active. continued allopurinol 100mg daily.
# GERD: Not active. continued Omeprazole 20 mg PO DAILY
# Back pain/Osteoperosis: Tylenol prn.
Transition Issues:
- Blood cultures from [**2182-8-12**] were pending. Call [**Telephone/Fax (1) 4645**]
for results.
- Discontinue vitamin D 50,000 U after 2 months, with transition
to 1000 U qday of vitamin D
- Day 1 of Prednisone 60mg daily on [**2182-8-15**]. Taper as below:
*****Continue 60mg until [**2182-8-18**], then taper to 50mg until
[**2182-8-21**], then taper to 40mg until [**2182-8-24**], then taper to 30mg
until [**2182-8-27**], then taper to 20mg until [**2182-8-30**], then return to
home dose of 10mg on [**2182-8-31**]*****
- End date of Cefpodoxime 200mg PO q12 on [**2182-8-18**].
- End date of azithromycin 500mg PO daily on [**2182-8-16**].
- Continue to wean O2 requirement as close to baseline as
possible which is 4L NC.
-f/u with PCP
[**Name Initial (PRE) **]/u with heme/onc
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR Patient is not clear as to
what he is taking, but states OMR is up to date..
1. PredniSONE 10 mg PO DAILY
Tapered dose - DOWN
2. Acetaminophen 1000 mg PO TID
3. Mirtazapine 15 mg PO HS
4. Allopurinol 100 mg PO DAILY
5. Tiotropium Bromide 1 CAP IH DAILY
6. Lorazepam 0.5 mg PO BID:PRN anxiety
7. Metoprolol Succinate XL 50 mg PO DAILY
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Multivitamins 1 TAB PO DAILY
10. Ropinirole 0.25 mg PO QPM
1 hour before bedtime
11. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
12. Omeprazole 20 mg PO DAILY
13. Calcium Carbonate 1200 mg PO DAILY
14. Potassium Chloride 20 mEq PO BID Duration: 24 Hours
Hold for K >
15. Tamsulosin 0.4 mg PO HS
16. albuterol sulfate *NF* 90 mcg/actuation Inhalation q4-6h PRN
wheeze
17. Citalopram 10 mg PO HS
18. Sulfameth/Trimethoprim SS 1 TAB PO 3X/WEEK (MO,WE,FR)
19. Vitamin D 50,000 UNIT PO 1X/WEEK ([**Doctor First Name **])
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Allopurinol 100 mg PO DAILY
3. Calcium Carbonate 1200 mg PO DAILY
4. Citalopram 10 mg PO HS
5. Lorazepam 0.5 mg PO BID:PRN anxiety
6. Mirtazapine 15 mg PO HS
7. Multivitamins 1 TAB PO DAILY
8. Omeprazole 20 mg PO DAILY
9. PredniSONE 60 mg PO DAILY
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Ropinirole 0.25 mg PO QPM
1 hour before bedtime
12. Tamsulosin 0.4 mg PO HS
13. Vitamin D 50,000 UNIT PO 1X/WEEK ([**Doctor First Name **])
14. Tiotropium Bromide 1 CAP IH DAILY
15. Metoprolol Succinate XL 50 mg PO DAILY
16. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
17. albuterol sulfate *NF* 90 mcg/actuation Inhalation q4-6h PRN
wheeze
18. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (MO,WE,FR)
19. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN wheeze/ dyspnea
20. Azithromycin 500 mg PO Q24H Duration: 2 Days
Last day on [**2182-8-16**]
21. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN sob/wheezing
22. Sodium Chloride Nasal [**1-21**] SPRY NU QID:PRN nasal congestion
23. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 4 Days
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **]-[**Location (un) 86**]
Discharge Diagnosis:
Pneumonia
Interstitial Lung Disease
Acute Exacerbation of COPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname 4401**],
It was our pleasure caring for you at the [**Hospital1 18**].
You were admitted to the hospital because you were having
shortness of breath. You were found to have pneumonia and low
oxygen levels. We are treating you with steroids and
antibiotics. In order for you to get better, you will need to
have pulmonary rehab. You are being discharged to a
rehabilitation center that will assist you in your recovery.
Followup Instructions:
Please be sure follow to keep the following appointments.
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2182-8-20**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: DIV OF ALLERGY AND INFLAM
When: MONDAY [**2182-9-2**] at 1:15 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 9316**]
Building: One [**Location (un) **] Place ([**Location (un) **], MA) [**Location (un) 895**]
Campus: OFF CAMPUS Best Parking: Parking on Site
Department: [**Hospital **] MEDICAL GROUP
When: MONDAY [**2182-10-7**] at 1 PM
With: DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3879**] [**Telephone/Fax (1) 133**]
Building: [**Street Address(2) 3375**] ([**Location (un) **], MA) [**Location (un) 858**]
Campus: OFF CAMPUS Best Parking: On Street Parking
|
[
"V58.65",
"600.00",
"564.00",
"530.81",
"274.9",
"491.21",
"333.94",
"515",
"401.9",
"486",
"V10.11"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11046, 11112
|
5704, 8878
|
329, 355
|
11219, 11219
|
4614, 4614
|
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|
3479, 3600
|
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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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|
247, 291
|
383, 1722
|
4630, 4902
|
11234, 11378
|
2198, 3170
|
3186, 3463
|
4252, 4595
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,667
| 193,261
|
29245
|
Discharge summary
|
report
|
Admission Date: [**2123-6-2**] Discharge Date: [**2123-6-6**]
Date of Birth: [**2057-2-10**] Sex: F
Service: MEDICINE
Allergies:
Haldol / Prozac / Clozaril / Chlorpromazine
Attending:[**First Name3 (LF) 30158**]
Chief Complaint:
Shortness of breath.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
66 year-old female with COPD and multiple admissions for
exacerbation, who presents from home with 5-7 days of SOB, cough
productive of white sputum, and increased use of nebulizers.
Denies any fevers, chills, CP/pressure, LH/dizziness.
.
In the ED, VS 96.6, 100, 132/81, 26, 90% RA. Initial exam with
poor air movement throughout. Given nebs, methylprednisolone 125
mg IV, ceftriaxone and azithromycin. ABG 7.45/39/60. She became
tachypnic to the 40s and was placed on BiPAP with good effect ->
ABG 7.40/42/120. CTA performed and negative for PE.
.
The patient was admitted to the MICU for hypoxia. On transfer,
the patient noted her breathing was improved. "I am hungry and
want my breakfast." The patient was taken off BiPAP on arrival.
.
MICU course: The patient was started on ceftriaxone and
azithromycin for CAP. The patient was started on steroids IV.
She was started on spiriva. The patient developed a rash thought
to be secondary to hypersensitivity to the cleaning products
used; it is improving despite continuing the above antibiotics.
The patient developed leukocytosis thought secondary to
steroids. The patient had sinus tachycardia thought secondary to
albuterol which was improved prior to transfer.
.
On transfer, the patient states her SOB is much improved, to 70%
of baseline. The patient's cough continues but is also improved.
The patient complains of mild generalized abdominal discomfort
attibuted to constipation. The patient denies fevers, chills,
chest pain. The patient denies hearing voices. No other
complaints.
.
Recent admission in [**Month (only) 547**]:
COPD exacerbation: She was hypoxic and required a face mask
initially. She was given standing nebulizers and started on IV
steroids, switched to oral prednisone after 3 days. She was
given Augmentin for inflammatory effect, and should complete a
7-day course (last day = [**2123-4-29**]). CTA chest was performed and
was negative for PE or pneumonia. Pt was evaluated by pulmonary
who recommended a long steroid taper (4-6 weeks) along with
Advair inhaled daily. She should take 40mg prednisone x 7days
([**Date range (1) 46556**]), then 20mg x 7days ([**Date range (1) 70307**]), then 10mg x 7days
([**Date range (1) 70308**]), then 5mg x 7days ([**Date range (1) 70309**]), then stop. The cause
for her flare is unkonwn, possibly viral illness vs allergies.
Speech and swallow evaluation was performed to see if aspiration
pneumonitis was the trigger, and revealed no difficulty with
swallowing and no sign of aspiration. She should remain on
supplemental O2 until she can maintain O2 saturations >93% on
room air at rest and with ambulation.
Past Medical History:
1. COPD
-PFTS [**5-10**]: FEV1/FVC 136%, FVC 67%
2. History of pneumonia
3. Schizophrenia
4. Hypertension
5. Osteoporosis
6. Arthritis
7. Urinary incontinence
8. Congenital nystagmus
Social History:
Smokes about 4 cigarettes a day but used to smoke much more
(long smoking history), quit one day prior to this admission.
Denies alcohol or illicits. Lives alone in her own appartment at
the [**Hospital1 **] Community housing for the
elderly. Does her own ADLs, walks independently. She has a
home-maker to help with cleaning once a week. She is divorced,
has no children. Recently discharge from rehab.
Family History:
Non-contributory.
Physical Exam:
On admission to the MICU:
VS T 95.4 HR 106 BP 137/77 O2 sat 99% on CPAP
On BIPAP, comfortable, O x3
Wheezing on right side of chest with rhonchi at bases, left with
less wheezing
Tachycardic, no murmur
Obese, soft, NT/D +BS
No LE edema, 2+ DP pulses
.
On transfer:
VS: Tm 97.8 Tc 97.5 HR 96 BP 118/69 RR 27 O2sat 93% on 5L
GEN: NAD
HEENT: PERRL, OP clear without lesions, MMM
NECK: No JVD
HEART: RRR, no MRG
LUNGS: Decreased breath sounds throughout, no WRR (30 minutes
post xopenex)
ABDOMEN: NABS, soft, NTND
EXT: No edema
Pertinent Results:
Labwork on admission:
[**2123-6-2**] 07:33AM TYPE-ART PO2-120* PCO2-42 PH-7.40 TOTAL
CO2-27 BASE XS-1
[**2123-6-1**] 11:55PM WBC-13.1* RBC-4.31 HGB-13.6 HCT-40.4 MCV-94
MCH-31.5 MCHC-33.6 RDW-15.3
[**2123-6-1**] 11:55PM PLT COUNT-403
[**2123-6-1**] 11:55PM GLUCOSE-129* UREA N-16 CREAT-0.9 SODIUM-140
POTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-31 ANION GAP-13
.
CHEST (PORTABLE AP) [**2123-6-1**]
FINDINGS: AP upright chest radiograph is reviewed and compared
to [**2123-4-22**] and [**2123-4-23**]. Cardiomediastinal contours are
unremarkable. There is no pulmonary vascular engorgement. The
lungs are clear, and there is no pleural effusion or
pneumothorax. Lung volumes remain low, unchanged from prior
exam.
IMPRESSION: No acute cardiopulmonary process.
.
ECG Study Date of [**2123-6-1**]
Sinus rhythm
Normal ECG
Since previous tracing of [**2123-4-22**], the rate is slower
.
CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2123-6-2**]
IMPRESSION:
1.No pulmonary embolism is identified. Multiple areas of linear
atelectasis is noted within both lungs. No pleural or
pericardial effusion is identified.
2. Abberant left vertebral artery that originates from the
aorta.
3.Small amount of mucous plugs / flaps are noted witin the left
bronchi with no evidence of obstruction.
.
CHEST (PORTABLE AP) [**2123-6-4**]
IMPRESSION: Clearing of left lower lobe atelectasis.
.
[**2123-6-5**] 07:02AM BLOOD WBC-24.4* RBC-4.06* Hgb-12.6 Hct-38.5
MCV-95 MCH-31.2 MCHC-32.9 RDW-15.4 Plt Ct-442*
[**2123-6-5**] 07:02AM BLOOD Glucose-88 UreaN-21* Creat-0.8 Na-142
K-4.3 Cl-104 HCO3-27 AnGap-15
Brief Hospital Course:
66 year-old female with history of COPD presenting with
shortness of breath, cough productive of white sputum, and
hypoxia.
.
1. Hypoxia: Most likely represented a COPD exacerbation, likely
due to community-acquired pneumonia. The patient was afebrile
but had mild leukocytosis and complained of a productive cough.
The patient was recently treated for community-acquired
pneumonia. A viral bronchitis could also have precipitated the
exacerbation. The patient had no evidence of congestive heart
failure on physical examination or imaging; the patient does not
have an echocardiogram in our system. CTA was negative for
pulmonary embolus on admission. The patient was initially
maintained on BiPAP but her oxygen requirement quickly improved.
The patient was given steroids, initially intravenously, then
changed to oral for a slow taper. The patient was started on
spiriva. The patient was continued on albuterol nebulizers
standing and with xopenex nebulizers as needed. The patient was
continued on advair. The patient was started on ceftriaxone and
azithromycin for community-acquired pneumonia and changed to
levofloxacin prior to discharge to complete a ten day course.
The patient's oxygen requirement improved during admission and
she did not require oxygen on discharge. The patient is on home
O2 2L at baseline overnight and with exertion. The patient was
advised to stop smoking.
.
2. Tachycardia: The patient had sinus tachycardia to heart rate
120s during admission. This was likely due to albuterol. The
tachycardia improved with the change of albuterol to xopenex
nebulizers as needed.
.
3. Leukocytosis: The patient's white blood cell count was 13.1
on admission, likely due to the patient's pneumonia as above.
The white blood cell count increased to 22-24 after initiation
of steroids, likely secondary to demarginalization of white
blood cells. The patient remained afebrile. Urinalysis was
negative for infection.
.
4. Rash: The patient developed a rash during admission,
initially an erythematous macular pruritic rash on the trunk and
flanks. This was likely a reaction to cleaning products and
improved during admission by using bleach-free sheets and
different self-care products. This was unlikely a reaction to
her antibiotics as it improved prior to changing the regimen.
The patient was given benadryl and sarna as needed.
.
5. Incidental lung nodule: The patient should receive an
outpatient CT scan to monitor for change per her primary care
physician.
.
6. Hypertension: The patient was normotensive during admission.
The patient was continued on her home regimen.
.
7. Schizophrenia: Stable. The patient was continued on her home
medications. The patient was stable while on steroids.
.
8. Arthritis: Stable. The patient did not require pain control.
The patient was ambulating without difficulty.
.
9. Urinary incontinence: Stable. The patient was continued on
detrol.
Medications on Admission:
Discharge Medications (per PCP note, pt did not recall):
Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours).
Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer
Inhalation Q2H (every 2 hours) as needed for SOB, wheeze.
Benztropine 1 mg Tablet Sig: One (1) Tablet PO qHS.
Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times
a day).
Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
Nifedipine 60 mg Tablet Sustained Release Sig: 0.5 Tablet
Sustained Release PO DAILY (Daily).
Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours).
Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
Mucinex 600 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO once a day for 10 days.
Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Olanzapine 10 mg Tablet Sig: Three (3) Tablet PO QHS (once a
day (at bedtime)).
Risperidone 1 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): hold for diarrhea.
Detrol LA 2 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One
(1) Cap PO DAILY (Daily).
Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: 0.5 Tablet
PO BID (2 times a day).
Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: [**5-13**]
MLs PO Q6H (every 6 hours) as needed for cough.
Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Discharge Medications:
1. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 6 days.
Disp:*6 Tablet(s)* Refills:*0*
2. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*30 Cap(s)* Refills:*0*
3. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q6H (every 6 hours) for 2 weeks.
Disp:*QS QS* Refills:*0*
4. Levalbuterol HCl 0.63 mg/3 mL Solution Sig: One (1) ML
Inhalation every 4-6 hours as needed for SOB, wheeze for 2
weeks.
Disp:*QS QS* Refills:*0*
5. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 2 days: Take [**Date range (1) 5568**].
Disp:*6 Tablet(s)* Refills:*0*
6. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day for
2 days: Take [**Date range (1) 26325**].
Disp:*4 Tablet(s)* Refills:*0*
7. Prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day for
2 days: Take [**Date range (1) 54651**].
Disp:*2 Tablet(s)* Refills:*0*
8. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day for
2 days: Take [**Date range (1) 70310**].
Disp:*2 Tablet(s)* Refills:*0*
9. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day for
2 days: Take [**Date range (1) 70311**].
Disp:*2 Tablet(s)* Refills:*0*
10. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Liquid Sig: Five
(5) ML PO Q4H (every 4 hours) as needed for 2 weeks.
Disp:*QS ML(s)* Refills:*0*
11. Benztropine 1 mg Tablet Sig: One (1) Tablet PO at bedtime.
12. Calcium 500 mg Tablet Sig: One (1) Tablet PO twice a day.
13. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
14. Clotrimazole 1 % Cream Sig: One (1) Topical twice a day.
15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
17. Nifedipine 30 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO DAILY (Daily).
18. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
19. Olanzapine 10 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
20. Risperidone 2 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
21. Tolterodine 2 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
22. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One
(1) Cap PO DAILY (Daily).
23. Vitamin D-3 400 unit Tablet Sig: 0.5 Tablet PO twice a day.
24. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
25. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. COPD exacerbation
2. Community-acquired pneumonia
3. Incidental lung nodule
.
Secondary:
1. Schizophrenia
2. Hypertension
3. Osteoporosis
4. Arthritis
5. Urinary incontinence
6. Congenital nystagmus
Discharge Condition:
Afebile, vital signs stable.
Discharge Instructions:
You were hospitalized with an exacerbation of your COPD. You are
on antibiotics and steroids for treatment. You should take
standing albuterol nebulizer treatments every six hours for now.
You can take xopenex treatments as needed. You should stop
smoking and should discuss this with your primary care doctor.
.
You have a lung nodule. While this may be benign, it could
represent cancer and you need a follow-up CT scan of your chest.
Please discuss this with your primary care doctor to arrange the
study.
.
Please contact a physician if you experience fevers, chills,
chest pain, increased shortness of breath, increased cough, or
any other concerning symptoms.
.
Please take your medications as prescribed.
- You should take levofloxacin for 6 more days.
- You should take prednisone for a slow taper. You should take
prednisone 60 mg x 2 days, 40 mg x 2 days, 20 mg x 2 days, 10 mg
x 2 days, 5 mg x 2 days, then stop.
- You should take spiriva daily.
- You should take albuterol nebulizers every 6 hours.
- You can take xopenex nebulizers every 4-6 hours as needed
shortness of breath or cough.
- You can take guaifenesin as needed for cough.
.
Please contact your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] follow-up
within the next two weeks.
Followup Instructions:
Please call your primary care doctor, Dr. [**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) **], at
[**Telephone/Fax (1) 719**], to [**Telephone/Fax (1) **] follow-up within the next 2-3 days.
|
[
"782.1",
"305.1",
"733.00",
"491.21",
"295.60",
"486",
"799.02",
"518.89",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
13477, 13483
|
5824, 8728
|
324, 332
|
13738, 13768
|
4220, 4228
|
15097, 15309
|
3642, 3661
|
10864, 13454
|
13504, 13717
|
8754, 10841
|
13792, 15074
|
3676, 4201
|
264, 286
|
360, 2997
|
4242, 5801
|
3019, 3204
|
3220, 3626
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,284
| 190,269
|
48645
|
Discharge summary
|
report
|
Admission Date: [**2118-3-16**] Discharge Date: [**2118-3-29**]
Date of Birth: [**2064-8-2**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Demerol / Ceftriaxone
Attending:[**First Name3 (LF) 2234**]
Chief Complaint:
hypoxia
Major Surgical or Invasive Procedure:
intubation
History of Present Illness:
56 yo female with history of schizoaffective disorder was
admitted from the ED with respiratory distress. She was
intubated upon arrival and no family/friends were available for
obtaining further history. History was obtained primarily from
chart review and ED records.
.
Of note, patient was recently admitted to [**Hospital1 18**] psychiatry from
[**Date range (1) 102314**] with the auditory hallucinations and paranoia.
During her admission, she was noted to refuse her outpatient
medications intermittenly and had elevated blood pressure at
these times.
.
Upon admission, patient had respiratory distress with
hypertension. Her vital signs were HR 120, BP 280/140, RR 40,
and 94% on NRB (60% on RA). She was intubated shortly after
admission to the ED, and right femoral line was placed due to
inability to obtain peripheral IVs. Patient received
nitroglycerin .4mg SL x 1, ativan 2mg IV x 2, lasix 40mg IV x 1,
propofol sedation, levofloxacin 750mg IV x 1, ceftriaxone g x 1,
aspirin 600mg x 1, and tylenol 650mg PR x 1.
.
Past Medical History:
1. Schizoaffective disorders with multiple psychiatric
hospitalizations and at least 1 previous suicide attempt in [**2102**]
(per previous discharge summary.
2. History of polysubstance abuse in the past - alcohol,
benzodiazepines, opiates, and heroin
3. Type 2 Diabetes Mellitus
4. Hypertension
5. History of endocarditis
6. Past positive PPD
7. Hematuria
8. s/p right hemicolectomy in [**2111**] for necrotic bowel
9. Asthma
10. Epidural Abscess in [**10-24**] from L3-L5 requiring
debridement/laminectomy/discectomy; completed 6 weeks of
amphotericin/vancomycin/C. albicans/CNS
11. Chronic Back Pain
12. Recurrent UTIs
Social History:
Home: immigrant from the [**Location (un) 3156**], widowed in [**2102**]
Occupation: unknown
EtOH: unknown
Drugs: history of IVDU
Tobacco: unknown
Family History:
History of psychiatric disorders
Physical Exam:
T 97.2 / HR 83 / BP 149/87 / Pulse ox 100%
Gen: intubated and sedated, diaphoretic
HEENT: Clear OP, MMM
NECK: Supple, No LAD, No JVD
CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops
LUNGS: bibasilar crackles (right greater than left) with no
rhonchi or wheezes
ABD: Soft, NT, ND. NL BS. No HSM
EXT: No edema. 2+ DP pulses BL
SKIN: No lesions
NEURO: intubated and sedated. absent reflexes throughout.
responds to painful stimuli
Pertinent Results:
[**2118-3-16**] CTA chest
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Bilateral tree-in-[**Male First Name (un) 239**] infiltrates that could be infectious
(for example atypical mycobacterial infection) or inflammatory
in etiology (infectious bronchiolitis).
3. Additional bilateral, peripheral, pleural-based
consolidations differential diagnosis for which includes
infection as well as chronic processes such as primary atypical
pneumonia, chronic eosinophilic pneumonia or cryptogenic
organizing pneumonia.
.
[**2118-3-17**] renal ultrasound
FINDINGS: Incredibly limited study due to portable nature,
patient inability to cooperate, and technical limitations of the
ICU space with multiple other machines. There is no evidence of
hydronephrosis. The bladder was not visualized. A Foley catheter
was noted to be in place.
.
[**2118-3-17**] ECHO
The left atrium is elongated. A small secundum atrial septal
defect is present. There is mild symmetric left ventricular
hypertrophy with normal cavity size and global systolic function
(LVEF>55%). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). Right ventricular
chamber size and free wall motion are normal. The number of
aortic valve leaflets cannot be determined. 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. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. No mass or
vegetation is seen on the mitral valve. Mild to moderate ([**12-22**]+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
Compared with the report of the prior study (images unavailable
for review) of [**2113-11-20**], the severity of mitral regurgitation
and tricuspid regurgitation has increased. A small secundum ASD
is now identified. No vegetation is identified, but aortic valve
images were suboptimal. If clinically indicated, a TEE is
recommended to assess endocarditis.
.
[**2118-3-24**] ECHO repeat (To assess MR while on nitro drip)
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 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.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Trivial mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2117-3-16**], the findings are similar.
Brief Hospital Course:
53 yo female with history of schizoaffective disorder was
admitted from the ED with likely hypoxic respiratory failure of
unclear etiology and in the setting of hypertensive urgency.
[**Hospital Unit Name 153**] course by problem:
1. Hypoxic Respiratory Failure: The patient was intubated when
she arrived to the [**Last Name (LF) 153**], [**First Name3 (LF) **] her differential was broad. She was
intially started on broad coverage antibiotics to cover
bacterial etiologies -- vanc, cefepime and azithromycin. The
vancomycin was discontinued after 2 days, and azithro was
completed for a 5 day. course. Her cultures remained negative.
DFA for flu was negative. urine legionalla negative. On her 7th
day of her hospitilzation, she spiked fever to 101. She was on
cefepime at the time, so vancomycin was started. for 48 hours,
she remained afebrile and cultures were negative, so vanc was
discontinued and cefepime was also discontinued (For a total of
9day course). Her vent settings were weaned, but she when
sedation was weaned, she was agitiated and hypertensive. The
hypertension was correlated with reduced PEEPs. The reduced peep
likely exacerbated her known mitral regurgitation. To optimize
her for extubation, she was started on a nitro drip. Her blood
pressure was controlled on this, and she was able to be
extubated without hemodynamic instablilty.
For sedation, she was intially on propfol, which was switched to
fentanyl and midazolam. When these were weaned off to put her on
pressure support, she was very agitated and required 5mg haldol
TID with 2.5-5mg PRNs. She also recieved several day of 10mg
valium TID as well. This controlled her enough for extubation.
.
2. Hypertension
Unclear etiology for patient's hypertensive urgency upon arrival
to the ED given inability to take any history. Differential
includes medication noncompliance, pain.
the patient was inreasingly hypertensive and she was started on
captopril and isosorbide mononitrate. It was then realized that
her a line pressure was higher then normal because of flicking
of the tip. She had urine metanephrines sent as part of work up
for secondary causes of HTN. As above, she was put on a
nitrodrip for preload reduction periextubation, as increased
preload with reduced PEEP exacerbated her MR. When the nitrodrip
was discontinued, she was started on 20 mg TID of isordil. and
continued on captopril 50mg TID.
3. Type 2 Diabetes Mellitus
Stable
- hold metformin for now and start insulin sliding scale
4. Schizoaffective Disorder
Unclear how patient's psychiatric status may have played into
her current situation of respiratory distress
- psych consult in the AM regarding her medications while
intubated or any further collateral information
- Haloperidol was held on day of transfer from the [**Hospital Unit Name 153**] given
prolonged QT.
===============================================================
Floor course:
Diastolic Heart Failure
COPD/Asthma with exacerbation
Schizophrenia:
Hypertension:
Diabetes:
Patient's heart failure and blood pressure medications were
titrated. Patient maintained on COPD regimen. Psychiatry
followed throughout, given fluphenazine depot on day of
discharge. Case discussed with patient's PCP and PCP [**Name9 (PRE) **] psych
follow up arranged. MEtformin re-started. See discharge
medication list for details of cardiac regimen. Prednisone
taper on discharge. Satting in mid tohigh 90's on room air
including with ambulation on discharge. QTc monitoring on
atypical antipsyhotics, somewhat prolonged but stable
throughout.
Medications on Admission:
(per discharge summary on [**2118-3-7**])
1. HCTZ 25mg PO daily
2. Lisinopril 5mg PO daily
3. Atenolol 75mg PO daily
4. Metformin 500mg PO daily
5. Pantoprazole
6. Multivitamin daily
7. Ibuprofen prn
8. Psyllium packet daily
9. Tolterodine 2mg PO bid
10. Fluphenazine Decanoate 12.5 qoweekly (last given on [**2118-3-3**])
11. Oxycodone prn - dispensed 2 tablets only
12. Ranitidine 150mg PO bid
13. benadryl 25mg PO qhs
14. Fluphenazine 2.5mg PO tid prn
Discharge Medications:
1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) puff Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 inhaler* Refills:*0*
2. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*30 Cap(s)* Refills:*0*
3. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day for
3 days: start tomorrow [**2118-3-30**].
Disp:*6 Tablet(s)* Refills:*0*
4. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO daily () for
3 days: start on [**4-2**].
Disp:*9 Tablet(s)* Refills:*0*
5. Prednisone 20 mg Tablet Sig: One (1) Tablet PO daily () for 3
days: start on [**4-5**].
Disp:*3 Tablet(s)* Refills:*0*
6. Prednisone 10 mg Tablet Sig: One (1) Tablet PO daily () for 3
days: start on [**4-8**].
Disp:*3 Tablet(s)* Refills:*0*
7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every six (6) hours.
Disp:*1 inhaler* Refills:*2*
8. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
9. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
Disp:*30 Tablet(s)* Refills:*0*
10. Imdur 120 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:*0*
11. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*0*
12. Fluphenazine HCl 2.5 mg Tablet Sig: One (1) Tablet PO twice
a day as needed for for auditory or visual hallucinations, or
agitation.
Disp:*10 Tablet(s)* Refills:*0*
13. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
14. Fluphenazine Decanoate 25 mg/mL Solution Sig: 12.5 mg
Injection every other week: Last dose given on [**2118-3-29**].
15. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) for 7 days.
Disp:*1 tube* Refills:*2*
16. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 13 days.
Disp:*39 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Acute respiratory failure
2. Acute on chronic diastolic heart failure
3. Asthma with acute exacerbation
4. Hypertension
5. Atrial Fibrillation
6. Schizophrenia
7. type II diabetes mellitus, uncontrolled
8. Narcotic/opiod abuse
9. Chronic back pain
10. Prolonged QTC
11. Presumed c. difficile colitis
Discharge Condition:
stable, afebrile, tolerating PO
Discharge Instructions:
You should follow up with your primary care doctor and your
psychiatrist as below. We were unable to schedule an
appointment with your primary care doctor despite trying
multiple times (no response after leaving messages). Please
call Dr. [**Last Name (STitle) 102312**] at [**Telephone/Fax (1) 102313**] tomorrow to schedule a
follow up appointment as soon as possible.
Take all your medications as prescribed. There are multiple
changes from the medications you had been taking. DO NOT TAKE
ANY OTHER MEDICATIONS THAT YOU WERE PREVIOUSLY TAKING. Take a
list of your new medications to DR. [**Last Name (STitle) 102312**] when you see
him. We have given you this list.
You should return to the emergency room if you develop fevers,
chills, chest pain, shortness of breath or any other new
concerning symptoms.
Followup Instructions:
Follow up with your psychiatrist at Mass mental Health. You
have an appointment on [**4-8**]. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6174**] at MMHC
([**Hospital1 **])
for [**4-8**] at 1:45pm. The number is [**Telephone/Fax (1) 95065**]
Follow up with Dr. [**Last Name (STitle) 102312**] as soon as possible. Please call
[**Telephone/Fax (1) 102313**] to schedule this appointment.
|
[
"724.5",
"424.0",
"250.02",
"782.1",
"008.45",
"305.90",
"295.70",
"493.22",
"401.9",
"305.1",
"794.31",
"780.6",
"428.0",
"427.31",
"428.33",
"276.3",
"424.2",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.6",
"33.24",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
11712, 11718
|
5628, 9191
|
303, 315
|
12065, 12098
|
2707, 5605
|
12967, 13384
|
2202, 2236
|
9696, 11689
|
11739, 12044
|
9217, 9673
|
12122, 12944
|
2251, 2688
|
256, 265
|
343, 1375
|
1397, 2022
|
2038, 2186
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,947
| 128,928
|
2901
|
Discharge summary
|
report
|
Admission Date: [**2181-6-15**] Discharge Date: [**2181-6-22**]
Service:
DIAGNOSIS:
Perforated duodenal ulcer.
HISTORY OF PRESENT ILLNESS: The patient is an 83 [**Hospital **]
nursing home resident with a history of Alzheimer's disease,
coronary artery disease status post coronary artery bypass
graft who developed acute onset of abdominal pain in the
morning of [**2181-6-14**]. The pain was mainly periumbilical
without radiation and without fevers or chills. The patient
was taken to the outside hospital where an abdominal x-ray
showed no evidence of obstruction and moderate feces. A
decision was made to transfer the patient to [**Hospital1 346**] for further evaluation.
HOSPITAL COURSE: On arrival the patient had vital signs of
98.5, 90, 161/84 and was saturating at 90% on room air, which
increased to 98% with 3 liters of oxygen. She was started on
Ampicillin, Levofloxacin and Flagyl in the Emergency
Department.
Pertinent physical examination findings included a minimally
distended abdomen with tenderness to palpation and
epigastrium and right abdomen. Voluntary guarding with
minimal rebound. Rectal examination revealed heme positive
brown stool with no masses.
White blood cell count was 43 with left shift. Alkaline
phosphatase was 120. Urinalysis was negative. Nasogastric
retrieved approximately 200 cc of coffee ground material.
Chest x-ray obtained revealed no obvious free air in the
abdomen. Further workup with CT revealed free air and fluid
in the abdomen thought likely to be from the first part of
the duodenum. No other abnormal pathology was revealed on
this CT.
The decision was made to take the patient to the Operating
Room where an exploratory laparotomy revealed a large
duodenal perforation secondary to a duodenal ulcer. A
Billroth two, tube duodenostomy, J tube placement and
antecolic gastrojejunostomy were performed over five hours.
The patient was then admitted to the CICU where she remained
sedated and intubated. Triple antibiotic coverage was
continued. The patient was extubated on postoperative day
number two that is on [**2181-6-17**]. Trophic tube feeds were
started on postop day number three at the time the patient's
white blood cell count was down to 16.8. Results of belly
swab from [**6-14**] were reported to be growing yeast on [**6-17**] and
Fluconazole was started. On postoperative day number five
the decision was made that the patient was stable enough for
transfer to a regular medical surgical floor. During her
Intensive Care Unit stay the patient was awake and alert
following discontinuation of sedation and extubation even
though she had periods of confusion possibly secondary to her
underlying dementia. Her white blood cell count continued to
trend downward.
On [**2181-6-20**] postop day number five the patient remained stable
on the floor with satisfactory oxygen saturation on 2 to 4
liters of oxygen via nasal cannula. She received q 6
Albuterol and Atrovent nebulizer treatments. Tube feeds
continued. The patient's medications were changed from
intravenous to J tube administration route. Also on postop
day number five the patient's antibiotic therapy with Flagyl,
Levofloxacin and Metronidazole was discontinued. Case
management and social work in put on discharge planning was
requested, which revealed the patient had a compromise
family support system, but had ready access to a bed at her
previous nursing home facility. Plans were therefore made
for discharging the patient back to [**Hospital 9013**] on [**6-22**].
During her entire stay on the floor the patient was kept on
soft restraints following attempts by the patient to remove
some of her lines. The head of her bed was also kept
elevated as an aspiration precaution. On the night of [**6-20**]
and again on the morning of [**6-21**] the patient was found to be
experiencing some respiratory difficulty with desaturations
to the upper 80s and then later to the mid 70s. This was
suspected to be secondary to the patient's hydration status
contributing to thickening of pulmonary mucous secretions.
Fluid management was adjusted to resolve this problem with
orders written for installation of 750 cc of free water into
her J tube in one 8 cc boluses q.i.d., q 4 Albuterol and
Atrovent nebulizer treatments continued as well as
intermittent pulmonary hygiene treatments by suction. A
duodenal tube study was scheduled for the morning of [**6-22**] and
is currently pending. A comment on the results of this study
will be noted in the patient care referral form that the
patient will carry with her to her nursing home. At this
moment the patient remains stable and discharge is
anticipated early in the afternoon of [**2181-6-22**].
PERTINENT DIAGNOSTIC STUDIES: CT of the abdomen with and
without contrast performed on [**2181-6-15**] revealed three
intraperitoneal gas with ascites, likely site of rupture is
in the duodenal blood. The gallbladder might be secondarily
inflamed.
LABORATORIES ON ADMISSION: White blood cell count was 35.4,
hemoglobin 14.7, platelets 229, sodium 134, potassium 5.1,
chloride 93, bicarb 25, BUN 35, creatinine 8.2, glucose 82.
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 4984**]
Dictated By:[**Doctor Last Name 14026**]
MEDQUIST36
D: [**2181-6-22**] 09:28
T: [**2181-6-22**] 09:43
JOB#: [**Job Number 14027**]
|
[
"568.89",
"789.5",
"244.9",
"V45.81",
"331.0",
"532.20",
"294.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.22",
"46.39",
"96.6",
"43.7",
"54.59"
] |
icd9pcs
|
[
[
[]
]
] |
714, 4997
|
152, 696
|
5012, 5422
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,779
| 192,862
|
25433
|
Discharge summary
|
report
|
Admission Date: [**2179-5-7**] Discharge Date: [**2179-6-12**]
Date of Birth: [**2145-4-9**] Sex: M
Service: PLASTIC
Allergies:
Penicillins / Aspirin
Attending:[**First Name3 (LF) 5883**]
Chief Complaint:
Patient admit for multiple injuries s/p unhelmeted motorcycle
accident.
Major Surgical or Invasive Procedure:
[**2179-5-31**]- vac change -wounds look good
[**2179-5-28**]: vac change
[**2179-5-21**]: Vac change-wound look good
[**2179-5-19**]: I+D of left Upper Ext,vac change LUE/LLE Wound growing-
serratia sensitive to bactrim (levo)
[**2179-5-14**]: VAC change
[**2179-5-12**]: ORIF L humerus, ulna/ placement vac at fasciotomy site
change vac of L thigh
[**5-8**]: fasciotomies of LUE, ORIF of R tib/fib
History of Present Illness:
Admitted [**5-7**] s/p motorcycle accident wtih multiple injuries; rt
tib-fib frature,left comminuted elbow fracture and left thigh
degloving
Past Medical History:
none
Social History:
mechanic
Pertinent Results:
[**2179-5-7**] 07:20PM FIBRINOGE-245
[**2179-6-9**] 04:45AM BLOOD Plt Ct-370
[**2179-5-7**] 07:20PM BLOOD PT-15.8* PTT-24.3 INR(PT)-1.7
[**2179-6-9**] 04:45AM BLOOD Glucose-109* UreaN-7 Creat-0.5 Na-138
K-4.3 Cl-101 HCO3-30 AnGap-11
[**2179-5-8**] 02:53AM BLOOD Glucose-156* UreaN-9 Creat-0.7 Na-142
K-3.9 Cl-109* HCO3-25 AnGap-12
[**2179-5-12**] 04:05PM BLOOD Glucose-153* UreaN-17 Creat-0.6 Na-138
K-4.6 Cl-103 HCO3-26 AnGap-14
[**2179-6-9**] 04:45AM BLOOD ALT-17 AST-13 LD(LDH)-155 AlkPhos-148*
TotBili-0.3
[**2179-5-8**] 02:53AM BLOOD ALT-30 AST-79* LD(LDH)-304* CK(CPK)-5667*
AlkPhos-50 Amylase-41 TotBili-0.7
[**2179-5-23**] 05:50AM BLOOD Lipase-78*
[**2179-5-8**] 02:53AM BLOOD CK-MB-43* MB Indx-0.8 cTropnT-<0.01
[**2179-6-6**] 08:43AM BLOOD Calcium-8.3* Phos-4.1 Mg-1.5*
[**2179-5-8**] 02:53AM BLOOD Albumin-2.6* Calcium-7.5* Phos-3.4
Mg-1.4*
[**2179-5-8**] 05:45AM BLOOD TSH-1.2
[**2179-6-9**] 04:45AM BLOOD Vanco-10.7*
[**2179-5-10**] 03:10AM BLOOD Type-ART Temp-36.8 Rates-/18 pO2-99
pCO2-47* pH-7.40 calHCO3-30 Base XS-2 Intubat-NOT INTUBA
[**2179-5-7**] 07:26PM BLOOD pO2-130* pCO2-51* pH-7.30* calHCO3-26
Base XS--1
[**2179-5-10**] 01:29PM BLOOD Glucose-127* Lactate-0.7 K-4.0
[**2179-5-7**] 07:26PM BLOOD Glucose-155* Lactate-1.9 Na-140 K-4.7
Cl-105
Brief Hospital Course:
Pt admitted [**2179-5-7**] to trama service and placed T-ICU for
multiple injuries s/p motorcycle accident. On [**2179-5-7**] patient
recieved fasciotomy of the left forearm and intrameduallary rod
of the right tibia. On [**2179-5-12**] patient recieved ORIF of left
humerus fracture and left ulna fracture followed with placement
of vac dressings.On [**2179-5-19**] patient recieved incision and
debridement of left upper extremity s/p fever of unknown origin.
During this procedure culture taken from both the left forearm
and the left thigh grew serratia and were sensitive to bactrim.
Patient received a series of vac changes([**5-14**], [**5-21**], [**5-28**], [**5-31**]).
On [**6-7**] the patient was taken the OR for split thickness skin
grafting (STSG) and replacement of VAC dressing over STSG sites
ie:left anterior thigh and left volar and dorsal forearm. The
patient tolerated the procedure well. After five days the
patient's VAC dressing was removed from the STSG sites revealing
nearly 100% take of all grafts. The patient should continue to
place a xeroform gauze and dry keflex over all graft sites for 1
week. The patient was also followed by the infectious disease
service to assist with antibiotic coverage of complicated wounds
with othropedic hardware. Initially the patient was on
vancomycin and broad spectrum antibiotics. Two days prior to
discharge the patient's vanco was discontinued. The patient
remains on cephalosporin abx and should have weekly CBC, lytes
and LFTs these labs should and will be monitored by the
infectious disease consulting physician.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
4. Hydromorphone 2 mg Tablet Sig: 1-4 Tablets PO Q2H (every 2
hours) as needed.
5. Oxycodone 40 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO Q8H (every 8 hours).
6. Enoxaparin Sodium 40 mg/0.4mL Syringe Sig: One (1)
Subcutaneous QD ().
7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
10. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
Q8H (every 8 hours) as needed.
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
12. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
13. Ceftazidime 2 gm IV Q8H
14. Lorazepam 2 mg/mL Syringe Sig: One (1) Injection Q4H (every
4 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
Southern [**Hospital **] Rehab
Discharge Diagnosis:
Left humerus and ulna fracture; right open tibia-fibular
fracture; degloving of the left anterior thigh
Discharge Condition:
stable
Discharge Instructions:
Please call your surgeon or return to the emergency room if you
experience fever > 101.5, foul smelling drainage from your
wounds, extreme pain or any significant change in your medical
condition.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD Where: LM [**Hospital Unit Name 4341**] DISEASE Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2179-7-7**] 10:00
Please follow up with Dr. [**Last Name (STitle) 1005**] (ortho) in [**11-22**] weeks call to
schedule an appointment. ([**Telephone/Fax (1) 2007**]
Please follow up with Dr. [**First Name (STitle) **] (plastic surgery) in [**11-22**] weeks
call to schedule an appointment. [**Telephone/Fax (1) 23144**]
|
[
"890.0",
"354.0",
"958.8",
"E815.2",
"824.5",
"812.41",
"682.3",
"682.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"04.43",
"79.66",
"83.45",
"79.31",
"93.59",
"79.36",
"86.69",
"00.14",
"78.17",
"86.22",
"83.14",
"79.01",
"77.62"
] |
icd9pcs
|
[
[
[]
]
] |
5195, 5252
|
2307, 3894
|
351, 771
|
5400, 5408
|
1015, 2284
|
5653, 6162
|
3949, 5172
|
5273, 5379
|
3920, 3926
|
5432, 5630
|
240, 313
|
799, 942
|
964, 970
|
986, 996
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,412
| 173,066
|
51939
|
Discharge summary
|
report
|
Admission Date: [**2142-4-16**] Discharge Date: [**2142-4-19**]
Date of Birth: [**2080-1-12**] Sex: M
Service: MEDICINE
Allergies:
Horse Blood Extract / Lipitor
Attending:[**First Name3 (LF) 3016**]
Chief Complaint:
weakness, dyspnea
Major Surgical or Invasive Procedure:
Paracentesis
Blood transfusion with 6 units of packed red blood cells
History of Present Illness:
62-year-old M with history of cholangiocarcinoma (C2D15
gemcitabine and oxaliplatin on [**2142-4-9**]), CAD, remote renal
transplant, who presents with diffuse weakness, rigors, dyspnea,
emesis x 1.
This morning, the patient's wife found him in the showers,
crouching over, rigoring, with dyspnea, complaining of
generalized weakness. At home, T was 98.1. His symptoms are
associated with worsening abdominal distention over the last few
days. He also complains of watery diarrhea over the last few
months. He denies headache, visual changes, weakness or
paresthesias. No changes in smell. No CP. No sore throat, cough
rhinorrhea. No weight loss. Had similar symptoms on thursday but
did not make much of them. Over last few weeks had decreased
appetite and has been taking appetite stimulant. His anginal
equivalent is chest pain.
Patient received C2D15 of his gemcitabine and oxaliplatin on
[**2142-4-9**]. His first cycle was uncomplicated.
Of note, his clopidogrel and ASA were discontinued in [**Month (only) **] for
liver biopsy.
In ED, T 95.5, BP 80-100s/50-70s (baseline SBP 100s), HR 120s,
RR 24, 100%RA. Exam revealed distended abdomen with significant
hepatomegaly. ECG showed no ischemic changes. Labs were notable
for Hct 21, AG of 16 with lactate 4.5. He received 3L NS, and HR
decreased to 90s. With hypothermia, tachycardia, lactic
acidosis, and ongoing chemo, he received empiric vancomycin and
pip-tazo and was admitted to the MICU.
In the floor he complains of abdominal pain and worsened
abdominal distention. He doesnt have any other complaints but
expresses being sad regarding his cancer burden.
Review of sytems:
(+) Per HPI
(-) Denies headache, sinus tenderness, rhinorrhea or congestion.
Denied coughs. Denied chest pain or tightness, palpitations. No
dysuria. Denied arthralgias or myalgias. Denies hematochezia,
melena, arthralgias.
Past Medical History:
- Renal transplant (LRRT) [**2105**] [**1-1**] to post-strep GN on imuran
- CAD with MI in [**12/2135**] s/p stent. MI in [**10/2136**] and area of
stent was found to be occluded but no other interventions done.
First stent was BMS; found to have total occlusion; at
subsequent cath had attempt at correcting with placement of [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) **]/b dissection and resulting no flow at end of procedure.
- TIA/stroke in left eye causing decreased vision
- Hyperlipidemia
- Depression
- Hypertension
- Avascular necrosis of his left patella
- Recent diagnosis of adenocarcinoma at liver, s/p liver biopsy
[**1-17**].
- Mild chronic cardiomyopathy with LVEF of 50-55%
- Small secundum ASD
- Hiatal hernia
Social History:
Married. No smoking, he drinks alcohol almost on a daily basis,
2 to 3 drinks daily. This has been ongoing for 15 to 20 years.
He also smokes marijuana a few times per week due to nausea. He
denies any cocaine or heroin. He works in school food services.
Family History:
Mother had [**Name2 (NI) 499**] cancer; maternal uncle and paternal aunt had
liver cancer. Maternal aunt had pancreatic cancer. The patient
does not know if they had cirrhosis or not.
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: distended and tympanic but soft, non-tender, bowel
sounds present, no rebound tenderness or guarding, unable to
appreciate hsm on palpation, percussion consistent with
hepatomegaly.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CN2-12 intact, intact sensation to touch and 5/5 strength
throughout.
Pertinent Results:
[**2142-4-16**] 11:42AM LACTATE-4.5*
[**2142-4-16**] 11:35AM GLUCOSE-136* UREA N-23* CREAT-1.5* SODIUM-136
POTASSIUM-3.5 CHLORIDE-100 TOTAL CO2-20* ANION GAP-20
[**2142-4-16**] 11:35AM estGFR-Using this
[**2142-4-16**] 11:35AM ALT(SGPT)-14 AST(SGOT)-28 CK(CPK)-49 ALK
PHOS-151* TOT BILI-1.0
[**2142-4-16**] 11:35AM LIPASE-62*
[**2142-4-16**] 11:35AM CK-MB-NotDone cTropnT-0.02*
[**2142-4-16**] 11:35AM ALBUMIN-3.1* IRON-27*
[**2142-4-16**] 11:35AM calTIBC-152* VIT B12-1013* FOLATE-6.2
FERRITIN-1455* TRF-117*
[**2142-4-16**] 11:35AM TSH-4.7*
[**2142-4-16**] 11:35AM WBC-9.0# RBC-2.26* HGB-6.8* HCT-21.0* MCV-93
MCH-30.2 MCHC-32.4 RDW-20.6*
[**2142-4-16**] 11:35AM PT-18.4* PTT-29.5 INR(PT)-1.7*
[**2142-4-16**] 11:35AM PT-18.4* PTT-29.5 INR(PT)-1.7*
CXR [**2142-4-16**]: FINDINGS: In comparison with the study of [**2142-2-26**],
the central catheter remains in position. Low lung volumes, but
no evidence of acute focal pneumonia, vascular congestion, or
pleural effusion.
Peritoneal cytology [**2142-4-18**]: pending
Brief Hospital Course:
62 yo male with hx of cholangiocarcinoma (C2D15 gemcitabine and
oxaliplatin on [**2142-4-9**]), CAD, remote renal transplant, who was
admitted due to hypotension, N/V, and abdominal pain, now
resolving
# Hypotension: With hypothermia initially, tachycardia, lactic
acidosis, and ongoing chemo, he received empiric vancomycin and
pip-tazo and was admitted to the MICU. His SBPs remained stable
after initial volume resuscitation and his Vanc/zosyn was
stopped on [**4-18**]. He underwent a paracentesis on [**4-18**] which
showed no evidence of SBP. He remained afebrile and clinically
stable after the antibiotics were stopped. His initial
hypotension was thought to be due to dehydration likely from
decreased po intake and vomiting.
# N/V: Patient had multiple days of N/V during his
hospitalization which resolved after he underwent a paracentesis
during which 6 L were removed from his abdomen. His nausea was
controled with Dronabinol 5 mg PO BID prn, Prochlorperazine 10
mg PO/IV Q6H prn, Ondansetron 8 mg IV Q8H prn, Metoclopramide 10
mg PO TID, and Lorazepam 0.5 mg PO Q4H prn. He was given IVF
until he was able to tolerate adequate po intake.
# Lactic acidosis: Lactate of 4.5 on admission likely related to
hypovolemia. Normalized after receiving IVF.
# Normocytic anemia: Likely secondary to recent chemotherapy. He
received a total of 6 units of PRBC during this hospitalization
over many days. Anemia of chronic disease by recent iron
studies. Folate and Vit B12 normal/high. He had no clinical
evidence of bleeding.
# Thrombocytopenia: Related to chemotherapy and perhaps
intrahepatic obstruction of portal circulation leading to
hypersplenism. This remained stable in the mid 100's during
this admission.
# Acute renal failure: Patient had a Cr of 1.5 on admission
thought to be due to hypovolemia as his UNa < 10. He received
IVF with improvement of his Cr to baseline.
# Cholangiocarcinoma: Patient was dianoged in [**2141-12-31**], on s/p
two cycles of gemcitabine and oxaliplatin (#C2D15 on [**2142-4-9**]).
His pain was controlled with his home regimen: MS Contin 30 mg
PO Q12H with Morphine 15 mg PO Q6H:PRN. He will follow up with
his outpatient oncologist on [**4-25**].
# History of CAD: Patient had a MI in [**2135**] s/p BMS complicated
by in stent thrombosis and DES without flow improvement. Plavix
stopped in [**Month (only) **]. He was ruled out for MI on admission given his
hypotension. He remained asymptomatic during this
hospitalization and was continued on his aspirin and statin.
His B-blocker was initially held due to hypotension, but
restarted after he had been clinically stable for a few days.
# h/o CAD with MI [**2135**] s/p BMS c/b in stent thrombosis and DES
without flow improvement. Anginal equivalent is chest pain. LVEF
of 50-55%. R/O MI in MICU. Note ASx currently.
- re-start asa, cont statin, off plavix since [**Month (only) **].
# S/p renal transplant: Patient on azathioprine and prednisone
as an outpatient. Cr improved to his baseline with IVF as above.
Renal followed him during his admission and recommended
decreasing azathioprine from 100 mg daily to 50 mg daily. He
was discharged on this lower dose. He was continued on 5 mg
prednisone daily.
# Code: DNR/DNI
Medications on Admission:
APREPITANT [EMEND] - 125 mg (1)-80 mg (1)-80 mg (1) Capsule,
Dose Pack - 1 Capsule(s) by mouth once a day Take 125mg 1 hr
prior to chemotherapy on day 1 and 80mg tablet in am first and
second day after chemo
AZATHIOPRINE [IMURAN] - 50 mg Tablet - 2 Tablet(s) by mouth
daily
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - (Prescribed by Other
Provider) - 50,000 unit Capsule - one Capsule(s) by mouth one
tablet per week times 4 weeks Last dose taken on [**2142-1-16**]
LORAZEPAM - 0.5 mg Tablet - [**12-1**] Tablet(s) by mouth q6-8hrs as
needed for nausea, anxiety, insomnia avoid if ovrsedated
MEGESTROL - 400 mg/10 mL Suspension - [**9-18**] mL by mouth once a
day Start at 10mL, can increase to 20mL
METOCLOPRAMIDE - 10 mg Tablet - 1 Tablet(s) by mouth prior to
meals (three times a day)
METOPROLOL SUCCINATE [TOPROL XL] - 50 mg Tablet Sustained
Release 24 hr - one Tablet(s) by mouth once a day
MORPHINE - 30 mg Tablet Sustained Release - One Tablet(s) by
mouth Twice daily, every 12 hours
MORPHINE - 15 mg Tablet - one Tablet(s) by mouth every six horus
as needed for as needed for pain
PANTOPRAZOLE [PROTONIX] - 40 mg Tablet, Delayed Release (E.C.) -
1 Tablet(s) by mouth daily. brand name only
PREDNISONE - 5 mg Tablet - 1 Tablet(s) by mouth daily
PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 Tablet(s) by mouth
three times a day as needed for nausea
SERTRALINE [ZOLOFT] - 100 mg Tablet - 1 Tablet(s) by mouth daily
SIMVASTATIN - 80 mg Tablet - 1 Tablet(s) by mouth daily
Medications - OTC
ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet, Delayed
Release (E.C.) - 1 Tablet(s) by mouth daily Stopped [**2142-1-9**]
until [**2142-1-24**]- pre & post liver biopsy
Discharge Medications:
1. Azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours
as needed for nausea, anxiety, insomnia.
3. Megestrol 400 mg/10 mL Suspension Sig: Ten (10) mL PO DAILY
(Daily).
4. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO at bedtime.
9. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
12. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for break through pain. Tablet(s)
13. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day): prior to meals.
14. Zofran 8 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for nausea.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Primary -
Hypotension
Nausea and vomiting
Anemia
Secondary -
History of renal transplantation
Discharge Condition:
Stable, afebrile, tolerating an a regular diet.
Discharge Instructions:
You were admitted to the hospital due to low blood pressure and
nausea and vomiting. You were initially treated with
antibiotics due to concern for infection, however there was no
evidence of infection so these were stopped and you remained
stable.
Your abdomen is elarged due to fluid and some of this was
drained which improved your nausea and vomiting. You were also
anemic likely secondary to recent chemotherapy you received.
You were transfused with a total of 6 units of packed red blood
cells over your hospitalization.
Medication changes:
1. Your azathioprine (imuran) was decreased from 100 mg daily
to 50 mg daily. You should only take 1 tablet daily of your
previous prescription.
Call your primary doctor, or go to the emergency room if you
experience fevers, chills, dizziness, shortness of breath, chest
pain, inability to tolerate oral intake, blood in your stool, or
black stool.
Followup Instructions:
Please keep your previously scheduled appointments:
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2142-4-25**] 2:00
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2502**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2142-4-25**] 2:00
Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 14688**], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2142-4-25**] 3:30
[**Name6 (MD) **] [**Name8 (MD) 831**] MD, [**Doctor First Name 3018**]
Completed by:[**2142-4-20**]
|
[
"311",
"155.1",
"285.22",
"789.59",
"287.4",
"458.9",
"V42.0",
"414.01",
"584.9",
"276.2",
"272.4",
"425.4",
"745.5",
"401.9",
"276.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
11543, 11614
|
5231, 8488
|
308, 380
|
11753, 11803
|
4160, 5208
|
12755, 13448
|
3330, 3516
|
10211, 11520
|
11635, 11732
|
8514, 10188
|
11827, 12359
|
3531, 4141
|
12379, 12732
|
251, 270
|
2051, 2277
|
408, 2033
|
2299, 3041
|
3057, 3314
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,502
| 145,440
|
43460
|
Discharge summary
|
report
|
Admission Date: [**2165-4-15**] Discharge Date: [**2165-4-24**]
Service: MEDICINE
Allergies:
Atorvastatin / Tylenol / Ibuprofen / Rosuvastatin
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Respiratory failure
Major Surgical or Invasive Procedure:
Endotracheal Intubation
History of Present Illness:
Ms. [**Known lastname 3659**] is a [**Age over 90 **] year old female with CAD, CHF (EF 40%
[**2165-3-11**]), COPD who is admitted for respiratory failure. She had a
recent admission to OSH on [**4-3**] for CHF and pneumonia. She was
treated here from [**3-9**] - [**3-18**] for NSTEMI and underwent cardiac
cath with stent placement. Per her daughter, her breathing was
labored yesterday afternoon, but was at baseline last night.
There is no report of cough or fevers from her daughter.
.
Patient was noted to be in respiratory distress at her nursing
home. She had an O2 Sat of 72% on 2LNC, which improved to 100%
on NRB. She was dypsneic, tachypneic and cyanotic. She intubated
by EMT at the nursing home and was given duonebs x 4, lasix 40 x
1, solumedrol 125 x 1 and morphine 1 mg x 1. She was noted to be
wheezing at [**Hospital 8**] Hospital and was given lasix 80 and
ertapenem. She was given ertapenem for concern for PNA.
.
Upon arrival to [**Hospital1 18**], her vitals were T 97, HR 78, BP 151/58,
RR 18, 100% intubated. She was given vanco/levo for treatment of
pneumonia. She remained hemodynamically stable.
.
On the floor, review of sytems unable to obtain due to sedation,
intubation.
Past Medical History:
# Coronary Disease - s/p NSTEMI [**2164-9-8**], declined cath,
medically managed. Normal stress test [**2163**]
# Chronic renal failure, stage III CKD - Dr [**Last Name (STitle) **]
# Chronic systolic/diastolic congestive heart failure, most
recent EF>60%
# Hypertension
# Hyperlipidemia, intolerant of statins
# Type 2 diabetes, diet-controlled
# GERD
# Breast Cancer - diagnosed in [**2145**], s/p lumpectomy in [**State 108**]
# s/p total abdominal hysterectomy [**2094**] for fibroids
# Cataracts
.
Cardiac Risk Factors: Diabetes, Dyslipidemia, Hypertension
Social History:
She lives at home alone, but has family in the area. Social
history is significant for the absence of current tobacco use.
There is no history of alcohol abuse. Has home [**Year (4 digits) 269**] w tele
reports daily and PT. due to multiple admissions, had been at
rehab most recently, but would prefer to go home.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Her father had hypertension. Her sister is
alive and healthy at 93.
Physical Exam:
Admission:
Vitals: HR 64, BP 132/56, 100% on 400x16, 40%, PEEP 5
General: intubated, sedated
HEENT: Sclera anicteric, ET tube present
Neck: supple, JVP not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley present
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Discharge:
afebrile 148/51 p67 18 97%RA
Breathing comfortably, talking full sentences without
difficulty. Lungs CTA B.
JVP WNL
RRR.
No edema lower extremities bilaterally.
Pertinent Results:
[**2165-4-15**] 10:30AM BLOOD WBC-10.6 RBC-4.05* Hgb-11.5* Hct-35.3*
MCV-87 MCH-28.3 MCHC-32.5 RDW-15.3 Plt Ct-304
[**2165-4-24**] 06:45AM BLOOD WBC-7.3 RBC-3.72* Hgb-11.2* Hct-33.6*
MCV-90 MCH-30.0 MCHC-33.3 RDW-14.9 Plt Ct-272
[**2165-4-20**] 06:20AM BLOOD PT-13.8* INR(PT)-1.2*
[**2165-4-15**] 10:30AM BLOOD Glucose-221* UreaN-57* Creat-2.4* Na-142
K-3.5 Cl-99 HCO3-29 AnGap-18
[**2165-4-21**] 06:30AM BLOOD Glucose-175* UreaN-94* Creat-3.0* Na-141
K-3.1* Cl-94* HCO3-30 AnGap-20
[**2165-4-22**] 06:10AM BLOOD Glucose-133* UreaN-95* Creat-2.9* Na-139
K-3.6 Cl-95* HCO3-31 AnGap-17
[**2165-4-24**] 06:45AM BLOOD Glucose-119* UreaN-91* Creat-2.9* Na-139
K-3.3 Cl-95* HCO3-31 AnGap-16
[**2165-4-15**] 10:30AM BLOOD CK-MB-NotDone proBNP-[**Numeric Identifier **]*
[**2165-4-15**] 10:30AM BLOOD cTropnT-0.04*
[**2165-4-15**] 07:04PM BLOOD CK-MB-3 cTropnT-0.04*
[**2165-4-24**] 06:45AM BLOOD Phos-5.1* Mg-2.2
[**2165-4-17**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
INPATIENT:
GRAM STAIN (Final [**2165-4-17**]):
[**12-2**] PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Final [**2165-4-19**]):
SPARSE GROWTH Commensal Respiratory Flora.
[**2165-4-15**] MRSA SCREEN MRSA SCREEN-Negative
[**2165-4-15**] BLOOD CULTURE Blood Culture, Routine-Negative
Initial CXR:
CHEST, AP: The vascular markings are slightly prominent, may be
consistent
with mild central CHF. There is ground-glass opacification in
the superior
segment of the left lower lobe. Small bilateral pleural
effusions, left
greater than right, noted.
An endotracheal tube is seen with tip 4 cm from the carina. The
osseous
structures are demineralized. The soft tissues are unremarkable.
IMPRESSION: Mild CHF. Ground-glass consolidation in superior
segment of left lower lobe may represent aspiration or
pneumonia.
Brief Hospital Course:
Ms. [**Known lastname 3659**] is a [**Age over 90 **] year old female with CAD, CHF, COPD, HTN,
admitted with respiratory failure requiring intubation likely
secondary to flash pulmonary edema.
.
1. Respiratory failure; required mechanical ventilation: Likely
secondary to CHF exacerbation given elevated BNP and history of
CHF. Most recent echo in [**3-20**] showed EF of 40% following NSTEMI.
The patient was diuresed in the ICU with IV lasix 80mg [**Hospital1 **].
Fluid balance was -4.5L on ICU Day 3. She received her home
doses of hydralazine for afterload reduction and carvedilol for
beta blockade. She was sedated initially with propofol but
apneic on high doses and agitated on low doses, with several
failed SBTs. Sediation was switched to Precedex on ICU Day 2.
Patient was extubated without difficulty on ICU Day 3 with RA O2
sat 98-100%. She was changed to 80mg lasix PO BID for continued
diuresis. This was changed to 40 mg po bid on [**4-21**] due to
worsening azotemia. PNA was not suspected given her lack of
leukocytosis and lack of evidence of consolidation on CXR,
therefore empiric antibiotics that had been started on admission
were discontinued by ICU Day 1.
She is not on an ace-inhibitor due ot her renal disease. She is
not followed routinely by a cardiologist, she should likely be
seen in [**Hospital 1902**] clinic, appointment scheduled through care
connections.
Pt currently appears euvolemic, with appropriate JVP. Fluid
balance currently appears about even, but pt did not collect all
of urine.
.
2. HTN.
Contin home carvedilol, felodipine, isosorbide monoitrate,
hydralazine
.
3. Renal failure. Baseline Cr likely approx 2.4.
Pt's Cr not currently back to baseline, but pt appears
euvolemic. Suspect pt's renal function may have suffered an
insult with recent events, and it may take time to see what
amount of function she may recover. As pt currently appears
euvolemic, and is clinically doing very well, maintaining
current doses of lasix.
.
4. Anemia, CKD. Stable, at baseline. Resume iron at discharge.
.
5. CAD. EKG with LBBB. Cardiac enzymes negative. Recent stent
placement last month. The patient ruled out for myocardial
infarction with negative cardiac enzymes and EKG. Her [**Hospital **] and
Clopidogrel were continued but her statin was held as it was not
on formulary and pt with history of multiple allergies to
statins. Her fluvastatin will be resumed at time of discharge
with CoQ-10, as previously prescribed. Please monitor for side
effects, including myalgias on this medication.
.
7. Type 2 diabetes. Patient is diet controlled. HgA1C was 6.1 in
[**5-17**].
- treated with sliding scale insulin while inpatient; diet
controlled as an outpatient.
.
8. Hyperlipidemia. History of intolerance to many statins.
Patient's statin is not on formulary and therefore was held.
See "CAD" above for details.
.
CODE: Full, confirmed with HCP, daughter.
[**Name2 (NI) **]: Daughter, patient, PCP [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3029**]
[**Name9 (PRE) **]: [**Hospital 100**] Rehab today
Medications on Admission:
Albuterol nebs prn
Aspirin 81 mg daily
calcitrol 0.25 q Mon/Wed/Fri
Carvedilol 12.5 mg [**Hospital1 **]
[**Hospital1 **] 75 mg daily
Coenzyme q 10 100 mg [**Hospital1 **]
Colace 100 mg daily
Felodipine 10 mg ER daily
Lasix 20 mg [**Hospital1 **]
Isosorbide monnitrate 30 TID
MVI daily
Ranitidine 150 mg daily
Tiotriopium 18 mg inhaled daily
Hydralazine 10 mg QID
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
3. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO QMOWEFR
(Monday -Wednesday-Friday).
4. Aspirin 81 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable
PO DAILY (Daily).
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Cyanocobalamin 500 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
8. Isosorbide Mononitrate 20 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Felodipine 10 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
11. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
13. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One
(1) Tablet PO once a day.
14. Nitrostat 0.4 mg Tablet, Sublingual Sig: One (1) tab
Sublingual as directed: Q 5min as needed for chest pain. Seek
immediate medical attention if not relieved after 3rd dose.
15. Fluvastatin 80 mg Tablet Sustained Release 24 hr Sig: One
(1) Tablet Sustained Release 24 hr PO once a day: (per previous
admission. Pt has failed multiple other statins. Please monitor
for side effects, including myalgias, and notify MD if present).
16. Coenzyme Q10 100 mg Capsule Sig: One (1) Capsule PO twice a
day: (to help prevent myalgias on statin, per previous
admission).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Respiratory failure
Congestive Heart Failure, systolic, acute
Acute on chronic Renal Failure
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
You were admitted with respiratory failure due to congestive
heart failure. This caused fluid to build up on your lungs. You
will need to take your medications daily and watch your weight
closely.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Department: CARDIAC SERVICES
When: MONDAY [**2165-4-29**] 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: CARDIAC SERVICES
When: TUESDAY [**2165-5-14**] at 2:30 PM
With: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5250**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: THURSDAY [**2165-5-16**] at 9:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2540**], RN [**Telephone/Fax (1) 721**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"414.01",
"403.90",
"V10.3",
"518.81",
"428.0",
"250.00",
"584.9",
"412",
"285.21",
"E932.0",
"496",
"486",
"530.81",
"V45.89",
"585.3",
"428.43"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
10425, 10510
|
5299, 8364
|
277, 302
|
10647, 10647
|
3337, 5276
|
11137, 12124
|
2470, 2620
|
8777, 10402
|
10531, 10626
|
8390, 8754
|
10827, 11114
|
2635, 3318
|
218, 239
|
330, 1535
|
10662, 10803
|
1557, 2121
|
2137, 2454
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,124
| 109,129
|
11297
|
Discharge summary
|
report
|
Admission Date: [**2188-7-11**] Discharge Date: [**2188-7-31**]
Date of Birth: [**2135-11-25**] Sex: M
Service: MICU/Acove
HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old
male who is a nursing home resident with a history of a
multi-system atrophy, right DVT and recent aspiration
pneumonia. He presents with an episode of hematuria from a
longstanding Foley which was recently removed two days prior
to admission. In addition, he had a meatal tear noted and
bleeding from the laceration was noted and he was brought to
[**Hospital1 69**] for further management
of the hematuria. Also of note there were blood clots
surrounding the meatus and clots in the urine and they were
unable to replace the Foley at that time. On admission he
also has had increasing sizes of his sacral pressure ulcers
which despite topical treatment have increased in size and
depth. Also of note, he has recently completed a 10 day
course of Levo/Flagyl on [**7-9**] for aspiration pneumonia. He
has a history of multiple aspiration pneumonias.
PAST MEDICAL HISTORY: Multisystem atrophy, dysphagia, he is
not a G tube candidate per patient's previous wishes. Benign
prostatic hypertrophy. Diabetes mellitus diet controlled.
Distant history of hypertension. Chronic obstructive
pulmonary disease. History of schizophrenia, currently off
psych meds for multiple months. Right femoral DVT in [**2187**],
in [**Month (only) 956**]. Depression.
MEDICATIONS: On admission included Celexa 20 mg po q day,
Lovenox 100 mg subcu [**Hospital1 **], Permax 1.5 mg po bid, Tylenol #3
prn, Multivitamin, ProMod tid, Trazodone 100 mg q h.s.,
Vitamin C 500 mg [**Hospital1 **], Zinc 220 mg three times per week.
ALLERGIES: Patient is allergic to Haldol which causes extra
pyramidal symptoms.
SOCIAL HISTORY: Patient is a resident of the [**Hospital3 36255**] Home. His guardian is [**Name (NI) **] [**Name (NI) 36260**], [**Telephone/Fax (1) 36257**].
PHYSICAL EXAMINATION: Patient is ill appearing, slightly
tachypneic on admission. His vital signs on admission were
blood pressure of 116/66, temperature 100, pulse 133, satting
91% on room air. HEENT: Bilateral conjunctival injection
with moist oropharynx, nasopharynx. On pulmonary exam he has
coarse rhonchi throughout his entire lung fields with upper
and lower chest congestion. Cardiovascular is regular rate
and rhythm with normal S1 and S2. Abdomen is soft,
nontender, non distended, positive bowel sounds and no
masses. GU exam, he has traumatic hypospadias with blood
surrounding the urethral meatus. On dermatologic exam he has
large, greater than 6 cm stage IV sacral ulcers. Neuro exam,
patient opens his eyes, was non verbal and lethargic. He is
extremely stiff throughout and has severe contracture in his
extremities.
LABORATORY DATA: On admission, white count 15.7 with 88%
neutrophils. His hematocrit was 35.1 which is his baseline
and his platelet count was 597,000. His BMP with sodium 140,
potassium 4.1, chloride 105, CO2 24, BUN 20, creatinine 0.5
and glucose 87 with an albumin of 2.8. His lactate was
normal at 1.1. Coags were notable for an INR of 1.4, PT 14.0
and PTT 23.9. Initial urinalysis showed that patient had
specific gravity of 1.025 with positive nitrites, negative
leukocyte esterase and [**2-19**] white blood cells with occasional
bacteria and [**5-26**] red blood cells with large blood. Arterial
blood gas on admission was 7.44, 34 and 64, PO2 on three
liters of oxygen.
HOSPITAL COURSE: The patient initially was brought to the
hospital given his episode of hematuria noted after removal
of the Foley. During his admission in the Emergency Room he
was noted to become hypotensive with a blood pressure in the
50's/30's as well as tachycardic with a rate to the 130's.
He was started on Zosyn and Vanco at this time and had a
chest x-ray which showed that he had a new left lower lobe
opacity. He did not require pressors for his hypotension.
The patient then was noted to have hypoxemic respiratory
failure and was intubated on [**7-11**] for this. He had
difficulty and was admitted to the medical care intensive
unit. He had difficulty with extubation and weaning from the
ventilator due to high levels of copious secretions. Also
during the MICU course he continued to spike fevers despite
being treated with Vancomycin and Zosyn. He had sputum
cultures which grew out Klebsiella which were resistant to
all antibiotics tested except for Zosyn and Imipenem. Also
it was noted that he had yeast in the urine and Diflucan was
started for this. In addition, patient was seen by the GU
service during his MICU admission and they recommended
possible placement of a suprapubic catheter due to his
decubitus ulcers, history of hypospadias and history of
urethral meatal tear. NG tube was placed and patient was fed
with NG tube feedings and was also supplemented with Vitamin
C and Zinc for improved wound healing. The patient was
extubated on [**7-23**] after an extended intubation course due to
significant amount of secretions. The patient's secretions
eventually had decreased and patient was transferred to the
Acove service. The patient, after he was extubated, had a
repeat episode of tachypnea on [**7-27**] where his respiratory
rate was in the 40's and elevated heart rate. His O2 sats
were dropping. He spiked a fever to 100.8 and chest x-ray
showed repeat right lower lobe infiltrate. Arterial blood
gas showed an AA gradient of approximately 39. At this point
he had still been on Zosyn and Vancomycin which had been
started upon his admission. It was discussed with ID who
recommended a 21 day course treatment of the Zosyn and Vanco.
Tube feeds were stopped at this point, given it was felt that
he had an aspiration pneumonitis. On the following day the
patient had multiple episodes of desaturation with PCO2 to
the 60's for approximately 20 minutes and noted to have
extremely thick secretions upon suctioning. Prior to this,
aggressive chest physical therapy had been continued. The
patient also was noted to be relatively hypotensive with a
systolic blood pressure over the 90's later that day. Given
the patient's worsening respiratory status, it was discussed
with the guardian about patient's overall prognosis. The
patient's guardian believes the importance of keeping the
patient comfortable during the remainder of his hospital
course as well as future treatments. At this point it was
decided that patient would have focus on his comfort
measures. The patient's NG tube was removed and afterwards
the patient felt more comfortable subjectively. In addition,
patient was started on pain medications for pain control.
Also patient's other medications such as antibiotics were
stopped as it was felt that if patient were to have a septic
compromise, it would be more gentler and kinder than a
respiratory compromise. The patient at this point appears
comfortable, in no acute distress and previously when he had
been turned he expressed signs of discomfort such as moaning,
but currently feels comfortable upon position changes.
Regarding patient's pain medications, patient initially was
started on IV Morphine at 2 mg per hour and appeared
comfortable on this medication. His medications were changed
over to po Roxanol sublingual q 2 hours. If patient is to
have continuing breakthrough pain, we plan to decrease this
interval to q 1 hour. It is important that patient have a
continuos pain medication so he does not have breakthrough
pain. In addition, the Scopolamine patch was added to help
decrease the patient's secretions. Also, Fentanyl patch was
added to the patient's pain regimen.
DISCHARGE CONDITION: Good.
DISCHARGE STATUS: Patient to be discharged to nursing home.
DISCHARGE DIAGNOSIS:
1. History of multisystem atrophy.
2. History of multiple aspiration pneumonia.
3. History of stage 3 and 4 pressure ulcers.
DISCHARGE MEDICATIONS: Roxanol 4 mg sublingual po q 2 hours,
Fentanyl patch 50 mcg q 72 hours, Scopolamine patch [**12-19**]
patches q 72 hours, Tylenol 325 mg to 650 mg per rectum prn
fever.
[**First Name11 (Name Pattern1) 2671**] [**Last Name (NamePattern4) 2672**], M.D. [**MD Number(1) 2673**]
Dictated By:[**Last Name (NamePattern1) 27308**]
MEDQUIST36
D: [**2188-7-31**] 10:26
T: [**2188-7-31**] 10:34
JOB#: [**Job Number 36261**]
|
[
"599.7",
"996.76",
"518.84",
"038.9",
"333.0",
"250.00",
"507.0",
"707.0",
"458.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.72",
"96.04",
"86.28",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
7698, 7767
|
7941, 8395
|
7788, 7917
|
3515, 7676
|
1987, 3497
|
172, 1059
|
1082, 1801
|
1818, 1964
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,996
| 198,641
|
45864
|
Discharge summary
|
report
|
Admission Date: [**2161-12-9**] Discharge Date: [**2162-1-9**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 81-year-old
female who was transferred from an outside hospital after
being treated for flash pulmonary edema and a subsequent
myocardial infarction.
PAST MEDICAL HISTORY: (The patient has a past medical
history of)
1. Protein S deficiency with recurrent deep venous
thrombosis and pulmonary emboli (she is on chronic Coumadin).
2. She has had cardiac stenting performed.
3. She has schizophrenia.
4. Chronic renal insufficiency.
MEDICATIONS ON ADMISSION: Her home medications included
prednisone (for her chronic obstructive pulmonary disease),
Coumadin, nitroglycerin patch, Aricept, Aldactone, Bactrim,
metoprolol, Neurontin, Lasix, Flovent, Zyprexa, and
Pravachol.
ALLERGIES:
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed the patient was afebrile. Vital signs were stable.
The neck veins were distended. There were bibasilar rales.
There was a [**2-27**] holosystolic murmur at the base of the heart.
The abdomen was nontender. The extremities were without
edema.
CONCISE SUMMARY OF HOSPITAL COURSE: The patient was admitted
to the Coronary Care Unit where she was treated medically for
her myocardial infarction and congestive heart failure. She
was also treated empirically with antibiotics (for a question
of pneumonia) and with stress-dose steroids.
While in house, early in her stay, the patient experienced
bright red blood per rectum for which she was treated with
vitamin K and underwent a colonoscopy which showed internal
hemorrhoids and diverticulosis in the sigmoid and descending
colon; otherwise a normal study.
Also while in house, the patient underwent an echocardiogram
which showed a left ventricular ejection fraction of 25% and
severe aortic stenosis. A coronary artery angiogram was also
performed which showed 2-vessel coronary artery disease,
severe aortic stenosis, as well as severe systolic and
diastolic ventricular dysfunction.
After being optimized medically, the patient was taken to the
operating room on [**2161-12-22**] where an aortic
replacement and coronary artery bypass graft were performed
using a mechanical valve and the left internal mammary artery
to the left anterior descending artery.
Postoperatively, the patient did well. She was initially
weaned from all pressors and extubated. Her chest tubes were
removed. She was kept on heparin early on as she did have a
protein S deficiency and there was concern that she could
have complications of emboli. However, the patient did have
recurring problems in which she would have bronchospastic
attacks requiring reintubation.
Interventional Pulmonology was consulted and determined that
the patient suffered from tracheomalacia. For this reason,
and due to failure of resolution of the problem, the patient
underwent stenting of her trachea. Once performed, the
patient was restarted on Coumadin and spent the rest of her
days in the Intensive Care Unit being cared for with close
respiratory care; including nebulizer treatment such a
physical therapy and close monitoring in bringing up her
secretions.
Also while in house, the patient did test positive for
methicillin-resistant Staphylococcus aureus pneumonia which
was treated with vancomycin. She also tested positive for
gram-negative rods in her urine. Therefore, she was treated
with Levaquin for a urinary tract infection.
CONDITION AT DISCHARGE: The patient was in good condition on
[**2162-1-9**].
DISCHARGE DISPOSITION: The patient was to be transferred to
an acute care facility which will be able to give close
respiratory care and attention.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient will require q.6h. nebulizer as well as q.6h.
chest physical therapy.
2. She will require her INR to be checked in order to best
monitor her Coumadin dosing. She has a goal INR of 2 to 2.5.
3. The patient has a baseline creatinine of approximately
1.6 to 1.7 and will also need her urine status closely
monitored.
4. The patient may not drive for one week. She may not lift
more than 10 pounds for three months.
5. She may shower but not take bathes.
6. The patient was instructed to follow up with Dr. [**Last Name (STitle) 11679**]
in one to two weeks.
7. The patient was instructed to follow up with Dr. [**Last Name (STitle) **] in
two to three weeks.
8. The patient was instructed to follow up with Dr. [**Last Name (STitle) **] in
four weeks.
MEDICATIONS ON DISCHARGE: (The patient was to be discharged
on)
1. Aspirin 650 mg by mouth q.4h. as needed.
2. Prednisone 5 mg by mouth every other day and 10 mg by
mouth every other day.
3. Albuterol and Atrovent nebulizer q.6h.
4. Olanzapine 2.5 mg by mouth every day.
5. Levofloxacin 500 mg by mouth once per day (for seven
days).
6. Miconazole powder to be used as needed.
7. Prevacid 30 mg by mouth once per day.
8. Zinc oxide/cod liver oil 40% ointment to be used as
needed.
9. Citalopram 10 mg by mouth twice per day.
10. Aricept 10 mg by mouth at hour of sleep.
11. Guaifenesin 100 mg/5 mL 10 mL q.6h.
12. Mucomyst 20% one nebulizer q.4-6h. as needed.
13. Lopressor 50 mg by mouth three times per day.
14. Aspirin 81 mg by mouth once per day.
15. Colace 100 mg by mouth twice per day.
16. Montelukast 10 mg by mouth once per day.
17. Albuterol inhaler q.6h.
18. Ipratropium inhaler q.6h.
19. Tramadol 50 mg by mouth q.4-6h. as needed.
20. Coumadin 1-mg tablet by mouth at hour of sleep (to be
monitored with a goal INR of 2 to 2.5).
21. Vancomycin 750 mg intravenously q.48h. (times 10 days).
22. Levaquin (to be extended for seven days).
DR.[**Last Name (STitle) **],[**First Name3 (LF) 275**] 02-248
Dictated By:[**Last Name (NamePattern4) 12487**]
MEDQUIST36
D: [**2162-1-9**] 11:14
T: [**2162-1-9**] 12:02
JOB#: [**Job Number 97680**]
|
[
"996.72",
"295.90",
"482.41",
"410.41",
"289.81",
"424.1",
"599.0",
"578.1",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.91",
"39.61",
"36.15",
"88.56",
"88.53",
"33.24",
"88.72",
"35.22",
"99.04",
"34.04",
"31.99",
"45.23",
"37.23",
"96.05"
] |
icd9pcs
|
[
[
[]
]
] |
3567, 3693
|
4528, 5915
|
594, 1143
|
3726, 4501
|
1172, 3473
|
3488, 3542
|
112, 281
|
304, 567
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,195
| 176,776
|
49680
|
Discharge summary
|
report
|
Admission Date: [**2123-5-22**] Discharge Date: [**2123-6-7**]
Date of Birth: [**2044-10-23**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / hydrochlorothiazide /
Enalapril
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
resp failure
Major Surgical or Invasive Procedure:
intubation
RIJ
History of Present Illness:
77 yo F with PMHx of L CVA BIBA from her nursing facility for
increasing respiratory distress. Per report, she had no h/o CHF
or asthma. Staff noticed difficulty breathing, SOB, and
coughing. No reported fevers. Pt unable to give history. EMS
bagging her on arrival but breathing on own. 60-70s RA->5L in
80s. IO put in ambulance. Per sister, visited by sister in law,
found to be in USOH this am. Pt has been in NH since stroke
three years ago but has normal mentation.
.
Upon arrival to the ED, BP 80s. Intubated with etomidate and
succ. CXR: RML pna. RIJ. Lactate normal. Not requiring
pressors. Got 2L of fluids, given vanc/zosyn. On propofol and
fentanyl. Gap 15 and bicarb 18. Last labs improving. Thick
secretions, yellow, ?aspiration pna. Unclear baseline mental
status. 22 R foream. Prior to transfer, 99.9 rectal 91 122/77
100% Fio2, TV 500x16 PEEP of 5.
.
Upon arrival to ICU, patient was intubated and sedated. Appeared
comfortable. In speaking with sister, then only thing new was
that pt had right side pain that she was receiving ultram
periodically for.
She was intubated, placed with a RIJ, and transferred to the ICU
for further management.
.
On admission, her CXR was consistent with a RML infiltrate,
which ultiamtely ended up growing MRSA, BETA STREPTOCOCCI, NOT
GROUP A, and rare GNRs.
.
In the ICU, she was started on Vancomycin and Zosyn, and
ultimately did require pressor support with alternating
norepinephrine and vasopressin. Eventually was weaned off
pressors, and antibiotic overage was narrowed to Vancomycin. She
received several IV boluses of fluid, such that upon her
discharge from the ICU, she was noted to be 13 L positive. She
was also briefly on Cipro, as well. Ultimately, she ended up
requiring IV Furosemide diuresis, at first with a lasix gtt, and
then by discharge 10 mg IV Lasix daily.
.
Also on admission, was noted to to have a possible SVT,
initially controlled with IV metoprolol, now tolerating home
atentolol, and appears to be in a sinus rhytym.
.
On [**2123-5-24**] she was noted to have a large R sided pleural
effusion, which was tapped 2 days later revealing 1.4 L of
serous fluid, with a pgitail in place initially, but ultimately
removed. She was extuabated on [**2123-5-27**], but in [**2123-5-28**] was noted
to have difficulty bringing up her secretions, and failed a S&S
evaluation.
.
Vitals prior to transfer: 98.3 120/63 77 99% 2L
.
ROS (patient is unable to relay secondary to garbled speech at
baseline secondary to stroke)
Past Medical History:
-L CVA with right sided hemipareisis, in NH since stoke three
years prior
-HTN
-HL
-GI bleed
-depression
-hypothyroidism
-?lung ca->treated at [**Hospital1 3278**] s/p chemo/radiation 5 years ago
Social History:
Ex-smoker, live in NH after stroke
.
Family History:
unable to obtain
Physical Exam:
Physical Exam on Admission:
VS: Temp:100.7 BP: 98/66 HR:89 RR: 20 O2sat hard to obtain CMV
500X16 5 100% FiO2 CVP on admission 0mmHG
GEN:intuabted sedated comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no
supraclavicular or cervical lymphadenopathy, no jvd, no carotid
bruits, no thyromegaly or thyroid nodules
RESP: bronchial b/s b/l with transmitted mechanical BS
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, cool extremities
SKIN: no rashes/no jaundice/no splinters
NEURO: sedated, could not be assessed, arousable to painful
stimuli like suctioning
Physical exam on Discharge:
Pertinent Results:
Labs:
CBC:
[**2123-5-21**] 11:50PM BLOOD WBC-5.8 RBC-3.84* Hgb-9.7* Hct-30.3*
MCV-79* MCH-25.2* MCHC-31.9 RDW-17.3* Plt Ct-416
[**2123-5-22**] 05:14AM BLOOD WBC-3.5* RBC-3.59* Hgb-8.8* Hct-29.4*
MCV-82 MCH-24.6* MCHC-30.0* RDW-17.3* Plt Ct-314
[**2123-5-23**] 04:52AM BLOOD WBC-5.2 RBC-2.83* Hgb-7.0* Hct-23.1*
MCV-82 MCH-24.7* MCHC-30.3* RDW-17.7* Plt Ct-254
[**2123-5-24**] 03:40AM BLOOD WBC-8.3# RBC-2.76* Hgb-6.8* Hct-22.1*
MCV-80* MCH-24.8* MCHC-30.8* RDW-17.7* Plt Ct-298
[**2123-5-25**] 03:24AM BLOOD WBC-12.5*# RBC-3.04* Hgb-7.5* Hct-24.1*
MCV-79* MCH-24.7* MCHC-31.2 RDW-18.3* Plt Ct-408
[**2123-5-26**] 01:10AM BLOOD WBC-8.0 RBC-3.17* Hgb-7.9* Hct-24.7*
MCV-78* MCH-25.1* MCHC-32.1 RDW-18.5* Plt Ct-383
[**2123-5-26**] 06:43PM BLOOD WBC-6.2 RBC-3.19* Hgb-7.8* Hct-25.0*
MCV-78* MCH-24.5* MCHC-31.3 RDW-18.5* Plt Ct-365
[**2123-5-27**] 04:01AM BLOOD WBC-6.5 RBC-3.16* Hgb-7.6* Hct-24.9*
MCV-79* MCH-24.1* MCHC-30.6* RDW-18.4* Plt Ct-353
[**2123-5-28**] 05:08AM BLOOD WBC-7.4 RBC-3.40* Hgb-8.3* Hct-26.3*
MCV-77* MCH-24.5* MCHC-31.6 RDW-18.6* Plt Ct-347
[**2123-5-29**] 04:54AM BLOOD WBC-8.6 RBC-3.23* Hgb-7.8* Hct-24.7*
MCV-77* MCH-24.0* MCHC-31.4 RDW-19.0* Plt Ct-383
[**2123-5-30**] 05:54AM BLOOD WBC-9.6 RBC-3.00* Hgb-7.4* Hct-23.2*
MCV-77* MCH-24.6* MCHC-31.8 RDW-18.8* Plt Ct-376
[**2123-5-31**] 05:56AM BLOOD WBC-12.6* RBC-2.98* Hgb-7.1* Hct-22.9*
MCV-77* MCH-23.8* MCHC-30.9* RDW-18.7* Plt Ct-396
[**2123-6-1**] 05:43AM BLOOD WBC-13.0* RBC-2.94* Hgb-7.0* Hct-22.7*
MCV-77* MCH-23.9* MCHC-31.0 RDW-18.8* Plt Ct-463*
[**2123-6-2**] 11:30AM BLOOD WBC-10.5 RBC-2.79* Hgb-6.6* Hct-21.3*
MCV-76* MCH-23.8* MCHC-31.2 RDW-18.5* Plt Ct-430
[**2123-6-3**] 12:35AM BLOOD WBC-10.1 RBC-3.22* Hgb-8.1* Hct-24.9*
MCV-77* MCH-25.2* MCHC-32.5 RDW-18.0* Plt Ct-425
[**2123-6-3**] 05:37AM BLOOD WBC-9.8 RBC-3.16* Hgb-7.9* Hct-24.6*
MCV-78* MCH-25.0* MCHC-32.1 RDW-18.2* Plt Ct-361
[**2123-6-4**] 06:17AM BLOOD WBC-8.1 RBC-3.11* Hgb-7.9* Hct-24.3*
MCV-78* MCH-25.3* MCHC-32.4 RDW-18.5* Plt Ct-429
[**2123-6-5**] 06:00AM BLOOD WBC-8.1 RBC-3.07* Hgb-7.9* Hct-24.1*
MCV-78* MCH-25.8* MCHC-32.9 RDW-19.2* Plt Ct-531*
[**2123-6-6**] 06:00AM BLOOD WBC-7.6 RBC-3.01* Hgb-7.5* Hct-23.7*
MCV-79* MCH-25.0* MCHC-31.7 RDW-19.0* Plt Ct-432
[**2123-6-7**] 05:54AM BLOOD WBC-6.7 RBC-2.94* Hgb-7.3* Hct-23.4*
MCV-80* MCH-24.7* MCHC-31.0 RDW-18.9* Plt Ct-402
Diff:
[**2123-5-21**] 11:50PM BLOOD Neuts-61 Bands-6* Lymphs-27 Monos-3 Eos-0
Baso-0 Atyps-0 Metas-3* Myelos-0
[**2123-5-22**] 05:14AM BLOOD Neuts-66 Bands-6* Lymphs-19 Monos-3 Eos-0
Baso-0 Atyps-0 Metas-6* Myelos-0
[**2123-5-25**] 03:24AM BLOOD Neuts-91.0* Lymphs-6.0* Monos-2.6 Eos-0.2
Baso-0.2
[**2123-5-26**] 01:10AM BLOOD Neuts-83.9* Lymphs-11.8* Monos-3.6
Eos-0.4 Baso-0.3
[**2123-5-31**] 05:56AM BLOOD Neuts-88.9* Lymphs-7.9* Monos-2.3 Eos-0.4
Baso-0.5
[**2123-6-1**] 05:43AM BLOOD Neuts-86.5* Lymphs-8.5* Monos-4.6 Eos-0.2
Baso-0.2
[**2123-6-2**] 11:30AM BLOOD Neuts-84.8* Lymphs-10.7* Monos-4.0
Eos-0.4 Baso-0.1
[**2123-6-3**] 05:37AM BLOOD Neuts-85.9* Bands-0 Lymphs-9.5* Monos-3.7
Eos-0.8 Baso-0.1
Red Cell Morphology:
[**2123-5-21**] 11:50PM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-2+
Macrocy-NORMAL Microcy-1+ Polychr-NORMAL Ovalocy-1+ Tear Dr[**Last Name (STitle) **]1+
Bite-OCCASIONAL
[**2123-5-22**] 05:14AM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL
Tear Dr[**Last Name (STitle) 833**] [**Name (STitle) 4486**]
[**2123-6-3**] 05:37AM BLOOD Hypochr-3+ Anisocy-2+ Poiklo-2+
Macrocy-NORMAL Microcy-2+ Polychr-OCCASIONAL Ovalocy-1+
Stipple-OCCASIONAL Tear Dr[**Last Name (STitle) **]2+ Ellipto-1+
Coags:
[**2123-5-21**] 11:50PM BLOOD PT-14.9* PTT-23.9 INR(PT)-1.3*
[**2123-5-23**] 04:52AM BLOOD PT-18.1* PTT-41.7* INR(PT)-1.6*
[**2123-5-23**] 06:15AM BLOOD PT-17.9* PTT-37.5* INR(PT)-1.6*
[**2123-5-24**] 03:40AM BLOOD PT-14.7* PTT-36.3* INR(PT)-1.3*
[**2123-5-25**] 03:24AM BLOOD PT-13.1 PTT-30.5 INR(PT)-1.1
[**2123-5-31**] 05:56AM BLOOD PT-12.4 PTT-29.9 INR(PT)-1.0
[**2123-6-1**] 05:43AM BLOOD PT-12.7 PTT-27.3 INR(PT)-1.1
[**2123-6-2**] 09:15AM BLOOD PT-11.9 PTT-21.7* INR(PT)-1.0
[**2123-6-3**] 05:37AM BLOOD PT-12.1 PTT-25.1 INR(PT)-1.0
[**2123-6-4**] 06:17AM BLOOD PT-12.7 PTT-26.2 INR(PT)-1.1
Fibrinogen:
[**2123-5-23**] 01:05PM BLOOD Fibrino-564*
Reticulocyte Count:
[**2123-6-1**] 05:43AM BLOOD Ret Aut-2.3
Electrolytes:
[**2123-5-21**] 11:50PM BLOOD Glucose-131* UreaN-23* Creat-1.0 Na-146*
K-5.1 Cl-113* HCO3-18* AnGap-20
[**2123-5-22**] 05:14AM BLOOD Glucose-118* UreaN-20 Creat-0.9 Na-144
K-4.5 Cl-114* HCO3-18* AnGap-17
[**2123-5-22**] 02:05PM BLOOD Glucose-107* UreaN-17 Creat-0.7 Na-145
K-3.9 Cl-115* HCO3-18* AnGap-16
[**2123-5-23**] 04:52AM BLOOD Glucose-142* UreaN-13 Creat-0.6 Na-146*
K-4.2 Cl-119* HCO3-17* AnGap-14
[**2123-5-23**] 06:15AM BLOOD Glucose-151* UreaN-14 Creat-0.6 Na-144
K-4.2 Cl-118* HCO3-19* AnGap-11
[**2123-5-24**] 03:40AM BLOOD Glucose-130* UreaN-13 Creat-0.6 Na-143
K-3.9 Cl-116* HCO3-19* AnGap-12
[**2123-5-25**] 03:24AM BLOOD Glucose-118* UreaN-10 Creat-0.6 Na-137
K-4.0 Cl-108 HCO3-18* AnGap-15
[**2123-5-26**] 01:10AM BLOOD Glucose-115* UreaN-11 Creat-0.9 Na-144
K-4.2 Cl-114* HCO3-20* AnGap-14
[**2123-5-26**] 06:43PM BLOOD Glucose-98 UreaN-11 Creat-0.9 Na-144
K-4.1 Cl-113* HCO3-22 AnGap-13
[**2123-5-27**] 04:01AM BLOOD Glucose-123* UreaN-11 Creat-0.9 Na-146*
K-3.7 Cl-115* HCO3-23 AnGap-12
[**2123-5-27**] 05:51PM BLOOD UreaN-11 Creat-0.8 Na-143 K-4.0 Cl-111*
[**2123-5-28**] 05:08AM BLOOD Glucose-93 UreaN-10 Creat-0.8 Na-142
K-4.2 Cl-109* HCO3-25 AnGap-12
[**2123-5-29**] 04:54AM BLOOD Glucose-123* UreaN-10 Creat-0.9 Na-143
K-3.5 Cl-108 HCO3-25 AnGap-14
[**2123-5-29**] 05:17PM BLOOD Glucose-113* UreaN-11 Creat-0.9 Na-145
K-3.8 Cl-107 HCO3-26 AnGap-16
[**2123-5-30**] 05:54AM BLOOD Glucose-101* UreaN-12 Creat-0.9 Na-145
K-3.9 Cl-106 HCO3-28 AnGap-15
[**2123-5-31**] 05:56AM BLOOD Glucose-110* UreaN-13 Creat-0.8 Na-144
K-3.8 Cl-104 HCO3-31 AnGap-13
[**2123-5-31**] 04:55PM BLOOD Glucose-98 UreaN-13 Creat-0.9 Na-145
K-4.8 Cl-104 HCO3-29 AnGap-17
[**2123-6-1**] 05:43AM BLOOD Glucose-118* UreaN-16 Creat-0.8 Na-145
K-4.6 Cl-105 HCO3-30 AnGap-15
[**2123-6-2**] 11:30AM BLOOD Glucose-97 UreaN-19 Creat-0.9 Na-141
K-5.1 Cl-101 HCO3-32 AnGap-13
[**2123-6-3**] 05:37AM BLOOD Glucose-94 UreaN-18 Creat-0.9 Na-141
K-4.9 Cl-101 HCO3-33* AnGap-12
[**2123-6-4**] 06:17AM BLOOD Glucose-78 UreaN-16 Creat-0.9 Na-140
K-4.9 Cl-100 HCO3-29 AnGap-16
[**2123-6-5**] 06:00AM BLOOD Glucose-114* UreaN-15 Creat-0.9 Na-140
K-4.3 Cl-99 HCO3-29 AnGap-16
[**2123-6-6**] 06:00AM BLOOD Glucose-98 UreaN-19 Creat-1.0 Na-136
K-4.3 Cl-98 HCO3-31 AnGap-11
[**2123-6-7**] 05:54AM BLOOD Glucose-107* UreaN-21* Creat-1.0 Na-141
K-4.2 Cl-103 HCO3-31 AnGap-11
Enzymes and Bilirubin:
[**2123-5-23**] 04:52AM BLOOD ALT-9 AST-18 AlkPhos-77 TotBili-0.2
[**2123-5-23**] 06:15AM BLOOD ALT-9 AST-20 AlkPhos-82 TotBili-0.2
[**2123-5-26**] 01:10AM BLOOD ALT-12 AST-18 LD(LDH)-328* AlkPhos-124*
TotBili-0.2
[**2123-6-1**] 05:43AM BLOOD LD(LDH)-611* TotBili-0.1 DirBili-0.1
IndBili-0.0
[**2123-6-2**] 11:30AM BLOOD LD(LDH)-599*
[**2123-6-3**] 05:37AM BLOOD LD(LDH)-533*
[**2123-6-4**] 06:17AM BLOOD LD(LDH)-497*
[**2123-6-5**] 06:00AM BLOOD LD(LDH)-482*
[**2123-6-6**] 06:00AM BLOOD LD(LDH)-453*
[**2123-6-7**] 05:54AM BLOOD LD(LDH)-423*
proBNP:
[**2123-5-21**] 11:50PM BLOOD cTropnT-<0.01 proBNP-2766*
[**2123-5-25**] 03:24AM BLOOD proBNP-[**Numeric Identifier **]*
Elements:
[**2123-5-21**] 11:50PM BLOOD Albumin-3.2* Calcium-8.5 Phos-4.3 Mg-1.8
[**2123-5-22**] 05:14AM BLOOD Calcium-7.6* Phos-2.9 Mg-1.5*
[**2123-5-22**] 02:05PM BLOOD Calcium-8.0* Phos-2.4* Mg-3.1*
[**2123-5-23**] 04:52AM BLOOD Calcium-7.0* Phos-1.9* Mg-2.0
[**2123-5-23**] 06:15AM BLOOD Calcium-7.4* Phos-2.0* Mg-2.0
[**2123-5-24**] 03:40AM BLOOD Calcium-7.6* Phos-1.7* Mg-1.8
[**2123-5-25**] 03:24AM BLOOD Calcium-8.3* Phos-3.4# Mg-2.3
[**2123-5-26**] 01:10AM BLOOD Calcium-8.1* Phos-3.1 Mg-2.0
[**2123-5-26**] 06:43PM BLOOD Calcium-8.3* Phos-3.0 Mg-2.0
[**2123-5-27**] 04:01AM BLOOD Calcium-8.0* Phos-3.0 Mg-2.0
[**2123-5-27**] 05:51PM BLOOD Mg-1.9
[**2123-5-29**] 05:17PM BLOOD Calcium-8.0* Phos-2.6* Mg-1.9
[**2123-5-30**] 05:54AM BLOOD Calcium-7.7* Phos-3.1 Mg-1.9 Iron-14*
[**2123-5-31**] 05:56AM BLOOD Calcium-8.3* Phos-2.6* Mg-2.0
[**2123-5-31**] 04:55PM BLOOD Calcium-8.2* Phos-3.0 Mg-1.9
[**2123-6-1**] 05:43AM BLOOD Calcium-8.3* Phos-3.1 Mg-2.2
[**2123-6-2**] 11:30AM BLOOD Calcium-8.1* Phos-3.4 Mg-2.0
[**2123-6-3**] 05:37AM BLOOD Calcium-8.8 Phos-3.8 Mg-2.0
[**2123-6-4**] 06:17AM BLOOD Calcium-8.5 Phos-3.6 Mg-1.9
[**2123-6-5**] 06:00AM BLOOD Calcium-8.6 Phos-2.9 Mg-2
[**2123-6-6**] 06:00AM BLOOD Calcium-8.4 Phos-2.9 Mg-2.1
[**2123-6-7**] 05:54AM BLOOD Calcium-8.8 Phos-2.8 Mg-2.1
Iron Studies:
[**2123-5-30**] 05:54AM BLOOD calTIBC-168* Ferritn-317* TRF-129*
[**2123-6-1**] 05:43AM BLOOD Hapto-530*
TSH:
[**2123-5-24**] 03:40AM BLOOD TSH-1.0
Cortisol:
[**2123-5-24**] 02:33PM BLOOD Cortsol-19.8
[**2123-5-24**] 03:10PM BLOOD Cortsol-36.3*
[**2123-5-25**] 03:24AM BLOOD Cortsol-32.6*
Vancomycin Troughs:
[**2123-5-24**] 03:40AM BLOOD Vanco-10.2
[**2123-5-25**] 07:06PM BLOOD Vanco-30.6*
[**2123-5-26**] 06:03AM BLOOD Vanco-25.0*
[**2123-5-26**] 06:43PM BLOOD Vanco-25.7*
[**2123-5-27**] 06:18AM BLOOD Vanco-23.5*
[**2123-5-27**] 05:51PM BLOOD Vanco-18.4
[**2123-5-29**] 04:54AM BLOOD Vanco-19.2
[**2123-5-30**] 05:54AM BLOOD Vanco-12.3
[**2123-5-31**] 11:46AM BLOOD Vanco-17.7
[**2123-6-1**] 10:50AM BLOOD Vanco-11.7
[**2123-6-3**] 12:44PM BLOOD Vanco-14.4
Microbiology:
Right Pleural Fluid ([**5-26**]): 4+ PMN, NGTD
Sputum Culture ([**5-22**]): MRSA heavy growth, Beta Streptococcus
heavy growth, sparse GNR
Blood cultures ([**5-25**], [**5-22**], [**5-21**]): NEGATIVE
Urine Culture ([**6-1**], [**5-25**], [**5-22**]): Negative
Urine Legionella ([**5-23**]): Negative
RRV Swab: Negative
Stool sample ([**6-6**]) C. Diff NEGATIVE
Imaging:
ECG Study Date of [**2123-5-31**] 7:56:42 AM
Moderate baseline artifact. Sinus tachycardia, rate 103, with
occasional
ventricular premature beats. Poor R wave progression. Low
voltage in the
standard leads. Non-specific ST-T wave changes. Compared to the
previous
tracing of [**2123-5-26**] the precordial voltage is much higher and the
ST-T wave
changes noted at that time are less prominent.
CXR ([**5-31**]):
As compared to the previous radiograph, there is a mild decrease
in lung volume. However, no typical signs of aspiration are
seen. Unchanged minimal bilateral areas of atelectasis,
persistent right upper lobe atelectasis and atelectatic
opacities in the retrocardiac lung areas. The
presence of minimal bilateral pleural effusions cannot be
excluded. No pulmonary edema. The monitoring and support devices
are unchanged, except for a newly placed left PICC line with a
tip projecting over the inferior SVC.
EKG: NSR at 91 bpm, NA, NI, no STTW changes with no baseline
comparison
CXR: ET tube 7cmm above carina, OG at GE junction, advance 10cm.
RIJ. RUL collapse. Perihilar infiltrates.
CXR ([**5-29**]):
There is a right IJ central venous catheter with distal lead tip
in the mid to proximal SVC. There is a nasogastric tube whose
tip and side port are well below the gastroesophageal junction.
There is an unchanged persistent left retrocardiac opacity.
There is increased opacity within the right upper lobe which may
be due to collapse.
CXR ([**5-28**]):
The tip of the nasogastric tube and side port are well below the
gastroesophageal junction. The tip is within the distal body.
Cardiac
silhouette is enlarged. There is some volume loss within the
right upper
lobe. This may represent atelectasis. There is a right IJ
central venous
catheter with distal lead tip in the distal SVC. The right lung
base is
clear. There is a left retrocardiac opacity.
CXR ([**5-27**]):
As compared to the previous radiograph, the monitoring and
support
devices, including the endotracheal tube are unchanged. The
opacities at the left lung base have minimally increased, the
presence of a minimal left pleural effusion cannot be excluded.
Otherwise, the radiograph is unchanged. The position of the
right pleural drain is constant.
CXR ([**5-26**]):
Uniform opacification in the right lower lung is probably severe
right lower lobe consolidation or atelectasis. Right upper lobe
remains collapsed and right pleural effusion is moderate to
large, increasing slowly over the past several days.
Heterogeneous consolidation has developed in the left lower lobe
since [**5-22**], probably a second region of pneumonia. ET tube is
in standard placement. Right jugular line ends in the mid to low
SVC. Nasogastric tube ends in the stomach. No pneumothorax.
TTE ([**5-26**]):
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
are normal. The left ventricular cavity is unusually small.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). There is no
ventricular septal defect. with depressed free wall
contractility. The diameters of aorta at the sinus, ascending
and arch levels are normal. There is no aortic valve stenosis.
No aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. There is moderate pulmonary artery systolic
hypertension. There is a small pericardial effusion. The
effusion is echo dense, consistent with blood, inflammation or
other cellular elements. There are no echocardiographic signs of
tamponade.
KUB ([**5-24**]):
Nasogastric tube not well seen, although it follows the expected
course, coiling over the expected location of the stomach on the
chest
radiograph from four minutes earlier.
Abdominal Xray ([**5-24**]):
No obstruction or ileus.
CXR ([**5-22**]):
In comparison with the earlier study of this date, the tip of
the
endotracheal tube lies at the mid clavicular level,
approximately 6 cm above the carina. Nasogastric tube extends
well into the stomach beyond the lower margin of the image.
There is continued opacification in the right upper zone
consistent with right upper lobe collapse. Patchy opacification
in the right mid and lower zones is again seen.
CXR ([**5-21**], day of admission):
IMPRESSION:
1. Complete right upper lobe collpase, raising question of
endobronchial plug or mass.
2. Perihilar right lung opacity could represent asymmetric edema
versus
pneumonia.
3. Enteric tube could be further advanced.
Brief Hospital Course:
A/P: 77 yo F with PMHx of L CVA BIBA from her nursing facility
for increasing respiratory distress now s/p intubation for
respiratory failure [**1-20**] aspiration PNA.
#Respiratory failure: The patient presented with fever and
hypoxic respiratory failure secondary to aspiration PNA. CXR
supportive of RLL/RML infiltrate as well as left retrocardiac
opacity which became apparent as the patient was diuresed and
has been stable. She was initially on Vanc/Zosyn for broad
coverage, which was switched to Vanc/[**Last Name (un) **] and then transitioned
to Vanc/Levo before ultimately being placed on Vanc for a 14 day
course in order to treat her MRSA PNA. The patient also had a
large right sided pleural effusion which progressed during her
initial hospital course and which was believed to be
contributing to her difficulty weaning off the vent. She
underwent a thoracentesis by IP, draining 1.4 L serous fluid,
and had a pigtail catheter placed which was pulled prior to
leaving the MICU. Pleural fluid showed 4+ PMNs without growth
and was negative for malignant cells, consistent with a
parapneumonic effusion. She was successfully extubated on
antibiotics and with aggressive diuresis, and her respiratory
status continued to improve, such that on discharge she was on
room air. Of note, the patient also has right upper lobe
collapse which may be old given history of lung Ca; the
patient's records regarding her prior chest CT should be
compared to see if there any evidence of change or progression
of this collapse.
#Hypotension: The patient's hypotension was likely [**1-20**] sepsis
from aspiration pneumonia. She initially given significant IVF
with good response, and was on pressors which were subsequently
weaned when the patient's blood pressure stabilized on
antibiotics and with discontinuation of sedation for mechanical
ventilation. Her home Atenolol, which was initially held, was
re-started prior to call-out from the MICU, and was continued
upon her discharge.
# NUTRITION: The patient had a Dobhoff placed for nutrition once
it became clear that she was aspirating her oral intake. She was
evaluated by speech and swallow team twice in hospital, and both
times was recommended to remain NPO. Given these findings, in
discussion with both the patient and the healthcare proxy, it
was agreed to go forward with a PEG tube placement, which the
patient underwent without complication on [**2123-6-3**]. The patient
should be monitored in the future for possible further trial of
S&S as she had had a PEG tube in the past, and her swallowing
has improved such that it could be removed.
#Elevated BNP: Patient's elevated BNP likely [**1-20**] volume
overload and acute CHF exacerbation given the significant volume
of IVF she received on initial presentation with sepsis. She
has been improving clinically and by CXR from a respiratory
standpoint with aggressive diuresis with IV Lasix. An ECHO
performed in house showed a normal LVEF, moderate pulmonary
artery systolic hypertension, as well as a small pericardial
effusion, which was echo dense, consistent with blood,
inflammation or other cellular elements. There was no
echocardiographic signs of tamponade. On discharge from the ICU,
she was noted to be 20 L positive secondary to fluid
resuscitation during sepsis; throughout her stay on the floor,
she continued to received 10 IV Lasix for diuresis. Upon
discharge, she went home with 40 mg PO Lasix, to be discontinued
at such time as her total body edema resolves. Upon her
discharge, her bicarbonate was noted to be trending up,
consistent with a metabolic alkalosis from contraction, which
should continue to be monitored.
#Rapid Heart Rate: The patient had an episode of HR 170's, and
then episodes of HR 140's-150's on telemetry concerning for SVT
vs afib, less likely sinus tachycardia vs accelerated junctional
rhythm. EKGs were only obtained with HR's in the 90's and one
EKG with HR 119, and these showed sinus tachycardia vs less
likely accelerated junctional rhythm, although somewhat
difficult to assess consistently due to low voltages. She was
started on Metoprolol with improved heart rates. She was
switched from Metoprolol to her home Atenolol prior to call-out
from the MICU and tolerated that well with HR in the 90's-100's.
Repeat EKGs on the floor and monitoring on telemetry continued
to show only sinus tachycardia, again improved with the home
dose of Atenolol.
#Anemia: Microcytic anemia has been stable in-house, unclear
baseline. No signs of active bleed, most likely marrow
suppression from critical illness vs antibiotics. Continued
home iron and trended hct in-house. On the floor, her HCT did
nadir as low as 21, for which she received 1 uPRBC transfusion,
with an appropriate bump in her HCT to 24. Her anemia should
continue to be monitored as an outpatient. Hemolysis labs were
negative, although the patient was noted to have an elevated
LDH. Her iron studies were consistent with an anemia of chronic
inflammation.
#Elevated LDH: The patient was noted to have elevated LDH at a
peak of 600 at one point during her hospitalization, trending
down to the 400s. Etiologies considered where inflammation and
cell turnover from her PNA, which was actually improving at the
time these labs were drawn. In addition, there was concern that
this elevation in LDH could represent recurrence of her small
cell lung cancer; her CT at Tuft's will need to be reviewed,
with consideration towards possible treatment/diagnosis of small
cell lung cancer.
#s/p stroke: Residual right hemiparesis. Continued home
simvastatin, plavix.
#Hypothyroidism: Continued home synthroid.
#Depression: Continued home mirtazapine.
# History of lung cancer: The patient was previously followed
for this at [**Hospital 3278**] Medical Center. Records obtained from that
institution documented small cell lung cancer of the right upper
lobe s/p cisplatin 4 cycles in [**2119**]. Question of recurrence
based on current CXRs, and reportedly had CT chest at [**Hospital1 3278**].
This will need to be followed as an outpatient.
Contact:[**Last Name (NamePattern4) **] in [**Name (NI) 9012**] ([**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
-proxy)[**Telephone/Fax (1) 103891**]
sister in law in [**Name (NI) 86**] ([**First Name8 (NamePattern2) **] [**Name (NI) 103892**]) [**Telephone/Fax (1) 103893**]
Code: full code confirmed
Medications on Admission:
-levothyroxine 50mcg daily
-albuterol/ipratropium prn
-bisacodyl 10 mg Rectal Suppository Rectal Once Daily prn
-Mapap (acetaminophen) 325 mg Tab Oral 2 Tablet(s) Every [**3-24**]
hrs, as needed
-loperamide 2 mg prn-mylanta prn
-simvastatin 20 mg Tab Oral 1 Tablet(s) Once Daily
-gabapentin 300 mg at bedtime
-omeprazole 40mg daily
-atenolol 25mg qday
-mvi
-plavix 75mg daily
-spiriva 18mcg IH daily
-iron 32mg dialy
-colace/senna
-mirtazapine 30mg qhs
-ultram 25mg q8h prn pain
Discharge Medications:
1. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. ipratropium bromide 0.02 % Solution Sig: One (1) inh
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
3. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
4. bisacodyl 10 mg Suppository Sig: One (1) suppository Rectal
once a day as needed for constipation.
5. Mapap (acetaminophen) 325 mg Tablet Sig: 1-2 Tablets PO every
4-6 hours as needed for pain.
6. loperamide 2 mg Capsule Sig: One (1) Capsule PO three times a
day as needed for diarrhea.
7. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
8. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
9. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
13. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
14. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours)
as needed for pain.
15. mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
16. senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
17. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
18. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) U
Injection every eight (8) hours.
Disp:**qs for 1 month * Refills:*0*
19. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] LivingCenter - Heathwood - [**Location (un) 55**]
Discharge Diagnosis:
Primary Diagnosis:
- MRSA Pneumonia
- Aspiration
Secondary Diagnosis:
- Stroke
- Hypertension
- Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Ms. [**Known lastname **],
It was a pleasure taking care of you in the hospital. You were
admitted to us from your nursing home because your were having a
hard time breathing. You were having such a hard time breathing
that you needed to come to our intensive care unit to have a
tube placed down your throat. We found a pneumonia which we
think was the reason you were having trouble breathing. This
pneumonia was likely the result of food and fluid which you were
swallowing going into the wrong tube and down your lungs; we
call this "aspiration." In the ICU, we placed a needle near your
lungs to help take off some fluid which had accumulated there.
We also were able to take the tube out of your throat, and you
breathed well on your own. We treated you for your pnuemonia
with antibiotics, and you got better. However, our speech and
swallow specialists saw you twice, and both times felt that it
was unsafe for you to continue to eat foods by mouth, because of
the risk of aspiration. For this reason, we placed a "PEG" tube,
which helps give you nutrition directly to your stomach.
When you leave the hospital:
- START Furosemide 40 mg Daily (continue to take this until your
body swelling improves)
- START heparin 5000 U subcutaneously every eight (8) hours
- STOP Gabapentin 300 mg at night (you did not require this
medication while in the hospital)
We did not make any other changes to your home medications, so
please continue to take them as you normally have been.
Followup Instructions:
Please have your nursing home make you an appointment with your
primary care doctor, Dr. [**Last Name (STitle) **], by calling [**Telephone/Fax (1) 10688**], within a
week of your discharge from the hospital.
Please have your nursing home contact your primary lung cancer
doctor as well to discuss the results of your CT Scan at [**Hospital1 3278**].
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,160
| 143,835
|
22352
|
Discharge summary
|
report
|
Admission Date: [**2169-8-19**] Discharge Date: [**2169-9-6**]
Date of Birth: [**2139-9-3**] Sex: M
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
decreased mental status, respiratory failure
Major Surgical or Invasive Procedure:
mechanical ventilation
History of Present Illness:
Mr. [**Known lastname **] is a 30 year old male found by side of road,
cyanotic, and brought to the Emergency Department in [**Hospital1 1562**] by
a passerby. When he reached the Emergency Department, the
patient was found to be apneic, intubated and started on
dopamine. His urine toxicology screen was positive for opiods,
cocaine, and benzodiazepines. Mr. [**Known lastname **] received narcan, D50,
NaHCO3 and clindamycin in the Emergency Room for possible
aspiration. At the time, his past medical history, social
history, and family history were unknown.
Labs on arrival to [**Hospital1 18**] showed a potassium of 6.0. and
creatinine of 2.4 down from 3.4 at outside hospital. He also had
elevated liver function tests and amylase and lipase.
Past Medical History:
noncontributory
Social History:
Lives with mother and sometime girlfriend. Used many
recreational drugs and alcohol. Mother is also a multisubstance
user. Works in landscaping and lives in [**Hospital1 1562**].
Family History:
noncontributory
Physical Exam:
T 99.5, HR 76, BP 128/78, O2 98% on 2 liters face mask
Gen: nonresponsive, comfortable looking
HEENT: c-spine collar in place, intubated, with copious oral
secretions
CV: RRR, no murmurs
Pulm: CTAB, no wheezes
Abd: soft, NT, ND, + BS
Ext: several tatoos, warm and well perfused, DT, PT, radial
pulses 2+ bilaterally, lower extremities areflexive, left upper
extremity with 1+ edema
Neuro: +gag, corneal reflex, vestobulocular reflex, PERRLA,
EOMI, roving gaze, upper extremities posture to noxious stimuli,
lower extremities withdraw to noxious stimuli, but at times do
not respond to noxious stimuli
Pertinent Results:
[**2169-8-19**] 06:46PM WBC-10.2# RBC-3.99*# HGB-13.2*# HCT-38.2*#
MCV-96 MCH-33.0* MCHC-34.5 RDW-12.8
[**2169-8-19**] 06:46PM NEUTS-79* BANDS-10* LYMPHS-8* MONOS-3 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2169-8-19**] 06:10PM TYPE-ART PO2-69* PCO2-56* PH-7.30* TOTAL
CO2-29 BASE XS-0
[**2169-8-19**] 05:46PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2169-8-19**] 05:46PM URINE bnzodzpn-POS barbitrt-NEG opiates-POS
cocaine-POS amphetmn-NEG mthdone-NEG
[**2169-8-19**] 05:30PM ALT(SGPT)-763* AST(SGOT)-930* LD(LDH)-1318*
CK(CPK)-8143* ALK PHOS-106 AMYLASE-314* TOT BILI-0.9
[**2169-8-19**] 05:30PM cTropnT-0.06*
[**2169-8-19**] 05:30PM CK-MB-171* MB INDX-2.1
[**2169-8-27**] 5:26 pm BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
FOREARM.
**FINAL REPORT [**2169-8-31**]**
BLOOD/FUNGAL CULTURE (Final [**2169-8-31**]):
DUE TO OVERGROWTH OF BACTERIA, UNABLE TO CONTINUE
MONITORING FOR
FUNGUS.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. FINAL
SENSITIVITIES.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. SECOND TYPE.
FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
| STAPHYLOCOCCUS,
COAGULASE NEGATIVE
| |
CLINDAMYCIN----------- =>8 R =>8 R
ERYTHROMYCIN---------- =>8 R =>8 R
GENTAMICIN------------ <=0.5 S <=0.5 S
LEVOFLOXACIN----------<=0.12 S <=0.12 S
OXACILLIN------------- =>4 R <=0.25 S
PENICILLIN------------ =>0.5 R =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ 2 S
BLOOD/AFB CULTURE (Final [**2169-8-30**]):
DUE TO OVERGROWTH OF BACTERIA, UNABLE TO CONTINUE
MONITORING FOR AFB.
TECHNIQUE: Portable Doppler ultrasonography was performed. No
studies are available for comparison.
There is focal thrombosis in the left internal jugular vein,
where there is noncompressibility of a short segment of the
internal jugular vein associated with visible intraluminal mass,
representing thrombus. The axillary vein demonstrates poor flow
but is patent and compressible. The brachial vein is normal. The
cephalic vein was not visualized.
IMPRESSION: Short segment non-occlusive thrombus left of
internal jugular vein.
The study and the report were reviewed by the staff radiologist.
MRI BRAIN WITHOUT CONTRAST: There is intense T2 signal
abnormality within the globus pallidus bilaterally. There is T2
prolongation seen diffusely within the deep white matter of both
cerebral hemispheres without mass effect. Additionally, there is
abnormal T2 signal within the [**Doctor Last Name 352**] matter of the hippocampus
bilaterally. These areas show abnormal signal on the diffusion-
weighted images, which is probably due to T2 shine-through (ADC
mapping is not available on the scanner on which this study was
performed). There is no evidence of intracranial hemorrhage.
Fluid levels are seen within both maxillary sinuses and
increased signal is seen within the ethmoid and sphenoid air
cells. A trace amount of increased signal is seen within the
right mastoids. These signal abnormalities in the sinuses are
consistent with fluid and mucosal thickening secondary to the
patient being intubated.
IMPRESSION: Findings consistent with diffuse anoxic brain
injury, likely subacute. No intracranial mass, hemorrhage, or
cerebral edema at this time.
EEG:
ABNORMALITY #1: The entired record consisted of moderate to
moderately
high voltage polymorphic delta and slow theta seen over all head
regions. No focality was noted. The pattern was fairly invarient
throughout the record.
BACKGROUND: The anterior-posterior voltage gradient was poorly
preserved. No normal waking rhythms were seen appropriate to
age. No
frank epileptiform discharges were seen.
HYPERVENTILATION: Not performed.
INTERMITTENT PHOTIC STIMULATION: Not performed.
SLEEP: Not obtained.
CARDIAC MONITOR: No arrhythmias noted.
IMPRESSION: Abnormal EEG, due to diffuse and continued slowing
throughout the record, suggestive of a moderate to moderately
severe
diffuse encephalopathy.
Brief Hospital Course:
Renal: [**Known firstname **] arrived with acute renal failure, as evidenced by
a creatinine of 3.4 and a very high CPK consistent with
rhabodmyolysis. To prophylax against further kidney damage, he
was aggressively hydrated and his creatinine soon returned to
his presumed baseline.
Neuro: [**Known firstname 58186**] history and physical exam were consistent with
severe anoxic brain injury. He then developed status epilepticus
which was diagnosed clinically when he had a 45 minute period of
total body rigidity followed by myotonic jerking of the upper
extremities. He responded to 30 mg valium and was loaded with
phenytoin. He was made therapeutic on phenytoin and discharged
on the medication.
ID: [**Known firstname **] developed an edematous left upper extremity soon
after a PICC line was placed. On ultrasound, a thrombus was
visualized in the left internal jugular vein. He was started on
heparin and titrated until therapeutic with a PTT ranging from
60-80. Within a day, he spiked a fever. He was pancultured and 3
out of 4 blood culture bottles grew out gram positive cocci in
clusters. Immediately, vancomycin was started. Soon after micro
data revealed that the organism was coagulase negative staph
sensitive to oxacillin. He was continued on the heparin IV and
his antibiotics were switched to oxacillin as treatment for his
septic thrombus. He was not transitioned to coumadin in since a
decision needed to made regarding CMO status or placement of a
tracheostomy and PEG tube. In either of these cases, the patient
should not be anticoagulated. Of note, [**Known firstname **] had been wearing
pneumoboots and receiving heparin SQ three times per day during
his whole course of hospitalization.
GI: The patient arrived with increased liver function tests,
likely the result of anoxia and possibly ingested/injected
toxins. The liver function tests trended down to normal values
over the first week that he was here.
Social: During her first visits during the first week of his
hospitalization, [**Known firstname 58186**] mother and fiance arrived and spent
the evenings with him. His mother appeared intoxicated and upon
further meetings with her, she was unable to voice understanding
of her son's condition and prognosis. She missed one family
meeting entirely and came to the second family accompanied by
friends who indicated that she had been drinking before the
meeting. The family meeting was attended by the intern, [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 2423**], the neurology team, headed up by Dr. [**Last Name (STitle) **], [**First Name3 (LF) 24606**]
Meinelt, social worker, [**Name (NI) **] [**Name (NI) 58187**], case manager, and
attending Dr. [**Last Name (STitle) **]. When it became apparent that [**Doctor First Name **] was
intoxicated again, it appeared that she would not be able to act
in [**Known firstname 58186**] best interest.
Proceedings to find an appropriate guardian were [**Name2 (NI) 16690**].
During the second week of [**Known firstname 58186**] hospitalization, [**Doctor First Name **] went
to a rehabilitation facility and thereafter was able to
participate in decision making since she was no longer
intoxicated when she came to visit the hospital. She voiced
understanding of his condition and prognosis. After a series of
conversations with her priest, her primary care physician, [**Name10 (NameIs) **]
this team, she agreed with the team's assessment of futility and
decided to withdraw life support. She stated that all of
[**Known firstname 58186**] friends have indicated that although he never discussed
this eventuality with them, he would never want to live in a
persistent vegetative state.
Medications on Admission:
none
Discharge Medications:
phenytoin PR PRN for seizures, to be discussed at the [**Hospital1 1501**]
ativan SL PRN for seizures, to be discussed at the [**Hospital1 1501**]
scopalamine
fentanyl patch
morphine drip
Discharge Disposition:
Extended Care
Facility:
[**Male First Name (un) 4542**] Nursing Center - [**Hospital1 1562**]
Discharge Diagnosis:
persistent vegetative state
septic thrombus
seizures
Discharge Condition:
poor
Discharge Instructions:
The phenytoin may be given PR and ativan sublingual as seizure
prophylaxis. Scopalamine and fentanyl patches are also new
medications. For agonal breathing, morphine via IV nitro drip
may be used and titrated for comfort.
Followup Instructions:
Please call Dr.[**Last Name (un) 58188**] office for a follow up.
|
[
"780.01",
"453.8",
"507.0",
"348.1",
"780.03",
"276.7",
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icd9cm
|
[
[
[]
]
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[
"96.6",
"38.91",
"38.93",
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icd9pcs
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[
[
[]
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10873, 10879
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2062, 6693
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1212, 1392
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,071
| 186,735
|
44111
|
Discharge summary
|
report
|
Admission Date: [**2123-6-8**] Discharge Date: [**2123-6-10**]
Date of Birth: [**2050-7-5**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 29055**]
Chief Complaint:
complete heart block
Major Surgical or Invasive Procedure:
[**6-9**]- placement of permanent pacemaker
History of Present Illness:
72 yo F w/ CAD s/p CABG and MV repair '[**22**], HTN, IDDM who
presented to [**Hospital **] Hospital in complete heart block. She
states she felt lousy for a few days beginning on Friday [**6-4**]
when she experienced sudden-onset head and neck pressure
described as "someone pushing down on her head trying to make it
go inside her neck". She had never experienced this type of
sensation before. The pain was constant, not associated with
exertion or time of day and she had no associated symptoms,
denying nausea/vomiting, chest discomfort or difficulty
breathing. She spoke to her daughter on the phone this morning
who was concerned about her symptoms, so drove in from RI to
take her to the hospital. Ms. [**Known lastname **] [**Last Name (Titles) **] having dizziness,
loss of consciousness or feeling palpitations. At [**Hospital **]
Hospital, her initial VS in ED were 98.8/ 39/ 24/ 123/84/ 100%
RA. In the ED, her EKG revealed complete heart block. She
underwent insertion of R-IJ temporary pacing wire placement and
was sent via Med Flight to [**Hospital1 18**] for further evaluation and
likely placement of permanent pacemaker. In the CCU, pt is
hemodynamically stable and only c/o neck pain at pacing wire
insertion site. All other ROS otherwise negative.
Past Medical History:
Atrial fibrillation, on beta blocker and Coumadin
Insulin dependent Diabetes
Hypertension
L-BRCA s/p LN removal (dx [**10-4**]) on Arimidex
3+ MR
hx stage II Hodgkin's lymphoma s/p CHOP x9 [**2117**]
hx gastric blood clots
s/p hysterectomy
s/p B/L TKRs
s/p L-lung abscess removal
s/p CABG x3 (LIMA-> LAD, rSVG-> OM1 of PDA) with MV repair
(#26-mm CG future annuloplasty ring) with Dr.[**Last Name (STitle) **] on [**2122-11-20**]
Social History:
Is widowed and lives alone in [**Hospital1 6930**], MA. Her daughter is very
involved in her care, but lives near [**Hospital1 789**], RI where she
owns a flower shop. Ms. [**Known lastname **] previously worked as an attendant
at a laundrymat. She has a 180 pack-year smoking hx (3 PPD x
60yrs) and [**Known lastname **] EtOH and IVDU.
Family History:
non-contributory
Physical Exam:
VS: afebrile, 70, 120/55, 89% RA
GEN: pleasant elderly F in NAD
HEENT: EOMI, PERRLA, no scleral icterus, R-IJ Cordis sheath in
place, w/ temporary pacing wire, JVP not elevated
CV: bradycardic rate, nl S1, S2 no appreciated murmur, midline
sternotomy scar
LUNGS: CTAB/L, no wheezes/rales appreciated
ABD: +BS soft NT ND
EXT: well-healed B/L mid-patellar scars, trace edema, 2+ distal
pulses DP and PT, 2+ radial pulses b/l
NEURO: A&Ox3, appropriate affect, good insight. no focal neuro
deficits.
Pertinent Results:
[**2123-6-8**] 07:39PM GLUCOSE-72 UREA N-62* CREAT-1.5* SODIUM-141
POTASSIUM-5.4* CHLORIDE-106 TOTAL CO2-26 ANION GAP-14
[**2123-6-8**] 07:39PM ALT(SGPT)-88* AST(SGOT)-61* ALK PHOS-109* TOT
BILI-0.3
[**2123-6-8**] 07:39PM MAGNESIUM-2.4
[**2123-6-8**] 07:39PM WBC-9.3 RBC-3.55* HGB-10.8* HCT-31.5* MCV-89
MCH-30.5 MCHC-34.4 RDW-15.6*
[**2123-6-8**] 07:39PM PLT COUNT-160
[**2123-6-8**] 07:39PM PT-22.8* PTT-34.4 INR(PT)-2.1*
[**2123-6-8**] CXR:
A right transjugular RV pacer lead follows the expected course
to the apex of the dilated right ventricle. No pneumothorax,
pleural effusion, or
mediastinal widening. Moderate cardiomegaly, status post
mediansternotomy,
valve replacement and coronary bypass grafting, unchanged.
Lateral aspect of the right lower chest is excluded from the
examination. Other pleural surfaces are normal.
[**2123-6-9**] TTE:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is mild regional left ventricular systolic
dysfunction with distal septal and basal infero-lateral
hypokinesis. There is no ventricular septal defect. The right
ventricular cavity is mildly dilated with borderline normal free
wall function. The ascending aorta is mildly dilated. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. There is severe mitral annular calcification. There is
mild functional mitral stenosis (mean gradient 5 mmHg) due to
mitral annular calcification. Mild (1+) mitral regurgitation is
seen. [Due to acoustic shadowing, the severity of mitral
regurgitation may be significantly UNDERestimated.] The
tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
[**2123-6-10**]: CHEST PA & LATERAL -The heart size is normal. Aorta is
tortuous. Mild pulmonary vascular congestion is noted. The
pacemaker device leads project in expected location of right
atrium and right ventricle. Patient is status post mitral valve
replacement. No focal consolidation, pneumothorax, or pleural
effusion is noted.
Brief Hospital Course:
Ms. [**Known lastname **] is a 72 year-old lady with known coronary artery
disease s/p CABG and MV annuloplasty who was transferred from
[**Hospital **] Hospital in complete heart block for placement of a
permanent pacemaker.
1. COMPLETE HEART BLOCK- Ms. [**Known lastname **] presented to [**Hospital **] Hospital
complaining of head and neck "pressure" and was found to be in
complete heart block on EKG. A R-IJ temporary pacing wire was
placed and she was transferred to [**Hospital1 18**] in stable condition. She
never became hypotensive during her course. The etiology of her
complete heart block was unclear but could be related to her
previous procedures (CABG and MV annuloplasty) which could cause
some myocardial scarring and ischemia to the SA and AV nodes, in
combination with changes in the myocardium from normal aging.
She was largely asymptomatic from heart block, so the chronicity
was unclear. She had a stat CXR upon arrival to CCU to confirm
placement of the temporary pacer, which was in the RV, and she
was pacing appropriately. The cardiology fellow tested her pacer
in the CCU and patient had echocardiogram done on [**6-9**]. Her TTE
revealed mild regional left ventricular systolic dysfunction
with distal septal and basal infero-lateral hypokinesis, mild MS
and MR. She had placement of permanent pacemaker on [**6-9**] which
she tolerated without complication. After the procedure, her
home coumadin, ACEi and beta blocker were restarted, but
metoprolol was decreased from 100mg [**Hospital1 **] to 50mg [**Hospital1 **]. She had a
Pa & Lateral CXR which showed appropriate placement of pacemaker
leads. She will follow-up in device clinic in one week on [**6-16**].
2. CAD- she is s/p CABG w/ Dr. [**Last Name (STitle) **] in 10/[**2122**]. She was
chest-pain free during her hospital course. Home aspirin and
statin were continued.
3. [**Name (NI) 12329**] pt remained normotensive in-house and did not have any
episodes of hypotension. After her pacemaker placement,
beta-blocker, ACEi, and home diuretics (lasix and
spironolactone) were reinstated.
4. IDDM- home insulin regimen- lantus 35 u QHS and novolog
sliding scale were continued in house.
5. BRCA-daily arimidex was continued in house.
Medications on Admission:
1. Simvastatin 10mg daily
2. Coumadin 10mg daily
3. Lasix 80mg qAM and 40mg qPM
4. Lisinopril 10mg daily
5. Metoprolol 100mg [**Hospital1 **]
6. Lantus 35 u QHS
7. Novolog sliding scale
8. Spironolactone 25 (?)mg daily
9. Arimidex 1mg daily
10. ASA 81 mg daily
11. Docusate 100mg [**Hospital1 **]
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Warfarin 5 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM.
5. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Furosemide 80 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
9. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) for 3 days.
Disp:*9 Capsule(s)* Refills:*0*
10. Insulin Glargine 100 unit/mL Cartridge Sig: Thirty Five (35)
units Subcutaneous at bedtime: 35 units lantus at bedtime.
11. Novolin N 100 unit/mL Suspension Sig: ASDIR Subcutaneous
ASDIR: as directed by home sliding scale .
12. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain.
Disp:*10 Tablet(s)* Refills:*0*
13. Anastrozole 1 mg Tablet Sig: One (1) Tablet PO daily ().
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY: complete heart block
SECONDARY: hypertension, diabetes, coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital in complete heart block, which
required the placement of a permanent pacemaker. You underwent
the procedure without complications. You will need to follow-up
with the EP (heart rhythm) doctors [**Last Name (NamePattern4) **] 1 week.
Your medications have CHANGED as follows:
1. We DECREASED your metoprolol from 100mg twice per day to 50mg
twice per day (this medicine is for heart rate and blood
pressure)
2. We ADDED cephalexin (keflex) an antibiotic you will need to
take for 3 days (last dose on [**6-12**]) to help prevent infection
from the procedure.
3. ADDED a few oxycodone tablets for pain relief if your chest
is hurting from the procedure. This will go away in time.
Please continue to take the rest of your medications as you have
been before.
Followup Instructions:
Please follow-up with your primary care doctor, Dr. [**Last Name (STitle) 911**] within
the next week or so. Her office phone # is [**Telephone/Fax (1) 59456**].
Please also follow-up with the EP (heart rhythm doctors) as
below:
DEVICE CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2123-6-16**] 1:00 PM
|
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icd9cm
|
[
[
[]
]
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[
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icd9pcs
|
[
[
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9170, 9176
|
5392, 7627
|
335, 381
|
9309, 9309
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3056, 5369
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10281, 10595
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409, 1680
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2151, 2489
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,232
| 157,495
|
39288
|
Discharge summary
|
report
|
Admission Date: [**2162-12-15**] Discharge Date: [**2162-12-23**]
Date of Birth: [**2095-6-15**] Sex: M
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 2758**]
Chief Complaint:
presyncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
67 yo male with hx of stage IV (T3 N1 M1b) squamous cell lung
cancer, factor V leiden with hx of DVT/PE, presents with syncope
at home. Pt states that he was getting up out of bed and
walking to the kitchen, when he suddenly felt lightheaded,
dizzy, vision became blurry, and he fell on the floor. He is
unsure if he lost consciousness. Next thing he knew, his wife
was at his side. His wife states that she does not think he lost
consciousness. Denies head injury. He states that he felt
confused for a few moments, and then normalized. No loss of
bowel/bladder. No tongue biting. No focal weakness, difficulty
with speech.
Pt notes that his vising nurse found that he was orthostatic
approx 1 week ago, with SBP drop to 70's with standing. He
states that he usually needs to take his time standing up, or
else he feels light headed.
Pt currently denies any neurologic complaints. No HA, vision
change.
Pt has chronic pain from his cancer, most notably R chest
wall/ribs; currently [**4-29**].
ROS:
+: as per HPI, plus: weight loss (218# [**Month (only) 205**], 165.8# currently).
Anorexia, malnutrition, 6 pillow orthopnea, chronic SOB, cough,
nausea intermittently, constipation, confusion on medications,
dizziness, easy bleeding/bruising.
Denies:
fever, chills/rigors, night sweats, photophobia, loss of vision,
sore throat,
palpitations, LE edema, PND, hemoptysis, vomiting, abdominal
pain, abdominal swelling, diarrhea, hematemesis, hematochezia,
melena, LAD, dysuria, rashes, myalgias, arthralgias, headache,
vertigo, paresthesias, weakness, depression.
Past Medical History:
Squamous cell carcinoma lung; stage IV T3 N1 M1b
- s/p 2 cycles of [**Doctor Last Name **]/gem [**7-/2162**]
- changed to docetaxel; hx reaction with rigors/flushing/sob
Rib pain from lung cancer invasion
DVT/PE with factor V Leiden
Anxiety
Malnutrition
Decubitus
ANTICOAGULANT LONG-TERM USE
Malignancy associated hypercalcemia
ATRIAL FLUTTER
FAMILY HISTORY DIABETES MELLITUS
ATRIAL FIBRILLATION
TRICUSPID VALVE INSUFFIC
DERMATITIS - STASIS, UNSPEC
HYPERCHOLESTEROLEMIA
VARICOSE VEINS
Social History:
60 pack year history tobacco; quit x 14 yrs. No alcohol x 22
yrs. Married. Previously worked as a glass [**Doctor Last Name **].
Family History:
Daughter died non-hodkin's lymphoma age 20
Father died complications COPD
Physical Exam:
Admission Exam:
VS: 98.6 100/60 75 20 96 RA 165.8 lbs
GEN: AAOx3. Pleasant, thin, appears frail, uncomfortable.
HEENT: eomi, perrl, MMM.
Neck: No LAD. JVP WNL.
RESP: scattered coarse BS throughout B. R chest wall swelling,
R axilla.
CV: RRR. No mrg.
ABD: +BS. Soft, NT/ND.
Ext: No CEE. Venous stasis skin changes LE B.
Neuro: CN 2-12 grossly intact.
Pertinent Results:
NOTABLE STUDIES:
[**2162-12-20**] 07:50AM BLOOD PT-29.8* INR(PT)-3.0*
[**2162-12-21**] 07:50AM BLOOD PT-38.0* INR(PT)-3.9*
[**2162-12-23**] 12:05PM BLOOD PT-32.8* INR(PT)-3.3*
[**2162-12-15**] CT HEAD W/O CONTRAST: No acute intracranial process.
Likely old infarcts in left frontoparietal regions.
[**2162-12-20**] CTA:
- TECHNIQUE: Contiguous helical acquisition through the chest
was performed with and without intravenous contrast. 2.5 and
5-mm axial in addition to sagittal, coronal, and oblique images
of the pulmonary arteries were created.
- FINDINGS: The heart is normal in size. There is moderate
atherosclerotic calcification of the coronary arteries and
aortic arch. There is no pericardial effusion. The aorta
opacifies normally without evidence of dissection. The pulmonary
arteries opacify normally without intrinsic filling defects to
suggest pulmonary embolism. There has been interval enlargement
of mediastinal and bilateral hilar lymphadenopathy, some of
which are centrally necrotic, measuring up to 2.2 cm in the
lower right paratracheal station, 1.4 cm in the right hilar
station, and 1.2 cm in the left hilar station. There is
deformity, narrowing and splaying of the right lower lobe
segmental pulmonary arteries which remain patent secondary to
external compression from bulky right hilar lymphadenopathy.
Secretions are noted within the airway at the level of the
carina in the bilateral main stem bronchi. There has been
interval enlargement of a 11.5cm x 8.4cm centrally necrotic mass
centered in the right chest wall and extending medially into the
right upper lobe with interval worsening of rib destruction
involving ribs three through six laterally on the right. The
mass previously measured 7.1 cm x 8.0 cm and has demonstrated
significant interval growth into the right subpectoral region.
There is encasement and irregular narrowing of the right middle
lobe bronchus with subsequent distal partial atelectasis which
is new. New centrilobular nodules, tree-in-[**Male First Name (un) 239**] opacities, and
foci of peribronchial consolidation, predominantly involve the
lower lobes and to a lesser extent within the lingula, which are
concerning for aspiration pneumonitis. Diffuse emphysema is
noted throughout the lungs. No pleural effusions are identified.
A sclerotic lesion is noted in the left clavicle, which is only
partially imaged, but present on prior PET study. Deformities
multiple ribs are likely post traumatic in nature, involving the
left posterior tenth and eleventhribs, left lateral fourth and
sixth ribs, in addition to the right lateral sixth rib. No
additional suspicious lytic or sclerotic lesions are noted
within the osseous structures. Multilevel degenerative changes
noted throughout the spine. Although this study was not designed
for subdiaphragmatic evaluation, images of the upper abdomen
demonstrate a stable-appearing hypodense right adrenal lesion
measuring 2.4 x 1.7 cm consistent with an adrenal adenoma. No
additional abnormalities are noted within the visualized upper
abdomen.
- IMPRESSION: 1. No evidence of pulmonary embolism. 2. Large
centrally necrotic right chest wall mass, with worsening rib
destruction and significant increase in size of the right
subpectoral component. Interval worsening of metastatic
mediastinal and hilar lymphadenopathy. 3. Centrilobular nodules,
tree-in-[**Male First Name (un) 239**] opacities and peribronchial consolidations
predominantly within the bilateral lower lobes. In light of
the distribution and coexisting central bronchial secretions,
these findings are most likely attributed to aspiration
pneumonitis. 4. Partially imaged sclerotic lesion within the
left clavicle, present on
prior PET CT, likely benign in nature given no FDG avidity was
seen
corresponding to this lesion. 5. Stable right adrenal nodule
consistent with an adrenal adenoma.
Brief Hospital Course:
Mr. [**Known lastname 185**] is a 67 M with a medical history notable for stage IV
squamous cell lung carcinoma and previous atrial fibrillation
requiring an ablation procedure. He was admitted with syncope.
This was ultimately thought to be secondary to poor PO intake
and atrial fibrillation.
On the second day of the admission he developed atrial
fibrillation with ventricular rates >150. He briefly required
admission to the MICU for a diltiazem drip to control his rates.
At these rates he was pre-syncopal and this was likely what
caused his presenting symptoms.
After control of the atrial fibrillation he was transferred to
the floor. He had a complicated course on the floor with issues
outlined below. Ultimately, a repeat CT scan of the chest
revealed that he was not responding to his chemotherapy and he
decided to be discharged home to hospice. See specific
management issues below.
1. Non-small cell lung cancer
- he did not have adequate pain control on his admission
Fentanyl patches due to a small amount of body fat; he was
discharged on long and short-acting morphine.
- he was also discharged on home oxygen
2. Atrial fibrillation
- as above. His rates were ultimately controlled with
long-acting diltiazem and atenolol. He occasionally had
hypotension when he would take these and not take adequate POs;
if this continues at home his atenolol could be changed to once
daily.
3. Aspiration pneumonia
- failed speech and swallow and placed on 7 days of
levofloxacin and Flagyl along with aspiration precautions
4. Concern for adrenal insufficiency
- while in the ICU he was hypotensive and was started on
empiric steroids for adrenal insufficiency as he has an adrenal
metastasis. A random cortisol was 3.7. It is hard to know if
this really represents adrenal failure butit likely does not. He
was rapidly tapered down to 5mg at discharge. Further testing
for his adrenal glands can be arranged given his goals of care.
5. Factor V Leiden deficiency
- the patient decided to continue on warfarin anticoagulation
for his hypercoagulable state. His last dose of warfarin was on
[**12-20**] (0.5mg). See Labs for recent INRs. Next INR to be drawn on
[**12-24**].
Given his goals of care, other non-essential medications were
discontinued including folic acid, daily multivitamin, and
Zometa. No tests were pending at discharge. He was discharged to
home with hospice services.
Medications on Admission:
oxycodone 10-15 mg po q prn pain
Fentanyl 100 mcg/hr TD q 48 hr
Trazodone 50mg as needed for insomnia
folic acid 1 mg po q day
Atenolol 25mg twice daily
warfarin 2mg daily
Ativan 1 mg po q6hr prn anxiety, nausea, or insomnia
Dexamethasone 4 mg po q 8hr prn nausea
Zofran 8 mg po q 8hr prn nausea
Compazine 10 mg po q6hr prn nausea
Colace 100 mg po q 12 hr
lactulose 30 ml po q 6hr prn constipation
Albuterol inhaler as needed
Multivitamin 1 tab po q day
Fluticasone 110 mcg 2 puffs [**Hospital1 **]
Megace 1 TSP q am
Zometa; next dose 3 weeks
Magic mouthwash
Nystatin mouthwash
Discharge Medications:
1. morphine 30 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO Q12H (every 12 hours).
Disp:*120 Tablet Sustained Release(s)* Refills:*0*
2. morphine 15 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for breakthrough pain.
Disp:*30 Tablet(s)* Refills:*0*
3. morphine concentrate 20 mg/mL Solution Sig: 5-20 mg PO every
four (4) hours as needed for pain.
Disp:*30 cc* Refills:*0*
4. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
5. atenolol 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day).
6. warfarin Oral
7. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO every six (6) hours
as needed for anxiety.
Disp:*60 Tablet(s)* Refills:*0*
8. Zofran 8 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for nausea.
9. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
every six (6) hours as needed for nausea.
10. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
11. lactulose 10 gram/15 mL Solution Sig: Fifteen (15) mL PO
once a day as needed for constipation.
12. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for
shortness of breath or wheezing.
Disp:*1 inhaler* Refills:*5*
13. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 inhaler* Refills:*2*
14. megestrol 400 mg/10 mL (40 mg/mL) Suspension Sig: Forty (40)
mg PO QID (4 times a day).
15. Maalox/Diphenhydramine/Lidocaine Sig: 15-30 cc four
times a day as needed for mouth pain.
16. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: Three (3) cc Inhalation Q2H (every 2 hours) as
needed for SOB. cc
17. prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day for
3 days.
Disp:*3 Tablet(s)* Refills:*0*
18. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 5 days.
Disp:*15 Tablet(s)* Refills:*0*
19. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
20. diltiazem HCl 180 mg Tablet Sustained Release 24 hr Sig: One
(1) Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] hospice care
Discharge Diagnosis:
Syncope
Non-small cell lung cancer
Atrial fibrillation
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Breathing comfortably at rest on 3 liters by nasal cannula.
Discharge Instructions:
Dear Mr. [**Known lastname 185**],
You were admitted with syncope (passing out). We think this was
from atrial fibrillation resulting in a fast heart rate and
dehydration after your chemotherapy. Unfortunately, it appears
your cancer has not responded to your chemotherapy and we have
arranged for you to have hospice services at home to treat your
cancer-related pain and shortness of breath. You also developed
a pneumonia while in the hospital and we are recommending 5 more
days of antibiotics and a thickened diet to prevent aspiration.
We made the following changes to your medications:
- change Fentanyl and oxycodone to Morphine long-acting and
short-acting for pain control
- stop folic acid and multivitamin
- decrease atenolol to 12.5mg twice daily
- discuss if you want to continue your warfarin with your
hospice service; your INR is still high and you do not need any
warfarin until at least Friday, [**12-24**]
- stop Zometa
- start Flagyl and levofloxacin to treat your pneumonia for 5
more days
- start diltiazem to help control your heart rate
- continue prednisone for 3 more days and then stop
Followup Instructions:
Your hospice team will meet you at home today at 2pm.
|
[
"300.00",
"289.81",
"V15.82",
"682.3",
"459.81",
"507.0",
"880.13",
"E888.8",
"198.5",
"V85.1",
"V12.51",
"454.9",
"E933.1",
"285.3",
"V58.61",
"338.3",
"707.23",
"276.51",
"198.89",
"920",
"427.31",
"780.2",
"262",
"707.03",
"255.41",
"780.52",
"196.1",
"427.32",
"272.0",
"424.2",
"275.42",
"V58.69",
"162.8"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12212, 12271
|
6932, 9342
|
281, 288
|
12370, 12370
|
3039, 6909
|
13763, 13820
|
2569, 2645
|
9970, 12189
|
12292, 12349
|
9368, 9947
|
12615, 13181
|
2660, 3020
|
13211, 13740
|
231, 243
|
316, 1891
|
12385, 12591
|
1913, 2404
|
2420, 2553
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,635
| 180,673
|
26752
|
Discharge summary
|
report
|
Admission Date: [**2165-5-14**] Discharge Date: [**2165-6-10**]
Date of Birth: [**2140-10-22**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
[**2165-5-14**] Exploratory Lap; closed sigmoid colostomy; closed small
bowel fistula
History of Present Illness:
24 yo male who was involved in a Motor vehicle crash last
[**Month (only) **] sustaining multiple orthopedic injuries and bowel
injury. Returned to hospital with increasing abdominal pain.
Past Medical History:
seasonal allergies
asthma
s/p Motor Vehicle Crash
[**2164-12-23**]: ex-lap, sigmoid colectomy, L popliteal vein primary
repair. L AK-[**Doctor Last Name **]/PT [**Name (NI) 65897**] graft, ORIF R knee dislocation, ex-fix L
knee and ankle
[**2164-12-25**]: L AKA, IVC filter placement
[**2164-12-28**]: T10-L3 instrumented fusion, component separation/abd
closure with Marlex mesh
[**2165-1-2**]: L ureteroureteral anastomosis and repair of transected
L ureter, L ureteral stent placement
[**2165-1-16**]: ORIF R tibia pilon fx
[**2165-2-12**]: Ex-lap/LOA, removal of Marlex mesh, closure of abd wall
with Vicryl mesh
[**2165-3-5**]: removal L ureteral stent
[**2165-5-15**] Fistula takedown
Social History:
+ETOH
Family History:
Non-contributory
Pertinent Results:
[**2165-5-14**] 06:00AM GLUCOSE-105 UREA N-18 CREAT-0.7 SODIUM-139
POTASSIUM-4.7 CHLORIDE-101 TOTAL CO2-25 ANION GAP-18
[**2165-5-14**] 06:00AM ALT(SGPT)-98* AST(SGOT)-32 LD(LDH)-174 ALK
PHOS-564* AMYLASE-21 TOT BILI-1.7*
[**2165-5-14**] 06:00AM LIPASE-14
[**2165-5-14**] 06:00AM ALBUMIN-3.7 CALCIUM-9.6 PHOSPHATE-5.1*#
MAGNESIUM-1.7
[**2165-5-14**] 06:00AM WBC-9.0 RBC-5.14 HGB-14.8 HCT-44.9 MCV-87
MCH-28.7 MCHC-32.9 RDW-18.2*
[**2165-5-14**] 06:00AM PLT COUNT-322
CHEST (PORTABLE AP) [**2165-5-23**] 1:38 PM
CHEST (PORTABLE AP)
Reason: picc placement
[**Hospital 93**] MEDICAL CONDITION:
REASON FOR THIS EXAMINATION:
picc placement
CHEST
HISTORY: PICC placement.
COMPARISON: [**2165-5-20**].
Compared to the prior study right IJ line has been removed. Tip
of a right-sided PICC line is in the proximal SVC. NG tube has
been removed. There has been improved aeration of both lower
lobes with partial resolution of the lower lobe opacities, more
pronounced on the left than on the right.
IMPRESSION: Improving bilateral lower lobe opacities. Tip of the
PICC line is in the proximal SVC.
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 65898**],[**Known firstname **] J [**2140-10-22**] 24 Male [**Numeric Identifier 65899**]
[**Numeric Identifier 65900**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/dif
SPECIMEN SUBMITTED: ABDOMINAL MESH, APPENDIX, SMALL BOWEL
FISTULA, SMALL BOWEL SEGMENT, SIGMOID COLON, GALLBLADDER.
Procedure date Tissue received Report Date Diagnosed
by
[**2165-5-15**] [**2165-5-16**] [**2165-5-22**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 18795**]/vf
Previous biopsies: [**Numeric Identifier 65901**] MESH.
[**-6/4242**] L. AKA & URETER.
[**-6/4202**] SIGMOID COLON.
DIAGNOSIS:
I. Abdominal mesh (A-B):
1. Skin with ulceration, hypertrophic scar, and acute and
chronic inflammation.
2. Soft tissue with fat necrosis, fibrosis, and foreign body
giant cell reaction consistent with prior procedure site.
II. Appendix, appendectomy (C-D):
Appendix:
No diagnostic abnormalities recognized.
III. Small bowel fistula, resection (E-H):
Extensive serosal and muscularis propria chronic inflammation,
foreign body giant cell reaction, fibrosis, and adhesions, with
kinking of the bowel wall and focal mucosal/mural ulceration.
No ischemic infarction identified.
IV. Small bowel; resection (I-J):
Small bowel segment:
Unremarkable except for extensive serosal adhesions.
V. Sigmoid colon, section (K-L):
Colonic segment with focal ulceration and granulation tissue at
one resection margin. There are also scattered crypt abscesses
within the specimen, and areas of ischemic damage of the
muscularis propria.
VI. Gallbladder, cholecystectomy (M-N):
Chronic cholecystitis.
Clinical: Small bowel obstruction. S/P MVA with multiple
traumas.
Gross:
The specimen is received fresh in six parts, all labeled with
"[**Known lastname 1001**], [**Known firstname **]" and the medical record number.
Part 1 is additionally labeled "abdominal mesh" and consists of
a 25 cm in length piece of skin with underlying soft tissue.
Within this skin are embedded pieces of synthetic material which
appear confluent with a recently healed skin wound. The
synthetic material is excluded from the specimen and the
specimen is represented in A-B.
Part 2 is additionally labeled "appendix" and consists of a 7 cm
in length appendectomy specimen with a 0.8 cm proximal staple
line. The serosa appears smooth and a small fragment of
meso-appendix is included with the specimen. It is opened to
reveal yellow liquid material that is serous in nature and an
unremarkable pink mucosa. The specimen is represented as
follows: C = proximal appendix cross sectional and longitudinal
sections, D = appendiceal tip.
Part 3 is additionally labeled "small bowel fistula" and
consists of a segment of small bowel measuring 31 cm in length
with a stapled end measuring 3.0 cm. There is an area in which
the bowel kinks upon itself measuring 5.0 x 3.4 cm. This area
is located 4.7 cm from one of the stapled ends. There is a
markedly erythematous area with a fibrous rim adjacent to this
kink. The mucosa appears edematous and erythematous; however,
it retains the normal folds of the small bowel. The specimen is
represented as follows: E = specimen ends, F = representative
sections of unremarkable small bowel, G-H = sections through
area of fibrous tissue with erythematous mucosal surface.
Part 4 is additionally labeled "small bowel" and consists of a
segment of small bowel measuring 7 cm in length and an average
of 3.3 cm diameter with two stapled ends. The serosa has
multiple attached adhesions and is otherwise smooth without
exudate or hemorrhage. The specimen is opened to reveal grossly
unremarkable mucosa with normal mucosal folds. The specimen is
represented as follows: I = ends of small bowel segment, J =
representative small bowel sections.
Part 5 is additionally labeled "sigmoid" and consists of a 1.9
cm in length segment of large bowel measuring 3 cm in diameter.
The specimen is opened to reveal largely unremarkable mucosa
with normal folds and no intraluminal masses or abnormalities.
The specimen is represented as follows: K = specimen ends, L =
representative sections of large bowel.
Part 6 is additionally labeled "gallbladder" and consists of a
cholecystectomy specimen measuring 11.2 cm in length and a
maximum of 2.7 cm in greatest diameter. The specimen is opened
to reveal a smooth, tan mucosal surface without stones, polyps,
or masses. The specimen is represented as follows: M = sections
of proximal gallbladder adjacent to cystic duct, N = sections of
gallbladder from fundus and body.
CT ABDOMEN W/CONTRAST [**2165-5-14**] 12:06 AM
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
Reason: MULTIPLE SURGERY WITH NEW PAIN
Field of view: 36 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
24 year old man with multiple abd surgeries here with abd pain
and vomiting
REASON FOR THIS EXAMINATION:
eval for SBO, other acute pathology
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 24-year-old male with multiple abdominal surgeries
with abdominal pain and vomiting. Evaluate for small-bowel
obstruction.
COMPARISON: [**2165-3-12**].
TECHNIQUE: MDCT-acquired axial images of the abdomen and pelvis
were performed with IV contrast. Multiplanar reformations were
obtained.
CT ABDOMEN WITH IV CONTRAST: Bibasilar atelectasis. The liver,
pancreas, spleen, gallbladder, adrenal glands, kidneys are
unremarkable. The patient has IVC filter in place. There are
multiple distended loops of small bowel with air fluid levels
with likely transition point seen within the mid abdomen on
series 2, image 55. Findings are consistent with small bowel
obstruction. Small amount of free fluid is seen tracking into
the pelvis.
Again noted within the abdominal aorta is a thin soft tissue
density sliver, unchanged compared to prior study. The
previously seen left external iliac and left common femoral deep
venous thrombosis is not visualized well secondary to bolus
timing.
No definite fistulous tract is identified.
CT PELVIS: The urinary bladder, prostate, rectum are
unremarkable. Small amount of fluid is seen within the pelvis.
BONE WINDOWS: Metallic hardware is seen within the lumbar spine,
unchanged compared to prior study. No suspicious lytic or
sclerotic bony lesions. Bone graft harvest site is again noted
within the right ileum.
IMPRESSION:
1. Dilated loops of small bowel with transition point seen
within the mid abdomen with collapsed loops of small bowel
distally. Findings consistent with small bowel obstruction.
2. No definite fistulous tract.
LIVER OR GALLBLADDER US (SINGLE ORGAN) [**2165-5-14**] 8:50 PM
LIVER OR GALLBLADDER US (SINGL
Reason: ELEVATED LFTS PLEASE EVAL FOR BILIARY OBSTRUCTION
[**Hospital 93**] MEDICAL CONDITION:
24 year old man with elevated LFT
REASON FOR THIS EXAMINATION:
please eval for biliary obstruction
INDICATION: 24-year-old male with elevated LFTs.
COMPARISONS: CT abdomen dated [**2165-5-14**], at 058 hours.
LIMITED RIGHT UPPER QUADRANT ULTRASOUND: The liver is normal in
echotexture without focal mass or intrahepatic ductal
dilatation. The gallbladder contains echogenic layering material
in its dependent portion consistent with sludge. There is no
gallbladder wall edema or adjacent pericholecystic fluid to
suggest acute cholecystitis. There is no perihepatic ascites.
Limited views of the right kidney demonstrate no hydronephrosis.
IMPRESSION:
1. Tumefactive sludge within the gallbladder without evidence of
acute cholecystitis.
2. No evidence of ascites or focal hepatic mass.
Brief Hospital Course:
Patient admitted under the Trauma Service. He was taken to the
operating room on [**5-15**] for takedown of his fistula. A VAC
dressing was placed and continues; he will need the next change
on this Thursday [**2165-6-13**]. An appointment with Dr. [**Last Name (STitle) 519**] will need
to be made for this Monday [**2165-6-17**] for a wound check and VAC
sressing change. He was followed closely by the wound specialist
nurses during his stay for his many skin issues.
He was followed closely by Nutrition; his tube feedings were
stopped during this hospital stay. He is taking in po's now;
initially did not do well with his intake. His calorie counts
and weights were followed closely, he has actually gained weight
and was 135# today. He was started on Ritalin for appetite
stimulation which has seemed to help. He is also on Boost
supplements.
Orthopedics did also see patient during his stay here and he
will follow up with Dr. [**Last Name (STitle) 1005**] in one month for his right
ankle.
He was followed by Physical and Occupational therapy during his
hospital stay.
Discharge Medications:
1. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous
once a day.
2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for wheeze.
4. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**2-4**]
Drops Ophthalmic QID (4 times a day).
6. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to
6 hours) as needed for anxiety.
9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
12. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for insomnia.
13. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for back pain.
14. Methylphenidate 5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day): Give at 8am & 12 noon.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Small bowel obstruction
Enterocutaneous fistula
Wound infection
Discharge Condition:
Stable
Discharge Instructions:
Continue VAC dressing changes as ordered.
Calorie counts
Weights [**3-8**] x/week
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 519**] in the next Monday [**6-17**] call
[**Telephone/Fax (1) 6554**].
Follow up with Dr. [**Last Name (STitle) 1005**], Orthopedics in 1 month, call
[**Telephone/Fax (1) 1228**] for an appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2165-6-10**]
|
[
"V02.59",
"569.69",
"493.90",
"V49.76",
"718.56",
"E928.9",
"552.21",
"568.0",
"918.1",
"569.81",
"276.52",
"575.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.94",
"86.28",
"93.26",
"96.08",
"45.62",
"53.61",
"46.52",
"99.15",
"99.04",
"47.09",
"99.07",
"46.74",
"51.22",
"54.59",
"93.59"
] |
icd9pcs
|
[
[
[]
]
] |
12820, 12890
|
10307, 11389
|
330, 418
|
12998, 13007
|
1428, 1999
|
13139, 13540
|
1391, 1409
|
11412, 12797
|
9492, 9526
|
12911, 12977
|
13031, 13116
|
276, 292
|
9555, 10284
|
446, 636
|
658, 1351
|
1367, 1375
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,378
| 172,447
|
38758
|
Discharge summary
|
report
|
Admission Date: [**2188-5-18**] Discharge Date: [**2188-5-28**]
Date of Birth: [**2106-7-16**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2291**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Thoracentesis [**2188-5-23**]
Bronchoscopy [**2188-5-26**]
History of Present Illness:
This is an 81 year old lady with hx COPD, CABG-AVR ([**2-18**]),
atrial fibrillation, hypertension and hyperlipidemia who
presents with progressive shortness of breath and cough.
She reports the symptoms of shortness of breath are chronic and
have been worsening for the past year exacerbated by a
protracted hospital course in [**Month (only) 958**] for a CABG-AVR. The
symptoms over the weekend have worsened and today, she called
her daughter who encouraged her to go to the emergency
department for evaluation. She denies fevers, chills, nausea,
vomiting, GI sx, chest pain. She reports her symptoms are not
easily improved with home nebulyzer therapy. She denies sick
contacts and reports discharge from rehab in late [**Month (only) 958**]. She has
not been hospitalized or received antibiotics since that time.
She has no contact with small children or recent travel. Lives
alone. No h/o blood clots or cancer history. Quit smoking 15-20
years ago. She was given azithromycin 1 month prior for
management of her shortness of breath and experienced no
improvement. She is on hme oxygen which initially was for just
at night but she uses continuously. Unclear oxygen requirement.
She sleeps with 2 pills, unable to lie flat. Denies lower
extremity swelling.
In the ED, initial VS were: 80 153/71 40 69%. Initial labs
were significant for wbc Na 129, Hc03 33, cr 0.6, lactate 1.4
and troponin < 0.01. A CXR demonstrated an extensive right
infrahilar opacity and a patchy retrocardiac opacity that was
concerning for pneumonia in addition to mild vascular
congestion. An EKG showed afib at 89 w/ lateral ST depressions.
For her tachypnea, the patient was given albuterol and
ipratropium nebulyzer therapy x 2 in addition to 125 mg IV
methylprednisone. For her possible pneumonia she was started on
vancomycin and levofloxacin. Given her worsening exam and
persistent tachypnea, a trial of biPAP was started which the
patient ultimately did not tolerate and refused. Transfer to
the medical ICU was initiated when the patient did not improve
with initial medical therapy. Vitals on tranfer were: Vitals 100
156/100 34 100% on 4L.
On arrival to the MICU, initial vitals were: 110 158/93 19 95%
on 2L NC. She was comfortable and reported her breathing was
improved since being in the emergency department.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain, chest pressure, palpitations, or
weakness. Denies nausea, vomiting, diarrhea, constipation,
abdominal pain, or changes in bowel habits. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
Hyperlipidemia
Hypertension
COPD
Osteopenia
Pulmonary Nodule
Transaminitis
Atypical Chest Pain
Diverticulosis
Aortic Valve Stenosis: AVR/single vz CABG (SVG-OM) by Dr. [**Last Name (STitle) **]
[**Name (STitle) 86083**] on [**2188-2-14**]
CABG
Primary Open Angle Glaucoma
Multifocal Atrial Tachycardia
Transient Ischemic Attack: (s/p TPA @ NWH [**2187-12-4**] after
presenting with RLE weakness
Carotid Stenosis: (50-69% [**Country **] and [**Doctor First Name 3098**] stenoses)
Seizure History
Atrial Fibrillation
Social History:
- Tobacco: quit > 15 years ago
- Alcohol: glass of wine in the evening
- Illicits: no
- housing: lives alone, close with adaughter who live nearby
- employment; formerly worked in travel
Family History:
NC
Physical Exam:
Admission:
Vitals: 110 158/93 19 95% on 2L
General: Alert, oriented, breathing through pursed lips.
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI
Neck: supple, JVP not elevated, no LAD
CV: irregular rate and rhythm. systolic ejection murmur.
Lungs: inspiratory and expiratory wheeze with prolongued
expiratory phase. no crackles.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact
Discharge:
VS: 98-98.6, 100-138/50-79, 60-93, 98-100% 2L O2
GENERAL- Alert, oriented x 3, lying comfortable in no acute
distress
HEENT: sclera anicteric, PERRLA, EOMI, MMM, OP clear
THORAX- Decreased breath sounds with scattered bibasilar
rhonchi. No wheezes or rales.
CV- irregularly irregular rhythm with regular rate, normal S1
and loud S2 with some irregular splitting. No rubs, gallops. No
JVD
ABDOMEN- Soft, non-tender, non-distended w/ normoactive bowel
sounds, no organomegaly
MS- No evidence of swelling or deformity. Good ROM present
EXT- WWP, 2+ pulses in DP bilaterally. No clubbing, cyanosis or
edema
SKIN- Few ecchymoses noted bilaterally on leg. No ulcers,
lesions
NEURO- CNs2-12 grossly intact but decreased hearing to finger
rub
Pertinent Results:
[**2188-5-18**] 06:50PM GLUCOSE-122* UREA N-13 CREAT-0.5 SODIUM-129*
POTASSIUM-3.8 CHLORIDE-88* TOTAL CO2-33* ANION GAP-12
[**2188-5-18**] 06:50PM CALCIUM-9.0 PHOSPHATE-3.4 MAGNESIUM-1.7
[**2188-5-18**] 06:00PM LACTATE-1.4
[**2188-5-18**] 05:50PM cTropnT-<0.01
[**2188-5-18**] 05:50PM WBC-9.0 RBC-4.34 HGB-12.8 HCT-39.2 MCV-90
MCH-29.5 MCHC-32.7 RDW-13.6
[**2188-5-18**] 05:50PM NEUTS-79.5* LYMPHS-13.9* MONOS-4.4 EOS-1.5
BASOS-0.7
[**2188-5-18**] 05:50PM PLT COUNT-294
[**2188-5-18**] 05:50PM PT-48.7* PTT-42.4* INR(PT)-4.8*
[**2188-5-26**] 07:30AM BLOOD WBC-6.2 RBC-4.11* Hgb-12.0 Hct-36.9
MCV-90 MCH-29.1 MCHC-32.5 RDW-13.7 Plt Ct-198
[**2188-5-25**] 06:30AM BLOOD PT-18.9* PTT-30.4 INR(PT)-1.8*
[**2188-5-26**] 07:30AM BLOOD PT-16.2* PTT-31.6 INR(PT)-1.5*
[**2188-5-27**] 07:35AM BLOOD PT-16.9* INR(PT)-1.6*
[**2188-5-28**] 07:30AM BLOOD PT-26.0* INR(PT)-2.5*
[**2188-5-26**] 07:30AM BLOOD Glucose-83 UreaN-11 Creat-0.5 Na-134
K-4.1 Cl-93* HCO3-36* AnGap-9
[**2188-5-22**] 03:20PM BLOOD LD(LDH)-261*
[**2188-5-24**] 06:20AM BLOOD proBNP-2627*
[**2188-5-18**] 05:50PM BLOOD cTropnT-<0.01
[**2188-5-26**] 07:30AM BLOOD Calcium-8.5 Phos-2.9 Mg-2.0
[**2188-5-19**] 05:43AM BLOOD Osmolal-269*
[**2188-5-21**] 03:47PM BLOOD Type-ART pO2-87 pCO2-55* pH-7.47*
calTCO2-41* Base XS-13
[**2188-5-18**] 06:00PM BLOOD Lactate-1.4
[**2188-5-21**] 06:41PM URINE Hours-RANDOM Na-71 K-47 Cl-52
[**2188-5-23**] 04:30PM PLEURAL WBC-1800* RBC-1050* Polys-14*
Lymphs-39* Monos-4* Meso-6* Macro-37*
[**2188-5-23**] 04:30PM PLEURAL TotProt-2.5 Glucose-149 LD(LDH)-115
Amylase-11 Albumin-1.5 Cholest-56 Triglyc-9
[**2188-5-26**] 02:55PM OTHER BODY FLUID Polys-96* Lymphs-3* Monos-0
Macro-1*
Micro:
[**2188-5-26**] 2:50 pm BRONCHIAL WASHINGS BRONCHIAL WASH.
GRAM STAIN (Final [**2188-5-26**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Final [**2188-5-28**]):
Commensal Respiratory Flora Absent.
STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML..
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2188-5-27**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
[**2188-5-26**] 2:55 pm BRONCHOALVEOLAR LAVAGE RIGHT MIDDLE LOBE.
GRAM STAIN (Final [**2188-5-26**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Final [**2188-5-28**]):
Commensal Respiratory Flora Absent.
STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML..
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2188-5-26**]):
Test cancelled by laboratory.
PATIENT CREDITED.
This is a low yield procedure based on our in-house
studies.
if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (7-2306).
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2188-5-27**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
[**2188-5-23**] 3:28 pm PLEURAL FLUID
GRAM STAIN (Final [**2188-5-23**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2188-5-26**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
[**2188-5-20**] 6:00 am URINE Source: Catheter.
**FINAL REPORT [**2188-5-20**]**
Legionella Urinary Antigen (Final [**2188-5-20**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
[**2188-5-22**] 4:38 pm SPUTUM Source: Expectorated.
**FINAL REPORT [**2188-5-22**]**
GRAM STAIN (Final [**2188-5-22**]):
<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 [**2188-5-22**]):
TEST CANCELLED, PATIENT CREDITED.
[**2188-5-19**] 9:30 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2188-5-21**]**
MRSA SCREEN (Final [**2188-5-21**]): No MRSA isolated.
Blood cultures negative x2
Reports:
ECG Study Date of [**2188-5-18**] 5:48:38 PM
Atrial fibrillation with a controlled ventricular response.
Baseline artifact. Anteroseptal myocardial infarction of
indeterminate age. Compared to the previous tracing of [**2186-4-19**],
atrial fibrillation has replaced sinus rhythm. Otherwise, no
diagnostic interim change.
CHEST (PORTABLE AP) Study Date of [**2188-5-18**] 6:00 PM
FINDINGS: The patient is status post coronary artery bypass
graft surgery. The heart appears likely at the upper limits of
normal size although not optimally assessed. The mediastinal
contours are unremarkable. There is a confluent right
infrahilar opacity in the right lower lung with Kerley B lines
and blunting of the right cardiophrenic angle, quite asymmetric.
Patchy retrocardiac opacity is less specific but an additional
focus of pneumonia could be considered versus atelectasis.
There is mild background perihilar fullness suggesting pulmonary
venous hypertension or slight fluid overload, but not
substantial. Each costophrenic sulcus is blunted which may
suggest pleural effusions.
IMPRESSION: Extensive right infrahilar opacity worrisome for
pneumonia.
Follow-up radiographs are recommended to show resolution.
Patchy retrocardiac opacity, possibly atelectasis or pneumonia.
Findings also suggestive of mild vascular congestion or fluid
overload.
Portable TTE (Complete) Done [**2188-5-19**] at 11:50:28 AM FINAL
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved global and regional
biventricular systolic function. Well seated aortic valve
bioprosthesis with normal gradient. Mild-moderate mitral
regurgitation. Pulmonary artery hypertension. Increased PCWP.
CLINICAL IMPLICATIONS:
Based on [**2182**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis IS recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
CT CHEST W/O CONTRAST Study Date of [**2188-5-19**] 10:00 AM
FINDINGS: Moderate right and small left nonhemorrhagic pleural
effusions
layer posteriorly. In addition to asbestos-related pleural
plaques, some
calcified, such as the largest adjacent to the right middle
lobe, 2:40, and others on both sides of the posterior chest,
2:41, there is a suggestion of even greater pleural thickening
in the right posterior pleural sulcus which raises concern for
pleural tumor. There is no indication of pulmonary fibrosis. A
roughly elliptical opacity in the right middle lobe sitting on
an elevated aspect of the right major fissure has both the
morphology--short, nodular branching extensions--and also the
low attenuation characteristics of mucoid impaction, 15 to 18
[**Doctor Last Name **], but does not really conform to bronchial branches, 4:147-185
and 601b:19-12. The only other lung lesion is an irregular 4-mm
wide nodule in the right middle lobe, 4:166. There is no
consolidation. The questionned right lower lobe "infiltrate"
was probably a combination of the middle lobe lesion and
superimposed, moderate right pleural effusion. Motion artifact
makes it difficult to say whether mild bronchial wall thickening
is present, but there is no substantial bronchiectasis.
The only enlarged central lymph node is in the right lower
paratracheal
station, 13 mm across, 2:27. The caliber of the
intrapericardial pulmonary artery, 31 mm, suggests pulmonary
arterial hypertension. The patient has had median sternotomy,
coronary bypass grafting and aortic valve replacement. Moderate
cardiomegaly is mostly due to enlarged atria.
Atherosclerotic calcification is most pronounced at the origin
of the left subclavian artery, but is scattered throughout head
and neck vessels and the normal size thoracic and abdominal
aorta.
IMPRESSION:
1. Despite asbestos-related pleural plaques found elsewhere,
moderate right pleural effusion and more pronounced pleural
thickening in the right lower chest raise concern for malignant
mesothelioma or adenocarcinoma in the right pleural space.
2. Lesion in right middle lobe could be an atypical mucoid
impaction, but endobronchial tumor is a reasonable alternative.
PET CT scanning is recommended for evaluation of both lung and
pleural
lesions.
3. Possible pulmonary arterial hypertension.
CT CHEST W/CONTRAST Study Date of [**2188-5-25**] 9:34 AM
FINDINGS: Small right and trace left non-hemorrhagic pleural
effusions are improved since the prior exam. Note is again
made of asbestos-related pleural plaques, some of which are
calcified. The pulmonary vasculature appears unremarkable.
There is atherosclerotic calcification within the thoracic
aorta. Right main pulmonary artery measures 31 mm, suggesting
pulmonary arterial hypertension. Cardiomegaly is also noted.
Right paratracheal lymph nodes are unchanged from the prior exam
measuring upto 9mm in short axis diameter. There are multiple
areas of mucoid impaction scattered throughout the lungs
bilaterally ($eries 4: Images 132;135;145;147;149). Bronchial
wall thickening is noted in the right lower lobe as well.
Multiple sub-5mm pulmonary nodules (Series 603: Images 9, 16;
22; 25; 27) are unchanged. An elliptical lesion in the right
middle lobe with short nodular branching extensions appears most
consistent with mucoid impaction, measuring 19 x 11mm,
previously 24 x 10mm at a comparable level.
IMPRESSION:
1. Asbestos-related pleural plaques with improved small right
pleural
effusion and trace left pleural effusion.
2. An elliptical lesion in the right middle lobe with short
nodular branching extensions appears most consistent with mucoid
impaction, measuring 19 x 11mm, previously 24 x 10mm at a
comparable level
(size comparisons were requested by the consulting pulmonary
team).
Bronchosocpy with direct visualization should be considered to
rule out a
smaller stenotic lesion or endobronchial tumor.
3. Possible pulmonary arterial hypertension.
4. Multiple areas of mucoid impaction scattered throughout the
lungs
bilaterally as noted above.
5. Multiple sub-5mm pulmonary nodules (Series 603: Images 9, 16;
22; 25; 27) are unchanged.
BRONCHIAL WASHINGS Procedure Date of [**2188-5-26**]
DIAGNOSIS: Bronchial washings:
ATYPICAL.
Scattered atypical epithelial cells, cannot exclude reactive
changes.
Numerous neutrophils.
Brief Hospital Course:
81F w/ hx of COPD, AVR-CABG x 1 (SVG-OM) ([**2-/2188**]), atrial
fibrillation, and hypertension who presented with acute on
chronic dyspnea and was treated for COPD exacerbation, pneumonia
and acute on chronic congestive heart failure.
# Right middle lobe lesion/ MRSA pneumonia/ other etiology: Seen
initially on chest CT and was comperable following a 7 day
course of levofloxacin, Chest PT, and diuresis. Consider mucus
impaction, infection versus neoplastic growth. By bronchoscopy,
patient with lots of mucus and friable mucusa. Bronchoscopy
cultures growing MRSA and patient started on MRSA coverage with
vancomycin x1 day and sent out with 2 weeks of linezolid PO as
well as an additional 2 weeks of levofloxacin. Concerning
atypical cells found on cytology from washings. Patient was
instructed to continue chest PT with:
- TID nebulized saline with flutter device.
- repeat Chest CT in 1 month
- Follow up in clinic after chest ct
# Pleural effusions: 350ml of amber pleural fluid was drained
from the right side and was positive for WBC and RBCs with
lymphocyte and macrophage predominance. The fluid's protein and
LDH ratios do not meet Light's criteria although Cholesterol
content is > 45mg/dL: likely transudative and is concerning for
heart failure or an atypical presentation of malignancy related
effusion. Given that she had mild vascular congestion on CT and
known hx of AS and HTN, she may have diastolic dysfuntion that
is primarily contributing bilaterally to the pleural effusion.
It is also concerning for a malignancy due to the pronounced
pleural thickening that is concerning for malignant mesothelioma
or endobronchial tumor. Patient continued on Hydrochlorothiazide
25 mg PO/NG DAILY
- f/u with pleural fluid cytology/ cell block
# Dyspnea with 2L O2 NC. Treated as a COPD exacerbation
initially with 5 days of prednisone and a 3 week course of
levofloxacin and 2 weeks of linezolid (starting at time of
discharge). Mrs.[**Known lastname 86084**] dyspnea has improved and is closer to
her baseline following inital treatment with predinsone. It is
likely that it was multifactorial with a combination of COPD
exacerbation, pneumonia, and vascular congestion. Patient was
started on Morphine Sulfate IR 7.5 mg PO/NG Q6H:PRN dyspnea and
continued Levofloxacin 750 mg PO/NG Q48H Duration: 22 Days day 1
= [**5-18**] Last day is [**6-9**] as well as:
- Albuterol 0.083% Neb Soln 1 NEB IH
- Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **]
(decreased from 500/50)
- Stop Guaifenesin [**4-17**] mL PO/NG Q6H:PRN Cough
- continue Ipratropium Bromide Neb 1 NEB IH Q6H
- continue Tiotropium Bromide 1 CAP IH DAILY
Ambulator sat above 90% with walking and 2L NC, although
component of deconditioning/ fatigue.
# ATRIAL FIBRILLATION: CHADS2 score: 4. Initially presented as
peri-operative complication from her AVR in [**Month (only) 958**] and now
persistent. She is scheduled for cardioversion week of [**5-27**] -
[**5-30**]. Rate controlled with diltiazem and anticoagulation with
coumadin. INR supratherapeutic on admission at 4.8 (Goal INR
[**1-11**]) so coumadin was held while in MICU. Given initial concern
for AFib causing pulm edema, TTE was performed which showed
LVEF>55%, mild LVH, mild-mod MR, PAH with elevated PCWP>18. She
had no palpitations or chest pain. We decreased her dilt to
diltiazem Extended-Release 120 mg PO DAILY. Patient was bridged
with lovenox, stopped on [**5-28**] with INR of 2.6 and discharged on
1mg warfarin daily.
# HYPERTENSION: continued home HCTZ, decreased diltiazem as
above.
# SP CABG AVR: CP free on admission with negative cardiac
enzymes. No baseline EKG.
Continued aspirin.
# White spots in oropharynx: improved spots on oropharynx are
concerning for [**Female First Name (un) **] thrush due to inhaled steroid use. Given
that spots persists, this is less concerning for food stuck on
palate. Unroofing of the spots was not attempted on physical
exam. She is not known to be immunocompromised systemically.
Decreasing in size, but persisting. We discharged with 5 more
days of Nystatin Oral Suspension 5 mL PO TID and instructed
patient to rinse mouth after inhaled steroid use
# SEIZURE: Peri-operative complication of recent AVR. Continued
keppra 50mg ER [**Hospital1 **]. No evidence of seizure activity during
admission. She is scheduled for outpatient MRI and EEG in 2
weeks.
# Glaucoma: pt has a history of glaucoma s/p surgical
intervention on the right.
- continue Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE HS
- continue Timolol Maleate 0.5% 1 DROP LEFT EYE [**Hospital1 **]
# INSOMNIA: continued trazadone qHS
# CODE STATUS: DNR/DNI (confirmed with patient)
# Transitional:
- Patient needs follow up with Atrius pulmonology in 1 month and
CT chest prior to appointment (pending but patient on call back
list)
- Pleural fluid and cell block pending from thoracentesis
- Atypical cells on bronchial washings, likely reactive but
needs follow up CT which is being scheduled.
- Weekly CBC while on linezolid
Medications on Admission:
1. Metoprolol Tartrate 25 mg Oral Tablet 1 tab po bid
2. Diltiazem HCl 90 mg Oral Capsule,Extended Release 12 hr 1
capsule twice daily
3. Warfarin 1 mg Oral Tablet take 1 tablet (1mg) for 3 days
(mwf) and 2 tablets (2mg) for 4 daily or AS DIRECTED
4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Inhalation Solution
for Nebulization Use 1 ampule (3mL) every four to six hours as
needed
5. Fluticasone-Salmeterol (ADVAIR DISKUS) 500-50 mcg/dose
Inhalation Disk with Device inhale 1 puff TWICE DAILY and rinse
mouth thoroughly afterward
6. Tiotropium Bromide (SPIRIVA WITH HANDIHALER) 18 mcg
Inhalation Capsule, w/Inhalation Device 1 capsule inhaled daily
7. Trazodone 50 mg Oral Tablet take [**12-10**] tablet (25mg) at bedtime
as needed for sleep.
8. Aspirin ([**Location (un) **] LOW-DOSE ASPIRIN) 81 mg Oral Tablet,
Chewable 1 by mouth once daily
9. Docusate Sodium 100 mg Oral Capsule Take [**12-10**] capsules daily
as needed; available over the counter
10. Levetiracetam (KEPPRA XR) 500 mg Oral Tablet Extended
Release 24 hr 1 po bid
11. Hydrochlorothiazide 25 mg Oral Tablet Take 1 tablet daily
12. Latanoprost (XALATAN) 0.005 % Ophthalmic Drops instill 1
drop in left eye AT BEDTIME
13. Albuterol Sulfate (PROAIR HFA) 90 mcg/Actuation Inhalation
HFA Aerosol Inhaler INHALE 2 PUFFS FOUR TIMES DAILY ; rinse
mouthpiece at least once per week.
14. Timolol Maleate (TIMOPTIC) 0.5 % Ophthalmic Drops Instill 1
drop in left eye twice daily
15. MULTIVITAMIN CAPSULE PO (MULTIVITAMINS) 1 TABLET DAILY
16. CALCIUM + D TABLET 600-200 PO 1 tablet po qd
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **]
4. Hydrochlorothiazide 25 mg PO DAILY
do not give if SBP < 100 or HR <60
5. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE HS
6. LeVETiracetam 500 mg PO BID
7. Metoprolol Tartrate 25 mg PO BID
hold for SBP < 100 or HR< 60
8. Morphine Sulfate IR 7.5 mg PO Q6H:PRN dyspnea
hold for sedation, RR<10
9. Timolol Maleate 0.5% 1 DROP LEFT EYE [**Hospital1 **]
10. Tiotropium Bromide 1 CAP IH DAILY
11. traZODONE 25-50 mg PO HS:PRN insomnia
12. Levofloxacin 750 mg PO Q24H
Day 1 = [**5-18**]. Planned duration until [**2188-6-9**].
13. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
14. Polyethylene Glycol 17 g PO DAILY:PRN constipation
15. Senna 1 TAB PO BID:PRN constipation
16. Nystatin Oral Suspension 5 mL PO TID
swish and spit. STOP on [**6-2**].
17. Albuterol 0.083% Neb Soln 1 NEB IH Q6H
18. Diltiazem Extended-Release 120 mg PO DAILY
19. Warfarin 1 mg PO DAILY16
20. Simvastatin 20 mg PO DAILY
21. Ipratropium Bromide Neb 1 NEB IH Q6H
22. Linezolid 600 mg PO Q12H
Continue through [**2188-6-9**].
23. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea/wheezing
24. Neb
Nebulized saline TID followed by flutter valve.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary: COPD exacerbation, Acute heart failure, pulmonary
effusions
Secondary: Hyperlipidemia, Hypertension, Primary Open Angle
Glaucoma, coronary artery disease, atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname 22204**],
It was our pleasure to care for you at [**Hospital1 18**]. You were admitted
for shortness of breath and were found to have numerous possible
causes. We treated you for an exacerbation of your COPD,
started you on antibiotics for pneumonia, and removed fluid from
your outside your lung. In addition, you underwent a procedure
to test the fluid in your lung to see which bacteria was causing
the pneumonia to ensure that you are on the correct antibiotics.
You are being discharged to rehab on supplemental oxygen.
There, you will complete your antibiotics (Linezolid and
Levofloxacin) and should have a weekly blood test (CBC) to make
sure that your blood levels remain fine, as Linezolid can drop
your white blood cell count. You will follow up with your
Pulmonologist in ~4 weeks including a repeat of the chest CT.
At the time of discharge today, there are some studies pending
but you can discuss the results at your follow-up appointment.
Note that today ([**5-28**]) your INR is therapeutic, but recently it
was not. Whenever your INR is <2, you should be covered with
Lovenox injections because of your risk of stroke. You are
scheduled to have follow-up with your Cardiologist, especially
because there are possible plans for an intervention on your
abnormal heart rhythm.
We made the following changes to your medications:
Please START levofloxacin until [**2188-6-9**]
Please START linezolid until [**2188-6-9**]
Please DECREASE Simvastatin to 20mg daily, from 40mg daily
Please DECREASE Fluticasone-Salmeterol Diskus to 250/50 from
500/50
CHANGED Warfarin dose
CHANGED Diltiazem dose
Please START a short course of Nystatin for thrush (stop on
[**6-2**])
Please START Morphine as needed for pain
Please START Colace, Senna, Miralax, and Bisacodyl as needed for
constipation
Please get your INR checked on [**2188-5-30**]
Please get a CBC checked on [**2188-6-4**] and [**2188-6-10**]
Followup Instructions:
CARDIOLOGY
Name: [**Last Name (LF) 2920**], [**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**]
Appt: [**7-2**] at 8:50am
PULMONOLOGY
***It is recommended you follow up with a pulmonologist within 4
weeks of discharge. The Pulmonary office at [**Location (un) 2274**] [**Location (un) **] is
working on an appt for you and will call you at home with the
appt. If you dont hear from them by within 2 business days,
please call the office directly at [**Telephone/Fax (1) 2296**] to book.
|
[
"V42.2",
"934.8",
"272.4",
"112.0",
"428.33",
"793.11",
"511.9",
"491.21",
"511.0",
"564.00",
"275.3",
"276.4",
"733.90",
"V49.86",
"414.00",
"365.9",
"276.1",
"E912",
"562.10",
"427.31",
"428.0",
"345.90",
"482.42",
"401.9",
"780.52",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"34.91",
"96.56"
] |
icd9pcs
|
[
[
[]
]
] |
25889, 25959
|
17999, 23030
|
292, 353
|
26188, 26188
|
5196, 8151
|
28340, 29063
|
3886, 3890
|
24625, 25866
|
25980, 26167
|
23056, 24602
|
26371, 27723
|
3905, 5177
|
10164, 10377
|
13375, 17976
|
10006, 10130
|
27752, 28317
|
2722, 3123
|
233, 254
|
381, 2703
|
10413, 13352
|
26203, 26347
|
3145, 3662
|
3678, 3870
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,175
| 100,489
|
29276
|
Discharge summary
|
report
|
Admission Date: [**2164-1-23**] Discharge Date: [**2164-2-20**]
Date of Birth: [**2102-3-25**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
multiple bronchoscopies
[**1-30**]: CT guided lung biopsy
[**1-31**]: Chest tube (left) placed; removed [**2-10**]
[**2-7**]: started chemoradiation (stopped [**2-13**]) after d/w family
[**2-8**]: PEG placement, Trach placement, VATS, pleurodesis
History of Present Illness:
61 M Cantonese-speaking only, former smoker who quit 10 yrs ago,
admitted on Mon to [**Location **] service for workup of L lung
mass which is likely malignant, here with dysphagia x 2 months,
hemoptysis x 2 months, weight loss of [**5-10**] lbs, reduced PO
intake, became acutely SOB today at 2 pm. He was doing very well
yesterday, was not SOB at all, RR 14, was very comfortable. He
has been in isolation getting r/o for TB (due to hemoptysis),
and bronch was planned for tomorrow PM. Throughout today, he
developed worsening SOB, with O2 sats ranging from 95-98% RA at
2 pm, 92% RA at 5 pm, 87% 2L nc at 9 pm, 85% 100% FM at 11 pm.
.
He became severely SOB, with no rales, no wheezing, first ABG
7.35/60/68, O2 sat 95-98% RA. ENT was consulted for SOB, and
found normal vocal cords, normal posterior pharynx, no lesions
on vocal cords, +mediastinal lymph nodes. CXR shows no
cardiomegaly, no pleural effusions, no infiltrate. Earlier
today, patient was sitting straight up on the side of bed
drooling, with severe SOB, RR 30. EKG showed mild STD in lateral
leads, no previous for comparison. Patient failed bedside video
swallow study.
.
Patient has one AFB negative, one AFB pend. Bronch was planned
by IP for tomorrow after r/o TB.
Past Medical History:
stomach ulcer- ?of partial gastrectomy (30 years ago)
.
Social History:
Previous smoker, quit 10 yrs ago. Lives with son at home, worked
as a dishwasher in restaurant.
Family History:
noncontributory
Physical Exam:
VS: 95.5 / 154/81 / 30 / 87% 5L nc
GEN: Cachectic, too SOB to speak, akathisic, fatigued
HEENT: JVD flat, no LAD, OP clear, anicteric sclerae
LUNGS: CTA B
HEART: RRR, no m/r/g
ABD: Soft, thin, +BS, ND NT
EXTR: No c/c/e
NEURO: No exam performed
SKIN: No rash
Pertinent Results:
Admission labs:
136 99 14
-------------< 99
4.9 28 0.8
.
14.5
7.3 >---< 551
42
N:79.6 L:15.4 M:2.9 E:1.5 Bas:0.5
.
Trends:
Discharge CBC:
[**2164-2-16**] 04:33AM BLOOD WBC-15.2* RBC-3.37* Hgb-10.1* Hct-29.7*
MCV-88 MCH-29.9 MCHC-33.9 RDW-14.5 Plt Ct-386
Discharge coags:
[**2164-2-15**] 05:56AM BLOOD PT-12.2 PTT-40.9* INR(PT)-1.1
Discharge Chem panel:
[**2164-2-17**] 02:50AM BLOOD Glucose-127* UreaN-32* Creat-0.6 Na-142
K-3.6 Cl-103 HCO3-36* AnGap-7*
[**2164-2-17**] 02:50AM BLOOD ALT-27 AST-30 LD(LDH)-207 AlkPhos-76
Amylase-92 TotBili-0.2
.
CE:
[**2164-1-25**] 03:45PM BLOOD CK-MB-5 cTropnT-<0.01
[**2164-1-26**] 12:25AM BLOOD CK-MB-11* MB Indx-4.4 cTropnT-0.9*
[**2164-1-26**] 06:13AM BLOOD CK-MB-10 MB Indx-5.5 cTropnT-0.23*
[**2164-1-28**] 09:54AM BLOOD CK-MB-3 cTropnT-0.09*
[**2164-1-31**] 02:43AM BLOOD CK-MB-2 cTropnT-0.01
.
[**2164-1-29**] 05:27AM BLOOD calTIBC-170* VitB12-449 Folate-9.8
Ferritn-55 TRF-131*
[**2164-1-25**] 03:32PM BLOOD Lactate-1.3
[**2164-2-4**] 03:34PM BLOOD Lactate-0.8
.
Micro:
Multiple blood, sputum, urine, and BAL cultures negative.
BAL from [**1-25**]: RESPIRATORY CULTURE (Final [**2164-2-2**]):
>100,000 ORGANISMS/ML. OROPHARYNGEAL FLORA.
BETA STREPTOCOCCI, NOT GROUP A. 10,000-100,000
ORGANISMS/ML..
SENSITIVITY PER DR [**First Name (STitle) **] #[**Numeric Identifier 70374**].
UNABLE TO ISOLATE FOR FURTHER WORK UP.
Thought to be contaminant.
.
Cytology:
Pleural fluid negative x3 for malignancy
CT guided bx positive for adenoca of lung
.
Imaging:
[**1-24**]: CT Abd: 1. Focal liver lesions with peripheral
enhancement, most likely representing hemangiomas.
2. 2 cm left adrenal nodule with enhancement, worrisome for
metastasis in this patient with lung mass. PET CT may help for
further staging.
3. Small free fluid in the lower pelvis.
.
[**1-23**]: CT chest: Chest CT [**2164-1-23**]: (1) Mass or mass-like
consolidation in two segments of the left upper lobe. (2) Small
left adrenal mass.
Extensive heterogeneity in liver texture. (3) Esophageal
distention, probably functional.
.
[**1-26**]: ECHO: 1.The left atrium is normal in size.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. There is mild regional left
ventricular systolic dysfunction with mid septal hypokinesis.
Overall left ventricular systolic function is low normal (LVEF
50-55%).
3. Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4.The aortic valve leaflets are mildly thickened. No aortic
regurgitation is seen.
5.The mitral valve leaflets are mildly thickened. No mitral
regurgitation is seen.
6.The estimated pulmonary artery systolic pressure is normal.
7.There is no pericardial effusion.
.
CXR upon admission:
1. New left upper lobe consolidation occupying predominantly the
upper portion of the lobe in addition to known left upper
lobe/lingular consolidation/mass. These finding may represent
massive aspiration or hemorrhage
2. New retrocardiac left lower lobe atelectasis.
.
CXR upon discharge:
Tracheostomy tube and G-tube seen in relatively stable position.
Cardiac and mediastinal contours appear stable. There is
improved aeration of the left lung with persistent atelectasis
and consolidation with air bronchograms noted. Left-sided PICC
seen with the tip in the region of the cavoatrial junction.
IMPRESSION: Improved aeration in the left lung with persistent
atelectasis and consolidation
Brief Hospital Course:
61 yo former smoker admitted for workup of L lung mass after
presenting w/ c/o dysphagia, hemoptysis, and weight loss x 2
months, admitted to the ICU for acute SOB. Hospital course by
problem:
.
# Hypoxemic respiratory failure: Likely [**2-3**] mucus plugging of L
upper lung field complicated by ? postobstructive pneumonia.
Bronchoscopy was performed x4 each time with evidence of mucus
plugging and thick secretions. Sputum cultures did not,
however, yield growth in order to guide antibiotic coverage. He
was continued on zosyn and vancomycin x14 days then switched to
meropenem for 1 week to treat possible ESBLs. Following his 4th
bronchoscopy, he was tolerating trials of PS. Thereafter, we
placed a trach on [**2-8**] which he tolerated well. We aggressively
diuresed. On [**2-16**] he did very well on a trach collar and
remained off the vent for >24 consecutive hours. We recommend
continued lasix 40mg PO daily for approx 1-2 weeks as he was
quite volume overloaded during this admission.
.
# Adenoca of the lung: CT guided biopsy showed adenoca of the
lung. He had a negative head CT for mets but did have an
adrenal met noted on abdominal CT scan. He had pleural fluid
neg x3 for malignancy. We were unable to accurately stage him
without a PET scan. Given his poor respiratory status and
extensive disease burden, the heme/onc service did not feel that
he would benefit from surgical resection or high dose chemo. We
did however treat him for a 5 day course of chemoradiation to
help decrease the size of the mass in an attempt to assist with
weaning off the vent. This may have helped as he was
subsequently off the vent several days after therapy. The
family and patient are no longer interested in treating this
malignancy.
.
# Cards Vasc: In the setting of hypoxia and hemoptysis, the
patient had a troponin peak to 0.9. His CKs were negative. An
echo showed some mid-septal hypokinesis. It was thought that
this was a demand ischemic event and there were no further
issues during his hospitalization.
..
# Left pneumothorax: Patient had a PTX s/p CT guided biopsy. He
had a chest tube placed on the left. It remained in place for
approx one week. Thereafter the PTX resolved. He did undergo
VATS with pleurodesis on [**2-8**] given his signifant pleural
effusion.
.
# A fib: on [**2-10**], went into afib with rvr to 160s. BP stable.
- lopressor 37.5 tid achieved good rate control
.
# HTN- Consistently elevated BP, especially when he becomes
agitated.
-continue lopressor 37.5 tid,
-lorazepam 0.5 prn
.
# Hemodynamic instability: Originally he was hypotensive. This
appeared to be combination of sedation for intubation and
hypovolemia. He did, however, remain largely levophed
dependent. His BP would rise to >170s systolic with agitation.
However, for at least 10 days prior to discharge, his blood
pressure was well controlled on metoprolol 37.5 tid.
.
# FEN: A peg was placed on [**2-8**]. Tube feeds were started. He
tolerated these well.
.
# Anxiety: ambien and/or ativan prn
.
# Code: DNR per discussion with family. final discussion
revealed that patient is DNR but would be hooked up to
ventilator if in respiratory distress.
.
# Communication: Son = [**Name (NI) **] [**Name (NI) 3443**]: speaks English. [**Telephone/Fax (1) 70375**]
Medications on Admission:
unknown, ? antihypertensives
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution [**Telephone/Fax (1) **]: One (1)
Injection TID (3 times a day).
2. Albuterol 90 mcg/Actuation Aerosol [**Telephone/Fax (1) **]: 6-8 Puffs Inhalation
Q4H (every 4 hours).
3. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Telephone/Fax (1) **]: 6-8 Puffs
Inhalation Q4H (every 4 hours).
4. Senna 8.6 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO BID (2 times a
day).
5. Docusate Sodium 50 mg/5 mL Liquid [**Telephone/Fax (1) **]: One (1) PO BID (2
times a day).
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Telephone/Fax (1) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. Chlorhexidine Gluconate 0.12 % Mouthwash [**Telephone/Fax (1) **]: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day).
8. Zolpidem 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
9. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: 1.5 Tablets PO TID (3
times a day).
10. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
11. Furosemide 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily): we recommend continuing this for another 5-7 days to
correct his positive fluid balance.
12. Lorazepam 0.5 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO HS (at bedtime).
13. Morphine 2 mg/mL Syringe [**Last Name (STitle) **]: One (1) mg Injection Q4H
(every 4 hours) as needed.
14. Albuterol Sulfate 0.083 % Solution [**Last Name (STitle) **]: One (1) treatment
Inhalation Q4H (every 4 hours) as needed. treatment
15. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) treatment
Inhalation Q6H (every 6 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary:
- Adenocarcinoma of the lung
- hypoxic respiratory failure
- postobstructive pneumonia
- atrial fibrilation
- hypertension
- left pneumothorax (now resolved)
- prolonged intubation requiring trach placement
- s/p VATS, pleurodesis
- s/p PEG placement
Discharge Condition:
fair, breathing on trach collar.
Discharge Instructions:
You were admitted with shortness of breath and coughing up
blood. You had a mass in your lung which is consistent with
adenocarcinoma of the lung. We treated you for a prolonged
course on the ventilator and ultimately you were extubated and
did well with a trach. You briefly received chemotherapy and
radiation. However, given the severity of your disease, we did
not continue these measures.
.
Please contact your PCP with any questions. Please take your
medications as instructed.
Followup Instructions:
please followup with your PCP within the next month
|
[
"401.9",
"162.3",
"427.31",
"E912",
"786.3",
"584.9",
"512.1",
"414.8",
"276.52",
"518.81",
"428.0",
"496",
"934.1",
"486",
"V45.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.24",
"96.72",
"00.17",
"33.22",
"96.05",
"33.24",
"34.04",
"96.04",
"96.6",
"33.26",
"34.92",
"92.29",
"99.25",
"38.93",
"43.11",
"31.1"
] |
icd9pcs
|
[
[
[]
]
] |
10987, 11066
|
5838, 9133
|
333, 583
|
11370, 11405
|
2371, 2371
|
11942, 11997
|
2060, 2077
|
9212, 10964
|
11087, 11349
|
9159, 9189
|
11429, 11919
|
2092, 2352
|
274, 295
|
5412, 5815
|
611, 1851
|
2387, 5109
|
5123, 5396
|
1873, 1931
|
1947, 2044
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,590
| 148,816
|
29483
|
Discharge summary
|
report
|
Admission Date: [**2163-11-7**] Discharge Date: [**2163-11-10**]
Service: NEUROLOGY
Allergies:
Haldol
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Lethargy, garbled speech
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is an 83 yo RHM with cerebral amyloid angiopathy, left
temporal hemorrhage [**2163-10-23**], atrial fibrillation now off
coumadin, HTN, seizures, and previous strokes, recently
discharged from the stroke service at [**Hospital1 18**] [**2163-11-3**] for
treatment of above-mentioned hemorrhage. He was discharged to
[**Hospital3 7**] where he has been convalescing until last
night when he had a fairly acute onset of garbled speech to the
point where he would just be mumbling. His daughter notes that
he also has left-sided weakness however she attributes this to
previous strokes. He was sent to [**Hospital1 18**] for evaluation.
In the ED, he had a head CT and received IV Levaquin after he
was found to have a UTI.
Past Medical History:
cerebral amyloid angiopathy
left temporal hemorrhage [**2163-10-24**]
HTN
Atrial fibrillation
Stroke '[**59**] with resultant left sided deficits
Stroke '[**55**] with left eye blindness
Seizures started in 50s, last years ago
Hypercholesterolemia
BPH s/p TURP
Social History:
Worked as TV repairman and janitor. smoked for five years in his
20's. No ETOH.
Family History:
non-contributory
Physical Exam:
T 103.6 HR 104 BP 104/44 RR 24 Sat 98% 2L NC
PE: Gen ill-appearing
HEENT AT/NC, mouth dry
Neck Supple, no thyromegaly, no [**Doctor First Name **]
Chest CTA B
CVS irregularly irregular, II/VI SEM
ABD soft, NTND, + BS
EXT no C/C/E. no rashes or petechiae, no asterixis
Neuro
MS: Lethargic, awake. Responds to name. Knows name. Disoriented
to place and condition.
Speech garbled seemingly fluent, less than 20% intelligible
There is significant L/R confusion.
There is left-sided neglect of the face arm and leg. Patient
shows left thumb on command. Moves right body when stimulated on
left (unlikely secondary to weakness alone).
Definite left gaze preference. Possible right hemianopsia.
CN:
- PERRL 2.5-1.5 bilat., left eye blind;
- Left gaze preference, can cross midline;
- ? face sensation intact to LT/PP, masseters strong
symmetrically;
- left face weak; left palpebral fissure widened
- voice normal, palate elevates symmetrically, uvula midline
- SCM/trapezii >4 bilat.
- tongue protrudes midline
Motor: Strength: formal testing limited by mental status
NO adventitious movement
Delt [**Hospital1 **] Tri WE FF FE
R >4 5 >4 >4 5 >4
L >3 5 >4 >2 >4 >2
IP Quad Ham TA [**First Name9 (NamePattern2) **] [**Last Name (un) 938**]
R >4 5 >4 >3 >3 >3
L >3 5 >4 >3 >3 >3
Coord: cannot test secondary to mental status
Refl:
[**Hospital1 **] Tri Brachio Pat [**Doctor First Name **] Toe
R 2 2 - 2 1 up
L 2 2 - 1 1 up
[**Last Name (un) **]: withdraws right side to left sided tactile stimulation
Pertinent Results:
WBC-20.5* RBC-3.65* Hgb-11.8* Hct-35.2* MCV-96 MCH-32.4*
MCHC-33.6 RDW-14.0 Plt Ct-256 Neuts-90.4* Lymphs-4.9* Monos-3.8
Eos-0.6 Baso-0.3 Macrocy-1+
Glucose-170* UreaN-39* Creat-1.3* Na-143 K-5.5* Cl-106 HCO3-29
AnGap-14 Calcium-5.6* Phos-2.2* Mg-1.4*
PT-13.4* PTT-27.8 INR(PT)-1.2*
[**2163-11-7**] 05:45PM BLOOD CK(CPK)-65 CK-MB-2 cTropnT-0.05*
[**2163-11-8**] 03:11AM BLOOD CK(CPK)-36* CK-MB-NotDone cTropnT-0.04*
[**2163-11-8**] 04:12AM BLOOD CK(CPK)-37* CK-MB-NotDone cTropnT-0.05*
Albumin-2.3* Phenoba-10.1 Lactate-2.1*
URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.021 Blood-SM
Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG
Urobiln-1 pH-5.0 Leuks-SM RBC-[**1-30**]* WBC-[**10-17**]* Bacteri-FEW
Yeast-NONE Epi-0-2 Uric AX-MOD
STUDIES:
[**11-7**] PCXR: Left lower lobe atelectasis.
[**11-7**] Head CT: 1. Unusual appearance of a bihemispheric process
involving the left temporal and right temporoparietal lobes. The
latter appears more acute, as there was no evidence of such a
process on the MR examination obtained less than two weeks ago.
There is a suggestion of [**Doctor Last Name 352**] matter involvement, this may
represent _____ edema related to relatively acute infarction.
The persistent vasogenic edema in the contralateral temporal
lobe may relate to evolving hematoma at that site given the lack
of enhancement of underlying lesions on the interval MR study,
the process is most consistent with infarctions of different
ages, perhaps with hemorrhagic conversion on the left, and the
bilaterality is most suggestive of embolic events from a
central, perhaps cardiac, source.
[**11-7**] EKG: Atrial fibrillation with rapid ventricular response
Probable right arm-left arm reversed Right bundle branch block
ST-T wave changes
Since previous tracing, rate increased, QRS wider Suggest repeat
tracing and clinical correlation
Intervals Axes
Rate PR QRS QT/QTc P QRS T
131 0 134 340/[**Telephone/Fax (2) 70763**]7
[**11-8**] Head CT: Resolving hematoma in the left temporal lobe with
vasogenic edema. Low attenuation in the right temporoparietal
lobe, also likely represent a subacute infarct, with possible
petechial hemorrhage versus gelatinous/proteinaceous material.
These likely represent infarcts of different ages. Followup is
recommended to evaluate for hemorrhagic conversion.
[**11-8**] ECHO: Markedly dilated atria in the setting of atrial
fibrillation. Severe symmetric left ventricular hypertrophy with
preserved regional/global biventricular systolic function. Mild
mitral regurgitation. At least moderate pulmonary hypertension.
Small pericardial effusion.
[**11-8**] EKG: Atrial fibrillation Premature beat, ventricular or
aberrant
Left axis deviation RBBB with left anterior fascicular block
Since previous tracing, the rate has decreased, limb leads
probably correct,
premature beat new
Intervals Axes
Rate PR QRS QT/QTc P QRS T
89 0 148 408/454.57 0 -45 24
Brief Hospital Course:
In summary, 83 yo man with amyloid angiopathy, s/p left temporal
hemorrhage [**2163-10-23**] with recent d/c from [**Hospital1 18**] on [**2163-11-3**]
(neuro service), afib not anticoagulated, HTN, seizures, CVAs
who presented with left sided neglect/hemiparesis. Found to have
a subacute stroke (event likely last night) in right posterior
MCA territory. Also with UTI.
# NEURO: Patient initially presented with report of left sided
neglect/hemiparesis. Head CT with an area of new edema in right
posterior MCA territory; c/w subacute infarct and left temporal
hemorrhage (old). Neurologic exam was signficant for
inattentiveness, mumbling speech, left gaze preference and right
hemianopsia. Repeat head CT at 24 hours was unchanged. Patient
was started on Aspirin 325mg QD given new stroke. Kept HOB <30
degrees and autoregulated SBP goal 120-180.
History of seizure-continued phenobarbitol. Trough level was
7.9. Continue outpatient PO dose PGT. Also, will recommend
speech therapy and re-evaluation speech and swallow when more
stable and rehabilitated from stroke.
# CV: Patient was in atrial fibrillation with RVR in ED that was
responsive to fluids. Continued beta blocker increased to TID
dosing. Also, responded well to IVF resuscitation.
Elevated troponin- Likely [**12-30**] afib and worry of an acute
ischemic event is low. No changes on EKG. Will check set in am
only.
Given likely embolic stroke, will control BP to goal SBP
120-180. Titrate up metoprolol as tolerated. Continued outpt
fenofibrate for hypercholesterolemia.
# ID: Likely [**12-30**] UTI. Started levaquin at rehab; however was
spiking through with leukocytosis. Switched to IV ceftriaxone x7
day course. Urine culture at [**Hospital1 **] was contaminated. Resent
UA and urine culture which were pending at discharge. Patient
remained afebrile since switching to ceftriaxone. He was
discharged on cefpodoxime to complete the 7day course.
# WOUND CARE: Place pt on 1st step select mattress. Pressure
relief per pressure ulcer guidelines. Turn and reposition pt q
2 hours. When sitting in chair use 4" foam cushion and limit
sitting to 1hour at a time. Cleanse coccyx skin with wound
cleanser pat dry apply Allevyn foam dressing change q 3 days and
prn.
# GU: CRI (b/l 1.2-1.3). Monitored closely.
# FEN: RISS, FS QID. Continue folic acid, thiamine, zinc,
vitamin c. Electrolyte checked and repleted. On jevity at
[**Hospital1 **]. We do not carry that here; nutrition consulted for
tube feeding recommendations and started on FS Probalance
@20cc/hr adv to goal 80cc/hr, checking residuals q4hr hold TFs
if >150cc. Monitored I/Os.
# PPX: Pneumoboots. Eye drops per outpt. Bowel regimen per
outpt.
# Code Status: Full Code. Discussed with HCP daughter [**Name (NI) 2270**]
[**Name (NI) 70764**]. (h) [**Telephone/Fax (1) 70765**]; (c) [**Telephone/Fax (1) 70766**]
Medications on Admission:
Phenobarbital 30 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO Q
day
Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
Travoprost 0.004 % Drops Sig: One (1) Drop Ophthalmic daily
Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H
Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO BID
Chlorhexidine Gluconate 0.12 % Mouthwash
Ascorbic Acid 500 mg Tablet PO BID (
Zinc Sulfate 220 mg Capsule
Thiamine HCl 100 mg/mL
Discharge Medications:
1. Phenobarbital 30 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q12
HOURS ().
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) as needed for PEG.
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
8. Insulin Regular Human 100 unit/mL Solution Sig: PER SLIDING
SCALE UNIT Injection ASDIR (AS DIRECTED).
9. Travoprost 0.004 % Drops Sig: One (1) gtt OU Ophthalmic
DAILY (Daily).
10. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
11. Docusate Sodium 150 mg/15 mL Liquid Sig: One Hundred (100)
mg PO BID (2 times a day).
12. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
UNIT Injection TID (3 times a day).
14. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day): Hold for SBP<110, HR<60.
15. Ceftriaxone-Dextrose (Iso-osm) 1 g/50 mL Piggyback Sig: One
(1) gram Intravenous Q24H (every 24 hours): until [**11-13**].
16. Midline care
Midline care per protocol
17. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
18. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours): until [**11-13**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary diagnosis:
Subacute right temporoparietal lobe stroke
Urinary tract infection
Atrial fibrillation with rapid ventricular response
Sacral skin breakdown
Secondary diagnosis:
Cerebral amyloid angiopathy
Left temporal hemorrhage [**2163-10-24**]
Hypertension
Stroke '[**59**] with resultant left sided deficits
Stroke '[**55**] with left eye blindness
Discharge Condition:
Neurologically stable. Left sided weakness (face, arm, leg).
Mumbling and incoherent speech but is able to follow commands.
Discharge Instructions:
Please take medications as prescribed.
Please keep follow-up appointments.
If you have any change in mental status, worsening
fevers/chills, worsening weakness or any other worrying
symptoms, please call your primary care physician or return to
the emergency room.
Followup Instructions:
Provider: [**Name10 (NameIs) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**]
Date/Time:[**2163-11-29**] 3:00
Please follow-up with your primary care physician [**Name Initial (PRE) 176**] [**11-29**]
weeks of discharge.
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
Completed by:[**2163-11-10**]
|
[
"345.90",
"277.39",
"781.8",
"427.31",
"438.89",
"585.9",
"707.05",
"434.11",
"272.0",
"369.60",
"784.3",
"707.07",
"403.90",
"342.90",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
11071, 11150
|
5983, 7924
|
241, 247
|
11552, 11679
|
3026, 3856
|
11994, 12413
|
1403, 1422
|
9555, 11048
|
11171, 11171
|
8883, 9532
|
11703, 11971
|
1437, 3007
|
177, 203
|
7936, 8857
|
275, 1004
|
11353, 11531
|
5013, 5960
|
11190, 11332
|
1026, 1289
|
1305, 1387
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,219
| 116,852
|
25262
|
Discharge summary
|
report
|
Admission Date: [**2176-7-1**] Discharge Date: [**2176-7-7**]
Date of Birth: [**2115-8-12**] Sex: M
Service: [**Last Name (un) **]
PREOPERATIVE DIAGNOSIS: End-stage liver disease secondary to
alcoholic cirrhosis.
PAST MEDICAL HISTORY:
1. History of encephalopathy.
2. Grade I varices.
3. History of gout.
4. History of depression.
5. Status post exploratory laparotomy and left-sided
colectomy for perforated diverticulitis in [**Month (only) 956**] of
[**2175**].
PRINCIPAL PROCEDURE: Orthotopic liver transplant on [**2176-7-1**].
HOSPITAL COURSE: Mr. [**Known lastname **] is a 60-year-old gentleman
with a history of end-stage liver disease secondary to
alcoholic cirrhosis. He was admitted to the transplant
surgery service on [**2176-7-1**] for a workup for an
orthotopic liver transplant. On [**2176-7-1**] he received
an orthotopic liver transplant, and postoperatively was
admitted to the surgical intensive care unit. He did quite
well in the surgical intensive care unit. LFTs were trending
downward. He received a liver transplant ultrasound which
showed good flow within his hepatic veins, portal vein, as
well as his hepatic artery. On postoperative days #1 and #2,
he was weaned off the ventilator towards extubation. He was
extubated without complication.
On postoperative day #2, Mr. [**Known lastname **] was doing well in the
ICU and was transferred to floor status. He continued to do
well. His diet was advanced to a regular diet, which he
tolerated without difficulty. He was seen and evaluated by
physical and occupational therapy and worked well with them.
Additionally, he was seen and evaluated by ostomy care nurses
for assistance with management of his colostomy status post
transplant surgery.
On postoperative day #6 - on [**2176-7-7**] - Mr. [**Known lastname **]
was ambulating well on his own, he was tolerating a regular
diet, had appropriate output from his ostomy, and was ready
for discharge home; per the transplant surgery service and
per physical and occupational therapy.
DISCHARGE STATUS: Mr. [**Known lastname **] was discharged home from [**Hospital1 **] Hospital on [**2176-7-7**].
DISCHARGE INSTRUCTIONS:
1. He was instructed to follow up with the Transplant
Surgery Clinic on this coming Thursday; or to call or
follow up sooner if he has any concerns or questions.
2. He was instructed on appropriate care for his ostomy, and
will be seen and evaluated by our visiting nurse
assistance for management of this. He has taken care of
this before, but will need some assistance status post
transplant.
DISCHARGE MEDICATIONS:
1. Colace 100 mg p.o. b.i.d..
2. Famotidine 20 mg p.o. b.i.d..
3. Clozaril 400 mg p.o. daily.
4. Mycophenolate 1 gram p.o. b.i.d..
5. Oxycodone 1 to 2 tablets p.o. q.4-6h. p.r.n. pain.
6. Prednisone 20 mg p.o. daily.
7. Senna 1 tablet p.o. p.r.n..
8. Tacrolimus ______ mg p.o. b.i.d.; he is to follow up for
level checks - this was arranged with the transplant
coordinator.
9. Valcyte 900 mg p.o. daily.
10. Bactrim 1 tablet p.o. daily.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**], M.D. [**MD Number(2) 6727**]
Dictated By:[**Name8 (MD) 57264**]
MEDQUIST36
D: [**2176-7-7**] 16:23:48
T: [**2176-7-7**] 17:21:25
Job#: [**Job Number 63239**]
|
[
"V11.3",
"311",
"274.9",
"571.2",
"V44.2",
"V12.79",
"V15.82",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"99.07",
"50.59",
"99.05",
"00.93",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
2641, 3354
|
590, 2172
|
2196, 2618
|
258, 572
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,982
| 114,211
|
48525
|
Discharge summary
|
report
|
Admission Date: [**2200-10-16**] Discharge Date: [**2200-11-8**]
Date of Birth: [**2142-1-23**] Sex: M
Service: MEDICINE
Allergies:
Chlohexadine
Attending:[**First Name3 (LF) 4616**]
Chief Complaint:
metastatic melanoma
Major Surgical or Invasive Procedure:
1. Right frontal craniotomy.
2. Excision of tumor with stereotactic navigation.
History of Present Illness:
HPI: Patient is a 58 year old gentleman with a history of
malignant melanoma who presented to an outside hospital
complaining of nausea and headaches. He was previously on
hospice care but had a change of heart. His melanoma had
previously metastasized to his lungs,brain, and bowels, which
required surgical intervention. CT scan recently at OSH showed
new lesions in the head necrosis vs. new mets. The patient
changed his mind RE hospice care and would like this treated. An
MRI today at the OSH showed edema concerning for metastatic
disease at R frontal parietal. There was also increase vasogenic
edema, and 5mm osseous neoplastic disease. Was transfered here
to get Thallium PET. [**Month (only) 116**] get cyberknife vs resection.
Past Medical History:
PAST MEDICAL HISTORY:
HTN(?)
Atrial fibrillation, [**2195**], resolved
Depression
Bradycardia
Social History:
Lived with his brother [**Name (NI) **]. Was a Polaroid technician. Never
smoked tobacco, rare EtOH use.
Family History:
Mom and dad with diabetes. Aunt with unknown malignancy, cousin
with breast ca.
Physical Exam:
On Admission
Vitals - T:97.6 BP:116/64 HR:74 RR:18 02 sat:94
GENERAL: slow to respond, but AAOx3
SKIN: warm and well perfused, no excoriations or lesions, no
rashes, some hemangiomas throughout body.
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition, nontender supple neck, no
LAD, no JVD. Eyes dysconjugate.
CARDIAC: RRR, S1/S2, no mrg
LUNG: CTAB
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
M/S: moving all extremities well, no cyanosis, clubbing or
edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
.
On Discharge:
Vitals - 96.6, 122/70, 87, 16, 95RA
GENERAL: lying in bed
SKIN: warm and well perfused, no excoriations or lesions, no
rashes, some hemangiomas throughout body.
HEENT: AT/NC, EOMI, anicteric sclera, MMM, nontender supple
neck, no LAD, no JVD.
CARDIAC: RRR, S1/S2, no mrg
LUNG: CTAB
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
M/S: moving all extremities well, no cyanosis, clubbing or
edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
Pertinent Results:
On Admission:
[**2200-10-17**] 05:35AM BLOOD WBC-8.0 RBC-4.87 Hgb-14.1 Hct-43.5 MCV-89
MCH-29.0 MCHC-32.5 RDW-12.4 Plt Ct-260
[**2200-10-17**] 05:35AM BLOOD Plt Ct-260
[**2200-10-17**] 05:35AM BLOOD Glucose-83 UreaN-16 Creat-0.8 Na-138
K-4.0 Cl-101 HCO3-29 AnGap-12
[**2200-10-21**] 06:00AM BLOOD ALT-21 AST-13 LD(LDH)-170 AlkPhos-87
TotBili-0.2
[**2200-10-17**] 05:35AM BLOOD Calcium-8.8 Phos-2.9 Mg-2.0
[**2200-10-31**] 02:09PM BLOOD Type-ART pO2-174* pCO2-24* pH-7.61*
calTCO2-25 Base XS-4
[**2200-10-31**] 02:09PM BLOOD Glucose-98 Lactate-1.1 Na-135 K-2.8*
Cl-107
[**2200-10-31**] 02:09PM BLOOD freeCa-0.99*
.
Pertinent Results:
.
CT head [**2200-11-7**]
IMPRESSION: No acute hemorrhage or mass effect. Expected
post-surgical
changes.
.
CXR [**2200-11-2**]
FINDINGS: Right internal jugular vascular catheter has been
repositioned, now terminating in the mid superior vena cava,
with no visible pneumothorax. Endotracheal tube and nasogastric
tube have been removed. Cardiomediastinal contours are stable in
appearance. Persistent right lower lobe scarring versus
atelectasis adjacent to surgical chain sutures as well as a
small right pleural effusion versus pleural thickening. No new
or worsening lung or pleural abnormalities.
.
ECG [**2200-11-2**]
Sinus tachycardia, rate 107 with frequent ventricular premature
beats. There is moderate baseline artifact. Left atrial
abnormality. Compared to the previous tracing of [**2200-10-28**],
except for the change in rate and the presence of frequent
ventricular premature beats, no diagnostic interval change.
.
Brain Tissue Biopsy
DIAGNOSIS:
I. Brain, right craniotomy:
Necrosis and changes consistent with radiation changes. See
note.
II. Brain, right craniotomy:
Necrosis and changes consistent with radiation changes. See
note.
.
MRI BRAIN [**2200-10-28**]
IMPRESSION:
1. Right frontal enhancing mass from tumor/radiation necrosis at
the
resection site with associated significant perilesional edema/
radiation
induced changes. There is extensive perilesional FLAIR and T2
hyperintensity
surrounding this mass. There is mild decrease in enhancement as
compared to the previous MRIS with no change in the perilesional
hyperintensity. This mass is likely to represent radiation
induced necrosis rather than residual/ recurrent neoplasm. For
surgical planning.
2. No evidence of new enhancing lesion.
.
Discharge Labs:
.
[**2200-11-7**] 01:45PM BLOOD WBC-8.5 RBC-4.32* Hgb-13.1* Hct-37.1*
MCV-86 MCH-30.2 MCHC-35.2* RDW-12.9 Plt Ct-227
[**2200-10-30**] 07:45AM BLOOD WBC-12.0* RBC-4.84 Hgb-14.7 Hct-41.6
MCV-86 MCH-30.3 MCHC-35.3* RDW-12.7 Plt Ct-270
[**2200-11-7**] 01:45PM BLOOD Glucose-91 UreaN-15 Creat-0.5 Na-134
K-3.7 Cl-97 HCO3-27 AnGap-14
[**2200-11-7**] 01:45PM BLOOD ALT-24 AST-20 AlkPhos-95 TotBili-1.2
[**2200-11-7**] 01:45PM BLOOD Albumin-3.5 Calcium-8.6 Phos-2.6* Mg-1.6
[**2200-11-1**] 08:01PM BLOOD Type-ART pO2-147* pCO2-40 pH-7.45
calTCO2-29 Base XS-4
Brief Hospital Course:
Mr. [**Name14 (STitle) 102120**] presented from an outside hospital with severe
headaches and nausea. Thallium scan that was inconclusive. The
neurosurgical team saw the patient and agreed to do a craniotomy
and biopsy. Following the surgery, was cared for by the
neurosurgical team for several days. The patient had some relief
to nausea and headache, but symptoms were not completely
resolved. The pathology shows necrosis and arrangements were
made for an outpatient family meeting with neuroncology next
week. In the meantime, he will go to a living facility. During
his stay, Mr. [**Known lastname 76901**] received PT for general weakness.
Palliative care provided significant input regarding medication
for pain and anxiety.
Medications on Admission:
Scopolamine patch 1.5mg TD q3days (next change [**2200-10-17**])
Dilaudid 4mg PO q4h prn pain [**1-22**]
Dilaudid 6mg PO q4h prn pain [**6-27**]
Senna 2tabs PO qhs
Bisacodyl 10mg PR qod
Fentanyl 25mcg TD q3days (next change [**2200-10-16**])
Dilaudid 6mg PO q4h
Decadron 4mg PO q6h
Ativan 1mg PO q6h prn
Compazine 10mg PO q6h prn
Keppra 750mg PO BID
MVI 1tab PO daily
Miralax 17g PO daily
Fioricet 2tab PO daily
Haldol 2mg PO daily
Valium 10mg PR prn q15min x 4 doses until seizure activity
subsides
Maalox 15mL q4h prn
Baclofen 5mg PO TID prn
Effexor 37.5mg PO daily
Zofran 4mg PO q6h prn
Levsin 0.125mg PO daily QIDACHS
Levsin 0.125mg PO q6h prn secretions
Reglan 10mg PO QIDACHS
Colace 100mg PO BID
Discharge Medications:
1. venlafaxine 37.5 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO DAILY (Daily).
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. labetalol 100 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
5. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q 12h () for
4 days.
6. levetiracetam 250 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
8. fentanyl 12 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
9. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for nausea or anxiety.
10. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
12. olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
13. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Rehabilitation and Nursing Center - [**Location (un) 701**]
Discharge Diagnosis:
Metastatic Malignant Melanoma
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Mr. [**Known lastname 76901**], you presented to us with severe headaches and
nausea and were to be worked up for possible new brain
metastasis of your pre-existing cancer. While with us, you
underwent several imaging studies of your brain, and had
neurosurgical intervention to remove the mass from your head.
We have changed several of your medications. Please only take
the medications listed below. Do not take any medications not
listed below.
Followup Instructions:
Department: NEUROLOGY
When: TUESDAY [**2200-11-11**] at 9:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12567**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1844**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2200-11-9**]
|
[
"599.0",
"V15.3",
"197.0",
"276.7",
"V10.82",
"V12.55",
"348.5",
"112.0",
"041.04",
"784.0",
"564.09",
"V66.7",
"E932.0",
"198.3",
"787.02",
"V87.41",
"V49.86",
"293.0",
"V49.87",
"288.60",
"311",
"292.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.59",
"01.59"
] |
icd9pcs
|
[
[
[]
]
] |
8355, 8457
|
5655, 6389
|
294, 376
|
8531, 8531
|
3340, 5064
|
9186, 9553
|
1405, 1487
|
7142, 8332
|
8478, 8510
|
6415, 7119
|
8711, 9163
|
5080, 5632
|
1502, 2145
|
2159, 2688
|
235, 256
|
404, 1148
|
2721, 3321
|
8546, 8687
|
1192, 1266
|
1282, 1389
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,896
| 153,544
|
12425
|
Discharge summary
|
report
|
Admission Date: [**2117-3-25**] Discharge Date: [**2117-4-2**]
Date of Birth: [**2054-5-2**] Sex: M
Service: ICU SERV
CHIEF COMPLAINT: Respiratory failure.
HISTORY OF PRESENT ILLNESS: The patient is a 62 year old
male with a recent history of diffuse pulmonary hemorrhage,
who presented with worsening hypoxia and was transferred for
further evaluation from Bermuda. The patient was previously
in good health until [**Month (only) 359**] or [**Month (only) **], when he started to
lose weight and had a 60 pound weight loss since [**Month (only) 359**]. In
mid-[**Month (only) 404**], the patient developed shortness of breath on
exertion, tiredness and pallor, cough and hemoptysis. The
patient saw his doctor in late [**Month (only) 404**] or early [**Month (only) 956**] and
chest x-ray was without infiltrate but showed bibasilar
haziness. The patient had a negative stress test.
In [**Month (only) 956**], the patient had increasing shortness of breath
and cough and was admitted to the hospital in Bermuda on
[**2117-3-16**]. He was also noted to have a decreased
hematocrit. The patient had an esophagogastroduodenoscopy
which showed fresh blood but no bleeding source. A
colonoscopy was done that was negative. Bronchoscopy
revealed diffuse hemorrhage. The patient had a low ESR,
negative ANKA, negative [**Doctor First Name **], negative anti-GBM antibody,
negative urinalysis. The patient was treated with
intravenous steroids, Cytoxan and Bactrim, transfused ten
units, stabilized and transferred to [**Hospital1 190**]. The patient was intubated upon arrival.
PAST MEDICAL HISTORY:
1. Noninsulin dependent diabetes mellitus.
2. Food poisoning.
MEDICATIONS:
1. Glucophage.
2. Aspirin.
SOCIAL HISTORY: The patient is a married banker. He has
never smoked and uses occasional alcohol.
FAMILY HISTORY: Myocardial infarction and cancer.
PHYSICAL EXAMINATION: On physical examination, the patient
had a blood pressure of 98/48; pulse of 85; oxygen saturation
of 99%. On general examination, the patient was overweight,
in no apparent distress. On neck examination, the patient
had normal carotid pulses, a normal thyroid and normal
jugular venous distention. On cardiovascular examination,
the patient had regular rate and rhythm, normal S1, S2, with
no murmurs, rubs or gallops. On pulmonary examination, the
patient had lungs that were rhonchorous bilaterally. On
abdomen examination, the patient's belly was obese,
nontender, soft, with normal bowel sounds. Peripheral
vascular examination revealed pulses within normal limits.
On neurological examination, the patient was able to follow
simple commands and respond to verbal stimuli.
LABORATORY: Pertinent laboratory findings, arterial blood
gas of 7.38, pCO2 of 42 and pO2 of 78. The patient had a
white blood cell count of 16.9 with a hematocrit of 27.7 and
platelets of 211. The patient had a sodium of 136, potassium
5.2, chloride of 103, bicarbonate of 26, BUN of 46 and
creatinine of 1.3 with a glucose of 320.
Chest x-ray revealed a diffuse bilateral opacification.
CT scan from outside hospital revealed bibasilar
consolidation with small pulmonary nodule on the left.
SUMMARY OF HOSPITAL COURSE: This 62 year old man was
previously healthy but presented with several months of
weight loss and progressive dyspnea and fatigue. He was
hospitalized for diffuse pulmonary hemorrhage and transferred
from an outside hospital for further evaluation. The patient
underwent VATS procedure which revealed diffuse involvement
of atypical cells infiltrating the lung parenchyma and pleura
and vessels suspicious for malignancy. The patient had a
history of a right adrenal mass.
The [**Hospital 228**] hospital course was complicated by need for
intubation, development of acute renal failure, anemia,
metabolic acidosis and worsening respiratory status. The
patient required paralysis and full ventilatory support. The
patient was found to have declining respiratory status with
continuing respiratory failure despite full ventilatory
support.
On [**2117-4-2**], the family elected to withdraw care and the
patient expired at 01:50 p.m.
CONDITION ON DISCHARGE: Expired.
DISCHARGE DIAGNOSES:
1. Diffuse pulmonary hemorrhage.
2. Atypical cells infiltrating the lungs diffusely
consistent with metastatic malignancy.
3. Right adrenal mass.
4. Acute renal failure.
5. Anemia.
DISCHARGE STATUS: An autopsy was requested by the family and
permission was granted.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], M.D. [**MD Number(1) 292**]
Dictated By:[**Last Name (NamePattern1) 5246**]
MEDQUIST36
D: [**2117-4-2**] 14:19
T: [**2117-4-2**] 21:21
JOB#: [**Job Number 38629**]
|
[
"197.0",
"250.00",
"276.2",
"584.9",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.04",
"32.29"
] |
icd9pcs
|
[
[
[]
]
] |
1856, 1891
|
4223, 4782
|
3228, 4167
|
1915, 3199
|
154, 176
|
206, 1607
|
1629, 1737
|
1755, 1839
|
4192, 4202
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,783
| 146,223
|
5995
|
Discharge summary
|
report
|
Admission Date: [**2200-4-6**] Discharge Date: [**2200-4-24**]
Date of Birth: [**2132-12-5**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1363**]
Chief Complaint:
Nausea and Poor PO intake
Major Surgical or Invasive Procedure:
None
History of Present Illness:
67M with metastatic pheochromocytoma presents with early
satiety, decreased appetite, nausea/vomiting. He states that
these symptoms have been ongoing since [**Month (only) **], worse over the
past month. He thinks its due to the labetalol he takes for his
blood pressure. Endorses low grade temps <100 and chills over
the past few weeks. STates he has lost 35 lbs over 4 weeks.
.
Pt presented to the [**Hospital1 18**] ED at the behest of his oncologist.
There, a brief fever workup was performed as the patient had
endorsed recent subjective fevers and chills. A UA was negative
for UTI, and a CXR failed to reveal an infiltrate. He was then
transferred to 11R in stable condition. Laboratory evaluation
was notable for a thrombocytosis to 570 and a Hct of 27.
Orthostatics revealed: Supine= T-98.0 H-68 02-97% R-16
BP-173/93, Sitting= H-72 02-98% R-16 BP-165/92, Standing= H-73
02-99% R-16 BP-153/88. VS on transfer from ED were 98, 68,
173/93, 16, 100 ra.
Past Medical History:
Past Oncologic History:
[**2171-1-18**]: Diagnosed with Pheo in the setting of hypertension,
elevated VMA/metanephrine/catechol, and CT scan showing a
right-sided 6 cm mass; Surgical resection at [**Hospital **] Hospital
and path unavailable. [**2187-6-18**]: He developed anxiety,
diaphoresis, dyspnea, and pain in back head with hypertension
with renewed elevation of catechols; CT shows left adrenal
lesions and retroperitoneal lymphadenopathy; Octreotide scan
showed left neck mass [**2188-2-18**]: Resection of neck mass abutting
thyroid, found to be paraganglioma or metastatic
pheochromocytoma [**2188-10-17**]: Resection of multiple retroperitoneal
masses on the right. Left retroperitoneal mass was unable to be
resected due to involvement in proximity of IVC.
[**2191-5-18**]: Briefly on octreotide; discontinued after two cycles
due to side effects from lack of significant response based on
chromogranin A marker, radiology, and clinical impression.
[**2192-5-17**]: Commenced cyclophosphamide, vincristine, and
dacarbazine (CVD) with remission induction with six cycles.
[**2196-11-17**]: Restarted CVD for progression and received four cycles
with interval response.
[**2198-5-18**]: Documented progression on imaging, restarted CVD on
[**2198-6-21**]. Completed 4 cycles of CVD in [**2198-8-18**] and restarted
CVD on [**7-12**]; his last dose was on [**10-4**].
.
PAST MEDICAL HISTORY: History of diabetes in the setting of
pheochromocytoma, HTN, and history of incisional ventral hernia.
Social History:
He is not currently working, lives with his wife. History of
tobacco but quit greater than 30 years ago.
Family History:
NC
Physical Exam:
ADMISSION EXAM:
GEN: AOx3, NAD
HEENT: PERRLA. MMM. no LAD. no JVD. neck supple. No cervical,
supraclavicular, or axillary LAD
Cards: RR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: No dullness to percussion, CTAB no crackles or wheezes
Abd: BS+, soft, distended, NT, no rebound/guarding, no HSM, no
[**Doctor Last Name 515**] sign
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: no rashes or bruising
Neuro: CNs II-XII intact. 5/5 strength in U/L extremities. DTRs
2+ BL. sensation intact to LT, cerebellar fxn intact (FTN, HTS).
gait WNL.
Pertinent Results:
ADMISSION LABS:
[**2200-4-6**] 01:59PM GLUCOSE-251* UREA N-12 CREAT-0.8 SODIUM-136
POTASSIUM-4.3 CHLORIDE-98 TOTAL CO2-26 ANION GAP-16
[**2200-4-6**] 01:59PM ALT(SGPT)-13 AST(SGOT)-12 LD(LDH)-128 ALK
PHOS-81 TOT BILI-0.2
[**2200-4-6**] 01:59PM WBC-6.8 RBC-3.28* HGB-8.8* HCT-27.9* MCV-85#
MCH-26.7*# MCHC-31.4 RDW-15.6*
[**2200-4-6**] 01:59PM PT-12.8 PTT-25.3 INR(PT)-1.1
.
CT Chest:
1. Interval moderate increase of mediastinal and retrocrural
lymphadenopathy
and left adrenal mass.
2. Overall minimal-to-mild progression of the extensive
metastatic disease in the lungs.
3. Unchanged appearance of severe T12 compression fracture.
.
MR Abd/pelvis [**4-8**]
IMPRESSION:
1. Overall increase in size of retroperitoneal, mesenteric, and
portocaval lymphadenopathy compared with prior, consistent with
progression of disease.
2. Probable 3 cm rectal mass as described above. This may also
represent a metastatic lesion. If indicated,
protoscopy/sigmoidoscopy or dedicated imaging could be
considered to further assess this region.
3. Unchanged compression deformity of T12.
4. Left adrenal nodule, previously characterized as an adenoma.
5. Gallstones.
.
WRIST, AP & LAT VIEWS RIGHT Study Date of [**2200-4-15**]
FINDINGS: A fiberglass cast obscures the bony detail of the
right wrist. A comminuted intra-articular fracture of the distal
radius is noted. There is no significant angulation. The
fracture is mildly impacted. There may be mild scapholunate
interval widening of approximately 2.5 mm. No dislocations. Soft
tissue swelling.
IMPRESSION:
1. Intra-articular comminuted distal radius fracture as above.
2. Possible scapholunate ligament injury with mild widening as
above
.
CT ABD & PELVIS WITH CONTRAST Study Date of [**2200-4-15**]
IMPRESSION:
1. Extensive retroperitoneal, retrocrural, and mesenteric
adenopathy, unchanged compared to the recent MRI. Bulky
adenopathy also seen in the pelvis, also unchanged compared to
the recent MR.
2. Dilated loop of small bowel in the left flank suggests
incomplete small bowel obstruction given the presence of oral
contrast distally within the large bowel.
3. The rectal mass suggested by the MRI is not appreciated on
the current study.
.
MRI PELVIS ([**4-20**])
There is no definite evidence of rectal or anal mass. The
abnormality noted on previous MRI likely represents collapsed
bowel.
.
Brief Hospital Course:
67yo M w/ pheochromocytoma who presents with poor PO intake and
nausea, imaging demonstrates progression of disease. His
hospital course was complicated by respiratory failure in the
setting of aspiration, for which he required ICU-level care.
.
# FTT/Poor PO intake: Likely that poor PO intake and failure to
thrive secondary to disease progression. MRI abdomen showed
overall increase in size of retroperitoneal, mesenteric, and
portocaval lymphadenopathy compared with prior, consistent with
progression of disease. Patient's albumin of 3.9, suggests that
poor nutrition alone as the sole cause of weight loss/FTT.
Poorly controlled sugars (as discussed below) also believed to
be contributing to patient's weight loss and generalized
symptoms. Patient was evaluted by nutrition service, who
recommened soft mechanical diet, thin liquids, and Boost
(glucose control) supplements.
.
# HTN: Titrations in blood pressure medications driven by
Endocrine consult service. Attempts to reduce his labetalol dose
per patient request were ultimately aborted as his BPs were
poorly controlled. Atenolol was added, with the hope to
uptitrate atenolol, and downtitrate labetalol in the outptatient
setting. Doxazosin dose increased to 4 mg [**Hospital1 **] during his
hospital stay. Diltiazem was discontinued as this was felt to be
contributing to his constipation. Goal BP range was 140-160
systolic per Endocrine service.
.
# Diabetes: Poorly controlled blood sugars likely secondary to
progressive pheochromocytoma. The patient's home oral
medications were discontinued. Outpatient endocrinologist
recommended insulin as the most appropriate way to manage his
sugars in the face of his progressive disease. The patient
carried a previous history of insulin allergy; this testing was
re-peated during his inpatient stay, and found to be negative.
His insulin regimen was adjusted [**First Name8 (NamePattern2) **] [**Last Name (un) **] recommendation. He
will be discharged home on glargine and a sliding scale
(attached).
.
# Pheochromocytoma: Followed by Dr. [**First Name (STitle) **] as an outpatient.
Patient not currently on active treatment regimen, but will
re-visit this at follow up appointment.
.
MICU COURSE:
.
# Respiratory failure: On HD9, patient aspirated, and was placed
on non-rebreather with SaO2 88%. Though he was not pulseless,
code blue was called for intubation on the floor, [**Location (un) 2452**] fluid
was returned on deep broncheal suctioning. He was admitted to
the [**Hospital Unit Name 153**] and started on broad spectrum antibiotics
(vancomycin/zosyn) given his immunocompromised state. He was
initially treated with ARDS net ventilation; he improved rapidly
and was diuresed with Lasix in anticipation of extubation. He
was extubated successfully.
.
# Hypotension: The evening of admission to the ICU, the patient
became hypotensive with systolic blood pressures in the 80s. A
subclavian CVC was placed. He received IVF boluses to maintain
CVP >10 and required Vasopressin for pressure support. Likely
etiology was sepsis from suspected pulmonary source. He was
continued on Vancomycin and Zosyn and his hypotension resolved.
.
# Abdominal Distension: Patient had evidence of dilated loops of
small bowel on imaging prior to his aspiration event, which
likely contributed to his nausea and vomiting. KUB confirmed
this and surgery was consulted for ileus vs obstruction. A CT
A/P with PO contrast was obtained and revealed a incomplete
small bowel obstruction near the left flank. Initially believed
to be secondary to a rectal mass visualized on pelvic MRI,
however re-peat MRI demonstrated that this mass was merely
collapsed bowel. Ileus ultimately resolved with an aggressive
bowel regimen, including lactulose, miralax, colace/senna, and
dulcolax suppository.
.
# S/P right forearm fracture: On arrival to the MICU, the cast
overlying previous forearm fracture appeaered tight related to
edema. Orthopedics was consulted and removed the cast, replacing
it with a volar splint which he will need to wear until follow
up with orthopedics on discharge.
.
# Transitions of care:
- Will require continued titration of insulin regimen as he
modifies his dietary intake with recovery.
- Will require continued uptitration of atenolol and
downtitration of labetalol (patient requests that labetalol
dosing be decreased)
Medications on Admission:
DILTIAZEM HCL [CARTIA XT] - 180 mg Capsule [**Hospital1 **]
DOXAZOSIN - 4 mg Tablet - 1 (One) Tablet(s) by mouth at hs
GLIPIZIDE - 10 mg Tablet Extended Rel 24 hr - 1 (One) Tablet(s)
by mouth once a day - No Substitution
LABETALOL - 200 mg Tablet - 3-3-3 Tablet(s) by mouth
METFORMIN - (Dose adjustment - no new Rx) - 1,000 mg Tablet - 1
(One) Tablet(s) by mouth twice a day
Discharge Medications:
1. doxazosin 4 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day) as needed for constipation.
3. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) pkt
PO BID (2 times a day).
4. Lantus 100 unit/mL Solution Sig: Sixteen (16) units
Subcutaneous every morning.
5. Insulin sliding scale
As per attached sheet
6. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
7. labetalol 200 mg Tablet Sig: Three (3) Tablet PO Q 8H (Every
8 Hours).
8. ondansetron 4 mg Tablet, Rapid Dissolve Sig: [**1-19**] Tablet,
Rapid Dissolves PO every 6-8 hours as needed for nausea.
9. prochlorperazine maleate 5 mg Tablet Sig: 1-2 Tablets PO
every 6-8 hours as needed for nausea.
10. atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 23607**] Nursing and Rehab Center - [**Location (un) 8973**]
Discharge Diagnosis:
Primary:
- Hypertension
- Diabetes Mellitus
- Constipation
- Respiratory Failure
- Aspiration Pneumonia
Secondary:
- Metastatic Pheochromocytoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr [**Known lastname **],
You were admitted to [**Hospital1 18**] for the concern of nausea, poor
eating, and generally feeling unwell. We performed an MRI of
your abdomen that unfortunately showed that your disease has
progressed. While you were here, we made some adjustments to
your medications for your blood pressure. You also underwent
insulin allergy testing, which demonstrated that you do not have
an allergy to insulin. You were started on an insulin regimen
to help control your sugars in the outpatient setting.
You spent a period of time in the intensive care unit after
having difficulty breathing. This was likely related to food
traveling into your lung. You were treated with antibiotics, and
recovered quickly.
Please STOP the following medications after discharge:
DILTIAZEM
METFORMIN
GLIPIZIDE
Please INCREASE the following medications:
From DOXAZOSIN 4 mg daily to 4mg twice daily
Please START the following medications:
INSULIN (as per medication sheet)
POLYETHYLENE GLYCOL
COLACE
ATENOLOL
If you experience any symptoms that concern you after leaving
the hospital, please call your primary care doctor or return to
the emergency room.
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: MONDAY [**2200-4-28**] at 4:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6198**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2200-5-2**] at 2:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6198**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: THURSDAY [**2200-5-8**] at 12:00 PM
With: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 13645**], M.D. [**Telephone/Fax (1) 1803**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: THURSDAY [**2200-5-8**] at 10:20 AM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: THURSDAY [**2200-5-8**] at 10:40 AM
With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1368**]
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,191
| 114,997
|
24505
|
Discharge summary
|
report
|
Admission Date: [**2174-5-22**] Discharge Date: [**2174-6-21**]
Date of Birth: [**2107-7-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Biliary drain placement
Intubation and extubation
Central line placement
Radial arterial line placement
History of Present Illness:
66 year-old gentleman who initially presented on [**2174-5-22**] from an
outside hospital with a 3 day history of abdominal pain and one
day history of fever. The pt. was found to have acute hepatitis
and pancreatitis at the OSH. He quickly became hypotensive on
the floor with systolic blood pressures in the 60s. He was
started on pressors, as well as Unasyn and Flagyl for presumed
sepsis. He was transferred to [**Hospital1 18**] for further management. On
arrival at [**Hospital1 18**], he was started on levofloxacin and cefepime.
He was intubated and sedated on HD 1 for worsening mental status
and acidosis. He was found to be bacteremic with Klebsiella
pnuemoniae ([**5-24**]).
Past Medical History:
-HTN
-alcohol abuse
-pulmonic stenosis s/p bovine valve replacement in [**2127**]
-colon polyps s/p open excision
Social History:
Pt is retired and has a very large and supportive family. His
daughter works on the board at [**Hospital1 18**]. He has a heavy etoh abuse
history but did not smoke.
Family History:
His sister has CAD, mother had breast cancer.
Physical Exam:
97.5 HR 108 BP 100/54 RR 26 %Sat 92 on 2L
Gen: Tired, jaundiced, slightly labored breathing
HEENT: Mild icterus bilateral, O/P dry
Neck: Supple, no cervical LAD, RIJ in place, could not assess
JVP due to RIJ dressing
Chest: Decreased breath sounds bilaterally
Cor: Tachy no rubs/m/g
Abd: Soft, Distended, tender to deep palpation, no rebound and
no guarding
Ext: cool, trace edema bilaterally, DP/PT pulses dopplerable
Neuro: A+O x 3, grossly non-focal. Garbled voice. No tremor.
Pertinent Results:
RUQ U/S:
1) Distended gallbladder, with pericholecystic edema and sludge.
Common bile duct is not dilated; there is no biliary ductal
dilatation. Findings may be consistent with acute cholecystitis,
in the appropriate clinical setting.
2) Incidental note of adenomyomatosis.
CT Abd/Pelvis:
1) Lack of appropriate contrast in spleen, concerning for
splenic infarction or low flow state .
2) Stenotic but patent celiac axis and superior mesenteric
artery.
3) Changes of chronic liver disease, with left lobe hypertrophy,
chronic portal vein thrombosis, extensive vascular
collateralization, and small- moderate amount of ascites.
4) Dilated gallbladder, with gallbladder wall edema, as seen on
ultrasound of [**2174-5-22**]. Gallbladder wall edema may be due to
ascites or third spacing of fluid.
Repeat RUQ U/S:
Transabdominal ultrasound examination was performed. The
gallbladder is decompressed with cholecystostomy tube fitted in
the gallbladder fossa. The common duct is not dilated and
measures five millimeters.
Repeat Chest/Abd/Pelvis CT:
1) Moderate bilateral pleural effusions. Nonspecific nodules
within bilateral lung bases, as described above.
2) Pigtail cholecytstostomy catheter in place, with tip in
gallbladder fossa. 4 mm stone remains in gallbladder neck.
3) Intraabdominal ascites, with no loculated, or drainable fluid
collections. No evidence of abscess formation. 2.9 x 1.4 cm
hypodense lesion within the interpolar right kidney with mild
enhancement possibly a hyperdense cyst, but not clearly
characterized on this study. Ultrasound may be helpful for
further evaluation.
4) Sigmoid diverticulosis without evidence of diverticulitis.
5) Anasarca.
EEG:
This is a normal portable EEG. No lateralizing or
epileptiform abnormalities were seen.
Brief Hospital Course:
66y/o male with htn, etoh abuse, admitted with klebsiella
cholecystitis/sepsis, complicated by a altered mental status,
difficult vent wean, pancreatitis, ARF, and DIC.
Mr. [**Known lastname 61944**] came into the hospital with Klebsiella sepsis and
cholecystitis. The initial management included starting at
first empiric antibiotics (then changed to meropenem once
sensitivities came back), intubation for hypoxic respiratory
failure, and a percutaneous gallbladder drain. His initial ICU
course was marked by multiple problems, including persistent
hypotension requiring pressors, difficult vent wean, acute renal
failure from acute tubular necrosis, hepatitis, pancreatitis,
and DIC. However, his hemodynamics improved to the point where
he maintained an adequate blood pressure off pressors and he
eventually self-extubated himself and did well. He remained in
nearly anuric renal failure, dependent on hemodialysis, in DIC,
and had delirium.
Just prior to being called out to the general medicine floor,
blood cultures (drawn for a low grade temperature elevation)
came back with 4/4 bottles positive for gram positive cocci in
pairs and clusters. His central and arterial lines were all
pulled, and he was empirically started and vancomycin. He
remained hemodynamically stable and did not require pressors.
An surface and esophogeal echocardiograms failed to demonstrate
vegetations. He did well for approximatelt 72 hours on the
floor when he had a blood bowel movement, became hypotensive,
and returned to the ICU.
There his hemodynamics were initially stable. Concern for an
active GI bleed seemed incorrect as following stools were guaiac
negative and his hematocrit remained stable. However, his
hemodynamic status began to decline and he was started on first
norepinephrine and then vasopressin drips to support his blood
pressure. Follow-up blood cultures were negative, he had no
fever and but an increased WBC, ECG showed no changes. As there
as concern for cholangitis/[**Last Name (LF) 61945**], [**First Name3 (LF) **] MRCP was performed
that showed a non-distended GB and was otherwise fairly
unremarkable. A U/S was performed to look for ascited and a
place to tap; the imaging showed moderate ascites, and a tap was
performed that was grossly bloody. With concern for a possible
perforation, an abdominal CT was performed that showed extensive
bowel ischemia and splenic infarcts.
At this point, the patient's hemodynamic status continued to
decline and he was reintubated. Discussions were held with the
family, who said that this course of treatment would not have
been consistent with the patient's wishes and that they wanted
to stop treatment and make him comfortable. This was done and
the patient died soon thereafter.
Discharge Disposition:
Expired
Discharge Diagnosis:
Septic shock
Klebsiella sepsis
Klebsiella cholescytitis
Delirium
Hypoxic respiratory failure
Ischemic hepatitis
Pancreatitis
Bowel ischemia/infarction
Acute tubular necrosis
Acute renal failure
Hemolysis
Dissemintated intravascular coagulation
Secondary:
Coronary artery disease
Hypertension
Alcohol abuse
Discharge Condition:
Expired
|
[
"577.0",
"584.5",
"053.9",
"286.7",
"357.82",
"571.1",
"348.39",
"305.00",
"359.81",
"557.0",
"575.0",
"038.49",
"286.6",
"570",
"578.1",
"428.0",
"560.1",
"041.11",
"567.8",
"995.92",
"996.62",
"518.81",
"785.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.05",
"33.24",
"38.93",
"88.72",
"46.32",
"96.6",
"99.15",
"99.04",
"38.95",
"96.72",
"96.04",
"51.01",
"00.17",
"99.07",
"39.95",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
6631, 6640
|
3844, 6608
|
329, 434
|
6989, 6999
|
2051, 3821
|
1488, 1535
|
6661, 6968
|
1550, 2032
|
275, 291
|
462, 1150
|
1172, 1287
|
1303, 1472
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,123
| 196,551
|
3583
|
Discharge summary
|
report
|
Admission Date: [**2199-12-5**] Discharge Date: [**2199-12-12**]
Date of Birth: [**2125-4-12**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1148**]
Chief Complaint:
LE cellulitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 16352**] is a 74 yo female with PMH significant for
diabetic neuropathy, chronic lower extremity edema, and
recurrent lower extremity cellulitis. She presented to her PCP
this AM and was found to have bilateral cellulitis with green
discharge between her left toes. She was sent to the ED for
further work-up. Patient notes increased swelling, erythema, and
warmth of her lower extremites over the past few days. Due to
her neuropathy she is unable to feel anything on her feet. She
states that she or her visiting nurses not noticed the green
discharge.
She denies any recent fevers, chills, cough, or any other
concerning symptoms. In the ED initial vitals were T 97.6 BP
156/66 AR 78 RR 18 O2 sat 97% RA. She received Vancomycin 1gm IV
and Cipro 400mg IV.
Past Medical History:
1)Chronic atrial fibrillation.
2)Type 2 Diabetes complicated by peripheral neuropathy
3)Hypertension
4)Hyperlipidemia
5)PVD s/p bilateral fem [**Doctor Last Name **] bypasses
6)Colon cancer [**2187**] s/p colectomy, treatment with 5-FU, in
remission since.
7)Bilateral cataracts
8)Obstructive sleep apnea
9)Urge incontinence
Social History:
Patient is retired and formerly worked at [**Location (un) 8599**]Hospital
in computers. She lives alone in senior housing in [**Location (un) 686**].
She has several close friends that help her with her shopping
and getting to appointments. She has a remote smoking and
alcohol history (puffed an occasional cigarette in social
gatherings 50 years ago) denies any illict drug use.
Family History:
NC
Physical Exam:
vitals T 98.4 BP 136/78 AR 84 RR 18 O2 sat 95% RA
Gen: Awake and alert, NAD, pleasant female
HEENT: MM dry
Heart: irreg, irreg, no s3/s4, no m,r,g
Lungs: CTAB, poor air movement but no crackles
Abdomen: obese, soft, NT/ND, +BS
Extremities: Bilateral edema, chronic venous stasis changes with
overlying erythema & warmth, 2+ DP/PT pulses; + discharge
between L 1st and 2nd toes, +escoriations on R shin
Pertinent Results:
Laboratory results:
[**2199-12-5**] 01:45PM BLOOD WBC-8.8 RBC-3.27* Hgb-9.4* Hct-26.9*
MCV-82 MCH-28.6 MCHC-34.9 RDW-14.1 Plt Ct-328
[**2199-12-11**] 05:49AM BLOOD WBC-8.9 RBC-3.29* Hgb-9.2* Hct-27.3*
MCV-83 MCH-27.9 MCHC-33.6 RDW-14.0 Plt Ct-375
[**2199-12-6**] 05:39AM BLOOD PT-12.4 PTT-30.5 INR(PT)-1.1
[**2199-12-5**] 01:45PM BLOOD Glucose-165* UreaN-57* Creat-1.7* Na-139
K-5.1 Cl-101 HCO3-28 AnGap-15
[**2199-12-11**] 05:49AM BLOOD Glucose-76 UreaN-68* Creat-1.6* Na-140
K-4.1 Cl-97 HCO3-30 AnGap-17
[**2199-12-11**] 05:49AM BLOOD Calcium-9.1 Phos-4.6* Mg-2.2
Relevant Imaging:
1)L foot xray ([**12-6**]): No evidence of osteomyelitis
2)Cxray ([**12-6**]): No infiltrate, evidence of heart failure
Brief Hospital Course:
Ms. [**Known lastname 16352**] is a 74 yo female with PMH significant for DM,
HTN and atrial fibrillation who presents with bilateral LLE
cellulitis. Her hospital course was complicated by increased
respiratory distress and was transferred to the ICU overnight
for closer monitoring.
1)Cellulitis: Patient presented with LE erythema, warmth, and
discharge from the [**Hospital 191**] clinic. She was hospitalized for
cellulitis in [**7-7**] and cultures grew Pseudomonas, which was
sensitive to Cipro. She received Vancomycin and Cipro in the ED.
She remained afebrile with no leukocytosis during her hospital
stay. She was continued on Cipro IV and Vancomycin was added for
gram + coverage. Cipro changed to PO and she was continued on
Vancomycin for +MRSA in wound cultures. PICC line was placed.
She will require 2 week course of antibiotics to be completed on
[**2199-12-19**]. Vancomycin levels should be monitored closely with goal
between 15-20. Podiatry was consulted and they recommended daily
betadine dressing of the L foot. She is scheduled for follow-up
in the podiatry clinic as listed in the discharge instructions.
2)Respiratory distress: Patient acutely decompensated 1-2 days
into admission with increased O2 requirements and a drop in her
O2 saturation into the 70's. Cxray suggested acute pulmonary
edema. This occurred on her last admission and the cause is
unclear. Cardiac enzymes were negative. She was transferred to
the ICU for closer monitoring and was diuresed agressively with
improvement in her respiratory status. She is on Lasix 20mg TID
at home and this was changed to Lasix 40mg [**Hospital1 **] after she
returned to the medical floor. Her daily I/O's and weights were
closely monitored.
3)Pulmonary hypertension: Secondary to long standing sleep
apnea. Patient has failed multiple CPAP trials on prior
admissions due to urinary incontinence. Pulmonary was consulted
in the ICU and they recommended the following tests once her
volume status had improved: repeat ECHO, R heart
catheterization, PFT's, and CT scan to r/o interstitial lung
disease. CT scan was done during this admission which did not
suggest significant ILD.
4)Hypertension: Patient was continued on home regimen of
Norvasc, Diltiazem, and Lisinopril.
5)Acute on chronic renal failure: Patient's baseline creatinine
is between 1.3-1.5. Initially 1.7 and decreased to 1.6 on day of
discharge. Likely pre-renal component based on physical exam. No
further work-up was done during this admission.
6)Diabetes: Patient continued on home regimen of Insulin 70/30
15 units [**Hospital1 **] with sliding scale. Her sugars were well
controlled.
7)Atrial fibrillation: Patient remains in afib on exam. She
remains asymptomatic. She continues to refuse anti-coagulation.
She was maintained on Diltiazem for rate control.
8)Urinary incontinence: Patient is on long acting form of
Ditropan at home. She was placed on the short acting form on
admission since the long acting form was not available on
formulary. She complained of increased incontinence, likely
secondary to being on short acting form. She was discharged on
long acting form.
9)Anemia: Baseline Hct~ 27. Likely anemia of chronic disease
secondary to chronic renal insufficiency. No further work-up was
done during this admission.
10)Sleep apnea: Patient has been tried on CPAP in the past but
has not been able to wear mask at night due to incontinence. She
underwent CPAP trial during this admission and tolerated well.
She does not want to wear since she has difficulties wearing the
mask and has to go to the bathroom several times during the
night.
Medications on Admission:
Norvasc 10mg PO daily
Diltiazem 240mg PO daily
Aspirin 81mg PO daily
Lisinopril 40mg PO daily
Ditropan 15mg PO daily
Lasix 20mg PO TID
Iron Polysaccharides Complex 150 mg PO daily
Insulin 70/30 15u [**Hospital1 **]
Docusate 100mg PO daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day). Capsule(s)
4. Ciprofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q24H
(every 24 hours): pt will complete course on [**2199-12-19**].
5. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO DAILY (Daily).
9. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: 1000 (1000)
milligrams Intravenous Q48H (every 48 hours): please stop on
[**12-19**].
12. Ditropan XL 15 mg Tab,Sust Rel Osmotic Push 24HR Sig: One
(1) Tab,Sust Rel Osmotic Push 24HR PO once a day.
13. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) patch
Transdermal once a week: changed on Mondays.
14. Insulin regimen
Please continue home regimen of Insulin 70/30 15 units twice
daily. Also cover with insulin sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 392**] Rehabilitation & Nursing Center - [**Hospital1 392**]
Discharge Diagnosis:
Primary diagnosis:
1)Cellulitis
2)Congestive heart failure
3)Pulmonary hypertension
4)Hypertension
5)Diabetes
Secondary diagnoses:
1)Atrial fibrillation
2)Urinary incontinence
3)Anemia
4)Chronic renal insufficiency
Discharge Condition:
Stable
Discharge Instructions:
1)Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet.
2)Please take all medications as listed in the discharge
instructions. Few changes have been made, please note them.
3)You have also been started on 2 antibiotics for your
cellulitis. You must take these antibiotics for 2 weeks. You
will complete your antibiotic course on [**2199-12-19**].
4)Please attend all appointments that have been scheduled for
you. Please see below.
5)If you experience any fevers, chills, chest pain, SOB,
dizziness or any other concerning symptoms please return to the
emergency department.
Followup Instructions:
1)Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**] in Podiatry Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2199-12-19**] 11:40
2)Provider: [**First Name4 (NamePattern1) 247**] [**Last Name (NamePattern1) 248**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2200-2-25**] 9:00
|
[
"285.21",
"403.90",
"327.23",
"V10.05",
"585.9",
"416.8",
"428.0",
"357.2",
"428.33",
"682.7",
"584.9",
"427.31",
"250.60",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"86.28"
] |
icd9pcs
|
[
[
[]
]
] |
8323, 8422
|
3087, 6704
|
330, 337
|
8682, 8691
|
2356, 2923
|
9365, 9682
|
1914, 1918
|
6994, 8300
|
8443, 8443
|
6730, 6971
|
8715, 9342
|
1933, 2337
|
8575, 8661
|
277, 292
|
2941, 3064
|
365, 1148
|
8462, 8554
|
1170, 1497
|
1513, 1898
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,338
| 162,619
|
28143
|
Discharge summary
|
report
|
Admission Date: [**2131-1-10**] Discharge Date: [**2131-1-17**]
Date of Birth: [**2069-9-12**] Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 8850**]
Chief Complaint:
Headache and right facial droop.
Major Surgical or Invasive Procedure:
CT guided stereotaxic biopsy.
History of Present Illness:
This is a 61-yearold right-handed woman with history of
migraines, glaucoma who presented from [**Hospital1 18**] at [**Location (un) 620**] for
further evaluation of abnormal finding brain MRI findings.
Patient was seeing Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 68413**] for several months for
chronic right hip pain and acute on chronic headache, when she
noticed that she had a facial droop. The timeline of the onset
of this new finding remains unclear, she states that she has
always had an asymmetrical face. A brain MRI was ordered and
found to be abnormal with lesion noted in the left thalamus.
She reports a history of migraines for the past 20 years.
However, she reports headaches which have become progressively
worse over the past 1 month and these headaches have now tended
to wake her up from bed. She also reports subtle speech changes
which was first been noticed by her sister. She further reports
ataxia She denies any seizures, fever, chills, niight sweat or
weight lost.
On general review of systems, the pt denies recent fever or
chills. Denies cough, shortness of breath. She denies chest
pain or tightness, palpitations. She denies nausea, vomiting,
diarrhea, constipation or abdominal pain. She has no recent
change in bowel or bladder habits. She has no dysuria. She
denies arthralgias, myalgias, or rash.
Neurological Review of Systems: She denies other than those
mentioned in the HPI.
Past Medical History:
-Diverticulosis
-Migraine Headaches: left frontal, occasionally migraine to the
back of the left head, with photophobia, nausea, ultimately
severe. She sees a Dr. [**Last Name (STitle) 68414**] at the [**State 17405**] for this, at his headache treatment center, and
has had considerable improvement after starting verapamil as a
prophylactic [**Doctor Last Name 360**]. She tried other agents such as amitriptyline
10 mg which made her very groggy, and Topamax which gave her
insomnia and other side effects.
-MGUS
-Glaucoma
-Chronic Dry Eyes
-Constipation
-Benign ovarian tumor status post resection
-Breast lumps
-L4/L5 radiculopathy
Social History:
She is a part-time teacher of English as a foreign language at
the SHOA Institute in [**Location (un) 538**]. She holds a master's
degree. She lives with his sister. She does not smoke. She
uses alcohol rarely.
Family History:
It is notable for idiopathic pulmonary fibrosis, colorectal
cancer, and HIV in her father, and [**Name (NI) **] granulomatosis in a
sister. There is also B-cell lymphoma in her family. She does
not have children.
Physical Exam:
VITAL SIGNS: Temperature 97.2 F, blood pressure 110/60, pulse
62, respiration 18, and Karofsky Performance Score 80.
GENERAL: Awake, cooperative, NAD.
SKIN: No rashes or lesions noted.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted
in oropharynx.
NECK: Supple, no masses or lymphadenopathy.
PULMONARY: Lungs CTA bilaterally without R/R/W.
CARDIOVASCULAR: RRR, nl. S1S2, no M/R/G noted.
ABDOMEN: Soft, NT/ND, no masses or organomegaly noted.
EXTREMITIES: Warm and well perfused.
NEUROLOGICAL EXAMINATION:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name [**Doctor Last Name 1841**] backward
without difficulty. Language is fluent with intact repetition
and comprehension. Normal prosody. There were no paraphasic
errors. Patient was able to name both high and low frequency
objects. She is able to read without difficulty. Speech was
slightly dysarthric. She is able to follow both midline and
appendicular commands. She is able to register 3 objects and
recall [**3-17**] at 5 minutes. She has good knowledge of current
events. There was no evidence of apraxia or
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV and VI: EOM are intact and full, no nystagmus.
V: Facial sensation intact to light touch.
VII: Right nasal labial flattening, facial musculature
symmetric during smile.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. pronator drift on right.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
R 5- 4+ 4+ 5 5 5 5 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
proprioception throughout. No extinction to DSS.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 3 1
R 2 2 2 2 1
Plantar response: mute bilaterally
-Coordination: No intention tremor, no dysdiadochokinesia
noted. No dysmetria on FNF or HKS bilaterally.
-Gait: Defered.
Pertinent Results:
Admission Labs:
[**2131-1-10**] 07:50PM BLOOD WBC-3.1* RBC-4.54 Hgb-13.8 Hct-39.8
MCV-88 MCH-30.4 MCHC-34.7 RDW-13.5 Plt Ct-221
[**2131-1-10**] 07:50PM BLOOD Neuts-52.2 Lymphs-38.7 Monos-6.8 Eos-1.9
Baso-0.4
[**2131-1-10**] 07:50PM BLOOD PT-11.7 PTT-28.5 INR(PT)-1.1
[**2131-1-10**] 07:50PM BLOOD CD5-DONE CD16-DONE CD23-DONE CD56-DONE
CD45-DONE HLA-DR[**Last Name (STitle) 7735**] [**Name (STitle) 7736**]7-DONE Kappa-DONE CD2-DONE CD7-DONE
CD10-DONE CD19-DONE CD20-DONE Lambda-DONE CD57-DONE
[**2131-1-10**] 07:50PM BLOOD CD3%-DONE CD4%-DONE CD8%-DONE
[**2131-1-10**] 07:50PM BLOOD IPT-DONE
[**2131-1-10**] 07:50PM BLOOD Glucose-130* UreaN-14 Creat-0.6 Na-136
K-3.9 Cl-101 HCO3-28 AnGap-11
[**2131-1-10**] 07:50PM BLOOD ALT-38 AST-49* LD(LDH)-281* AlkPhos-98
TotBili-0.3
[**2131-1-10**] 07:50PM BLOOD TotProt-7.1 Albumin-4.2 Globuln-2.9
Calcium-9.5 Phos-3.6 Mg-2.0
[**2131-1-10**] 07:50PM BLOOD PEP-ABNORMAL B b2micro-3.0*
IFE-MONOCLONAL
[**2131-1-10**] 07:50PM BLOOD HIV Ab-NEGATIVE
[**2131-1-10**] 07:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Imaging:
CT Chest, Abdomen, and Pelvis
FINDINGS:
CHEST: No evidence for axillary, hilar, or mediastinal
lymphadenopathy. No pleural effusions. A 2-mm nodule is
identified in the superior aspect of the right lower lobe and a
4-mm nodule is identified in the superior aspect of the left
lower lobe. Followup imaging is recommended. A 10-mm bleb is
identified in the left lower lobe as also a 2.3-cm bleb in the
medial aspect of the right lower lobe.
ABDOMEN: The liver and spleen are normal in size. No focal
hepatic lesions are identified. The gallbladder, pancreas,
adrenals, and kidneys are unremarkable. There is no evidence for
hydronephrosis or nephrolithiasis. There is no retroperitoneal
or mesenteric lymphadenopathy.
PELVIS: The small and large bowel is unremarkable. The patient
is status
post hysterectomy and bilateral salpingo-oophorectomy. The
urinary bladder is well distended and does not show any gross
abnormalities. Review of images on bone windows does not show
any suspicious bony lesions.
IMPRESSION:
1. No systemic processes such as lymphoma are identified. No
evidence for
lymphadenopathy.
2. A 2-mm pulmonary nodule is identified in the right lower lobe
and a 4-mm pulmonary nodule is identified in the left lower
lobe. Followup imaging is recommended.
MRI Cervical, Thoracic, and Lumbar Spine
FINDINGS: There is normal lordotic curvature of the cervical
and lumbar as well as kyphotic curvature of the thoracic spine.
There is mild
anterolisthesis of C4 on C5 (less than grade 1). Otherwise, the
dorsal
alignment as well as vertebral body height are well maintained.
The vertebral body bone marrow signal is likewise unremarkable.
Discrete disc bulges at the level of the cervical spine are
identified at
C4/C5, C5/C6, and C6/C7, mildly indenting the anterior thecal
sac, but without evidence of spinal canal stenosis.
No significant degenerative changes are seen involving the
thoracic spine.
At L3/L4, there is diffuse disc bulge with superimposed right
foraminal
protrusion. The spinal canal is patent, the right neural foramen
is mildly narrowed by facet joint osteophytes and disc material.
At L4/L5, there is diffuse disc bulge without spinal canal
stenosis. The
bilateral neural foramina are narrowed by facet joint
arthropathy, mild on the left and moderate on the right.
At L5/S1, there is loss of disc height with diffuse bulge, but
no spinal canal stenosis. The bilateral neural foramina are
narrowed due to facet joint arthropathy and posterior endplate
osteophytes, moderate on the right and mild on the left.
The craniocervical junction is normal. The cervical and thoracic
cord, conus and cauda equina demonstrate normal morphology and
intrinsic T2 signal. There is no abnormal enhancement involving
cord, conus, cauda, or meninges. The posterior elements and
paraspinal soft tissues are unremarkable.
IMPRESSION:
1. No evidence of medullary involvement or leptomeningeal
spread.
2. Mild degenerative changes involving the cervical and lumbar
spine as
detailed above.
CT Head:
FINDINGS: A CT stereotaxis devise surrounds the visualized
aspect of the brain. Centered within the left thalamus there is
a 14 x 9 mm hyperattenuating focal lesion, presumed to be
related to the lesion of interest. In addition a second more
linear focus of hyperattenuation is demonstrated within the left
temporal subinsular region (2:22) measuring up to 11 mm. There
is surrounding hypoattenuation compatible with adjacent edema.
There is associated mass effect with mild rightward shift of
normally midline structures by approximately 6 mm. Evaluation of
the posterior far fossa is extremely limited by artifact.
There is no evidence of acute infarction with preservation of
the [**Doctor Last Name 352**]-white matter differentiation. The ventricles and sulci
are normal in size and configuration. There is no acute
fracture. The visualized portions of the paranasal sinuses and
mastoid air cells are well aerated.
IMPRESSION: CT stereotaxis of known hyperattenuating lesion
measuring up to 1.4 cm centered within the left thalamus with
associated surrounding vasogenic edema and mass effect with
shift of normally midline structures to the right by 6 mm.
Echocardiogram:
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 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 appears structurally normal
with trivial mitral regurgitation. There is no mitral valve
prolapse. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. No clinically-significant valvular disease seen.
CT HEAD W/O CONTRAST:
FINDINGS: A small amount of air and hemorrhage along the biopsy
tract is
stable. Vasogenic edema surrounding the left thalamic lesion,
exerts stable rightward shift of normally midline structures
measuring approximately 7 mm. No new hemorrhage, major vascular
territorial infarction, edema, mass or hydrocephalus is noted.
Left frontal pneumocephalus is unchanged. A left frontal burr
hole is again seen. Size of the ventricles and sulci is
unchanged. The basal cisterns are patent. Visualized paranasal
sinuses and mastoid air cells are well aerated.
IMPRESSION: Stable post-biopsy changes after biopsy of a left
thalamic
lesion. Biopsy tract blood products and associated vasogenic
edema are
stable.
CSF
[**2131-1-11**] 01:27PM CEREBROSPINAL FLUID (CSF) WBC-4 RBC-1* Polys-0
Lymphs-80 Monos-20
[**2131-1-11**] 01:27PM CEREBROSPINAL FLUID (CSF) TotProt-78*
Glucose-60 LD(LDH)-25
[**2131-1-11**] 01:27PM CEREBROSPINAL FLUID (CSF) CSF-PEP-NO OLIGOCL
METHOTREXATE LEVELS:
[**2131-1-17**] 05:13AM BLOOD mthotrx-0.02
[**2131-1-16**] 05:49PM BLOOD mthotrx-0.05
[**2131-1-16**] 05:49AM BLOOD mthotrx-0.07
DISCHARGE LABS:
[**2131-1-17**] 05:13AM BLOOD WBC-5.2 RBC-3.89* Hgb-11.8* Hct-34.4*
MCV-88 MCH-30.4 MCHC-34.4 RDW-13.5 Plt Ct-209
[**2131-1-17**] 05:13AM BLOOD Glucose-107* UreaN-10 Creat-0.4 Na-136
K-3.4 Cl-99 HCO3-29 AnGap-11
[**2131-1-17**] 05:13AM BLOOD ALT-230* AST-241* LD(LDH)-375* AlkPhos-78
TotBili-0.3
[**2131-1-17**] 05:13AM BLOOD Calcium-8.8 Phos-3.7 Mg-1.8
Brief Hospital Course:
Ms. [**Known firstname **] [**Last Name (NamePattern1) **] is a 61-year-old woman with a history of
diverticulosis, migraine headaches, glaucoma, L4/l5
radiculopathy on gabapentin presenting with worsening headaches
and a right facial droop, found to have a left thalamic contrast
enhancing mass on MRI.
(1) Likely CNS Lymphoma: Examination on admission was notable
for a mild right facial droop, and mild right arm weakness in an
UMN pattern. On admission she underwent a lumbar puncture for
cytology, results still pending. On [**1-13**] she underwent a
stereotactic guided biopsy of the thalamic lesion, with
preliminary pathology consistent with lymphoma, for which she
was transferred to the floor for treatment with high dose
methotrexate. Patient on arrival to floor had infusion on [**1-14**],
with alkalkination of urine to PH >8 which was consistently
monitored. Her Methotrexate levels were drawn and found to be
very low .02 prior to discharge. She also underwent a
leucovorin rescue s/p infusion of methotrexate. Patient's
pathology from her biopsy was concerning for CNS lymphoma. She
was given dexamethasone for help with intracranial swelling post
biopsy, and also due to her nausea/headache symptoms. She will
continue the dexamehtasone as an outpatient.
(2) Headache: Likely combination of post-op pain and migraine.
Her home verapmil was changed to short acting while inpatient,
and she was given dexamethasone and Fioricet PRN with good
improvement in her headache. Her home Maxalt was stopped.
(3) Nausea: Patient was given reglan, and zofran for help with
nausea emesis. This was relieved prior to discharge without any
episodes of emesis.
(4) Cataracts: Continued on home eye gtts
(5) Rosacea: Contnued home doxycycline
(6) Code Status: Full Code
TRANSITIONAL ISSUES:
(1) Patient will be admitted on Friday [**2131-1-26**] for Port-a-Cath
placement with plan for another cycle of induction high-dose
methotrexate.
Medications on Admission:
Restasis eye drops
Timolol eye 1 drop both eyes
Omega-3 fatty acids
Flax Seed
Doxycycline 100BID
Maxalt 10mg PRN migraine
Aleve PRN migraine
Fioricet PRN migraine
Gabapentin 300mg daily
Fluticasone Spray
Verapamil 480mg daily
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for headache, fever T>38.3C.
2. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
3. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
4. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic
DAILY (Daily).
5. cyclosporine 0.05 % Dropperette Sig: One (1) Drop Ophthalmic
[**Hospital1 **] (2 times a day).
6. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
9. verapamil 240 mg Tablet Extended Release Sig: Two (2) Tablet
Extended Release PO once a day.
10. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: One
(1) Tablet PO Q8H (every 8 hours) as needed for headache.
11. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
12. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO twice
a day.
13. omega-3 fatty acids-fish oil 300-1,000 mg Capsule Sig: One
(1) Capsule PO once a day. Capsule(s)
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: CNS Lymphoma
Secondary Diagnosis:
-Migraine Headaches
-Monclonal Gammopathy of Undertermined Significance
-Glaucoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Dear Ms. [**Name13 (STitle) **],
You were admitted to [**Hospital1 18**] after having some neurological issues
with facial droop and headaches. You were seen by the
Neurosurgery team who performed a biopsy in your brain.
Aftewards, you received a CT scan of your head due to concern
for swelling/bleeding in the brain which was negative. The
prelimnary biopsy results were consistent with a lymphoma, and
therfore you were given a dose of chemotherapy treatment
(methotrexate). You were monitored during the infusion of your
chemotherapy, and will require more therapy. Please see your
scheduling below as you will need to have a port placed in order
to receive your chemo infusions in the future. You will be
discharged on a steroid medication in order to help you with
your headaches, please take this as prescribed.
MEDICATION CHANGES:
START Dexamethasone as prescribed
STOP Maxalt 10mg
General Instructions:
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures have been removed.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? You were NOT on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin, prior to your surgery, if a
physician [**Name9 (PRE) 68415**] these medications to you please call our
office prior to initiation.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
?????? You are scheduled to have a port-a-cath placed on Friday
[**2131-1-26**]. You should check in at 11 [**Hospital Ward Name 1827**] around 10:00 AM for
placement. You will be admitted following the procedure and are
scheduled for chemotherapy 3 days later. You will have your
sutures removed by surgery at that time.
?????? 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.
|
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icd9cm
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,963
| 126,924
|
37464
|
Discharge summary
|
report
|
Admission Date: [**2140-11-21**] Discharge Date: [**2140-11-23**]
Date of Birth: [**2064-8-19**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor First Name 1402**]
Chief Complaint:
Post-procedural hypotension
Major Surgical or Invasive Procedure:
Atrial Fibrillation ablation
History of Present Illness:
Ms. [**Known lastname 10446**] is 76 year old woman has a history of myasthenia
[**Last Name (un) 2902**], atrial fibrillation and aortic stenosis s/p
bioprosthetic AVR who is was admitted to the CCU for hypotension
after an AF ablation earlier in the day.
In [**2139-9-26**] she underwent an AFib ablation at [**Hospital1 **] by Dr. [**Last Name (STitle) 3271**]. She subsequently had recurrence
of her AF and, in [**2140-1-24**], she had a bioprosthetic aortic
valve replacement, excision of left atrial appendage, and
pulmonary vein isolation.
She again had a subsequent return of her atrial fibrillation and
underwent successful DC cardioversion in [**2140-5-25**] with early
recurrence. She underwent repeat DC cardioversion in [**2140-6-25**]
and was initiated on sotalol 80mg b.i.d. In [**2140-9-25**] she
was admitted to [**Hospital3 **] with persistent palpitations and
tachycardia, possibly flutter versus atrial tachycardia at 120
bpm. She was rate controlled with the addition of diltiazem, to
which she responded well symptomatically, and was referred to
the [**Hospital1 18**] EP service for repeat ablation.
On the day of admission the patient underwent elective AF/AT
ablation. The procedure lasted more than six hours, during which
the patient was intubated. Near the end of the procedure, the
patient was noted to be hypotensive (systolics in the high 60s
on two occasions by report). She was started on peripheral
dopamine at 5 mcg/kg/hr with a good response in her BP. An
informal echocardiogram was negative for significant pericardial
effusion. Over the course of her case, she had been given a
total of 3L IVF.
On arrival to the CCU, the patient reported feeling slightly
groggy and fatigued, but otherwise is without complaint. Shortly
after arrival, her dopamine was titrated down to 3 mcg/mg/kg
without significant fall in her BP.
On ROS, she denies any recent fevers or chills. No cough or
wheeze, but some DOE at baseline. No chest, jaw, or arm pressure
or discomfort. No orthopnea, ankle edema, current palpitations,
syncope or presyncope. No abdominal symptoms. No change to bowel
or bladder habbits. No MSK or neuro symptoms. All of the other
review of systems were negative.
Past Medical History:
*Aortic stenosis s/p AVR
*Paroxysmal AF/flutter s/p prior ablation/DC cardioversion
*s/p bioprosthetic AVR/pulmonary vein isolation, excision of
left atrial appendage ([**Hospital6 **], [**1-/2140**])
*GERD
*hypothyroidism
*myasthenia [**Last Name (un) 2902**] with left eye ptosis, left leg weakness,
*occasional difficulty swallowing
*cervical disc disease
*s/p resection of right benign breast lump
*sleep apnea (does not use CPAP)
*s/p bilateral carpal tunnel release
*s/p trigger finger release
*s/p remote left sided hernia repair
*s/p surgical resection of pilonidal cyst
Social History:
Patient is widowed and lives alone. She had 7 children, 5 are
living. She formerly worked as a pharmacy technician and
administrator.
Contact upon discharge: [**Name (NI) **] [**Name (NI) 10446**] (son): [**Telephone/Fax (1) 84171**]
ETOH: none currently.
Tobacco: Quit 30 years ago, former 20 pack years.
Family History:
The patient's father died of a heart related condition in his
late 60s. The patient has a granddaugher who also has AF and
underwent an ablation around age 20. She has a sister who may
also have an atrial arrhythmia. The patient's mother passed away
from a cancer at an advanced age.
Physical Exam:
Gen: Well appearing adult female, no acute distress.
HEENT: PERRL, EOMI. MMM. OP clear. Conjunctiva well pigmented.
Neck: Supple, without adenopathy or JVD. Flat neck veins.
Chest: Lungs clear to auscultation with normal respiratory
effort.
Cor: Normal S1, S2. RRR. No murmurs appreciated.
Abdomen: Soft, non-tender and non-distended. +BS, no HSM.
Extremity: Warm, without edema. 2+ DP pulses bilaterally.
Neuro: Alert and oriented. CN 2-12 intact. Motor strength intact
in all extremities. Sensation intact grossly.
Pertinent Results:
EKG: Sinus versus atrial ectopic rhythm. Ventricular rate of 94.
LAD, LAFB. PR interval 186. Possible mild lateral T wave
flattening.
Brief Hospital Course:
76 yoF with a history of myasthenia, bioprosthetic AVR and
atrial fibrillation/AT now s/p ablation procedure complicated by
hypotension, admitted to the CCU for ongoing monitoring.
1. Hypotension: Most likely precipitated by anesthetics in the
setting of prolonged procedure time, compounded by mild volume
depletion. Patient was initially maintained on peripheral
dopamine to keep MAP > 60, although this was able to weaned off
quickly. Home antihypertensives were initially held.
Post-procedural echo showed normal biventricular cavity sizes
with preserved global and regional biventricular systolic
function, LVEF > 55%. By time of discharge, patient was
normotensive. Metoprolol succinate 25mg was initiated in place
of patient's prior medication regimen of sotalol and diltiazem.
2. Atrial fibrillation: Patient was admitted following
successful atrial fibrillation ablation, in NSR.
Post-procedural echo did show residual atrial septal defect from
instrumentation. Prior antiarrhythmic (sotalol) was
discontinued and patient was started on amiodarone. Once blood
pressure could tolerate, patient was also started on bblockade
with metoprolol for adequate rate control. Patient continued
anticoagulation for CHADS score of 2 with coumadin and was
discharged with INR of 2.1. Of note, patient will need close
monitoring of PT/INR and follow up of TFT, LFTs, and PFT as an
outpatient since recently started amiodarone.
2. Myasthenia [**Last Name (un) 2902**]: stable, continued on patient's home
pyridostigmine. Confirmed with neurology that amiodarone should
not interact with pyridostigmine.
3. Hypothyroidism: Clinically euthyroid, continued home
levothyroxine.
4. GERD: Continue home omeprazole.
5. OSA: Does not wear CPAP at home. Continued Zonagran.
Monitored on pulse oximetry throughout the night.
Medications on Admission:
DILTIAZEM HCL - 120 mg sustained release daily
LEVOTHYROXINE - 100 mcg - 1 tabletby mouth every morning six
days a week, half a tablet on Wednesdays.
OMEPRAZOLE - 20 mg capsule daily
PYRIDOSTIGMINE BROMIDE - 60 mg TID
SOTALOL - 80 mg [**Hospital1 **]
WARFARIN - 5 mg M/W, 2.5 mg all other days
ZONISAMIDE - 100 mg - 3 capsules by mouth at bedtime
LORATADINE - 10 mg daily
OMEGA-3 FATTY ACIDS [FISH OIL] - 1,200 mg-144 mg capsule daily
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 7 days: last day [**2139-12-1**].
Disp:*120 Tablet(s)* Refills:*2*
2. Acetaminophen 650 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for fever, pain.
3. Zonisamide 100 mg Capsule Sig: Three (3) Capsule PO HS (at
bedtime).
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Pyridostigmine Bromide 60 mg Tablet Sig: One (1) Tablet PO
three times a day.
6. Claritin 10 mg Tablet Sig: One (1) Tablet PO once a day.
7. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO 1X/WEEK
(WE).
8. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO 6X/WEEK
([**Doctor First Name **],MO,TU,TH,FR,SA).
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily) for 1 months.
10. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
11. Outpatient Lab Work
Please check INR on [**2140-11-24**] and call results to Dr. _________
at __________
12. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
13. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day
for 7 days: Start on [**2140-12-1**], last day on [**2140-12-7**].
14. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
Start on [**2140-12-8**] and continue thereafter.
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Atrial fibrillation
[**First Name9 (NamePattern2) **] [**Last Name (un) **]
S/P bioprosthetic AVR
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
You had an atrial fibrillation ablation and you are now in a
normal rhythm with some bursts of atrial fibrillation. You were
started on amiodarone and metoprolol to try to keep you in a
regular rhythm. You will need to have regular monitoring of your
liver, thyroid and lung function while you are on amiodarone.
Dr. [**Last Name (STitle) 3321**] will arrange this after you are home. No lifting
more than 10 pounds for one week. No baths or pools for one
week, you may shower.
.
Medication changes:
1. discontinue sotolol and diltiazem
2. Start amiodarone to prevent atrial fibrillation
3. Start metoprolol to prevent atrial fibrillation
4. Start a baby aspirin daily
Followup Instructions:
Electrophysiology:
[**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone: [**Telephone/Fax (1) 62**] Date/time: [**12-31**] at 2:00pm.
[**Hospital Ward Name 23**] Clinical Center, [**Location (un) 436**], [**Hospital1 18**] [**Hospital Ward Name 516**], [**Location (un) **].
Primary Care:
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) 84172**] [**Name Initial (NameIs) **]. Phone: [**Telephone/Fax (1) 84173**] Date/time: [**12-1**] at
12:00pm.
Please call to confirm appts.
You will get a call from the cardiac MRI office to schedule an
MRI in 1 month. Their number is [**Telephone/Fax (1) 9559**]
|
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26,921
| 117,906
|
23757
|
Discharge summary
|
report
|
Admission Date: [**2113-8-24**] Discharge Date: [**2113-8-30**]
Date of Birth: [**2044-9-24**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamides) / Prednisone / Avelox
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Shortness of breath, Bloody JP drainage
Major Surgical or Invasive Procedure:
[**2113-8-24**] Re-exploration for Bleeding
[**2113-8-25**] Placement of Bilateral Chest Tubes
History of Present Illness:
68 y/o male who is s/p CABG, AVR, MVR, ascending aorta
replacement c/p sternal wound dehiscence requiring pectoralis
major flap and omental flap on [**2113-8-2**] presents from rehab with
increased sanguinous JP output, tachycardia, and tachypnea. In
the ER Hct was found to be 27 down from 32. Taken emergently to
OR for exploration.
Past Medical History:
Coronary artery disease
Aortic Stenosis
Mitral Regurgitation
Atrial Fibrillation
Obesity
Hypertension
Elevated cholesterol
PAF and previous cardioversions and ablation
Chronic obstructive pulmonary disease
PVD/Carotid Disease
Social History:
never used tobacco
retired photographer
rare use of ETOH
lives with wife
Family History:
father expired of MI @54; mother died of CAD @67
Physical Exam:
Post op:
102 A fib 110/68 36/20 CI 2.0 RR 16 100%
NAD
Intubated, sedated
Coarse rhonchi
Irreg irreg heart rate
Sternum with Left pectoral fluid collection
Abdomen soft/NT
Extrem cool, [**1-21**] + edema
Discharge
vitals 98.6, 128/74, 80 SR, 20, 94% on 2L NC wt 108.4kg
neuro alert and oriented x3 nonfocal
pulm clear to ausculation except left base no airation
cardiac RRR no M/R/G
Abd soft, NT, ND +BS last BM [**8-30**]
Ext warm pulses palpable generalized edema +1
Sternal inc with staples healing no drainage no erythema - JP x2
serosang drainage
Bilat old chest sites healing - DSD
Pertinent Results:
[**2113-8-29**] 05:50AM BLOOD WBC-12.1* RBC-3.20* Hgb-9.9* Hct-28.6*
MCV-89 MCH-30.9 MCHC-34.6 RDW-15.1 Plt Ct-368
[**2113-8-24**] 12:08PM BLOOD WBC-12.6* RBC-3.41* Hgb-10.2* Hct-31.0*
MCV-91 MCH-29.9 MCHC-32.9 RDW-15.2 Plt Ct-561*
[**2113-8-24**] 12:08PM BLOOD Neuts-87.3* Bands-0 Lymphs-8.4* Monos-3.0
Eos-0.8 Baso-0.5
[**2113-8-29**] 05:50AM BLOOD Plt Ct-368
[**2113-8-29**] 05:50AM BLOOD PT-14.2* INR(PT)-1.3*
[**2113-8-24**] 12:08PM BLOOD Plt Smr-HIGH Plt Ct-561*
[**2113-8-24**] 12:08PM BLOOD PT-14.9* PTT-24.1 INR(PT)-1.3*
[**2113-8-24**] 02:54PM BLOOD Fibrino-423*
[**2113-8-29**] 05:50AM BLOOD Glucose-98 UreaN-22* Creat-0.8 Na-131*
K-3.9 Cl-92* HCO3-32 AnGap-11
[**2113-8-24**] 10:55AM BLOOD Glucose-156* UreaN-20 Creat-1.0 Na-129*
K-4.2 Cl-90* HCO3-30 AnGap-13
[**2113-8-24**] 10:55AM BLOOD CK(CPK)-424*
[**2113-8-24**] 10:55AM BLOOD CK-MB-6 cTropnT-0.08*
[**2113-8-29**] 05:50AM BLOOD Mg-2.1
RADIOLOGY Preliminary Report
CHEST (PA & LAT) [**2113-8-29**] 11:08 AM
CHEST (PA & LAT)
Reason: s/p CT removal ? ptx
[**Hospital 93**] MEDICAL CONDITION:
68 year old man with AS,AVR
REASON FOR THIS EXAMINATION:
s/p CT removal ? ptx
HISTORY: 68-year-old male with aortic stenosis and aortic valve
replacement, status post chest tube removal, question
pneumothorax.
COMPARISON: Radiographs [**2113-8-28**].
TWO VIEWS OF THE CHEST BY PORTABLE TECHNIQUE: There is a small
right pleural effusion and a small-to-moderate left pleural
effusion. There is a right internal jugular catheter, the tip of
which is in the SVC. There is no change in the cardiomediastinal
contour. No pneumothorax is identified.
IMPRESSION: Small right pleural effusion and small-to-moderate
left pleural effusion. No pneumothorax.
DR. [**First Name (STitle) **] [**Doctor Last Name 3900**]
DR. [**First Name (STitle) 3901**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3902**]
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4392**]
RADIOLOGY Final Report
UNILAT UP EXT VEINS US LEFT [**2113-8-28**] 12:58 PM
UNILAT UP EXT VEINS US LEFT
Reason: r/o dvt - swelling
[**Hospital 93**] MEDICAL CONDITION:
68 year old man s/p CABG, MVR, AVR, ASc Aorta, sternal
debridement
REASON FOR THIS EXAMINATION:
r/o dvt - swelling
INDICATION: 68-year-old man with left arm swelling, rule out
DVT.
COMPARISON: No previous extremity ultrasound for comparison.
FINDINGS: [**Doctor Last Name **]-scale, color and Doppler son[**Name (NI) 1417**] of the left
jugular, subclavian, axillary, brachial, basilic, and cephalic
veins were performed. There is thrombus identified in the left
cephalic below the level of the antecubital fossa. At this
level, the vein demonstrates no flow and does not compress.
There is normal flow, compression, and augmentation in the
remainder of the left arm vessels. No deep vein thrombus is
identified in any of the deep veins.
IMPRESSION: No DVT in the left arm. Thrombus is identified in
the left cephalic vein, which is a superficial vein, below the
level of the antecubital fossa.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7832**]
Approved: TUE [**2113-8-29**] 4:06 PM
Cardiology Report ECG Study Date of [**2113-8-25**] 12:07:14 AM
Probable sinus tachycardia, though atypical atrial flutter
cannot be excluded.
Right bundle-branch block with left anterior fascicular block.
Possible prior
inferior wall myocardial infarction. Compared to the previous
tracing of [**2113-8-24**]
the ventricular rate is now regular suggesting either sinus
tachycardia or
atypical atrial flutter. Otherwise, no diagnostic interim
change.
TRACING #3
Read by: [**Last Name (LF) **],[**First Name3 (LF) **] V.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
112 164 184 310/401 36 -21 89
RADIOLOGY Final Report
CT CHEST W/O CONTRAST [**2113-8-25**] 10:59 AM
CT CHEST W/O CONTRAST
Reason: assess lft effusion/adhesions
[**Hospital 93**] MEDICAL CONDITION:
68 year old man s/p AVR/MVR/CABG/Ao root [**Doctor First Name **] reexplored
REASON FOR THIS EXAMINATION:
assess lft effusion/adhesions
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 68-year-old male status post AVR/MVR/CABG/aortic
root, status post surgical re-exploration. Please assess left
effusion, and adhesions.
COMPARISON: Multiple chest radiographs dating back to [**2113-7-25**].
TECHNIQUE: MDCT-acquired axial imaging of the chest without
intravenous contrast. Multiplanar reformatted images were
obtained and reviewed.
FINDINGS: There is evidence of previous cardiac surgery, and
re-exploration. Mediastinal wires have been removed, along with
a portion of the left hemisternum, and there has been closure
with a omental/pectoral muscle flap. The flap is relatively
large, and appears to displace mediastinal structures
posteriorly. Within the soft tissue of the flap, there is a
moderate amount of soft tissue stranding, which most likely
correlates with post-surgical edema, but could also represent
residual of old hemorrhage. There is no large fluid collection
or other sign of active bleeding. Two drains are seen within
this flap, situated anterior to the sternum bilaterally. A third
drain is seen within the flap situated deep, and adjacent to the
pericardium.
There are small bilateral pleural effusions which contain simple
fluid, slightly greater on the left. There is adjacent left
basilar atelectasis. There is also a small simple pericardial
effusion.
There is heavy atherosclerotic calcification of the native
coronary arteries. The aortic root graft is unremarkable on this
non-contrast enhanced CT.
There are bilateral chest tubes. Chest tube on the right is
situated within the major fissure. There is a small right
pneumothorax. Left chest tube is situated laterally, near the
apex. There is a tiny left hydropneumothorax near the chest tube
tip.
Other than small amount of left basilar atelectasis described
above, the lungs are clear. Central bronchi are patent to the
subsegmental level. Endotracheal tube and nasogastric tube are
in appropriate positions. There is a small amount of soft tissue
anasarca.
Limited views of the upper abdomen are notable for surgical
clips anterior to the stomach. There is a small volume of
ascites surrounding the liver. There is mild elevation of the
left hemidiaphragm, possibly related to left basilar
atelectasis.
Osseous structures demonstrate no suspicious abnormalities. As
described above, there has been prior median sternotomy, and
partial resection of the left hemisternum. There is no sign of
periosteal reaction, osseous destruction, or other finding to
suggest osteomyelitis.
IMPRESSION:
1. Small bilateral pleural effusions, containing simple fluid.
2. Small pericardial effusion.
3. Small right pneumothorax. Right chest tube is situated within
the major fissure. Tiny left hydropneumothorax.
4. Large anterior mediastinal flap closure containing pectoralis
musculature and omentum with a moderate amount of stranding
within, likely related to a combination of edema and residua of
prior hemorrhage. No sign to suggest active bleeding. Posterior
displacement of mediastinal structures secondary to large flap.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5718**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**]
Approved: SAT [**2113-8-26**] 4:53 PM
Cardiology Report ECHO Study Date of [**2113-8-24**]
PATIENT/TEST INFORMATION:
Indication: Shortness of breath; bleeding from two weeks old
sternal flap; s/p AVR, MV repair and ascending aorta replacement
Status: Inpatient
Date/Time: [**2113-8-24**] at 16:16
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007AW04-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
MEASUREMENTS:
Left Ventricle - Ejection Fraction: 35% (nl >=55%)
INTERPRETATION:
Findings:
Emergent limited TEE exam to rule major causes of shortness of
breath
LEFT ATRIUM: No spontaneous echo contrast or thrombus in the
LA/LAA or the
RA/RAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Moderate global LV hypokinesis.
RIGHT VENTRICLE: Mild global RV free wall hypokinesis. Moderate
global RV free
wall hypokinesis.
AORTA: Normal ascending aorta diameter. Normal aortic arch
diameter. Normal
descending aorta diameter.
AORTIC VALVE: AVR well seated, normal leaflet/disc motion and
transvalvular
gradients.
MITRAL VALVE: Mitral valve annuloplasty ring.
TRICUSPID VALVE: Moderate [2+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
PERICARDIUM: Effusion is loculated.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. The patient
was under
general anesthesia throughout the procedure. No TEE related
complications. The
patient appears to be in sinus rhythm. Resting tachycardia
(HR>100bpm).
patient.
Conclusions:
1) Large sized bilateral pleural effusion.
2) moderate sized loculated anterior pericardial effusion (open
pericardium
postoperative)
3) Thoracic aortic contour is intact. No evidence of dissection
or aneurysms.
4) Aortic valve bioprosthesis is intact and functioning well.
5) Mitral valve ring is intact and mild Mitral regurgitation
seen.
6) No evidence of thrombus in the RA, RV or main pulmonary
arteries.
7) There is mod RV global systolic dysfunction with moderate TR
with bowing of
interatrial septum to the left.
8) With epinephrine 0.02mcg/kg/min, there is an improvement of
global
biventricular systolic function and mild to moderate TR.
Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD on [**2113-8-24**] 16:27.
[**Location (un) **] PHYSICIAN:
Brief Hospital Course:
He was transfused and a groin line was placed in the ED. He was
taken to the operating room on by plastic surgery and cardiac
surgery for exploration, hematoma evacuation and was also found
to have a component of tamponade. He was transferred to the ICU
where he had bilateral chest tubes placed. He underwent
bronchoscopy on [**8-25**] for LLL collapse. He was extubated later
on POD #1. He was transferred to the floor on POD #2. His
converted to SR and the last episode of Atrial fibrillation was
[**8-28**] short burst. He continued to progress, his chest tubes
were removed. He was ready for discharge to rehab on POD 6 with
2 JP drains. Plan for coumadin to be held until all JP drains
removed per Dr [**Last Name (STitle) 914**] and Dr [**First Name (STitle) **].
Medications on Admission:
Docusate Sodium
Aspirin
Hydromorphone
Montelukast
Albuterol-Ipratropium
Ezetimibe
Fluticasone-Salmeterol 9. Clopidogrel 75 mg Tablet Sig: One (1)
Tablet PO DAILY
(Daily).
Ranitidine
Potassium Chloride
Verapamil
Digoxin
14. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day
for 7 days: then 200 mg daily until seen by Dr. [**Last Name (STitle) **].
15. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO QID
(4 times a day).
17. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
18. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation Q4H (every 4 hours).
5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q24H (every 24 hours).
9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed.
10. Ranitidine HCl 15 mg/mL Syrup Sig: Ten (10) mL PO BID (2
times a day).
11. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
13. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO once a day.
14. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day.
15. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-20**] Sprays Nasal
QID (4 times a day) as needed.
16. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO once a day: while on
lasix.
17. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection three times a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Cardiac Tamponade
Wound Hematoma
Pleural Effusions
Discharge Condition:
Good
Discharge Instructions:
1)Please shower daily. No baths. Pat dry incisions, do not rub.
Wash in incision daily with mild soap and water. Staples to
remain intact and will be removed by plastic surgery (Dr [**First Name (STitle) **]
2)Avoid creams and lotions to surgical incisions.
3)Call Dr [**First Name (STitle) **] for drainage, erythema, or fever
4)No lifting more than 10 lbs unit after seen [**9-21**] Dr [**Last Name (STitle) 1290**]
5) Any questions or concerns please call cardiac surgery office
[**Telephone/Fax (1) 170**]
Followup Instructions:
Dr. [**Last Name (STitle) 1290**] [**Name (STitle) 8784**] [**2113-9-21**] at 1pm [**Doctor First Name **] [**Hospital Unit Name **] [**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) 2161**] after discharge from rehab [**Telephone/Fax (1) 60677**]
[**Name6 (MD) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 2934**] Date/Time:[**2113-10-27**]
4:00
Dr. [**First Name (STitle) **] (Plastic Surgery) appointment [**2113-9-7**] at 9am
[**Apartment Address(1) 1414**] [**Location (un) **], [**Numeric Identifier 1415**] Phone:
[**Telephone/Fax (1) 1416**] appointment [**2113-9-7**] at 9am
Completed by:[**2113-8-30**]
|
[
"427.31",
"496",
"414.00",
"511.9",
"512.8",
"423.9",
"V45.81",
"272.0",
"401.9",
"998.11",
"998.12",
"285.1",
"V42.2",
"998.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.04",
"34.1",
"33.23",
"54.74"
] |
icd9pcs
|
[
[
[]
]
] |
14725, 14804
|
11825, 12601
|
349, 446
|
14899, 14906
|
1841, 2870
|
15465, 16115
|
1167, 1217
|
13293, 14702
|
5790, 5867
|
14825, 14878
|
12627, 13270
|
14930, 15442
|
9368, 11764
|
1232, 1822
|
270, 311
|
5896, 9342
|
474, 810
|
11802, 11802
|
832, 1060
|
1076, 1151
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,272
| 104,675
|
54031+54058+59568
|
Discharge summary
|
report+report+addendum
|
Admission Date: [**2115-3-9**] Discharge Date: [**2115-3-29**]
Date of Birth: [**2056-8-4**] Sex: F
Service: MEDICINE
HISTORY OF PRESENT ILLNESS: The patient is a 58 year old
with diabetes complicated by end stage renal disease on
hemodialysis, hypertension, who presents with left hip pain,
fever, hyperglycemia. Patient had left hip fracture and was
pinned at [**Hospital3 2576**] in [**1-13**]. However, subsequently since
[**2114-8-12**], patient has been complaining about pain in
her hip and for unclear reasons it increased in severity on
the day of admission. She denies any trauma or fall. She
also reports fever to 101.9 with chills without nausea at
last hemodialysis. She denies rigors, emesis, chest pain,
headache, shortness of breath, cough, sputum, abdominal pain,
recent antibiotics, back pain, vaginal or urinary symptoms.
She also reports that her finger sticks have been elevated
for the past three to four days and she complains of
polydipsia. She sleeps in a chair secondary to her hip pain,
but denies paroxysmal nocturnal dyspnea or orthopnea. She
reports increased swelling in her legs. In the emergency
department serum glucose was 663, potassium 5.9, anion gap 18
with moderate acetone in her blood. She is anuric. She was
given 10 units of insulin and started on an insulin drip and
received normal saline times 1 liter, morphine for hip pain.
Given her fever, elevated white blood cell count and left
shift, she was given vancomycin times 1 gm for presumed line
infection. Chest x-ray was performed which revealed left
pleural effusion greater than right, interstitial edema.
Patient received 2 liters of normal saline only because of
concern about volume overload.
PHYSICAL EXAMINATION: On admission temperature was 97.7,
pulse 93, blood pressure 130/40, respirations 26, 90% in room
air. In general, a middle aged female in no acute distress.
HEENT surgical right, pinpoint on left. No JVP. Mucous
membranes dry. Oropharynx clear. No lymphadenopathy. HC
catheter in right IJ, no erythema or pain. Lungs clear to
auscultation bilaterally except for decreased breath sounds
in bilateral bases. Heart regular rate and rhythm, normal
S1, S2, 3/6 systolic murmur apex. Abdomen soft,
nondistended, nontender, normoactive bowel sounds.
Extremities 3+ edema on right, right lower extremity ulcer.
Left lower extremity with warmth and redness, shortened and
externally rotated, painful to palpation. Neuro exam alert
and oriented times three, grossly nonfocal.
LABORATORY DATA: On admission CBC WBC 18.7, hematocrit 35.0,
platelets 345, 93% neutrophils, 4% lymphs, 3% monocytes, MCV
102, 3+ hypochromic, 1+ anisocytosis, 3+ macrocytosis.
Chem-7 sodium 125, potassium 5.6, chloride 85, bicarb 22, BUN
25, creatinine 2.3, sugar 646, moderate acetones, anion gap
18. Blood cultures pending. PT/INR 14.4/1.4, PTT 32.8. EKG
normal sinus rhythm at 74, normal axis and intervals, [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) 6192**] in comparison with EKG on [**2112-2-5**]. T waves are
normalized from flipped in V3 to V6, 1, 2, L, F seen on old
EKG. Chest x-ray left pleural effusion greater than right,
interstitial edema, atelectasis.
HOSPITAL COURSE:
1. Endocrine. The patient was admitted with hyperosmolar
hyperglycemia. She was initially continued on an insulin
drip, was not given any additional normal saline given her
end stage renal disease. Her chem-7 was checked q.three
hours. ABG was checked which revealed pH of 7.39, PCO2 47,
PO2 100. Therefore, patient was switched to her standing
insulin regimen of Lantus in the evening with Humalog p.r.n.
during meals. Lantus was adjusted during her stay as
initially she was hyperglycemic on 13 units q.p.m. However,
she had several episodes of hypoglycemia and so Lantus was
decreased to her standing dose. When she was NPO, Lantus was
halved to 7 units. Her sugars remained stable throughout the
remaining hospital course.
2. Infectious disease. The initial blood cultures revealed
four out of four bottles of methicillin resistant staph
aureus. The presumed etiology included the left hip, line
infection, urosepsis, cellulitis, pneumonia. Patient was
continued on vanco dosed according to levels for less than 15
and was started on levofloxacin to cover for
pneumonia/cellulitis. As the left hip has hardware in it, we
were not able to obtain an MRI. CT scan of the hip was
performed, looking for signs of infection and none were seen.
However, given concern of possible joint infection, an
ultrasound was ordered to evaluate for fluid collection in
the left hip and none was visualized, so no aspiration was
performed. Blood cultures continued to show MRSA; therefore,
a transthoracic echo was performed. Patient was additionally
started on Flagyl for broad spectrum coverage given many
possible sources to cover for possible lower extremity
cellulitis. Transthoracic echo was performed on [**2115-3-13**], and revealed normal left ventricular systolic function
greater than 55%. Mitral valve moderately thickened with no
discrete vegetation, more prominent than seen on prior study
in 3/00. To rule out endocarditis, a transesophageal echo
was performed which revealed no vegetation. Given concern
about possible right IJ PermCath infection, the hemodialysis
catheter was removed on [**2115-3-16**], by the surgical line
service. Daily blood cultures continued to be obtained and
blood culture on [**3-16**] was positive for MRSA. Additionally
a blood culture on [**3-18**] was positive for MRSA. At this
point the leg cellulitis had cleared. She received a 10 day
course of levo and Flagyl for cellulitis/pneumonia which was
completed. She no longer had the hemodialysis catheter so
most likely source of the infection was felt to be the left
hip, given the indwelling hardware. Dr. [**First Name (STitle) 1022**] from
orthopaedics evaluated patient and felt that, although
surgical intervention was high risk, he agreed to do it if
everyone understood the risks. A bone scan was performed
which revealed increased uptake in the left femur, coccyx and
left mid-clavicle. As initially pain control had been the
issue, a sacral decubitus ulcer was not initially identified.
When it was seen, plastic surgery was consulted and graded
it as a stage 3 decubitus ulcer. Patient was taken to the
O.R. on [**2115-3-26**] and the pin hardware was removed. Culture
was taken of the left hip which, at the time of this
dictation, is significant for MRSA. With infectious disease
consult it was determined that patient will continue a six
week course of vancomycin from the date of pin removal to
treat her osteomyelitis. Her blood cultures remained sterile
following the [**3-18**] positive blood culture.
3. Orthopaedics. The patient was initially noted to have an
externally rotated and shortened left lower extremity.
Therefore, concern was raised about possible new hip
fracture. Initially a portable pelvis film was performed
which revealed malalignment of the femur. Orthopaedics was
consulted who initially felt there was no sign of infection
in the left hip. They recommended total hip replacement
after her acute issues of MRSA bacteremia were resolved.
However, given thorough workup for infection source as above,
it was determined that the left hip was the most probable
source of infection. Therefore, patient was brought to the
O.R. on [**2115-3-26**] by Dr. [**First Name (STitle) 1022**]. The two screws were removed.
The hip was turned into internal rotation and mild extension.
The femoral neck fracture was then separated and completed
and the femoral head was removed. Debridement was performed
of the acetabulum as well as the proximal femur. After
irrigation a drain was left in and closed in layers with PDS
and staples for the skin. Orthopaedic surgery continued to
follow patient. Plan is to return to the operating room for
complete repair of the hip once she receives the full six
week course of antibiotics to treat her osteomyelitis.
4. Renal. The patient has end stage renal disease on
hemodialysis. Renal consult was obtained. Patient continued
to receive hemodialysis q.Monday, Wednesday and Friday
initially through her right IJ hemodialysis catheter. On
[**2115-3-19**] a temporary Quinton catheter was placed in the right
femoral vein and this was accessed until it was discontinued
on [**2115-3-27**] when a left femoral tunneled catheter was placed
by interventional radiology.
5. Neuro. Pain control was difficult in this patient's
case. She was initially given morphine, but became
oversedated and on hospital day one received an injection of
Narcan for respiratory rate less than 10. Subsequently her
medications were changed. Patient was very stable on
OxyContin 40 mg p.o. b.i.d. with oxycodone for break through
pain until postoperatively when she became more confused and
delirious, thought to be secondary to the narcotics given
intraoperatively. Patient remains with tolerable pain with
this regimen. On [**2115-3-23**] patient was complaining of diplopia
and increased confusion. Emergent head CT was performed and
this was negative for bleed. Per Dr. [**Last Name (STitle) 16258**], her PCP, [**Name10 (NameIs) **]
baseline she has waxing and [**Doctor Last Name 688**] mental status which is a
chronic issue. Her finger sticks were normal. Head CT was
negative. Most likely secondary to transient bacteremia.
6. Pulmonary. Bilateral pleural effusions. Repeat chest
x-ray on [**3-24**] showed a small pleural effusion.
7. Heme. Patient with macrocytosis, normal B-12 and folate,
normal TSH. Continue to monitor. She was also noted to be
iron deficient and received iron in hemodialysis.
8. GI. The patient was continued on Protonix and given
stool regimen for narcotics. Liver function tests and
transaminases were checked and were within normal limits
except for elevated alkaline phosphatase which was felt most
likely to be secondary to bone.
[**First Name8 (NamePattern2) 11595**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 17144**]
Dictated By:[**Last Name (NamePattern1) 41557**]
MEDQUIST36
D: [**2115-3-29**] 11:01
T: [**2115-3-29**] 12:24
JOB#: [**Job Number 110754**]
Admission Date: [**2115-3-9**] Discharge Date: [**2115-4-5**]
Date of Birth: [**2056-8-4**] Sex: F
Service:
ADDENDUM TO PREVIOUS DISCHARGE SUMMARY:
On [**2115-3-30**] Ms.[**Location (un) 110808**] had an episode of hypoglycemia
with fingerstick to 19. She was unresponsive and was given 2
amps of D50 and subsequently awoke. However, one hour later
her blood pressure was noted to be 70/30. She was given
intravenous fluid and Narcan times two with good response.
She was transferred to the Medical Intensive Care Unit for
further monitoring. Long acting narcotics were held.
Antihypertensives were held. She was ruled out for
myocardial infarction by enzymes. Her long acting insulin
was initially held and her blood pressure remained stable.
She was transferred back to the floor on [**2115-4-1**]. On
transfer to the floor she was noted to have palpable bladder
on examination and was complaining of urinary urgency so
Foley catheter was placed and 2 liters of dark brown urine
was drained from her bladder. Patient's mental status
subsequently cleared, was felt to e multifactorial due to
urinary retention and long acting narcotics given
intraoperatively. She was continued on Percocet p.r.n. for
pain. The Foley catheter remained in place until it was
discontinued and plan is to continue with q.o.d. straight
catheterization. Fingersticks were monitored and her insulin
regimen was changed for better control.
[**First Name8 (NamePattern2) 11595**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 17144**]
Dictated By:[**Last Name (NamePattern1) 2918**]
MEDQUIST36
D: [**2115-4-3**] 15:45
T: [**2115-4-3**] 15:50
JOB#: [**Job Number **]
Name: [**Known lastname 6408**] [**Known lastname 11916**], [**Known firstname **] M Unit No: [**Numeric Identifier 18142**]
Admission Date: [**2115-3-9**] Discharge Date: [**2115-4-5**]
Date of Birth: [**2056-8-4**] Sex: F
Service:
ADDENDUM: Discharged to extended care facility.
DISCHARGE INSTRUCTIONS CONTINUE:
1. Hemodialysis q Monday, Wednesday, Friday, check complete
blood count, basic metabolic panel, Vancomycin level, blood
cultures qhd, straight catheter qod, check Vancomycin level q
day until [**5-7**] and give Vancomycin 1 gram x1 prn level less
than or equal to 15.
2. Dry sterile dressing to sacral decubitus ulcer [**Hospital1 **] with
Santal.
DISCHARGE DIAGNOSES:
1. Persistent methicillin-resistant Staphylococcus aureus
bacteremia.
2. Acute on chronic left hip fracture.
3. Left hip osteomyelitis.
4. Sacral decubitus ulcer Stage III.
5. Community acquired pneumonia.
6. Lower extremity cellulitis.
7. End-stage renal disease on hemodialysis.
8. Narcotics induced delirium.
9. Urinary retention.
RECOMMENDED FOLLOWUP: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] in four weeks, Dr.
[**Last Name (STitle) **], PCP, [**Name10 (NameIs) **] Infectious Disease Clinic.
DISCHARGE CONDITION: Good.
DISCHARGE MEDICATIONS:
1. Acetaminophen 325 mg po q4-6h prn.
2. Colace 100 mg po bid.
3. Dorzolamide 2% ophthalmic tid.
4. Folic acid.
5. B12 complex 1 mg po q day.
6. Pantoprazole 40 mg po q24h.
7. Timolol 0.5% ophthalmologic drops one [**Hospital1 **].
8. Senna two tablets po bid.
9. Bisacodyl prn.
10. Heparin 5,000 units subQ q12.
11. Collagenase topical [**Hospital1 **] to sacral decube.
12. Oxycodone/acetaminophen 5/325 one tablet po q6h prn pain.
13. Sevelamer 800 mg po tid with meals.
14. Insulin glargine 14 units q hs, hold if decrease in po
intake or NPO.
15. Insulin LysPro per sliding scale.
DISPOSITION: The patient was discharged to skilled-nursing
facility.
[**First Name8 (NamePattern2) 2710**] [**Last Name (NamePattern1) 2711**], M.D. [**MD Number(1) 2712**]
Dictated By:[**Last Name (NamePattern1) 1464**]
MEDQUIST36
D: [**2115-4-4**] 12:13
T: [**2115-4-4**] 12:27
JOB#: [**Job Number 18143**]
|
[
"707.0",
"790.7",
"998.59",
"682.6",
"403.91",
"730.05",
"733.82",
"996.67",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"78.65",
"88.72",
"39.95",
"86.22",
"38.95",
"77.65",
"77.85"
] |
icd9pcs
|
[
[
[]
]
] |
13277, 13284
|
12736, 13255
|
13307, 14244
|
3233, 12715
|
1752, 3216
|
168, 1729
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,297
| 123,149
|
16749
|
Discharge summary
|
report
|
Admission Date: [**2116-5-18**] Discharge Date: [**2116-5-22**]
Date of Birth: [**2046-9-20**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Tape / Percocet
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
DOE/Orthopnea
Major Surgical or Invasive Procedure:
[**2116-5-18**] - AVR (21mm St. [**Male First Name (un) 923**] Epic Pericardial Valve)
History of Present Illness:
69 year old female with h/o AS with DOE who has had progressive
worsening of symptoms over the past several months. Work-up
revealed severe aortic stenosis withoit significant coronary
artery disease. Given these findings she has been admitted for
surgical management.
Past Medical History:
cervical and lumbar spondylosis and rheumatoid arthritis /
chronic steroid use secondary to asthma
HTN
AS
Depression
Toxic Multinodular Goiter
Pulmonary fibrosis
Anemia
Asthma
Lupus
Social History:
lives with husband
Family History:
Non-contributory
Physical Exam:
72 sr 14 164/70 150/72 67" 265
GEN: NAD
SKIN: Unremarkable
HEENT: Unremarkable
NECK: Supple, FROM, No JVD
LUNGS: Diminished BS at bases
HEART: RRR, [**5-10**] holosystolic murmur
ABD: S/NT/ND/NABS/Obese
EXT: Warm, well perfused, 1+ Edema. Some varicosities noted.
Faint DP/PT pulses bilaterall.
NEURO: Nonfocal
Pertinent Results:
[**2116-5-21**] ECHO
PRE-BYPASS:
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. No atrial septal defect is seen
by 2D or color Doppler. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). Right ventricular chamber size and free
wall motion are normal. There are focal calcifications in the
aortic arch. There is moderate aortic valve stenosis (area
1.0-1.2cm2). Moderate (2+) aortic regurgitation is seen. The
ascending aorta is 3.9cm in diameter. The mitral valve leaflets
are mildly thickened. There is no pericardial effusion. Dr.
[**Last Name (STitle) **] was notified in person of the results on [**Known lastname 47344**], [**Known firstname 17**] at
9AM.
POST-BYPASS:
Thoracic aortic contour is intact.
There is a bioprosthesis seen in the native aortic position,
well positioned, stable with a peak of 30 and a mean of 15mm of
Hg.
Mild TR. No MR.
Brief Hospital Course:
Mrs. [**Known lastname 47344**] was admitted to the [**Hospital1 18**] on [**2116-5-18**] for surgical
management of her aortic valve stenosis. She was taken to the
operating room where she underwent an aortic valve replacement
using a tissue prosthesis. Please see operative note for
details. Postoperatively she was taken to the cardiac surgical
intensive care unit for monitoring. Within 24 hours, she awoke
neurologically intact and was extubated. Beta blockade and
aspirin were resumed. On postoperative day one, she was
transferred to the step down unit for further recovery. She was
gently diuresed towards her preoperative weight. Narcotics were
found to sedate her heavily and were therefore discontinued.
The physical therapy service was consulted for assistance with
her postoperative strength and mobility. She complained of
diminished strength in her left lower extremity and an
ultrasound was obtained which ruled out a deep vein thrombosis.
Medications on Admission:
Prednisone 10'
Methimazole 5'
Alphagan eye drops
MVI
Calcium/Vitamin D
Glucosamine
Omega 3
Ambien
Diovan
Prednisone eye drops
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Prednisone 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Methimazole 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
5. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
Two (2) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours).
6. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
7. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
8. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**2-5**] Sprays Nasal
QID (4 times a day) as needed.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1439**] [**Last Name (NamePattern1) 13089**] Care Center - [**Location (un) 1439**]
Discharge Diagnosis:
AS s/p AVR(21mm St. [**Male First Name (un) 923**] epic pericardial) [**2116-5-18**]
HTN
Depression
Pulmonary fibrosis
Asthma
Anemia
Toxic multinodular goiter
Discharge Condition:
Stable
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month.
7) Wear surgical bra at all times until seen in clinic with Dr.
[**Last Name (STitle) **].
8) Call with any questions or concerns.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**]
Follow-up with Dr. [**Last Name (STitle) 3497**] in 2 weeks.
Follow-up with Dr. [**Last Name (STitle) **] 2 weeks.
Completed by:[**2116-5-22**]
|
[
"493.90",
"242.20",
"401.9",
"710.0",
"428.32",
"515",
"714.0",
"428.0",
"424.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
4439, 4579
|
2375, 3333
|
296, 385
|
4782, 4791
|
1308, 2352
|
5625, 5858
|
941, 959
|
3509, 4416
|
4600, 4761
|
3359, 3486
|
4815, 5602
|
974, 1289
|
243, 258
|
413, 683
|
705, 888
|
904, 925
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,363
| 174,543
|
51106
|
Discharge summary
|
report
|
Admission Date: [**2158-8-28**] Discharge Date: [**2158-9-1**]
Date of Birth: [**2098-7-29**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamides) / Mold/Yeast/Dust
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Presyncope
Major Surgical or Invasive Procedure:
[**2158-8-28**] Aortic Valve Replacement(21mm [**Doctor Last Name **] Pericardial Valve)
and Two Vessel Coronary Artery Bypass Grafting utilizing vein
graft to obtuse marginal and vein graft to right coronary
artery.
History of Present Illness:
This is a 60 year old female with known aortic stenosis. She
presented with presyncope in [**2158-5-28**]. Echocardiogram at that
time showed progression of her aortic valve disease - [**Location (un) 109**] of 0.5
cm2, mean 82mmHg, mild AI. She subsequently underwent cardiac
catheterization which showed a right dominant coronary system
with two vessel coronary artery disease - 50% lesion in the RCA,
70% lesion in the obtuse marginal. Based upon the above results,
she was referred for cardiac surgical intervention.
Past Medical History:
Aortic Stenosis
Coronary Artery Disease
Hypertension
Hypercholesterolemia
Type II Diabetes Mellitus
Carotid Disease
Morbid Obesity
B12 Anemia
Diabetic Retinopathy
Asthma
Nephrolithiasis - ?Lithotripsy in past
Cataracts
Gastric Bypass [**2153**]
Cesarean Section [**2130**]
Social History:
The patient is an ex-smoker, quit approximately 30 years ago;
smoked 1ppd before that. She denies any significant alcohol use.
No illicit drug abuse. She lives with her husband and her 27 yo
son. [**Name (NI) **] a daughter in [**Name (NI) 108**].
Family History:
Strong family history of DM. Mother also had stroke in her 60's.
Uncle died at 35 from blood clot and MI. Sister had breast ca.
Grandmother had angina in her 80's.
Physical Exam:
Vitals: 120-140/57-60, 60-70, 14, 100% RA
General: Obese female in no acute distress
HEENT: Oropharynx benign, EOMI
Neck: Supple, no JVD, transmitted murmurs noted
Lungs: CTA bilaterally
Heart: Regular rate and rhythm, harsh systolic murmur radiating
to carotid region
Abdomen: Soft, nontender with normoactive bowel sounds, obese
Ext: Warm, tr edema. Superficial varicosities noted
Pulses: 2+ distally
Neuro: Alert and oriented, CN 2- 12 grossly intact, no focal
deficits noted
Pertinent Results:
[**8-28**] Echo: PREBYPASS: Due to patient's previous history of
gastric bypass TEE probe inserted into esophagous only. No
gastric views obtained.-limited study. No atrial septal defect
is seen by 2D or color Doppler. There is symmetric left
ventricular hypertrophy. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. There are simple atheroma in
the descending thoracic aorta. The aortic valve leaflets are
moderately thickened. There is moderate to severe aortic valve
stenosis. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. MV leaflet opening is limited but
not stenotic (MVA~2.4cm2) There is moderate thickening of the
mitral valve chordae. Mild (1+) mitral regurgitation is seen.
POSTBYPASS: Preserved biventricular systolic function. There is
a well seated well functioning bioprosthesis in the aortic
position. No AI is visualized in the esophageal views but AI
cannot be ruled out secojndary to shadowing of the valve ring.
Study is otherwise unchanged from prebypass exam.
[**8-31**] CXR: PA and lateral upright chest radiographs compared to
[**2158-8-29**]. The heart size is moderately enlarged but
stable. The sternal sutures are intact. Aortic valve is in a
standard location. The bilateral pleural effusions and bibasal
atelectasis are unchanged. No pneumothorax is demonstrated.
[**2158-8-28**] 12:07PM BLOOD WBC-11.6*# RBC-2.86*# Hgb-8.0* Hct-23.5*#
MCV-82 MCH-27.9 MCHC-34.0 RDW-14.6 Plt Ct-141*
[**2158-9-1**] 06:30AM BLOOD WBC-10.1 RBC-2.80* Hgb-7.8* Hct-23.4*
MCV-84 MCH-28.0 MCHC-33.5 RDW-15.5 Plt Ct-160
[**2158-8-28**] 12:07PM BLOOD PT-14.1* PTT-45.3* INR(PT)-1.2*
[**2158-8-28**] 01:20PM BLOOD UreaN-33* Creat-0.8 Cl-115* HCO3-22
[**2158-9-1**] 06:30AM BLOOD Glucose-119* UreaN-49* Creat-1.1 Na-139
K-4.6 Cl-103 HCO3-28 AnGap-13
[**2158-8-30**] 06:00AM BLOOD Mg-2.8*
Brief Hospital Course:
Mrs. [**Known lastname **] was a same day admit after undergoing pre-operative
work-up as an outpatient. On day of admission she was brought to
the operating room and underwent an aortic valve replacement and
coronary artery bypass grafting by Dr. [**Last Name (STitle) 1290**]. For surgical
details, please see separate dictated operative note. Following
the operation, she was brought to the CVICU for invasive
monitoring in stable condition. Within 24 hours, she awoke
neurologically intact and was extubated without incident. She
maintained stable hemodynamics and transferred to the SDU on
postoperative day one. Beta blockers and diuretics were started
and she was gently diuresed towards her pre-op weight. Chest
tubes and epicardial pacing wires were removed per protocol. She
gradually improved and worked with physical therapy for strength
and mobility. On post-op day five she appeared to be doing well
and was discharged home with VNA services and the appropriate
follow-up appointments.
Medications on Admission:
Januvia 100 qd, Amaryl 4 qd, Diovan 160 qd, HCTZ 25 qd, Zocor 40
qd, Aspirin 81 qd, B12 shots monthly, Voltaren eye gtts
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
4. JANUVIA 100 mg Tablet Sig: One (1) Tablet PO daily ().
Disp:*30 Tablet(s)* Refills:*0*
5. Glimepiride 2 mg Tablet Sig: Two (2) Tablet PO daily ().
Disp:*60 Tablet(s)* Refills:*0*
6. Diclofenac Sodium 0.1 % Drops Sig: One (1) Ophthalmic QID
().
Disp:*QS 1 month* Refills:*0*
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
11. Niferex 60 mg Capsule Sig: One (1) Capsule PO once a day.
Disp:*30 Capsule(s)* Refills:*2*
12. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Aortic Stenosis, Coronary Artery Disease - s/p Aortic Vavlve
Replacement and Coronary Artery Bypass Graft x 2
PMH: Hypertension, Hypercholesterolemia, Type II Diabetes
Mellitus, Carotid Disease, Morbid Obesity s/p Gastric Bypass,
B12 Anemia, Asthma, Cataracts, s/p c-section [**2130**],
Nephrolithiasis s/p lithotripsy
Discharge Condition:
Good
Discharge Instructions:
1)Please shower daily. No baths. Pat dry incisions, do not rub.
2)Avoid creams and lotions to surgical incisions.
3)Call cardiac surgeon if there is concern for wound infection.
4)No lifting more than 10 lbs for at least 10 weeks from
surgical date.
5)No driving for at least one month.
Followup Instructions:
Dr. [**Last Name (STitle) 1290**] in [**3-2**] weeks, call for appt
Dr. [**Last Name (STitle) **] in [**12-31**] weeks, call for appt
Dr. [**Last Name (STitle) **] in [**12-31**] weeks, call for appt
Completed by:[**2158-9-1**]
|
[
"493.90",
"433.10",
"362.01",
"414.01",
"250.50",
"424.1",
"272.0",
"401.9",
"281.1",
"V45.86"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"35.21",
"36.12",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
6764, 6819
|
4273, 5274
|
315, 533
|
7181, 7187
|
2340, 4250
|
7522, 7751
|
1661, 1826
|
5446, 6741
|
6840, 7160
|
5300, 5422
|
7211, 7499
|
1841, 2321
|
265, 277
|
561, 1083
|
1105, 1380
|
1396, 1645
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,194
| 103,326
|
47863+59034
|
Discharge summary
|
report+addendum
|
Admission Date: [**2141-11-16**] Discharge Date: [**2141-11-23**]
Date of Birth: [**2082-10-4**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
ESRD
Major Surgical or Invasive Procedure:
[**11-16**]: DCD Renal Transplant
History of Present Illness:
59 year old male with ESRD [**1-3**] DM and
HTN. Currently on peritoneal dialysis. He does urinate large
amounts daily (>2L). He had not had any recent infections or any
fevers, chills or night sweats. He also denies any chest pain,
SOB, claudication, urinary symptoms, nausea, vomiting or
abdominal pain. He denies any constipation or diarrhea and his
last bowel movement was at midnight.
Past Medical History:
minor stroke with loss temp sensation R hand
HTN
Diabetes mellitus
Coronary artery disease status post CABGx2 '[**32**], NSTEMI [**7-10**]
End-stage renal disease on HD (2nd to DM/HTN)
Gout
Colonoscopy 4yrs ago normal per pt report.
Social History:
works as plumber, no ETOH/drug/tobacco use
Family History:
signif for HTN and DM, father with [**Name2 (NI) 499**] cancer
Physical Exam:
Gen: NAD
HEENT: MMM no lesions
CV: RRR no MRG
RESP: CTAB no WRR
ABD: soft, NT, slight distention but no tympany. No G/R
WOUND: LLQ incision with staples intact, clean and dry
EXT: 2+ PE up to the knees b/l
Pertinent Results:
[**2141-11-16**] 03:27PM GLUCOSE-187* UREA N-105* CREAT-12.0*
SODIUM-139 POTASSIUM-6.5* CHLORIDE-104 TOTAL CO2-15* ANION
GAP-27*
[**2141-11-16**] 03:27PM PHOSPHATE-10.0* MAGNESIUM-1.6
[**2141-11-16**] 03:27PM WBC-7.6 RBC-2.74* HGB-8.6* HCT-26.9* MCV-98
MCH-31.5 MCHC-32.0 RDW-15.8*
[**2141-11-17**] 03:30PM BLOOD CK-MB-57* MB Indx-7.1* cTropnT-1.81*
[**2141-11-17**] 10:45PM BLOOD CK-MB-49* MB Indx-5.9 cTropnT-1.97*
[**2141-11-18**] 04:20AM BLOOD CK-MB-44* MB Indx-5.0 cTropnT-1.81*
[**2141-11-19**] 04:59AM BLOOD CK-MB-16* MB Indx-1.9 cTropnT-2.30*
[**2141-11-20**] 05:20AM BLOOD CK-MB-10 MB Indx-1.9 cTropnT-2.24*
TTE [**11-20**]:
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size. There is
mild to moderate regional left ventricular systolic dysfunction
with severe hypokinesis of the distal half of the septum and
anterior wall and basal inferior wall. The apex is not well
seen. The remaining segments contract normally (LVEF = 35-40 %).
The right ventricular cavity is mildly dilated with moderate
global free wall hypokinesis. The aortic root is mildly dilated
at the sinus level. The aortic valve leaflets are mildly
thickened (?#). There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. Mild (1+) mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Symmetric left ventricular
hypertrophy with regional systolic dysfunction suggestive of
multivessel CAD. Mild mitral regurgitation.
Compared with the prior study (images reviewed) of [**2140-7-18**],
inferior wall hypokinesis is now suggested c/w ischemia.
Brief Hospital Course:
Pt was admitted electively on [**2141-11-16**] for DCD renal tranplant.
The operation was notable for a donor kidney cold ischemia time
of ~22 hours. The patient tolerated the procedure well with no
complications. He was admitted to the SICU because he required
BIPAP overnight for hypoxemia, but was weaned off by the
morning. Of note, the patient's SBP remained in the mid 90's on
POD1, and this prompted troponin analysis. His initial troponin
was found to be elevated to 1.97. The patient's EKG showed
evidence of ST segment depression, similar to his previous
episode of demand ischemia seen in [**7-10**]. This picture was
confounded, however, by the patient's continued renal failure in
the immediate post operative period. He required hemodialysis
on POD 0 for fluid overload, and he tolerated temoval of 1.5 L.
Early in the am of POD2, the patient was found to be recovering
well, with no need for hemodynamic or respiratory support. He
was transferred to F10 in good condition.
Over the weekend, his hospital course was notable for difficult
to control FBG's in the setting of post operative
methylprednisolone. He was placed on an insulin drip, which was
weaned off the next day with the aid of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consult and the
administration of a strict fixed and sliding scale insulin
regimen. On POD 3, the patient's troponin was found to be
persistently elevated to 2.3, after briefly decreasing to 1.8
from 1.97. Based on this information and his past medical
history of CABG and NSTEMI, a cardiology consult was obtained.
A TTE showed a new area of hypokinesis consistent with a new
ischemic event. The cardiology staff recommended medical
management considering his recent renal transplant; a
contraindication to cardiac catherization. He was discharged on
aspirin/plavix, carvedilol, imdur, and hydralazine.
By POD 4, the patient's graft function appeared to be picking
up, with a doubling in urine output from the day prior. The
transplant nephrology staff was impressed with this finding, and
suggested that the patient may not need outpatient dialysis. In
fact, they suggested that his residual volume overload could be
treated with lasix instead of hemodialysis. Because he was set
to leave on Thursday before a holiday weekend, the patient was
dialyzed prior to discharge and given a laboratory appointment
on Sunday. He was instructed to take Lasix 100mg PO BID on days
he was not going to have dialysis.
He was deemed safe to discharge home on post operative day 7.
By this time he had received medication and insulin teaching,
and had received treatment and follow up recommendations from
the cardiology staff. He is fully ambulatory, and is eating and
voiding without difficulty. His post operative pain is well
controlled on oral medications.
Medications on Admission:
Atorvastatin 80', VitB/VitC/Folic ac 1',
Phoslo 1334 after meals, Carvedilol 25", Cinacalcet, Plavix 75',
Colchicine prn, protronix 20', sevelamer 1600''', Valsartan 240'
Discharge Medications:
1. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
Disp:*2 bottles* Refills:*2*
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO prn: every
8 hours as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
5. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
Disp:*30 Tablet(s)* Refills:*2*
6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO EVERY
OTHER DAY (Every Other Day).
Disp:*60 Tablet(s)* Refills:*2*
8. atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
9. lamivudine 10 mg/mL Solution Sig: 2.5 ml PO DAILY (Daily).
Disp:*2 bottles* Refills:*2*
10. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
11. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
12. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
13. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
14. hydralazine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
15. isosorbide mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*2*
16. tacrolimus 1 mg Capsule Sig: Six (6) Capsule PO Q12H (every
12 hours).
Disp:*360 Capsule(s)* Refills:*2*
17. sevelamer carbonate 800 mg Tablet Sig: Three (3) Tablet PO
TID W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*120 Tablet(s)* Refills:*2*
18. furosemide 40 mg Tablet Sig: 2.5 Tablets PO BID (2 times a
day): ONLY ON DAYS WHEN NOT GETTING DIALYSIS.
Disp:*150 Tablet(s)* Refills:*2*
19. Outpatient Lab Work
Sunday [**11-26**] at 9:30 at [**Hospital1 18**] [**Hospital Ward Name 516**]
Felberg [**Location (un) **]
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA, [**Hospital1 1559**]
Discharge Diagnosis:
ESRD
S/P Renal Transplant
Perioperative Myocardial Infarction
Discharge Condition:
Alert and oriented to all spheres, ambulating without difficulty
Discharge Instructions:
You were admitted for an elective DCD Renal Transplant. Your
operation went well with no complications.
You need to have blood drawn for labs on Sunday [**11-26**] at the
[**Hospital Ward Name 516**] lab located in the [**Hospital Ward Name 1826**] building [**Location (un) **] Lab ,
9:30AM
While you were in the immediate post operative period, your
cardiac enzymes were elevated. This may have been due to a
myocardial infarction, likely due to the strain on your heart
during surgery. The Cardiologists saw you and recommended
medical management instead of cardiac cath, because of the risk
of contrast damaging your new kidney.
You also had elevated blood sugars after your surgery. The
specialists from the [**Hospital **] clinic helped us, and recommended
that you go home on insulin. Please follow the instructions and
teaching given to you by the nursing staff. Record your blood
sugars at mealtime and before bed. Keep track of them in a
notebook, and bring them to your next appointment.
Please take all of the medications prescribed to you exactly as
they are written, and remember to avoid all over the counter
medications, especially if the transplant team has not ok'd them
first. You will likely need HD for a short while until your new
kidney is at full speed. Make sure to keep all your
appointments and to notify the transplant team of any changes.
Follow your urine output at home, and make sure to keep track of
your weight. Your staples from your incision will come out at
your follow up appointment.
Followup Instructions:
Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2141-11-27**] 2:40
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2141-12-4**]
10:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2088**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2141-12-11**] 1:00
Please follow up with your outpatient cardiologist, Dr. [**Last Name (STitle) **]
on [**12-25**] at 1240pm.
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]: [**Numeric Identifier **] Office Phone: ([**Telephone/Fax (1) 10857**]
Office Location: W/[**Hospital Ward Name **] 4 Department: Medicine Organization:
[**Hospital1 18**]
Name: [**Known lastname **],[**Known firstname 33**] M Unit No: [**Numeric Identifier 16219**]
Admission Date: [**2141-11-16**] Discharge Date: [**2141-11-23**]
Date of Birth: [**2082-10-4**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2648**]
Addendum:
Tacrolimus dose decreased to 5mg [**Hospital1 **] at time of discharge per
trough level of 13.3.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA, [**Hospital1 6688**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2649**] MD [**MD Number(2) 2650**]
Completed by:[**2141-11-23**]
|
[
"276.4",
"E878.0",
"276.7",
"V58.65",
"403.91",
"274.9",
"585.6",
"518.5",
"285.1",
"997.1",
"V12.54",
"284.1",
"410.41",
"272.4",
"V45.81",
"428.0",
"V12.72",
"428.22",
"V45.11",
"250.40",
"412"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"00.93",
"38.95",
"55.69"
] |
icd9pcs
|
[
[
[]
]
] |
11771, 12002
|
3200, 6041
|
310, 347
|
8767, 8834
|
1406, 3177
|
10420, 11748
|
1099, 1163
|
6263, 8565
|
8682, 8746
|
6067, 6240
|
8859, 10397
|
1178, 1387
|
266, 272
|
375, 766
|
788, 1022
|
1038, 1083
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,448
| 179,259
|
21370
|
Discharge summary
|
report
|
Admission Date: [**2200-6-18**] Discharge Date: [**2200-6-22**]
Date of Birth: [**2153-1-21**] Sex: F
Service: PSURG
Allergies:
Vicodin / Demerol / Tape / Morphine
Attending:[**First Name3 (LF) 5883**]
Chief Complaint:
R breast cancer
Major Surgical or Invasive Procedure:
6/40 R modified Radical Mastectomy, L total mastectomy, [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5884**],
R tissue expander.
History of Present Illness:
47 y/o with past medical history of L breast DCIS ([**2195**]) and R
breast bx [**2200-4-19**] positive for IDC, LVI+ that intially
presented as a palpable mass. Pt was taken to the OR on [**2200-6-18**] and underwent a R modified radical mastectomy, L total
mastectomy performed by general surgery, Dr. [**Last Name (STitle) 11635**], and L
[**Last Name (un) 5884**] and R tissue expander, peformed by plastic surgery, Dr. [**First Name (STitle) **]
and Dr. [**First Name (STitle) 3228**].
Past Medical History:
R breast lumpectomy- [**2200-4-19**]
L breast lumpectomy- [**Month (only) **] & [**2200-6-19**]
3 c-sections- [**2173**], [**2176**], [**2180**]
Social History:
Patient does not smoke tobacco, use any recreational drugs and
drinks less than 1 alcoholic drink per week. Pt. has been
married for 27 years.
Family History:
breast cancer, paternal aunt- 70's
maternal grandmother- astrocytoma in her 90's
Mother passed at 56 y/o- astrocytoma
Father passed at 57y/o- astrocytoma
Physical Exam:
On discharge patient was afebrile with stable vitals. Wounds had
no sign of infection and flap was pink and warm. 1 axillary jp
and 2 abdominal jp were in place and draining. Abdomen was soft,
and appropriately tender. Patient was ambulating independently.
Pertinent Results:
Please see hosptial course section.
Brief Hospital Course:
Patient was taken to the [**6-18**] for the above procedures. No
surgical compliation in the OR. Pt was transfused 1 U PRBC in
the PACU for a HctT of 22.9. Follow Hct on [**6-20**] was 28.0.
Immediately post-op, dopplers were performed q 1 hour,
confirming blood flow. On post op check, flap was pink and warm.
On post-op day 1, patient was advanced to clear liquids which
she tolerated well. On post-op day 2, patient was transferred to
the floor and dopplers were performed q 2 hours, confirming
blood flow. On post-operative day 3, patient was tolerating
general diet, oral medications and began ambulating the hallways
with the assistance of her husband. Pt. was discharged home on
hospital day 4 with prescription for antibiotics.
Medications on Admission:
effoxor
topamax, maxalt and replax for migraines
lorazapam
Discharge Medications:
1. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*50 Tablet(s)* Refills:*2*
2. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO Q4-6H
(every 4 to 6 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
3. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 5 days.
Disp:*20 Capsule(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*50 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Right breast Cancer
Discharge Condition:
good
Discharge Instructions:
Finish antibiotic.
Record daily jp drains output and please bring to Dr.[**Last Name (STitle) 17650**]
appointment on Wednesday.
Any consistant fever not relieved by tylenol, patient should go
to the emergency department.
Finish antibiotic.
Record daily jp drains output and please bring to Dr.[**Last Name (STitle) 17650**]
appointment on Wednesday.
Any consistant fever not relieved by tylenol, patient should go
to the emergency department.
Followup Instructions:
Please Call Dr.[**Last Name (STitle) 17650**] office Tuesday morning to make appointment
to be seen on Wednesday, [**6-25**].
|
[
"196.3",
"174.8",
"V10.3",
"611.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"85.43",
"85.95",
"85.41",
"85.7"
] |
icd9pcs
|
[
[
[]
]
] |
3181, 3187
|
1826, 2563
|
309, 454
|
3251, 3257
|
1766, 1803
|
3749, 3877
|
1319, 1474
|
2673, 3158
|
3208, 3230
|
2589, 2650
|
3281, 3726
|
1489, 1747
|
254, 271
|
482, 974
|
996, 1143
|
1159, 1303
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,936
| 122,616
|
38122
|
Discharge summary
|
report
|
Admission Date: [**2124-5-26**] Discharge Date: [**2124-6-10**]
Date of Birth: [**2054-9-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2124-6-1**] Coronary artery bypass grafting x5(left internal mammary
artery to left anterior descending artery and reverse saphenous
vein grafts to the posterior descending artery, obtuse marginal
artery and saphenous Y-grafts to the ramus intermedius artery
and the first diagonal artery)
History of Present Illness:
This 69 year old Hispanic male with known triple vessel disease
had a recent admission to an outside hospital for congestive
heart failure with last documented LVEF=25-30%. He presented on
[**5-24**] complaining of acute shortness of breath, not associated
with other symptoms. Cardiac catheterization revealed
multivessel coronary artery disease. He was transferred to [**Hospital1 18**]
for cardiac surgical evaluation of coronary artery
revascularization.
Past Medical History:
Coronary Artery Disease
s/p RCA stent [**4-3**]
Acute systolic heart failure-?ischemic cardiomyopathy
Bilateral carotid stenosis
Chronic Obstructive Pulmonary disease
h/o Rhabdomyolysis
noninsulin dependent Diabetes Mellitus
s/pDiabetic foot ulcer debridement
s/p right hand tendon repair
Social History:
Lives with: daughter and grandaughter
Tobacco: quit '[**96**], started at age 14
ETOH: denies
speaks only Spanish
Family History:
non-contributory
Physical Exam:
Admission:
Pulse:76 Resp:20 O2 sat: 96% 3L
B/P Right:127/61 Left:
Height: Weight:63.2 KG
General:A&Ox3, NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI []
Neck: Supple [x] Full ROM [x]
Chest: Lungs bibasilar crackles, R>L
Heart: RRR [x] Irregular [] Murmur SEM II/VI
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema (B)LE 2+
Varicosities: None []? vein stripping-(B) medial incisions
evident
Neuro: Grossly intact
Pulses:
Femoral Right: Left:
DP Right: Left:
PT [**Name (NI) 167**]: Left:
Radial Right: Left:
Carotid Bruit +(B)thrills/bruits, pulses 2+ (B)
Pertinent Results:
[**6-1**] Echo: PRE-CPB:1. The left atrium is moderately dilated. Mild
spontaneous echo contrast is seen in the body of the left
atrium. Mild spontaneous echo contrast is present in the left
atrial appendage. The left atrial appendage emptying velocity is
depressed (<0.2m/s). No thrombus is seen in the left atrial
appendage. 2. No atrial septal defect is seen by 2D or color
Doppler. 3. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. The
LVEF = 55%. 4. Right ventricular chamber size and free wall
motion are normal. 5. There are simple atheroma in the aortic
root. There are simple atheroma in the ascending aorta. There
are simple atheroma in the descending thoracic aorta. 6. There
are three aortic valve leaflets. The aortic valve leaflets are
moderately thickened and there is limited excursion of the RCC.
There is no aortic valve stenosis. Trace aortic regurgitation is
seen. 7. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen. 8. Bilateral pleural effusions are
seen. Dr. [**Last Name (STitle) **] was notified in person of the results. POST-CPB:
On infusion of phenylephrine, av pacing. Preserved LV systolic
function with some air detected in LV apex. MR, AI remain mild.
Aortic contour is normal post decannulation. Right pleural
effusion remains.
[**2124-6-5**] 05:49AM BLOOD WBC-4.9 RBC-3.03* Hgb-8.4* Hct-24.9*
MCV-82 MCH-27.9 MCHC-33.9 RDW-16.1* Plt Ct-212
[**2124-5-26**] 12:00PM BLOOD WBC-4.5 RBC-3.51* Hgb-8.6* Hct-27.6*
MCV-79* MCH-24.4* MCHC-31.0 RDW-16.7* Plt Ct-441*
[**2124-6-4**] 03:31AM BLOOD PT-14.6* PTT-30.3 INR(PT)-1.3*
[**2124-6-6**] 05:19AM BLOOD UreaN-37* Creat-1.2 Na-142 K-3.7 Cl-102
[**2124-5-26**] 12:00PM BLOOD Glucose-96 UreaN-29* Creat-1.1 Na-142
K-4.4 Cl-100 HCO3-33* AnGap-13
[**2124-6-8**] 08:19AM BLOOD WBC-3.8* RBC-3.33* Hgb-9.2* Hct-27.9*
MCV-84 MCH-27.7 MCHC-33.1 RDW-15.6* Plt Ct-317
[**2124-6-8**] 08:19AM BLOOD Glucose-153* UreaN-40* Creat-1.3* Na-140
K-3.9 Cl-100 HCO3-35* AnGap-9
Brief Hospital Course:
On [**2124-6-1**] Mr. [**Known lastname 1005**] was taken to the Operating Room and
underwent coronary artery bypass grafting x5 with the left
internal mammary artery to left anterior descending artery and
reverse saphenous vein grafts to the posterior descending
artery, obtuse marginal artery and saphenous Y-grafts to the
ramus intermedius artery and the first diagonal artery with
Dr.[**Last Name (STitle) **]. Please refer to his operative report for further
details.
He tolerated the procedure well and was transferred to the CVICU
in critical but stable condition. He awoke neurologically intact
and was extubated without incident.All drips were weaned to off
and beta blocker,Statin,ASA and diuresis were
He was transferred to the step down unit for further monitoring
on POD#3. Physical Therapy was consulted for strength and
mobility evaluation. Cts and temporary pacing wires were removed
per protocols and medications were adjusted for optimal care.
He was prepared for discharge to Sun Brideg wood Mill [**Hospital 487**]
rehabilitation on [**2124-6-10**]
Medications on Admission:
Lasix 80mg [**Hospital1 **],Norvasc 10mg daily,ASA 325mg daily,Plavix 75mg
daily,Iron 325mg daily,,Glipizide 5 Q AM,Hydralazine 25
TID,Imdur 30mg daily,Lopressor 75BID,Remeron 15 qHS, Ambien 5
HS/prn
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 weeks.
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever or pain.
7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
8. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
10. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
11. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. Amlodipine 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
13. Lasix 40 mg Tablet Sig: Two (2) Tablet PO twice a day: home
dose.
Discharge Disposition:
Extended Care
Facility:
Colonial Heights Care and Rehabilitation Center - [**Hospital1 487**]
Discharge Diagnosis:
Coronary Artery Disease
s/p Coronary Artery Bypass Graft x 5
s/p RCA stent [**4-3**]
Acute systolic heart failure-? transient ischemic cardiomyopathy
Bilateral carotid stenosis
Chronic Obstructive Pulmonary disease
h/o Rhabdomyolysis
noninsulin dependent diabete mellitus
Hypertension
s/p Diabetic foot ulcer debridement
s/p right hand tendon repair
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
leg - healing well, no erythema, scant thin seorosanguimous
drainage from Left drain site.
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 until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon:
Dr. [**Last Name (STitle) **] on Wed, [**2124-7-5**] at 1:45pm
Please call to schedule appointments with your
Primary Care Dr.[**Doctor Last Name **] in [**11-27**] weeks
Cardiologist Dr. [**Last Name (STitle) 4922**] in [**11-27**] 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:[**2124-6-10**]
|
[
"414.2",
"496",
"428.21",
"428.0",
"250.00",
"E878.2",
"427.31",
"401.9",
"997.1",
"V45.82",
"414.01",
"433.30",
"427.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.15",
"36.14"
] |
icd9pcs
|
[
[
[]
]
] |
6798, 6894
|
4324, 5397
|
298, 593
|
7288, 7555
|
2279, 4301
|
8309, 8803
|
1540, 1558
|
5647, 6775
|
6915, 7267
|
5423, 5624
|
7579, 8286
|
1573, 2260
|
239, 260
|
621, 1081
|
1103, 1393
|
1409, 1524
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,085
| 189,456
|
7492
|
Discharge summary
|
report
|
Admission Date: [**2108-6-15**] Discharge Date: [**2108-6-24**]
Date of Birth: [**2047-8-25**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Left Upper lobe mass
Major Surgical or Invasive Procedure:
VATS Left upper lobecetomy
History of Present Illness:
The patient is a 60 year old female who had recently been
hospitalized at [**Hospital3 7571**]for 5 days in the beginning of
[**Month (only) 404**] for treatment of
pneumonia.. She denies any further fevers, chills, or sweats.
She denies any unintentional change
in her weight, though she notes that she has had approximately a
50-pound weight loss over the last 3-4 years, which she says is
intentional. She has some dyspnea on exertion, but she can walk
two flights of stairs without stopping. She notes no change in
her voice quality. She notes no neurologic symptoms including
headaches, weakness, paresthesias, visual changes, or bony pain.
During her workup for her pneumonia, she did undergo a chest
x-ray, which revealed a left upper lobe nodule and this was
followed with a chest CT, which confirmed the same. A head MRI
was negative for [**Last Name (LF) 1364**], [**First Name3 (LF) **] the pt is taken to the OR for
medistineoscopy and VATS LUL resection
Past Medical History:
COPD
Asthma
multiple bouts of pneumonia
Social History:
Extensive smoking history
No suspicious exposures or travel
Family History:
Non-contributory
Physical Exam:
97.5 74 16 102/47
NAD
RRR
CTA-long expiratory phase
Abd- soft, nt, nd
ext- warm, well perfused, no c/c/e
Pertinent Results:
[**2108-6-14**] 09:30AM PT-11.8 PTT-24.7 INR(PT)-1.0
[**2108-6-14**] 09:30AM PLT COUNT-247
[**2108-6-14**] 09:30AM WBC-5.9 RBC-4.06* HGB-13.7 HCT-40.2 MCV-99*
MCH-33.7* MCHC-34.0 RDW-14.8
[**2108-6-14**] 09:30AM ALT(SGPT)-13 AST(SGOT)-16 ALK PHOS-62
AMYLASE-100 TOT BILI-0.2
[**2108-6-14**] 09:30AM GLUCOSE-103 UREA N-21* CREAT-0.7 SODIUM-141
POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-27 ANION GAP-14
[**2108-6-15**] 01:30PM freeCa-1.21
Brief Hospital Course:
The patient was brought to the operating room and underwent
mediastinoscopy and VATS LULectomy, as described in Dr. [**Name (NI) 5794**] operative report. She was kept in the PACU
overnight, and required pressor support initially. Her post op
CXR showed pneumothorax and extensive sub-q emphysema, so an
additional chest tube was placed. This tube put out 300 cc of
fairly bloody output upon placement. She was then admitted to
the ICU on POD 1, due to her blood pressure. She did well
there, and her pressor requirement was weaned off. On the night
of POD 1, she had an episode of acute delirium, which was
controlled with anxiolytics and antipsychotic medications. She
was monitored for alcohol withdrawal. She was transferred to
the floor on POD 2 and did fairly well there. She had one
episode of mild confusion and medication refusal, but this
resolved on it's own. When her chest tube was placed to water
seal on POD 4, a pneumothorax reaccumulated, so it was put back
to suction. Throughout the admission pain was controlled with a
thoracic epidural, until POD 5, when she was transitioned to PO
pain medication. Once on the floor she did much better, having
her [**Doctor Last Name 406**] drains removed on POD 4, her chest tube was d/DC'ed on
POD 5, with the resulting pneumothorax described above. She was
discharged home on POD 6 tolerating food, on oral pain
medication with all her tubes d/c' ed.
Medications on Admission:
Aspirin
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
2. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours).
Disp:*1 inhaler* Refills:*2*
3. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 inhaler* Refills:*2*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Left Upper lobe mass, pathology pending
Discharge Condition:
Good
Discharge Instructions:
Call the Thorasic Surgery office ([**Telephone/Fax (1) 170**]) with any
problems, including but not limited to: Chest pain, shortness of
breath, bleeding or oozing from your incisions, fever,
increasing redness at your incisions or any other concering
sign.
Followup Instructions:
See Dr. [**Last Name (STitle) **] in [**11-24**] days. Call the number above for an
appointment
Completed by:[**2108-6-26**]
|
[
"998.81",
"E878.6",
"512.1",
"162.3",
"493.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.22",
"32.29",
"34.04",
"40.3",
"32.4"
] |
icd9pcs
|
[
[
[]
]
] |
4169, 4175
|
2155, 3579
|
342, 371
|
4259, 4266
|
1687, 2132
|
4572, 4700
|
1526, 1544
|
3637, 4146
|
4196, 4238
|
3605, 3614
|
4290, 4549
|
1559, 1668
|
282, 304
|
399, 1370
|
1392, 1433
|
1449, 1510
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,702
| 102,939
|
48075
|
Discharge summary
|
report
|
Admission Date: [**2189-1-25**] Discharge Date: [**2189-1-28**]
Date of Birth: [**2137-6-19**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1042**]
Chief Complaint:
hypotension, bradycardia s/p crack/EtOH
Major Surgical or Invasive Procedure:
none
History of Present Illness:
51 yo M with h/o bipolar disorder, schizoaffective disorder,
polysubstance abuse, and HIV who presents with hypotension and
bradycardia s/p crack cocaine and alcohol use. Per pt, had
snorted a large amount of crack at 12 am and drank a [**12-24**] bottle
of alcohol at 12:30 am when he attempted to reenter his group
home and was not allowed. He then began to hear voices in his
head telling him to "kill" himself and that he was a "loser." He
was reportedly noted to be altered and was brought in by EMS for
further evaluation.
In the ED, BP 60/36, HR 52. He was given atropine 1 mg and then
glucagon 5 mg with good response of SBPs from 50s to 110s and HR
from 50s to 70s. One hour later, the pt was noted to be
bradycardic and hypotensive, responding once again to glucagon.
An EKG was notable for a prolonged QTc of 473 msec, FS 94, Cr
elevated to 2.2. Urine tox + cocaine, serum EtOH 227. In the ED,
the pt denied SI and further auditory hallucinations. He was
started on a glucagon drip and transferred to the ICU for
further care.
Currently, the pt complains of a headache, lightheadedness, and
fatigue. He states that he feels as he usually does after doing
a large amount of crack. He denies SI, HI, fevers, cough, SOB,
CP, abd pain, diarrhea, nausea, vomiting, dysuria. Denies taking
any other additional medications beyond prescribed meds, but did
speak vaguely about taking "street methadone" or suboxone.
Past Medical History:
HIV positive
Bipolar disorder - h/o multiple psychiatric admissions
Schizoaffective disorder
Polysubstance abuse
EtOH abuse - no h/o seizures, but h/o withdrawals, ? DTs
HTN
Hepatitis A, B and C
ALL: NKDA
Social History:
The patient has a history of cocaine and heroin use. The
longest time sober was two years. + EtOH abuse. Lives in group
home.
Family History:
Father an alcoholic.
Physical Exam:
T 96.4 BP 89/52 HR 55 RR 13 O2 sat 97% on RA
Gen - sleepy but arousable to voice, follows commands
HEENT - sclerae anicteric, dry MM, neck supple, no LAD, JVD flat
CV - bradycardic, nl s1/s2, I/VI holosystolic murmur over apex
Lungs - expiratory wheezes b/l, no rhonchi or rales
Abd - Soft, NT, ND, normoactive BS
Ext - no LE edema, WWP, mildly tremulous
Skin - no rashes or lesions
Pertinent Results:
[**2189-1-25**] 01:47AM BLOOD WBC-7.8# RBC-3.00* Hgb-13.1* Hct-36.6*
MCV-122*# MCH-43.8* MCHC-35.9* RDW-13.0 Plt Ct-193
[**2189-1-25**] 01:47AM BLOOD Glucose-77 UreaN-53* Creat-2.2*# Na-136
K-3.8 Cl-101 HCO3-18* AnGap-21*
[**2189-1-25**] 03:38PM BLOOD Glucose-121* UreaN-38* Creat-1.0# Na-140
K-4.0 Cl-113* HCO3-20* AnGap-11
[**2189-1-25**] 01:47AM BLOOD ALT-119* AST-152* LD(LDH)-277*
AlkPhos-38* Amylase-23 TotBili-0.3
[**2189-1-25**] 01:47AM BLOOD ASA-NEG Ethanol-227* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2189-1-25**] 03:38PM BLOOD VitB12-817 Folate-GREATER TH
[**2189-1-25**] 01:47AM BLOOD Lipase-17
[**2189-1-25**] 01:47AM BLOOD Albumin-4.2
EKG: sinus bradycardia @ 51 bpm, nl axis, prolonged QTc 478
msec, LVH, TWI III, T wave flattaening aVF, J point elevation
V2-V6
Imaging:
CXR [**2189-1-25**]:
No acute cardiopulmonary process.
Brief Hospital Course:
51 yo M with extesive psych history, polysubstance abuse, and
HTN who presents s/p crack and EtOH ingestion with bradycardia
and hypotension.
.
#) Hypotension/Bradycardia - Likely in setting of post-crack
sympathetic burnout with beta-blocker on board in acute renal
failure. Hypotension and bradycardia have resolved on glucagon
drip.
- Continue glucagon gtt at 5 mg/hr.
- Monitor FS q1h.
- Start D5 1/2 NS @ 125 cc/hr to prevent hypoglycemia.
- Allow pt to take pos.
- Hold all antihypertensives.
- Telemetry monitoring.
- Resolved and was transferred out of ICU.
.
#) Acute renal failure - Per pt, no prior h/o renal dysfunction,
prior Cr in OMR in [**2181**] 0.8 - 1.1. ARF likely pre-renal in
etiology given large intake of crack cocaine and alcohol without
taking fluids or other pos.
- IVFs as above.
- Check pm lytes, BUN, Cr.
- UA negative, consider checking urine lytes in afternoon if Cr
not trending down.
- Resolved after IVF resuscitation.
.
#) Anion-gap metabolic acidosis - AG 17 in setting of uremia and
ingestions. Will continue to monitor closely.
- Resolved with IVF resuscitation.
.
#) Alcohol abuse - Concern for withdrawal and possible DTs.
Currently without significant signs or symptoms of EtOH
withdrawal.
- CIWA q2h, valium 10 mg po prn for CIWA > 10.
- SW, addictions consult.
- CIWA was discontinued after 72 hours, with CIWA 0-1
.
#) Prolonged QTc - of 478 msec. Pt on zyprexa as outpt, concern
for other possible ingestions as well that pt does not report.
- Repeat EKG.
- Continue zyprexa for now while closely monitoring QTc.
- QTc remained stable
.
#) Macrocytic anemia - In setting of EtOH abuse, HAART meds.
Continue to monitor, guaiac stools, check B12, folate.
.
#) Bipolar/schizoaffective disorder - Currently denies SI, but
did have auditory hallucinations to harm himself last pm after
using crack and EtOH.
- Psych consult.
- No need for 1:1 sitter for now.
- Continue cogentin, depakote, zyprexa.
.
#) Hypertension. After resuscitation, patient returned to
baseline high blood pressure. His outpatient regimen was
restarted, and subsequently titrated to a goal blood pressure of
< 140/90. A beta blocker was not resumed due to his overdose and
cocaine abuse. He was discharged on clonidine PO, nifedipine,
and lisinopril.
.
#) Patient was referred by social work to [**Hospital1 **] for rehab/detox
program.
.
#) AIDS. He was continued on his anti-retroviral therapy.
Medications on Admission:
Combivir 150-300 mg 1 tab [**Hospital1 **]
Sustiva 600 mg daily
Cogentin 1 mg [**Hospital1 **]
Depakote 250 mg qam, 500 mg qhs
Zyprexa 20 mg qhs
Trazodone 300 mg qhs prn
HCTZ 25 mg daily
Lopressor 100 mg daily
Protonix 40 mg daily
Ibuprofen 800 mg tid prn
Zestril 20 mg daily
Clonidine 0.3 mg tid
Discharge Medications:
1. Benztropine 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*1*
2. Trazodone 100 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime) as needed.
Disp:*90 Tablet(s)* Refills:*1*
3. Efavirenz 600 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QAM (once a day (in the
morning)).
5. Divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO QHS (once a day (at bedtime)).
6. Lamivudine-Zidovudine 150-300 mg Tablet Sig: One (1) Tablet
PO BID (2 times a day).
7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
8. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Olanzapine 10 mg Tablet, Rapid Dissolve Sig: Two (2) Tablet,
Rapid Dissolve PO HS (at bedtime).
12. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*1*
13. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*1*
14. Nifedipine 30 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO DAILY (Daily).
Disp:*30 Tablet Sustained Release(s)* Refills:*1*
15. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
1. Alcohol withdrawal with delirium tremans
2. Cocaine withdrawal
3. Bradycardia
4. Hypotension
5. Hypertension
6. HIV/AIDS
Discharge Condition:
Stable, without tremors or hallucinations
Discharge Instructions:
Please contact your primary care physician if you develop
tremors, anxiety, or hallucinations.
You have a intake appointment at [**Hospital1 **] on Monday, [**2-2**].
Stop drinking alcohol and using crack cocaine.
An appointment has been made with your new primary care
physician.
Stop taking Lopressor (metoprolol).
Followup Instructions:
Provider: [**Name10 (NameIs) 39063**] [**Last Name (NamePattern4) 39064**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2189-3-3**] 2:00
|
[
"042",
"401.9",
"458.9",
"291.0",
"303.90",
"304.20",
"070.30",
"070.70",
"427.89",
"070.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"94.68"
] |
icd9pcs
|
[
[
[]
]
] |
7861, 7867
|
3522, 5934
|
355, 361
|
8035, 8079
|
2643, 3499
|
8448, 8594
|
2202, 2224
|
6281, 7838
|
7888, 8014
|
5960, 6258
|
8103, 8425
|
2239, 2624
|
276, 317
|
389, 1812
|
1834, 2041
|
2057, 2186
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,870
| 169,160
|
55061
|
Discharge summary
|
report
|
Admission Date: [**2155-9-5**] Discharge Date: [**2155-9-11**]
Date of Birth: [**2078-5-22**] Sex: M
Service: NEUROSURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 5084**]
Chief Complaint:
Left arm/leg ataxia, confusion, word finding difficulties, R
frontal mass on CT
Major Surgical or Invasive Procedure:
[**9-8**] right craniotomy; partial temporal tumor resection
History of Present Illness:
Mr. [**Known lastname 112376**] is a 77 yo M with h/o CAD, HTN, HLD who is
transferred to [**Hospital1 18**] ED for right frontal mass seen on OSH head
CT. Patient was in his usual state of health until two days ago
when he awoke at 4am with left arm weakness, clumsy left hand,
and pain/paresthesias on his medial left arm. When he tried to
get out of bed his left leg collapsed underneath him. Since then
these symptoms have persisted and he has had several more falls;
unsure whether he was falling to right or left. Never hit his
head. His son, who is with him for exam, notes that he has also
had new slurred speech, confusion, is talking slower than usual,
and has some word finding difficulties. Per son, he has also
been
reaching out with his left hand to grab for objects that aren't
there. This morning he called his PCP (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at
[**Hospital 86**] [**Hospital 12018**] Hospital) who was concerned he was having a
stroke and told him to go to the ED. At OSH ED, non-contrast
head
CT showed right frontal mass. He was transferred to [**Hospital1 18**] for
further evaluation.
On arrival to [**Hospital1 18**] ED, vitals are 98.7 178/82 60 20 97% 2L NC.
Patient is AAOx3, talking slowly but appropriately but with
word-finding difficulty. Throughout exam he had several episodes
of reaching out for objects with his right hand, then was unsure
what he was reaching for. For cancer screening history, he
states
his most recent colonoscopy was 2 years ago, and was normal.
Denies h/o cigarettes. His most recent PSA was 6 (up from 2.5
previously).
Past Medical History:
-CAD s/p angioplasty
-HTN
-Hyperlipidemia
-H/O GI bleed (due to aspirin overuse)
-Insomnia
Social History:
lives at home. Used to work in construction. Drinks ETOH
extremely rarely. Has never smoked cigarettes or used illicits.
Family History:
2 brothers died of prostate cancer. Sister died of ovarian
cancer (61 yo).
Physical Exam:
On admission:
PHYSICAL EXAM:
O: 98.7 178/82 60 20 97% 2L NC.
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 3->2 BL EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**2-11**] objects at 5 minutes.
Language: Speech slow but fluent with good comprehension and
repetition. Naming intact. No dysarthria, occasional paraphasic
errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**6-14**] throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Toes downgoing bilaterally
Coordination: +past-pointing on finger nose finger bilaterally
(L>R), +ataxia with rapid alternating movements and heel to shin
bilaterally (L>R)
Gait not tested.
Pertinent Results:
MRI Brain [**2155-9-6**]:
FINDINGS: There is a focal lesion with heterogeneous
enhancement, solid
enhancing and non-enhancing components, in the right frontal
lobe superiorly (series 14, image 21), which may represent
either a single lesion or two adjacent lesions with mild
surrounding edema and FLAIR hyperintense signal. The lesion
overall measures 1.2 x 1.7 cm. In the right temporal lobe,
there is a larger lesion with heterogeneous enhancement and a
few non-enhancing foci within, the lesion measuring 1.9 x 3.8 x
1.2 cm with mild surrounding edema. A few smaller enhancing
lesions are noted adjacent to this lesion. The lesions
demonstrate increased DWI signal intensity with some degree of
low signal on the ADC sequence. No large foci of negative
susceptibility are noted within except for a tiny focus in the
right temporal lesion.
No cerebellar lesions are noted. There are multiple small
periventricular FLAIR hyperintense foci noted adjacent to the
frontal and the atria of the lateral ventricles, likely
nonspecific in appearance.
The major intracranial arterial flow voids are noted. Mild
mucosal thickening is noted in the ethmoid air cells on both
sides and in
the left mastoid air cells.Small retention cysts/polyps are
noted in the maxillary sinuses on both sides,incompletely
imaged. The ocular lenses are not well seen.
IMPRESSION:
1. Multiple enhancing lesions as described above in the right
frontal and the right temporal lobes with heterogeneous
enhancement. Possibilities include metastatic lesions, primary
multifocal neoplasm such as lymphoma/glioma. Though there is
some degree of slow diffusion within these lesions and cortical
involvement, the enhancement pattern does not resemble the usual
subacute infarcts. However, clinical correlation is recommended
and a close followup study to assess interval evolution for
further characterization can be helpful (if needed with MR
Spectroscopy and perfusion).
[**2155-9-6**] CT Torso:
1. Right upper lobe, 4 mm peripheral nodule. No prior studies
are available for comparison.
2. Pleural plaques, consistent with prior asbestos exposure.
3. There is no evidence of mediastinal, supraclavicular or
axillary
lymphadenopathy.
4. Small left adrenal nodule, measuring 1.2 x 0.9 cm,
indeterminate in
nature. If further investigation is desired, MRI without
contrast or a CT
with washout protocol may be obtained.
5. No other masses or evidence of malignancy seen within the
chest, abdomen
or pelvis.
[**2155-9-6**] Femur/Pelvic xray:
Bones are mildly osteopenic. There are degenerative changes in
the lower
lumbar spine as well as involving both hip joints and symphysis
pubis.
Contrast is seen within a non-distended bladder. Several
calcifications in the pelvis are consistent with phleboliths.
No displaced fracture or
dislocation of the left hip is seen. There is possibly a tiny
left
suprapatellar joint effusion and mild patellofemoral
degenerative change. No displaced fracture is or dislocation is
seen.
Brief Hospital Course:
77M who presented to the ER with new neurological findings, a
head CT showed a right frontal brain mass. He was admitted to
Neurosurgery under Dr[**Name (NI) **] care. He was admitted to the floor.
Overnight he had a witnessed tonic clonic seizure and received a
Dilantin load. He had Tod's paralysis post-ictal. He also had a
period of hypertension to 190/100 and received Hydralazine with
good effect. On morning labs his uric acid was high at 8.5, a
LDH was also sent as onc workup. On [**9-6**], he underwent a MRI
brain. The MRI showed right frontal and temporal lesions that
were concerning for metastatic lesions vs lymphoma. A CT torso
was also performed which showed a small lung and adrenal
nodules. A dilantin level was drawn and was 11.7, no load was
given and plan to repeat the level in the AM. On exam, it was
noted there was some bruising and the patient c/o groin pain, a
pelvic and femur xray were done and showed no significant
abnormality. He was kept NPO after midnight in preparation for
the OR on [**9-8**]. He tolerated the procedure well with no
complication. Post operatively he was transferred to the ICU for
further care including SBP control and q1 neuro checks. He
remained stable and was tranferred to the floor. His floor
course was otherwise eventful. He is stable for discharge home
in stable condition.
Medications on Admission:
ASA 81mg daily
Atenolol 25mg daily
Diazepam 5-10mg daily
Omeprazole 20mg daily
Zolpidem 1tab qhs
Simvastatin 40mg daily
Discharge Medications:
1. Atenolol 25 mg PO DAILY
2. Omeprazole 20 mg PO DAILY
3. Simvastatin 40 mg PO DAILY
4. Zolpidem Tartrate 5 mg PO HS
5. Acetaminophen 325-650 mg PO Q6H:PRN pain
6. Docusate Sodium 100 mg PO BID
RX *Colace 100 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
7. LeVETiracetam 1000 mg PO BID
RX *Keppra 1,000 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*3
8. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*90 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Right frontal and temporal masses
Cerebral edema
Seizure
Lung mass
Adrenal mass
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Dressing may be removed on Day 2 after surgery.
?????? **You have dissolvable sutures you may wash your hair and get
your incision wet day 3 after surgery. You may shower before
this time using a shower cap to cover your head.
?????? **Your wound was closed with staples or non-dissolvable
sutures then you must wait until after they are removed to wash
your hair. You may shower before this time using a shower cap to
cover your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace) &
Senna while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? **You have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**].
?????? **You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? If you are being sent home on steroid medication, make sure
you are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: increasing redness,
increased swelling, increased tenderness, or drainage.
?????? Fever greater than or equal to 101.5?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
** No wound check needed if being seen in BTC within 14 days.
??????Please return to the office in [**8-19**] days (from your date of
surgery) for removal of your staples/sutures and/or a wound
check. This appointment can be made with the Physician [**Name9 (PRE) 14355**]
or [**Name9 (PRE) **] Practitioner. Please make this appointment by calling
[**Telephone/Fax (1) 1669**]. If you live quite a distance from our office,
please make arrangements for the same, with your PCP.
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**2155-9-22**] at
10:30. Please be aware that your appointment could take up to
3-4 hours. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**]
of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone number
is [**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
??????You will need an MRI of the brain with/without gadolinium
contrast. If you are required to have a MRI, you may also
require a blood test to measure your BUN and Cr within 30 days
of your MRI. This can be measured by your PCP, [**Name10 (NameIs) **] please
make sure to have these results with you, when you come in for
your appointment.
Completed by:[**2155-9-11**]
|
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icd9cm
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[
[
[]
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[
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icd9pcs
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,960
| 152,618
|
41953
|
Discharge summary
|
report
|
Admission Date: [**2196-4-24**] Discharge Date: [**2196-4-27**]
Date of Birth: [**2113-3-21**] Sex: M
Service: NEUROLOGY
Allergies:
Pradaxa / OxyContin
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Garbled speech and right-sided weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
83RHM with a past medical history of atrial fibrillation on
warfarin, previous TIA [**2194**], CAD with recent cath for ST changes
found to have non-occulsive CAD, CKD, alcoholic cirrhosis s/p
portal shunt in [**2154**] and encephalopathy and with recent septic
left knee (growing coagulase negative staph) s/p I&D with linear
exchange and completed course of IV vancomycin and left hip
hemiarthroplasty [**2196-3-24**] for femoral neck fracture who
presents from rehab with sudden onset garbled speech and right
sided weakness and Code Stroke called.
Patient has AF and had problems with multiple episodes of
supratherapeutic INR last 3.3 on [**4-22**] and were holding warfarin
at rehab planning to restart at 1mg tonight. From theor
perspecctive, his alcoholic cirrhosis was stable ans they were
continuing lactulose. BP was noted as 158/[**Age over 90 **] yesterday. Patient
found to have garbled speech at 08:50 at rehab which was far
from baseline (previosu documentation states A+Ox3) and possibly
right weakness. Patient was transferred to [**Hospital1 18**] and on
presentation to the ED, patient was hypertensive at 188/137 and
was noted to be not verbalising and had clear right sided
weakness. His exam somewhat improved regarding his speech which
was initially anarthric and felt severe non-fluent aphasia as
not verbalising butthsi improved and although difficult to
understand was able to name pretty well suggesting mostly
dysarthria.
Patient BP then settled in 160s/100s and given INR 2.0 was
reversed with Factor 9 Complex and 10mg IT vitamin K. He was
started on a nicardipine drip. He has a PICC in situ for
hydration having finished vancomycin course.
On neuro ROS, difficult to assess but patient grossly denies
headache, loss of vision, vertigo, tinnitus or hearing
difficulty.
On general review of systems, grossly difficultto assess but the
pt denies shortness of breath or chest pain or nausea.
Past Medical History:
- Atrial Fibrillation on warfarin
- TIA [**11/2195**]
- C. Cath for STEMI found to have non-occlusive CAD
- Alcoholic cirrhosis s/p portal shunt in [**2154**] (TIPS?)
- [**3-14**] ERCP
- [**2-29**] I&D and linear exchange L knee
- CKD - baseline Cr of 1.5-2.3 (also interstitial nephritis s/p
Nafcillin)
- Gout
- prior alcoholabuse sober for 24 years
- Fall and underwent left hip hemiarthroplasty [**2196-3-24**] for
femoral neck fracture
- TKR '[**88**]
Social History:
He has been at rehab since discharge in [**Month (only) 547**]. Prior to
[**Month (only) **] when he was admitted for NSTEMI, lived at home in
[**Hospital1 **] by himself but had 24 hour care and VNA since his
discharge from rehab in [**Month (only) **]. He had worked as a
geneologist and finds missing heirs to estates. He smoked for 10
years quit 40 years ago. Previosu very heavy drinker quit 24
years ago has been in AA since.
Family History:
- Brother had TIAs is 86, mother and father both lived
to old age.
Physical Exam:
Admission Physical Exam:
Vitals: T:98 P:101 regular on monitor R:15 BP: 168/115
SaO2:100% 2L O2
General: Awake profound dysarthria but understands most
questions. PICC line.
HEENT: NC/AT, no scleral icterus noted, very dry mucus membranes
but mouth breathing, 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 actually regular on assessment but
somewhat intermittenttly regular on ECG. JVP 3-4cm.
Abdomen: right upper abdominal scar soft, NT/ND, normoactive
bowel sounds, no masses or organomegaly noted.
Extremities: Scar and reecnt procedure on left knee. Pitting
edema to just above knee L>R. 2+ radial, DP pulses bilaterally.
Calves SNT bilaterally.
Skin: Multiple bruises in legs and arms esp arms. Significant
leukonychia to halfway up nails.
Neurological examination:
- Mental Status:
E4 V4 M6. Very dysarthric almost anarthic initially and
initially not verbalising other than incomprehensibbel noises
but this immproved and now very dysarthric but reasonable naming
but still non-fluent broken speech in 1 word phrsies suggestive
of non-fluent aphasia but predominant feature is dysarthria.
Reasonably attentive but unable to be assessed further and at
time sinconsistently follow commands. Seems to be attending to
both sides.
- Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2.5mm and brisk. Inconsistently blinks to threat
bilaterally but can track very well suggesting no hemianopia.
Funduscopic exam reveals no papilledema, exudates, or
hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal pursuits.
V: Facial sensation intact to light touch and temperature per
patient. Good power in muscles of mastication.
VII: Right facial droop.
VIII: Hearing intact to voice bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM on left and reduced on
right.
XII: Tongue protrudes in midline but very clumsy and unable to
move from side to side.
- Motor: Normal bulk and reduced tone in right arm and leg.
Unabel to lift right arm antigravity. Prominent left asterixis.
Spontaneously moving right leg and right arm much less so. Some
spontaneous movement in left side but dificulty in left leg.
Withdraws right side reasonably well to noxious. Below exam is
at times inferred by response to passive movement on the right.
SAbd SAdd ElF ElE WrE FFl FE HipF HipE KnF KnE AnkD AnkP
L 4+ 5 5 5 5 5 5 [**12-14**] 4+ 4 4 4 4
R [**12-14**] 4 4 4 1 [**1-15**] 1 3 4+ [**2-14**] 4 3 2
- Sensory: Patient states feels light touch, pain (grimaces) and
vibration in all 4 limbs.
- DTRs:
BJ SJ TJ KJ AJ
L 2 2 2 0 0
R 2 2 2 1 0
There was no evidence of clonus.
[**Last Name (un) 1842**] negative.
Plantar response was extensor on right adn flexor on left.
- Coordination: Reaches well to hand on left but asterixis
noted.
- Gait: Deferred.
.
Discharge examination:
Dysarthria and normal mental status with no evidence of aphasia
and able to name objects and fully oriented. Patient has a right
facial droop and otherwise cranial nerves unremarkable. Right
arm>leg hemiparesis worse distally in the UE and the right
plantar was extensor. Good power on the left side but limited by
left knee procedure. Intact sensation. Asterixis improved and
only just present. Coordination normal on left and unabel to
assess due to weakness on the right.
Pertinent Results:
Laboratory investigations:
Admission labs:
[**2196-4-24**] 10:04AM BLOOD WBC-6.8 RBC-3.29* Hgb-10.7* Hct-34.6*
MCV-105* MCH-32.4* MCHC-30.8* RDW-18.2* Plt Ct-322
[**2196-4-24**] 10:04AM BLOOD PT-21.1* PTT-41.4* INR(PT)-2.0*
[**2196-4-24**] 10:04AM BLOOD UreaN-42*
[**2196-4-24**] 10:04AM BLOOD Creat-1.5*
[**2196-4-24**] 04:35PM BLOOD Glucose-98 UreaN-41* Creat-1.3* Na-140
K-4.4 Cl-109* HCO3-21* AnGap-14
[**2196-4-24**] 04:35PM BLOOD ALT-22 AST-37 LD(LDH)-247 AlkPhos-183*
TotBili-1.0
[**2196-4-24**] 04:35PM BLOOD Calcium-9.8 Phos-3.0 Mg-1.8
.
INR trend:
[**2196-4-24**] 10:04AM BLOOD PT-21.1* PTT-41.4* INR(PT)-2.0*
[**2196-4-24**] 04:35PM BLOOD PT-13.3* PTT-32.2 INR(PT)-1.2*
[**2196-4-25**] 01:35AM BLOOD PT-12.6* PTT-32.0 INR(PT)-1.2*
[**2196-4-27**] 05:05AM BLOOD PT-12.2 PTT-32.6 INR(PT)-1.1
.
Other pertinent labs:
[**2196-4-24**] 04:35PM BLOOD Lipase-44
[**2196-4-24**] 10:04AM BLOOD CK-MB-4 cTropnT-0.08*
[**2196-4-24**] 04:35PM BLOOD CK-MB-4 cTropnT-0.07*
[**2196-4-25**] 12:34PM BLOOD CK-MB-4 cTropnT-0.10*
[**2196-4-25**] 05:27PM BLOOD CK-MB-4 cTropnT-0.11*
[**2196-4-26**] 02:16AM BLOOD CK-MB-4 cTropnT-0.12*
[**2196-4-25**] 01:35AM BLOOD Calcium-9.9 Phos-3.0 Mg-1.7 Cholest-173
[**2196-4-25**] 01:35AM BLOOD Triglyc-82 HDL-49 CHOL/HD-3.5 LDLcalc-108
[**2196-4-25**] 02:10AM BLOOD Ammonia-61*
[**2196-4-26**] 02:16AM BLOOD Ammonia-60
[**2196-4-24**] 02:26PM BLOOD %HbA1c-4.8 eAG-91
[**2196-4-25**] 01:35AM BLOOD %HbA1c-4.9 eAG-94
[**2196-4-25**] 01:35AM BLOOD TSH-2.9
[**2196-4-24**] 04:35PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2196-4-25**] 12:41PM BLOOD Type-ART pO2-89 pCO2-29* pH-7.45
calTCO2-21 Base XS--1
[**2196-4-24**] 10:13AM BLOOD Glucose-101 Lactate-1.2 Na-139 K-4.8
Cl-109* calHCO3-22
[**2196-4-25**] 12:41PM BLOOD freeCa-1.34*
.
Discharge labs:
[**2196-4-27**] 05:05AM BLOOD WBC-3.8* RBC-3.75* Hgb-12.4* Hct-39.8*
MCV-106* MCH-33.0* MCHC-31.1 RDW-18.2* Plt Ct-181
[**2196-4-27**] 05:05AM BLOOD PT-12.2 PTT-32.6 INR(PT)-1.1
[**2196-4-27**] 05:05AM BLOOD Glucose-94 UreaN-32* Creat-1.3* Na-145
K-4.0 Cl-116* HCO3-21* AnGap-12
[**2196-4-27**] 05:05AM BLOOD Calcium-9.2 Phos-2.8 Mg-1.9
.
.
Urine:
[**2196-4-24**] 12:46PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010
[**2196-4-24**] 12:46PM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG
[**2196-4-24**] 12:46PM URINE RBC-39* WBC-59* Bacteri-FEW Yeast-MANY
Epi-0 TransE-<1
[**2196-4-24**] 12:46PM URINE CastGr-3*
.
.
Microbiology:
[**2196-4-24**] 12:46 pm URINE
**FINAL REPORT [**2196-4-25**]**
URINE CULTURE (Final [**2196-4-25**]):
YEAST. >100,000 ORGANISMS/ML..
.
.
Radiology:
CT HEAD W/O CONTRAST Study Date of [**2196-4-24**] 9:52 AM
FINDINGS: Examination is suboptimal due to extensive patient
motion. There is an acute, 1.7 x 1.2 cm hematoma in the left
thalamocapsular region (2B:56), with a rim of surrounding
vasogenic edema. This mildly effaces the left atrium, but there
is no shift of the normally midline structures.
Ventricles and sulci remain enlarged, compatible with
age-related involutional changes. Faint periventricular and
subcortical white matter hypointensities reflect small vessel
ischemic disease. There are calcifications in the
bilateral cavernous carotid arteries.
Note is made of an atelectatic right maxillary sinus, with
inward retraction of the sinus walls and convex lateral bowing
of the right nasal cavity. No current evidence of sinus or
infundibular opacification. Incidental note of a right
scleral plaque.
IMPRESSION:
1. Acute small left thalamocapsular hematoma with surrounding
vasogenic
edema. Likely due to hypertension.
2. Right maxillary sinus syndrome with associated orbital
asymmetry.
.
CHEST (PORTABLE AP) Study Date of [**2196-4-24**] 2:26 PM
FINDINGS: Cardiac silhouette is persistently enlarged and
accompanied by mild pulmonary vascular congestion, bilateral
small pleural effusions, and adjacent basilar atelectasis. As
compared to the prior study, the right pleural effusion has
apparently decreased in size, and both lung bases are slightly
better aerated.
.
CT HEAD W/O CONTRAST Study Date of [**2196-4-25**] 4:33 AM
FINDINGS: Examination is limited due to patient motion. The
left thalamocapsular region hematoma measures 18 x 13 mm,
essentially unchanged from the previous examination, with a rim
of surrounding vasogenic edema which is perhaps slightly
minimally more apparent, compatible with continued evolution.
No additional sites of hemorrhage are seen. Ventricles and
sulci remain prominent, compatible with age-related involutional
changes. No shift of normally midline structures. The basal
cisterns are patent. No fracture is seen. There are
periventricular and subcortical white matter
hypodensities, hypodensities are compatible with small vessel
ischemic disease. Collapsed right maxillary sinus is again
noted.
IMPRESSION: Continued evolution of left thalamocapsular
hematoma with
surrounding vasogenic edema without significant change.
.
CHEST (PORTABLE AP) Study Date of [**2196-4-26**] 4:33 AM
FINDINGS: In comparison with the study of [**4-24**], the nasogastric
tube has been removed. Continued enlargement of the cardiac
silhouette with bilateral small effusions and mild pulmonary
vascular congestion. Bibasilar atelectatic change without
definite acute pneumonia.
.
.
Cardiology:
ECG Study Date of [**2196-4-24**] 10:19:20 AM
Atrial fibrillation with moderate ventricular response. Diffuse
non-specific
ST-T wave changes. Compared to the previous tracing of [**2196-4-1**]
lateral
ST-T wave changes are slightly more prominent. Clinical
correlation is
suggested.
TRACING #1
Read by: [**Last Name (LF) **],[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
97 0 100 354/418 0 24 173
.
ECG Study Date of [**2196-4-25**] 8:38:14 AM
Atrial fibrillation with rapid ventericular response. Compared
to tracing #1
ventricular response has slightly increased but the lateral ST-T
wave
abnormalities are slightly more prominent. Clinical correlation
is suggested.
TRACING #2
Read by: [**Last Name (LF) **],[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
106 0 98 350/430 0 27 -177
.
ECG Study Date of [**2196-4-25**] 12:09:38 PM
Sinus tachycardia. Baseline artifact. Left ventricular
hypertrophy with
secondary repolarization abnormalities. Compared to the previous
tracing
of [**2196-4-25**] sinus rhythm is noted.
Read by: [**Last Name (LF) **],[**First Name3 (LF) **]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
107 186 98 340/422 86 17 -179
Brief Hospital Course:
83RHM with a past medical history of AF on warfarin, previous
TIA [**2194**], CAD with recent cath for ST changes found to have
non-occulsive CAD, CKD, alcoholic cirrhosis s/p portal shunt in
[**2154**] and encephalopathy and with recent septic left knee
(growing coagulase negative staph) s/p I&D with liner exchange
and completed course of IV vancomycin and left hip
hemiarthroplasty [**2196-3-24**] for femoral neck fracture presented
from rehab with acute onset right-sided weakness and garbled
speech and was found to have a left thalamocapsular IPH likely
hypertensive in the setting of supratherapeutic INR. Patient was
initially admitted to the neuro ICU for close monitoring and IV
nicardipine. Patient was transferred out of the ICU on [**2196-4-26**]
and remained stable on the floor. Repeat NCHCT stable and HTN
now under better controlled and uptitrating his
anti-hypertensives. He was admitted to the stroke neurology
service on [**2196-4-24**] and transferred to rehab on [**2196-4-27**].
Patient had neurology follow-up.
.
.
# Neurology:
At rehab, patient had problems with multiple episodes of
supratherapeutic INR last 3.3 on [**4-22**] and were holding warfarin
at rehab since. On presentation to the ED, patient was
hypertensive at 188/137 and was noted to be not verbalising and
had clear right sided weakness.
Initial NIHSS was 17 and patient had what seemed to be a severe
non-fluent aphasia although latterly this seemed to represent
most likely just significant dysarthria and was initially almost
anarthric with no clearly intelligible speech but was gesturing
and trying to vocalise without clear words, nodding and shaking
head appropriately. This later improved and although difficult
to understand, he improved and was able to name objects. On
examination, patient was attending to both sides and had a right
facial droop and right arm>leg hemiparesis worse distally in the
UE and a right plantar was extensor. Patient seemed to have
intact sensation and grimaced to noxious throughout. In addition
patient had prominent left asterixis.
CT head showed an acute, 1.7 x 1.2 x 2.0 cm left thalamocapsular
hemorrhage with minimal edema and no mass effect. He was
monitored on telemetry which showed paroxysmal AF. He was
started on a HISS with goal of normoglycemia. Stroke risk
factors were assessed and HbA1c was 4.9% and FLP revealed Chol
173 TGCs 82 HDL 49 LDL 108. His ammonia was 61-60 and serum tox
screen was negative. CEs were elevated and stable and there were
no new ECG changes and this was attributed to his CRF and
possible demand ischemia with discharge TnT 0.12. MB was flat
throughout.
In the ED his warfarin was reversed with factor 9 concentrate
and 10mg IV vitamin K and 2 units of FFP and was started on IV
nicardipine for hypertension. He was admitted to the neuro ICU
for BP control and close monitoring. His warfarin was held on
admission due to his IPH and he was continued on Nicardipine
gtt. An NGT was placed and his home BP medications lisinopril
was started and Metoprolol was introduced at a reduced dose.
Nicardipine was stopped. In the ICU he clinically improved and
although was initially fed with an NG tube he later passed his
speech and swallow assessment for a pureed and thin liquid diet.
Repeat NCHCT stable and HTN was better controlled with
uptitrating his anti-hypertensives. Prior to transfer to floor
he was started on heparin sc. Patient was transferred out of the
ICU on [**2196-4-26**] and remained stable on the floor. We further
uptitrated his anti-hypertensives and was discharged on
lisinopril 5mg qd (home dose) and metoprolol 50mg qid (dose at
rehab was 75mg qid). He was started on aspirin 81mg qd on the
day of discharge.
His thalamocapsular intraparenchymal hemorrhage is likely
hypertensive in aetiology in the setting of a high INR.
He was assessed by PT/OT and was deemed to benefit from rehab
and was transferred to rehab on [**2196-4-27**]. Patient had neurology
follow-up.
.
# Cardiology: Patient has a history of HTN and non-occlusive
CAD. He had paroxysmal AF on telemetry. CEs were elevated and
stable and there were no new ECG changes and this was attributed
to his CRF and possible demand ischemia in the setting of his
IPH with discharge TnT 0.12. MB was flat throughout. His
metoprolol was gradually uptitrated and was discharged on 75mg
qid and this will likely need to be further increased at rehab.
Lisinopril 5mg qd was restarted.
.
# Renal: Patient has CRF and Cr was at baseline ranging from 1.3
to 1.5 and 1.3 on discharge.
.
# ID: UTI showing mild WBC. He was not started on empiric Abx
and did not show signs/symptoms of infection. He had a PICC on
admission which had been used for hydration at rehab and this
was removed prior to transfer.
.
# Nutrition: Patient initially had an NG tube and was evaluated
by SS eval and was passed for pureed solids and thin liquids.
.
# Heme: Patient was hemodynamically stable during his admission
after correction of his hypertension. He was noted to have a
slight downtrend in his WCC to 3.8 and PLT 181 and this should
be trended at rehab.
.
# GI: Patient has a history of alcoholic cirrhosis s/p portal
shunt in [**2154**] and encephalopathy and seemed encephalopathic on
admission with prominent asterixis. His ammonia was 61-60. He
was started on lactulose and continued on his home dose and this
improved.
.
# # GU: Patient had straight cathing for high PVRs. A urinary
catheter was inserted prior to transfer with a plan for a
voiding trial at rehab.
.
# PPx: Given his hemorrhage, he was initially only on
pneumoboots and was restarted on heparin sc on transfer.
.
.
Transitional issues:
- We stopped warfarin and patient was continued on s/c heparin
and aspirin 81mg qd
- Up-titrating anti-HTN medications and will need further
uptitration at rehab
- Catheter inserted on transfer and for voiding trial at rehab
- Trend CBC at rehab given slight decrease in WCC and PLT
Medications on Admission:
Was on warfarin INR 3.3 on [**4-22**] and holding
Acetaminophen 650mg PRN
Allopurinol 100mg qd
Aspirin 81mg qd
Docusate [**Hospital1 **]
Lactulose 10ml [**Hospital1 **]
Lisinopril 5mg qd
Metoprolol tartrate 75mg qid
MVI
Omeprazole 40mg qd
Bisacodyl 10mg PR qd
Senna HS
Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
2. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day) as needed for constipation.
3. insulin lispro 100 unit/mL Solution Sig: as directed
Subcutaneous ASDIR (AS DIRECTED).
4. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO TID (3
times a day).
6. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).
9. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
10. multivitamin Tablet Sig: One (1) Tablet PO once a day.
11. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for fever or pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary diagnoses:
1. Left thalamocapsular intraparenchymal hemorrhage likely
hypertensive in aetiology in the setting of a high INR
2. Dysphagia secondary to above
.
Secondary diagnosis:
Atrial fibrillation - warfarin stopped and changed to aspirin
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Neurology:
Dysarthria and normal mental status with no evidence of aphasia
and able to name objects and fully oriented. Patient has a right
facial droop and otherwise cranial nerves unremarkable. Right
arm>leg hemiparesis worse distally in the UE and the right
plantar was extensor. Good power on the left side but limited by
left knee procedure. Intact sensation. Asterixis improved and
only just present. Coordination normal on left and unable to
assess due to weakness on the right.
Discharge Instructions:
It was a pleasure taking care of you during your stay at the
[**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **]. You presented after acute
right-sided weakness and garbled speech and you were found to
have a bleed on the left side of your brain in an area called
the thalamus and extending into another area called the internal
capsule. These areas control strength in the right side of your
body. We felt that this was likely due to high blood pressure
and you being on warfarin which increases the risk of bleeding.
You were initially admitted to the Neuro ICU and your blood
thinner (warfarin) was reversed to reduce the risk of further
bleeding and you were initially treated with an IV medication to
lower your blood pressure. You were found to have swallowing
problems and you initially required a feeding tube and latterly
after you were seen by the swallowing specialists, you were
passed for a pureed and thin liquid diet. Your repeat CT scan
was stable and you remained stable and clinically improved.
We stopped your warfarin and started aspirin in its place given
too high a risk of bleeding on warfarin.
We have arranged for neurology follow-up. You were seen by PT
and OT and deemed to benefit from rehabilitation and were
transferred to rehab on [**2196-4-27**].
.
Medication changes:
We STOPPED warfarin
We REDUCED metoprolol to 50mg four times per day and this will
likely need to be increased further
Please continue your other medications as prescribed
Followup Instructions:
Please see your PCP soon after discharge from rehab.
.
We have arranged the following neurology follow-up:
Department: NEUROLOGY
When: TUESDAY [**2196-7-5**] at 1:30 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 2574**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
[
"585.9",
"348.5",
"274.9",
"427.31",
"412",
"414.01",
"572.2",
"342.90",
"781.94",
"600.00",
"V43.65",
"V43.64",
"571.2",
"431",
"599.0",
"305.03",
"784.51",
"V58.61",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
20881, 20947
|
13573, 19197
|
320, 327
|
21241, 21241
|
6833, 6860
|
23474, 23935
|
3230, 3299
|
19822, 20858
|
20968, 21135
|
19528, 19799
|
21902, 23258
|
8647, 13550
|
3339, 4212
|
19218, 19502
|
23278, 23451
|
241, 282
|
355, 2282
|
4691, 6814
|
21156, 21220
|
6876, 7636
|
7658, 8631
|
21256, 21878
|
2304, 2762
|
2778, 3214
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,033
| 145,544
|
26567
|
Discharge summary
|
report
|
Admission Date: [**2200-1-21**] Discharge Date: [**2200-1-28**]
Date of Birth: [**2133-7-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac Catherization [**2200-1-21**]
s/p Coronary artery bypass graft x3 (Left internal mammary
artery > left anterior descending, Saphenous vein graft > RAMUS,
saphenous vein graft > obtuse marginal) [**2200-1-23**]
History of Present Illness:
The patient is a 66 year old male with a history of CAD s/p DES
to LAD in [**4-20**], hyperlipidemia, borderline diabetes who
presented to an OSH with chest pain and was transferred for
cardiac catheterization. The patient was in his usual state of
health and chest pain free until the day prior to admission,
when he was welding a piece of metal in his car which lit a
[**Doctor Last Name **] and caught on fire. He used a fire extinguisher in the
garage to try to put out the fire, but the extinguisher ran out.
He then made [**2-16**] trips carrying 5 gallon pales full of water to
finally put out the fire. This episode occurred at 3:30 pm, and
immediately after he noticed a band of chest pressure from
"nipple to nipple." The pain peaked at 8/10 and did not
radiate. He initially felt SOB after running with the pales,
but did not feel SOB once he had settled down. He also felt
sweaty because he was running with his work jacket, but no
diaphoresis after that. He denied nausea/vomiting. He also
noticed a burning "harsh feeling" in his throat, which he
thought was secondary to smoke inhalation. He ate 2 dinner
rolls at home which helped with his throat pain, but his chest
pain persisted so his family drove him to the OSH ED. He took
ASA for the 7 days prior to this episode.
Past Medical History:
1. Coronary artery disesase
- Cath ([**4-20**]): LAD mid 80% stenosis, stented with drug eluting
stent as part of the ENDEAVOR-IV study. LM, LCx, RCA normal.
2. Hyperlipidemia: Lipid Panel ([**5-21**]) Chol: 179, TG 279, HDL 39,
LDL 102
3. Hypertension
4. Borderline diabetes: HgA1c 6.9% 11/06
5. Epididymitis
6. s/p Appendectomy
7. s/p 3 prior hernia repairs
8. s/p Removal of a lipoma from his back
9. Anemia, baseline Hct 35-38
Social History:
Tobacco denies
ETOH occassional drink
works as a charter bus driver and occasionally must lift luggage
to and from his bus.
He is married with two adult children.
Family History:
There is no family history of premature coronary artery disease
or sudden death. His father died of a stroke at age 68 and also
had hypertension. His mother died at the age of 62 due to
metastatic lung cancer.
Physical Exam:
VS - t 97.3, bp 119/63, hr 57, rr 18, SaO2 99% on 2L
Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with no evidence of JVD.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Soft R carotid bruit.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Quiet BS. Soft, NT, distended/obese abdomen. No HSM or
tenderness.
Ext: No lower extremity edema.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: Radial 2+ DP 1+ PT 1+
Left: Radial 2+ DP 1+ PT 1+
Pertinent Results:
[**2200-1-28**] 07:15AM BLOOD WBC-8.9 RBC-3.13* Hgb-9.1* Hct-27.5*
MCV-88 MCH-29.2 MCHC-33.3 RDW-14.4 Plt Ct-362
[**2200-1-28**] 07:15AM BLOOD PT-14.1* INR(PT)-1.2*
[**2200-1-28**] 07:15AM BLOOD Glucose-128* UreaN-25* Creat-1.2 Na-139
K-4.5 Cl-99 HCO3-30 AnGap-15
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2200-1-26**] 1:09 PM
CHEST (PORTABLE AP)
Reason: ? effusion
[**Hospital 93**] MEDICAL CONDITION:
66 year old man with s/p cabg
REASON FOR THIS EXAMINATION:
? effusion
CLINICAL HISTORY: Status post CABG, evaluate for effusion.
CHEST AP:
Heart is enlarged. Some blunting of the left costophrenic angle
and loss of the left hemidiaphragm suggest the presence of a
left pleural effusion. The right side appears clear. Atelectasis
is still present at the left base.
IMPRESSION: Left effusion and atelectasis persist.
DR. [**First Name11 (Name Pattern1) 3347**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 5034**]
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 65577**] (Complete)
Done [**2200-1-23**] at 3:16:26 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
Division of Cardiothoracic [**Doctor First Name **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2133-7-10**]
Age (years): 66 M Hgt (in): 68
BP (mm Hg): 120/60 Wgt (lb): 225
HR (bpm): 45 BSA (m2): 2.15 m2
Indication: Coronary artery bypass grafting
ICD-9 Codes: 440.0, 413.9
Test Information
Date/Time: [**2200-1-23**] at 15:16 Interpret MD: [**Name6 (MD) 3892**] [**Name8 (MD) 3893**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3893**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW04-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Diastolic Dimension: 4.7 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 55% >= 55%
Aortic Valve - Peak Velocity: 1.0 m/sec <= 2.0 m/sec
Findings
LEFT ATRIUM: No spontaneous echo contrast or thrombus in the
LA/LAA or the RA/RAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
regional/global systolic function (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 aortic arch diameter. Simple
atheroma in aortic arch. Normal descending aorta diameter.
Complex (>4mm) atheroma in the descending thoracic aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Trace AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Resting bradycardia (HR<60bpm). Results
Conclusions
PRE-BYPASS:
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. There are simple
atheroma in the aortic arch. There are complex (>4mm) atheroma
in the descending thoracic aorta. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. Trace
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no pericardial effusion.
Post_Bypass:
Preserved normal biventricular systolic function. Overall LVEF
55%.
Trivial MR. [**First Name (Titles) **] [**Last Name (Titles) **]. Trace AI.
Intact thoracic aorta post decannulation
Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2200-1-23**] 15:20
Brief Hospital Course:
Transferred for outside hospital after ruling in for NSTEMI for
cardiac catherization. Cardiac catherization revealed coronary
atery disease and he was referred to cardiac surgery for
surgical evaluation. He underwent preoperative work up and went
to the operating [****] for coronary artery bypass graft.
See operative for further details. He was transferred to the
ICU for hemodynamic monitoring. In the first 24 hours sedation
was weaned, he woke neurologically intact and he was extubated
without incidence. He was transferred to the post op floor on
POD 1. He was started on beta blockers and gently diuresised
towards his preoperative weight. Physical therapy worked with
him for strength and mobiliy. On POD 2 he went into atrial
fibrillation that converted with beta blockers. He continued to
have intermittent afib and was started on Amiodorone. He
converted to SR and was discharged to home on POD#5 in stable
condition.
Dr. [**Last Name (STitle) **] was called regarding coumadin follow up and the pt.
will have an INR drawn on [**2200-1-30**].
Medications on Admission:
CURRENT MEDICATIONS:
Aspirin 325mg daily
Atenolol 25 mg daily
Lisinopril 10 mg daily
Ezetimibe 10 mg daily
Lipitor 40mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
[**Date Range **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Date Range **]:*30 Tablet(s)* Refills:*0*
3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours
as needed.
[**Date Range **]:*60 Tablet(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
[**Date Range **]:*60 Capsule(s)* Refills:*0*
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Date Range **]:*30 Tablet(s)* Refills:*2*
6. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Date Range **]:*30 Tablet(s)* Refills:*2*
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
[**Date Range **]:*60 Tablet(s)* Refills:*2*
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
10 days.
[**Date Range **]:*10 Tablet(s)* Refills:*0*
9. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO once
a day for 10 days: Please take with Lasix.
[**Date Range **]:*10 Packet(s)* Refills:*0*
10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 7 days: Then decrease to 1 tab twice daily for 7
days, then decrease to 1 tab daily until follow up with MD.
[**Last Name (Titles) **]:*90 Tablet(s)* Refills:*0*
11. Warfarin 2.5 mg Tablet Sig: Two (2) Tablet PO QPM: Take as
directed by MD. Daily dose may vary according to INR.
[**Last Name (Titles) **]:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
vna southeastern ma
Discharge Diagnosis:
Coronary artery disease s/p CABG
Atrial Fibrillation (post op)
NSTEMI
Hypercholesterolemia
Diabetes mellitus type 2
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:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2385**], MD Phone:[**Telephone/Fax (1) 2386**]
Date/Time:[**2200-2-24**] 11:00
Please call to schedule appointments with
Dr [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Dr [**Last Name (STitle) **] in [**1-15**] weeks [**Telephone/Fax (1) 65578**]
Wound check [**Hospital Ward Name **] 6 please schedule with RN [**Telephone/Fax (1) 3071**]
Completed by:[**2200-1-28**]
|
[
"250.00",
"V45.89",
"E878.2",
"785.9",
"410.71",
"401.9",
"997.1",
"285.9",
"427.31",
"272.4",
"414.01",
"V45.82",
"276.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"36.15",
"88.72",
"37.22",
"39.61",
"39.64",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
10915, 10965
|
8080, 9148
|
332, 552
|
11125, 11132
|
3580, 3956
|
11644, 12111
|
2532, 2745
|
9325, 10892
|
3993, 4023
|
10986, 11104
|
9174, 9174
|
11156, 11621
|
2760, 3561
|
282, 294
|
4052, 8057
|
9195, 9302
|
580, 1880
|
1902, 2336
|
2352, 2516
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,711
| 174,924
|
7376
|
Discharge summary
|
report
|
Admission Date: [**2131-7-30**] Discharge Date: [**2131-8-2**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2610**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is a [**Age over 90 **] year old female w hx of severe AS s/p
valvuloplasty [**3-/2131**], subsequent CVA, s/p CABG, hx systolic and
diastolic CHF, hypothyroidism transferred from [**Hospital1 18**] [**Location (un) 620**] ED
for surgical evaluation for possible appendicitis. She presented
with 1 week of worsening belly pain and temp 100.3 taken by VNA.
No n/v/d. Was given cipro, flagyl and 4 L of fluid which
resulted in flash pulmonary edema (hx of MI). She was placed on
Bipap and given lasix unknown dose. CT abdomen notable for
pan-colitis with fluid filled appendix wo stranding - guaiac
neg, nl lactate, well appearing. Surgery eval at [**Last Name (LF) 620**], [**First Name3 (LF) **]
need OR for appy, not clear - would like transfer to [**Location (un) 86**] for
ACS eval due to operative risk. Recieved IV abx. Vitals on
arrival to [**Location (un) 620**]: T 99.5, 101/48, 67, 16, 97/RA.
Her GI history is notable for a colonoscopy that was done in
[**2126**], which showed two polyps, one was removed completely, but
one was flat and behind a fold. Pathology turned out to be an
adenoma. She required 2 blood transfusions on [**5-30**] at [**Hospital1 **] Hospital in [**Location (un) 620**] and has been on iron
supplementation. She was evaluated by Dr. [**First Name (STitle) 679**] from GI and she
declined colonoscopy to w/u malignancy at this time.
ED Course: Surgery consulted. They weaned her O2 from bipap to
NC. Noted to be in afib. She put out 300cc foley to 40mg IV
lasix administered at [**Location (un) **]. Not given add'l lasix.
Discontinued abx given benign imaging findings. UA unremarkable.
EKG: old RBBB, no ST changes - not sent with pt. No labs
obtained - last checked noon at [**Location (un) 620**]. Current access: 18 L x
2 wrist and foley cath for UO. Chest xray showed mild hilar
fullness and pleural effusion on L side.
Exam notable for pulm crackles bibasilar, and abd benign.
Surgery reviewed imaging w radiology: nonspecific edema of
bowel, unclear if colitis, no stranding or specific signs of
infection. Vitals prior to transfer: HR80, BP99/43, 24, 99%3L
NC.
On the floor, she feels well and states that her abd pain has
resolved. Denies chest pain or SOB with position change.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, or changes in
bowel habits. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
1. CAD, Severe aortic stenosis with [**Location (un) 109**] of 0.8 cm2, CABG: 3V
CABG
recent catheterization with widening of her aortic valvuloplasty
[**4-4**]
complicated by CVA.
2. Diabetes mellitus type 2.
3. Hypertension
4. Hyperlipidemia.
5. Ischemic and valvular cardiomyopathy with an EF 20-25%
6. History of left breast cancer, grade 3.
7. Right rotator cuff tendinopathy.
8. Right biceps tendinitis.
9. Polymyalgia rheumatica.
10. Osteoporosis.
11. Moderate mitral regurgitation
12. History of squamous cell carcinoma.
13. Moderate MR
14. Severe AS: symptoms started in [**2127**]
15. Atrial fibrillation: coumadin, amiodarone
.
PAST SURGICAL HISTORY:
1. Right mastectomy.
2. Coronary artery bypass graft 22 years ago.
3. Hysterectomy.
4. Excision of left dorsal hand squamous cell carcinoma.
5. Right fourth trigger finger release.
Social History:
Housing: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Hospital3 400**] Facility. Has a daughter
nearby who is her emergency contact.
Occupation: Was a homemaker.
Functional Status: Very active, exercises 3x week, does
treadmill, aerobics and yoga.
Tobacco/EtOH/Illicit Drugs: Denies
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Admission Physical Exam
Vitals: T: BP:102/66 P:83 R:16 O2:99/3L NC Wt: 47kg
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: bibasilar rales and diminished breath sounds at bases, no
wheezes or rhonchi
CV: Regular rate and rhythm, normal S1 + S2, III/VI cres/decresc
murmur at RUSB radiating to carotids, brisk upstroke
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:
[**2131-7-30**] 11:04PM BLOOD WBC-16.0*# RBC-3.57* Hgb-10.5* Hct-31.3*
MCV-88 MCH-29.4 MCHC-33.5 RDW-15.1 Plt Ct-226
[**2131-8-2**] 07:20AM BLOOD WBC-8.3 RBC-3.66* Hgb-10.7* Hct-32.1*
MCV-88 MCH-29.3 MCHC-33.4 RDW-15.3 Plt Ct-250
CHEST (PORTABLE AP) Study Date of [**2131-7-31**] 4:05 AM
FINDINGS: In comparison with the study of [**7-30**], there is
continued enlargement
of the cardiac silhouette. The degree of pulmonary congestion
appears to have
improved. Retrocardiac opacification is consistent with volume
loss in the
lower lobe and some blunting of the costophrenic angle suggests
pleural
effusion. Intact midline sternal wires are seen and there are
multiple
surgical clips in the right axillary region in this patient who
has undergone
a previous mastectomy.
CHEST (PA & LAT) Study Date of [**2131-7-30**] 10:21 PM
Minimal pulmonary edema, small bilateral pleural effusions are
present.
Severe cardiomegaly is chronic. No pneumothorax. Sternal wires
reflect
previous sternotomy, and vascular clips previous right axillary
and chest wall surgery, presumably related to breast cancer.
Brief Hospital Course:
Ms. [**Known lastname **] is a [**Age over 90 **] year old woman with hx notable for CABG, AF,
severe AS s/p valvuloplasty in [**3-/2131**], systolic and diastolic
CHF, and [**Hospital **] transferred from OSH for management of 1 week abd
pain and colonic edema, found to have pancolitis on CT, admitted
to MICU for acute on chronic systolic and diastolic CHF
exacerbation.
# Pancolitis
Patient presented initially with significant abdominal pain,
found to have colonic edema and fluid filled appendix with fat
stranding on CT scan at [**Hospital **] transfered to [**Hospital1 18**] for surgical
evaluation for concern for appendicitis because high risk
surgical candidate. Evaluated by surgery at [**Hospital1 18**] who felt that
pt did not have appendicitis and no surgery necessary. CT
findings presumably infectious, so she was started on
cipro and flagyl, and symptoms improved within 24 hrs. Lactate
normal. Differential also included mesenteric ischemia, which
was felt to be unlikely, or translocation with underlying
malignancy. Colonoscopy was felt to be too invasive for her
goals of care at a recent GI appointment with Dr. [**First Name (STitle) 679**]. Cipro
was changed to cefpodoxime prior to transfer to floor to
decrease risk of C diff. Cefpodoxime and Metronidazole should
be continued for 7 more days for total course of 10 days
antibiotics. Pt should follow up with PCP next week and with
gastroenterology as necessary.
# Acute on Chronic Systolic and Diastolic CHF
Pt with hx of severe aortic stenosis s/p valvuloplasty [**3-/2131**],
followed by Dr. [**Last Name (STitle) 911**]. EF improved from 25-30 to 50% s/p
valvuloplasty. On transfer to [**Hospital1 18**], patient was admitted to
MICU for hypoxia, likely secondary to fluid overload in setting
of receiving 4.5L of IVFs at OSH ED. CXR confirmed pulmonary
edema with pleural effusions, improved after bolus IV furosemide
in the MICU. Patient's home dose of furosemide was 40mg daily.
Diuretics were held for two days on transfer to floor in setting
of mild orthostasis. Patient felt no symptoms of orthostasis on
day of discharge. Patient was discharged on furosemide 40mg
every other day, but was asked to check daily weights at home
and call PCP if weights increasing by more than 3 lbs. Followup
appointment set up with primary care office in 6 days. VNA will
draw lytes in 4 days (Monday, [**8-5**]) to be faxed to PCP's office.
Discharge weight 51kg.
# Delirium
Pt with very mild hypoactive delirium noted during
hospitalization, partially improved upon discharge, but there
was concern for mild cognitive dysfunction. Recommend outpatient
cognitive evaluation once recovered completely from acute
illness.
# Diarrhea
Patient with some loose stools during hospitalization, likely in
setting of colitis. Stools seemed to be resolving on discharge,
semi-formed. C diff negative x2.
# Hypertension
Home carvedilol and lisinopril held on admission in setting of
hypotension. Carvedilol was restarted at home dose, but
lisinopril was still held on discharge and should be restarted
by PCP at followup visit as tolerated.
# CAD
Home aspirin and simvastatin continued. Could redose
simvastatin at decreased dose as outpatient of 10mg daily for
interaction with amiodarone. Her home carvedilol and lisinopril
were held initially in setting of relative low BPs. Home
carvedilol was restarted on the floor, but lisinopril should be
restarted at outpatient PCP [**Name Initial (PRE) 4939**].
# DM2
Patient on oral hyperglycemics at home. Fingersticks were
monitored, and she did not require insulin coverage. Her home
metformin was held during hospitalization and restarted on
discharge.
# Hx Paroxysmal Afib
Patient in sinus rhythm during this admission. Continues on
home dose amiodarone. Not requiring warfarin, per cardiologist.
# Decreased Appetite
In setting of hx of decreased appetite, patient was started on
mirtazapine 7.5mg at bedtime. Trazodone was stopped.
# Code: DNR/DNI
Medications on Admission:
AMIODARONE [PACERONE] - 200 mg Tablet - 1 (One) Tablet(s) by
mouth once a day
CARVEDILOL - 6.25 mg Tablet - 1 (One) Tablet(s) by mouth twice a
day
FUROSEMIDE - 40 mg Tablet - 1 (One) Tablet(s) by mouth daily
LEVOTHYROXINE - 50 mcg Tablet - 1 (One) Tablet(s) by mouth once
a
day
LISINOPRIL - 10 mg Tablet - one Tablet(s) by mouth daily
METFORMIN - 850 mg Tablet - one Tablet(s) by mouth once a day
ONDANSETRON HCL - 4 mg Tablet - 1 (One) Tablet(s) by mouth four
times a day as needed for nausea
SIMVASTATIN - 40 mg Tablet - 1 (One) Tablet(s) by mouth once a
day
TRAZODONE - 50 mg Tablet - 1 (One) Tablet(s) by mouth daily
.
Medications - OTC
ACETAMINOPHEN - 500 mg Tablet - 2 (Two) Tablet(s) by mouth three
times a day as needed for pain
ASPIRIN - 81 mg Tablet - one Tablet(s) by mouth daily
CHOLECALCIFEROL (VITAMIN D3) - 1,000 unit Capsule - 1 (One)
Capsule(s) by mouth once a day
DOCUSATE SODIUM - 100 mg Capsule - 1 Capsule(s) by mouth three
times a day
FERROUS SULFATE - 325 mg (65 mg iron) Tablet - 1 (One) Tablet(s)
by mouth three times a day
MULTIVITAMIN WITH MINERALS [MULTIPLE VITAMIN-MINERALS] -
Tablet
- 1 (One) Tablet(s) by mouth once a day
RANITIDINE HCL [ACID CONTROL] - 150 mg Tablet - 1 (One)
Tablet(s)
by mouth once a day
SALIVA STIMULANT AGENTS COMB.2 [BIOTENE ORALBALANCE] - (OTC) -
Liquid - Use twice daily for dry mouth
Discharge Medications:
1. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
2. cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a
day. Tablet(s)
6. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO twice a day.
8. metformin 850 mg Tablet Sig: One (1) Tablet PO once a day.
9. Colace 100 mg Capsule Sig: One (1) Capsule PO three times a
day.
10. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
11. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO twice a day: Do not take with thyroid hormone
(levothyroxine).
12. furosemide 40 mg Tablet Sig: One (1) Tablet PO every other
day.
13. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
14. multivitamin Tablet Sig: One (1) Tablet PO once a day.
15. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
16. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every 4-6 hours as needed for nausea.
17. Tylenol Extra Strength 500 mg Tablet Sig: One (1) Tablet PO
every six (6) hours as needed for pain.
18. mirtazapine 7.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
19. Outpatient Lab Work
Please draw electrolytes (Chem 7) on Monday [**8-5**] and fax results
to PCP's office:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] E.
Location: [**Hospital1 **]
DIVISION OF GERONTOLOGY
Address: [**Doctor First Name **], STE 1B, [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 719**]
Fax: [**Telephone/Fax (1) 716**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Colitis
Acute on Chronic Systolic and Diastolic Heart Failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mrs. [**Known lastname **],
You were admitted to the hospital because you were having
significant abdominal pain, found to have inflammation of your
entire colon. You were started on oral antibiotics for your
colitis which significantly improved your abdominal pain.
You had also been given a lot of fluids in the Emergency Room at
the other hospital because it is important to get fluids when
you have a bad infection, so you ended up having some trouble
breathing from your heart failure, which improved quickly. Your
blood pressures were also intermittently low while you were in
the hospital, so we have changed some of your medications as
below.
The following changes were made to your medications:
- Please take LASIX 40 mg every OTHER day (before, you were
taking it every day) until you are seen by your primary care
physician. [**Name10 (NameIs) 357**] make sure to check your weight every day and
let your doctor know if you are gaining weight by more than 3
lbs, and your doctor can adjust your medications as necessary.
- Please STOP taking your TRAZODONE
- Please START MIRTAZAPINE (also called REMERON) 7.5mg at
bedtime in the evenings to help you sleep.
Please continue to take the antibiotics we have prescribed, for
7 more days or through [**8-9**].
-MetRONIDAZOLE (FLagyl) 500 mg every 8 hours x 7 days
-Cefpodoxime Proxetil 200 mg once daily x 7 days
- If you have diarrhea, please do not take COLACE.
- Please start PRIOBIOTICS (you can buy this over the counter)
to help your intestines.
- Please stop your LISINOPRIL for now because of your low blood
pressure. This can be restarted by your primary care doctor or
her nurse practioner at your visit next week.
- You may DECREASE the iron tablets (FERROUS SULFATE)to twice
daily instead of three times daily
Please be sure to weigh yourself every morning and call the
doctor if your weight goes up more than 3 lbs.
Please have the VNA draw your labs on Monday to check your
electrolytes including your kidney function and have it sent to
your primary care doctor who will see you on Wednesday.
Name: [**Last Name (LF) **],[**First Name3 (LF) **] E.
Phone: [**Telephone/Fax (1) 719**]
Fax: [**Telephone/Fax (1) 716**]
Please see [**First Name8 (NamePattern2) 717**] [**Last Name (NamePattern1) 715**],NP next Wednesday for a followup visit,
as below.
Followup Instructions:
Please be sure to keep all of your followup appointments.
Department: GERONTOLOGY
When: WEDNESDAY [**2131-8-8**] at 10:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RNC [**Telephone/Fax (1) 719**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2131-8-22**] at 4:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,779
| 186,071
|
35847
|
Discharge summary
|
report
|
Admission Date: [**2173-11-27**] Discharge Date: [**2173-11-30**]
Date of Birth: [**2097-1-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
CC:[**CC Contact Info **]
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 81483**] is a 76 yo man w/ a pmh sig for AAA s/p graft repair,
NIDDM, HTN, and hypercholesterolemia who was transferred to the
[**Hospital1 18**] from [**Hospital 81484**] Hospital with a subdural hematoma, and
was incidentally found to have over 30 discrete circular lesions
throughout the lungs on CXR.
.
On [**11-26**], Mr. [**Known lastname 81483**] [**Last Name (Titles) 5058**] in the middle of the
night and went into the kitchen. The next thing he remembers is
lying on the floor in a puddle of blood with a cut on his head.
Mr. [**Known lastname 81483**] believes he hit his head on the freezer, but cannot
recall w/ certainty the events, though he denies loss of
conciousness. He denies feeling ill, lightheaded, or
experiencing change in vision or feelings of vertigo prior to
episode. He had eaten well the night before. His wife, hearing
a "thud," found him and called 911. At that time, however, Mr.
[**Known lastname 81483**] refused to go in the ambulance and sent EMS away. He
stopped bleeding without any sutures.
.
The next morning, at the insistence of his wife, Mr. [**Known lastname 81483**]
went to the [**Hospital 81484**] Hosp ED. There he was found to have a
7mm frontal-parietal subdural hematoma, along with a 2mm midline
shift. As part of his ED workup, he was also noted to have an
abnormal CXR, not further specified, but work-up was not pursued
at the time, as Mr. [**Known lastname 81483**] was transferred immediately to [**Hospital1 18**]
to the neurosurgery team.
.
Upon arrival to [**Hospital1 18**], Mr. [**Known lastname 81483**] was observed in the SICU
and then transferred to the floor. He was to be discharged
today ([**11-29**]), when follow-up CXR to the OSH note was completed
and revealed >30 discrete pulmonary nodules throughout the
entire lungs, ranging in size from several millimeters to >
2.5cm. At this time he was transferred to the medicine team for
further workup.
.
At time of transfer, Mr. [**Known lastname 81483**] is lying in his hospital bed
comfortably, not SOB nor ill-appearing. He denies any recent
change in his overall health, any fevers, chills, syncope, or
weight change. Mr. [**Known lastname 81483**] states that recently he has been in
good health and denies any recent changes in physical or mental
wellbeing. His family, however, notes that that for the past
several weeks, Mr. [**Known lastname 81483**] has been increasingly fatigued and has
napped with greater frequency than normal. The family also
believes he has lost weight in all areas of his body, though a
recent weight measurement at his PCP showed no change over the
past 6 mo. Ms. [**Known lastname 81483**] also notes that her husband has recently
begun walking more slowly, taking small steps, and having some
difficulty with balance.
.
His wife, however, notes Ms. [**Known lastname 81483**] has not noticed a change in
her husband's memory or concentration, though she believes he
has been a bit quicker to lose his temper as of late. She is
not certain if he has had fevers objectively, but has noted that
he has recently been very sweaty in an comfortably cooled room.
.
Per his family, Mr. [**Known lastname 81483**] has had a cough for the past
several years, which may have inc. slightly in recent weeks. It
"sounds loose" but is not productive. Mr. [**Known lastname 81483**], a former
Marine during the Korean War and subsequent IRS accountant,
denies any exposure to asbestosis or silicosis, but his wife
notes that he has always helped his children repair their houses
and frequently uses paints and wallpaper removers.
.
CT imaging after transfer to the medical team was consistent
with metastatic disease throughout the body, including lesions
in the liver, retroperitoneum, lungs, and ascending colon.
Past Medical History:
PMH:
1. AAA - s/p graft repair [**2167**], Dr. [**Last Name (STitle) **] of [**Hospital1 487**] Gen.
2. R inguinal hernia s/p herniorrhaphy
3. DM II - non-insulin dependent, diet controlled.
4. Hypercholesterolemia - on statin, pt does not recall exact
name
5. HTN - on felodipine
Social History:
SH: Mr. [**Known lastname 81483**] currently is retired and lives in [**Location 81485**] with
his wife, [**Name (NI) **]. [**Name2 (NI) **] enjoys entertaining his two grandkids and
has three children. As a marine he worked both on the ship and
fought on land. He was wounded after 1 year of fighting and
still has shrapnel in his chest. He was in the marines for a
total of 3 yrs and was stationed in [**Country 10181**] and [**Country 14635**]. He then
worked for >25 yrs for the IRS. He drinks EtOH 1 drink/night
and denies any abuse. He has smoked ~ [**3-16**] ppd for 60yrs. Denies
ilicit substance abuse.
Family History:
FH: Father passed away when pt very young; unaware of mother's
or father's medical hx. Brother (elder) died of ?brain tumor.
One other brother and sister in good health. No other known hx
of cancer, DM, depression, thyroid abnormalities, early MI.
Physical Exam:
On Admission:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: [**3-14**] bilaterally EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**3-15**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-17**] throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
On Discharge:
XXXXXXXXXXX
Pertinent Results:
Labs on Admission:
[**2173-11-27**] 06:45PM BLOOD WBC-9.7 RBC-3.58* Hgb-11.1* Hct-32.5*
MCV-91 MCH-31.0 MCHC-34.2 RDW-15.3 Plt Ct-169
[**2173-11-27**] 06:45PM BLOOD Neuts-72.8* Lymphs-20.9 Monos-5.0 Eos-0.6
Baso-0.7
[**2173-11-27**] 06:45PM BLOOD PT-11.6 PTT-23.3 INR(PT)-1.0
[**2173-11-27**] 06:45PM BLOOD Glucose-155* UreaN-23* Creat-1.4* Na-140
K-4.0 Cl-107 HCO3-22 AnGap-15
[**2173-11-28**] 03:03AM BLOOD Calcium-8.8 Phos-2.3* Mg-2.3
[**2173-11-28**] 03:03AM BLOOD Phenyto-7.6*
Labs on Discharge:
[**2173-11-30**] 06:35AM BLOOD WBC-8.3 RBC-3.52* Hgb-11.2* Hct-32.1*
MCV-91 MCH-31.8 MCHC-34.8 RDW-15.1 Plt Ct-151
[**2173-11-30**] 06:35AM BLOOD Glucose-108* UreaN-16 Creat-1.3* Na-136
K-4.2 Cl-101 HCO3-27 AnGap-12
[**2173-11-29**] 06:55AM BLOOD ALT-14 AST-21 LD(LDH)-196 AlkPhos-203*
TotBili-0.5
[**2173-11-29**] 06:55AM BLOOD calTIBC-222* Ferritn-560* TRF-171*
[**2173-11-30**] 06:35AM BLOOD CEA-2319* AFP-3.8
[**2173-11-29**] 06:55AM BLOOD PSA-1.2
Imaging:
Head CT [**11-27**]: IMPRESSION: Left frontal and left frontoparietal
subdural hematomas as described above. Global atrophy
accommodates relatively minimal size with no midline shift or
herniation noted. Although evaluation of progression was
requested, the outside studies have not been provided to allow
for comparison.
Head CT [**11-28**]:IMPRESSION: Stable left frontal and left
frontoparietal subdural hematomas. No new hemorrhage.
CXR(PA/LAT):
Multiple pulmonary nodules and masses are seen involving most of
the lungs
being more prominent in the mid and lower lungs although the
entire lung
parenchyma is involved. They range in size from 1.3 to masses
more than 3.5 cm in diameter. Some of them have ill-defined
borders but the others has some border irregularities. The
cardiomediastinal silhouette is preserved with no clear evidence
of lymphadenopathy. The heart size is normal. There is no
pleural effusion or pneumothorax. Multiple radiopaque objects
are projecting over the upper thorax and the right chest and are
consistent with prior gunshot injury.
IMPRESSION:
The above described picture is highly suspicious for advanced
metastatic
disease. Differential diagnosis (which is less likely) would
include septic emboli, vasculitis or nodular form of
sarcoidosis. Further comparison with prior radiographs and/or
crossectional imaging are crucial with the decision of further
evaluation based on the results.
.
CT CHEST/ABDOMEN/PELVIS:
CT CHEST WITH CONTRAST: Innumerable pulmonary nodules and masses
are detected throughout the lungs, most predominant at the lung
bases. The largest mass within the right lung base measures 6.6
x 4.4 cm and abuts the posterior pleural surface (series 3,
image 53). The largest mass within the left lower lobe abuts the
posterior pleural surface and measures 3.1 x 2.4 cm. No pleural
effusions are present. The major airways are patent down to the
subsegmental level. There is underlying mild-to-moderate
emphysematous changes, most notably in the lung apices. The
major airways are patent down to the subsegmental level. No
axillary, hilar, or mediastinal lymph nodes are present for CT
size criteria; however, there is a prominent conglomerate of
lymph nodes within the pretracheal region, the largest measuring
9 mm in short axis. No dissection flap is present within the
thoracic aorta. The main, right and left pulmonary arteries are
enlarged, the largest on the left measuring 2.9 cm and on the
right measuring 3.1 cm, suggesting component of pulmonary
arterial hypertension. Mild calcification of the aortic valve is
of unknown hemodynamic significance. There is no pericardial
effusion. Irregular
calcified atherosclerotic plaque is present within the thoracic
aorta which is mild.
CT ABDOMEN WITH CONTRAST: The liver demonstrates numerous
hypoattenuating
whose appearances are most consistent with metastatic disease.
The largest
lesion involves the majority of the inferior aspect of segment
IVb, measuring 3.6 x 3.3 cm in greatest axial dimension. The
portal vein is patent. There is intrahepatic biliary ductal
dilatation involving the left lobe of the liver which is mild
(series 3, image 63) and likely secondary to tumoral
obstruction. Enlarged periportal nodes are detected, the largest
measuring 2.1 cm in short axis (series 3, image 75). Paraaortic
lymphadenopathy is detected the largest measuring 1.7 cm in
short axis (series 3, image 82). Cholelithiasis without evidence
of cholecystitis. Fatty infiltration of the pancreas without
focal mass lesion identified. The spleen demonstrates subtle
heterogeneity within the inferior aspect without definitive
focal lesion at this time. Numerous hypoattenuating lesions are
present within the kidneys, too small to adequately
characterize. Two simple- appearing cysts are present within the
interpolar region of the left kidney, the largest measuring 2.8
cm.
The abdominal aorta is ectatic throughout its course.
Inflammatory stranding and irregular thickening is noted within
the ascending colon from the level of the hepatic flexure to the
cecum, concerning for malignant involvement. The remainder of
the colon appears within normal limits. No free air or free
fluid is present within the abdomen.
CT PELVIS WITH CONTRAST: The rectum and sigmoid colon
demonstrate fecal
material within. The prostate gland is mildly enlarged measuring
4.7 cm with focal calcification within. The bladder and
opacified loops of small bowel are unremarkable. There is no
evidence of small bowel obstruction.
OSSEOUS STRUCTURES: Degenerative changes are present throughout
the spine
without definite evidence of suspicious lytic or sclerotic
lesion identified. Intervertebral body disc space narrowing and
degenerative disc disease is most notable at the L3-L4 and L4-L5
levels with vacuum phenomenon.
IMPRESSION:
1. Widespread metastatic lesions throughout the lungs, with
findings
suggestive of pulmonary arterial hypertension. Numerous
metastatic lesions
also reside within the liver with retroperitoneal and periportal
adenopathy.
Given significant stranding and wall thickening/irregularity
involving the
ascending colon, a primary colonic adenocarcinoma is suspected.
Direct
visualization with colonoscopy and biopsy is recommended.
2. Emphysema.
3. Degenerative changes within the spine. End plate concavity
notd of T11
and L1.
Brief Hospital Course:
# Subdural hematoma: The patient was admitted after a fall and
found to have a subdrual hematoma. The subdural hematoma was
stable on repeat head CT. The patient was initiated on continue
seizure prophylaxis and should be continued on this medication
pending an outpatient Brain MRI for evaluation of possible
metastates to the Brain. The patient will require a follow up
head CT in 8 weeks and an appointment with neurosurgery. The
patient describes a mechanical fall rather than a syncopal
episode. The patient has noted increased gait instability over
the past few months. The etiolgy fall could be secondary to
deconditioning and weakness from a systemic illness or
brain/cerebellar involvement of metastatic cancer.
# Metastatic cancer, unknown primary: The patient was found to
have multiple bilat pulmonary nodules on CXR. The patient did
not have any repiratory compromise. Theses nodules most likely
represent metastatic colon cancer based on CT imaging. The CT
scan also revealed nodules in the liver and enlarged lymph
nodes. THe patient's CEA was elevated at 2319. The patient
preferred to be discharged and have the remainer of the
malignancy workup done as an outpatient. Physical therapy
evaluated the patient and felt he was safe to be discharged
home. He was medically stable for discharge. He had a follow
up appointment with his PCP arranged for the day after
discharge. We recommend that the patient have a colonoscopy,
possibly a liver biopsy and an MRI of the brain to further
evaluate the origin and extent of this malignancy. An
infectious process is still on the differential but less likely
due to lack of signs or symptoms.
.
# Diabetes Mellitus, type II - diet controlled
.
# Hypertension - stable, chronic
.
# Anemia - The patient's baseline Hct is unknown. The patient's
Hct was 30. Iron studies were consistent with anemia of chronic
disease. [**Month (only) 116**] also be secondary to occult blood loss from
possible colon cancer. However, patient was guiac negative on
exam.
.
# Chronic Kidney Disease: Patient's creatinine was elevated at
1.3. His baseline Creatinine is unknown. Patient was unaware
of any kidney disease. His Creatinine did not improve with
fluid hydration. Recommend oupatient evaluation of kidney
function.
Medications on Admission:
felodipine
unknown statin
ASA 81 qd
Discharge Medications:
1. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
Disp:*90 Capsule(s)* Refills:*0*
2. Felodipine 5 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day: Please continue
taking your home dose if different.
3. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day:
Please continue taking your home dose medication if different. .
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Primary Diagnosis:
Metastatic disease, unknown primary.
Left Frontoparietal Subdural Hematoma secondary to mechanical
fall.
Secondary Diagnosis:
Hypertension
Hyperlipidemia
Diabetes Mellitus, Type II, well controlled
Anemia
Chronic renal insufficiency (creatinine during admission was
1.3-1.4)
Discharge Condition:
Neurologically Stable
Discharge Instructions:
You were admitted to the hospital for a bleed in your head which
has not changed since you have been here. You were started on
dilantin as a precaution against seizures, which can occur with
head bleeds. You should take Dilantin (phenytoin) until you
obtain an MRI of your brain. You likely can discontine this
medication after a short period of time. Your doctor will need
to check the levels of this medication in approximately 1 weeks
time and he will tell you if you need to continue the medication
after that date. Signs of a serious side effect of Dilatin
include unsteady gait and rash. If you develop either of these
symptoms, stop taking Dilatin immediately and contact your
doctor or go to the emergency room.
While an inpatient, you had a chest x-ray which showed multiple
nodules in your lungs. A CT scan of your torso showed that
there are also lesions in your liver and colon. This is
concerning for a cancer, but more tests will be needed to find
out the type of cancer and what treatment is appropriate. We
have contact[**Name (NI) **] your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 81486**], to let him know of
these findings, and he will help coordinate further evaluation.
We have scheduled an appointment with Dr. [**Last Name (STitle) 81486**] tomorrow, [**12-1**], at 2pm.
We have made the following changes to your medication regimen.
Please stop taking the aspirin daily. Aspirin can increase the
risk of further bleeding in your head.
Please take dilatin (phenytoin) 100 mg tablets, 1 tablet by
mouth three times daily.
Continue to take your blood pressure medication and cholesterol
medication as you were before.
Physical therapy will come to see you 3-5x/wk for the next 4
weeks to work with you to avoid falls while walking.
If you lose consciousness, fall again, have any signs of
seizures, such as shaking or trembling, experience increased
confusion, have blood in your stools, or cough up blood, please
go to the ED or call your PCP [**Name Initial (PRE) 2227**]. In addition, if you
become incontinent of urine or have urinary retention, go to the
emergency room immediately.
Followup Instructions:
The following appointments have been made for you:
1. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 81486**]: [**2173-12-1**] at 2pm. The phone number
for the office is [**Telephone/Fax (1) 61383**].
For further evaluation of your metastatic disease, you will need
a colonoscopy with a biopsy or a liver biopsy of one of the
lesions. You will need an MRI of the brain. You should also
have a CEA level checked. Please also check the patient's blood
pressure as phenytoin can make felodipine less effective.
Please follow up on the patient's kidney function. Please check
a dilantin level in one week and consider discontinuing the
medication after obtaining an MRI of the brain.
In addition, you are encouraged to call the following doctors
for follow-up appointments:
1. Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with
Dr. [**Last Name (STitle) **], to be seen in 8 weeks.
?????? You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
Completed by:[**2173-12-12**]
|
[
"852.21",
"153.9",
"250.00",
"584.9",
"403.90",
"285.21",
"197.0",
"585.9",
"272.4",
"E885.9",
"426.52"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
15903, 15978
|
13091, 15380
|
342, 349
|
16316, 16339
|
6764, 6769
|
18569, 19341
|
5161, 5410
|
15466, 15880
|
15999, 15999
|
15406, 15443
|
16363, 18546
|
5425, 5425
|
19366, 19690
|
6732, 6745
|
277, 304
|
7266, 13068
|
377, 4204
|
5931, 6718
|
16145, 16295
|
16018, 16124
|
6783, 7247
|
5653, 5915
|
4226, 4508
|
4524, 5145
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,286
| 145,443
|
47738
|
Discharge summary
|
report
|
Admission Date: [**2194-8-19**] Discharge Date: [**2194-8-26**]
Date of Birth: [**2130-8-23**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Tetracycline
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Right upper lobe nodule
Major Surgical or Invasive Procedure:
[**2194-8-19**]
1. Right thoracotomy.
2. Right lower lobectomy.
3. Mediastinal lymph node dissection.
4. Buttressing of bronchial staple line with intercostal
muscle.
History of Present Illness:
The patient is a 63-year-old woman with stage IIIA non-small
cell lung cancer. A subcarinal lymph node was positive and she
underwent induction chemoradiation
therapy. She radiographically had a good response to therapy.
She was admitted following open lobectomy and mediastinal lymph
node dissection.
Past Medical History:
Coronary artery disease status post MI and two stents
Type 2 diabetes
Hypertension
Hypercholesterolemia
GERD
PAST SURGICAL HISTORY:
Right breast lumpectomy (negative),
lipoma resection from left chest wall, cholecystectomy,
bilateral
cataract surgery, resection of focal polyps, tonsillectomy,
appendectomy, and resection of a uterine fibroid.
Social History:
married and has five children and 10 grandchildren and two great
grandchildren.
She has an 80-pack-year history of cigarette smoking, but quit
eight years
ago. She rarely drinks alcohol.
Family History:
The patient's father died at age 56 from a brain
tumor and her mother died at age 77 from Alzheimer's disease;
she
has two half sisters who had lung cancer; a sister died of a
myocardial infarction.
Physical Exam:
VS: T: 97.7 HR: 84 SR BP: 108/62 Sats: 98% 4L BS 143/130/103
General: 64 year-old female sitting up in no apparent distress
HEENT: normocephalic, mucus membranes moist
Neck: supple no lymphadenopathy'
Cardiac: RRR normal S1,S2
Resp: decreased breath sounds on right with faint RML crackles,
no wheezes, left clear
GI: obsese benign
Extr:warm no edema
Incision: Right thoractomy site clean dry intact, margins well
approximation
Neuro: AA&O MAE
Pertinent Results:
[**2194-8-24**] WBC-9.6 RBC-2.99* Hgb-9.1* Hct-28.3 Plt Ct-308
[**2194-8-23**] WBC-9.3 RBC-2.92* Hgb-9.1* Hct-26.9 Plt Ct-240
[**2194-8-20**] WBC-9.8 RBC-3.03* Hgb-9.6* Hct-28.3 Plt Ct-248
[**2194-8-25**] Glucose-118* UreaN-11 Creat-0.8 Na-137 K-4.8 Cl-99
HCO3-29
[**2194-8-22**] Glucose-120* UreaN-11 Creat-0.9 Na-139 K-3.8 Cl-98
HCO3-32
[**2194-8-20**] Glucose-142* UreaN-14 Creat-0.8 Na-141 K-4.8 Cl-106
HCO3-27
[**2194-8-21**] CK(CPK)-352*
[**2194-8-21**] CK(CPK)-451*
[**2194-8-21**] CK-MB-2 cTropnT-<0.01
[**2194-8-24**] URINE CLEAN CATCH URINE CULTURE (Final [**2194-8-25**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
CXR:
[**2194-8-24**]: There is slight interval increase in the loculated air
collection within the right apex. Otherwise, no significant
change since the prior radiograph is demonstrated.
[**2194-8-23**]: There is evidence of a right apical air collection
within the right apical fluid consistent with localized
pneumothorax. Another area of localized pneumothorax is seen in
the right mid lung base. There is interval progression of right
lower lobe consolidation, worrisome for progression of
infectious process.
[**2194-8-21**]: Right chest tubes remain in place and there is a
continued apical pleural capping. Some mild basal pneumothorax
is again seen on this side. Bilateral atelectatic changes are
seen at the bases. No evidence of acute focal pneumonia
[**2194-8-19**]: Two right chest tubes are in
correct position. Minimal basal pneumothorax. Minimal air
inclusions in the soft tissues. Overall, the lung volumes have
decreased. The size of the cardiac silhouette has minimally
increased. There is no pulmonary edema and no evidence of focal
parenchymal opacities suggesting pneumonia.
Chest CT: [**2194-8-22**]:
1. No evidence of pulmonary embolus. Thrombus at the surgical
stump of the
right lower lobe pulmonary artery, an expected finding.
2. Small right hydropneumothorax with chest tube in place.
3. Small left pleural effusion with associated atelectasis.
4. Right lower lobe opacities concerning for aspiration.
Brief Hospital Course:
[**2194-8-19**]: Admitted to thoracic surgery service s/p right
thoracotomy and right lower lobectomy for stage IIIA non-small
cell lung cancer. She was extubated in the operating room,
monitored in the PACU prior transfer to the floor. On POD2 she
developed respiratory distress and required tranfer to the SICU.
A chest CT was negative for pulmonary embolism. With diuresis,
aggressive pulmonary toilet, nebs she improved. She transfer
back to the floor in stable condition.
Respiratory: With aggressive pulmonary toilet, schedule nebs,
incentive spirometer and ambulation she titrated her oxygen
requirement to 4L nasal cannula with oxygen saturations of 94%.
She was discharged home on supplemental oxygen.
Chest-tube: 2 anterior basilar and posterior apical on suction
converted to water-seal without leak
Chest films: serial chest films showed right lower lobe effusion
(see reports)
Cardiac: She had intermittent atrial fibrillation with rates of
140-150 and hypotensive. Her cardiac enzymes were negative for
ischemia. She was started on diltiazem drip once rate control
hypotension resolved. IV lopressor was given and she converted
to sinus rhythm 79-80s with blood pressure of 120's. Once stable
her home dose of 240 Diltiazem and Atenolol 25 [**Hospital1 **] were
restarted, she remained in sinus rhythm 70-80's. She was started
on Aspirin 325 mg daily.
GI: mild nausea immediate postoperative which resolved with
antinausea medication.
PPI and a bowel regime were continued
Nutrition: diabetic diet was restarted, she tolerated.
Endocrine: type 2 diabetes BS were well controlled 103-140 with
insulin sliding scale. She will resume her home regime once
discharged.
Renal: Foley was removed when Epidural was removed. She voided
without difficulty.
Her renal function remained normal
Pain: Bupivacaine Epidural and Dilaudid PCA with good pain
control was managed the acute pain service. Once removed she
converted to PO pain medication with good control.
Disposition: she was seen by physical therapy who deemed her
safe for home with physical therapy for pulmonary rehab. She
was discharged to home with her husband and [**Name (NI) 269**] on oxygen 4L and
will follow-up with Dr. [**First Name (STitle) **] as an outpatient.
Medications on Admission:
atenolol 25 [**Hospital1 **], dilt 240 mg daily, metformin 1000 QAm, 500 QPM,
omeprazole 20 daily, simvastatin 40 mg daily, ASA 325 mg daily,
colace prn, lactulose prn
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Atenolol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
3. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO once a day.
4. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO QAM.
5. Metformin 500 mg Tablet Sig: One (1) Tablet PO Dinner.
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime.
8. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
9. Home Oxygen
[**2-13**] LPM continuous via nasal cannula keep sats > 90%
Conserving device for portability
Sats: 82% RA
10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain .
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Stage IIIA non small cell lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, cough or chest pain
-Incision develops drainage
-You may shower. No tub bathing or swimming until all incisions
healed
-No driving while taking narcotics
-Take stool softners with narcotics.
-Walk 4-5 times a day for 10-15 minutes increasing as tolerates
Followup Instructions:
Follow-up with Dr. [**First Name (STitle) **] [**0-0-**] Date/Time:[**2194-9-9**] 11:30
on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical Center [**Location (un) 24**]
Chest X-Ray [**Location (un) 861**] Radiology 30 minutes before your
appointment
Please call your Cardiologist for a follow-up appointment
[**Telephone/Fax (1) 2258**]
Completed by:[**2194-9-2**]
|
[
"427.31",
"V15.3",
"412",
"V45.82",
"530.81",
"276.6",
"162.5",
"196.1",
"401.9",
"272.0",
"250.00",
"458.29",
"518.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"40.3",
"32.49"
] |
icd9pcs
|
[
[
[]
]
] |
7609, 7667
|
4217, 6476
|
303, 475
|
7749, 7749
|
2080, 4194
|
8319, 8710
|
1397, 1598
|
6694, 7586
|
7688, 7728
|
6502, 6671
|
7900, 8296
|
961, 1175
|
1613, 2061
|
240, 265
|
503, 806
|
7764, 7876
|
828, 938
|
1191, 1381
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,423
| 150,266
|
27959
|
Discharge summary
|
report
|
Admission Date: [**2190-7-30**] Discharge Date: [**2190-8-10**]
Date of Birth: [**2112-5-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1561**]
Chief Complaint:
bloody pleural effusions
Major Surgical or Invasive Procedure:
Left thoracotomy with total lung
decortication.
History of Present Illness:
78-year-old gentleman , chronically on Coumadin anticoagulation
and recently was found to have a bloody left pleural effusion
which on cytology was negative.
He had mediastinal adenopathy as well. We took him forward
for a cervical mediastinoscopy and left thoracoscopy and
pleural biopsy. All pleural biopsies and mediastinal lymph
nodes were free of malignancy. In the left lung, the left
upper and left lower lobe were completely trapped on
thoracoscopy. We, therefore, took him forward today for a
total lung decortication.
Past Medical History:
afib s/p cardioversion 3 yrs ago, MVP, bradycardia s/p pacer in
'[**83**], asthma, GERD, s/p inguinal hernia repair, s/p bcc excision
Physical Exam:
NAD AOx3
CTA b/l with decreased bs on left
no cerv/sc lymphadenopathy
RRR, paced
soft, NT ND
no c/c/e
Brief Hospital Course:
Pt was admitted w/ benign pleural effusion and taken to the Or
[**7-30**] for left thoracotomy, decortication, mechanical pleuradesis.
Post operatively, pt was admitted to the ICU an dremained
intubated over noc. 3 chest tubes in place and to sxn w/
moderate serosang output. dilaudid PCA for pain. started on
levaquin for positive U/A. POD#1 extubated, basilar tube placed
to water seal, given PRBc and lasix. POD#3 transferred from ICU
- continue pul toilet for thick tan sputum, diuresis ongoing and
HCT stable. shortly after arrivel from ICU pt being placed on
stretcher for CXR- became unresponsive, pulseless. CPR
initiated, pt intubated and transferred back to ICU for ongoing
resusitation measures. Emeregent CT showed bilat pulmonary
emboli. Started on IV heparin. Pacer check after CPR OK- no
disruption.
POD#4 intubated, awake ,alert and following commands. Extubated
w/o incident. Neurologically intact. remained in ICU for
pulmonary hygiene.
POD#5 one apical chest tube removed w/ stable PTX. reamining
chest tubes to water seal w/ air leak. Transferred from ICU to
floor for ongoing care and ongoing anticoagulation w/ heparin
and coumadin.
POD#6 second chest tube removed. cont'd to require aggressive
pul ygiene and PT.
POD#7 remaining chest tube placed to pneumostat w/ persistant
air leak. CXR w/PTX decreasing in size.
POD#8 INR therapeutic at 2.0 on 2 mg of coumadin daily. heparing
gtt d/c'd.
Brief asymptomatic, non -sustained episodes of VT while asleep.
Seen by cardiology- no indication for ICD, cont betablockers for
rate control, echo done -no evidence of LVH.
POD#9 continues to make progress w/ rehab but deconditioned. On
stable dose of coumadin. no episodes of VT. Cxr w/ lung
re-expaned. chest tube to remain in place until air leak
resolved x2 days.
Medications on Admission:
advair, digoxin, coumadin 5mg x 5 days, 2.5mg x 2 days
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: as per sheet
Injection ASDIR (AS DIRECTED).
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed.
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
8. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
9. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
10. Warfarin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
for 1 doses: please have level checked q3 days.
11. Megestrol 40 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
12. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
Discharge Disposition:
Extended Care
Facility:
The Pavillion
Discharge Diagnosis:
L fibrothorax-s/p left thoracotomy, decortication, mechanical
pleuradesis.
bilat pulmonary emboli
s/p resp arrest
afib-cardioverted [**2186**], MVP, brady s/p v-pacer 200,asthma, gerd,
s/p inguinal hernia repair, s/p basal cell carcinoma
Discharge Condition:
deconditioned
Discharge Instructions:
please call dr.[**Doctor Last Name **] office [**Telephone/Fax (1) 170**] if you experience
fever > 101.5, severe nausea, vomitting, pain, shortness of
breath, severe redness or drainage at old chest tube sites
no tub bathing or swimming until chest drain is removed.
check pneumostat for air leak daily. measure and recored
drainage q8hrs.
Followup Instructions:
please call Dr[**Name (NI) 1816**] office for an appointment at
[**Telephone/Fax (1) 170**]
Completed by:[**2190-8-10**]
|
[
"530.81",
"415.11",
"424.0",
"511.0",
"427.1",
"427.31",
"599.0",
"997.3",
"799.1",
"493.90",
"V45.01",
"V58.61",
"E878.8",
"276.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04",
"34.51",
"99.60"
] |
icd9pcs
|
[
[
[]
]
] |
4483, 4523
|
1261, 3047
|
355, 405
|
4805, 4820
|
5212, 5335
|
3152, 4460
|
4544, 4784
|
3073, 3129
|
4844, 5189
|
1135, 1238
|
290, 316
|
433, 963
|
985, 1120
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,046
| 191,832
|
50752
|
Discharge summary
|
report
|
Admission Date: [**2195-6-6**] Discharge Date: [**2195-6-18**]
Date of Birth: [**2124-2-1**] Sex: F
Service: MEDICINE
Allergies:
Tetracycline Analogues / Zinc / Optiray 350
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Respiratory failure
Major Surgical or Invasive Procedure:
Intubated
IR guided PEG tube study
CVL placement
History of Present Illness:
71 yo F with Parkinson's disease, Castleman's disease, COPD,
recurrent pneumonia, reportedly A+Ox3 at baseline, presenting
with altered mental status and respiratory distress. This
morning, the patient felt cold, and had a "rolling" sound from
her throat/chest. No cough. Looked shorted of breath. She was
given a nebulizer treatment. She developed increased agitation,
and her caretaker found her on the ground on a rug.
.
Thursday, the patient was complaining of pain around her J-tube
site, which is chronic for her. She was treated for
constipation.
.
In the ED, initial vital signs were T 103 HR 105 BP 187/85 RR 28
Sat 100%/NRB. Her lung fields were diffusely rhonchorous. There
was erythema around the site of her J-tube. Labs were notable
for WBC 17.7, Cr 1.4, trop 0.03, lactate 2.2. CXR showed large
left-sided infiltrate. She was intubated, receiving etomidate 20
mg IV and succinylcholine 80 mg IV. He was subsequently started
on a propofol gtt. He was given ceftriaxone 1 gm IV, levaquin
750 mg IV, vancomycin 1 gm IV, Tylenol 1 gm PR, and 4 L NS, with
the last liter still running during transport to the MICU.
.
ABG post-intubation was 7.33/55/84 on AC 350/16/5/50%.
Post-intubation CXR showed ET tube 7.1 cm above the carina. This
was not advanced in the ED. Vitals on transfer T 103.2 HR 88 BP
124/62 RR 30 Sat 96%.
.
Review of systems is unobtainable.
Past Medical History:
1. Castleman's disease: unicentric. Found incidentally on
splenectomy done for "splenic pain" around [**2176**]. Has had lymph
nodes sampled in past to r/o lymphoma but all have shown
reactive lymph tissue only. Followed by Dr. [**Last Name (STitle) 410**]. (Heme/Onc)
2. anaplastic thyroid cancer s/p radical neck dissection, at age
15
3. Esophageal webs and esophageal dysmotility. Has had numerous
esophageal dilatations.
4. Recurrent aspiration pneumonias sputum Cx growing
Pseudomonas, MRSA
5. Chronic pulmonary disease
6. MRSA osteomyelitis of olecranan s/p multiple debridements
7. Hx Bipolar d/o
8. GERD
9. Osteoporosis: has broken both hips, left in [**11-7**], right with
failed ORIF and redo at [**Hospital1 2025**]
10. Hx zoster
11. Hx depression, chronic pain
12. HTN
13. Parkinson's disease
Social History:
Retired social worker. [**Name (NI) 6934**] with walker and assistance at
baseline. No Etoh, [**Name (NI) **], drugs. Lives at home w/ 24 hour health
aid ([**Name (NI) 96555**]). Health care [**Doctor Last Name 360**] = [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 105568**] (attorney)
[**Telephone/Fax (1) 105579**] = HCP
Family History:
1. Father: HTN, DM, depression, died MI, age 59.
2. Mother: HTN, hypercholesterolemia, died MI, age 82.
3. Sister: HTN
Physical Exam:
General: Intubated. Sedated.
HEENT: Anicteric sclerae.
Neck: Supple. Post-surgical or post-radiation changes on right
side of neck. JVP low.
Chest: Intubated. Synchronous with ventilator. Left basilar
rales.
CV: RRR. Normal s1, s2. No M/G/R.
Abd: +BS. Soft. NT/ND. Erythema around J-tube site.
Ext: Warm extremities.
Neuro: Sedated. PERRL. Moves all extremities.
.
By discharge pt's PE:
Last fever 100.7 on [**6-15**] at 1200
p 60-70's
SBP 127 - 154 x24 hrs
RR 19-28
97-100% on 2L NC
Thin, elderly frail appearing female in no distress, she opens
eyes and responds with simple one word answers to questions.
Unable to answer more complicated questions. Tardive dyskinesia
motions of her mouth and tongue appear improved today but have
been noted for many days. Able to follow simple commands ("show
two fingers")
Jugular pulsations not noted
Lungs with upper airway grunting and rhonchi, but pt able to
produce a cough
S1/S2 difficult to hear given lung sounds
Abd soft NT ND, with gauze covering GJ tube, the bag covering
the enterocutaneous fistula inferior to her GJ tube has been
removed and the maceration and cellulitis of her stomach is much
improved
No BLE edema noted, extrems are warm
Wriggling motion of her lower extremities is noted
Pertinent Results:
[**2195-6-18**] 05:34AM BLOOD WBC-13.8* RBC-3.14* Hgb-8.9* Hct-27.5*
MCV-88 MCH-28.4 MCHC-32.5 RDW-18.0* Plt Ct-419
[**2195-6-17**] 03:11AM BLOOD WBC-11.8* RBC-3.03* Hgb-8.6* Hct-26.9*
MCV-89 MCH-28.3 MCHC-31.9 RDW-17.6* Plt Ct-393
[**2195-6-16**] 02:59AM BLOOD WBC-11.3* RBC-2.79* Hgb-8.2* Hct-25.3*
MCV-91 MCH-29.2 MCHC-32.3 RDW-17.5* Plt Ct-397
[**2195-6-15**] 03:03AM BLOOD WBC-12.1* RBC-2.94* Hgb-8.9* Hct-26.5*
MCV-90 MCH-30.3 MCHC-33.5 RDW-17.5* Plt Ct-436
[**2195-6-14**] 03:17AM BLOOD WBC-12.0* RBC-2.80* Hgb-8.2* Hct-24.7*
MCV-88 MCH-29.4 MCHC-33.3 RDW-17.6* Plt Ct-381
[**2195-6-13**] 03:46AM BLOOD WBC-16.7* RBC-3.05* Hgb-8.9* Hct-26.9*
MCV-88 MCH-29.2 MCHC-33.1 RDW-17.6* Plt Ct-384
[**2195-6-12**] 03:40AM BLOOD WBC-14.4* RBC-3.12* Hgb-9.3* Hct-27.7*
MCV-89 MCH-29.7 MCHC-33.5 RDW-17.8* Plt Ct-392
[**2195-6-11**] 04:27AM BLOOD WBC-13.8* RBC-3.21* Hgb-9.2* Hct-28.7*
MCV-89 MCH-28.6 MCHC-32.0 RDW-17.9* Plt Ct-384
[**2195-6-10**] 01:10AM BLOOD WBC-15.6* RBC-2.75* Hgb-8.2* Hct-25.0*
MCV-91 MCH-29.6 MCHC-32.6 RDW-18.2* Plt Ct-381
[**2195-6-9**] 03:08AM BLOOD WBC-18.1* RBC-2.95* Hgb-8.6* Hct-27.0*
MCV-92 MCH-29.2 MCHC-31.9 RDW-17.7* Plt Ct-416
[**2195-6-8**] 03:36AM BLOOD WBC-15.9* RBC-2.99* Hgb-8.5* Hct-26.5*
MCV-89 MCH-28.5 MCHC-32.2 RDW-17.3* Plt Ct-411
[**2195-6-7**] 02:49PM BLOOD Hct-25.5*
[**2195-6-7**] 04:32AM BLOOD WBC-21.5* RBC-2.87* Hgb-8.4* Hct-25.9*
MCV-90 MCH-29.3 MCHC-32.4 RDW-17.0* Plt Ct-409
[**2195-6-6**] 11:25PM BLOOD WBC-25.8* RBC-3.10* Hgb-9.0* Hct-28.8*
MCV-93 MCH-29.2 MCHC-31.4 RDW-17.2* Plt Ct-464*
[**2195-6-6**] 02:20PM BLOOD WBC-17.7* RBC-3.93* Hgb-11.3* Hct-35.8*
MCV-91 MCH-28.8 MCHC-31.6 RDW-17.2* Plt Ct-521*
[**2195-6-13**] 03:46AM BLOOD Neuts-86* Bands-0 Lymphs-11* Monos-3
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2195-6-13**] 03:46AM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+
Macrocy-OCCASIONAL Microcy-OCCASIONAL Polychr-NORMAL
Ovalocy-OCCASIONAL Target-1+ Bite-OCCASIONAL
[**2195-6-10**] 01:10AM BLOOD PT-13.5* PTT-44.8* INR(PT)-1.2*
[**2195-6-9**] 06:01AM BLOOD PT-13.6* PTT-45.0* INR(PT)-1.2*
[**2195-6-18**] 05:34AM BLOOD Glucose-121* UreaN-25* Creat-1.0 Na-138
K-4.5 Cl-104 HCO3-26 AnGap-13
[**2195-6-17**] 03:11AM BLOOD Glucose-123* UreaN-23* Creat-0.9 Na-136
K-4.4 Cl-105 HCO3-25 AnGap-10
[**2195-6-16**] 02:59AM BLOOD Glucose-136* UreaN-21* Creat-1.0 Na-138
K-3.5 Cl-104 HCO3-28 AnGap-10
[**2195-6-15**] 12:58PM BLOOD Glucose-105* UreaN-19 Creat-1.0 Na-135
K-3.8 Cl-99 HCO3-29 AnGap-11
[**2195-6-15**] 03:03AM BLOOD Glucose-135* UreaN-20 Creat-1.0 Na-138
K-4.1 Cl-101 HCO3-30 AnGap-11
[**2195-6-14**] 05:22PM BLOOD UreaN-19 Creat-0.8 Na-139 K-3.7 Cl-98
[**2195-6-14**] 03:17AM BLOOD Glucose-111* UreaN-20 Creat-0.9 Na-141
K-3.5 Cl-95* HCO3-40* AnGap-10
[**2195-6-13**] 04:55PM BLOOD Glucose-150* UreaN-16 Creat-0.9 Na-140
K-4.0 Cl-95* HCO3-38* AnGap-11
[**2195-6-13**] 03:46AM BLOOD Glucose-140* UreaN-13 Creat-0.8 Na-141
K-4.0 Cl-97 HCO3-37* AnGap-11
[**2195-6-12**] 03:40AM BLOOD Glucose-135* UreaN-9 Creat-0.7 Na-142
K-3.9 Cl-103 HCO3-35* AnGap-8
[**2195-6-11**] 05:31PM BLOOD UreaN-8 Creat-0.8 Na-142 K-4.2 Cl-105
[**2195-6-11**] 04:27AM BLOOD Glucose-117* UreaN-6 Creat-0.9 Na-142
K-4.0 Cl-109* HCO3-26 AnGap-11
[**2195-6-10**] 01:10AM BLOOD Glucose-70 UreaN-6 Creat-0.9 Na-143 K-4.4
Cl-115* HCO3-22 AnGap-10
[**2195-6-6**] 02:20PM BLOOD UreaN-24* Creat-1.4*
[**2195-6-6**] 11:25PM BLOOD Glucose-95 UreaN-17 Creat-1.0 Na-144
K-5.4* Cl-114* HCO3-23 AnGap-12
[**2195-6-8**] 03:36AM BLOOD Glucose-70 UreaN-13 Creat-0.9 Na-144
K-4.2 Cl-117* HCO3-19* AnGap-12
[**2195-6-15**] 10:54PM BLOOD CK-MB-3 cTropnT-0.04*
[**2195-6-15**] 03:03AM BLOOD CK-MB-2 cTropnT-0.05*
[**2195-6-14**] 05:22PM BLOOD CK-MB-2 cTropnT-0.05*
[**2195-6-9**] 03:08AM BLOOD CK-MB-5 cTropnT-0.14*
[**2195-6-8**] 03:36AM BLOOD CK-MB-7 cTropnT-0.22*
[**2195-6-7**] 02:49PM BLOOD CK-MB-8 cTropnT-0.27*
[**2195-6-7**] 04:32AM BLOOD CK-MB-9 cTropnT-0.34*
[**2195-6-6**] 11:25PM BLOOD CK-MB-9 cTropnT-0.43*
[**2195-6-18**] 05:34AM BLOOD Calcium-10.4* Phos-2.5* Mg-2.6
[**2195-6-17**] 07:44AM BLOOD Cholest-103
[**2195-6-17**] 03:11AM BLOOD Calcium-10.0 Phos-2.4* Mg-2.4
[**2195-6-15**] 03:03AM BLOOD Calcium-10.0 Phos-2.7 Mg-2.3
[**2195-6-14**] 05:22PM BLOOD Mg-2.1
[**2195-6-14**] 03:17AM BLOOD Calcium-9.2 Phos-2.6* Mg-2.1
[**2195-6-13**] 04:55PM BLOOD Calcium-9.7 Phos-2.6* Mg-2.1
[**2195-6-12**] 03:40AM BLOOD Calcium-9.6 Phos-2.4* Mg-2.5
[**2195-6-11**] 05:31PM BLOOD Mg-1.9
[**2195-6-6**] 11:25PM BLOOD Calcium-7.7* Phos-2.4* Mg-1.8
[**2195-6-17**] 07:44AM BLOOD Triglyc-140 HDL-47 CHOL/HD-2.2 LDLcalc-28
LDLmeas-<50
[**2195-6-8**] 05:13PM BLOOD TSH-33*
[**2195-6-6**] 11:25PM BLOOD TSH-9.9*
[**2195-6-13**] 03:46AM BLOOD T4-4.4* T3-58* Free T4-0.61*
[**2195-6-12**] 03:40AM BLOOD T4-3.9* T3-57* calcTBG-1.11 TUptake-0.90
T4Index-3.5* Free T4-0.57*
[**2195-6-11**] 04:27AM BLOOD T4-4.0* T3-48* calcTBG-1.10 TUptake-0.91
T4Index-3.6* Free T4-0.55*
[**2195-6-9**] 03:08AM BLOOD T3-47* Free T4-0.51*
[**2195-6-6**] 11:25PM BLOOD T4-2.7* T3-55* calcTBG-0.95 TUptake-1.05
T4Index-2.8* Free T4-0.52*
[**2195-6-17**] 07:44AM BLOOD Vanco-19.7
[**2195-6-12**] 04:46PM BLOOD Vanco-26.5*
[**2195-6-9**] 06:01AM BLOOD Vanco-16.5
[**2195-6-15**] 07:28AM BLOOD Type-ART PEEP-5 pO2-161* pCO2-45 pH-7.45
calTCO2-32* Base XS-7 Intubat-INTUBATED
[**2195-6-14**] 08:03AM BLOOD Type-ART pO2-141* pCO2-49* pH-7.54*
calTCO2-43* Base XS-17
[**2195-6-8**] 10:40AM BLOOD Type-[**Last Name (un) **] pO2-143* pCO2-43 pH-7.26*
calTCO2-20* Base XS--7 Comment-GREEN TOP
[**2195-6-7**] 03:03AM BLOOD Type-ART Temp-36.9 pO2-111* pCO2-39
pH-7.33* calTCO2-21 Base XS--4
[**2195-6-7**] 12:02AM BLOOD Type-ART Temp-36.9 pO2-79* pCO2-47*
pH-7.29* calTCO2-24 Base XS--3 Intubat-INTUBATED
[**2195-6-6**] 08:07PM BLOOD Type-ART Temp-37.9 FiO2-50 pO2-130*
pCO2-54* pH-7.31* calTCO2-28 Base XS-0 Intubat-INTUBATED
[**2195-6-8**] 10:40AM BLOOD Lactate-0.8
[**2195-6-7**] 11:42AM BLOOD Lactate-1.1
[**2195-6-7**] 05:31AM BLOOD Lactate-1.2
[**2195-6-7**] 03:03AM BLOOD Lactate-2.1* K-5.0
[**2195-6-18**] 12:00PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.020
[**2195-6-18**] 12:00PM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2195-6-18**] 12:00PM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-<1
[**2195-6-15**] 10:12AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
Blood cultures negative x4
Urine culture negative x2
[**2195-6-6**] 3:30 pm SPUTUM ENDOTRACHEAL.
**FINAL REPORT [**2195-6-13**]**
GRAM STAIN (Final [**2195-6-6**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN CLUSTERS.
2+ (1-5 per 1000X FIELD): BUDDING YEAST.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2195-6-13**]):
Commensal Respiratory Flora Absent.
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup will be performed appropriate to the isolates
recovered from
this site.
STAPH AUREUS COAG +. HEAVY GROWTH. TWO MORPHOLOGIES.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
Piperacillin/Tazobactam sensitivity testing confirmed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**]. TWO MORPHOLOGIES.
ESCHERICHIA COLI. SPARSE GROWTH.
IDENTIFICATION AND SENSITIVITY REQUESTED BY DR.[**First Name (STitle) 5478**]
[**Name (STitle) **]
#[**Numeric Identifier 11644**] ON [**2195-6-10**].
WARNING! This isolate is an extended-spectrum
beta-lactamase
(ESBL) producer and should be considered resistant to
all
penicillins, cephalosporins, and aztreonam. Consider
Infectious
Disease consultation for serious infections caused by
ESBL-producing species.
Piperacillin/Tazobactam sensitivity testing confirmed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
YEAST. SPARSE GROWTH.
PSEUDOMONAS AERUGINOSA. RARE GROWTH. SECOND
MORPHOLOGY.
Piperacillin/Tazobactam sensitivity testing confirmed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
| PSEUDOMONAS AERUGINOSA
| | ESCHERICHIA
COLI
| | |
PSEUDOMONAS AERU
| | | |
AMIKACIN-------------- 8 S 16 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- R
CEFEPIME-------------- 4 S R 8 S
CEFTAZIDIME----------- 2 S R 2 S
CEFTRIAXONE----------- R
CIPROFLOXACIN--------- =>4 R =>4 R =>4 R
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S =>16 R <=1 S =>16 R
LEVOFLOXACIN---------- =>8 R
MEROPENEM------------- 4 S <=0.25 S 4 S
OXACILLIN------------- =>4 R
PIPERACILLIN/TAZO----- <=4 S 16 S 8 S
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TOBRAMYCIN------------ =>16 R <=1 S =>16 R
TRIMETHOPRIM/SULFA---- <=0.5 S =>16 R
VANCOMYCIN------------ <=0.5 S
[**2195-6-6**] 11:25 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2195-6-7**]**
GRAM STAIN (Final [**2195-6-7**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Final [**2195-6-7**]):
DUPLICATE SPECIMEN.
PLEASE REFER TO CULTURE # [**Numeric Identifier 105580**],[**2195-6-6**].
PATIENT CREDITED.
[**2195-6-7**] 12:03 pm Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
**FINAL REPORT [**2195-6-10**]**
Respiratory Viral Culture (Final [**2195-6-10**]):
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
[**Telephone/Fax (1) 6182**]
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final [**2195-6-8**]):
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture for further
information.
[**2195-6-10**] 3:12 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2195-6-13**]**
GRAM STAIN (Final [**2195-6-10**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2195-6-13**]):
Commensal Respiratory Flora Absent.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 105580**]
([**2195-6-6**]).
STAPH AUREUS COAG +. SPARSE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 105580**]
([**2195-6-6**]).
.
ADMISSION CXR [**6-6**] IMPRESSION: Large patchy opacification in the
left mid to lower lung, concerning for pneumonia and/or
aspiration. If history of trauma, contusion/pulmonary hemorrhage
would also [**Last Name (un) 10737**] the differential. Recommend followup with chest
radiograph after appropriate treatment.
.
[**6-6**] CT HEAD IMPRESSION: No acute intracranial process. Chronic
involutional changes.
.
[**6-8**] ECHO
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. There is mild regional
left ventricular systolic dysfunction with hypokinesis of the
distal half of the anterior septum, distal distal anterior wall,
and apex. The remaining segments contract normally (LVEF = 45-50
%). No intraventricular thrombus is seen. 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.
Mild to moderate ([**1-4**]+) mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Normal left ventricular
cavity size with regional systolic dysfunction c/w CAD (mid-LAD
distribution). Mild-moderate mitral regurgitation.
Compared with the prior study (images reviewed) of [**2195-5-18**],
the wall motion abnormality is new and c/w interim ischemia.
.
[**6-11**] CT HEAD IMPRESSION: No hemorrhage. Very limited scan due to
patient positioning; if there is concern for stroke, repeat, or
preferably MRI would be the preferred means for evaluation.
.
[**6-14**] MR HEAD IMPRESSION:
1. No evidence of an acute infarction.
2. Small vessel ischemic change and an old small right
cerebellar infarct.
.
[**6-16**] DISCHARGE CXR FINDINGS: As compared to the previous
radiograph, the patient has been extubated. The left central
venous access line is in unchanged position. Improvement of the
bilateral parenchymal opacities, notably on the right, the right
lung now shows improved ventilation. Unchanged size of the
cardiac silhouette.
Brief Hospital Course:
71 yo F with complex medical history including Parkinson's,
Castleman's disease, COPD, hypothyroidism, and recurrent
aspiration pneumonias who was admitted to MICU with septic shock
likely from MRSA and Pseudomonas pneumonia, course has been
complicated by profound hypothyroidism (slowly improving),
NSTEMI, abdominal cellulitis/maceration from draining
entercutaneous fistula (now stopped draining), altered mental
status and slow awakening from sedation. She is being discharged
in stable condition to [**Hospital1 **] LTAC.
.
1. Septic shock: Pt required IVF's, pressors, and emergent CVL
placement. These eventually improved and she was weaned off
pressors without further complication.
.
2. Pneumonia: The patient has a history of recurrent pneumonias.
In the past, she has had infection with multiple resistent
organisms, including MRSA, ESBL Klebsiella (sensitive only to
carbapenems), and pseudomonas (sensitive to Zosyn and
carbapenems, resistent to cipro and tobra). Her sputum culture
grew MRSA and Pseudomonas and she was treated with broad
spectrum ABx and eventually narrowed to Vancomycin and Cefepime
based on culture sensitivities as above (of note, the very
resistant Ecoli was only sparse growth and pt was clinically
improving, so not specifically treated). Thursday [**2195-6-18**] is
day 13/14 and she should be treated for one more day after
discharge.
.
3. Respiratory failure: Patient intubated in ED for hypercarbic
respiratory failure. She improved with ABx and diuresis and was
eventually able to be extubated. Of note, she was still 3L
positive through LOS even after having been diuresed, so if
clinically relevant could consider diuresis but pt thought to be
approaching euvolemia. Of note, after extubation the pt was able
to cough on command, but noted to have a lot of secretions and
had a couple episodes of desaturations in which mucus plugs were
suctioned.
.
4. Altered mental status: Pt was sedated during intubation but
noted to have prolonged course of awakening. Over several days
she finally started opening her eyes to voice and finally was
able to answer simple questions and follow simple commands. We
avoided oversedating her and are currently holding her home
Seroquel despite her caregiver's strident insistence on starting
it. Her outpt Psychiatrist was OK with holding it while mental
status not at baseline. IV Fentanyl was used for pain. She had
two head CT without contrast wihtout acute process (chronic
changes) and an MRI that showed no acute infarct and small
vessel ischemic changes and old small R cerebellar infarct.
.
5. Hypothyroidism: She was initially started on 50 mcg daily IV
thyroxine; the pt's TFT's were then drawn while intubated and
noted to be grossly abnormal, with TSH 9.9 --> 33 and fT4 low at
0.52 (0.93 - 1.7). Her total T4 and T3 also noted to be low.
Endocrine consult obtained and the question of thyroxine home
non-compliance (called pharmacy, takes 75mcg levothyroxine
daily) was raised; given the GJ tube the issue of non-absorption
also raised. She received a 100 mcg IV thyroxine load and
increased to 75 mcg IV thyroxine daily. Her TFT's slowly
improved over time to a TSH of 8.7, fT4 0.61, T3 58, T4 4.4 by
discharge. Endo recommended restarted her PO thyroxine at 75 mcg
daily (hold tube feeds 2 hrs before and 2 hrs after), rechecking
TFT's in [**6-10**] wks after discharge and follow up as outpt -- her
endocrinologist Dr. [**Last Name (STitle) 7711**] at [**Hospital1 18**] was contact[**Name (NI) **] and made
aware of the situation. Of note, Endo consult did NOT feel
hypothyroidism to be the etiology of this admission.
.
6. NSTEMI: The pt had lateral deep inverted TW inversions and
produced cardiac enzymes with Troponin peak to 0.43 (<0.1) but
never made MB fraction, all consistent with NSTEMI. TTE showed
new WMA of distal anterior septum, distal wall, apex, mild
decrease of EF 45-50%. Cardiology consult felt this consistent
with demand ischemic process, pt was treated with 48 hrs of
Heparin gtt, daily ASA 325, Plavix 75, and Atorvastatin 40 mg
daily (not 80 mg given that this was demand ischemia). She was
started on beta blocker, but noted through admission to get
bradycardic with sleep so this was eventually stopped. She was
started on ACEi (Captopril eventually uptitrated to 50 mg TID)
for hypertension to the SBP 140-150's. She should continue to
have her ACEi titrated for HTN. Her cardiac enzymes trended down
to normal by discharge. She should follow up with Cardiology
once she is more stable for consideration for cardiac
catheterization.
.
7. Leukocytosis: The pt was admitted with WBC count 17.7, peaked
to 26, and trended down however was 13.8 by discharge without
any clinical decompensation to suggest further infection. Last
fever was [**6-15**] at 100.7, at which point she has re-cultured with
blood, urine negative to date. Cdiff was gathered [**6-18**]; we will
contact the rehab with the results.
.
8. Cellulitis: Pt had complicated GJ tube history with an
enterocutaneous fistula inferior to tube insertion site. It was
draining bilious fluid and wound care was consulted; the bilious
fluid was felt to be causing maceration and cellulitis on her
stomach. IR evaluated the tube and repositioned it and
re-inflated the balloon. Of note, there has been a question of
pt's noncompliance with NPO at home leading to GJ malfunction
and possibly aspiration. A collection bag was placed over the
fistula to prevent bilious fluid from irritating her skin, and
the redness/maceration improved over time, and eventually was
able to be removed. Review of previous surgery notes indicates
that this fistula was a very long standing issue, that she had
refused surgery for it, she had had IR guided attempts to fix
it; and the most recent recommendations were for wound care and
nutrition. Eventually by the time of discharge the fistula had
stopped draining fluid.
.
9. Acute kidney injury: Creatinine 1.4 on admission from
baseline 0.7; this returned to [**Location 213**] by day 2 of admission with
IVF's and renal fxn no further issue this admission, Cr by
discharge 1.0.
.
10. Chronic pain: On fentanyl, dilaudid, gabapentin at home; she
was continued on gabapentin and was sedated for her intubation.
After extubation, she was given IV Fentanyl prn for pain.
.
11. Bipolar disorder: Spoke with her outpt psychiatrist Dr.
[**First Name8 (NamePattern2) 714**] [**Last Name (NamePattern1) **]: [**Telephone/Fax (1) 105581**] who said the pt had bipolar
type 2 -- prolonged depression with some hypomania but never
fully manic. The vast maojrity of time she's mildly depressed
but it's mostly situation -- as outpt was on Lexapro 20,
Lamicatal 200, and Seroquel 300 (Seroquel was good bc she tends
to have trouble sleeping at night). She had some QTc
prolongation during her NSTEMI so Seroquel was held which was OK
with Dr. [**Last Name (STitle) **]. However, this could be added back over time
should she need it. She was continued on Lexapro and Lamictal
while admitted (Lexapro at half dose when QTc was prolonged but
normalized by discharged so back to home dose 20 mg daily).
.
12. Parkinson's disease: continued levodopa/carbidopa at home
doses
.
Communication:
-caretaker is [**Name (NI) 96555**] [**Telephone/Fax (1) 105582**], [**Telephone/Fax (1) 105574**]
-healthcare [**Doctor Last Name 360**] is [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 105568**], attorney home - ([**2195**],
([**Telephone/Fax (1) 105583**], ([**Telephone/Fax (1) 105584**]
.
Code status: FULL CODE, confirmed with healthcare [**Doctor Last Name 360**].
Medications on Admission:
(from recent discharge summary):
1. carbidopa-levodopa 25-100 mg Tablet [**Doctor Last Name **]: One (1) Tablet PO
QID (4 times a day).
2. escitalopram 10 mg Tablet [**Doctor Last Name **]: Two (2) Tablet PO DAILY
(Daily).
3. fentanyl 100 mcg/hr Patch 72 hr [**Doctor Last Name **]: One (1) Transdermal
Q72H (every 72 hours).
4. gabapentin 300 mg Capsule [**Doctor Last Name **]: One (1) Capsule PO HS (at
bedtime).
5. hydromorphone 2 mg Tablet [**Doctor Last Name **]: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
6. lamotrigine 100 mg Tablet [**Doctor Last Name **]: One (1) Tablet PO DAILY
(Daily).
7. levothyroxine 75 mcg Tablet [**Doctor Last Name **]: One (1) Tablet PO DAILY
(Daily).
8. lorazepam 1 mg Tablet [**Doctor Last Name **]: One (1) Tablet PO QAM (once a day
(in the morning)).
9. lorazepam 1 mg Tablet [**Doctor Last Name **]: 1-2 Tablets PO QPM (once a day (in
the evening)).
10. ondansetron 4 mg Tablet, Rapid Dissolve [**Doctor Last Name **]: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea .
11. primidone 50 mg Tablet [**Doctor Last Name **]: 0.5 Tablet PO DAILY (Daily).
12. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Doctor Last Name **]: One (1) Inhalation Q4H (every 4 hours) as
needed for sob, wheezing.
13. esomeprazole magnesium 20 mg Capsule, Delayed Release(E.C.)
[**Doctor Last Name **]: One (1) Capsule, Delayed Release(E.C.) PO once a day.
14. senna 8.6 mg Tablet [**Doctor Last Name **]: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
15. docusate sodium 50 mg/5 mL Liquid [**Doctor Last Name **]: Two (2) PO BID (2
times a day).
16. cholecalciferol (vitamin D3) 400 unit Tablet [**Doctor Last Name **]: Two (2)
Tablet PO DAILY (Daily).
17. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
[**Doctor Last Name **]: One (1) Tablet, Chewable PO twice a day: Do NOT take at
same time as other medications. Take at least 2 hours away from
other medications.
18. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette [**Doctor Last Name **]: [**1-4**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
19. miconazole nitrate 2 % Powder [**Month/Day (2) **]: One (1) Appl Topical QID
(4 times a day) as needed for G tube site.
Disp:*qs qs* Refills:*0*
20. fentanyl 25 mcg/hr Patch 72 hr [**Month/Day (2) **]: One (1) patch
Transdermal every seventy-two (72) hours.
21. quetiapine 200 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO at bedtime.
22. Miralax 17 gram/dose Powder [**Month/Day (2) **]: One (1) packet PO once a
day as needed for constipation.
.
Allergies: Tetracycline Analogues / Zinc / Optiray 350
Discharge Medications:
1. carbidopa-levodopa 25-100 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO
QID (4 times a day).
2. escitalopram 10 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO DAILY
(Daily).
3. Fentanyl Citrate 50-100 mcg IV Q4H:PRN pain
hold for rr<10
4. gabapentin 250 mg/5 mL Solution [**Month/Day (2) **]: One (1) PO HS (at
bedtime).
5. lamotrigine 100 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO BID (2 times
a day).
6. levothyroxine 75 mcg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY
(Daily).
7. primidone 50 mg Tablet [**Month/Day (2) **]: 0.5 Tablet PO DAILY (Daily).
8. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Month/Day (2) **]: One (1) Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
9. senna 8.6 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
10. docusate sodium 50 mg/5 mL Liquid [**Month/Day (2) **]: One (1) PO BID (2
times a day).
11. cholecalciferol (vitamin D3) 400 unit Tablet [**Month/Day (2) **]: Two (2)
Tablet PO DAILY (Daily).
12. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
[**Month/Day (2) **]: One (1) Tablet, Chewable PO twice a day: This should be
taken 2 hours away from other medications.
13. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette [**Month/Day (2) **]: [**1-4**]
Ophthalmic once a day as needed for dry eyes.
14. miconazole nitrate 2 % Cream [**Month/Day (2) **]: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
15. polyethylene glycol 3350 17 gram/dose Powder [**Hospital1 **]: One (1)
PO DAILY (Daily) as needed for constipation.
16. clopidogrel 75 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
17. aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
18. heparin (porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1)
Injection TID (3 times a day).
19. atorvastatin 20 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily).
20. captopril 25 mg Tablet [**Hospital1 **]: Two (2) Tablet PO TID (3 times a
day).
21. Vancomycin 1000 mg IV Q 24H
22. CefePIME 2 g IV Q12H
Start day 1 = [**6-12**]. Please infuse over 3 hrs
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary diagnoses this admission:
Septic shock
Respiratory failure from MRSA and Pseudomonas PNA, s/p
intubation and extubation
NSTEMI while intubated
Acute hypothyroidism
Cellulitis/maceration of abdominal skin from enterocutaneous
fistula
Secondary diagnoses this admission/past medical history:
1. Castleman's disease: unicentric. Found incidentally on
splenectomy done for "splenic pain" around [**2176**]. Has had lymph
nodes sampled in past to r/o lymphoma but all have shown
reactive lymph tissue only. Followed by Dr. [**Last Name (STitle) 410**]. (Heme/Onc)
2. anaplastic thyroid cancer s/p radical neck dissection, at age
15
3. Esophageal webs and esophageal dysmotility. Has had numerous
esophageal dilatations.
4. Recurrent aspiration pneumonias sputum Cx growing
Pseudomonas, MRSA
5. Chronic pulmonary disease
6. MRSA osteomyelitis of olecranan s/p multiple debridements
7. Hx Bipolar d/o
8. GERD
9. Osteoporosis: has broken both hips, left in [**11-7**], right with
failed ORIF and redo at [**Hospital1 2025**]
10. Hx zoster
11. Hx depression, chronic pain
12. HTN
13. Parkinson's disease
Discharge Condition:
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Mental Status: Alert to voice stimuli, able to answer simple
questions, but not extensively conversant
Discharge Instructions:
You were admitted to [**Hospital1 18**] with respiratory distress, low blood
pressures, and a significant pneumonia. You were intubated, had
a central venous line placed, and supported with blood pressure
medicines, IV fluids, and put on a breathing machine. You were
given antibiotics for the pneumonia and eventually improved and
were able to have the breathing tube taken out. Your blood
pressure also stabilized.
Your hospital course was also complicated by some damage to your
heart for which you were given anticoagulation for 48 hrs and
will continue on other cardiac medications. You thyroid function
was noted to be very low and you are being given thyroid
medicine; these are slowly improving.
The following changes were made to your medication regimen:
1. STOP Fentanyl patches -- these should be held until your
mental status improves and you are less sedate. You can be given
this medication IV at the LTAC should it be appropriate.
2. STOP oral Dilaudid -- these should be held until your mental
status improves and you are less sedate. You can be given this
medication IV at the LTAC should it be appropriate.
3. INCREASE Lamotrigine from 100 mg daily to 200 mg [**Hospital1 **] -- this
was the dosage that your home health care aid [**Hospital1 96555**] said that
you were taking.
4. STOP oral Ativan -- these should be held until your mental
status improves and you are less sedate. You can be given this
medication IV at the LTAC should it be appropriate.
5. STOP oral Zofran -- this can be restarted at the LTAC should
it be necessary; it was not needed during this admission.
6. STOP Esomeprazole -- this is a heartburn medicine that can be
restarted if you are having heartburn
7. STOP Seroquel -- these should be held until your mental
status improves and you are less sedate. This can be restarted
at the LTAC if your mental status improves
8. START Clopidogrel (Plavix) -- this medicine is for the small
heart attack you had while intubated. You should continue this
for at least 6 months and should follow up with a Cardiologist
9. START Aspiring -- this medicine is for the small heart attack
you had while intubated. You should continue this for at least 6
months and should follow up with a Cardiologist
10. START subcutaneous Heparin -- this is to prevent deep vein
thromboses; the LTAC may continue this until you start walking
more
11. START Atorvastatin -- this a cholesterol lowering medicine
12. START Captopril -- this is a blood pressure lowering
medicine
13. START Vancomycin 1 gram IV q24 -- this is an antibiotic.
[**2195-6-18**] is day 13 of 14 and should be stopped after [**2195-6-19**]
14. START Cefepime -- this is an antibiotic. [**2195-6-18**] is day 13
of 14 and should be stopped after [**2195-6-19**]
Followup Instructions:
The pt will need follow up with her PCP [**Name9 (PRE) **] [**Name10 (NameIs) **],[**Name11 (NameIs) 8741**]
[**Telephone/Fax (1) 82179**] once clinically stabilized.
She will also need follow up with her Endocrinologist, Dr.
[**First Name4 (NamePattern1) 1726**] [**Last Name (NamePattern1) 7711**] at [**Hospital1 18**], and should be set up for Cardiology
follow up once stabilized. Finally, her Psychiatrist Dr.
[**Last Name (STitle) **] was made aware of her admission and once she is
settled, should follow up with her as well.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
Completed by:[**2195-6-23**]
|
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icd9cm
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icd9pcs
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,734
| 190,796
|
40630
|
Discharge summary
|
report
|
Admission Date: [**2139-8-29**] Discharge Date: [**2139-9-16**]
Date of Birth: [**2058-3-25**] Sex: M
Service: MEDICINE
Allergies:
Tetracycline
Attending:[**First Name3 (LF) 633**]
Chief Complaint:
jaundice, transferred to MICU for hypotension
Major Surgical or Invasive Procedure:
1. right IJ placed in ED [**8-29**]
2. cholecystostomy tube placement [**8-29**] by Interventional
Radiology (Dr. [**First Name4 (NamePattern1) 402**] [**Last Name (NamePattern1) **] Mhuircheartaigh and Dr. [**First Name (STitle) **] G.
Sheim)
History of Present Illness:
The patient is an 81 year old male with PMH Diabetes, unknown
other PMH as no previous medical records here, with reported
history of pancreatic mass s/p ERCP and stent now transferred
from [**Hospital6 40383**] for hypotension. Patient is a poor historian,
his
medical history was obtained from ED chart, GI fellow's note and
conversation with Dr. [**First Name (STitle) 3459**], gastroenterologist at [**Location 1268**]
VA. Per records from ACS discussion with Dr. [**Name (NI) 3459**], pt
presented to WVA about 2-3 weeks ago with painless jaundice. His
Tbili was reported to be in the low 20s and AP ~2200 His work up
including a CT pancreas protocol which showed a large pancreatic
mass at the head involving that involving the SMA, SMV and
possible portal vein. Surgery was consulted but recs were
unknown. Patient underwent EUS with biopsies which didn't yield
carcinoma. However, brush biopsy (sent out) was highly
suspicious for malignancy. Patient
underwent ERCP with covered stent placement and his LFTs
improved. Patient was either d/c home or left AMA on [**8-28**] and
was
brought to [**Hospital6 5016**] by his wife today given
continued jaundice and was transferred to [**Hospital1 18**] for hypotension.
Per the patient, he denies having any abdominal pain, and has
had an appetite. He does endorse a 65lb weight loss, but cannot
say over what time period. He does report [**Male First Name (un) 1658**]-like stools and
"blood" in his urine.
.
In the ED, initial VS 98 76 88/51 18 99% on RA. He was
hypotensive to the systolic low 80s, and was bolused 3L NS
without much responsive. Labs were notable for WBC to 19.6 with
91% PMN's, Tbili 9.7. Exam notable for pt mildly confused,
non-focal neuro exam otherwise. Appeared comfortable, making
jokes with nursing staff in ED. Pt had R IJ placed for access,
and 2 large bore IV's. He was given Zosyn x1. Surgery was
consulted, and recommended no surgical intervention given pt was
not stable. IR was consulted, and recommedned bedside u/s with
percutaneous cholecystostomy on admission. Levophed was started
for borderline low BP. His BP responded to systolic 140s. VS
prior to transfer HR 70, v-paced, RR 17, 98% RA.
.
On the floor, he says that he feels well, without complaints.
"I'm comfortable". Denies any pain or nausea. Endorses
occasional chills, [**Male First Name (un) 1658**]-colored stools, dark urine, but
otherwise feels well currently.
.
Review of systems:
(+) Per HPI. Also notable for occasional constipation.
(-) Denies fever, night sweats, weight gain. Denies headache,
sinus tenderness, rhinorrhea or congestion. Denies cough,
shortness of breath, or wheezing. Denies chest pain, chest
pressure, palpitations, or weakness. Denies nausea, vomiting,
diarrhea, abdominal pain, or changes in bowel habits, bloody or
black stools. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
Past Medical History: per note from consult in ED who spoke
with OSH physician
newly diagnosed pancreatic mass
pancreatitis - [**3-18**] alcohol likely
DM2
MI
Afib
gout
left-sided pacer
Social History:
Lives by himself. Separated from Wife (who is his next of [**Doctor First Name **]).
Family History:
unable to obtain
Physical Exam:
On ICU admission:
Vitals: T: 97.4 BP: 118/71 P: 76 R: 20 O2: 99%RA
General: Alert, lying down in bed, appears slightly agitated,
NAD
HEENT: EOMI, jaundiced, icteric sclera, dry MM, OP clear
Neck: supple, R IJ in place, JVP not elevated, no LAD
Lungs: no use of access mm, Clear to auscultation bilaterally
anteriorly, no wheezes, rales, ronchi
Chest: L-sided pacer in place
CV: irregularly, irregular, + S1 S2, 2/6 systolic murmur loudest
at LUSB, no apparent radiation
Abdomen: NABS, umbilical hernia, soft, tender in RUQ without
[**Doctor Last Name **] sign, non-distended, no rebound tenderness or guarding,
no organomegaly
GU: foley in place with dark urine
Ext: warm, well perfused, 1+ edema to mid-ankle bilaterally
Neuro: alert, oriented to person, place, states "[**2135**]", "[**8-30**]" (off by one day only), moving all extremities, no gross
deficits, gait deferred
On ICU discharge:
VS T 36.1??????C, HR 72, BP 89/47 mmHg, RR 16, SpO2 98% RA
GEN: sitting up in bed in chair, resting comfortably
HEENT: MMM, ?5 cm JVP
CV: RRR III/VI crescendo-decrescendo murmur, no S1 or S2
appreciated
CH: CTAB, decreased breath sounds at bases
ABD: soft, diffusely tender to shallow palpation, R-sided
dressing with yellowish leakage at bottom of bandage, chole
drain +minimal clear/yellow output
EXT: wwp w/bilateral LE 2+ pitting edema to knees (R>L), LUE 1+
nonpitting edema to elbow (known DVT), +distal pulses
GU: foley in place
ICU Re-admission:
Vitals: T 96.3, BP 96/53, HR77, RR 21, SpO2 99% on RA
General: Mildly lethargic, oriented, no acute distress
HEENT: Icteric sclera, MMM, oropharynx clear
Neck: Supple, JVP not elevated, no LAD
Lungs: Decreased BS at bases, otherwise clear with no wheezes,
rhonchi, or rales
CV: Regular rate with occasional PVCs, normal S1/S2, III/VI
crescendo-decrescendo murmur, no rubs or gallops
Abdomen: Bowel sounds present. Soft, non-distended. Mild
tenderness in RUQ, no rebound tenderness or guarding. No
organomegaly. PTC site without erythema, drainage, or
tenderness. Evidence of recent slight leakage.
GU: No foley
Ext: Right PICC in place without erythema or drainage. Left
upper extremity edema. Bilateral lower extremity edema ([**3-19**]+).
Fingertips slightly cool. Distal pulses 2+ in all extremities.
Pertinent Results:
ADMISSION LABS:
[**2139-8-29**] 03:30PM BLOOD WBC-19.6* RBC-3.06* Hgb-10.2* Hct-30.4*
MCV-100* MCH-33.5* MCHC-33.7 RDW-15.1 Plt Ct-171
[**2139-8-29**] 03:30PM BLOOD Neuts-91* Bands-2 Lymphs-3* Monos-4 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2139-8-29**] 03:30PM BLOOD PT-14.5* PTT-27.4 INR(PT)-1.3*
[**2139-8-29**] 03:30PM BLOOD Glucose-128* UreaN-27* Creat-0.7 Na-134
K-3.5 Cl-102 HCO3-23 AnGap-13
[**2139-8-29**] 03:30PM BLOOD ALT-43* AST-74* AlkPhos-182* TotBili-9.7*
[**2139-8-29**] 03:30PM BLOOD Albumin-2.2* Calcium-8.1* Phos-2.0*
Mg-2.0 Iron-18*
[**2139-8-29**] 03:30PM BLOOD calTIBC-143* VitB12-1493* Folate-11.3
Ferritn-1719* TRF-110*
[**2139-8-29**] 03:42PM BLOOD Lactate-2.6*
DISCHARGE LABS:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2139-9-13**] 05:20 8.2 2.87* 9.6* 28.8* 101* 33.4* 33.2 15.1
193
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2139-9-14**] 13:00 167*1 16 1.2 140 3.8 105 25 14
Source: Line-PICC
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2139-9-13**] 05:20 14 26 110 2.7*
Source: Line-R Picc
OTHER ENZYMES & BILIRUBINS Lipase
[**2139-9-1**] 03:53 14
Source: Line-cvc
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2139-9-13**] 05:20 2.1* 7.6* 3.0 1.9
.
STUDIES:
CXR [**2139-8-29**]:
FINDINGS: No consolidation or edema is evident. The mediastinum
is
unremarkable. Dual-chamber pacemaker is in standard course and
position from a left subclavian approach. Calcified plaque is
seen at the aortic arch. The cardiac silhouette is within normal
limits for size. No effusion or pneumothorax is noted. The
osseous structures reveal degenerative change throughout the
thoracic spine.
IMPRESSION: No acute pulmonary process.
CT TORSO [**2139-8-29**]:
IMPRESSION:
1. No discrete pancreatic mass. However, given given pancreatic
dustal
dilatation and abnormal morphology of pancreatic head, an
infiltrative process cannot be excluded. Correlate with ERCP
findings and pathology from OSH.
2. Gallbladder features suggest acute cholecystitis.
3. Pneumobilia is related to common bile duct stent, which
extends to the
duodenum.
4. Small ascites.
5. Small bilateral pleural effusions and associated compressive
atelectasis.
5. Left upper lobe ground glass nodule. Given suspected
pancreatic
malignancy, recommend follow up in no longer than 12 months with
dedicated
chest CT.
RUQ u/s [**2139-8-29**]:
1. linear hyperechoic foci scattered throughout the liver,
presumably
pneumobilia related to recent ERCP, but portal venous gas can't
be excluded and can be assessed on CT.
2. Distended gallbladder with stones and sludge, mild
circumferential wall thickening to 4mm. Features suggest acute
cholecystitis.
3. pancreas not well visualized.
4. MPV patent
5. CBD is 8mm, normal for age.
Unilateral Right Upper Extremity ultrasound:
IMPRESSION: Diminished flow and in one of the peroneal veins may
represent a non-occlusive thrombus in the calf.
Unilateral Left Lower Extremity:
IMPRESSION: Diminished flow and in one of the peroneal veins may
represent a non-occlusive thrombus in the calf.
MICRO:
Blood cultures [**2139-8-29**]: negative
Urine cx [**2139-8-29**]: negative
UCX-negative.
Biliary cx [**2139-8-29**]:
GRAM STAIN (Final [**2139-8-30**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
3+ (5-10 per 1000X FIELD): GRAM POSITIVE ROD(S).
FLUID CULTURE
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| STAPH AUREUS COAG +
| |
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN---------<=0.25 S
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ 2 S <=0.5 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM------------- 0.5 S
OXACILLIN------------- =>4 R
PIPERACILLIN/TAZO----- 8 S
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=0.5 S
.
ANAEROBIC CULTURE (Final [**2139-9-3**]): NO ANAEROBES ISOLATED.
.
NEGATIVE FOR MALIGNANT CELLS.
.
Paucicellular sample consisting predominantly of
gastrointestinal mucosal contaminant (see note).
.
Note:
It is difficult to distinguish between gastrointestinal
mucosal contaminant and reactive ductal epithelium in
occasional smaller groups of cells. Although suboptimal
sampling of a well-differentiated pancreatic adenocarcinoma
is a remote possibility, there is no definitive evidence of
malignancy in this sample.
Common bile duct brushings (RCY-[**12/4796**] A, [**2139-8-25**]):
ATYPICAL.
Atypical ductal epithelial cells, favor reactive.
EUS-FNA, Pancreatic mass (RCY-[**12/4796**] B, [**2139-8-25**]):
NON-DIAGNOSTIC.
The aspirate specimen is paucicellular and consists
predominantly of gastrointestinal mucosal contaminant
and blood.
Common bile duct stricture, needle biopsy (RSP-[**12/4804**],
[**2139-8-25**]):
NON-DIAGNOSTIC.
Scant stromal fragment and blood.
Brief Hospital Course:
Pt is an 81 year old with PMH of T2DM, CAD, and new history of
painless jaundice with pancreatic mass on imaging, and elevated
LFTs suspicious for pancreatic tumor, in addition to hypotension
with concerns for sepsis, requiring MICU transfer.This is an 81
y/o male with DM, afib, ischemic cardiomyopathy with EF 35%, s/p
pacer, with reported recent history of pancreatic mass on CT
abdomen s/p ERCP and EUS with palliative biliary stent placement
at [**Location 1268**] VA, initially transferred from [**Hospital3 **] to MICU Green for hypotension (SBPs 70s-80s).
.
He initially presented to WXVA about 2-3 weeks ago with painless
jaundice. His T. bili was reported to be in the low 20s and AP
~2200 His work up including a CT pancreas protocol which showed
a large pancreatic mass at the head involving that involving the
SMA, SMV and possible portal vein. Patient underwent EUS with
biopsies which did not show carcinoma. However, brush biopsy
(sent out) was highly suspicious for malignancy. His LFTs
improved after stent placement. After being home for 2-3 days
(?left AMA vs. discharged), he was brought to [**Hospital3 **] by his wife due to continued jaundice and was
transferred to [**Hospital1 18**] for hypotension.
.
He was admitted to the MICU for biliary sepsis and started on
leveophed. He was continued on Levophed for persistent
hypotension, with continued poor response to IVF and low urine
output. Due to a question of an element of cardiogenic shock,
TTE was done, showing an EF of 35% and critical AS. Also, due to
UE and LE edema, ultrasounds were done which demonstrated left
brachial and right peroneal DVTs, so he was started on lovenox.
A PTC was performed on [**8-29**] and the drained bile grew out
Pseudomonas and MRSA/ Vanc/Zosyn initially started but switched
to Vanc/Cefepime/Flagyl due to more favorable MICs. With mixed
picture of sepsis and cardiogenic shock, diureses with Lasix
10mg IV was started with mild improvement of SBPs to 90s-100s
and improved UOP.
The pathology slides from the EUS biopsies were obtained and
there is no confirmation of malignancy, but CA-19-9 is very
elevated. ERCP service was consulted for ERCP vs. EUS and asked
for transfer to the [**Hospital Unit Name 153**] for consideration of ERCP in the AM for
replacement of the stent, which they believe may be occluded.
He was transferred to the [**Hospital Unit Name 153**] on [**9-2**].
.
In the [**Hospital Unit Name 153**], he was continued on leveophed, which was weaned off
at 3 am [**9-6**]; and was continued on vanc/cefepime/flagyl. ERCP
felt stent was still viable per [**Last Name (un) **] data, continued to have
drainage from PTC. Went for EUS on [**9-11**] that showed 2cm
pancreatic head mass, but not biopsied given recent plavix use.
[**Doctor First Name **] Onc spoke with pt and family re: mass, however the family
was not interested in surgical treatment nor would he likely be
a surgical candidate given critical AS and other medical
comorbidities. Med Onc saw patient on floor and felt that
cancer was likely, but not definitive diagnosis without actual
tissue. Pt initially refused medical oncologic treatment, as he
was not interested in chemo and XRT. Abx d/c;d on [**9-12**] after
14d course. Plavix d'c'd on [**9-13**] given GOC and risk of bleeding
while on lovenox, aspirin and with likely malignancy.
Dr. [**Last Name (STitle) **] spoke with wife of 55 years (now seperated, but
still current [**Name8 (MD) 88896**] RN) [**First Name8 (NamePattern2) **] [**Name (NI) 45777**] [**2139**] about
overall condition and she agreed that given co-morbidities of
malnutrition, poor functional status, critical AS and CHF,
worsening renal function, and likely cancer which he most likely
wouldn't be a candidate for chemo and his wishes of pursuing
least medical treatments as possible, that goals of care should
be comfort focused/hospice. Pt also defers all medical decision
making to his wife. Letter written to his PCP, [**Name10 (NameIs) 88897**] [**Name11 (NameIs) 51426**],
[**Name Initial (NameIs) **].D. VA in [**Location (un) **] MA [**Telephone/Fax (1) 88898**] Ext.5050 updating him about
the clinical course and change to hospice.
.
By problem:
#pancreatic mass-see above
.
#cholangitis/cholecystitis/s/p septic shock- s/p abx tx course
14d with vanco/cipro/flagyl for MRSA/pseudomonas. S/p ICU course
see above. PTC drain was placed by IR and reevaluated on [**2139-9-15**].
Drained appeared occluded in IR, however, it was recommended to
keep this drain in place given risk of recurrent infection.
Therefore, upon discharge, will plan on keeping PTC drain in
place. If causing discomfort and not within goals of care, can
remove. In addition, if drainage were found to be decreasing,
consider IR cholangiography evaluation for patency.
.
# Acute on chronic sCHF- Pt volume overloaded on exam with
edema. However, given critical AS, recent sepsis, and borderline
BPs (SBP 90's), attempt at diuresis was challenging. As urine
output steady and patient on RA, did not give additional lasix
on the floor. However, can consider gentle doses of IV lasix for
goal -500cc/day. Pt was not hypoxic, but did report occasional
SOB while eating or lying flat. Pt was given oxycodone and
trialed ativan for symptomatic management. However, if this were
to fail or patient actually became dyspneic, hypoxic would
consider gentle diuresis. Pt was given gentle diuresis in the
ICU.
.
# DVT, acute- Pt started on lovenox [**Hospital1 **]. Likely due to suspected
malignancy, will Will continue for now, as large PE would likley
not be comfort care.
.
# [**Name (NI) **] unclear of exact cardiac history leading to pacemaker,
?arrhythmia and heart failure given his depressed EF, ?due to
critical AS vs. ischemic cardiomyopathy. Pt did not report chest
pain during admission. Cardiac medications appear to have been
discontinued per [**9-13**] GOC conversation by prior provider. [**Name10 (NameIs) **] had
been on ASA 81mg daily, Plavix 75mg daily. BB and ACEI initially
avoided due to hypotension/low BP and statin held given elevated
LFTs. Pt requested to continue his aspirin therapy. Therefore,
will continue this, but not plavix given that pt is on lovenox
for DVT and triple therapy will increase bleeding risk
especially with suspected malignancy. Restarted low dose BB,
metoprolol 6.25mg [**Hospital1 **] if BP allows to prevent discomfort from
possible angina, tachycardias.
.
#acute renal failure-Cr 0.7 to 1.2. Likely prerenal from poor PO
intake and possible CHF. Pt not given IV fluids as has
CHF/critical AS and would likely cause flash pulmonary
edema/hypoxia.
.
#DM2- continued HISS with finger sticks. Conservative insulin
coverage in order to avert symptomatic hyperglycemia. This can
be discontinued, if becomes painful for patient.
.
FEN: regular diet as tolerated
.
Access: PICC dc'd prior to discharge.
.
#goals of care-please note. Pt had been CMO/DNR/DNI per prior
discussions in ICU and goals of care conversations. However, pt
decided day of discharge that he would not sign the DNR/DNI
comfort care form for the ambulance ride to [**Hospital **] hospital. He
stated that he does not make decisions during emergencies and
would want his wife called during an emergency to determine
goals of care. Explained that this is not feasible during an
emergency and that a quick decision would have to be made. Pt
stated that we have to "talk to his wife" and that he would not
sign the form at this time.
.
Medications on Admission:
Medications on discharge from [**Last Name (un) **] VA in chart
Medications from [**Hospital3 **]
ASA 81mg daily
Calcium 250mg qhs
Docusate 100mg daily
Glyburide 5mg po daily
Metformin 500mg [**Hospital1 **]
Simvastatin 80mg daily
Omeprazole 20mg daily
Metoprolol 25mg po daily
Camphor prn itching
Clopidogrel 75mg daily
Loratidine 10mg daily
Discharge Medications:
1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for
wheeze.
6. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for indigestion.
7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
8. enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours).
9. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
10. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for severe pain: prn pain/dyspnea.
11. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for SOB.
13. insulin lispro 100 unit/mL Solution Sig: as directed
Subcutaneous ASDIR (AS DIRECTED): for blood sugar >200-in order
to prevent symptomatic hyperglycemia if within goals of care. (.
14. metoprolol tartrate 25 mg Tablet Sig: 0.25 Tablet PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] [**Hospital **] Hospital
Discharge Diagnosis:
pancreatic mass-elevated CA19-9
sepsis/cholangitis
acute on chronic systolic CHF
critical aortic stenosis
DVT
Discharge Condition:
alert confused at times,
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were initially admitted to the ICU with a severe infection
of your bile ducts (cholangitis). You were given antibiotics and
had a gallbladder drain placed. This should remain in place to
prevent future infection. Your symptoms improved from an
infection standpoint and you were transferred to the regular
medical floor. You likely have pancreatic cancer. A surgery
would be too risky and you expressed that you would not want any
therapies, such as chemotherapy and radiation, that would not be
curative. Therefore, a discussion was had between you and your
HCP, your wife, to transition your care to comfort
oriented/hospice care.
.
Medication changes:
1.start oxycodone 2.5 mg q6hrs for pain
2.start senna/colace to prevent constipation
3.start ativan 0.25-0.5mg for anxiety
4.start zofran for nausea
5.start lovenox for blood clots
.
Please take all of your medications as prescribed and follow up
with the appointments below.
Followup Instructions:
Department: GASTROENTEROLOGY
When: WEDNESDAY [**2139-9-30**] at 10:00 AM
With: [**Name6 (MD) 1948**] [**Last Name (NamePattern4) 1949**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
|
[
"427.89",
"428.0",
"584.9",
"V49.86",
"577.1",
"576.8",
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"428.23",
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"250.00",
"785.52",
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"041.12",
"038.9",
"V85.1",
"453.82",
"413.9",
"575.10",
"424.1",
"577.9",
"041.7",
"453.42",
"V45.01",
"414.01",
"263.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.74",
"51.01",
"87.54",
"45.13",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
21019, 21086
|
11628, 19095
|
318, 563
|
21240, 21382
|
6152, 6152
|
22365, 22714
|
3838, 3856
|
19490, 20996
|
21107, 21219
|
19121, 19467
|
21406, 22044
|
6857, 11605
|
3871, 6133
|
3031, 3509
|
22064, 22342
|
233, 280
|
591, 3012
|
6168, 6841
|
3554, 3720
|
3736, 3822
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,041
| 170,437
|
32896
|
Discharge summary
|
report
|
Admission Date: [**2146-12-6**] Discharge Date: [**2147-1-4**]
Date of Birth: [**2084-6-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
[**12-29**] Replacement of ascending aorta and hemiarch
History of Present Illness:
62 yo M with recent history of chest pain and syncope on [**11-30**]. At
that time he refused treatment, but agreed to go to hospital on
day of admission. Echocardiogram revealed Type A dissection,
also with elevated LFTs, creatinine and coagulopathy. Tranferred
to [**Hospital1 18**] for further management.
Past Medical History:
:^chol, HTN, DM, COPD, +EtOH
Physical Exam:
On admission:
Afebrile HR 62 BP 125/63
Ill appearing
Lungs bilat rhonchi
CV Reg, soft systolic and diastolic murmurs
Abdomen soft/NT
Extrem without edema
Pertinent Results:
Labs on discharge:
[**2147-1-3**] 09:34AM BLOOD WBC-12.0* RBC-3.29* Hgb-10.0* Hct-28.7*
MCV-87 MCH-30.5 MCHC-34.9 RDW-14.3 Plt Ct-240
[**2147-1-3**] 09:34AM BLOOD Plt Ct-240
[**2146-12-31**] 02:51AM BLOOD PT-13.1 INR(PT)-1.1
[**2147-1-4**] 05:50AM BLOOD Glucose-99 UreaN-48* Creat-2.1* Na-142
K-3.7 Cl-101 HCO3-30 AnGap-15
[**2147-1-1**] 03:56PM BLOOD Amylase-73
[**2146-12-31**] 02:51AM BLOOD ALT-154* AST-82* AlkPhos-137*
Amylase-119* TotBili-2.7*
Labs on Admission:
[**2146-12-6**] 06:47PM BLOOD WBC-6.5 RBC-3.57* Hgb-11.4* Hct-31.2*
MCV-88 MCH-32.0 MCHC-36.5* RDW-12.7 Plt Ct-21*
[**2146-12-6**] 06:47PM BLOOD PT-19.8* PTT-37.3* INR(PT)-1.8*
[**2146-12-6**] 06:47PM BLOOD Plt Smr-VERY LOW Plt Ct-21*
[**2146-12-6**] 06:47PM BLOOD Glucose-101 UreaN-88* Creat-7.5* Na-127*
K-4.8 Cl-88* HCO3-20* AnGap-24*
[**2146-12-6**] 06:47PM BLOOD ALT-8367* AST-6911* CK(CPK)-295*
AlkPhos-88 Amylase-132* TotBili-2.8*
[**2147-1-4**] 05:50AM BLOOD Amylase-83
CHEST (PORTABLE AP) [**2146-12-31**] 12:41 PM
CHEST (PORTABLE AP)
Reason: Removal CT
[**Hospital 93**] MEDICAL CONDITION:
62 year old man s/p ASC Ao Aneurysm repair
REASON FOR THIS EXAMINATION:
Removal CT
REASON FOR EXAMINATION: Followup of a patient with ascending
aorta aneurysm repair.
Portable AP chest radiograph compared to [**2146-12-30**].
There is no interval change in the position of the Swan-Ganz, ET
tube, and NG tube. There is also no change in the left
retrocardiac opacity consistent with atelectasis. On the other
hand, there is bilateral increase in perihilar opacities
continuing toward the lower lungs with bilateral interstitial
prominence; findings consistent with worsening pulmonary edema.
Left lateral chest wall was not included in the field of view,
thus precise evaluation of left pleural effusion cannot be
obtained.
IMPRESSION: Worsening mild-to-moderate pulmonary edema.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 76566**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 76567**] (Complete)
Done [**2146-12-29**] at 1:39:28 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
Division of Cardiothoracic [**Doctor First Name **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2084-6-9**]
Age (years): 62 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Abnormal ECG. Aortic dissection. Aortic valve
disease. Chest pain.
ICD-9 Codes: 402.90, 780.2, 786.51, 440.0, 441.2, 424.1
Test Information
Date/Time: [**2146-12-29**] at 13:39 Interpret MD: [**Known firstname **] [**Last Name (NamePattern1) 5209**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5209**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW2-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *5.6 cm <= 4.0 cm
Right Atrium - Four Chamber Length: *5.7 cm <= 5.0 cm
Left Ventricle - Ejection Fraction: 45% to 55% >= 55%
Aorta - Ascending: *5.6 cm <= 3.4 cm
Aorta - Arch: *4.0 cm <= 3.0 cm
Pericardium - Effusion Size: 1.1 cm
Findings
LEFT ATRIUM: Moderate LA enlargement. No spontaneous echo
contrast in the body of the LA. No spontaneous echo contrast or
thrombus in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. Good (>20 cm/s) LAA
ejection velocity. No thrombus in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A catheter
or pacing wire is seen in the RA and extending into the RV. PFO
is present. Left-to-right shunt across the interatrial septum at
rest.
LEFT VENTRICLE: Normal LV wall thickness. Top normal/borderline
dilated LV cavity size. Mildly depressed LVEF. No resting LVOT
gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Markedly dilated ascending aorta.
Focal calcifications in ascending aorta. Moderately dilated
aortic arch. Simple atheroma in aortic arch. Mildly dilated
descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Mildly thickened
aortic valve leaflets. No masses or vegetations on aortic valve.
No AS. Moderate (2+) AR. Moderate to severe (3+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
TRICUSPID VALVE: Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with physiologic PR.
PERICARDIUM: Moderate pericardial effusion. No echocardiographic
signs of tamponade.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The patient received antibiotic prophylaxis. The
TEE probe was passed with assistance from the anesthesioology
staff using a laryngoscope. No TEE related complications.
patient.
Conclusions
PRE-CPB:1. The left atrium is moderately dilated. No spontaneous
echo contrast is seen in the body of the left atrium. No
spontaneous echo contrast or thrombus is seen in the body of the
left atrium or left atrial appendage. No thrombus is seen in the
left atrial appendage.
2. A patent foramen ovale is present. A left-to-right shunt
across the interatrial septum is seen at rest.
3. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is top normal/borderline dilated.
Overall left ventricular systolic function is mildly depressed
(LVEF= 45-55 %).
4. Right ventricular chamber size and free wall motion are
normal.
5. The ascending aorta is markedly dilated .The aortic arch is
moderately dilated. There is a dissection flap extending from
the sino tubular junction to the descending thoracic aorta with
a true lumen visible. There are simple atheroma in the aortic
arch. The descending thoracic aorta is mildly dilated.
6. There are three aortic valve leaflets. The aortic valve
leaflets are mildly thickened. No masses or vegetations are seen
on the aortic valve. There is no aortic valve stenosis. Moderate
(2+)- (3+) aortic regurgitation is seen.
7. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen.
8. There is a moderate sized pericardial effusion. There are no
echocardiographic signs of tamponade.
9. There are moderate sized bilateral pleural effusions.
9. Dr. [**Last Name (STitle) **] was notified in person of the results.
POST-CPB: On infusion of phenylephrine and A-V pacing.
Biventricular systolic function is preserved. AI now 1+.
Synthetic graft in aortic position without hematoma. Descending
aorta shows no flow in the false lumen. MR is trace. Pericardial
effusion is small. Pleural effusion on left is small.
Brief Hospital Course:
He was admitted to the cardiac surgery ICU. Echo showed no
tamponade. The risk of operating in the setting of coagulopathy
and liver failure was deemed too high and he awaited recovery
prior to surgery. He was transfused with platelets, FFP and
vitamin K. he was followed by hepatology, cardiology and
nephrology. He was maintained on a labetalol and/or nicardipine
drips for blood pressure control. He was oliguric and started on
CVVH. He had pancreatitis and was started on TPN. He remained
on bedrest. His LFTs improved. He developed an ileus and an NG
tube was placed. He remained NPO on TPN. Pancreatitis and ilieus
improved and he tolerated a clear liquid diet. CVVH was dc'd and
he did not require HD. He awaited further recovery of liver and
renal function prior to surgery. He was transferred to the floor
on [**12-27**]. He was transfused for HCT 22. He was taken to the
operating room on [**12-29**] where he underwent a replacement of his
ascending aorta and hemiarch with a #28 gelwaeve graft. He was
transferred to the ICU in stable condition. He was started on
lasix and nitro drips. He was extubated on POD #2. He did not
require dialysis postop and his creatinine improved. He was
weaned from his nitro and lasix drips and his lopressor and
hydralazine were increased. TPN continued and his diet was
advanced. He was transferred to the floor on POD #4. He was seen
by physical therapy and will require rehab. He continued to
improve, and was ready for transfer to rehab on POD #6. He
remained in NSR and will not require telemetry. He will need
outpatient renal follow up.
Medications on Admission:
ASA 81', HCTZ 25', fosinopril 40', simvastatin 80' albuterol prn
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 25750**]
Discharge Diagnosis:
Type A Dissection
Acute renal failure
Shock liver
Coagulopathy
pancreatitis
ileus
PMH:^chol, HTN, DM, COPD, +EtOH
Discharge Condition:
Stable.
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 lifting more than 10 pounds for 10 weeks from surgery.
No driving until follow up with surgeon.
Followup Instructions:
Dr. [**Last Name (STitle) **] 4 weeks
[**Hospital 2793**] clinic after discharge from rehab
Cardiologist and PCP after discharge from rehab
Completed by:[**2147-1-4**]
|
[
"584.9",
"V11.3",
"428.0",
"285.9",
"250.00",
"577.0",
"560.1",
"274.9",
"441.01",
"998.11",
"287.5",
"410.41",
"272.0",
"424.1",
"496",
"286.9",
"570",
"420.99"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"38.45",
"50.11",
"39.61",
"99.06",
"39.95",
"99.04",
"38.95",
"99.15",
"99.07",
"99.05"
] |
icd9pcs
|
[
[
[]
]
] |
10315, 10363
|
7879, 9471
|
330, 389
|
10521, 10531
|
969, 969
|
10856, 11026
|
9587, 10292
|
2044, 2087
|
10384, 10500
|
9497, 9564
|
10555, 10833
|
794, 794
|
280, 292
|
2116, 7856
|
988, 1425
|
417, 727
|
1439, 2007
|
750, 779
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,700
| 140,444
|
14176
|
Discharge summary
|
report
|
Admission Date: [**2157-6-9**] Discharge Date: [**2157-6-30**]
Date of Birth: [**2157-6-9**] Sex: M
Service: NEONATOLOGY
HISTORY: Baby [**Name (NI) **] [**Known lastname 26581**] is a former 31 [**1-19**] week male,
born to a 34-year-old GII PI woman whose pregnancy was
complicated by prolonged rupture of membranes on [**6-7**].
Prenatal screens: O positive, antibody negative, rubella
negative, GBS unknown. The mother was afebrile at the time
of delivery, was ruptured for greater than 28 hours, received
greater than 34 hours of antibiotics.
Mother was transferred to [**Hospital1 188**] after evaluation at [**Hospital3 **] following rupture of
membranes. Was noted to have decelerations during Pitocin
The baby emerged vigorous, with [**Name (NI) **] of 8 and 8, required
blow-by oxygen, and received CPAP in the delivery room, and
was transferred to the Newborn Intensive Care Unit after
visiting briefly with his family.
PHYSICAL EXAMINATION: On admission, pink, active,
non-dysmorphic, well perfused, saturated in low FIO2 on
ventilator. Skin without lesions. Regular rate and rhythm,
S1, S2, without murmurs. Lung sounds coarse, with faint
breath sounds bilaterally. Abdomen benign, no
hepatosplenomegaly. Three vessel cord. Normal male
premature genitalia. Appropriate for gestational age
clavicles, and palate intact. Stable hips, straight spine,
no dimple.
HOSPITAL COURSE BY SYSTEM:
1. Respiratory: Baby received one dose of surfactant, and
then was extubated. Remained in room air, with no further
respiratory distress. He had an occasional apnea and
bradycardia. Did not require methylxanthine treatment, and
has been without apnea or bradycardia or desaturations for
greater than a week. His baseline respiratory rate is 40s to
60s, and has no further issues.
2. Cardiovascular: Baby has been cardiovascularly stable.
Initially had a soft systolic murmur, which had resolved but
recurred on the day of discharge. Characteristics were consistent
with peripheral pulmonic stenosis. Initial cardiac investigations
including electrocardiogram, chest radiograph, four-extremity
blood pressures and hyperoxia test, were normal on [**2157-6-30**].
Infant has been asymptomatic, with baseline heart rate of 130s to
160s, with blood pressure systolics in the 50s to 60s, diastolics
in the 30s, and means in the 40s. Plan for clinical observation
of murmur, with referral to cardiology if persistent.
3. Fluids, electrolytes and nutrition: The baby initially
received nothing by mouth, with peripheral intravenous,
maintenance intravenous fluids. Enteral feedings were
started on day of life one, and advanced to full enteral
feeds without difficulty. He did require some gavage feedings.
He was feeding premature Enfamil formula, was transitioned
over to Enfamil 20, and is all oral feedings, taking greater
than 140 cc/kg/day ad lib. He is voiding and stooling, and
had no enteral issues. His last set of electrolytes were
within normal limits, with a sodium of 137, potassium 6.7
hemolyzed, chloride 103, CO2 23. He is on supplemental iron
.2 cc by mouth once daily, which equals 2 mg/kg/day.
4. Gastrointestinal: The baby did not require any blood
products during this admission. Did exhibit physiologic
jaundice, had a peak bilirubin of 12.3/0.3 on day of life
three. Did not require phototherapy. Last bilirubin on day
of life six was 6.3/0.3.
5. Hematology: No issues. No blood products required.
6. Infectious Disease: Baby initially had a blood culture
and CBC drawn because of prolonged rupture of membranes and
prematurity. Had a white count of 11.5, with 34 polys, 8
bands, 52 lymphs, platelet count of 315,000, hematocrit of
46.8. He was started on 48 hours of ampicillin and
gentamicin. Cultures remained negative. The baby looked
clinically well, and antibiotics were discontinued. On day
of life five, his umbilicus was noted to be red, and he was
started on oxacillin and gentamicin for omphalitis. The
culture of the umbilicus was positive for gram-positive cocci
in pairs and clusters, and the blood culture also was
positive for what ultimately was identified as staphylococcus
epidermidis. He was treated for staphylococcus epidermidis
sepsis for seven days, which completed on day of life 12. He
had a lumbar puncture with white blood cell count of 12, 239
reds, protein of 126, glucose of 54. The baby has had no
further issues with infection.
7. Neurology: The baby had a head ultrasound done on day of
life eight, which was within normal limits for gestational
age, with no evidence of intraventricular hemorrhage.
Examination is within normal limits.
8. Sensory: Passed audiology screening. Ophthalmology:
Eye examination mature. Follow up recommended in one year.
9. Psychosocial: Parents have been visiting and look
forward to discharge home.
CONDITION AT DISCHARGE: Stable.
DISCHARGE DISPOSITION: Home with family.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 42184**], [**Hospital **]
Pediatrics, [**Telephone/Fax (1) 42185**].
CARE RECOMMENDATIONS:
1. Feedings: Continue ad lib feedings.
2. Medications: Fer-in-[**Male First Name (un) **] .2 cc by mouth once daily, which
equals 2 mg/kg/day.
3. Car seat positioning screening passed.
4. State newborn screen was done on [**6-14**] and [**6-23**], and one
will be done on the day of discharge. Results are pending.
5. Immunizations received: Hepatitis B vaccine on [**2157-6-24**].
6. Immunizations recommended: Synagis respiratory syncytial
virus prophylaxis should be considered from [**Month (only) 359**] through
[**Month (only) 547**] for infants who meet any of the following three
criteria: (1) Born at less than 32 weeks gestation; (2) Born
between 32 and 35 weeks, with plans for day care during
respiratory syncytial virus season, with a smoker in the
household, or with preschool siblings; or (3) With chronic
lung disease.
Influenza immunization should be considered annually in the
fall for pre-term infants with chronic lung disease once they
reach six months of age. Before this age, the family and
other care givers should be considered for immunization
against influenza to protect the infant.
7. Follow-up appointments:
a. With primary pediatrician per routine.
b. [**Company 1519**] will be following this family, telephone
number [**Telephone/Fax (1) 12065**].
DISCHARGE DIAGNOSIS:
1. Former 31 [**4-24**] week male
2. Status post rule out sepsis with antibiotics
3. Status post staphylococcus epidermidis omphalitis and
bacteremia
4. Status post apnea and bradycardia of prematurity
[**Doctor Last Name **] [**Last Name (NamePattern5) 36094**], M.D. [**MD Number(1) 36095**]
Dictated By:[**Last Name (NamePattern1) 36144**]
MEDQUIST36
D: [**2157-6-30**] 00:19
T: [**2157-6-30**] 01:16
JOB#: [**Job Number 36960**]
|
[
"763.82",
"769",
"038.19",
"771.8",
"776.6",
"770.8",
"765.18",
"686.9",
"V30.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"64.0",
"96.04",
"93.90",
"96.71",
"96.6",
"03.31",
"99.55"
] |
icd9pcs
|
[
[
[]
]
] |
4925, 5111
|
6453, 6931
|
5133, 5528
|
1436, 4877
|
6286, 6432
|
981, 1409
|
4892, 4901
|
5556, 6262
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,040
| 118,695
|
7927
|
Discharge summary
|
report
|
Admission Date: [**2128-8-11**] Discharge Date: [**2128-8-19**]
Date of Birth: [**2070-2-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
CABGx4
History of Present Illness:
58 M c h/o hyperchol, and who has had CP and left arm pain for
few weeks. Had +ETT at OSH and transfered to [**Hospital1 18**] for cardiac
cath on [**8-9**]. Cath showed severe 3VD and he was d/c home for
CABG schedule for [**2128-8-17**]. On [**2128-8-11**] he developed
intermittent L sided chest pain lasting minutes at a time while
at rest. Not associated with diaphoresis or dyspnea. No radiaton
to neck or arms. He went to OSH and started on heparin gtt. He
was transferred to [**Hospital1 18**] for CABG.
Past Medical History:
1. Hyperlipidemia
2. HTN
3. Anxiety
4. CAD -cath [**2128-8-10**]: 3VD
LMCA: mild diffuse dz
LAD: 95% mid lesion; distal R-L collaterals via acute marginal
LCX: 80% prox; OM1 60%
RCA: 80% distal; acute marginal 80% lesion
LVgram: EF 50% with anteriolateral HK
5. s/p appy
6. s/p hernia hydrocele repair
7. s/p anal fissure surgery
Social History:
Attorney, also works in real estate and writes tour books
related to national [**Doctor Last Name **]. Lives alone. Non smoker.
Family History:
Mother had AF, PM, silent MI in later years.
Father had several CVA's.
Physical Exam:
139/61 79 20 97%(2L)
Gen: NAD, comfortable, lying in bed flat
HEENT: o/p clear, mmm, eomi
Neck: jvd @ 7 cm; no carotid bruits
CV: rrr, no m/r/g
PULM: cta b/l
Abd: soft, nt, nd; no cva tenderness
EXT: +2 carotid, radial, femoral and d.pedis pulses b/l; mild
eccymosis at Right groin sight; no femoral bruits
NEURO: CN II-XII intact, moves all 4 ext
Pertinent Results:
EKG: NSR @ 65, N axis, no hypertrophy, IVCD (Right bundle
pattern); TWI in III, aVF
[**2128-8-10**] 11:00AM BLOOD WBC-6.7 RBC-4.47* Hgb-14.4 Hct-38.0*
MCV-85 MCH-32.3* MCHC-38.0* RDW-12.4 Plt Ct-234
[**2128-8-10**] 11:00AM BLOOD Neuts-76.3* Lymphs-19.9 Monos-2.8 Eos-0.4
Baso-0.6
[**2128-8-10**] 11:00AM BLOOD PT-13.3 PTT-28.3 INR(PT)-1.2
[**2128-8-10**] 11:00AM BLOOD Plt Ct-234
[**2128-8-10**] 11:00AM BLOOD Glucose-125* UreaN-12 Creat-0.8 Na-138
K-3.6 Cl-104 HCO3-24 AnGap-14
[**2128-8-10**] 11:00AM BLOOD ALT-17 AST-16 CK(CPK)-62 AlkPhos-75
Amylase-22 TotBili-2.1*
[**2128-8-10**] 11:00AM BLOOD Albumin-4.2
[**2128-8-10**] 11:00AM BLOOD %HbA1c-4.9 [Hgb]-DONE [A1c]-DONE
Brief Hospital Course:
The patient was admitted to the hospital and taken to the
operating room on [**2128-8-13**], where he underwent a CABGx4. Please
see operative note for full details. The patient tolerated this
procedure well. He was taken to the CSRU immediately
post-operatively and was extubated that night. The following
day, the patient did well and was transferred to the floor. On
the night of post-op day #2, the patient became acutely confused
and agitated. He was sedated and seen the following day by the
neurologic and psychiatric services. It was felt at the time
that this acute confusion was most likely due to a combination
of narcotics and anxiety stemming from hospitalization rather
than oxygen desaturation. The patient was transferred back to
the CSRU for monitoring and was found to be mentating well
throughout the remainder of his hospital stay. The patient was
transferred back to the floor on post-op day #4. He was
ambulated and cleared by the physical therapy service. He was
discharged home on post-op day #6 in stable condition.
Medications on Admission:
1. ASA 325 PO Qday
2. Lopressor 25 mg PO BID
3. Lipitor 10 mg PO Qday
4. Ativan 0.5 mg PO TID prn
*
had indigestion with captopril
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
10 days.
Disp:*10 Tablet(s)* Refills:*0*
2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO once a day for 10 days.
Disp:*20 Capsule, Sustained Release(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 Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
All Care VNA
Discharge Diagnosis:
Coronary artery disease
Hypertension
Hypercholesterolemia
Anxiety disorder
Discharge Condition:
Stable
Discharge Instructions:
Please return tot he hospital or call Dr. [**Last Name (STitle) **] office of you
experience chills or fever greater than 101 degrees F. Please
call if you notice redness, swelling, or tenderness of your
chest wound, or if it begins to drain pus.
No heavy lifting or driving until follow up with Dr. [**Last Name (STitle) **].
You may shower. Wash incision with mild soap and waten, then pat
dry.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 170**] Follow-up appointment
should be in 1 month
Please follow up with your primary care physician [**Name Initial (PRE) **]/or
cardiologist in 2 weeks time.
|
[
"401.9",
"272.0",
"414.01",
"293.0",
"300.00",
"411.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.13",
"99.04",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
4467, 4510
|
2556, 3598
|
332, 341
|
4629, 4638
|
1857, 2533
|
5085, 5356
|
1399, 1471
|
3779, 4444
|
4531, 4608
|
3624, 3756
|
4662, 5062
|
1486, 1838
|
282, 294
|
371, 885
|
907, 1238
|
1254, 1383
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,736
| 180,021
|
6127
|
Discharge summary
|
report
|
Admission Date: [**2190-4-4**] Discharge Date: [**2190-4-30**]
Date of Birth: [**2115-6-2**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Post-op Bleed
Dyspnea
Major Surgical or Invasive Procedure:
Right Thoracentesis
Right Thoracostomy Tube
Right VATS with decortication and drainage
Trach/PEG
Bronchoscopy
History of Present Illness:
This is a 74 year old male s/p Lap appy by Dr [**Last Name (STitle) **] 8 days a
go at the
[**Last Name (un) 4068**]. He was discharged home pod #2 with an INR of 1.2 at
discharge. His preop HCT was 36.6 and decreased to 30.2
immediately post op and to 27 just before discharge. He was
transferred form the [**Hospital1 18**] [**Location (un) 620**] with
shortness of breath and vomiting x1. INR measured at the [**Last Name (un) 4068**]
was 10 and HCT 16. He was sent to [**Hospital1 18**] for further management.
He received 3 units FFP, 10 mg Vit K IV, 1 U PRBC.
Past Medical History:
1. Hypertension. 2. Placement of DDD pacemaker secondary to AV
block 3. Left ventricular Hypertrophy 4. CHF EF 50% last echo
[**2184**]
PSH:
[**5-18**] Replacement of the arch ascending aorta and aortic valve
with a valve conduit composite using a [**Street Address(2) 11688**]. [**Male First Name (un) 923**] mechanical
prosthesis and a separate piece of 25 mm weave tube graft
with profound hypothermia and circulatory arrest, and direct
reimplantation of the coronary ostia.
Lap appy [**3-24**]
Social History:
The patient quit smoking 40 years ago.
Married
Physical Exam:
97.3 80 147/68 28 98 2 l NC
Appearance: tachypneic, diaphoretic, uncomfortable
Lungs deceased r side coarse left side
Heart RRR
ABD soft in the left side tense on the Right side. No rebound
rectal No blood guaiac neg
Ext no edema
Pertinent Results:
CTA ABD W&W/O C & RECONS [**2190-4-4**] 1:00 PM
IMPRESSION:
1. There is a 7.3 cm x 7.5 cm contained hematoma within the
surgical bed of recent appendectomy, just inferior to the suture
line. There is a hematocrit effect indicating recent bleed
without evidence of active extravasation.
2. Moderate amount of high density free fluid within the abdomen
and pelvis, suggesting intra-peritoneal extension of the bleed
into the abdomen and pelvis.
3. Airspace opacity within the lingula consistent with pneumonia
or atelectasis.
4. Small right pleural effusion with associated relaxation
atelectasis.
5. Multiple compression fractures within the spine with
post-vertebroplasty changes at L1, L3, and L5. These fractures
are old and no evidence of acute fracture is identified.
.
Cardiology Report ECG Study Date of [**2190-4-4**] 12:07:18 PM
Atrial fibrillation
Ventricular paced beat
Nonspecific ST-T abnormalities
Since previous tracing of [**2187-7-26**], atrial fibrillation now
present
Intervals Axes
Rate PR QRS QT/QTc P QRS T
73 0 88 400/425.57 0 34 -50
.
CT CHEST W/CONTRAST [**2190-4-5**] 2:24 PM
IMPRESSION:
1. Simple-appearing right pleural effusion with adjacent
atelectasis, without evidence of hemorrhage or enhancement.
2. Persistent hemorrhagic ascites around the liver and spleen.
3. Hypodensities within the kidneys seen bilaterally, better
characterized on the prior multiphasic study from [**2190-4-4**].
.
CHEST (PORTABLE AP) [**2190-4-6**] 8:36 AM
CONCLUSION: Relatively stable appearance as compared to
yesterday. No pneumothorax.
.
CHEST (PORTABLE AP) [**2190-4-14**] 3:19 PM
IMPRESSION: Increased right pleural effusion and adjacent
opacity representing atelectasis and/or consolidation. Interval
increase in the left retrocardiac opacity and left pleural
effusion as well.
.
CHEST (PORTABLE AP) [**2190-4-16**] 9:48 AM
SINGLE AP PORTABLE VIEW OF THE CHEST: When compared to prior
study performed the day before, there has been mild interval
increase in moderate right pleural effusion and associated right
lower lobe atelectasis. Three right chest tubes remain in place.
There has been interval improvement with better aeration of the
left lower lobe. There is no pneumothorax. Cardiomediastinal
contour is unchanged with right cardiac border obscured by
pleural and lung abnormalities. Pacemaker leads in unchanged
position. NG tube tip is in the stomach.
.
CHEST (PORTABLE AP) [**2190-4-21**] 5:45 PM
IMPRESSION:
1. Probable small increase in size of right-sided pleural
effusion with increased right lower lobe
atelectasis/consolidation.
2. Stable appearance to retrocardiac opacity and lines and
tubes.
3. Small left apical lucency is likely related to technical
artifact from lordotic view with pneumothorax felt unlikely.
This may be reevaluated on followup radiographs. If there is
clinical concern, a repeat radiograph may be obtained sooner.
Dr. [**First Name (STitle) **] was paged at approximately 6:30 to discuss these
findings.
.
CT CHEST W/O CONTRAST [**2190-4-23**] 1:30 PM
IMPRESSION:
1) Previously seen right loculated effusion. This has been
evacuated, and there are tiny bilateral pleural effusions
present. Consolidation in the right lower lobe has progressed as
has the consolidation in the left lower lobe.
2) Right upper extremity fat containing mass inadequately
assessed on this study.
.
CHEST (PORTABLE AP) [**2190-4-26**] 9:59 PM
IMPRESSION: AP chest compared to [**4-20**] through 5:
Mild pulmonary edema has worsened and small bilateral pleural
effusions, right greater than left, have increased since [**4-22**]. Heart size top normal. No pneumothorax. New tracheostomy tube
abuts the lateral wall of the trachea and should be evaluated
clinically. Tip of a right jugular line projects over the
superior cavoatrial junction. Patient has had median sternotomy
and at least a mitral valve replacement. Transvenous right
atrial and right ventricular pacer leads are continuous from the
left axillary pacemaker and unchanged. No pneumothorax.
.
CHEST (PORTABLE AP) [**2190-4-29**] 8:58 AM
INDICATION: Status post right-sided VATS procedure.
AP single view of the chest has been obtained with patient in
semi-upright position, and analysis is performed in direct
comparison with a similar study dated [**2190-4-27**]. Status
post sternotomy and aortic valve replacement as before.
Permanent pacer with dual electrode system in unchanged
position. Tracheostomy cannula in place. Pulmonary vasculature
with bilateral considerable perivascular haze and diffuse
densities on the bases consistent with bilateral pleural
effusions. No significant interval change is identified during
the recent examination interval [**4-27**] through [**4-29**].
.
Brief Hospital Course:
He was admitted on [**2190-4-4**] and he was transfused 3 FFP and 1
unit PRBC, and 10mg Vit K.
Resp: On CT, he was noted to have right sided pleural effusion
with associated relaxation atelectasis. On [**4-5**], he had a
increasing moderate size pleural effusion and he had a US guided
tap for ~400cc fluid. He received Lasix for the effusion with
good effect.
Thoracic Surgery then placed a CT on the right side for the
effusion. He received TPA x 3 on three consecutive days. A
repeat CT on [**2190-4-9**] showed Right basal chest tube in place,
with overall decrease in amount of right pleural fluid, with
small loculated component along the right major fissure. Also,
interval increase in size of small left pleural effusion.
He was transferred to the ICU for respiratory distress on and
was eventually intubated.
Due to the persistent effusion and repeated taps and tPA of the
chest tubes on the right side, the Thoracic team took him to the
OR on [**2190-4-14**] for a VATS. He had a Right-sided pneumonia and
right
complex parapneumonic effusion. Right vats decortication,
pleural biopsy and
flexible bronchoscopy.
He was managed by the Thoracic Surgery Service in regards to the
chest tubes.
On [**2190-4-20**] he had a Flexible bronchoscopy for Respiratory
failure, ventilator-
associated pneumonia, and moderate-to-severe tracheal
bronchomalacia.
He was extubated on [**2190-4-22**], but was unable to tolerate for any
extended time. He had to be re-intubated.
On [**2190-4-26**], he had a Trach/PEG placed. He contiued to need good
respiratory care due to thick secretions.
He continued on Lasix PRN for diuresis and was kept at a
negative fluid balance to improve his pulmonary status. The
trach was in place and he intermittently needed some ventilatory
support.
.
.
HEME: s/p transfusion his HCT was stable in the low 20's and
continued to increased slowly over the next few days. His INR
corrected. He was eventually restarted on Heparin and Coumadin
for his mechanical valve. He was switched over from Heparin to
Lovenox.
ID: He was started on Levaquin for evidence of pneumonia. He
will need one more week of Linezolid for MRSA pneumonia.
CV: He was in A-flutter, rate controlled. He received Lopressor
5mg IV PRN. He was then started on a Amiodorone gtt per the
cardiologist. He will continue on Amiodorone and Lopressor. He
is V-paced.
FEN: Continue on Tube feedings.
Medications on Admission:
Coumadin 7.5/5.0, Lopressor 25", Fentanyl patch, ASA 81 Cozaar
100' Colace 100', Norvasc 10'
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution [**Date Range **]: Sliding Scale
Injection ASDIR (AS DIRECTED).
2. Amiodarone 200 mg Tablet [**Date Range **]: Two (2) Tablet PO DAILY
(Daily).
3. Sertraline 50 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily).
4. Docusate Sodium 50 mg/5 mL Liquid [**Date Range **]: [**1-19**] PO BID (2 times a
day).
5. Bisacodyl 10 mg Suppository [**Month/Day (2) **]: One (1) Suppository Rectal
DAILY (Daily) as needed for for no BM.
6. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Month/Day (2) **]: Six (6)
Puff Inhalation Q4H (every 4 hours).
7. Albuterol 90 mcg/Actuation Aerosol [**Month/Day (2) **]: Six (6) Puff
Inhalation Q4H (every 4 hours).
8. Albuterol Sulfate 0.083 % Solution [**Month/Day (2) **]: One (1) Inhalation
Q6H (every 6 hours) as needed.
9. Ipratropium Bromide 0.02 % Solution [**Month/Day (2) **]: One (1) Inhalation
Q6H (every 6 hours).
10. Acetaminophen 160 mg/5 mL Solution [**Month/Day (2) **]: [**11-6**] ml PO Q4-6H
(every 4 to 6 hours) as needed.
11. Oxycodone 5 mg/5 mL Solution [**Month/Year (2) **]: One (1) PO Q4H (every 4
hours) as needed for pain.
12. Linezolid 600 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO Q12H (every
12 hours) for 1 weeks: MRSA Pneumonia.
13. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
14. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID
(2 times a day): hold for SBP<100 or HR <60 .
15. Olanzapine 5 mg Tablet, Rapid Dissolve [**Last Name (STitle) **]: One (1) Tablet,
Rapid Dissolve PO BID (2 times a day).
16. Haloperidol 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times
a day) as needed.
17. Warfarin 3 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day for 1
doses: Adjust according to INR and dose daily.
Check INR daily.
18. Enoxaparin 80 mg/0.8 mL Syringe [**Last Name (STitle) **]: One (1) Subcutaneous
Q12H (every 12 hours).
19. Furosemide 10 mg/mL Solution [**Last Name (STitle) **]: Two (2) Injection TID (3
times a day) for 1 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
Intraperitoneal Bleed
Right Pleural Effusion
Elevated INR
Blood Loss Anemia
Ventilator Dependent Respiratory failure. Trach/PEG [**2190-4-26**]
Pneumonia
Tracheobronchomalacia
Discharge Condition:
Fair
Discharge Instructions:
* Increasing pain
* Fever (>101.5 F)
* Persistent vomiting
* Inability to pass gas or stool
* Increasing shortness of breath
* Chest pain
.
Take any new meds as ordered.
.
Continue to ambulate several times per day.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in [**2-20**] weeks. Call ([**Telephone/Fax (1) 15807**] to schedule an appointment.
Please follow-up with Cardiology in [**2-20**] weeks.
Completed by:[**2190-4-30**]
|
[
"519.19",
"V43.3",
"510.9",
"511.8",
"790.92",
"427.31",
"V09.0",
"V45.01",
"428.0",
"482.41",
"285.1",
"568.81",
"998.11",
"203.01",
"518.5",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"96.6",
"34.04",
"96.05",
"34.51",
"43.11",
"33.22",
"99.10",
"96.04",
"31.1",
"34.91",
"33.24",
"96.72",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
11332, 11397
|
6625, 9023
|
333, 445
|
11616, 11622
|
1895, 6602
|
11887, 12108
|
9166, 11309
|
11418, 11595
|
9049, 9143
|
11646, 11864
|
1642, 1876
|
272, 295
|
473, 1041
|
1063, 1563
|
1579, 1627
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,272
| 135,341
|
13431
|
Discharge summary
|
report
|
Admission Date: [**2170-7-3**] Discharge Date: [**2170-7-6**]
Date of Birth: [**2099-7-12**] Sex: F
Service: NSU
HISTORY OF PRESENT ILLNESS: The patient is a 70-year-old
female admitted for elective coiling of left internal carotid
artery.
PAST MEDICAL HISTORY: The patient has history of coronary
artery disease.
History of MI.
Hypertension.
Dyspnea.
The patient experiences chest burning with ascending one
flight of stairs.
SURGICAL HISTORY: The patient had coronary angioplasty in
[**2153**] and [**2159**].
She had a right knee arthroscopy.
The patient has also undergone left internal carotid
endarterectomy and right carotid endarterectomy in recent
history.
MEDICATIONS:
1. The patient is taking atenolol 50 mg.
2. Lisinopril 20 mg q.d.
3. Ativan p.m.
4. Imodium p.r.n.
5. Protonix q.d.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is a former smoker, she quit
smoking in [**2153**]. She admits to occasional alcohol use,
denies recreational drug use.
HOSPITAL COURSE: The patient was admitted on [**2170-7-3**] for
elective angiography with left internal carotid artery
coiling. The patient was taken to the OR and coiled without
complications. She was released to the PACU in stable
condition. Blood loss was minimal. The patient was admitted
to the trauma SICU following elective coiling. Aneurysm was
found one month ago with an MRA evaluation pre-carotid
surgery.
PHYSICAL EXAMINATION: She was alert and oriented x 3. She
moved all extremities x 4. Strength was good bilaterally.
Smile was symmetrical. Tongue was midline. Her speech was
clear. Peripheral pulses of lower extremity were weakly
palpable, radial pulses palpable with ease. Lungs sounds
were clear. No respiratory distress noted. She was kept on
heparin at 450 units per hour, checking _______ q.6h. Her
hematocrit was 24 postprocedure. She was transfused with 2
units packed red blood cells with a.m. labs pending. The
plan was to decrease her PTT and remove the right groin
sheath. On [**2170-7-5**], the patient developed complaint of
chest pain. Cardiology was consulted and EKG showed inferior
lateral wall changes. Her blood pressure was less than 150.
Sheath was removed, chest x-ray was ordered and she was due
to have an echo in the a.m. Her EKG in the morning showed
that inferior lateral wall changes were resolving. Her
temperature was 99.1, blood pressure was 125/48, heart rate
was 74, respiratory rate was 17, and SPO2 was 98 percent.
Her ABG showed a pCO2 of 36.
LABORATORY DATA: Her labs at that time, her white blood cell
count was 7.1, hematocrit was 33.5, and platelets of 180.
Sodium was 135, potassium of 3.6, BUN 15, creatinine 1. Her
PT was 13.3, PTT 58.3, and INR of 1.1. It was decided at
this time that she should be ruled out for a postprocedure MI
and cardiac enzymes were drawn.
At this time, she was awake and alert without chest pain on
the morning of [**2170-7-5**]. Extraocular movements were full.
Her pupils were 4 to 3 bilaterally and brisk. Her IPs were
[**3-21**]. She had no hematoma palpable, pulses were intact.
Recommendations: At this time, it was okay to stop the
heparin if okayed by Cardiology. Continue on aspirin and
Plavix. Cardiology recommendations at this time; they want
to keep her blood pressure under 130 and up her atenolol dose
to 75 mg p.o. q.d. All her enzymes were negative and she was
transferred to the floor the following day. They recommended
that we consider nuclear stress test if enzymes negative in
the morning. If third set are negative, she may go to the
floor. On [**2170-7-6**], the patient was without complaints. All
vital signs were stable, full extraocular movements. The
patient was alert and oriented x 3. She had no hematoma in
the groin. The patient was stable. Nuclear stress test is
ordered and she can be discharged to home. The patient is
discharged on [**2170-7-6**].
CONDITION ON DISCHARGE: Stable.
DISCHARGE INSTRUCTIONS: Please immediately call the office
if you experience mental status changes, weakness, numbness
or slurred speech. No heavy lifting or strenuous activity
until follow-up in 2 weeks. Follow up with primary care
physician to schedule [**Name Initial (PRE) **] nuclear stress test for cardiac
catheterization to address cardiac issues.
FINAL DIAGNOSES: Status post left internal carotid artery
coiling on [**2170-7-4**].
RECOMMENDED FOLLOW UP: Follow up with Dr. [**Last Name (STitle) 1132**] on [**2170-8-19**]
at 3:00 p.m. Follow up with primary care physician regarding
stress test versus cardiac catheterization regarding cardiac
issues.
MAJOR SURGICAL INTERVENTION: Left internal carotid artery
coiling.
DISCHARGE CONDITION: Neurologically stable, tolerating p.o.
diet and ambulating.
DISCHARGE MEDICATIONS: The patient is discharged with the
following medications:
Aspirin 325 mg tablet, 1 tablet p.o. q.d., continue aspirin
325 mg for 7 days and then switch to 81 per day. Aspirin 81
mg tablet, 1 tablet p.o. q.d., dispense 60. Atenolol 15 mg
tablet, 1.5 tablets p.o. once a day.
[**Name6 (MD) **] [**Last Name (NamePattern4) 1359**], [**MD Number(1) 1360**]
Dictated By:[**Last Name (NamePattern1) 34587**]
MEDQUIST36
D: [**2170-7-6**] 14:32:22
T: [**2170-7-6**] 17:57:45
Job#: [**Job Number **]
|
[
"276.1",
"414.01",
"437.3",
"786.59",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.50",
"39.72"
] |
icd9pcs
|
[
[
[]
]
] |
4734, 4795
|
4819, 5343
|
1037, 1443
|
3997, 4332
|
4350, 4431
|
4443, 4712
|
1466, 3938
|
163, 263
|
286, 868
|
885, 1019
|
3963, 3972
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,482
| 191,442
|
20322
|
Discharge summary
|
report
|
Admission Date: [**2155-7-8**] Discharge Date: [**2155-7-8**]
Date of Birth: [**2121-11-4**] Sex: F
Service: MEDICINE
Allergies:
Reglan
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
SOB and leg swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
33F with hypothyroidism, h/o obesity now s/p bypass causing
anemia requiring IV iron Q3months, and h/o SVT in the past
presents with SOB and leg swelling. In [**Month (only) 205**] was started on Lasix
in [**State 33174**] for ankle&leg edema (LENI negative at the time).
Came home from a trip to [**Country 14635**] 3 days ago; while there her Lasix
dose was increased.
When she woke up today, she planned to work out which she does
daily, and walked in one circle to warm up then suddenly felt
SOB with SSCP. + Lightheaded. No palpitations. Called PCP who
said to go to ED.
.
In the ED, initial VS were as follows: 97.7 110 123/58 18 100%
on room air. Patient was noted to be in NAD but was panting when
speaking, complaints of significant dyspnea when lying flat.
Tachycardic on exam with clear lungs. She was noted to have
nonpitting edema bilaterally to the shins. Hematocrit was noted
to be 31 with microcytosis. Chem panel showed bicarb 20 with
anion gap 14. D-dimer was 491, within normal limits. Initial
trop negative. BNP 84. She was given a dose of aspirin 325mg
daily. Orthostatic on exam, sitting BP 125/85 HR 100, standing
BP 104/75 HR 110. She was not given a bolus of IVF as initially
planned because she felt very short of breath when it started.
EKG showed nonspecific T wave flattening, no signs of right
heart strain. CXR showed no acute process. Bilateral LENIs
showed no DVT. ABG showed respiratory alkalosis. Bedside echo
showed small amount of pericardial fluid. Pulsus paradoxus was
measured to be 6. Bedside TTE by cardiology was suboptimal
study, showed no pericardial effusion, appeared to show normal
RV function, preserved EF. Heparin gtt was started empirically.
CT-A was not done b/c pt was symptomatically very short of
breath when lying flat. Transferred to the MICU for further
mgmt.
.
On the floor, the patient appears stable with vitals 97.0 111/59
69 100%RA.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain, chest pressure, palpitations, or
weakness. Denies nausea, vomiting, diarrhea, constipation,
abdominal pain, or changes in bowel habits. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
hypothyroidism
class III obesity
h/o SVT which resolved after bypass
h/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] in the past, resolved per patient
h/o pregnancy-related cardiomyopathy
h/o leukemia
--s/p bypass
--says she had "3 small MI's because of obesity"
---iron deficiency anemia
Social History:
The patient reports a h/o home break-in and has anxiety
surrounding this experience and reports being unable to spend a
night in the hospital. Smokes 3 cigarettes daily.
Family History:
Non-contributory
Physical Exam:
Vitals: T: 97.0 BP: 111/59 P: 69 R: 20 O2: 100%RA
General: Alert, oriented, some destress [**1-15**] anxiety
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Labs:
[**2155-7-8**] 07:50AM BLOOD WBC-6.5 RBC-4.28# Hgb-9.1* Hct-30.8*#
MCV-72*# MCH-21.3*# MCHC-29.6*# RDW-16.3* Plt Ct-265#
[**2155-7-8**] 07:50AM BLOOD Glucose-142* UreaN-11 Creat-0.8 Na-142
K-3.6 Cl-108 HCO3-20* AnGap-18
[**2155-7-8**] 02:52PM BLOOD CK-MB-2 cTropnT-<0.01
[**2155-7-8**] 07:50AM BLOOD cTropnT-<0.01
[**2155-7-8**] 02:52PM BLOOD CK(CPK)-57
[**2155-7-8**] 07:50AM BLOOD CK(CPK)-67
[**2155-7-8**] 09:47AM BLOOD Type-ART pO2-201* pCO2-28* pH-7.52*
calTCO2-24 Base XS-1 Comment-GREEN TOP
Studies:
CTA Chest [**7-8**]-No pulmonary embolism. Mild bibasilar
atelectasis.
ECHO [**7-8**]-The left ventricular cavity size is normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size is
probably normal (views suboptimal) with normal free wall
contractility. The mitral valve leaflets are structurally
normal. There is no pericardial effusion.
LE Dopplers-No bilateral lower extremity DVT.
CXR-IMPRESSION: No pneumonia, effusion, or edema.
EKG: Nonspecific T wave flattening, no signs of right heart
strain
Brief Hospital Course:
Ms. [**Known lastname 7168**] is a 33 y/o female with PMH of hypothyroidism,
obesity now s/p bypass causing anemia requiring IV iron, and h/o
SVT in the past who presents with SOB and leg swelling likely
secondary to anxiety. Left MICU AMA.
# Dyspnea
The patient presented with leg swelling, SOB and a history of
recent travel and smoking. Concern was initially for PE. DDimer
and LENIs were negative in the ED. Sturating well on RA with HR
in the 70s. TTE was suboptimal but did not show RV strain.
Could not lie flat initially for CTA. CE cycled and were
negative. Given high index of suspicion from history, the
patient was started on heparin gtt and transferred to the MICU.
In the MICU, the patient immediatly reported near complete
resolution of her respiratory symptoms. She was able to lie
flat and a CTA was performed. Prelim read was no PE. A bedside
US did not show evidence of pericarditis/effusion. The patient
subsequently signed out AMA. Source of dyspnea is not
completely clear at the time of discharge; echo, EKG, cardiac
enzymes, and CTA have excluded the major immediately
life-threatening causes. Anxiety, esophageal disorders, and
other items remain in the differential. Symptoms had resolved by
the time of discharge.
# AMA:
Patient reported that she was feeling better and was expressing
significant anxiety about not spending the night in her home.
She reported a past experience as the source of these strong
emotions. It was explained to her that no definitive diagnosis
of her dyspnea had been made at the time of her leaving AMA and
that it would be in her best medical interest for her to stay in
the hospital while the evaluation was continuing. She was made
aware of the risks of leaving the hospital without a formal
diagnosis, including injuring, worsening symptoms, and possibly
even death. The patient verbalized her understanding of these
risks and appeared to have capacity to make independent
decisions about her care. She was therefore discharged against
medical advice.
# Anemia
The patient has a h/o iron deficiency anemia. Hemoglobin on
admission is 9.1 which is at or exceeds her baseline. No active
issues.
# Hypothyroidism
H/o of hypothyroidism and on home levothyroxine which was
continued. TSh sent and is pending.
Medications on Admission:
Lasix 40QAM, 20Qnoon, 40QPM
KlorCon 20mEq daily
Levoxyl 125mcg daily
iron IV (missed her last dose which was due 3 months ago)
prenatal vitamin
Discharge Medications:
Lasix 40QAM, 20Qnoon, 40QPM
KlorCon 20mEq daily
Levoxyl 125mcg daily
iron IV (missed her last dose which was due 3 months ago)
prenatal vitamin
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Shortness of Breath
Discharge Condition:
Mental Status: Clear and coherent but very anxious.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 7168**],
You were admitted to the intensive care unit at [**Hospital1 **] because you were having a lot of shortness of breath.
By the time you arrived in the ICU, you felt much improved, but
you were still having some symptoms. You had multiple studies
done, including a CT scan of your chest which preliminarily
showed no blood clots.
You expressed your desire to leave the hospital right away and
have chosen to leave AGAINST MEDICAL ADVICE. The risks of doing
so were explained to you, including a worsening of your
symptoms, further injury, and possbily death. You said that you
understand these risks. Please call 911 or return to the
hospital if your symptoms worsen, if you have more difficulty
breathing, chest pain, palpitations, or any other concerning
symptoms.
Followup Instructions:
Please be sure to follow up with your primary care doctor this
week.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
Completed by:[**2155-7-9**]
|
[
"244.9",
"280.9",
"300.00",
"305.1",
"412",
"786.05",
"V45.86"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7613, 7619
|
4963, 7249
|
287, 294
|
7702, 7702
|
3776, 4940
|
8700, 8928
|
3193, 3211
|
7444, 7590
|
7640, 7640
|
7275, 7421
|
7870, 8677
|
3226, 3757
|
2259, 2659
|
226, 249
|
322, 2240
|
7659, 7681
|
7717, 7846
|
2681, 2989
|
3005, 3177
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,469
| 162,357
|
48751+59113
|
Discharge summary
|
report+addendum
|
Admission Date: [**2132-2-2**] Discharge Date: [**2132-2-21**]
Date of Birth: [**2051-4-8**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Cough, SOB.
Major Surgical or Invasive Procedure:
Bubble study
S/P intubation for hypercarbic resp failure
History of Present Illness:
This is an 80 y/o M w/COPD, DM, hyperlipidemia who presents with
cough x 2 days. He noted a nonproductive cough as well as fevers
at home to 102 (although pt currently denies this). He denies
any chest pain or shortness of breath. He has noticed polyuria
and polydipsia. Mild rhinorrhea, no sore throat. Denies all
other complaints. Does not check his fingersticks at home.
In the ED, he was slightly febrile and tachycardic. He was
empirically started on steroid therapy, and Levofloxacin, as
well as nebs. He was also hyperglycemic to the mid 300s and was
given insulin. He was admitted to medicine.
Past Medical History:
1. Type 2 DM: on glucophage and possibly avandia (pt knows he is
on medicine that starts with an "a")
2. Hypercholesterolemia: had been on vytorin but felt badly on
this medicine (but was on avandia at the same time so unclr what
is causing adverse rxn)
3. COPD - never been intubated. baseline bicarb 32
4. Prostate Ca s/p XRT
5. Radiation cystitis
6. stage 2 transitional cell Ca of bladder
7. RBBB, hx atrial ectopy
Social History:
Lives with his wife, homes in [**Name (NI) 108**] and here in [**Name (NI) 745**]. smoked
up to 3 ppd x 52 years, quit in [**2113**]. rare EtOH. used to work in
advertising, then ran architectural lighting firm.
Family History:
Father died of MI at 77 y/o, numerous other family members with
CAD.
Physical Exam:
PE: T: 97 P: 82 SR BP: 118/72 R: 18 98% 40% face mask
Gen: alert and oriented pleasant male in NAD, very hard of
hearing
Neck: JVD not elevated.
Lungs: decreased air movement, rare wheezes. no egophony.
hyperresonant to percussion throughout. prolonged expiratory
phase.
CV: distant heart sounds, regular rate and rhythym, no m/r/g
Abd: soft, nontender, nondistended. NABS.
Ext: trace pedal edema bilaterally
Pertinent Results:
Relevant laboratory data on admission:
[**2132-2-1**] 11:00PM BLOOD WBC-8.0 RBC-4.66 Hgb-13.9* Hct-40.5
MCV-87 MCH-29.9 MCHC-34.4 RDW-13.3 Plt Ct-123*
[**2132-2-1**] 11:00PM BLOOD Neuts-90.9* Lymphs-5.0* Monos-3.5 Eos-0.3
Baso-0.3
[**2132-2-1**] 11:00PM BLOOD PT-12.4 PTT-22.3 INR(PT)-1.1
[**2132-2-1**] 11:00PM BLOOD Plt Ct-123*
[**2132-2-1**] 11:00PM BLOOD Glucose-349* UreaN-19 Creat-1.1 Na-139
K-4.1 Cl-97 HCO3-30 AnGap-16
[**2132-2-1**] 11:00PM BLOOD CK(CPK)-34*
[**2132-2-3**] 06:15AM BLOOD ALT-24 AST-34 AlkPhos-79 TotBili-0.6
[**2132-2-1**] 11:00PM BLOOD cTropnT-<0.01
[**2132-2-4**] 07:20AM BLOOD proBNP-558
[**2132-2-5**] 07:40AM BLOOD CK-MB-7 cTropnT-<0.01
[**2132-2-8**] 02:48AM BLOOD CK-MB-5 cTropnT-<0.01
[**2132-2-1**] 11:00PM BLOOD Theophy-2.4*
CXR [**2132-2-1**]: No acute cardiopulmonary process.
ECG [**2132-2-1**]: Sinus arrhythmia. Incomplete right bundle-branch
block. Since the previous tracing of [**2129-4-27**] no significant
change.
Echo [**2132-2-5**]: The left atrium is normal in size. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
are mildly thickened. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is an
anterior space which most likely represents a fat pad, though a
loculated anterior pericardial effusion cannot be excluded.
CT chest [**2132-2-7**]: 1. No evidence of pulmonary embolism. 2.
Disproportionate enlargement of the left pulmonary artery
compared to the main and right pulmonary arteries, as shown on
the prior chest radiograph. While no pulmonary embolism is seen,
this finding may be also be seen more chronically in the setting
of pulmonary artery stenosis and pulmonart artery hypertension
may be [**Last Name (un) **] chronic lung disease. 3. Moderate centrilobular
emphysema. 4. Parenchymal subpleural opacities in the dependent
portions of the left lower lobe as well as the right upper lobe.
Right upper lobe findings appear to be dependent atelectasis.
Left lower lobe findings are probably a combination of
atelectasis and perhaps a degree of aspiration as well. However,
given the presence of underlying emphysema, recommend followup
examination to ensure resolution. 5. Coronary artery
calcifications.
Brief Hospital Course:
80 year-old male, ex-smoker, admitted with cough and shortness
of breath. His hospital course will be reviewed by problems.
1) Cough/SOB: His initial presentation was felt most consistent
with a COPD flare, and he was started on parenteral steroids,
bronchodilator therapy with nebulizers and Levofloxacin for
coverage of possible tracheobronchitis. His CXR was without
evidence of pneumonia. He was eventually converted to oral
steroids, but continued to have marked bronchospasm and high
osygen requirement. He was eventually transferred to the [**Hospital Unit Name 153**]
for high nursing care requirements, and proceeded to develop
hypercarbic respiratory failure following Haldol therapy
requiring intubation. He was succesfully extubated, and
transferred back to the floor.
He continued to have high oxygen requirements. A CTA on [**2-7**]
was nnegative for PE and without significant massess or
lymphadenopathy, but showed evidence of a dilated left pulmonary
artery suggestive of PA hypertension. A prior echo on [**2-5**] was
also consistent with moderate pulmonary hypertension, without TV
dilatation or atrial enlargemet.
The pulmonary service was consulted to further comment on his
hypoxemia. His hypoxemia was felt to be multifactorial, with
severe COPD (PFTs obtained on [**2132-2-14**] revealed FVC 0.97 (24%),
FEV1 0.51 (20%), ratio 83%) the most important contributor. The
possibility of a R->L shunt was also raised, but bubble study
was negative for ASD or PFO.
He completed a course of levofloxacin and was started on a slow
prednisone taper for the COPD. His oxygen saturations slowly
improved, and at discharge was requiring 0-1 liters via nasal
cannula. He will need to be evaluated for home oxygen use.
2. Arrhythmia: While on the [**Hospital Ward Name 516**], Mr. [**Known lastname 95655**] had
repeated episodes of supraventricular tachycardia to the 160's.
Review of the EKGs reveal that he had intermittent aflutter with
RVR. At other times, EKGs showed ST with PACs versus MAT. He was
initially started on beta blockade therapy for rate control,
which was changed to Verapamil per EP given his concomitant
pulmonary disease and bronchospasm. EP was consulted, and
recommendation was made to transfer to the [**Hospital Ward Name **] for
chemical conversion with Dofetilide therapy (poor candidate for
amiodarone given his pulmonary disease). Of note, he was also
started on Coumadin for anticoagulation.
Upon transfer, Verapamil was changed to Diltiazem, and he was
started on Dofetilide on [**2132-2-13**]. He continues to have
occasional episodes of supraventricular tachycardia while on
Dofetilide. QTc has been stable. The Diltiazem was titrated up
to 90 mg QID and will be discharged on Diltiazem ER 360 mg
daily.
4. Metabolic alkalosis/respiratory acidosis: While in hospital,
his HCO3 rose up to 41. His metabolic alkalosis was felt to be a
combination of chronic hypercarbia, with likely contribution
from steroid therapy. We started Diamox on [**2132-2-15**], with
improvement in HCO3 to 35, (goal HCO3 = 35 per Pulmonary). His
HCO3 will need to be monitored after discharge weekly. The
diomox was discontinued on [**2132-2-19**] because his creatinine was
beginning to rise slightly and his bicarb normalized.
5. DM type 2: He was continued on his out-patient regimen of
Avandia. Metformin was discontinued in the hospital in the
setting of ongoing hypoxemia, variable PO intake. He was covered
with a RISS QID. His glycemic control was further exacerbated by
steroid therapy, with suboptimal fingerstick values. We
increased his Avandia was increased to 2 mg [**Hospital1 **].
6. Renal: His creatinine increased slightly to 1.3 from baseline
fo 1-1.1, possibly due to diomox. Diomox was stopped. FENA was
not less than one so felt not to be prerenal, and urianlysis was
normal. It should be monitored at rehab.
Medications on Admission:
flomax 0.4
folate 1 mg
lisinopril 2.5 mg
glucophage reg 850 mg
avandia 2 mg
ipratropium MDI
protonix 40 qd
prednisone 60 qd (started [**2-4**])
insulin sc
simvastatin
dilt 30 qid ([**2-5**])
metoprolol 12.5 tid ([**2-5**])
levoflox ([**2-5**])
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
COPD
DMII
Hypercholesterolemia
H/O prostate cancer s/p XRT
RBBB
Atrial fibrillation/flutter
CKD
Discharge Condition:
Stable
Discharge Instructions:
Take all medications as prescribed. You will go to rehab with a
one week supply of Dofetilide.
You will have [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of hearts monitor to evaluate your heart
rhythm upon discharge. Please return it to the holter lab.
Name: [**Known lastname 16537**],[**Known firstname 16538**] Unit No: [**Numeric Identifier 16539**]
Admission Date: [**2132-2-2**] Discharge Date: [**2132-2-21**]
Date of Birth: [**2051-4-8**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 211**]
Addendum:
Mr. [**Known lastname **] had a positive urinalysis with 6-1- WBC and postive
nitrite, so he was started on ciprofloxacin. His creatinine had
improved to 1.1 on day of discharge.
Chief Complaint:
same
Major Surgical or Invasive Procedure:
Bubble study
S/P intubation for hypercarbic resp failure
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 41**] - [**Location (un) 42**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 224**] MD [**MD Number(1) 225**]
Completed by:[**2132-2-21**]
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"93.90",
"96.71",
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10011, 10236
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4669, 8531
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9036, 9045
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2174, 2199
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1659, 1729
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8917, 9015
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9069, 9868
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9885, 9891
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2213, 4646
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1430, 1643
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9,828
| 135,344
|
52387+59476
|
Discharge summary
|
report+addendum
|
Admission Date: [**2197-3-18**] Discharge Date: [**2197-4-3**]
Date of Birth: [**2149-10-17**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: This woman came in by ambulance
for confusion, shortness of breath and weakness. This is a
47-year-old female, with severe COPD and asthma, recently
hospitalized at [**Hospital3 **] from [**Date range (1) 108259**] for treatment of
bilateral pneumonia and respiratory failure, necessitating
intubation. The patient was discharged on [**3-6**] with
instructions to complete a 12-day course of Levofloxacin and
a prednisone [**Month/Year (2) 15123**].
The morning of admission, the patient awoke dyspneic and
confused. She was with her neighbor who called 911. When
EMS arrived, her systolic blood pressure was 60. On
presentation to the ED, SBP was in the 70s. The patient
febrile to 101.5 and tachycardic to the 120s. The patient
was noted to be dyspneic with poor air movement. The patient
was given 100 mg of Solu-Medrol IV, 500 mg of Levofloxacin,
and 100 mg of gentamicin. First ABG 7.26, 82, 109 with O2
sats of 99% on 100% face mask. The patient was placed on
BiPAP. Subsequent ABG was 7.36, 59, 167.
PAST MEDICAL HISTORY:
1. Asthma.
2. COPD with central lobe lobular emphysema.
3. Bilateral pulmonary nodules.
4. Hypertension.
5. Noninsulin dependent diabetes mellitus.
6. Partial nephrogenic diabetes insipidus (secondary to
lithium).
7. Bipolar disorder.
8. Migraine headaches.
9. CHF. Echo [**2-28**] showed EF of 30-35%, moderate global left
ventricular hypokinesis, 1+ MR.
ALLERGIES: Penicillin and ampicillin lead to rash. Motrin
leads to rash. Bactrim leads to unknown reaction. Lithium
leads to renal toxicity and nephrogenic diabetes insipidus.
MEDICATIONS ON DISCHARGE [**3-6**]:
1. Levofloxacin 500 mg po qd--to complete a 12-day course.
2. Prednisone [**Month/Year (2) 15123**].
3. Zestril 5 mg po qd.
4. ASA 81 mg po qd.
5. Valproic acid 250 mg po bid.
6. Risperidone 4 mg po bid.
7. Benztropine 0.5 mg po qd.
8. Combivent nebs.
9. Toprol XL 25 mg po qd.
10.Flovent 1 inhalation po bid.
SOCIAL HISTORY: Tobacco - 1 pack a day since the age of 10
(recently quit). Alcohol - none at present. IV drug abuse -
none at present. Unemployed. The patient lives with her
next door neighbor who is an obese female who requires a lot
of attention. Apparently Ms. [**Known lastname 1968**] [**Last Name (Titles) 2176**] the store for this
neighbor several times a day.
FAMILY HISTORY: Mother with [**Name (NI) 2481**] dementia, diabetes,
asthma, hypertension, recently died of MI. Sister has
asthma, as well.
PHYSICAL EXAM ON ADMISSION - VITALS: Temperature 101.5,
blood pressure 100/60, heart rate 116, respiratory rate 32,
O2 sat 98% on nonrebreather.
GENERAL: This is a cachectic, chronically ill female, lying
in bed.
HEENT: Patchy alopecia. MM dry. OP clear. BIPAP mask in
place.
NECK: Supple. No lymphadenopathy. No JVD.
HEART: Tachy. Normal S1, S2. II/VI holosystolic murmur
heard at the apex.
LUNGS: Crackles at the left base. Poor air movement
bilaterally.
ABDOMEN: Soft, nontender, nondistended, normoactive bowel
sounds.
EXTREMITIES: No CCE.
NEURO: Alert and oriented x 3. Cranial nerves II through
XII grossly intact. Exam otherwise nonfocal.
SKIN: No rashes. No lesions.
LAB DATA ON ADMISSION: White count 12.6, hematocrit 40.8.
Diff notable for 84.5% PMNs, 9.1% lymphs, 4.5% monos, and
1.2% eosinophils. SMA-10 on admission was notable for a
creatinine of 1.8 (baseline 1.1-1.2), bicarb 35 (30s at
baseline). UA was negative.
RADIOLOGY ON ADMISSION: Chest x-ray showed borderline
cardiomegaly, patchy opacities at both lung bases. No CHF or
effusions. Bullous changes at both apices.
EKG: Showed sinus tachycardia, pulse rate 108, QT 280, QTC
392, normal axis, positive left atrial abnormality, LVH by
voltage.
[**Hospital 12145**] HOSPITAL COURSE: The patient was admitted to the MICU
from the Emergency Room for hypercarbic respiratory failure,
where she was quickly intubated on arrival to the floor due
to persistent hypercarbia and acidemia that did not improve
on BIPAP and continued to get worse. The patient was
originally treated with Levofloxacin for pneumonia, steroids,
initially IV, for COPD flare/asthma flare, and treated with
nebs. The patient was also given fluid boluses for
hypernatremia and hypotension. All of her other outpatient
medications were continued with the exception of former
treatment with glipizide in the ICU setting.
The patient continued to have hypercarbic respiratory failure
and was unable to be weaned off of the vent. On [**2197-3-20**],
the patient was transferred from the [**Hospital Ward Name 517**] MICU to the
[**Hospital Ward Name 516**] [**Hospital Unit Name 153**]. She continued to be intubated on steroids
and nebulizer treatments. At that point, her respiratory
failure was deemed secondary to pneumonia, and more
prominently COPD flare, and least prominent her chronic
asthma. The patient was repeatedly tried on pressure
support, but did not tolerate, became apneic, and was
maintained on A/C ventilation with frequent suctioning of
white sputum.
On [**2197-3-22**], the patient was maintained on pressure support.
However, she continued to have difficulty with spontaneous
breathing, despite no positive sputum cultures at that point
except for presence of mold on her initial cultures. The
patient was maintained on her 10-day course of Levofloxacin,
remained intubated, and continued to receive supportive care.
The patient was found to have large pneumothoraces on chest
x-ray. The patient had ultrasound-guided tube thoracostomy
(12 French pigtail catheter) placed anteriorly by the
interventional pulmonology service. Prior to this procedure,
chest CT was performed which confirmed the large
pneumothorax. The patient remained on pressure support and
stable, but FIO2 had to be increased in the presence of this
large pneumothorax. The patient was also found to have a
second pneumothorax, both apical and basilar pneumothoraces.
However, the pigtail catheter drained only the apical
pneumothorax. The basilar pneumothorax was felt by CT
surgery and interventional pulmonology not to be able to
cause tension pneumo because of the current chest tube, and
further going to the OR would cause further air leaks.
Therefore, the patient was left as she was with CT evaluation
to follow-up.
In addition, the patient's sputum grew MRSA from samples on
[**3-21**] and [**3-22**]. Therefore, the patient was started on
Levofloxacin for a 14-day course of IV antibiotics. The
patient was also treated for thrush in the setting of her
prednisone [**Month/Year (2) 15123**].
Of note, this patient experienced ventilator-related
pneumothorax in [**2196-2-27**], as well. This patient has
bilateral bullous emphysema and is likely prone to ventilator
associated pneumothorax. Both of these pneumothoraces have
occurred on the right side.
HOSPITAL COURSE (AFTER MICU): The patient was transferred to
the ACOVE service on [**2197-3-31**], after having been extubated on
[**2197-3-30**] on 4 liters nasal cannula. The patient's chest
tubes were DC'd on [**2197-3-31**].
1) HYPERCARBIC RESPIRATORY FAILURE, COPD EXACERBATION, MRSA
PNEUMONIA COMPLICATED BY ASTHMA, AND POTENTIAL MEDICAL
NONCOMPLIANCE: The patient was stable status post extubation
on 4 liters nasal cannula initially, and weaned down to 2
liters nasal cannula (her baseline O2 requirement at home).
The goal was to maintain the patient on 92% O2 sat on
supplemental oxygen. She generally satted greater than 95%
on 2 liters NC.
2) ASTHMA: Likely part of the initial presentation, but
improved with minimal anterior wheezing throughout the course
of her floor stay. The patient continued on the steroid
[**Last Name (LF) 15123**], [**First Name3 (LF) **]-acting beta agonists, prn MDIs, added inhaled
steroid, and prn nebs.
3) COPD EXACERBATION: The patient was treated initially with
Levofloxacin and steroid [**First Name3 (LF) 15123**], as indicated above. The
patient was maintained on long-acting MDIs and inhaled
steroid, both of which should improve her chronic COPD
secondary to long-term smoking history and bullous emphysema.
4) PNEUMONIA: The patient was treated for pneumonia with
Levofloxacin x 10 days, but when continued to have MRSA in
the sputum and not clinically improved, the patient was
started on vancomycin, and was day 11 of 15 on the date of
dictation. Her white blood cell count was essentially
stable, although has been creeping up slightly to 13.7 on the
date of discharge (date of dictation). The patient, however,
remained afebrile throughout her floor hospital course. A
repeat sputum culture was obtained [**2197-4-2**], given cough
productive of green sputum. However, sputum was no growth to
date at the time of dictation, and the patient continued to
be afebrile and feel well, and breathe at her baseline.
5) LARGE RIGHT PNEUMOTHORAX, SPONTANEOUS, ON VENT: Likely
from known bullous emphysema. Pigtail catheter placed
anteriorly by ICU fellow [**2197-3-24**] and successfully removed
[**2197-3-31**]--resolved by chest x-ray.
6) HYPERNATREMIA 149 ON ADMISSION: Resolved with IV fluids,
free water boluses prn. The patient had normal sodium levels
since transfer out of the Intensive Care Unit
7) CARDIOVASCULAR - A) PUMP: EF 30-35%. Initially
hypotensive which responded to fluids. Goal I&O equal.
Patient clinically euvolemic.
B) CAD: No documented history of CAD. The patient had not
followed up with stress test on last admission. Elevated CK
values, but not during this admission. Continue aspirin,
beta blocker and ACE.
C) RHYTHM: Tachy, some NSVT in ICU. Follow electrolytes and
replete prn. The patient is sinus rhythm on the floor.
D) HYPERTENSION: Now on ACE inhibitor and beta blocker.
Continue to titrate up the ACE inhibitor throughout the floor
stay. Dose was 62.5 mg po tid at the time of dictation.
8) BIPOLAR DISORDER: The patient was continued on her
outpatient psych regimen including depakote and risperidone,
as well as benztropine. The patient was continued on her
outpatient regimen, although it was noted that her valproic
acid level was subtherapeutic. We will discuss with
psychiatrist at [**Hospital 1263**] Hospital prior to discharge. No
changes at this point given patient is stable without
evidence of psychosis or mania.
9) ELEVATED PTT: Likely secondary to heparin, chronic, and
has varied. Not a significant coagulopathy, as patient did
not bleed excessively with chest tubes. [**Doctor First Name **] is negative per
RMR records, and thus unlikely secondary to lupus
anticoagulant effect. Consider work-up for lupus
anticoagulant despite lack of lupus symptoms, as can be
associated with other diseases (as outpatient). No acute
symptoms of bleeding.
10) ANEMIA: The patient came in with a normal hematocrit and
has had no evidence of bleeding. The patient notably has
undergone significant phlebotomy. Iron studies were notable
for mild anemia of chronic disease which is certainly
plausible in the context of her myriad medical problems. The
patient has no symptoms of anemia and will need to be
followed as an outpatient.
11) FEN: Diabetic diet, tolerating POs.
12) PERIPHERAL ACCESS: Subcu heparin, PPI, bowel regimen.
13) PRERENAL AZOTEMIA: Creatinine returned to baseline with
fluids. Baseline ranged 1.0-1.4. Negative UA or urine
culture after admission.
14) DIABETES MELLITUS TYPE 2: Patient maintained on regular
insulin sliding scale with fingersticks qid.
15) COMMUNICATION: The [**Hospital 228**] healthcare proxy is her
daughter, [**Name (NI) 547**] [**Known lastname 108260**] if it is official yet, contact
numbers are home at ([**Telephone/Fax (1) 108261**], cell ([**Telephone/Fax (1) 108262**].
[**Name (NI) **] sister, [**Name (NI) 1743**] [**Name (NI) **], may be contact[**Name (NI) **] at ([**Telephone/Fax (1) 108263**], cell ([**Telephone/Fax (1) 108264**].
Social work was following for complicated home and social
issues. The patient was FULL CODE. The patient has a PICC
line for vancomycin, and long-term solution needs to be
arranged for her chronic living situation.
DISPO: Likely to [**Hospital 3058**] rehab.
CONDITION: Stable at the time of dictation.
DISCHARGE DIAGNOSES:
1. Chronic obstructive pulmonary disease.
2. Methicillin resistant Staphylococcus aureus pneumonia.
3. Asthma.
4. Hypertension.
5. Diabetes mellitus type 2.
6. Congestive heart failure.
7. Bipolar disorder.
RECOMMENDED FOLLOW-UP: With her PCP, [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD,
on [**4-28**] at 1:30 pm.
MAJOR SURGICAL/INVASIVE PROCEDURES: None.
DISCHARGE MEDICATIONS:
1. Aspirin 81 mg po qd.
2. Valproic acid 250 mg po bid.
3. Risperidone 4 mg po bid.
4. Benztropine 0.5 mg po bid.
5. Colace 100 mg po bid.
6. Subcu heparin 5,000 U q 8 h.
7. Insulin sliding scale.
8. Salmeterol 1 puff [**Hospital1 **].
9. Percocet prn.
10.Albuterol MDI prn.
11.Albuterol neb prn.
12.Ipratropium neb prn.
13.Protonix 40 mg po qd.
14.Ipratropium MDI 2 puffs qid.
15.Fluticasone 2 puffs [**Hospital1 **].
16.Maalox prn.
17.Compazine prn.
18.Ambien prn.
19.Captopril 62.5 mg po tid.
20.Vancomycin 1 gm IV bid x 3 days (total dose of 14 days).
21.Prednisone 10 mg po qd x 5 days.
Patient also advised to take all medications as prescribed.
Follow-up with Dr. [**Last Name (STitle) **], as well as weigh herself daily,
and be alert for any increasing shortness of breath, fever,
malaise, and to call Dr. [**Last Name (STitle) **] if any of these develop.
The patient also advised to follow a diabetic, low-sodium
diet.
[**First Name8 (NamePattern2) **] [**Doctor First Name **], M.D.
[**MD Number(1) 19814**]
Dictated By:[**Last Name (NamePattern1) 7364**]
MEDQUIST36
D: [**2197-4-3**] 10:30
T: [**2197-4-3**] 10:36
JOB#: [**Job Number 108265**]
Name: [**Known lastname 447**], [**Known firstname 1116**] Unit No: [**Numeric Identifier 17868**]
Admission Date: [**2197-3-18**] Discharge Date: [**2197-4-4**]
Date of Birth: [**2149-10-17**] Sex: F
Service: ACOVE
1. Pneumonia: Patient will be treated for a total of 14-day
course with vancomycin for MRSA pneumonia. Patient had a
PICC line at the time of dictation and is status post a
10-day course of levofloxacin. Patient's sputum culture from
[**2197-4-1**] is negative at the time of dictation. Positive only
for sparse growth of oropharyngeal flora.
2. Diabetes mellitus: Given some questions of the patient's
cognitive abilities and ability to self administer insulin,
the patient was restarted on her home dose of glyburide 2.5
mg p.o. q.d. yesterday [**2197-4-3**] with normal range
fingersticks as a result. Patient will continue to be
monitored at the rehab ([**Location (un) 3956**] [**Location (un) 3957**]).
3. Hypertension: Patient's captopril dose was converted into
q.d. dose of lisinopril 20 mg p.o. q.d. with systolic blood
pressures in the range of 120-130 and diastolic blood
pressures in the 70-80 range after administering the first
dose. This is an equivalent dose to her prior captopril dose
of 50 mg p.o. t.i.d.
4. COPD exacerbation: Patient is discharged on steroid
taper. She had four days left at the dose level of 10 mg
p.o. q.d. and to schedule to take 5 mg p.o. q.d. x5 days
thereafter, which is listed in the discharge instructions for
her inpatient rehab.
FOLLOW-UP PLANS: Patient has an appointment scheduled with
Dr. [**First Name (STitle) **] [**Name (STitle) **] [**2197-4-28**] at 1:30 p.m. at [**Hospital Ward Name **] Center.
[**Name6 (MD) **] [**Last Name (NamePattern4) 424**], M.D. [**MD Number(1) 425**]
Dictated By:[**Last Name (NamePattern1) 3665**]
MEDQUIST36
D: [**2197-4-4**] 13:22
T: [**2197-4-4**] 14:27
JOB#: [**Job Number 17869**]
(cclist)
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|
2106, 2466
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,746
| 199,183
|
22006
|
Discharge summary
|
report
|
Admission Date: [**2130-1-9**] Discharge Date: [**2130-1-13**]
Date of Birth: [**2082-6-12**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
exertional chest pain and +stress test
Major Surgical or Invasive Procedure:
s/p Coronary artery bypass grafting x
4(Lima->LAd/SVG->Diag/OM/PDA)
History of Present Illness:
47 year old male who recently has
been experiencing exertional angina. He describes chest
discomfort when he walks up a [**Doctor Last Name **] that is relieved with rest.
He
denies any chest pain at rest. He was seen in clinic last week
by
Dr. [**Last Name (STitle) 171**], who recommended stress testing. This was abnormal
as
noted below, so was referred for cardiac catheterization. He was
found to have three vessel disease and is now being referred to
cardiac surgery for revascularization.
Past Medical History:
dyslipidemia
impaired glucose tolerance
cholelithiasis
syncope [**2128**]
Social History:
Race:Caucasian
Last Dental Exam:2 weeks ago
Lives with:wife
Contact: wife
Occupation:works as a statistician at [**Hospital1 18**]
Cigarettes: Smoked no [x] yes []
Other Tobacco use:denies
ETOH: < 1 drink/week [x] [**3-21**] drinks/week [] >8 drinks/week []
Illicit drug use:denies
Family History:
Family History:Premature coronary artery disease- father died of
stroke at age 57
Physical Exam:
Admission Physical Exam
Pulse:62 Resp:18 O2 sat:99/RA
B/P Right:110/72 Left: 114/69
Height:5'6" Weight:150 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 [] 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: all palpable
Carotid Bruit Right: - Left:-
Pertinent Results:
[**2130-1-12**] 06:20AM BLOOD WBC-7.0 RBC-3.39* Hgb-10.6* Hct-31.2*
MCV-92 MCH-31.2 MCHC-33.9 RDW-12.8 Plt Ct-165
[**2130-1-9**] 01:03PM BLOOD WBC-12.5*# RBC-3.42*# Hgb-10.8*#
Hct-31.1*# MCV-91 MCH-31.7 MCHC-34.9 RDW-12.1 Plt Ct-183
[**2130-1-9**] 01:03PM BLOOD PT-15.2* PTT-36.6* INR(PT)-1.3*
[**2130-1-10**] 02:24AM BLOOD PT-11.8 PTT-30.4 INR(PT)-1.1
[**2130-1-12**] 06:20AM BLOOD Glucose-109* UreaN-9 Creat-0.9 Na-138
K-4.3 Cl-106 HCO3-25 AnGap-11
[**2130-1-9**] 02:10PM BLOOD UreaN-13 Creat-0.8 Na-142 K-3.5 Cl-112*
HCO3-22 AnGap-12
[**2130-1-9**] 02:10PM BLOOD UreaN-13 Creat-0.8 Na-142 K-3.5 Cl-112*
HCO3-22 AnGap-12
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 57604**] (Complete) Done
[**2130-1-9**] at 11:31:25 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: [**2082-6-12**]
Age (years): 47 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Abnormal ECG. Coronary artery disease. Hypertension.
Shortness of breath.
ICD-9 Codes: 786.05, 424.0
Test Information
Date/Time: [**2130-1-9**] at 11:31 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5209**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2011AW2-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: 55% to 65% >= 55%
Aorta - Ascending: 3.0 cm <= 3.4 cm
Findings
LEFT ATRIUM: Normal LA size. No spontaneous echo contrast is
seen in the LAA. Good (>20 cm/s) LAA ejection velocity. No
thrombus in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or
pacing wire is seen in the RA and extending into the RV. No ASD
by 2D or color Doppler.
LEFT VENTRICLE: 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. Normal aortic diameter at
the sinus level. Normal ascending aorta diameter. Normal
descending aorta diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Mildly thickened
aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
GENERAL COMMENTS: Results were personally reviewed with the MD
caring for the patient.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PRE- CPB:1. The left atrium is normal in size. No spontaneous
echo contrast is seen in the left atrial appendage. No thrombus
is seen in the left atrial appendage.
2. No atrial septal defect is seen by 2D or color Doppler.
3. Overall left ventricular systolic function is normal
(LVEF>55%).
4. Right ventricular chamber size and free wall motion are
normal.
5. The ascending, transverse and descending thoracic aorta are
normal in diameter and free of atherosclerotic plaque. There are
simple atheroma in the descending thoracic aorta.
6. There are three aortic valve leaflets. The aortic valve
leaflets (3) are mildly thickened. There is no aortic valve
stenosis. No aortic regurgitation is seen.
7. Mild (1+) mitral regurgitation is seen.
Dr. [**Last Name (STitle) **] was notified in person of the results.
POST-CPB: On infusion of phenylephrine briefly. A-pacing for
slow sinus rhythm. Preserved biventricular systolic function
post cpb. LVEF = 60%. MR is 1+. Aortic contour is normal post
decannulation.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2130-1-9**] 13:01
?????? [**2121**] CareGroup IS. All rights reserved.
Brief Hospital Course:
On [**2130-1-9**] Mr.[**Known lastname **] was taken to the operating room and underwent
Coronary artery bypass grafting x
4(Lima->Lad/SVG->Diag/OM/PDA)with Dr.[**Last Name (STitle) **]. Cross clamp
time=52 minutes. Cardiopulmonary Bypass time=66 minutes. Please
refer to operative report for further surgical details. He
tolerated the procedure well and was transferred to the CVICU
intubated and sedated in critical but stable condition. He awoke
neurologically intact and was extubated without incident. He
weaned off pressor support and was started on
Beta-blocker/Statin/Aspirin and diuresis. All lines and drains
were discontinued in a timely fashion. POD#1 he was transferred
to the step down unit for further monitoring. Physical Therapy
was consulted for strength and mobility. The remainder of his
postoperative course was essentially uneventful. He continued to
progress and on POD#4 he was cleared for discharge to home with
VNA services.
Medications on Admission:
FENOFIBRATE 54 mg daily
FLUOCINONIDE 0.05 % Cream - apply to affected areas on arms
twice
a day two weeks on, two weeks off
METOPROLOL SUCCINATE 25 mg daily
NITROGLYCERIN [NITROSTAT] 0.3 mg Tablet, Sublingual, 1 Tablet
sublingually every 5 minutes to the maximum of three as needed
for chest pain
SIMVASTATIN 80 mg daily
ASPIRIN 81 mg daily
OMEGA-3 FATTY ACIDS-VITAMIN E [FISH OIL] 1,000 mg Capsule - 4
Capsules by mouth once a day
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO three
times a day.
Disp:*90 Tablet(s)* Refills:*2*
2. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
5 days.
Disp:*5 Tablet(s)* Refills:*0*
3. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day for 5 days.
Disp:*10 Tablet Extended Release(s)* Refills:*0*
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).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
7. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
8. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for fever/pain.
9. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
10. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
11. fluocinonide 0.05 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
12. fenofibrate micronized 48 mg Tablet Sig: One (1) Tablet PO
daily ().
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Coronary artery disease
s/p Coronary artery bypass grafting x
4(Lima->LAd/SVG->Diag/OM/PDA)
Secondary:
dyslipidemia
impaired glucose tolerance
cholelithiasis
syncope [**2128**]
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with percocet and tylenol
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage. Edema:
None
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr.[**Last Name (STitle) **] on [**2-15**] at 1:00pm in the [**Hospital **] medical office
building [**Doctor First Name **] [**Hospital Unit Name **] [**Telephone/Fax (1) 170**]
wound check on [**1-24**] at 11:00am in the [**Hospital **] medical office
building [**Doctor First Name **] [**Hospital Unit Name **] [**Telephone/Fax (1) 170**]
Cardiologist:Dr [**Last Name (STitle) 171**] on [**2-1**] at 1:00pm
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) 674**] R. [**Telephone/Fax (1) 250**] in [**2-13**] 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:[**2130-1-13**]
|
[
"790.29",
"272.4",
"414.01",
"458.29",
"413.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"36.15",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
9172, 9221
|
6357, 7310
|
349, 419
|
9442, 9683
|
2018, 4884
|
10524, 11360
|
1375, 1444
|
7793, 9149
|
9242, 9421
|
7336, 7770
|
9707, 10501
|
4933, 6334
|
1459, 1999
|
270, 311
|
447, 945
|
967, 1043
|
1059, 1344
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,351
| 146,738
|
29943
|
Discharge summary
|
report
|
Admission Date: [**2171-1-10**] Discharge Date: [**2171-1-22**]
Date of Birth: [**2099-8-17**] Sex: M
Service: MEDICINE
Allergies:
Nafcillin
Attending:[**First Name3 (LF) 5438**]
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
CVVHD
intubation
History of Present Illness:
This is a 71 y/o male with a PMH of HTN, HL, NIDDM, EtOH abuse,
who sustained a fall on [**11-21**] with a C6/C7 fracture dislocation
with disruption of the anterior and posterior ligaments and cord
compression resulting in central cord syndrome who subsequently
underwent operative repair with posterior C3-T3 fusion and was
discharged to [**Hospital3 **] on [**2170-12-8**]. He was then re-admitted
to the medicine service from [**Date range (1) 71518**] for a wound dehiscence
requiring debridement in the OR. The wound deep tissue cultures
grew MSSA and he was started on Nafcillin on [**2170-12-31**] and
discharged to [**Hospital1 **] on [**1-1**] for a planned [**7-14**] week course
of Nafcillin. He was doing well at [**Hospital1 **] until Tuesday, when
he was noted to develop malaise, dizziness, fevers/chills, as
well as a diffuse erythematous, non-pruritic, papular rash. His
creatinine was also noted to rise from 1.7 to 2.5. His nafcillin
was changed to vancomycin at rehab, as it was presumed that the
rash was drug-related. Yesterday, he was
febrile to 104.6 and hypotensive to 80's/30's at rehab and found
to have worsening renal function with a dirty u/a and
hyponatremia of 119. He was then transferred to the [**Hospital1 18**] ED on
[**2171-1-9**] for further evaluation. In the ED, code sepsis was
initiated and he was given 8 L NS total with 2 U PRBCs for
anemia. In addition, he was given doses of Vancomycin, flagyl,
levofloxacin, and clindamycin. He was also given decadron 4 mg x
1 last night for concern of cord compression. Neurology, ID, and
renal were all consulted.
.
Currently, pt feels cold, but denies any other current c/o.
Past Medical History:
1. DM II, diagnosed about 3 years ago
2. HTN
3. Hypercholesterolemia
4. ETOH abuse, chronic. No h/o DTs or withdrawal.
5. ? stroke 10 years ago
6. ?CHF
7. Herniorrhaphy
8. S/p vasectomy
7. Skin grafting (finger)
8. Fall from a tree resulting in rib fractures and hemothorax
many years ago.
9. s/p IVC [**2170-12-7**] (placed prophylactically)
Social History:
He used to work as a jet engine enginer for GE. Retired x 11
years. He lives with his wife. [**Name (NI) **] 3 daughters. [**Name (NI) **] smokes cigars
occasionally. The family reports that the patient drinks wine,
beer, and sometimes liquor daily, but they do not know how much
he is drinking. Last drink Xmas eve per patient. No drug use.
Family History:
Mother and brother with history of aortic aneurysms.
Physical Exam:
VS: Tc 99.3, Tm 104, BP 107/52, HR 96, RR 25, SaO2 97%/3L NC,
CVP 7
General: Pleasant male in NAD, AO x 3 in NAD
HEENT: NC/AT, in collar. Pupils 2 mm b/l and reactive, EOMI. MM
dry, OP clear
Neck: supple, in collar, no spinal tenderness. No JVP or LAD
noted
Chest: CTA-B, no w/r/r
CV: RR tachy, s1 s2 normal, no m/g/r
Abd: soft, NT/ND, NABS, no HSM
Ext: trace to 1+ pitting edema b/l, wwp
Skin: diffuse macular rash over the upper extremities, torso,
extending to b/l thighs. Erythematous and blanching in nature.
Neuro: AO x 3, CN II-XII grossly inact. MS [**First Name (Titles) 213**] [**Last Name (Titles) **], 4+/5
throughout in all four extremities, plantar reflex not elicited.
DTR's 2+ in UE and absent in LE's. Sensory exam limited by
inattention. Normal rectal [**Last Name (Titles) **] present in ED.
Pertinent Results:
Trends:
WBC: 6.4, 9.1, 11.7, 14.5, 19.4, 20.7, 29.4, 53, 62.9
HCT: 22.3 - 29.7
[**2171-1-9**] 06:00PM BLOOD PT-15.8* PTT-62.5* INR(PT)-1.4*
[**2171-1-19**] 09:08AM BLOOD PT-18.1* PTT-43.4* INR(PT)-1.7*
[**2171-1-21**] 06:13AM BLOOD PT-20.9* PTT-47.4* INR(PT)-2.0*
[**2171-1-22**] 03:59AM BLOOD PT-35.1* PTT-82.3* INR(PT)-3.8*
.
Creatinine: 4.4 on admission, 4.6 on date of death
.
[**2171-1-11**] 01:43AM BLOOD ALT-72* AST-106* LD(LDH)-416*
AlkPhos-176* Amylase-38 TotBili-2.1*
[**2171-1-22**] 03:59AM BLOOD ALT-96* AST-326* LD(LDH)-715*
AlkPhos-246* TotBili-2.2*
.
[**2171-1-11**] 09:16AM BLOOD CK-MB-5 cTropnT-1.24*
[**2171-1-11**] 05:19PM BLOOD CK-MB-5 cTropnT-1.15*
[**2171-1-11**] 11:50PM BLOOD CK-MB-5 cTropnT-1.17*
[**2171-1-12**] 06:06AM BLOOD CK-MB-5 cTropnT-1.29*
[**2171-1-13**] 04:17AM BLOOD CK-MB-NotDone cTropnT-1.20*
[**2171-1-9**] 06:00PM BLOOD proBNP-5460*
.
[**2171-1-10**] 09:10AM BLOOD Cortsol-22.9*
[**2171-1-11**] 05:50AM BLOOD Cortsol-31.3*
.
ABG on [**1-22**]: 7.02/35/88
[**2171-1-18**] 06:53AM BLOOD Lactate-1.6
[**2171-1-20**] 03:00PM BLOOD Lactate-2.9*
[**2171-1-21**] 11:20AM BLOOD Lactate-5.9* K-4.2
[**2171-1-21**] 04:20PM BLOOD Lactate-9.0*
[**2171-1-21**] 08:13PM BLOOD Lactate-10.3*
[**2171-1-22**] 04:16AM BLOOD Lactate-17.3*
[**2171-1-22**] 06:42AM BLOOD Lactate-17.3*
.
Micro:
[**1-18**] blood cx: coag neg staph
other micro NGTD
.
[**1-10**] CXR - There is a new left subclavian central venous catheter
terminating in the lower SVC. Cervical fusion hardware is again
noted. Cardiac and mediastinal silhouettes appear stable.
There is stable vascular congestion, without frank edema.
.
[**1-10**] MRI - Deformities attributable to the previous fracture
dislocation at C6-C7 and subsequent posterior fusion and
fixation construct extending to T3 are noted. On today's study,
there appears to be less separation from C7 to T1 than there was
on the patient's CT scan of [**2170-12-3**]. There is no definite
evidence of
epidural mass or cord compression. Again is noted the remote
compression deformity of L1. There is some increased signal
within the disc space on both T1 and T2 sequences, but not on
the STIR sequence at T10-T11. Paravertebral material appears to
correspond to calcified material noted on the patient's CT scan
and probably reflect osteophytic spurring plus diffuse
idiopathic skeletal hyperostosis. There is no definite evidence
of discitis.
.
[**1-10**] Renal u/s - The right kidney measures 12.3 cm.
Visualization of the upper pole of the left kidney is limited.
The left kidney measures approximately 11 cm. There is no
hydronephrosis. No renal stones or masses are identified. The
bladder is not distended.
.
[**1-11**] Echo: The left atrium is elongated. Left ventricular wall
thickness, cavity size, and systolic function are normal
(LVEF>55%). Regional left ventricular wall motion is normal.
Transmitral Doppler and tissue velocity imaging are consistent
with Grade I (mild) LV diastolic dysfunction. Right ventricular
chamber size and free wall motion are normal. The aortic root is
mildly dilated at the sinus level. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. There
is focal fibro-calcific change seen on the left coronary cusp.
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. Mild (1+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is a small pericardial effusion. IMPRESSION:
No valvular vegetations seen. If clinically indicated, a TEE
would
be better to exclude a small valvular vegetation.
.
[**1-18**]: renal u/s: no hydronephrosis
.
[**1-16**]: CT chest/abd/pelvis: 1. Bilateral simple pleural effusions
(right slightly greater than left) with underlying
atelectasis/collapse of left and right lower lobes.
2. Patchy multifocal opacities within the right upper lobe with
areas of interstitial septal thickening. Differential includes
areas of atelectasis or early multifocal pneumonia. Pulmonary
edema is felt to be less likely given the asymmetry.
3. Diffuse abdominal and pelvic ascites with slightly nodular
liver contour which may suggest underlying cirrhosis.
4. Cholelithiasis, without evidence of acute cholecystitis.
5. Diffuse coronary and vascular calcifications.
6. No evidence of bowel obstruction or wall thickening. Distal
colonic air fluid level may suggest an early enteritis.
.
[**1-16**]: Head CT: 1. No evidence of hemorrhage.
2. Unchanged appearance of the brain compared to [**12-2**],
with lacunar infarctions and chronic microvascular ischemia as
described
.
[**1-21**]: CT abd/pelvis: 1. Diffusely thickened colon wall, new from
the prior study of [**1-16**]. This suggests colitis, and is
less likely related to third spacing of fluid. Infectious
colitis such pseudomembranous colitis is considered, and
inflammatory etiologies are also considered. Ischemia remains in
the differential diagnosis, though the area of thickening does
not correspond to a vascular territory. The vascular patency
cannot be assessed in the absence of IV contrast.
2. Increased ascites fluid, subcutaneous edema and bilateral
pleural effusions.
3. Consolidative changes at both lung bases, suggesting
pneumonia or aspiration.
4. Cholelithiasis, without evidence of cholecystitis.
5. Slightly nodular appearing liver contour, raising the
possibility of cirrhosis.
.
CXR: Widespread pulmonary opacification has worsened since
[**1-20**] accompanied by increasing moderate bilateral pleural
effusion, most likely pulmonary edema. ET tube is in standard
placement. Right jugular line tip projects over the mid SVC, and
a nasogastric tube passes in the stomach and out of view. Heart
is not grossly enlarged. No pneumothorax. Anterior aspect of the
left upper rib has been resected, and posterior ribs just below
that level show healed fracture.
Brief Hospital Course:
Hospital course: Pt was initially treated in the MICU for
concern over sepsis. He required pressors and received broad
specturm antibiotics. He was treated with vanco, flagyl, cipro,
and aztreonam. His rash was thought secondary to the nafcillin.
Culture data was no growth and there was discussion that his
hypotension was in fact a drug reaction to the nafcillin. His
pressors were weaned on [**1-13**] and he never required intubation.
he also had acute renal failure which was thought [**1-4**]
nafcillin/AIN vs prerenal azotemia. This also improved with IVF
and holding off on nafcillin. His mental status was altered
throughout much of his hospitalization. However, he was
determined stable for the floor on [**2171-1-14**]. Thereafter, he
remained delerious but also developed significant anasarca. He
developed a RUL pneumonia and began treatment with cipro and
vanco for nosocomial pneumonia. On [**1-17**]: a trigger was called
for decreased urine output. He also was noted to have shortness
of breath. He was treated with lasix 80mg IV with minimal
improvement. He also received atrovent nebs with some
improvement. His CXR revealed bilateral moderate pleural
effusions. his ABG showed poor oxygenation and acidosis so he
was transferred to the ICU-East.
.
ICU-East course by problem:
# Acute renal failure: Initially, he was noted to have poor
urine output. He did not respond to IVF so we attempted to
diurese with lasix. Again, no urine output. Renal input
suggested the development of ATN, etiology unclear. Renal u/s
showed no hydronephrosis and the foley had good flushes. He
became more altered and this was thought to be [**1-4**] uremia. His
metabolic acidosis became worse on [**1-20**] and we placed a femoral
line for CVVHD. This continued until late in the evening on
[**1-21**] with little response in his mental status or improvement in
his anasarca.
.
# Hypotension: He was intravascularly dry but had profound
edema. He required pressors in the ICU to maintain his MAP
greater than 60. The etiology was unclear but we broaded our
coverage for infectious causes as below.
.
# ID: On [**1-19**]: he spiked temp to 101.4. Cultures again did not
grow. Given his poor mental status, hypotension, and anasarca,
we broadened his coverage to linezolid, aztreonam, in addition
to levo and flagyl. His wbc climbed significantly prior to
death but a source was still not identified. We considered a
repeat MRI of his neck to assess for an epidural abscess.
However, this was delayed multiple times given his altered
mental status, acute renal failure (risk of using gad) and
unstable blood pressure. We covered systemically in the event
that he had an epidural abscess. On [**1-21**], we changed his
central line [**1-4**] concerns that this may have been the source.
.
# Hypoxic resp failure: In the setting of his altered mental
status and profound metabolic acidosis, he was intubated the
night of [**1-21**].
.
# Cervical Fx: Had been followed by ortho spine. Surgical wounds
intact. No evidence of superficial infection.
.
# Profound acidosis: CVVHD was started given worsening acidosis
as mentioned above. However, this persisted and his mental
status did not improve with CVVHD. He was intubated for airway
protection and hypoxia on the evening of [**1-21**]. His lactate and
WBC both climbed rapidly and his family was contact[**Name (NI) **]. We did
not think there was any chance of recovery from this episode.
After discussion with the wife and daughters, it was decided to
extubate the patient and focus on comfort. The patient passed
at 10:30am on [**1-22**] with his family and Priest present. The
family declined a post-mortem.
.
# Communication - with wife and daughter, [**Name (NI) 2411**] [**Name (NI) 71516**], (H)
[**Telephone/Fax (1) 71519**]; (C) [**Telephone/Fax (1) 71520**]
Medications on Admission:
(upon d/c [**2171-1-1**]) -
1. Famotidine 20 mg qd
2. Oxycodone 5 mg q6 hrs
3. Docusate Sodium 100 mg [**Hospital1 **]
4. Folic Acid 1 mg qd
5. Thiamine HCl 100 mg qd
6. Calcium Carbonate 500 mg qid
7. Glipizide 5 mg qd
8. Cyanocobalamin 500 mcg qd
9. Nafcillin 2 gm q4 hrs until [**2171-2-11**]
10. Labetalol 300 mg qd
11. RISS
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary:
- hypoxic respiratory distress
- acute renal failure [**1-4**] AIN and ATN
- aspiration pna
- nosocomial pna
- uremia
- altered mental status
- metabolic acidosis
- anasarca
- s/p cervical fracture
- drug rash
- anemia
Secondary:
- DMII
- transaminitis
- hyperchol
- hx of etoh abuse
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
|
[
"349.82",
"287.5",
"E930.0",
"V15.88",
"584.5",
"276.2",
"276.1",
"518.81",
"250.00",
"038.9",
"285.1",
"V45.4",
"599.0",
"995.92",
"286.7",
"709.8",
"486",
"693.0",
"570",
"789.5",
"428.0",
"995.0",
"785.59"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.95",
"99.07",
"99.04",
"38.93",
"96.6",
"96.71",
"00.14",
"39.95",
"96.04",
"00.17"
] |
icd9pcs
|
[
[
[]
]
] |
13910, 13919
|
9645, 9645
|
276, 295
|
14256, 14266
|
3631, 8183
|
14319, 14327
|
2729, 2784
|
13881, 13887
|
13940, 14235
|
13527, 13858
|
9662, 13501
|
14290, 14296
|
2799, 3612
|
231, 238
|
323, 1986
|
8192, 9622
|
2008, 2352
|
2368, 2713
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,247
| 105,172
|
15730
|
Discharge summary
|
report
|
Admission Date: [**2122-9-3**] Discharge Date: [**2122-9-10**]
Date of Birth: [**2059-1-8**] Sex: F
Service: MEDICINE
Allergies:
Percocet / Motrin / Nsaids / Aspirin / Dilantin
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
62yo F w/ a PMH of ESRD on HD s/p failed kidney transplant, DVT
(associated w/ HD cath), and HTN who presents to the ED today
after being found on her neighbors stoop confused and apparently
topless. History is primarily taken from EMS reports as the
patient recalls little of the event. Apparently she was feeling
her usual self when she went to HD today. She remembers the ride
home but she states she got off at the wrong street. The next
thing she remembers was being evaluated by EMS. Of note, her FS
was apparently 69 in the field but she is not taking insulin
currently. No history of incontinence, tongue laceration, injury
or LOC. It is not clear how long she was unattended prior to
being found. She had a similar presentation in [**1-13**] with
question of seizure activity but was eventually thought not to
be having seizures. Also reports blood in her urine last night,
and abdominal pain. Reports occasionaly missing her medications,
but always taking her statin and coumadin. Recent change in
coumadin from 5 to 7mg.
In the ED her vitals were 97.6, 108, 200/100, 100% RA. FS was in
100s on arrival. She received 5mg IV and 100mg PO of metoprolol
which slowed her rate and lowered her BP to more appropriate
levels. She did have episodes of sinus tach up into the 130s
during EJ placement attempts. However, this resolved prior to
transfer. She was evaluated by neurology in the ED who felt that
she was primarily encephalopathic without focality but could not
rule out a seizure.
Past Medical History:
1. Diabetes mellitus.- unclear hx, not on medication, nl [**Name (NI) **]
2. End-stage renal disease secondary to diabetes mellitus s/p
failed dual kidney transplant
3. Hemodialysis.
4. Hypertension.
5. Hyperlipidemia.
6. Thrombosis of bilateral IVJ (catheter placement)-- DVT
associated with HD catheter RUE on anticoagulation
7. SVC syndrome [**1-13**], s/p thrombectomy, on anticoagulation,
hospitalization complicated by obturator hematoma and required
intubation, PEG and Trach with VAP, and questionable seizure
8. Currently, in hemodialysis.
9. Osteoarthritis.
10. Arthritis of the left knee at age nine, treated with ACTH
resulting in secondary [**Location (un) **].
11. rheumatic fever as child
12. Afib with RVR
Past Surgical History:
1. Kidney transplant in [**2119**].
2. Left arm AV fistula for dialysis.
3. Removal of remnant of AV fistula, left arm.
4. Catheter placement for hemodialysis.
5. Low back surgery (unspecified)
Social History:
-lives with her nephew [**Name (NI) **], but does not know his number
-Brother is HCP
-[**Name (NI) 1139**]: 10pkyr [**Name2 (NI) 1818**], recently quit but states that she has
restarted and smoking 5 cigs per day
-denies etoh/illicits
Family History:
Mother and sister with diabetic mellitus.
Kidney failure in mother, sister
Physical Exam:
VS: 96.7, 155/84, 83, 20, 98%RA
GEN: Well appearing, NAD
HEENT: NCAT, EOMI, PERRL, oropharynx clear and without erythema
or exudate
NECK: Supple, no LAD, no appreciable JVD
CV: RRR, normal S1S2, systolic murmur at lower sternal border,
no rubs or gallops, 2+ pulses
PULM: CTAB, no w/r/r, good air movement bilaterally
ABD: Soft, ND, mild suprapubic tenderness without rebound or
guarding, normoactive bowel sounds, no organomegaly, no
abdominal bruit appreciated
EXT: Warm and well perfused, full and symmetric distal pulses,
no pedal edema
NEURO: AOx2, trouble with date. Memory [**1-8**] at 2min. Language
fluent. Strength 5/5 in all extremities. Sensation intact to
light touch diffusely. DTRs 2+ bilaterally in patella and
biceps, toes down going. Gait deferred. Seems confused about her
history
Pertinent Results:
[**2122-9-3**] 01:50PM BLOOD WBC-8.7 RBC-3.84*# Hgb-12.5# Hct-37.0
MCV-96 MCH-32.5* MCHC-33.8 RDW-15.5 Plt Ct-254#
[**2122-9-10**] 07:59AM BLOOD WBC-9.2 RBC-4.33 Hgb-14.1 Hct-42.7
MCV-99* MCH-32.5* MCHC-33.0 RDW-15.4 Plt Ct-451*
[**2122-9-3**] 02:46PM BLOOD PT-17.1* PTT-28.0 INR(PT)-1.6*
[**2122-9-10**] 07:59AM BLOOD PT-22.3* INR(PT)-2.1*
[**2122-9-3**] 01:50PM BLOOD Glucose-88 UreaN-15 Creat-4.9* Na-140
K-3.9 Cl-97 HCO3-28 AnGap-19
[**2122-9-8**] 07:45AM BLOOD Glucose-88 UreaN-60* Creat-12.2*# Na-139
K-4.0 Cl-97 HCO3-22 AnGap-24
[**2122-9-10**] 07:59AM BLOOD Glucose-199* UreaN-47* Creat-9.7*# Na-139
K-4.0 Cl-92* HCO3-26 AnGap-25*
[**2122-9-3**] 01:50PM BLOOD ALT-13 AST-16 AlkPhos-58 TotBili-0.5
[**2122-9-3**] 01:50PM BLOOD Calcium-10.1 Phos-3.8 Mg-1.9
[**2122-9-10**] 07:59AM BLOOD Calcium-9.7 Phos-7.0* Mg-2.3
[**2122-9-7**] 07:30AM BLOOD VitB12-1032* Folate-GREATER TH
[**2122-9-7**] 07:30AM BLOOD TSH-1.2
[**2122-9-4**] 05:40AM BLOOD PTH-401*
[**2122-9-3**] 01:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2122-9-3**] 07:30PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.005
[**2122-9-3**] 07:30PM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-250 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
[**2122-9-3**] 07:30PM URINE RBC-0-2 WBC-[**6-16**]* Bacteri-FEW Yeast-NONE
Epi-[**11-26**]
[**2122-9-4**] 01:30AM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG mthdone-NEG
Urine cx ([**9-3**], [**9-4**], [**9-6**]): mixed flora consistent with
contamination
Blood cx ([**9-4**]): 2 negative, 1 NGTD
Cdiff ([**9-6**]): negative
CXR [**2122-9-3**]:
IMPRESSION: No evidence of acute cardiopulmonary process
Head CT without Contrast [**2122-9-3**]:
IMPRESSION: No hemorrhage or acute edema.
EEG [**2122-9-4**]:
IMPRESSION: This is an abnormal routine EEG due to the slow
background,
generalized bursts of slow activity, and multifocal slow
transients with
triphasic features. These findings suggest a widespread
encephalopathy
afecting both cortical and subcortical structures. Medications,
metabolic disturbancies and infections are among the most common
causes.
There were no lateralized or epileptiform features noted.
Abdominal CT with contrast [**2122-9-4**]:
IMPRESSION: No evidence of abdominal inflammatory process, or
other specific CT finding to explain abdominal pain.
Head CT without Contrast [**2122-9-6**]: (prelim)
Limited study, despite being repeated, no acute intracranial
hemorrhage
appreciated.
MRI Head without contrast [**2122-9-7**]:
CONCLUSION: No definite interval change in the appearance of the
brain
compared to the prior study.
Brief Hospital Course:
1) Altered mental status: Pt with similar presentations in the
past. Labs to evaluate for a toxic-metabolic cause were
unrevealing. She was initially treated with Cipro for a
suspected UTI, but stopped on day 2 as this drug can lower the
seizure threshold and urine grew mixed flora. Head imaging with
CT and MRI was unrevealing. EEG showed generalized slowing. On
the morning of [**9-5**] during her HD treatment, she became very
agitated, confused, and then unresponsive. Her arms were
clutched to her chest in fists and her eyes were deviated to the
left. She was given 1 mg of Ativan and remained disoriented and
somnolent, presumably postictal. Of note, she was also dialyzed
earlier on the day of admission. Neurology was consulted and
felt her presentation was due to fluid and electrolyte shifts
with HD and recommended [**Date Range 13401**] for her apparent seizure.
Dilantin was avoided due to prior drug related angioedema. She
remained confused and agitated, and her somnolence increased.
She was vomiting and minimally responsive to sternal rub. She
was transferred to the MICU for observation, received IV haldol
for agitation, and was called out the next day as she remained
stable. She subsequently received HD two more times with no
adverse reaction. Her mental status improved and she was A&Ox3
at discharge, although likely with some chronic cognitive
deficits. Her sertraline was held during this admission as well
as on discharge, and can be addressed as an outpatient.
2) ESRD on HD: She was continued on her Tu/Th/Sat HD schedule.
She was continued on nephrocaps and cinacalcet and started on
sevelamer.
3) History of DVT/SVC syndrome: Her INR was initially
subtherapeutic at 1.6 and she was bridged on a heparin drip.
With warfarin 5mg daily, it improved to 1.9. However, her
heparin and warfarin were held when her mental status
deteriorated. Once CT head showed no bleed, her heparin was
continued. When decision was made to not perform LP, her
warfarin was restarted and heparin was stopped due to a
therapeutic INR of 2.2.
Medications on Admission:
ATORVASTATIN - 20 mg by mouth once a day
B COMPLEX-VITAMIN C-FOLIC ACID 1 Capsule(s) by mouth once a day
CINACALCET 90 mg by mouthonce a day
DARBEPOETIN ALFA IN POLYSORBAT - 40 mcg/mL Solution - once per
week weekly
LISINOPRIL - 5 mg by mouth daily
METOPROLOL TARTRATE - 100 mg by mouth daily
SERTRALINE 100 mg by mouth hs
WARFARIN - - 7 mg by mouth once a day
Tylenol 3 PRN pain
Discharge Medications:
1. Levetiracetam 250 mg Tablet [**Date Range **]: One (1) Tablet PO QHD (each
hemodialysis).
Disp:*12 Tablet(s)* Refills:*2*
2. Metoprolol Tartrate 50 mg Tablet [**Date Range **]: One (1) Tablet PO twice
a day.
Disp:*60 Tablet(s)* Refills:*2*
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Date Range **]: One (1) Cap
PO DAILY (Daily).
4. Atorvastatin 20 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY
(Daily).
5. Darbepoetin Alfa In Polysorbat 40 mcg/0.4 mL Pen Injector
[**Date Range **]: One (1) Subcutaneous once a week.
6. Lisinopril 5 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily).
7. Levetiracetam 250 mg Tablet [**Date Range **]: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Sevelamer HCl 800 mg Tablet [**Date Range **]: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS): Take with meals.
Disp:*90 Tablet(s)* Refills:*2*
9. Cinacalcet 90 mg Tablet [**Date Range **]: One (1) Tablet PO once a day.
10. Warfarin 5 mg Tablet [**Date Range **]: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
11. Warfarin 2 mg Tablet [**Date Range **]: One (1) Tablet PO once a day: Take
at same time as 5mg pill.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Caregroup
Discharge Diagnosis:
Primary: Altered mental status, seizure history
Secondary: End stage renal disease, status post renal transplant
Discharge Condition:
Stable.
Discharge Instructions:
You were admitted to [**Hospital1 18**] with confusion. This occurred after
your dialysis. It is possible that you had a seizure during your
confusion. It is not clear what caused the confusion, but it has
improved greatly, with no problems after your last dialysis.
Please take all medications as prescribed and go to all follow
up appointments. We are holding your sertraline (Zoloft) for now
as this might have contributed to your confusion. We have
started you on [**Last Name (LF) **], [**First Name3 (LF) **] antiseizure medication, with
assistance from the neurologists. We are also starting
sevelamer, a medication to help your electrolytes. Note that you
should take your metoprolol twice daily.
If you experience any confusion, seizures, weakness, fevers, or
any other concerning symptoms, please seek medical attention or
come to the ER immediately.
Followup Instructions:
Primary Care: Dr. [**Last Name (STitle) **], ([**Telephone/Fax (1) 45314**], Wed [**9-16**], 1pm
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2122-10-16**] 2:00
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) 540**] & [**Doctor Last Name **], Neurology Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2122-11-10**] 4:30
Completed by:[**2122-9-10**]
|
[
"272.4",
"250.40",
"345.90",
"715.90",
"780.97",
"996.73",
"V15.81",
"453.40",
"V58.61",
"E878.0",
"403.91",
"599.0",
"599.7",
"996.81",
"427.89",
"585.6",
"V45.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
10396, 10436
|
6674, 6685
|
326, 334
|
10593, 10603
|
4003, 6651
|
11514, 11965
|
3091, 3168
|
9160, 10373
|
10457, 10572
|
8755, 9137
|
10627, 11491
|
2627, 2822
|
3183, 3984
|
265, 288
|
362, 1859
|
6700, 8729
|
1881, 2604
|
2838, 3075
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,079
| 155,625
|
38254+58209
|
Discharge summary
|
report+addendum
|
Admission Date: [**2179-7-12**] Discharge Date: [**2179-7-18**]
Date of Birth: [**2135-4-6**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Niaspan / Imdur
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2179-7-14**] Re-do sternotomy and re-do coronary artery bypass
grafting x3 with reverse saphenous vein graft to the first
marginal branch, second marginal branch, and posterior
descending artery
History of Present Illness:
44 year old male with significant coronary artery disease, he
has already undergone CABG [**2169**] and PTCI with the last in
[**2177-2-7**]. Approximately 6 weeks prior to admission chest
pain with activity and esclating to at rest, with increased
nitroglycerin use. He started taking nitroglycerin continuously
a day prior to presenting to the emergency department, and then
presenting with 8/10 chest pain.
Past Medical History:
Hypertension
Ischemic heart disease
Anxiety
Depression
Familial hypercholestemia - treated with LDL apheresis q2weeks
Coronary Artery Bypass Graft x3 [**2169**] at [**Hospital **] hospital
Multiple stents - last [**2177-2-7**]
Social History:
Race: Caucasian
Last Dental Exam: about 4 years ago
Lives with: fiancee
Occupation: applying for disability
Tobacco: denies
ETOH: quit in [**2163**] - still occ drink every 3-4 months
Illicit drugs: occassional marjuana
Family History:
mother CABG and [**Name (NI) **] alive started in her 30's, father deceased
sudden MI - 53
Physical Exam:
Pulse: Resp: O2 sat:
B/P Right: Left:
Height: Weight:
General: arrived with chest pain [**3-17**] resolved with SL ntg x1-
no
ekg changes
Skin: Dry [x] intact [x] left groin cath site - mid line sternal
scar from surgery [**2169**]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur no
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] no palpable masses
Extremities: Warm [x], well-perfused [x] Edema none
Varicosities: None [x] right leg healed EVH site scars
Neuro: Grossly intact
Pulses:
Femoral Right: +1 Left: +1
DP Right: +1 Left: +1
PT [**Name (NI) 167**]: +1 Left: +1
Radial Right: +1 Left: +1
Carotid Bruit Right: no bruit Left: no bruit
Pertinent Results:
[**2179-7-14**] Echo: Pre-CPB: No spontaneous echo contrast is seen in
the left atrial appendage. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. There are simple atheroma in
the descending thoracic aorta. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is no
pericardial effusion. Post-CPB: The patient is AV-Paced, on no
inotropes. Normal RV systolic fxn. Initially the inferior wall
of the LV was hypokinetic but slowly improved to normal systolic
fxn. Trace - 1+ MR. [**First Name (Titles) **] [**Last Name (Titles) **]. Aorta intact.
[**2179-7-13**] Carotid U/S: Right ICA stenosis 0%. Left ICA stenosis
<40%.
[**2179-7-16**] 05:45AM BLOOD WBC-8.1 RBC-3.50* Hgb-10.9* Hct-30.8*
MCV-88 MCH-31.2 MCHC-35.5* RDW-14.2 Plt Ct-188
[**2179-7-16**] 05:45AM BLOOD Glucose-130* UreaN-10 Creat-0.9 Na-137
K-4.4 Cl-102 HCO3-26 AnGap-13
Brief Hospital Course:
As stated in the HPI, Mr. [**Known lastname **] presented to outside hospital ED
with chest pain. Work-up there, included cardiac cath revealed
severe native disease along with occluded bypass grafts from
surgery in [**2169**]. He was transferred to [**Hospital1 18**] for surgery. Upon
admission he was medically managed and underwent appropriate
pre-operative work-up. On [**7-14**] he was brought to the operating
room where he underwent a redo-sternotomy and 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 extubated.
Beta-blockers and diuretics were initiated and he was diuresed
towards his pre-op weight. The patient was transferred to the
telemetry floor for further recovery. Chest tubes and pacing
wires were discontinued without complication. The patient was
evaluated by the physical therapy service for assistance with
strength and mobility. By the time of discharge on POD 4 the
patient was ambulating freely, the wound was healing and pain
was controlled with oral analgesics. The patient was discharged
to home with VNA in good condition with appropriate follow up
instructions.
Medications on Admission:
Lopressor 150 mg twice a day
Plavix 75 mg daily
Norvasc 10 mg daily
Aspirin 325 mg daily
Crestor 40 mg daily
Paxil 20 mg daily
Nitroglycerin patch
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
6. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 2
weeks.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 486**] saco [**State 1727**]
Discharge Diagnosis:
Coronary Artery Disease s/p Re-do sternotomy and re-do coronary
artery bypass grafting x3
Past medical history:
Hypertension
Ischemic heart disease
Anxiety
Depression
Familial hypercholestemia - treated with LDL apheresis q2weeks
Coronary Artery Bypass Graft x3 [**2169**] at [**Hospital **] hosp. - Right
EVH
Multiple stents - last [**2177-2-7**]
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema trace bilaterally
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
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 Thursday, [**8-19**] at 1PM.
Please call to schedule appointments with your
PCP/Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**2-10**] weeks
[**Location (un) 34004**] Cardiology Associates
[**Initials (NamePattern4) 85261**]
[**Last Name (NamePattern4) **], [**Numeric Identifier 34009**]
Phone Number:([**Telephone/Fax (1) 85262**]
**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:[**2179-7-18**] Name: [**Known lastname 13542**],[**Known firstname **] Unit No: [**Numeric Identifier 13543**]
Admission Date: [**2179-7-12**] Discharge Date: [**2179-7-18**]
Date of Birth: [**2135-4-6**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Niaspan / Imdur
Attending:[**First Name3 (LF) 741**]
Addendum:
The following medication changes were made:
Crestor changed to simvastatin
added Ibuprofen
see below for details
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
5. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 2
weeks.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
9. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
10. Ibuprofen 800 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours as needed for pain.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 1066**] saco [**State 4488**]
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2179-7-18**]
|
[
"414.01",
"401.9",
"V58.66",
"272.0",
"411.1",
"V45.82",
"300.4",
"414.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.13"
] |
icd9pcs
|
[
[
[]
]
] |
9894, 10090
|
3462, 4772
|
292, 491
|
6464, 6690
|
2367, 3439
|
7529, 8662
|
1435, 1527
|
8685, 9871
|
6094, 6184
|
4798, 4946
|
6714, 7506
|
1542, 2348
|
242, 254
|
519, 932
|
6206, 6443
|
1198, 1419
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,611
| 126,790
|
40619
|
Discharge summary
|
report
|
Admission Date: [**2122-6-30**] Discharge Date: [**2122-7-15**]
Date of Birth: [**2079-5-4**] Sex: M
Service: SURGERY
Allergies:
aspirin
Attending:[**First Name3 (LF) 5569**]
Chief Complaint:
Hemoperitoneum
Major Surgical or Invasive Procedure:
[**2122-7-1**]: Exploratory laparotomy with evacuation of hematoma.
History of Present Illness:
43M with alcoholic cirrhosis and hepatitis B who presented to
[**Hospital 4199**] hospital (he was then transferred to [**Hospital 8**] Hospital)
[**6-24**] with acute hepatic failure and pancreatitis (unclear of
severity, lipase recorded as 108). He then discharged himself
AMA on [**6-27**] and returned on [**6-28**] with acute decompensated liver
failure (MELD 41, INR incr 1.8->3.5), anemia, oliguria/acute
renal failure and suspected sepsis. He is being transferred
from CH tonight due to hemoperitoneum following paracentesis.
.
The patient reportedly was noted to be more somnolent on [**6-29**]
and underwent paracentesis on [**6-29**] (of note he also had a
paracentesis on [**6-24**]) for 2.5L but no cell counts were sent and a
descriptive report of the fluid was not logged (family reports
fluid was non-bloody). He therefore underwent repeat
paracentesis this morning and 1L of frank blood was removed. His
hematocrit down trended from 36->24->22, he then received 5U
PRBC and a repeat hematocrit returned 20.5 at [**Hospital1 18**]. He also
recieved 4 units of FFP for an INR of 3.5 (INR on presentation
1.2). NGT lavage performed on arrival at [**Hospital1 18**] was negative.
Patient was intubated this evening due to aggitation for ease of
transport. Blood cultures from CH on [**6-28**] were negative x 4.
Past Medical History:
Hypertension, asthma, alcohol abuse, GERD, hypercholesterolemia,
asthma, hepatitis B, pancreatitis, cirrhosis, hepatic
insufficiency
Social History:
Drinks 10 beers per day for many years. Denies IVDU. Lives with
roommate.
Family History:
Brother with alcoholic cirrhosis.
Physical Exam:
On Admission:
Vitals: 95.6 107 89/53 23 96% (CMV 50% 450 x 12 5/-)(on
levophed)
GEN: intubated and sedated
HEENT: jaundiced, + scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: minimal crackles at lung bases b/l, No W/R/R
ABD: Soft, abdomen distended with ascites (bladder pressure
30->41), normoactive bowel sounds, no palpable masses, no
hernias, mild ecchymosis at midline, blood stained dressing in
LLQ
DRE: normal tone, no gross or occult blood
Ext: No LE edema, LE warm and well perfused
Pertinent Results:
On Admission: [**2122-6-30**]
WBC-18.1* RBC-2.08* Hgb-7.2* Hct-20.5* MCV-99* MCH-34.5*
MCHC-34.9 RDW-21.8* Plt Ct-140*
Neuts-76* Bands-6* Lymphs-6* Monos-10 Eos-1 Baso-0 Atyps-0
Metas-1* Myelos-0
PT-24.6* PTT-41.0* INR(PT)-2.3*
Glucose-94 UreaN-31* Creat-2.1* Na-131* K-4.2 Cl-93* HCO3-16*
AnGap-26*
ALT-49* AST-154* LD(LDH)-325* CK(CPK)-[**2085**]* AlkPhos-183*
Amylase-85 TotBili-18.8* DirBili-11.6* IndBili-7.2
Albumin-2.8* Calcium-7.3* Phos-8.4* Mg-2.2
Lipase-78*
CK-MB-52* MB Indx-2.6 cTropnT-0.01
.
[**2122-6-30**] 10:56 pm MRSA SCREEN Source: Nasal swab.
MRSA SCREEN (Final [**2122-7-3**]): No MRSA isolated.
[**2122-6-30**] 11:28 pm BLOOD CULTURE Source: Line-RIJ.
Blood Culture, Routine (Final [**2122-7-6**]): NO GROWTH.
[**2122-7-1**] 02:41AM BLOOD Hct-29.5*#
[**2122-7-1**] 03:31AM BLOOD CK-MB-45* MB Indx-2.5 cTropnT-0.01
.
[**2122-7-1**] 1:16 am PERITONEAL FLUID
GRAM STAIN (Final [**2122-7-1**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2122-7-4**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
.
[**2122-7-3**] 1:26 pm CATHETER TIP-IV Source: CVL.
WOUND CULTURE (Final [**2122-7-5**]): No significant growth.
[**2122-7-3**] 07:55AM BLOOD WBC-27.3* RBC-3.58* Hgb-11.5* Hct-32.6*
MCV-91 MCH-32.1* MCHC-35.3* RDW-19.2* Plt Ct-62*
[**2122-7-3**] 02:13AM BLOOD PT-19.4* PTT-42.9* INR(PT)-1.8*
[**2122-7-3**] 03:09PM BLOOD Glucose-115* UreaN-41* Creat-2.1* Na-133
K-3.8 Cl-100 HCO3-22 AnGap-15
[**2122-7-3**] 02:13AM BLOOD ALT-29 AST-92* LD(LDH)-220 AlkPhos-94
TotBili-19.1*
[**2122-7-3**] 03:09PM BLOOD Calcium-8.9 Phos-2.7 Mg-2.6
[**2122-7-4**] 11:45 am PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final [**2122-7-4**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
[**2122-7-4**] 07:28AM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-LG Urobiln-2* pH-5.5 Leuks-MOD
.
Radiologic Studies:
.
[**2122-6-30**] AXR:
IMPRESSION: Multiple air-filled dilated loops of small bowel
without air in the colon is concerning for small bowel
obstruction.
.
[**2122-7-1**] DUPLEX DOP ABD/PEL LIMITED POR; LIVER OR GALLBLADDER US
IMPRESSION:
1. No definite flow is noted within the main portal vein.
2. Ascites.
.
[**2122-7-6**] RUQ Ultrasound
FINDINGS: No focal liver lesion is identified. No biliary
dilatation is seen and the common duct measures 0.4 cm. A large
amount of sludge is seen within the lumen of the gallbladder.
The gallbladder wall is mildly thickened, likely due to
underlying liver disease. The midline structures and kidneys are
obscured from view by overlying bowel. The spleen is
unremarkable measuring 10.2 cm. There is a scant trace of
ascites seen in the abdomen in the perihepatic space. A small
left pleural effusion is noted. DOPPLER EXAMINATION: Color
Doppler and pulse-wave Doppler images were obtained. The main,
right and left portal veins are all patent and
demonstrate forward flow. Appropriate flow is seen in the
hepatic veins and in the main hepatic artery. The midline
vessels were obscured from view.
IMPRESSION:
1. Patent portal veins.
2. Sludge-filled gallbladder.
3. Scant trace of ascites and small left pleural effusion.
.
[**2122-7-8**] CT abdomen/pelvis with contrast:
TECHNIQUE: Multiple MDCT axial images were obtained from the
base of the neck through the proximal thighs after the
uneventful administration of 130 cc of Optiray intravenously.
Multiplanar reformats were derived.
.
CT OF THE CHEST WITH INTRAVENOUS CONTRAST: The visualized
thyroid enhances homogeneously. There is no axillary,
mediastinal or hilar pathologic lymphadenopathy. The thoracic
aorta and pulmonary arteries appear normal. Heart is normal in
size without pericardial effusion. The esophagus appears normal.
Central airways are patent to the level of subsegmental bronchi.
Ground-glass opacities are seen mainly peripherally with slight
upper lobe preponderance.A more nodular wedge-shaped opacity is
seen on the left. There is atelectasis and superimposed
consolidation in the right lower lobe. In this area, bronchioles
appear ectatic. There is no pleural effusion. There is no
pneumothorax.
.
CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: The liver is
significantly enlarged. There is periportal edema. There is
heterogeneous enhancement of the liver. The gallbladder is
enlarged with an edematous wall. The pancreas appears normal.
The spleen is normal. The left kidney is enlarged in
compensation for the right atrophic kidney. The adrenals appear
normal. Small bowel loops are significantly distended to 4.0 cm.
There is a smooth long transition point in the proximal ileal
loops proximal to which there is fecalization. Distal ileum is
decompressed. There is no free air within the abdomen. There is
a small amount of fluid adjacent to distal bowel loops on the
right and proximal to the jejunal loops on the left. There is no
pathologic lymphadenopathy in the abdomen. CT OF THE PELVIS WITH
INTRAVENOUS CONTRAST: Surgical drain is seen entering the left
lower abdominal wall and coursing into the contralateral side to
the anterior surface of the liver. The ascending colon
demonstrates an edematous prominent wall. The bladder appears
normal. The prostate and seminal vesicles appear normal.
MUSCULOSKELETAL: There is no suspicious osteolytic or
osteoblastic lesion. Degenerative changes are seen in the lower
thoracic spine. Midline staples are seen in the abdomen
anteriorly. IMPRESSION: 1. Distended small bowel with tapering
long segment transition to decompressed ileum; findings are
consistent with early or partial small-bowel obstruction. 2.
Hepatomegaly with heterogeneous enhancement consistent with
acute hepatitis. 3. Bibasilar atelectasis with probable
superimposed consolidation in the right lower lobe; coexistent
pneumonia cannot be excluded.
.
[**2122-7-13**] KUB: INDICATION: History of alcoholic cirrhosis
presenting from outside hospital with hemoperitoneum, status
post paracentesis and exploratory laparotomy for abdominal
compartment syndrome, now with a large quantity of ascites
draining from the [**Location (un) 1661**]-[**Location (un) 1662**] tube and diarrhea concerning for
C. diff. Worsening abdominal pain today. COMPARISON: Abdominal
radiographs from [**2122-6-30**]. Abdomen/pelvis CT from [**2122-7-8**]. FINDINGS: Air and contrast material are seen within a
distended stomach and there are multiple air-filled distended
loops of small bowel, measuring up to 4.3 cm. Air is also seen
within the colon and rectum, however. Several air-fluid levels
are seen on the decubitus radiograph. There is no free air in
the abdomen. A drainage catheter extends across the lower
abdomen, and then courses into and ends within the right upper
quadrant. Skin staples are noted along the abdominal and pelvic
midline.
IMPRESSION: 1) Multiple loops of air-filled distended small
bowel along with air in the colon and rectum is most consistent
with ileus. 2) No evidence of pneumoperitoneum.
.
[**2122-7-13**] Renal US:
TECHNIQUE: [**Doctor Last Name **]-scale and color ultrasound images of both
kidneys were obtained. COMPARISON: CT of the abdomen and pelvis
from [**2122-7-8**] and abdominal ultrasound from [**2122-7-6**].
FINDINGS: The right kidney is known to be atrophic from a
previous CT and is not demonstrated on this ultrasound
examination. The left kidney is hypertrophic measuring 14 cm
without hydronephrosis. There are no suspicious masses and no
renal stones. Trace free fluid is seen in the upper quadrant at
the [**Location (un) **] pouch. Urinary bladder is moderately filled with
urine. IMPRESSION: No hydronephrosis.
.
Labs at discharge:
Brief Hospital Course:
The patient was admitted to the surgery service for evaluation
and treatment. On admission, he recieved 5 units of PRBC and 4
units of FFP in the ED and was then transferred to the ICU. He
was further transfused with 6 units of blood , 6 units of FFP
and 2 units of platelets on hospital day 2. He was taking to the
OR on HD 2 for exploratory laparotomy and evacuation of the
hematoma.
.
Post operative course:
.
Neuro: The patient received intravenous dilaudid with good
effect and adequate pain control. When tolerating oral intake,
the patient was transitioned to oral pain medications.
.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
.
Pulmonary: The patient was gradually weaned off mechanical
ventilation and extubated on POD 2. Good pulmonary toilet, early
ambulation and incentive spirometry were encouraged throughout
this hospitalization.
.
GI/GU/FEN:
Post operatively, the patient was made NPO with IVF.
The patient's diet was advanced when appropriate, which was
tolerated well, however his oral intake was only fair and he was
to receive a post pyloric feeding tube.
The patient's intake and output were closely monitored as his JP
drain output was greater than 2 liters with ascitic fluid, and
at POD 9 it started to slow down to less than one liter and the
drain was pulled on POD 13. IVF repletions were adjusted when
necessary. The patient's electrolytes were routinely followed
during this hospitalization, and repleted when necessary. As
creatinine value was increasing, renal consult was called and in
concert with the hepatology service the patient was managed for
hepatorenal syndrome with the addition of IV albumin, octreotide
and midodrine. There was possible an early small bowel
obstruction on the [**7-8**] CT, however the patient continued to
have flatus and have daily BMs and continued lactulose and
started rifaxamin. Duplex of liver on [**7-6**] revealed patent
portal veins.
.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. He was started on
vancomycin and zosyn initially. WBC trended up in spite of
antibiotics with count 53.3 on [**2122-7-11**]. Blood cultures have been
sent throughout the hospitalization, and have always returned as
no growth. C diff was sent x 3 and c diff PCR were all negative.
He was treated empirically for c diff with PO Vanco and flagyl.
Cipro and Flagyl were continued for SBP prophylaxis. CT scan
done on [**7-8**] did not reveal any fluid collections or areas
concerning for infection. There was one positive peritoneal
fluid for VRE on [**7-10**], however the organism count was scant.
.
Endocrine: The patient's blood sugar was monitored throughout
this stay; insulin dosing was adjusted accordingly.
.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required during this stay
following the initial admission transfusions.
.
Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible. He was ambulatory on discharge without assistance. He
was begun on rifaximin while inpatient given concern for hepatic
encephalopathy since the patient intermittently appeared
confused.
.
At the time of discharge, in light of his worsening renal
failure and poor overall prognosis on aggressive treatment, the
patient in discussion with his family elected to be made CMO
(comfort measures only). Social work and palliative care met
with the patient and his family, and hospice was arranged. All
of his medications except those for pain control and nausea
control were discontinued on discharge to mothers home with
hospice.
Medications on Admission:
CIWA scale, Famotidine 40mg daily, Folate 1 mg daily,
Furosemide 20 mg daily, Haldol 0.5q4p, HSQ TID, Lactulose 30mg
[**Hospital1 **], MVI 1 tab daily, Pentoxifylline 400mg TID, Spironolactone
50mg daily, Thiamine [**Age over 90 **] m gdaily, protonix 40mg [**Hospital1 **]
Discharge Medications:
1. Medications
Palliative Care management package for pain, nausea, secretions
per your hospice protocol
2. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO q 2 hours as needed
for pain.
Disp:*20 Tablet(s)* Refills:*0*
3. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig:
10-30 mg SL PO hourly as needed for pain.
Disp:*30 ml* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Hospice of the [**Location (un) 1121**]
Discharge Diagnosis:
Alcoholic cirrhosis with hemoperitoneum and abdominal
compartment syndrome
Hepatorenal syndrome
Acute Liver failure
Acute Kidney Failure
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
He will become more lethargic and sleepy and this is to be
expected.
The Visiting Nurses will help you with medications and symptom
management including managing nausea and controlling pain.
Followup Instructions:
None
Completed by:[**2122-7-15**]
|
[
"V49.86",
"070.22",
"303.90",
"272.0",
"568.81",
"530.81",
"285.1",
"401.9",
"584.5",
"493.90",
"570",
"571.2",
"789.59",
"572.4",
"998.11",
"276.2",
"729.73",
"998.89",
"785.59"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.77",
"54.91",
"96.71",
"54.19"
] |
icd9pcs
|
[
[
[]
]
] |
14949, 15019
|
10547, 14260
|
281, 351
|
15200, 15200
|
2554, 2554
|
15595, 15631
|
1975, 2011
|
14585, 14926
|
15040, 15179
|
14286, 14562
|
15380, 15572
|
2026, 2026
|
227, 243
|
10524, 10524
|
379, 1710
|
2568, 3645
|
4655, 10504
|
15215, 15356
|
1732, 1867
|
1883, 1959
|
4605, 4619
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,336
| 172,837
|
29207
|
Discharge summary
|
report
|
Admission Date: [**2193-1-19**] Discharge Date: [**2193-2-22**]
Date of Birth: [**2129-8-24**] Sex: F
Service: SURGERY
Allergies:
Vancomycin / Iodine; Iodine Containing / Meropenem / Ceftriaxone
/ Ciprofloxacin / Flagyl
Attending:[**Last Name (NamePattern1) 4659**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
1.Exploratory laparotomy, sigmoid resection, Hartmann procedure
and end-colostomy.
2. Intra-abdominal drain placement, then removal on [**2193-2-22**]
History of Present Illness:
The patient is a 63-year-old female with past medical history
significant for atrial fibrillation, hyperlipidemia, asthma,
hypertension, diet-controlled type II diabetes mellitus,
myocardial infarction with PCI (RCA stent in [**2192-5-17**]),
status-post CABG x1 ([**2192-7-31**])and a history of Acute Myelogenous
Leukemia with allogenic bone marrow transplant done [**3-/2191**], on
regular low dose steroids for GVHD of the skin s/p BMT, who
presented on [**2193-1-19**] complaining of [**1-18**] days of "crampy" lower
abdominal pains. The pain was acute in onset over a 1 day
period. She denied any associated fevers, chills. No
accompanying nausea or emesis, and she also denied any pain with
urination.
.
Of relevance, Mrs. [**Known lastname **] has known diverticulosis which was
identified on a colonoscopy about four years ago. Other
pertinent GI related conditions include her history of abdominal
pains and diarrhea which eventually led to the discovery of
C.difficile colitis back in [**2191-3-17**]. She states she had a
recurrence of her C.difficile again in [**5-/2191**] but was then
effectively treated and her symptoms had completely resolved.
.
Due to her severe abdominal cramping and pains, she was
initially observed in the ICU setting with the intention to
manage her conservatively with medications and supportive
therapy as she was felt to be a poor surgical candidate given
her previous cancer and cardiac history and being on ASA and
Plavix on admission.
.
Past Medical History:
- Coronary Artery Disease, STEMI in [**2192-5-17**] s/p PCI/stenting to
RCA at that time
- History of AML, s/p chemotherapy, radiation and bone marrow
transplantation
- Hypertension
- Hypercholesterolemia
- GERD
- Type two diabetes mellitus - diet controlled
- Diverticulosis, noted on colonoscopy 4 years ago
- Occasional bronchospasm treated with Primatene Mist
- History of SVC clot [**2191**] [**2-18**] PORT (s/p course of lovenox)
- History of C.Diff [**3-23**] & [**5-23**]
- History of VRE
- History of Shingles
- History of Asthma
Social History:
She has two children. She has been married for 40 years. She is
postmenopausal. She has 2 sisters, one with [**Name (NI) 5895**] disease.
The patient is a smoker, has been an on and off smoker. She
smoked about 1 pack per day for 10 years, and quit [**1-23**]. She
denies EtOH, IVDU. She is a retired administrative assistant.
Family History:
The patient's mother with a history of stroke. Both of her
maternal and paternal grandmothers also had a history of CVA.
Father with history of colon caner. No other known history of
cancer in the family. No known blood disorders. Has a sister
with [**Name (NI) 5895**]. She has 2 sisters, the other sister with
hypertension.
Physical Exam:
Initial Physical Exam:
Vitals- T 95, HR 75, BP 104/53, RR 22, O2sat 96% RA
Gen- NAD, alert
Head and neck- AT, NC, soft, supple, no masses
Heart- RRR, no murmurs
Lungs- CTAB, no rhonchi, no crackles
Abd- soft, ND, tender in lower abdomen (R > L), no rebound, mild
tenderness to percussion
Ext- warm, well-perfused, no edema
.
.
Physical Exam on Admission to BMT service:
Vitals - T:96.7 BP:112/58 HR:77 RR:20 02 sat:96% on RA
HEENT: NCAT, PERRL, EOMI, no pharyngeal erythema, no scleral
icterus, no nasal d/c, no LAD
Cardiac: rrr nls1/s2 no m/r/g
Pulm: + mild crackles at the L lung base
Abd: + ostomy bag in place, no surrounding erythema, +bs, soft,
NTND, no HSM
UE: erythema around L arm line but no warmth or tenderness, +
non pitting edema in upper arm and elbow
LE: + non pitting edema in LE up to thigh
Neuro: alert and awake, UE/LE reflexes +2
.
.
Physical exam on day of discharge:
Vitals: Tc 98.5F, BP 108/74, HR 61, RR20, oxygen 96 RA
HEENT: NCAT, PERRL, EOMI, no pharyngeal erythema, no scleral
icterus, no nasal d/c, no LAD
Cardiac: RRR, S1/S2 regular, no murmurs/rubs/gallops
Pulm: mild bibasilar crackles noted at bases
Abd: + ostomy bag in place, no surrounding erythema, bowel
sounds in tact and normoactive, soft, NTND, no HSM
LE: no edema in extremities, 2+ pedal pulses bilaterally
Neuro: alert and awake, CNs [**2-28**] grossly in tact, upper and
lower extremities with appropriate motor and sensory exams
Pertinent Results:
LABS ON ADMISSION :
[**2193-1-19**] 06:55PM BLOOD WBC-5.2 RBC-4.66 Hgb-15.4 Hct-43.1 MCV-93
MCH-33.1* MCHC-35.7* RDW-14.8 Plt Ct-197
[**2193-1-19**] 06:55PM BLOOD Glucose-162* UreaN-23* Creat-1.3* Na-134
K-4.9 Cl-97 HCO3-25 AnGap-17
[**2193-1-19**] 06:55PM BLOOD Calcium-9.6 Phos-3.7 Mg-1.9
[**2193-1-19**] 06:55PM BLOOD PT-22.9* PTT-27.4 INR(PT)-2.2*
.
ADDITIONAL CARDIOLOGY REPORTS/STUDIES:
[**2193-1-19**] EKG : rate 77, Sinus rhythm. Left axis deviation and
diffuse ST-T wave changes in the anterolateral leads. Compared
to the previous tracing of [**2192-11-8**] the ST-T wave changes are
slightly more apparent and the other findings are similar.
.
[**2193-1-22**] EKG: Rate 128, Atrial fibrillation with rapid ventricular
response. Leftward axis. Inferior myocardial infarction, age
undetermined. There is somewhat early R wave progression. ST-T
wave abnormalities in the precordial leads. Since the previous
tracing of [**2193-1-21**] atrial fibrillation is new. Clinical
correlation is suggested.
.
[**2193-1-29**] EKG : rate 58-60, Baseline artifact. Sinus bradycardia.
Inferior wall myocardial infarction. ST-T wave abnormalities.
Since the previous tracing of [**2193-1-22**] atrial fibrillation with
rapid ventricular response is no longer seen.
.
ADDITIONAL IMAGING STUDIES:
[**2193-1-19**] CT ABDOMEN AND PELVIS W/O CONTRAST:
1. Small amount of pneumoperitoneum anteriorly and also around
the liver.
Small pelvic free fluid also tracking up along the right
paracolic gutter.
Extensive colonic diverticulosis, with mild stranding
surrounding a loop of
sigmoid colon in the left lower quadrant suggesting sigmoid
diverticulitis as possible source for perforation. The appendix
appears normal throughout its length.
2. Cholelithiasis.
3. Atherosclerotic disease.
.
.
[**2193-1-19**] PORTABLE CXR: The cardiomediastinal silhouette is
unremarkable. The lungs are clear. There is no free air under
the diaphragm. There is stable deformity of one of the right
ribs, likely related to old trauma or surgical intervention.
CONCLUSION: No acute cardiopulmonary process. No air under the
diaphragm.
.
[**2193-1-23**] CXR : New right picc line with tip in proximal svc.
Intraperitoneal air remains, possibly with slight increase vs
redistribution. Minimal retrocardiac opacity c/w atelectasis
however minimal infectious vs inflammatory process cannot be
excluded.
.
[**2193-1-24**] CT ABD/PELVIS W/O CONTRAST FINDINGS:
Visualized portions of the lung bases are unchanged from the
previous study. There is no pleural or pericardial effusion.
Coronary arterial calcification is also noted. A moderate-sized
pneumoperitoneum is enlarged since [**1-19**]. A small amount of
free-fluid is also seen, predominantly in a perihepatic location
as well as a second collection at the base of the mesentery
(2:49). The unenhanced liver, spleen, pancreas, adrenal glands
and kidneys are unremarkable. Note is made of a gallstone within
an otherwise unremarkable gallbladder, unchanged.
Atherosclerotic calcification is noted along the abdominal aorta
and its arterial branches and note is also made of aortic
ectasia. Scattered mesenteric and retroperitoneal lymph nodes
are visualized, none of which meet CT criteria for pathologic
enlargement.
The previously described area of thickening along the sigmoid
colon in the
area of known diverticulosis is again visualized, and there is
also
extraluminal leak of oral contrast. This extraluminal contrast
accumulates
predominantly in the pelvis, near the sigmoid colon. This
finding along with the enlarging pneumoperitoneum is indicative
of a perforation, likely
at the sigmoid colon.
A Foley catheter is seen within an otherwise normal urinary
bladder. The
uterus and rectum are unremarkable. There is no pelvic or
inguinal
lymphadenopathy.
OSSEOUS FINDINGS: Multilevel degenerative changes throughout the
thoracolumbar spine are unchanged. No suspicious sclerotic or
lytic lesions.
IMPRESSION:
1. Pneumoperitoneum, larger since [**1-19**] as well as
extraluminal leak of
oral contrast, collecting near the sigmoid colon. Overall, these
findings are concerning for a perforated sigmoid diverticulum.
2. Unchanged cholelithiasis.
3. Atherosclerotic disease.
.
[**2193-1-30**] CT CHEST :
FINDINGS: The previously seen scattered ground-glass opacities,
predominantly within the right lung have resolved. However, new
focal opacities, to a much lesser extent than previous, are seen
within the right upper lobe in the azygoesophageal recess and
along the medial anterior right lower lobe abutting the fissure
and mediastinum (5:180). There is diffuse acute dilatation of
the airways with several areas of mucoid impaction as well as
bronchial wall thickening bilaterally. There are no discrete
pulmonary nodules. There are small bilateral pleural effusions,
left greater than right, the left has slightly increased in size
since [**2192-3-17**]. There is no pericardial effusion or
lymphadenopathy. A new right main coronary artery stent has been
placed.
This examination was not tailored for subdiaphragmatic
evaluation. Limited views of the upper abdomen demonstrate new
ascites. Layering gallstones are noted. The remainder of the
upper abdomen is unremarkable.
There is extensive worsened anasarca.
There are no osseous lesions suspicious for malignancy.
IMPRESSION:
1. Acute airway infection with associated focal parenchymal
involvement.
2. Previous extensive ground-glass opacity has nearly resolved.
3. New ascites.
4. Stable little-sized aortic pseudoaneurysm incompletely
evaluated without IV contrast.
5. Small bilateral pleural effusions with the left, slightly
increased.
.
.
[**2193-2-6**] PA ans LAT CXR: PA and lateral upright chest radiograph
were compared to [**2193-1-29**] and chest CT from [**2193-1-30**].
The left PICC line tip is at the junction of brachiocephalic
vein and SVC. The cardiomediastinal silhouette is stable. The
lungs are essentially clear
except for linear atelectasis at the lingula. Bilateral left
more than right pleural effusions are grossly unchanged. Right
coronary artery is stented.
.
.
[**2193-2-9**] CT ABD AND PELVIS: IMPRESSION:
1. Large, likely multiloculated fluid collection extending from
the pelvis
adjacent to the surgical chain sutures into the lower left
abdomen. Given
patient's clinical symptoms superinfection is suspected.
Portions of the
fluid collection do appear amenable to percutaneous
aspiration/drainage.
2. Colonic diverticulosis without evidence of acute
diverticulitis. No
findings to suggest bowel obstruction, although oral contrast
has not yet
progressed through the entire remaining large bowel.
3. Interval development of small simple left pleural effusion
with adjacent
compressive atelectasis.
4. Unchanged cholelithiasis without secondary findings to
suggest acute
cholecystitis.
.
.
[**2193-2-10**] CT-GUIDED PELVIC ABSCESS DRAINAGE
HISTORY: 63-year-old patient with colostomy for perforated
diverticulitis.
CT scan from yesterday showed a left pericolic abscess. Catheter
drainage of the abscess was requested. PROCEDURE: Procedure and
its complications were explained. Informed consent obtained.
Laboratory values checked, INR was initially elevated, fresh
frozen plasma was used to lower this to 1.5. The patient is also
on aspirin and Plavix, which could not be discontinued because
of the cardiac considerations. It was decided to proceed with
the CT-guided abscess drainage. Timeout was performed. Area of
interest was localized under CT fluoroscopy. The skin was
prepped and draped in the usual manner. 1% lidocaine used for
local anesthetic. Conscious sedation was also used. Under CT
fluoroscopic guidance, a 10 French [**Last Name (un) 2823**] catheter was placed
in the left pericolic abscess. Approximately 30 cc of thick pus
were aspirated. Specimen has been sent for microbiology and cell
count. Patient tolerated the procedure well.
CONCLUSION: Successful placement of 10 French pigtail catheter
in the left
pericolic abscess. Tube left to JP bulb suction. No obvious
complications at the time of the procedure.
.
[**2193-2-15**] CT ABD & PELVIS W/OUT CONTRAST: IMPRESSION:
1. Slight interval decrease in size of a left flank and pelvic
collection
with pigtail catheter in place in unchanged position. No
interval change in
size of smaller possibly separate collection in the right flank.
2. Opacification of the Hartmann pouch shows no evidence of
contrast leakage into the adjacent fluid collection.
3. Diverting colonostomy with diverticulosis of the most distal
segment of
bowel and mild wall thickening, but no evidence of obstruction.
4. 2.5 cm focal ectasia of the infrarenal abdominal aorta.
5. Bilateral pelvicaliectasis. Other than inflammatory
process in the pelvis, no etiology for ureteral obstruction is
identified.
Suggest careful correlation with renal function tests. The
degree of
dilation of the collecting systems can be assessed with
ultrasound if
clinically indicated.
.
[**2193-2-21**] : CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST
IMPRESSION:
1. Further decrease in size of the left flank and pelvic
collection. The
catheter is in appropriate position.
2. Hartmann pouch opacified with contrast and no evidence of
leak.
3. Complete resolution of bilateral mild hydronephrosis.
.
MICROBIOLOGY :
Blood Culture, Routine (Final [**2193-2-19**]): NO GROWTH.
Blood Culture, Routine (Final [**2193-2-19**]): NO GROWTH.
Blood Culture, Routine (Final [**2193-2-18**]): NO GROWTH.
Blood Culture, Routine (Final [**2193-2-18**]): NO GROWTH.
Blood Culture, Routine (Final [**2193-2-15**]): NO GROWTH
Blood Culture, Routine (Final [**2193-2-15**]): NO GROWTH
Blood Culture, Routine (Final [**2193-2-12**]): NO GROWTH.
Blood Culture, Routine (Final [**2193-2-12**]): NO GROWTH.
Blood Culture, Routine (Final [**2193-1-25**]): NO GROWTH.
.
Log-In Date/Time: [**2193-2-10**] 4:34 pm
ABSCESS LEFT PARACOLIC GUTTER.S/P SURGERY FOR
DIVERTICULITIS.
**FINAL REPORT [**2193-2-24**]**
GRAM STAIN (Final [**2193-2-10**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2193-2-13**]):
PSEUDOMONAS AERUGINOSA. RARE GROWTH.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- 8 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
ANAEROBIC CULTURE (Final [**2193-2-14**]): NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Final [**2193-2-24**]): NO FUNGUS ISOLATED.
.
MRSA SCREEN (Final [**2193-1-23**]): No MRSA isolated.
.
RESPIRATORY SCREEN: FINAL REPORT [**2193-1-22**]**
Rapid Respiratory Viral Antigen Test (Final [**2193-1-22**]):
Positive for Respiratory Syncytial viral antigen.
SPECIMEN SCREENED FOR: ADENO,PARAINFLUENZA 1,2,3 INFLUENZA A,B
AND
RSV.
.
.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2193-2-7**]):
Feces negative for C.difficile toxin A & B by EIA.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2193-2-10**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2193-2-14**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
.
URINE CULTURE (Final [**2193-1-24**]): NO GROWTH.
URINE CULTURE (Final [**2193-2-2**]): NO GROWTH.
URINE CULTURE (Final [**2193-2-8**]): NO GROWTH.
URINE CULTURE (Final [**2193-2-10**]): NO GROWTH.
URINE CULTURE (Final [**2193-2-14**]): YEAST. 10,000-100,000
ORGANISMS/ML.
.
.
LABS ON DISCHARGE:
[**2193-2-22**] 12:02AM BLOOD WBC-7.0 RBC-3.50* Hgb-10.4* Hct-31.8*
MCV-91 MCH-29.9 MCHC-32.8 RDW-16.7* Plt Ct-356
[**2193-2-22**] 12:02AM BLOOD Neuts-66 Bands-0 Lymphs-20 Monos-8 Eos-4
Baso-1 Atyps-0 Metas-1* Myelos-0
[**2193-2-22**] 12:02AM BLOOD Plt Smr-NORMAL Plt Ct-356
[**2193-2-22**] 12:02AM BLOOD Glucose-93 UreaN-7 Creat-1.1 Na-138 K-4.0
Cl-104 HCO3-29 AnGap-9
[**2193-2-22**] 12:02AM BLOOD ALT-33 AST-38 LD(LDH)-199 AlkPhos-73
TotBili-0.4
[**2193-2-22**] 12:02AM BLOOD Calcium-8.8 Phos-2.5* Mg-2.0
Brief Hospital Course:
.
#Abdominal Pain: Mrs. [**Known lastname **] was admitted for lower quadrant
crampy abdominal pains. The patient was considered a high-risk
operative candidate due to her cardiac and cancer history, and
her pain was focal and isolated to her right lower quadrent, and
thus initially received conservative treatment. CT of
abdomen/pelvis at time of admission had showed small amount of
pneumoperitoneum anteriorly and also around the liver. Small
pelvic free fluid also tracking
up along the right paracolic gutter. Extensive colonic
diverticulosis, with mild stranding surrounding a loop of
sigmoid colon in the left lower quadrant suggesting sigmoid
diverticulitis as possible source for perforation.
She was started on Zosyn early on in her hospital course. Though
she initially responded quite well to the IV antibiotics with
significant improvement in her abdominal pain for the first [**2-19**]
days, he patient's abdominal pain & overall appearance worsened
on hospital day #4, and it was clear that she needed to be taken
to the operating room for a exploratory laparotomy. Repeat
imaging confirmed perforated sigmoid diverticulum. She was
given FFP, Vitamoin K to correct her INR of 8, and 1 unit of
PRBC and taken to the operating room. In the O.R. the surgical
team found a thickened indurated colon but no masses. There was
an extensive area of inflammatory changes with a small area of
focal perforation along sigmoid colon. There was contained stool
in the pelvis. She underwent surgery for a perforated
diverticulum including a sigmoidectomy, hartmann??????s pouch, and
colostomy with a plan for anastamosis in the future. Her
operative course was relatively uncomplicated, she did have some
intra-op bleeding which was managed with cautery and FFP.
Her post-op course was later complicated by fever after being
taken off Zosyn (her zosyn was continued post operatively for
PNA treatment). On CT of the abdomen she was found to have
loculated fluid collections which required post-operative IR
drainage and a JP drain was left in place. She then had to go
for repeat IR drainage to help break up the loculations. For
enteric broad coverage she was started on Zosyn, Vancomycin,
Caspofungin, and Gentamicin and her abdominal fluid grew
pseudomonas which was fortunately sensitive to multiple agents.
As she continued to recover steadily she was gradually taken off
of Vancomycin, Caspofungin and Gentamicin but continued on
Zosyn.
.
A repeat CT was done on [**2193-2-21**] to assess interval changes and it
appeared that there was continued decrease in size of the left
flank and pelvic collections, Hartmann pouch showed no evidence
of leak, and she also had complete resolution of bilateral mild
hydronephrosis. After this reassuring CT study the surgical team
removed her one remaining JP drain on her left abdomen.
Colostomy site and prior JP entry site were clean, dry,
non-edematous, non-erythematous and in tact at time of
discharge. She was set-up with home line care services for her
PICC line and she was also set up for additional home VNA
services at time of discharge. She had no signs of fevers,
abdominal pains, leukocytosis or discomfort for several days
leading up to her discharge date. She was instructed to continue
her daily Zosyn coverage up until her follow up surgery
outpatient appointment at the end of [**Month (only) 956**] with Dr. [**Last Name (STitle) **].
A repeat CT was set-up a few days prior to this appointment to
allow for final review for any recurrent abscesses or
collections prior to final removal of PICC and antibiotic
discontinuance.
.
# History of AML: The patient's hematologic/oncology history
dates back to fall [**2190**] after routine labs indicated persistent
pancytopenia. She had an initial bone marrow biopsy with
myelodysplasia with no cytogenetic abnormalities and additional
workup that was most consistent with MDS. A vitamin B12
deficiency was also diagnosed during her initial Heme/Oncology
work-up. A repeat bone marrow biopsy showed acute
erythroleukemia and she was diagnosed with AML. She was admitted
[**2-/2191**] for induction chemotherapy with 7+3 cytarabine and
idarubicin, which she tolerated well. She underwent allogeneic
transplantation from an HLA matched sibling donor with
pentostatin/TBI in [**2191-3-17**]. She had additional note of
subsequent mild GVHD, predominantly over her skin and mouth. At
time of this current admission she had been doing well from an
oncologic standpoint and she was on 3mg daily Prednisone, and a
prophylactic dose of acyclovir 400mg PO TID. During this
admission she was given her inhaled pentamidine on [**2193-2-5**]. Upon
discharge, Mrs. [**Known lastname **] was set up for close follow-up appointment
with Dr. [**Last Name (STitle) **], her primary oncologist.
.
# Anemia: The patient developed anemia while in the hospital but
it remained stable. Iron studies showed that she was not iron
deficient. As aforementioned she had a vitamin B12 deficiency
recognized back in [**2190**] during her initial referral visits to
the hematology/oncology service for pancytopenia. Her B12 shot
was given on [**2193-2-9**] during this hospital stay. She did require
blood transfusions during her hospitalization both
peri-operatively and after her IR drainage. She tolerated these
very well with no significant reactions of note. Hematocrit at
admission was 43 and she had nadir to 25-27 range and by time of
discharge her hematocrit was back to 31-33 range consistently
and she had no signs of any active bleeding.
.
# Hypoxia: Post operatively Mrs. [**Known lastname **] became hypoxic with an
oxygen requirement. She was found to have a positive RSV
respiratory study [**2193-1-22**]. A CT from [**2193-1-30**] showed new focal
opacities in the RUL. She also had diffuse acute dilatation of
the airways with mucoid impaction and bronchial wall thickening
bilaterally. She had slightly increased pleural effusions and
her ground-glass opacity has mostly resolved. Her oxygen
requirement resolved on [**2193-1-31**]. Per surgical team notes she ahd
been placed on Zosyn prior to her surgery and after being
diagnosed with probable RUL PNA her therapy was prolonged per ID
recommendations, particularly given her additional abdominal
collections (alongside Gentamicin). She was placed on albuterol
nebulizers and inhalers which she continued to use with
decreasing frequency as her breathing came back to baseline.
Blood cultures during her hospitalization were all negative.
Given her PMH of mild asthma she was discharged to continue her
usual home albuterol inhaler on an as-needed basis and to notify
her doctor if she had any additional fevers, productive cough or
recurrent dyspnea.
.
# Coronary Artery Disease: Mrs. [**Known lastname **] had history of CAD with
prior inferior STEMI in [**5-/2192**] for which she underwent RCA
stenting, and later had an endoscopic CABG x1. She was continued
on her usual Plavix, aspirin, and atorvastatin therapy. She was
set up for [**2193-3-17**] follow up appointment with Dr. [**Last Name (STitle) 911**] after
discharge.
.
#Hypertension: Metoprolol dose was decreased to metoprolol
tartrate 12.5 [**Hospital1 **] as her blood pressure well controlled on this
regimen and she was bradycardic at night when on a higher dose.
Normotensive at time of discharge.
.
# Atrial fibrillation: Mrs.[**Initials (NamePattern4) 24712**] [**Last Name (NamePattern4) 34306**] and
post-operative course were complicated by atrial fibrillation.
Before her laparotomy, she was evaluated by cardiology and her
coumadin therapy she had been taking for her known atrial
fibrillation was discontinued for the procedure. She had some
rapid bouts of atrial fibrillation on [**2193-1-22**] which required a
diltiazem drip for control. On [**2193-1-24**] she was taken to the O.R.
with no significant cardiac events. Post-surgery she was
monitored with serial EKGs, and continuous telemetry and she was
eventually converted back to NSR with Amiodarone therapy. She
was restarted on warfarin after her surgery and she continued
metoprolol. After discussion with Dr. [**Last Name (STitle) 911**] her warfarin was
discontinued and she had her dose of Amiodarone tapered prior to
discharge. She will see discuss length of her treatment and
further dose adjustments at her upcoming cardiology follow-up
appointment. She was discharged on 400mg Amiodarone [**Hospital1 **].
.
# Hypotension: She experienced hypotension preoperatively that
required fluid boluses. She also experienced hypotension post
operatively that was asymptomatic. Post operatively her
hypotensive episodes were attributed to the combination of
getting metoprolol and lasix per the surgical service notes. By
the time she was transferred to the BMT service on
post-operative day nine she was predominantly normotensive and
she remained stable for the remainder of her hospital stay.
.
# Edema: The patient had extensive lower extremity edema and
less prominent upper extremity edema post-operatively. She was
diuresed aggressively with lasix. She then auto-diuresed for
several days without the use of lasix. By the time of her
transfer to the BMT service her swelling was minimal although
still present. She ws seen by the physical therapy team and was
able to ambulate and do some minimal exercises which markedly
helped with her conditioning and edema collections. By time of
discharge she was near to her usual baseline and she was not
placed on any additional diuretics at discharge.
.
# GERD: She has a history of gastroesophageal reflux and she was
continued on her usual famotidine medication for GI protection
and relief during her stay.
.
# Diabetes Mellitus Type II: ??????Mrs.[**Initials (NamePattern4) 24712**] [**Last Name (NamePattern4) 1568**]2 is normally
exercise and diet controlled. She was placed on an additional
insulin sliding scale for tight control in the peri-operative
setting and while in the hospital. She had well controlled
fasting and prandial fingersticks which required minimal to no
SSI coverage. At time of discharge, she was therefore not placed
on any additional agents.
.
# Insomnia: She had some mild complaints of occasional insomnia
during her hospital course which was effectively relieved with
lorazepam 0.5 mg PO HS:PRN.
.
# Nutrition /electrolytes: She required TPN post-operatively but
was then transitioned to a regular diabetic diet which she
tolerated very well. No issues with colostomy training and care.
Nutrition helped with initial electrolyte balance and she was
repleted as needed during her stay with close daily monitoring
of all of her electrolytes.
.
# Elevated LFTs: Mrs. [**Known lastname **] had some transaminitis noted during
her hospital course which was thought to be secondary to her
antibiotics. Once she was tapered down to just Zosyn she seemed
to have a resolution of these abnormal labs. At the time of
discharge her LFTs were back to normal ranges with AST 39, ALT
33, ALP 82, LDH 199, and total bilirubin 0.4.
.
#Code Status: The patient was maintained as a full code status
for the entirety of her hospital course.
Medications on Admission:
Xalatan gtt
Atorvastatin 80mg qdaily
Clopidogrel 75mg qdaily
Protonix 40 [**Hospital1 **]
Aspirin 81mg daily
Ativan 0.5mg 1-2tablets PRN:QHS
Proventil HFA 90 mcg/Actuation Aerosol Inhaler
Prednisone 3mg daily
Docusate Sodium 100 [**Hospital1 **]
Warfarin 2 MWF/1.5 TTHSS
Azithromycin- finished course prior to admission for sore throat
Acyclovir 400mg tid
Metoprolol SR 100 qdaily
Discharge Medications:
1. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
2. Atorvastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Four (4) Puff Inhalation Q4H (every 4 hours) as needed.
5. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime)
as needed: Please note that this medication makes you drowsy,
please don't drive ot operate equipment/machinery while taking .
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO every twelve
(12) hours.
Disp:*120 Tablet(s)* Refills:*2*
8. Prednisone 1 mg Tablet Sig: Three (3) Tablet PO QAM (once a
day (in the morning)).
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
11. Zosyn 4.5 gram Recon Soln Sig: One (1) syringe Intravenous
every eight (8) hours for 18 days: Please take antibiotic via
PICC line up until your follow-up appointment on [**2193-3-12**].
Disp:*54 syringe* Refills:*0*
12. Line Care
1.Please flush with 10cc saline SASH and PRN
2.Please flush with Heparin 10 Units/ml, 3cc SASH and PRN
13. Oxycodone 5 mg Capsule Sig: One (1) Capsule PO every six (6)
hours as needed for pain for 15 doses: Please note that this
medication makes you drowsy, please don't drive ot operate
skilled machinery while taking this medication.
Disp:*15 Capsule(s)* Refills:*0*
14. Outpatient Lab Work
Please draw home CBC with differential, LFTs, Chemistry-10 panel
on friday [**2193-3-1**] and fax to Dr.[**Name (NI) 3930**] attention at
#[**Telephone/Fax (1) 21962**], Call Dr.[**Name (NI) 3930**] office #[**Telephone/Fax (1) 3241**].
15. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours.
Discharge Disposition:
Home with Service
Facility:
[**Location (un) 582**] of [**Location (un) 583**]
Discharge Diagnosis:
Primary:
-Diverticulitis
-Perforated sigmoid colon
-Intra-abdominal abscess
-Post-op hypotension-managed with fluid boluses
-Post-op Atrial fibrillation-managed with IV to PO Amiodarone
and Lopressor
-Post-op fever/pneumonia managed with IV antibiotics
-Post-op hyperglycemia-managed with insulin
-Post-op fluid volume overload-managed with IV Lasix
-Pneumonia
-RSV
.
Secondary:
- Coronary Artery Disease (prior STEMI in [**2192-5-17**], PCI/stenting
to RCA)
- Endoscopic CABG ([**2192-7-31**])
- history of Acute Myelogenous Leukemia, (s/p chemotherapy,
radiation and bone marrow transplantation [**3-/2191**])
- Hypertension
- Hypercholesterolemia
- GERD
- Type II Diabetes Mellitus - diet controlled
- Diverticulosis, noted on colonoscopy 4 years ago
- Occasional bronchospasm treated with Primatene Mist
- History of SVC clot [**2191**] [**2-18**] PORT (s/p course of lovenox)
- History of C.Difficile ([**3-23**] & [**5-23**])
- History of VRE
- History of Shingles
- History of Asthma
Discharge Condition:
Good. At time of discharge the patient was tolerating a
diabetic/heart healthy/low sodium diet well and her vital signs
were stable. She was in no apparent distress.
Discharge Instructions:
You were admitted to the hospital because you had a perforated
diverticulum. You underwent surgery and had your sigmoid colon
resected. You now have an ostomy bag and you will get your
colostomy bag removed once you undergo a later surgery to
re-connect a section of your colon that still needs later
attachment.
.
You required blood and blood products during your
hospitalization for anemia and low blood counts. You went into
an abnormal heart rhythm called atrial fibrillation but you were
converted back to a normal rhythm with a medication called
amiodarone. You required high dose steroids while you were in
the hospital but are now on your regular home dose of
prednisone. You also had a pneumonia, respiratory virus, and a
later abdominal abscess and you were treated with an antibiotic
called Zosyn. When you had some respiratory infections you had
some additional shortness of breath which was relieved with
supplemental oxygen, but you were gradually taken off of this
once you were no longer short of breath. You also received
inhaled pentamidine therapy during your stay.
Please continue an additional 18 days of your Zosyn, until your
next follow-up appointments on [**3-12**] with your surgeon
and your oncologist.
.
MEDICATION INSTRUCTIONS/ CHANGES:
1. Continue another 18 days of your Zosyn IV antibiotics through
your PICC line until you follow-up with Dr. [**Last Name (STitle) **].
2. You have been placed on a new dose of metoprolol: metoprolol
tartrate 12.5mg twice daily.
3. Please continue taking daily Amiodarone to maintain a normal
heart rhythm
4. You have been given an additional prescripyion for pain
medication if you have abdominal pain.
5. You no longer need to be on warfarin/coumadin. This was
discussed with your cardiologist, Dr.[**Last Name (STitle) 911**].
6. Otherwise please continue your prior home medications before
this hospitalizations as outlined below.
.
Please call your doctor or return to the ER if you have
abdominal pains, diarrhea, bloody stool or discolored stool in
your colostomy, new chest pain, chest pressure, chest tightness,
cough , wheezing, vomiting, fevers, chills or any new concerning
symptoms.
.
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon. Avoid driving or operating heavy machinery
while taking pain medications.
.
Incision care/recent drain removal site:
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites, colostomy site or
JP drain entry site.
.
Monitoring Ostomy Output/Prevention of Dehydration:
-Keep well hydrated
-Replace fluid loss from ostomy daily.
-Avoid only drinking plain water. Include [**1-18**] glasses a day of
Gatorade and/or other vitamin drinks to replace electrolytes and
nutrients.
-Your ostomy should put out between 1000mL to 1500mL per day, if
you notice less output please call Dr. [**Last Name (STitle) **].
-If Ostomy output >1.5 liters in 24hrs, call Dr. [**Last Name (STitle) **].
.
Followup Instructions:
1. Please follow-up with your surgeon, Dr. [**Last Name (STitle) **], on [**3-12**] at 9:30 am for a follow up appointment at her [**Street Address(2) 70243**] office in [**Location (un) **]. #[**Telephone/Fax (1) 8792**]. Please return to the
[**Hospital 18**] campus to the radiology department to have a repeat
abdominal/pelvic CT on [**3-11**] prior to your surgery
follow-up. This order has been sent to radiology department so
you just need to check in.
2. Follow-up with your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 59547**], [**Telephone/Fax (1) 18421**] in [**1-18**]
weeks.
.
3. You have a scheduled appointment with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] M.D.,
Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2193-2-25**] 11:15am
.
4. Follow-up with [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], NP. Phone:[**Telephone/Fax (1) 3241**],
Date/Time:[**2193-3-12**] 1:00
.
5. Please follow-up with your oncologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on
Monday [**2-25**] at 3:30pm and again on [**3-12**] at 2pm.
Phone:[**Telephone/Fax (1) 3241**]
.
6. VNA team will be checking some home lab values and sending
results to your primary oncologist for review.
.
7. You have a later cardiology appointment with Dr. [**Last Name (STitle) 911**] on
[**4-11**] at 1:20pm. Phone:[**Telephone/Fax (1) 62**], [**Location (un) 436**] of [**Hospital Ward Name 23**]
Building /[**Hospital1 18**] [**Hospital Ward Name 516**].
.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **] MD, [**MD Number(3) 4661**]
Completed by:[**2193-3-3**]
|
[
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"288.00",
"560.1",
"250.00",
"272.0",
"998.59",
"427.31",
"041.7",
"205.00",
"414.00",
"480.1",
"E878.3",
"V42.81",
"567.22",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"88.01",
"99.07",
"38.91",
"99.15",
"46.10",
"99.04",
"38.93",
"45.76"
] |
icd9pcs
|
[
[
[]
]
] |
30660, 30741
|
17109, 28219
|
373, 528
|
31777, 31945
|
4758, 6031
|
35082, 36823
|
2969, 3296
|
28650, 30637
|
30762, 31756
|
28245, 28627
|
31969, 35059
|
3334, 4739
|
318, 335
|
16577, 17086
|
556, 2045
|
2067, 2609
|
2625, 2953
|
6048, 16558
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,278
| 142,153
|
10239
|
Discharge summary
|
report
|
Admission Date: [**2153-11-30**] Discharge Date: [**2153-12-14**]
Date of Birth: [**2109-1-1**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
Transfer from OSH for total lung lavage.
Major Surgical or Invasive Procedure:
Bilateral total lung lavages.
History of Present Illness:
The pt. is a 44 year-old male with a history of pulmonary
alveolar proteinosis thought to be secondary to silica exposure
who initially presented to an OSH on [**2153-11-27**] with a 2 day
history of fever, chills, and shortness of breath. He also had
right posterior pleuritic chest pain consistent with prior
episodes of pneumonia. He denied productive cough on OSH
admission, but did have occasional cough with post-tussive
emesis PTA. Review of systems at that time was remarkable for
weight loss, but was negative for headache, visual changes,
night sweats, diarrhea, abdominal pain, rash, LE swelling or
recent travel.
The pt. was admitted to OSH febrile to 102F. He was initially
saturating at 95% on RA but quickly desaturated to 93% on 5L.
Per report, he was tremulous and dyspneic on presentation with
groaning on respiration and bilateral basilar dry crackles. He
was also tachycardic. He was admitted to the ICU and intubated
on [**2153-11-27**] (the evening of admission). He was treated with
bactrim, zosyn and vancomycin for presumed pneumonia. As he was
thought to be septic, he was also treated with xigris and he
also required levophed until [**2153-11-29**] to treat hypotension.
The pt. was transferred to [**Hospital1 18**] on [**2153-11-30**] in anticipation of
possible total lung lavage by interventional pulmonology.
Past Medical History:
-pulmonary alveolar proteinosis, had PTX in 12/00, total lung
lavage in [**1-18**].
-EtOH abuse
-COPD
-anxiety vs. bipolar d/o.
Social History:
Pt. currently on disability, former stone-cutter. Tobacco:
Greater than 40 pack years. Drug use: Ten years of crack
cocaine, quit in [**2145**]. Alcohol greater then ten liquor drinks
per night. Divorced with two kids.
Family History:
Alcoholism in brother, asthma in niece, brother with coronary
artery disease at 61.
Physical Exam:
Vitals: T: 98.5 P: 62 R: on vent at 16 BP: 170/86 SaO2:98%
General: Middle-aged male on ventilator.
HEENT: PERRL, MMM
Neck: prominent veins, no JVD or LAD
Chest: coarse breath sounds bilaterally, no rales
Cardiac: RRR, distant heart sounds, no m/r/g
Abdomen: distended, firm but not tender, liver palpable 2
fingerwidths below RCM, no splenomegaly or masses
Extremities: No LE edema noted, bilateral edema of hands, R
groin line in place.
Pertinent Results:
[**2153-11-30**] 08:04PM TYPE-ART TEMP-37.7 RATES-0/16 TIDAL VOL-600
O2-60 PO2-108* PCO2-37 PH-7.42 TOTAL CO2-25 BASE XS-0
-ASSIST/CON INTUBATED-INTUBATED
[**2153-11-30**] 08:04PM LACTATE-1.7
[**2153-11-30**] 08:04PM freeCa-1.13
[**2153-11-30**] 02:36PM LACTATE-1.8
[**2153-11-30**] 02:35PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.020
[**2153-11-30**] 02:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-1 PH-6.5 LEUK-NEG
[**2153-11-30**] 02:35PM URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE
EPI-0
[**2153-11-30**] 02:26PM GLUCOSE-133* UREA N-13 CREAT-0.9 SODIUM-147*
POTASSIUM-3.3 CHLORIDE-113* TOTAL CO2-25 ANION GAP-12
[**2153-11-30**] 02:26PM ALT(SGPT)-118* AST(SGOT)-223* LD(LDH)-309*
ALK PHOS-293* AMYLASE-246* TOT BILI-1.8*
[**2153-11-30**] 02:26PM LIPASE-34
[**2153-11-30**] 02:26PM WBC-12.4* RBC-3.22* HGB-11.8* HCT-36.7*
MCV-114*# MCH-36.7* MCHC-32.2 RDW-13.0
[**2153-11-30**] 02:26PM NEUTS-90.7* BANDS-0 LYMPHS-6.4* MONOS-2.7
EOS-0.1 BASOS-0.1
[**2153-11-30**] 02:26PM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-NORMAL
MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL
[**2153-11-30**] 02:26PM PLT COUNT-237#
[**2153-11-30**] 02:26PM PT-13.2 PTT-27.7 INR(PT)-1.1
Brief Hospital Course:
1) Pulmonary Alveolar Proteinosis: The pt. was taken for a total
lung lavage of his right lung on [**2153-12-3**]. Evidently there were
some minor difficulties with intubation and subglottic edema,
but the procedure was otherwise uneventful. A left total lung
lavage was performed on [**2153-12-5**] without complications. The pt.
was initally empirically treated for Nocardia with bactrim but
this was stopped on [**2153-12-4**] as cultures remained negative. He
remained intubated for 10 days, as the pt. became agitated at
times and also had episodes of what appeared to be respiratory
distress. He was extubated on [**2153-12-10**] without complications.
His respiratory status remained stable for the duration of this
hospital stay.
2) Pneumonia/?Sepsis: The pt. arrived from the OSH intubated and
was treated with pressors up to 24 hours prior to transfer. He
was also started on xigris at the OSH and he finished the course
at this facility. He was treated with a vancomycin and zosyn
for presumed pneumonia for a total of a 7 day course. Cultures
from the OSH and [**Hospital1 18**] remained negative throughout his stay.
It was thought that his septic appearance may have been
secondary to PAP alone. He remained afebrile and
hemodynamically stable for the duration of this admission.
3) Elevated LFTs: The pt. was noted to have elevated LFTs,
amylase, and lipase on presentation. A RUQ ultrasound was
obtained and showed a mildly thickened gall bladder wall, but no
evidence of CBD dilation or cholelithiasis. These laboratory
abnormalities quickly resolved. It was thought that these
abnormalities were related to the passage of a stone.
4) EtOH withdrawal: While in the MICU, the pt. was kept on a
versed drip. He was also started on thiamine, folate and MVI
supplementation. Prior to transfer to the floor, he was
transitioned to oral valium. He did appear somewhat tremulous
after this transition, but overall he tolerated this well and he
showed no other signs of withdrawal. He was discharged on a
valium taper. He plans to follow-up with a rehabilitation
program upon discharge.
6)Hypertension: Pt. developed elevated blood pressure during the
course of his MICU stay. Amlodipine was added with effect. He
will be discharged on low-dose amlodipine.
Medications on Admission:
At OSH:
-xigris 10mg IV q6h
-lovenox 40mg sc daily
-hydrocortisone 25mg IV bid
-levabuterol neb tid
-versed gtt
-morphine PCA
-MVI
-protonix 40mg IV daily
-propofol gtt
-vancomycin 1gram IV q12h
-zosyn 4.5gram IV qid
-bactrim 1 tab daily
-zyprexa 15mg po daily
Home Meds:
-combivent inhaler
-zyprexa 15mg po daily
Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO QD ().
Disp:*30 Tablet(s)* Refills:*2*
2. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Eight (8)
Puff Inhalation QID (4 times a day).
3. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation Q6H (every 6 hours).
4. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Amlodipine Besylate 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Zyprexa 15 mg Tablet Sig: One (1) Tablet PO once a day.
8. Valium 2 mg Tablet Sig: One (1) Tablet PO twice a day for 2
days: Please take 2 tablets on the evening of [**12-14**] and then 1
tablet in the morning and 1 tablet in the evening of [**12-15**].
Disp:*4 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Pulmonary alveolar proteinosis.
Alcohol abuse.
Discharge Condition:
Stable.
Discharge Instructions:
Please continue to take all of your prescribed medications. If
you experience any shortness of breath, chest pain, persistent
cough, uncontrolable shaking or tremulousness or any other
symptoms that are concerning to you, call your primary care
physician or come to the ED for evaluation.
Followup Instructions:
Please follow-up with your primary care doctor within the next
week to follow-up on this hospitalization. Please call her
office at [**Telephone/Fax (1) 34118**] to schedule an appointment at a time
convenient for you.
|
[
"502",
"518.81",
"038.9",
"496",
"785.52",
"995.92",
"516.0",
"305.01",
"296.80",
"428.0",
"300.00",
"291.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.99",
"00.11",
"94.62",
"96.04",
"96.72",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
7561, 7567
|
4016, 6308
|
357, 389
|
7658, 7667
|
2739, 3993
|
8005, 8228
|
2179, 2265
|
6674, 7538
|
7588, 7637
|
6334, 6651
|
7691, 7982
|
2280, 2720
|
277, 319
|
417, 1770
|
1792, 1922
|
1938, 2163
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,937
| 193,815
|
20664
|
Discharge summary
|
report
|
Admission Date: [**2198-7-13**] Discharge Date: [**2198-7-22**]
Date of Birth: [**2133-10-11**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Iodine / Penicillins / Oxycodone/Apap / Niaspan
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
exertional chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization [**2198-7-13**]
OPCABG x3 [**2198-7-17**] (LIMA to LAD, SVG to DIAG, SVG to PDA)
History of Present Illness:
64 year old female with history of CAD x 16 years (known 3VD,
medically managed) who presented with exertional angina x 2
week. She has had stable angina for the past 16 years with only
very occasional chest tightness. (roughly q6months) Over the
past two weeks she has had 3 episodes of chest discomfort with
minimal activity. Chest tightness w/ radiation down both upper
arms that also felt like a tightness, relieved with 2 SLNTG. She
has chest discomfort with activity such as doing yard/garden
work, going up and down the stairs twice or walking about 4
blocks. She denies symptoms at rest. No other associated
symptoms (No SOB, N/V, diaphoresis). She underwent P. Mibi on
[**2198-7-10**] which was positive for chest pain and ECG changes.
Nuclear imaging revealed new, small inferior infarct. She was
taken to cardiac catheterization on [**2198-7-13**] which demonstrated 3
vessel coronary artery disease [90% RCA, 70% Diagonal, 50%
mid-LAD]. Denies orthopnea, PND. She has stable pedal edema R>L,
chronic. occasional R leg discomfort. No urinary problems, no
[**Name2 (NI) **] in stool, normal BMs. Referred for CABG.
Past Medical History:
CAD 3VD
PVD s/p lower extremity stents (total of 7)including bilateral
common iliac stenting, right "fem-[**Doctor Last Name **]" bovine patch angioplasty
and stenting
GI Bleed 1.5 year ago with 3 unit transfusion while on Plavix
andASA- At that time had a normal colonscopy as well as
enteroscopy at [**Hospital1 18**] [**4-12**].
Right carotid endarterectomy [**2193**] at [**Hospital3 **] (note
records from [**Hospital1 **] indicate bilateral CEA's, however patient
denies this)
Carotid angio [**9-/2197**]: 50% subclavian stenosis, 90% carotid
siphon lesion, 60-70% right internal carotid stenosis, less than
50% left internal carotid stenosis, type I aortic arch.
Hyperlipidemia
Hypertension
Recurrent vasovagal syncope
"Lypodystrophy" (decreased fat cell distribution) as a child s/p
plastic surgery with fat flaps transferred from stomach to face
[**Hospital1 756**] and Women??????s)
Peripheral neuropathy
hypothyroidism
bone spurs removed from right arm
total abdominal hysterectomy
hyponatremia
Social History:
no history of tobacco use or alcohol abuse
lives with husband
retired [**Name (NI) 22957**] accountant
Family History:
Mother had CHF, brother had MI at age 56 and died of brain
cancer at 58.
Physical Exam:
5'4" 138#
VS: BP 117/62 HR 70 RR 18 O2 98% RA
Gen: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. no pallor or cyanosis of the oral
mucosa. No xanthalesma.
Neck: Supple with JVP of 7-8cm. + bilateral bruits.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. cresc-decresc SEM [**2-13**] which is soft sounding
and radiates to the carotids without delayed carotid upstroke,
[**2-13**] HSM @ apex and LLSB w/o radiation, No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness.
Ext: No c/c/e. No femoral bruits. fem cath site on R c/d/i, no
hematoma or ecchymoses.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
admission hct 36.9, WBC 4.7, plts 174. admission BUN 17, Cr
0.8. Sodium 124 on admission, ****** on discharge. Serum osm
280, Uosm 480, U sodium 30. TSH 0.97.
LFTs were normal. Folate>20, Vit B12: 1333, Ferritin 173.
HbAIc: ***********
U/A: Large [**Month/Day (4) **], 26 RBC, 100 protein. neg nitrites and leuk
es, 0 WBCs. pH 7.0, Spec [**Last Name (un) **] 1.053.
EKG demonstrated NSR w/ rate 65, nl axis, RBBB. PR and QTc
normal. LAE, new T-wave inversions in III, aVF. When compared to
previous ([**4-11**]) [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 55200**] and TWI are new- no other
significant change.
Cardiac Catheterization: ([**2198-7-13**]) 3 vessel coronary disease (90%
RCA, 70% diag, 50% mid-LAD) with normal LV function. (report in
system is reportedly wrong in stating "two vessel disease")
CT chest w/o contrast:
1. Extensive atherosclerotic calcification within the aortic
arch, descending aorta, and coronary vascular system. No
abnormal dilatation to the aorta identified. The ascending
aorta appears relatively free of mural calcification.
2. 5-mm left lower lobe nodule. Recommend followup chest CT
examination in approximately three months to assess for
stability given slightly suspicious margins.
3. Sub-3-mm pulmonary nodules along the left major fissure
likely represent intraparenchymal lymph nodes.
RADIOLOGY Preliminary Report
CAROTID SERIES COMPLETE [**2198-7-16**] 1:38 PM
CAROTID SERIES COMPLETE
Reason: please evaluate carotids pre-op CABG
[**Hospital 93**] MEDICAL CONDITION:
64 year old woman with 3 vessel coronary artery disease
REASON FOR THIS EXAMINATION:
please evaluate carotids pre-op CABG
STUDY: Carotid series complete.
REASON: Preop CABG.
FINDINGS: Duplex evaluation was performed of bilateral carotid
arteries. On the right, there is moderate plaque seen in the
proximal ICA. Peak velocities are 155, 68, and 181 cm/sec in the
right ICA, CCA and ECA respectively. The ICA end-diastolic
velocity is 39. The ICA/CCA ratio is 2.3. This is consistent
with 40-59% stenosis.
On the left, there is bulky heterogeneous plaque with
calcification seen in the proximal ICA and distal CCA. Peak
velocities are 274, 75, and 101 cm/ sec in the ICA, CCA, and ECA
respectively. The ICA end-diastolic velocity is 100. The ICA/CCA
ratio is 3.7. This is consistent with 70-99% stenosis.
There is antegrade vertebral flow bilaterally.
IMPRESSION: 40-59% right ICA stenosis. 70-99% left ICA stenosis
with calcified plaque.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Cardiology Report ECHO Study Date of [**2198-7-17**]
PATIENT/TEST INFORMATION:
Indication: Intra-op TEE for OPCAB
Height: (in) 64
Weight (lb): 135
BSA (m2): 1.66 m2
BP (mm Hg): 154/74
HR (bpm): 68
Status: Inpatient
Date/Time: [**2198-7-17**] at 10:37
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007AW01-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) **] R. [**Doctor Last Name **]
MEASUREMENTS:
Left Ventricle - Ejection Fraction: 55% (nl >=55%)
INTERPRETATION:
Findings:
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. No
ASD by 2D or
color Doppler.
LEFT VENTRICLE: Normal LV wall thickness and cavity size.
Overall normal LVEF
(>55%).
LV WALL MOTION: basal anterior - normal; mid anterior - normal;
basal
anteroseptal - normal; mid anteroseptal - normal; basal
inferoseptal - normal;
mid inferoseptal - normal; basal inferior - normal; mid inferior
- normal;
basal inferolateral - normal; mid inferolateral - normal; basal
anterolateral
- normal; mid anterolateral - normal; anterior apex - normal;
septal apex -
normal; inferior apex - normal; lateral apex - normal; apex -
normal;
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in
aortic root. Normal ascending aorta diameter. Focal
calcifications in
ascending aorta. Normal aortic arch diameter. Complex (>4mm)
atheroma in the
aortic arch. Normal descending aorta diameter. 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. Mild
mitral annular
calcification. No MS. Mild (1+) MR.
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. No TEE
related
complications. The patient was under general anesthesia
throughout the
procedure. The patient appears to be in sinus rhythm. Results
were personally
Conclusions:
Pre-CPB: No atrial septal defect is seen by 2D or color Doppler.
Left
ventricular wall thicknesses and cavity size are normal. Overall
left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber
size and free wall motion are normal. There are complex (>4mm)
atheroma in the
aortic arch. 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. Mild
(1+) mitral
regurgitation is seen.
Post-CPB: Preserved biventricular systolic fxn. Trivial MR. [**First Name (Titles) **] [**Last Name (Titles) **]I. Aorta
intact. Other parameters as pre-bypass.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD on [**2198-7-19**] 09:15.
[**Location (un) **] PHYSICIAN:
([**Numeric Identifier 55201**])
Brief Hospital Course:
1. CAD: history of stable angina x 16 years with a cath in [**2198**] showing 3 vessel disease, no intervention at
that time. Worsening of stable angina over the past 2 weeks or
so, with no rest symptoms. She had a persantine MIBI which
revealed chest pain and ECG changes, new small inferior infarct
on nuclar imaging. She subsequently had a cath on [**2198-7-13**] which
revealed 3 vessel disease (90% RCA, Diag 70%, and 50% mid LAD).
Patient underwent CABG on [**2198-7-17**].
2. Hyponatremia- history of chronic hyponatremia. Urine Osms
were higher than would be expected with her level of
hyponatremia. TSH was normal, patient was not high and she was
not hypotensive as would be expected with adrenal insufficiency.
Other possibilties include SIADH, reset osmostat or drug
effect. When diuretics (HCTZ and spironolactone) were held the
sodium increased to the low 130s from 124. on day of discharge
sodium was 131.
3. HTN: [**Date Range **] pressure was 118/64 at discharge, well controlled
while in house on home dose of lopressor and norvasc, as stated
above HCTZ and spironolactone were held.
4. Lung nodule on CT scan: there was a 5mm left lower lobe lung
nodule found on CT scan, a recommended 3 month follow up CT scan
should be set up by the patients primary care physician. [**Name10 (NameIs) 3754**]
were also some small 3mm (or less) nodules found at the Left
major fissure which likely represent intraparenchymal lymph
nodes.
5. Hematuria/Proteinuria: Her Urinalysis revealed protein and
red [**Name10 (NameIs) **] cells in here urine without evidence of infection.
She should have an outpatient workup with her primary care / a
urologist to help rule out a malignancy or to search for the
cause of these U/A findings such as nephrolithiasis or renal
disease.
Underwent off pump cabg x3 on [**7-17**] with Dr. [**Last Name (STitle) **]. Transferred
to the CSRU in stable condition on phenylephrine and propofol
drips. Extubated that afternoon and transferred to the floor on
POD #1 to begin increasing her activity level. Chest tubes
removed on POD #2. Seen by PT on POD#3; cleared to go home from
PT perspective. On POD4 hct was stalbe at 25; hyponatremia
resolving Na 131. Patient discharged home in good condition with
no new medications.
Medications on Admission:
Patient fills medications at [**Company 4916**] [**Telephone/Fax (1) 55202**]
Avapro 300mg daily in the am
Actonel 35mg weekly
Synthroid 100mcg daily
Metoprolol 25mg [**Hospital1 **]
Norvasc 5mg daily
Spironolactone 25mg daily MWF
Hctz 25mg daily
Isosorbide MN 120mg daily
Pravachol 80mg daily in the PM
Zyrtec 10mg daily
Calcium with vitamin D 600mg [**Hospital1 **]
Fish oil 1000mg [**Hospital1 **]
Aspirin 81mg daily
Flonase nasal spray 1 spray each nostril daily
Discharge Medications:
1. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
5. Cetirizine 10 mg Tablet Sig: One (1) Tablet PO daily ().
6. Omega-3 Fatty Acids 550 mg Capsule Sig: Two (2) Capsule PO
BID (2 times a day).
7. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: One (1)
Spray Nasal DAILY (Daily).
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: 0.5 Tablet
PO DAILY (Daily).
9. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
10. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
11. Actonel 35 mg Tablet Sig: One (1) Tablet PO once a week.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 2203**] VNA
Discharge Diagnosis:
CAD s/p OPCABG x3 [**7-17**]
Hypercholesterolemia
HTN
PVD s/p right CEA, bil. LE stents
GI bleed ( while on plavix and ASA)
lipodystrophy with fat transfer to face as a child
peripheral neuropathy
hypothyroidism
hyponatremia
Discharge Condition:
stable
Discharge Instructions:
Please call your doctor or return to the hospital if you
experience chest pain, shortness of breath or any other symptoms
that concern you, fever greater than 100.5, redness, drainage.
No driving for one month.
No lotions, creams, powders or ointments on any incision.
Shower daily and pat incisions dry.
No lifting greater than 10 pounds for 10 weeks.
Followup Instructions:
see Dr. [**Last Name (STitle) 17369**] in [**1-9**] weks
see Dr. [**Last Name (STitle) 10543**] in [**2-10**] weeks
see Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Completed by:[**2198-7-22**]
|
[
"791.0",
"244.9",
"355.8",
"518.89",
"276.1",
"414.01",
"433.10",
"440.0",
"433.30",
"443.9",
"410.41",
"401.9",
"599.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"36.15",
"88.56",
"88.42",
"88.72",
"37.22",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
13188, 13247
|
9522, 11798
|
337, 447
|
13517, 13526
|
3695, 5205
|
13927, 14148
|
2767, 2841
|
12316, 13165
|
5242, 5298
|
13268, 13496
|
11824, 12293
|
13550, 13904
|
6371, 9423
|
2856, 3676
|
276, 299
|
5327, 6345
|
475, 1601
|
9458, 9499
|
1623, 2631
|
2647, 2751
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,921
| 156,938
|
34379
|
Discharge summary
|
report
|
Admission Date: [**2179-3-12**] Discharge Date: [**2179-3-16**]
Date of Birth: [**2105-12-7**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 11415**]
Chief Complaint:
right hip pain
Major Surgical or Invasive Procedure:
1. removal of hardware
2. conversion to total hip arthroplasty
History of Present Illness:
Mr. [**Known lastname 79073**] is a 73yo male with onset of increasing right hip
pain due to late onset avascular necrosis. Patient is
approximately 1.5 years removed from ORIF of right femur and
acetabular fractures due to a motor vehicle crash.
Past Medical History:
- CAD, s/p coronary stent x2, s/p peripheral arterial stent
- depression
Social History:
Married, lives with wife
Family History:
non-contributory
Physical Exam:
upon admission:
General: NAD, AOx3
Chest: CTAB
CV: RRR, S1/S2 appreciated
Abdomen: soft, NT/ND
Extremties: no C/C/E, well healed RLE surgical incisions
Pertinent Results:
[**2179-3-12**] 01:45PM GLUCOSE-210* UREA N-20 CREAT-1.0 SODIUM-140
POTASSIUM-5.2* CHLORIDE-112* TOTAL CO2-20* ANION GAP-13
[**2179-3-12**] 01:45PM estGFR-Using this
[**2179-3-12**] 01:45PM CALCIUM-7.2* PHOSPHATE-3.8 MAGNESIUM-1.8
[**2179-3-12**] 01:45PM WBC-16.6*# RBC-3.03*# HGB-9.1*# HCT-27.4*#
MCV-91 MCH-30.1 MCHC-33.2 RDW-13.2
[**2179-3-12**] 01:45PM PLT COUNT-247
[**2179-3-12**] 11:25AM TYPE-ART PO2-210* PCO2-47* PH-7.31* TOTAL
CO2-25 BASE XS--2 INTUBATED-INTUBATED
[**2179-3-12**] 11:25AM GLUCOSE-122* LACTATE-1.2 NA+-141 K+-4.2
CL--111
[**2179-3-12**] 11:25AM HGB-11.5* calcHCT-35
[**2179-3-12**] 11:25AM freeCa-1.15
[**2179-3-12**] 10:03AM TYPE-ART PO2-211* PCO2-47* PH-7.33* TOTAL
CO2-26 BASE XS--1
[**2179-3-12**] 10:03AM GLUCOSE-90 LACTATE-0.8 NA+-141 K+-4.0 CL--109
[**2179-3-12**] 10:03AM HGB-12.6* calcHCT-38
[**2179-3-12**] 10:03AM freeCa-1.21
[**2179-3-12**] 08:20AM TYPE-ART PO2-151* PCO2-55* PH-7.31* TOTAL
CO2-29 BASE XS-0 INTUBATED-INTUBATED
[**2179-3-12**] 08:20AM GLUCOSE-88 LACTATE-1.3 NA+-139 K+-4.4 CL--103
[**2179-3-12**] 08:20AM HGB-13.0* calcHCT-39
[**2179-3-12**] 08:20AM freeCa-1.28
Brief Hospital Course:
Mr [**Known lastname 79073**] was a same day admission to [**Hospital1 18**] on [**2179-3-12**], for
right hip hardware removal and conversion to total hip
arthroplasty. He was taken to the operating room the same day
and underwent removal of hardware with conversion to a right
total hip replacement without complication. He was extubated
and transferred to the recovery room in stable condition. In the
early post-operatively course, the patient has low urine output
and was transfused 2 units of packed red blood cells for post
operative blood loss anemia. His post-transfusion Hct was 37
and his urine output improved slowly. He was also given albumin
5%(12.5 grams/250 ml)for on-going low urine output in the
recovery room. His vital signs and blood counts were monitored
closely for signs of anemia, infection, and electrolyte
imbalances. His operative cultures were negative and his
vancomycin was stopped. He was then started on oral keflex for
a 10 day course. On [**2179-3-14**] he was transfused with 2units of
packed red blood cells due to acute blood loss anemia. his post
tx hct was 33.3
During this admission, his pain was adequately controlled and he
worked with physical therapy. The remainder of his inpatient
stay was unremarkable and he was discharged in stable condition.
Medications on Admission:
1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for Pain. Disp:*80 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation. Disp:*30 Capsule(s)*
Refills:*2*
3. Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as
needed for Constipation. Disp:*30 Tablet(s)* Refills:*2*
4. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe
Subcutaneous DAILY (Daily) for 4 weeks. Disp:*28 syringe*
Refills:*0*
Discharge Medications:
1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for Pain.
Disp:*80 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*30 Capsule(s)* Refills:*2*
3. Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as
needed for Constipation.
Disp:*30 Tablet(s)* Refills:*2*
4. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe
Subcutaneous DAILY (Daily) for 4 weeks.
Disp:*28 syringe* Refills:*0*
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO DAILY (Daily).
7. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Divalproex 250 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO QAM (once a day (in the
morning)).
9. Divalproex 500 mg Tablet Sustained Release 24 hr Sig: 1 [**1-23**]
Tablet Sustained Release 24 hr PO QPM (once a day (in the
evening)).
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain / fever.
12. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 10 days.
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
1. right femoral head avascular necrosis
2. post operative blood loss anemia
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
Wound Care:
- keep incisions dry, do not soak the incision in a bath or pool
Activity:
- right lower extremity: weight-bearing as tolerated
- internal rotation pre-cautions
OTHER INSTRUCTIONS:
- Resume your regular diet.
- Avoid nicotine products to optimize healing.
- Resume your home medications. Take all medications as
instructed.
You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so plan ahead. You can either have them mailed
to your home or pick them up at the clinic located on [**Hospital Ward Name 23**] 2.
We are not allowed to call in narcotic (oxycontin, oxycodone,
percocet) prescriptions to the pharmacy. In addition, we are
only allowed to write for pain medications for 90 days from the
date of surgery.
- Narcotic pain medication may cause drowsiness. Do not drink
alcohol while taking narcotic medications. Do not operate any
motor vehicle or machinery while taking narcotic pain
medications. Taking more than recommended may cause serious
breathing problems.
If you have questions, concerns or experience any of the below
danger signs then please call your doctor at [**Telephone/Fax (1) 1228**] or go
to your local emergency room.
Followup Instructions:
please call [**Telephone/Fax (1) 1228**] to schedule your follow-up appointment
with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP in 2 weeks
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**] MD, [**MD Number(3) 11417**]
Completed by:[**2179-3-16**]
|
[
"905.3",
"733.42",
"311",
"414.01",
"285.1",
"V45.82",
"E929.0",
"E878.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"78.65",
"81.51",
"78.69"
] |
icd9pcs
|
[
[
[]
]
] |
5532, 5612
|
2215, 3518
|
335, 400
|
5733, 5733
|
1040, 2192
|
7144, 7471
|
834, 852
|
4077, 5509
|
5633, 5712
|
3544, 4054
|
5881, 5881
|
867, 869
|
281, 297
|
5893, 7121
|
428, 678
|
884, 1021
|
5748, 5857
|
700, 775
|
791, 818
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,124
| 113,717
|
50577
|
Discharge summary
|
report
|
Admission Date: [**2126-10-31**] Discharge Date: [**2126-11-7**]
Date of Birth: [**2063-9-7**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Lisinopril
Attending:[**First Name3 (LF) 678**]
Chief Complaint:
altered mental status, hyperglycemia, renal failure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
63 yof with IDDM c/b nephropathy, neuropathy and retinopathy,
htn, and anemia who presents with three days of nausea,
vomiting, cough, and high blood sugars. On the night prior to
admission her sugars where critically high, > 600. She was
evaluated by Dr. [**First Name (STitle) 216**] at her home who recommended 20U of NPH
at night and 40U lispro. She became altered overnight and was
brought into the ED in the AM for hydration. PCP recommended
adjustment of BP medications while hospitalized.
.
In the ED, vs were T101 BP126/60 HR56 RR16 O2 sat 100% 2L.
Her mental status had improved at this point and she was alert
and oriented X 3. She was given Ceftriaxone 1gm, Tylenol 1mg
and Azithromycin 500mg. She refused Levofloxacin. She was
given 2L normal saline. Labs were notable for normal
electrolytes, AG of 15, ketones in the urine. CXR showed left
lower lobe infiltrate.
.
On the floor, pt is refusing to answer questions, affirms
thirst, nausea, vomiting. Admits to low po intake and low urine
output for three days. Asks that all questions be directed to
her husband.
Past Medical History:
DM1, last A1c 8.5% on [**4-/2123**], c/b gastroparesis, retinopathy,
and neuropathy
Hypertension
Depression
Anemia
OSA on CPAP 11 CM
Legally blind
h/o pneumonia x2
h/o MSSA bacteremia
h/o T10-T11 discitis
s/p lap cholecystectomy
s/p ORIF left ankle
Social History:
Lives w/ husband. [**Name (NI) 1403**] as an administrator at BU. Walks w/
cane. Never smoked. [**1-26**] glass wine daily. No illicits.
Family History:
Non-contributory
Physical Exam:
Physical Exam:
Vitals: T 98.9 BP 151/56 P 61 RR 18 SaO2 97 RA
Blood glucose 133-440
General: mildly fatigued elderly woman with left eye closed
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP flat, no LAD, thyromegally
Lungs: Reduced breathsounds at LL base, otherwise clear
bilatearlly without wheezes, rales or rhonchi.
CV: RRR, 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:
Admission labs:
Labs:
WBC 11.7 Hct 30.3 Plt 220
N:80.3 L:12.1 M:7.1 E:0.2 Bas:0.3
.
133 92 69
---------------181
4.3 26 3.9
[**2126-10-31**] 01:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-150
GLUCOSE-1000 KETONE-50 BILIRUBIN-SM UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2126-10-31**] 02:21PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2126-10-31**] 02:21PM URINE HOURS-RANDOM
[**2126-10-31**] 03:37PM URINE OSMOLAL-355
[**2126-10-31**] 12:10PM GLUCOSE-181* UREA N-69* CREAT-3.9*#
SODIUM-133 POTASSIUM-4.3 CHLORIDE-92* TOTAL CO2-26 ANION GAP-19
[**2126-10-31**] 12:10PM estGFR-Using this
[**2126-10-31**] 12:10PM CK(CPK)-90
[**2126-10-31**] 12:10PM CK-MB-3 cTropnT-0.06*
[**2126-10-31**] 12:10PM OSMOLAL-306
[**2126-10-31**] 12:10PM WBC-11.7*# RBC-3.17* HGB-10.2* HCT-30.3*
MCV-96 MCH-32.3* MCHC-33.8 RDW-14.5
[**2126-10-31**] 12:10PM NEUTS-80.3* LYMPHS-12.1* MONOS-7.1 EOS-0.2
BASOS-0.3
[**2126-10-31**] 12:10PM PLT COUNT-220
CXR: [**10-30**]: Minimal left basilar atelectasis. Unchanged right
minor fissural thickening.
CXR: [**10-31**]: In comparison with the study of [**10-30**] there is little
overall
change. Continued low lung volumes with mild engorgement of
pulmonary vessels and atelectatic changes primarily in the
retrocardiac region. Minimal blunting of both costophrenic
angles could reflect some small pleural effusions. There is
slight asymmetric opacification in the left perihilar region
when compared to the right. This could merely reflect slight
differences in pulmonary vascular engorgement. However, if there
is strong clinical concern for infection, this could be an area
of developing consolidation.
CXR [**11-5**] 1. Interval improvement in vascular congestion.
2. Trace atelectasis at the left costophrenic angle. No evidence
of
aspiration.
Brief Hospital Course:
63 year old female with IDDM, who presents with DKA c/b
worsening dysphagia.
.
# DKA/hyperglycemia - The patient presented with DKA, perhaps
precipitated by an acute viral syndrome. On admission she was
sent to the ICU. Her anion gap was small and likely atleast
partially contiributed to by her acute on chronic renal failure.
However, there were ketones in the urine, though these may also
be secondary to poor po intake. HONK was also on the
differential initially but her serum osms were within normal
limits. Her blood glucose on presentation was 184, which had
been increasing slowly. She was started on insulin drip
administered with D5, 1/2NS when sugars < 200. This was stopped
once glucose was controlled. Once anion gap was closed and
sugars were under better control the patient was switched to ISS
and home NPH (qAM) and transferred to the floor. Despite being
on the home regimen, pt's sugars continued to have some high
elevations with episodes of hypoglycemia. Given the patient had
been hard to manage diabetic, [**Last Name (un) **] was consulted and
recommended lantus and changing sliding scale. The patient's
sugars were better managed however did continue to experience
some elevations. The patient will follow-up with [**Last Name (un) **] as an
outpatient.
.
# Inability to swallow: Speech and Swallow evaluated the patient
and found she was at aspiration risk for solids and liquids. The
cause was unclear, could be recrudescence of deficits from [**2-3**]
lacunar infarct [**2-26**] hypovolemia. The patient was made NPO but
was adamant that she could eat full diet. The patient and
husband were counseled about the risks of aspiration and
potential morbidities associated with it and agreed that they
were willing to accept the risk of aspiration. On repeat S&S the
following recommendations were made: 1. Safest recommendation
would be videoswallow study for better objective assessment of
swallow function 2. If pt remains uninterested in discussion of
aspiration risk,
modified diet, and further testing, would return her to regular
diet with thin liquids at her own risk. 3. If pt is to take PO,
aspiration precautions including: a) feed only when awake/alert
b) sit fully upright for all PO c) remain upright at least 30
minutes after meals d) do not lower HOB below 30 degrees.
.
# LLL infiltrate - The patient had a CXR questionable for LLL
infiltrate, along wiht cough, fever, and leukocytosis. She was
started on ceftriaxone and azithro given suspicion for CAP.
However given the inconclusiveness of the xray, the fact that
the patient was asymptomatic, and her slight leukocytosis on
admission was likely [**2-26**] DKA, we stopped antibiotics and the pt
continued afebrile, stable on ra. Repeat PA and lateral showed
interval improvement. UA negative, blood cx neg.
.
# Acute on chronic renal failure: Pt shows evidence of volume
depletion from hyperosmolar state suggesting a prerenal
azotemia. No sediment on UA to suggest intrinsic renal
pathology. No evidence of outflow obstruction. She was treated
with IVF and Cr improved to baseline.
.
#Hypertension - Dr. [**First Name (STitle) 216**] had been concerned about her blood
pressure for some time and recommended titration while
hospitalized. However, in the ICU she was normotensive, likely
due to volume depletion. Chlorthalidone 25mg daily was held due
to acute on chronic renal failure, and reduced diltiazem to 30mg
qid (120mg daily vs 540mg home dose)changed atenolol 25mg daily
to metoprolol tartrate 12.5mg tid given renal failure and
continued clonidinen 0.1mg qAM and 0.2mg qPM. On the floor,
Diltiazem was uptitrated to 360mg, she was continued on
metoprolol 25mg TID, continued clonidine and started on
hydralazine 25mg PO TID, as well as restarted on chlorthalidone
home dose.
.
#Elevated troponins - without elevation in CK/MB, no ECG
changes, there was very low suspicion for MI.
.
# Anemia: Hct trended from 34 to 27 this admission, likely
secondary volume resuscitation. Now 30. Baseline anemia is
likely due to CKD.
.
# Depression: Psych was consulted and signed off due to
patient's lack of interest in talking to them further. She was
continued on home fluoxetine
.
#HL - continued home simvastatin
Medications on Admission:
Atenolol 25mg daily
Chlorthalidone 25mg daily
Clonidine 0.1mg qAm and 0.2mg qpm
Diltiazem 540mg daily
Fluoxetine 40mg daily
Lispro 4 units tid for BG > 200
Metoclopramide 5mg daily
Omprazole 20mg daily
Percocet 0.5-1 tab q6h prn pain
Simvastatin 40mg qhs
ASA 81mg daily
Calcium + vit D [**Hospital1 **]
Vit D 100 U daily
MVI
NPH 20mg daily
Fish oil 1000mg daily
.
Allergies:
Codeine
Lisinopril
Discharge Medications:
1. fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO TID (3 times a day).
6. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
7. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day).
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily) as needed for constipation.
10. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
11. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO qAM.
12. chlorthalidone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. diltiazem HCl 180 mg Capsule, Sustained Release Sig: Two (2)
Capsule, Sustained Release PO DAILY (Daily).
Disp:*60 Capsule, Sustained Release(s)* Refills:*2*
14. hydralazine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*2*
15. metoclopramide 5 mg Tablet Sig: One (1) Tablet PO once a
day.
16. clonidine 0.2 mg Tablet Sig: One (1) Tablet PO qPM.
17. M.V.I. Adult 1-5-10-200 mg-mcg-mg-mg Solution Sig: One (1)
Intravenous once a day.
18. Fish Oil 1,000 mg Capsule Sig: One (1) Capsule PO once a
day.
19. insulin glargine 100 unit/mL Cartridge Sig: Eighteen (18)
unit Subcutaneous at bedtime.
Disp:*1 month supply* Refills:*2*
20. insulin lispro 100 unit/mL Cartridge Sig: sliding scale
insulin units per ss Subcutaneous qachs: BREAKFAST: <80 give 4,
80-130 give 7, 131-180 give 8, 181-230 give 9...increase 1unit
lispro every 50 increase of sugar. LUNCH and DINNER: <80 give
3u, 80-130 give 5u, 131-180 give 6u, continue to increase
insulin 1u for every 50 increase of blood sugar. BEFORE BED: if
blood sugar 181-230 give 2u lispro, continue to increase 1u
insulin per 50 increase sugar. .
Disp:*1 month supply* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
1) DKA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mrs. [**Known lastname **],
You were admitted for diabetic ketoacidosis (very high blood
sugars) likely precipitated by a respiratory illness probably
from a virus. You were in the intensive care unit where they
brought down your sugars with an insulin drip and then
transitioned you to the general wards. While here you were
consulted by [**Last Name (un) **] Diabetes Center and they changed your
insulin sliding scale and switched you from NPH to Lantus
(insulin glargine). You will follow up with a doctor [**First Name8 (NamePattern2) **] [**Last Name (Titles) **]
as an outpatient to further optimize your diabetes management.
You were also found to have difficulty swallowing and were
evaluated by speech and swallow. They found that you do aspirate
some food and liquids while eating and drinking, especially thin
liquids. However, in consultation with you and your husband, you
decided to accept the risks of eating in order to have an
unrestricted diet. If you decide in the future that you want
more specific recommendations on diet in order to decrease the
risk of aspirating, further imaging can be done to better
identify the source of this difficulty swallowing.
If you develop increased pain, sugars >500 that are not
being controlled with insulin, or other symptoms that concern
you, please call Dr. [**First Name (STitle) 216**] or return to the ED.
*********
Please START the following medications:
Lantus 18u at bedtime
Metoprolol 25mg every 8h
Hydralazine 25mg every 8h
Senna, Colace, Miralax as needed for constipation
.
Please STOP the following medications:
Atenolol
NPH insulin
.
The following medications have been CHANGED:
Take Diltiazem at 360mg daily
The Lispro sliding scale has changed
Followup Instructions:
Department: [**Hospital3 249**]
When: WEDNESDAY [**2126-11-13**] at 10:30 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
[**Last Name (un) **] Diabetes Center will call you with an appointment.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 684**]
|
[
"536.3",
"583.81",
"585.9",
"311",
"362.01",
"250.43",
"V58.67",
"250.63",
"272.0",
"357.2",
"584.9",
"327.23",
"403.90",
"250.53",
"250.13"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11266, 11323
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4401, 8617
|
332, 339
|
11374, 11374
|
2548, 2548
|
13281, 13716
|
1906, 1924
|
9063, 11243
|
11344, 11353
|
8643, 9040
|
11525, 13258
|
1954, 2529
|
241, 294
|
367, 1463
|
2564, 4378
|
11389, 11501
|
1485, 1735
|
1751, 1890
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,386
| 185,383
|
38398
|
Discharge summary
|
report
|
Admission Date: [**2173-4-19**] Discharge Date: [**2173-4-25**]
Date of Birth: [**2114-12-31**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3531**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
Red blood cell exchange transfusion [**2173-4-20**]
History of Present Illness:
Mr. [**Known lastname 23050**] is a 58 year old male with a PMH significant for
Hodgkin's disease treated more than 30 years ago with radiation
therapy and splenectomy who presents with fever, arthralgias,
myalgias, and headache after a tick bite. Patient reports
finding two tick bites 3 weeks ago. He believes these tick bites
occured at his home residence in [**Location (un) **], MA, likely brought into
the house from the dog or cats. He denies any recent
international travel, but has recently visited [**Location (un) 7453**]. Both ticks were removed manually with no signs of
rash, except a mild erythematous patch at the bite site. Patient
was in normal state of health until Wednesday [**4-14**] PM when he
began to experience low grade fevers. Over the next 48 hours,
his symptoms worsened to include high fevers (per patient 104),
chills, night-sweats, arthralgias, myalgias, and 'sharp'
headaches localized to the right temple. He reports chest
congestion and a mild, non-productive cough, but denies SOB or
chest pain. He denies vomiting and diarrhea, although reports
decreased appetite and nausea. He reports decreased urine output
and amber-colored urine, but denies dysuria.
.
Patient believed his symptoms were due to a viral infection and
initially self-managed with Tylenol and fluids. He reported to
[**Hospital1 **] [**4-19**] AM complaining of spiking fevers. Vitals
on arrival were BP 115/64, P 94, T 98.1, RR 18, SpO2 97%. Blood
smear showed parasites consistent with intracellular ring forms,
and other laboratory findings were consistent with hemolysis.
Patient has no international travel history.
.
Notable [**Hospital1 **] laboratory values include: WBC 8.0, Hgb 14.2,
Hct 41.9, Plts 64, LDH 797, AST 81, ALT 65, and Bilirubin Tot
2.5 (Indirect 1.7). UA was positive for RBCs.
.
Patient received 600 mg IV Clindamycin, 650 mg PO quinine, and
2.5 L NS. He was transferred to [**Hospital1 18**] [**4-19**] PM for possible
urgent RBC exchange transfusion.
.
On arrival to the floor, initial vitals were T= 100.9,
BP=128/66, HR=95, RR=18, O2sat= 97% RA. He reports fevers, a
'sharp' headache, myalgias, arthralgias, and fatigue.
.
Review of sytems:
(+) Per HPI
(-) Denies recent weight loss or gain. Denies sinus tenderness,
rhinorrhea or congestion. Denied shortness of breath. Denied
chest pain or tightness, palpitations. Denied nausea, vomiting,
diarrhea, constipation or abdominal pain. No dysuria.
Past Medical History:
-Hodgkin's Disease, s/p surgery, radiation, splenectomy in [**2141**]
-Hypothyroidism
-Essential hypertension
-Hyperlipidemia
-Esophageal stricture: s/p dilatation in [**2164**]
-Basal cell carcinoma
-CAD s/p PCI [**2165**]: 90% prox to mid LAD lesion with cypher sent,
nl left main and LCx
Social History:
Resides in [**Location (un) **] MA with wife, three children, dog and 2 cats.
Works in finance. Patient reports 14 pack year history (quit
[**2150**]), consumes ~6 drinks per week. Reports occasional marijuana
use in college and denies elicit drug use.
Family History:
No family members have experienced fevers in the past few weeks,
although children have had several tick bites. Father deceased
(48 [**Name2 (NI) 1686**]) from emphysema and mother deceased from 'old age.' No
family history of malignancy.
Physical Exam:
VS: T=100.9, BP=128/66, HR=95, RR=18, O2 sat=97% RA
GENERAL: well-appearing middle aged male in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP of 8 cm
CARDIAC: RRR, normal S1, S2. No m/r/g.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. Liver edge palpable with slight ttp.
EXTREMITIES: No c/c/e.
SKIN: No rash appreciated near bite sites (right clavicle and
midline abdomen).
Pertinent Results:
ADMISSION LABS:
[**2173-4-19**] 06:30PM BLOOD WBC-7.9 RBC-4.34* Hgb-12.8* Hct-39.3*
MCV-91 MCH-29.5 MCHC-32.6 RDW-15.2 Plt Ct-109*
[**2173-4-20**] 05:30PM BLOOD Neuts-46* Bands-0 Lymphs-37 Monos-12*
Eos-3 Baso-0 Atyps-1* Metas-1* Myelos-0
[**2173-4-20**] 05:42AM BLOOD PT-12.6 PTT-32.8 INR(PT)-1.1
[**2173-4-19**] 06:30PM BLOOD Ret Aut-1.9
[**2173-4-19**] 06:30PM BLOOD Glucose-108* UreaN-13 Creat-0.9 Na-138
K-3.6 Cl-104 HCO3-24 AnGap-14
[**2173-4-19**] 06:30PM BLOOD ALT-66* AST-76* LD(LDH)-734* AlkPhos-64
TotBili-2.0*
[**2173-4-19**] 06:30PM BLOOD Calcium-8.1* Phos-2.5* Mg-1.9
[**2173-4-19**] 06:30PM BLOOD Hapto-<5*
[**2173-4-19**] 08:24PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.007
[**2173-4-19**] 08:24PM URINE Blood-TR Nitrite-NEG Protein-25
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-8* pH-5.0 Leuks-NEG
[**2173-4-19**] 08:24PM URINE RBC-0-2 WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-0-2
.
DISCHARGE LABS:
[**2173-4-25**] 01:30PM BLOOD WBC-16.3* RBC-4.04* Hgb-11.8* Hct-36.3*
MCV-90 MCH-29.2 MCHC-32.6 RDW-16.1* Plt Ct-805*
[**2173-4-25**] 01:30PM BLOOD Glucose-80 UreaN-12 Creat-0.9 Na-138
K-4.9 Cl-103 HCO3-26 AnGap-14
[**2173-4-25**] 01:30PM BLOOD ALT-150* AST-102* AlkPhos-74 TotBili-0.5
[**2173-4-25**] 06:20AM BLOOD ALT-139* AST-104* LD(LDH)-291*
TotBili-0.5
[**2173-4-25**] 01:30PM BLOOD Calcium-9.2 Phos-3.7 Mg-2.5
[**2173-4-19**] 06:30PM BLOOD LYME BY WESTERN BLOT-PENDING
[**2173-4-20**] 04:08PM BLOOD ANAPLASMA PHAGOCYTOPHILUM (HUMAN
GRANULOCYTIC EHRLICHIA [**Doctor Last Name **]) IGG/IGM-PENDING
.
IMAGING/STUDIES:
[**2173-4-20**] CXR: Normal lung volumes. Normal size of the cardiac
silhouette.
Minimal fibrotic changes in the paramediastinal lung areas.
Otherwise
unremarkable lung parenchyma. No pleural effusions. No
pneumothorax.
.
[**2173-4-23**] Skin Biopsy: Pathology Pending.
Brief Hospital Course:
Mr. [**Known lastname 23050**] is a 58 yo male with past medical history
significant for Hodgkin's disease s/p splenectomy, CAD, and
hypothyroidism who presents with babesiosis & Lyme disease.
#.Babesiosis: Mr. [**Known lastname 23050**] was referred to [**Hospital1 18**] from [**Hospital1 2292**] with diagnosis of babesiosis complaining of fevers,
rigors, myalgias and headache. He presented with
thrombocytopenia to 64, abnormal LFTs, and elevated bilirubin.
Prior to admission, PCP had given patient quinine 650 mg PO plus
IV clindamycin 600mg, but per ID recommendation, antibiotics
were changed to atovaquone 750mg and azithromycin 750mg due to
side effect profile of quinine/clindamycin combination and
equivalent efficacy of atovaquone/azithromycin regimen.
.
Within 12 hours of admission, patient's parasitemia level
increased from 4.7% to 8.8%. ID recommended RBC exchange
transfusion given asplenia and rising parasitemia. After
receiving 15.5 units of blood, patient suddenly developed
chills, rigors, and a temperature of 99F. A code blue was called
and patient was stabilized with benadryl, solumedrol, demerol,
and albuterol. His symptoms resolved and he was transferred to
the ICU for further monitoring; he was transferred back to the
medicine floor within 24 hours. Pathology investigation was most
consistent with a febrile nonhemolytic transfusion reaction.
.
Following RBC exchange, patient's parasitemia percentage
remained stable at 0.8% for the remainder of his
hospitalization. His fever, headache and myalgias resolved.
However, post-trasfusion, the patient had a persistent
leukocytosis and rising transaminitis. Although leukocytosis
persisted until discharge, the level remained stable and was
most likely attributed to a reaction to steriods or an
inflammatory response to RBC exchange. Simultaneously, the
patient's liver enzymes continued to trend upwards to a maximum
ALT 150 and AST 104. ID consult suggested elevated LFT could be
a natural progression of infection (see below for details) or a
side effect of antibiotics, since atovaquone has a known risk of
hepatotoxicity and azithromycin is hepatically metabolized.
Azithromycin dosage was consequently lowered to 250mg. The
patient remained clinically stable despite these laboratory
findings, and was discharged on a planned two week course of
azithromycin, atovoquine and doxycycline. He was instructed to
follow-up in ID urgent care on [**4-27**] for a lab check, as well as
with his PCP.
.
#. Lyme Disease: [**Hospital1 **] Laboratory results returned
with a positive Lyme antibody, negative IgM, and positive IgG.
[**Hospital1 **] Laboratory Lyme Western Blot testing was pending at
discharge. Patient was started on doxyclycine 100 mg and
instructed to continue for a total 14 day course at discharge.
.
#. Skin lesion: Patient reported a dark, atypical lesion on left
clavicle. Dermatology was consulted and no tick was clearly
visualized, but given clinical situation, a bunch biopsy was
performed. Pathology report was pending at discharge. Patient
will be informed of results by telephone and encouraged to
follow-up with dermatology for total body skin examination.
.
#. Possible Anaplasmosis: Patient was tested for anaplasma
phagocytophilum co-infection. IgG/IgM serum results were pending
at discharge.
Medications on Admission:
ASA 81 mg daily
Plavix 75 mg daily
Levothyroxane 100 mcg daily
SL nitro prn
Viagra 25 mg prn
Rosuvastatin 40 mg qhs
Atenolol 25 mg daily
Lorazepam 0.5 mg PO BID prn
Discharge Medications:
1. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for anxiety.
6. Sub Lingual Nitro prn
7. Atovaquone 750 mg/5 mL Suspension Sig: Five (5) ml PO Q12H
(every 12 hours) for 7 days.
Disp:*70 ml* Refills:*0*
8. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
9. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours) for 8 days.
Disp:*16 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
Babesiosis
Lyme Disease
Transaminitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital because of a babesia
infection, which is transmitted by the deer tick. You were also
found to be positive for lyme disease. You were treated with
antibiotics and underwent a red blood cell exchange transfusion,
and your symptoms improved. Prior to discharge, your liver
tests became elevated; this could be a result of your
antibiotics, or a progression of your infection. You should go
to Urgent care [**Hospital **] clinic to have these labs re-checked on
Tuesday. You should also follow-up with your PCP on Tuesday.
We made the following medication changes:
- Stop rosuvastatin for now
- Take Atovoquone twice daily for a total two weeks (end on
[**2173-5-2**])
- Take Azithromycin once daily for a total two weeks (end on
[**2173-5-2**])
- Take Doxycycline for a total two weeks (end on [**2173-5-3**])
Followup Instructions:
Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 85521**], MD
Specialty: Internal Medicine
When: Tuesday [**4-27**] at 8am.
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 3530**]
|
[
"088.82",
"E879.8",
"401.9",
"V45.79",
"201.90",
"790.4",
"287.5",
"173.5",
"V45.82",
"414.01",
"283.9",
"088.81",
"780.60",
"272.4",
"794.8",
"999.89",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.01",
"86.11"
] |
icd9pcs
|
[
[
[]
]
] |
10436, 10442
|
6120, 9434
|
322, 376
|
10543, 10543
|
4276, 4276
|
11564, 11860
|
3437, 3677
|
9649, 10413
|
10463, 10522
|
9460, 9626
|
10694, 11274
|
5204, 6097
|
3692, 4257
|
11294, 11541
|
277, 284
|
2580, 2836
|
404, 2562
|
4292, 5188
|
10558, 10670
|
2858, 3150
|
3167, 3421
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,512
| 199,445
|
49008
|
Discharge summary
|
report
|
Admission Date: [**2140-2-17**] Discharge Date: [**2140-2-27**]
Date of Birth: [**2089-3-1**] Sex: M
Service: MEDICAL
CHIEF COMPLAINT: Renal artery stenosis.
HISTORY OF THE PRESENT ILLNESS: This is a 51-year-old male
with a medical history of hypertension, peripheral vascular
disease, status post aortobifemoral in [**2139-11-22**] now
with a right renal artery stenosis who was admitted for
reangiography and stent placement. The patient had a right
renal artery stent done in [**9-21**]. His creatinine at that
time was 4.0, post stent, he stabilized to a baseline
creatinine of 3.0.
In [**11-22**], he was admitted for a nonhealing right foot ulcer
and had an arteriogram done at that time which demonstrated
restenosis of the right renal artery stent as well as
bilateral iliac disease. He underwent an aortobifemoral with
subsequent healing of the foot ulcer and significant decrease
in his claudication with increased exercise endurance. He
denied any chest pain, shortness of breath, PND, orthopnea,
or lower extremity edema. He is now admitted for
prehydration and Mucomyst protocol.
ALLERGIES: Zestril, manifestation unknown.
MEDICATIONS ON ADMISSION:
1. Procrit 3,000 units three times per week, Monday,
Wednesday, and Friday.
2. Niferex 150 mg b.i.d.
3. .................... 40 mg t.i.d.
4. Lopressor 50/25.
5. Plavix 75 mg q.d.
6. Enteric coated aspirin.
7. Oxycodone for pain.
PAST MEDICAL HISTORY:
1. Coronary artery disease.
2. Hypertension.
3. Peripheral vascular disease.
4. Chronic renal insufficiency.
5. Osteoarthritis.
6. History of cervical disk disease.
7. history of low back pain secondary to motor vehicle
accident one year ago.
8. History of gout.
9. History of anemia.
10. History of renal artery stenosis.
PAST SURGICAL HISTORY:
1. Aortobifemoral in [**11-22**].
2. Herniorrhaphy.
3. Remote angioplasty with stent placement of the right
renal artery in [**9-21**] with restenosis.
SOCIAL HISTORY: The patient is a disabled man, married,
lives in [**Location 10022**]. He has a former 20 pack year history of
smoking.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: 99.4,
131/67, 73, 20. General appearance: The patient was an
alert white male in no acute distress. HEENT: Unremarkable.
There were no carotid bruits or JVD. Heart: Regular rate
and rhythm. There were no murmurs, gallops, or rubs. Lungs:
Clear to auscultation bilaterally. Abdomen: Soft, nontender
with bowel sounds. There were no abdominal bruits.
Extremities: The feet were warm. Palpable PTs bilaterally.
DPs were not palpable. Feet were pink, warm, without
ulcerations.
HOSPITAL COURSE: On [**2140-2-18**], the patient underwent right
renal angioplasty with a stent placement. Vascular was
consulted regarding expanding right groin hematoma after
removing the sheath. The patient underwent a right groin
exploration for expanding hematoma.
The patient tolerated the procedure well and was transferred
to the SICU for continued monitoring and care. The patient
did require a transfusion of 5 units of packed red blood
cells to maintain his hematocrit at 32. Serial enzymes were
obtained. Total CKs remained flat. Troponin levels peaked
at 2.5 and over the next 24 hours defervesced to 1.4.
The patient required nitroprusside for systolic hypertension
control. This was eventually weaned by postoperative day
number three. The patient was extubated on postoperative day
number one. Troponin levels were continued to be followed.
The EKG was without remarkable changes.
The patient was transferred out of the SICU to the regular
nursing floor on postoperative day number five. His
hematocrit remained stable. His wound ecchymosis and
erythema continued to diminish while he remained on the
vancomycin. His vancomycin was dosed according to a random
level less than 15. His PCA was discontinued and he was
begun on oral analgesic agents and he was discharged from
telemetry.
The patient developed a fever on postoperative day number
six. T. max 101.2 to 99. Blood and urine cultures were sent
which were finalized at no growth. Antibiotics were added to
his regimen at this time, vancomycin, levo, and Flagyl. The
line was changed over a wire. The chest x-ray was
unremarkable.
The JP was removed on postoperative day number six because of
increasing size in his thigh and knee with pain with
diminished drainage in the JP and they felt that these were
no longer adequately draining the surgical site.
The patient showed improvement in his temperature curve after
instituting broadening of his antibiotics. His hematocrit
continued to remain stable and his white count was not
elevated. Cultures from the JPs grew 1+ PMNs but no
organisms. An ultrasound was done. There was no bleeding,
no compression. Hematoma was present.
Physical Therapy was requested to see the patient in regards
to discharge planning and assessment of ambulation. The
patient will be discharged home in stable condition with VNA
services. The patient will follow-up with Dr. [**Last Name (STitle) 1860**] on
Wednesday, [**2140-3-9**]. He is to continue his current
Catapres patch, aspirin, Plavix, antihypertensives, and oral
antibiotics.
FOLLOW-UP: The patient should follow-up with Dr. [**Last Name (STitle) **]
in one to two weeks time.
DISCHARGE MEDICATIONS:
1. Epogen 3,000 units subcutaneously Monday, Wednesday, and
Friday.
2. Albuterol ipratropium inhaler one to two puffs q. six
hours.
3. Plavix 75 mg q.d.
4. Simethicone 40-80 mg q.i.d. p.r.n.
5. Metoprolol 75 mg b.i.d.
6. Ferrous sulfate 325 mg q.d.
7. Acetaminophen 325 to 650 mg q. four to six hours p.r.n.
8. Enteric coated aspirin 325 mg q.d.
9. Clonidine TTS 3 patch change q. Wednesday.
10. Levofloxacin 250 mg q. 24 hours.
DISCHARGE DIAGNOSIS:
1. Renal artery stenosis, status post angioplasty with stent
placement.
2. Right thigh/groin hematoma, status post thigh
exploration.
3. Blood loss anemia, transfused.
4. Hypertension, controlled.
5. Elevated troponin levels secondary to chronic renal
insufficiency, ruled out for myocardial infarction.
6. Peripheral vascular disease.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], M.D. [**MD Number(1) 6223**]
Dictated By:[**Last Name (NamePattern1) 22071**]
MEDQUIST36
D: [**2140-2-26**] 02:29
T: [**2140-2-26**] 21:02
JOB#: [**Job Number 102880**]
|
[
"998.12",
"998.2",
"443.9",
"998.89",
"401.9",
"996.74",
"682.2",
"285.1",
"458.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.50",
"54.12",
"39.31",
"39.90"
] |
icd9pcs
|
[
[
[]
]
] |
5342, 5781
|
5802, 6430
|
1195, 1432
|
2662, 5319
|
1810, 1966
|
157, 1169
|
2141, 2644
|
1454, 1787
|
1983, 2126
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,385
| 163,265
|
42483
|
Discharge summary
|
report
|
Admission Date: [**2104-4-17**] Discharge Date: [**2104-5-30**]
Date of Birth: [**2048-3-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Dilaudid / Oxycodone
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Dyspnea, fevers
Major Surgical or Invasive Procedure:
[**2104-4-21**] Redo Sternotomy, Bentall Procedure utilizing a 21mm
Homograft, and Replacement of Ascending Aorta with 26mm Gelweave
Graft.
[**2104-4-21**] Extraction of AICD
[**2104-4-25**] Placement of Dual Lumen PICC Line(5F - 55cm)
History of Present Illness:
This is a 56 year old gentleman s/p bioprosthetic valve
replacement 4 yrs ago, IVDA/alcohol abuse, transferred from
[**Hospital6 **] yesterday evening after he was found to
have aortic valve abscess, for surgical intervention. He was
apparently at his baseline until [**2104-4-8**] when he developed
shortness of breath and orthopnea, and was admitted to the
hospital with diagnosis of volume overload vs pneumonia. He was
treated with iv diuretics. BP mostly in low 100s. He is not
aware of any low blood pressures. Blood cultures grew coag neg
staph [**3-13**], and he was treated with vancomycin. TEE done in OSH,
showed aortic valve abscess extending to aortic root and
ascending aorta, but no fistula. He was started on rifampin and
transferred to [**Hospital1 **] for surgical intervention. 2D echo showed EF
of 50-55 % with mild diastolic dysfunction and mild PAH with
pressures of 35. According to him, he was first told of some
kidney dysfunction almost 1.5 yrs ago, however he has not been
following up with any nephrologist. According to records, he did
have [**Last Name (un) **] requiring dialysis at the time of his initial valve
replacement. He is however not aware of it. He denies taking any
NSAIDs. He does not know if he has had proteinuria. He does
acknowledge that recently he has been told by ophthalmologist
that he has diabetic retinopathy. On admission, he denies any
shortness of breath, swelling in his lower extremities, cough,
sore throat or flu like symptoms. He does have low grade fever.
Denies any dysuria, hematuria, urinary urgency or frequency.
Denies having a foley catheter in OSH. Denies any chest pain or
palpitations.
Past Medical History:
Aortic Valve Endocarditis - Coagulase Negative Staphylococcus
Aortic Root Abscess
Ascites
Acute Renal Failure
Pleural Effusions
C Diff colitis
Right knee effusion
Respiratory Failure
Umbilical Hernia
Seizures
Mycotic Aneurysm
Left Occipital Hemorrhage
Tube Feed Intolerance
Aspiration Pneumonia
Thalamic/Intraventricular Hemorrhage
PMH:
Prior Aortic Valve Replacement [**2100**]
Chronic Renal Insufficiency
Postoperative Stroke
Alcoholic Cardiomyopathy, Prior AICD
History of IVDA and ETOH Abuse
Insulin Dependent Diabetes Mellitus
Pulmonary Hypertension
Dyslipidemia
Social History:
Lives in [**Location 5583**] MA. Currently on disability, previous
employed as welder.
Family History:
No premature coronary artery disease
Physical Exam:
ADMIT EXAM
Vitals: 100.4, 103-116/71-75, 80-90, 96-98% RA
Weight 50.6 kg
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, systolic murmur
present all over the precordium, early diastolic murmur + (I/VI
in intensity)
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, no clubbing, cyanosis or edema
Pertinent Results:
[**2104-4-18**] Cardiac Catheterization:
1. Selective coronary angiography of this right dominant system
demonstrated no angiographically-apparent flow-limiting coronary
artery disease. The LMCA was a short, patent vessel. The LAD
had a 30% stenosis at the origin and a tubular 45% lesion after
the large D2. The D2 itself had a 30% stenosis at the origin.
The LCx had a tiny OM1, a modest caliber OM2 with diffuse
plaquing distally, and a patent (large) OM3 and OM4. The RCA
was a tortuous lesion in its middle aspect with a large RPDA. 2.
Limited resting hemodynamics revealed low-normal systemic
arterial pressures, with a central aortic pressure of 104/58,
mean 77 mmHg. 3. Left ventriculography was deferred.
.
[**2104-4-19**] Chest CT Scan:
1. Bibasilar pulmonary consolidations, which likely include an
atelectatic
component, but superimposed aspiration or infection cannot be
excluded.
2. Bilateral loculated pleural effusions with surrounding
hyperdense pleural thickening and calcification.
3. Ascending aortic aneurysmal dilation measuring up to 4.8 cm.
4. Marked cardiomegaly.
5. Right subclavian line terminating in the high right atrium.
.
[**2104-4-19**] Renal Ultrasound:
The right kidney measures 10.7 cm and left kidney measures 10.9
cm. There is no evidence of hydronephrosis, renal masses, or
nephrolithiasis bilaterally. The corticomedullary
differentiation is well preserved. The renal parenchyma is
normal in echotexture and vascularity. Bilateral renal arteries
are patent with appropriate arterial waveforms. Mildly elevated
RI up to 0.85 are noted, however there is no consistent evidence
of tardus parvus to suggest renal artery stenosis. Although a
few waveforms may appear slightly blunted, others show swift
upstrokes bilaterally. Main renal veins are patent.
.
[**2104-4-19**] Abdominal Ultrasound:
There is a 3 x 2.8 cm hypoechoic lesion in the posterior left
lobe of the liver, which is incompletely evaluated and of
indeterminate etiology. The main portal vein is patent with
hepatopetal flow. There is no intra- or extra-hepatic biliary
ductal dilation. The gallbladder is normal without evidence of
stones. The spleen measures 11.3 cm, within normal limits. The
aorta is of normal caliber in the visualized portions. The
visualized portions of the inferior vena cava are unremarkable.
No ascites is detected.
.
[**2104-4-21**] Intraop TEE:
Pre-CPB:
There is a wire from the ICD/Pacer which is associated with a
great deal of thickened material and is possibly adherent to the
tricuspid valve. The first step in the operation was to remove
the wire, which left 1 - 2+ TR.
No spontaneous echo contrast is seen in the left atrial
appendage.
Overall left ventricular systolic function is low normal (LVEF
50-55%). with mild inferior hypokinesis.
There is mild global free wall hypokinesis.
The ascending aorta is mildly dilated.
There are simple atheroma in the descending thoracic aorta.
Motion of the aortic valve prosthesis leaflets is abnormal.
There is a minimally increased gradient consistent with minimal
aortic valve stenosis. Trace aortic regurgitation is seen. There
is a .8 x .8 cm mass on the prosthetic valve at the commissure
of the left and right leaflets, though it seems mainly attached
to the left.
The aortic root, especially off the left cusp, has an abnormal
echogenicity and is likely the residual material of an abscess.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen.
There is no pericardial effusion.
Post-CPB:
The patient is on low-dose epinephrine and phenylephrine, and is
in sinus rhythm.
There is an aortic homograft in place with no AI, no leak and a
residual peak gradient of 6 mmHg.
Trivial MR. TR remains 1 - 2+.
Biventricular systolic fxn is unchanged.
.
[**2104-4-22**] Head CT Scan:
There is an approximately 1.9 x 2.8 x 3.0 cm area of
intraparenchymal hemorrhage in the left occipital lobe with
surrounding edema. There is no significant mass effect or shift
of normally midline structures. There is no intraventricular
extension. There is no uncal or transtentorial herniation. There
is no hydrocephalus. The ventricles and sulci are prominent,
consistent with atrophy, more than expected for stated age.
There is a small calcification in the left parietal lobe that
either represents a granuloma or vascular calcification. No
evidence of large acute vascular territorial infarction. No
fractures identified. Slightly prominent soft tissues over the
left parietal lobe. The visualized paranasal sinuses and mastoid
air cells are well aerated.
Brief Hospital Course:
Mr. [**Known lastname **] was transferred from [**Hospital6 16029**] with
shortness of breath and low grade fever, blood cultures positive
for coagulase negative staphylcoccus, and an aortic valve
vegetation with root involvement. He was seen in consultation
by the infectious disease service who recommended continuation
of his Vancomycin and Rifampin. On [**2104-4-21**] he underwent a redo
sternotomy, Bentall, ascending aortic replacement, and
extraction of his AICD. This procedure was performed by Dr.
[**Last Name (STitle) **]. Please see the operative note for details.
Oral Vancomycin was started for presumed CDiff. The patient
developed seizures in the immediate post-op period when sedation
was weaned. Head CT revealed left occipital hemorrhage
concerning for underlying mycotic aneurysm. Neurosurgery was
consulted. Recommendations were made for blood pressure
parameters as well as to continued antibiotics. Angio was
deferred in the setting of acute renal failure- with hope for
recovery. Renal followed the patient as he had a baseline renal
insufficiency. CRRT was required.
GI was consulted on [**4-27**] for anemia and guaiac positive stool.
IV PPI was made [**Hospital1 **]. Additional labs were sent. Endoscopy was
deferred.
The patient was weaned and extubated on [**4-25**], however, required
re-intubation on [**4-28**] for respiratory distress. Antibiotic
regimen was broadened per the ID team in the setting of rising
bilirubin. The evening of [**5-1**] the patient had new fever and
hypotension concerning for new infection and CT showed large
anterior pleural collection. On [**5-2**] he had IR guided drainage
(per report appeared to be old blood) with cultures negative and
clinical improvement after drainage. He was broadened to
Vanco/Meropenem/Rifampin and once abscess cultures were
negative, meropenem was stopped on [**5-5**]. Urine output picked up
and CVVH was discontinued briefly. He decompensated on [**5-9**]
with respiratory distress, vomiting and diarrhea. Tracheostomy
was performed. He spiked a fever and was started on empiric
treatment for C Diff. CT Torso showed bilateral pleural
effusions and continued, but smaller anterior mediastinal
collection. HD line was discontinued. On [**5-13**] HD line was placed
and had continued fever and started vasopressors. CVVH
restarted and he was started on TPN. TEE on [**5-15**] did not reveal
any valvular vegetation, abscess or pericardial effusion.
Ortho was consulted on [**2104-5-25**] for a right knee effusion. This
was tapped and did not reveal infection or crystal process.
The patient struggled with tube feed intolerance with suspected
aspirations. He was started on Zosyn for pneumonia.
He developed hypothermia, requiring active warming. Fluconazole
was added for concern of fungal infection.
Ventilator requirements increased.
The patient was noted to be unresponsive on the evening of
[**2104-5-29**]. He was brought emergently to head CT. This revealed a
large left thalamic hemorrhage with extension into the
intraventricular system with significant hydrocephalus.
Neurosurgery was consulted. He did not respond to any aspect of
neurological exam including cough, gag, corneal reflex or
noxious stimuli.
Family was contact[**Name (NI) **]. The patient was put on trach collar and
comfort measures were initiated. He expired soon after with
family at the bedside.
Medications on Admission:
Lasix 80mg [**Hospital1 **], Norvasc 5mg daily, aAspirin 81 mg daily,
Carvedilol 12.5mg twice daily, Heparin 5000units every 8 hours,
Glargine insulin 10 units at bedtime, Insulin sliding scale,
Multivitamin daily, Rifampin 600mg every 24 hours, Simvastatin
20mg dailly at bedtime, Vancomycin 500 mg every 48 hours-last
dose, Acetominophen 650mg as needed for pain, Morphine as needed
for pain, Ambien 5mg as needed for sleep
Discharge Disposition:
Expired
Discharge Diagnosis:
Aortic Valve Endocarditis - Coagulase Negative Staphylococcus
Aortic Root Abscess
Ascites
Acute Renal Failure
Pleural Effusions
C Diff colitis
Right knee effusion
Respiratory Failure
Umbilical Hernia
Seizures
Mycotic Aneurysm
Left Occipital Hemorrhage
Tube Feed Intolerance
Aspiration Pneumonia
Thalamic/Intraventricular Hemorrhage
PMH:
Prior Aortic Valve Replacement [**2100**]
Chronic Renal Insufficiency
Postoperative Stroke
Alcoholic Cardiomyopathy, Prior AICD
History of IVDA and ETOH Abuse
Insulin Dependent Diabetes Mellitus
Pulmonary Hypertension
Dyslipidemia
Discharge Condition:
.
Discharge Instructions:
.
Followup Instructions:
.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2104-5-30**]
|
[
"421.0",
"431",
"E849.8",
"E879.8",
"345.90",
"425.5",
"038.12",
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"276.7",
"362.01",
"403.91",
"799.4",
"250.60",
"585.6",
"250.40",
"250.50",
"583.81",
"442.89",
"285.9",
"276.0",
"518.81",
"428.33",
"428.0",
"584.9",
"357.2",
"996.61",
"416.8",
"486",
"331.4",
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icd9cm
|
[
[
[]
]
] |
[
"38.93",
"39.61",
"33.24",
"39.95",
"38.95",
"96.71",
"37.79",
"96.04",
"99.15",
"35.22",
"89.49",
"31.1",
"96.72",
"37.77",
"81.91"
] |
icd9pcs
|
[
[
[]
]
] |
12048, 12057
|
8167, 11571
|
301, 538
|
12669, 12672
|
3580, 8144
|
12722, 12845
|
2939, 2977
|
12078, 12648
|
11597, 12025
|
12696, 12699
|
2992, 3561
|
246, 263
|
566, 2227
|
2249, 2818
|
2834, 2923
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,155
| 142,957
|
47881
|
Discharge summary
|
report
|
Admission Date: [**2179-4-10**] Discharge Date: [**2179-4-14**]
Service: MEDICINE
Allergies:
Dilantin / Depakote
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is an 82yo M wiith history of recurrent meningioma(resected
twice, radiation,treated with steroids, ventriculoperitoneal
shunt)DVT in [**2176**] who presented with shortness of breath.
Patient complained of shortness of breath since one day prior to
admission. According to him, it started suddenly while he was at
rest and had been progressively worse. He denies chest
pain/nausea/palpitation. He claims that he has no history of
COPD/asthma. OFnote, he had recent history of URI and was
started on prednisone and levaquin. Initial vitals were BP
180/100, R 40 93% on NRB, P120s. In the ED, he was treated for
reactive airway and was given aspirin, lasix, solumedrol 80 and
levoflox.
Past Medical History:
- Coronary artery disease, status post coronary artery bypass
graft times five vessels
- hypertension
- hypercholesterolemia
- history of deep vein thrombosis
- history of pneumonia
- transitional cell meningioma, status post resection times two,
blood pressure shunt
- glaucoma
- Adhesions of the abdominal cavity and obstructed
abdominal end of ventriculoperitoneal shunt, now status post
revision
- steroid myopathy resulting right hemiparesis in the arms and
proximal legs
- dementia
- cholecystectomy
-h/o meningioma: since [**2173**]. first embolized at the [**Hospital1 24300**] Hospital,and he was placed on prophylactic Dilantin. He
was then a rash to Dilantin and was subsequently switched to
Keppra. Carbitol was to be added by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**], Since he no
longer had any events he was taken off of Keppra. There seemed
to be no recurrent events after that. He underwent radiation
therapy in [**2175-5-28**] and was placed on steroids. Repeat scan in
[**2175-6-28**] showed tumor recurrence actually at the resection
site. Dr. [**Last Name (STitle) 1338**] placed a ventriculoperitoneal shunt for
hydrocephalus in [**2173-12-28**].
Social History:
The patient is a retired physics professor. He has two children.
He is a member of the Orthodox [**Hospital1 **] Community.
Family History:
non-contributory
Physical Exam:
T 97.3, BP 131/58, HR 80, RR31 97% on NRB
gen: obese elderly male, on NRB, no resp distress
heent: mucus membranes dry. PERRLA
JVP: unobtainable due to body habitus
Lungs: diffuse expiratory wheezes. coarse b/s b/l. no crackles.
no accessory muscle use
CV: RRR. no m/r/g dist heart sounds
ABd: soft, NT. NABS
EXT: 1+ pitting edema b/l LE's.
Neuro: A&O to person, not place or time. motor exam non-focal.
Pertinent Results:
admission labs:
---------------
CBC: WBC-8.3 RBC-4.65 HGB-14.6 HCT-41.6 MCV-90 PLT 254
DIFF: NEUTS-82.9* LYMPHS-12.8* MONOS-4.2 EOS-0 BASOS-0.2
CHEM: GLUCOSE-285* UREA N-26* CREAT-1.3* SODIUM-131*
POTASSIUM-6.4* CHLORIDE-96 TOTAL CO2-20* ANION GAP-21
COAGS: PT-12.5 PTT-27.9 INR(PT)-1.0
*
U/A: BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-250 KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG RBC-0-2 WBC-0
BACTERIA-NONE YEAST-NONE EPI-0
*
cardiac enzymes:
[**2179-4-9**] 10:25PM CK-MB-6 proBNP-716
[**2179-4-9**] 10:25PM cTropnT-0.03*
[**2179-4-10**] 04:19AM CK-MB-57* MB INDX-11.0* cTropnT-0.66*
[**2179-4-10**] 04:19AM CK(CPK)-518*
[**2179-4-10**] 11:35AM CK-MB-63* MB INDX-12.7* cTropnT-1.07*
[**2179-4-11**] 04:06AM CK-MB-21* MB Indx-7.4* cTropnT-1.20*
[**2179-4-11**] 04:06AM CK(CPK)-285*
[**2179-4-12**] 04:44AM cTropnT-0.78*
[**2179-4-13**] 04:47AM CK(CPK)-197*
*
[**4-9**] EKG: Sinus tachycardia. Left anterior fascicular block.
Intraventricular conduction delay. R waves in lead V1 which may
represent right ventricular hypertrophy. Compared to the
previous tracing sinus tachycardia and R waves in lead V1 are
new.
*
Radiologic Studies:
------------------
[**4-9**] CXR: no evidence of CHF
[**4-10**] CXR: There is no evidence of failure, pulmonary parenchymal
consolidation, pleural effusion, or pneumothorax.
[**4-11**] CTA: No evidence of pulmonary embolism. Diffuse, faint
ground glass opacity with nonspecific patchy opacities at the
bases dependently, suggesting an element of fluid overload.
*
[**4-12**] ECHO:
1. The left atrium is normal in size. The left atrium is
elongated.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic function is normal
(LVEF>55%).
3. Right ventricular chamber size and free wall motion are
normal. Right
ventricular chamber size is normal. Right ventricular systolic
function is normal.
4. The number of aortic valve leaflets cannot be determined. The
aortic valveleaflets are mildly thickened. There is mild aortic
valve stenosis. Mild (1+) aortic regurgitation is seen.
5.The mitral valve leaflets are mildly thickened. Mild (1+)
mitral
regurgitation is seen.
6.There is no pericardial effusion.
Brief Hospital Course:
82 yo M with history of recurrent meningioma, DVT in [**2176**] who
presented with shortness of breath, hypoxic respiratory distress
#hypoxic respiratory distress: Suspect secondary to CHF in
setting of NSTEMI. Initial CXR showed mild pulmonary edema his
pro-BNP was elevated consistent with CHF. He was initially
treated with nitro drip, biPap and lasix. He had symptomatic
improvement and was weaned off nitro gtt and bipap to cool
nebulizer face mask at 12 liters/min. He continued to have an
oxygen requirement and diffuse wheezes on exam, therefore CTA
was performed to rule out PE as a cause of his symptoms. CTA was
negative for PE but did show evidence of CHF. There was no noted
infiltrate by CXR or chest CT, therefore antibiotics were not
continued (he recieved one does of ceftriaxone/azithro in the
ED). In addition, systemic steroids were not continued since he
has no history of asthma/copd. He was given
albuterol/ipratropium nebs for symptomatic relief, with some
effect. Mucomyst nebs were also tried, without much improvement.
He was diuresed aggressively with lasix (40mg IV prn) with some
improvement in wheezing and air entry as well. His O2
requirement decreased to 4L O2 via nasal cannula (no usual home
O2 requirement).
#NSTEMI: Ruled in by enzymes with no acute ST changes. Initial
EKG showed initial ST depression in anterior leads which
resolved and old slightly wide QRS. He remained chest pain free
and his troponin peaked at 1.2, CK max of 518. After discussion
with the patient and his wife, medical management was opted for,
so no plan was made for diagnostic or therapeutic cath. He
recieved lovenox initially for anti-coagulation and this was
discontinued after 48h post MI. In addition he was continued on
medical management of ASA/Statin/B-Blocker. Echo obtained on
[**4-12**] showed EF 55-60% with no wall motion abnormality.
#acute renal failure: Initially up to 1.4 on admission from
baseline of 1.0. Suspected pre-renal etiology secondary to
intravascular volume depletion from CHF. His creatine has
improved with diuresis. Enalapril was restarted on discharge
Medications on Admission:
amlodipine 10
ECASA 325
Enalapril 15
Finasteride 5
MVI
simvastatin 40
sorbitol 70%
albuterol
combivent
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Brimonidine Tartrate 0.15 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
8. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
9. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
12. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
13. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
14. Ipratropium Bromide 0.02 % Solution Sig: 1-2 puffs
Inhalation Q4 ().
15. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
ml Injection TID (3 times a day).
16. Albuterol Sulfate 0.083 % Solution Sig: 1-2 puffs Inhalation
Q4H (every 4 hours) as needed for shortness of breath or
wheezing.
17. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
18. Enalapril Maleate 5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
19. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
congestive heart failure due to myocardial infarction
Discharge Condition:
stable
Discharge Instructions:
Please return to the hospital or call your doctor if you
experience shortness of breath, chest pain or if there are any
concerns at all
Please take all prescirbed medication. You have been started on
lasix to help you get access fluid off.
Followup Instructions:
PLease follow up with Dr. [**Last Name (STitle) 172**], [**First Name3 (LF) **] at [**Telephone/Fax (1) 133**] in one
month after discharge
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2179-4-14**]
|
[
"396.2",
"294.8",
"401.9",
"518.81",
"426.2",
"398.91",
"272.0",
"V45.81",
"584.9",
"410.71"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9064, 9129
|
5170, 7280
|
242, 248
|
9227, 9235
|
2807, 2807
|
9524, 9831
|
2350, 2368
|
7434, 9041
|
9150, 9206
|
7306, 7411
|
9259, 9501
|
2383, 2788
|
3267, 5147
|
195, 204
|
276, 969
|
2823, 3250
|
991, 2193
|
2209, 2334
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,390
| 102,561
|
11412
|
Discharge summary
|
report
|
Admission Date: [**2184-4-26**] Discharge Date: [**2184-5-5**]
Date of Birth: [**2121-1-4**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Macrobid / Cipro / Erythromycin Base / Bactrim
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
SOB/claudication
Major Surgical or Invasive Procedure:
[**4-27**] CABG x 2 (LIMA to LAD , SVG to OM)
History of Present Illness:
63 yo female with known CAD/MI, claudication, PVD, s/p
mult.peripheral and coronary interventions, presents for cath
and peripheral angiography. Cath showed 70% LM, 80% OM 1, RCA
stent patent. LE angio revealed patent left fem-opo bypass graft
and previous PTA site widely patent. Carotid US in [**3-8**] showed
[**Country **] < 40%, left nl.echo [**3-7**] EF >55%. Referred for CABG to Dr.
[**Last Name (STitle) **].
Past Medical History:
CAD ( RCA stents)
MI
PVD with peripheral interventions)
s/p left fem-[**Doctor Last Name **] BPG
PNA
carotid dz /TIA [**2180**]
hyperlipidemia
IBS
fibromyalgia
asthma
GERD
?DM
OA
gout
melanoma left heel
s/p right carpal tunnel, left knee, right thumb, discectomy,
hemorrhoid, L [**Last Name (LF) **], [**First Name3 (LF) 3098**] ligation surgeries
Social History:
not working
lives with husband
no ETOH or recr. drugs
quit smoking 14 years ago
Family History:
father died of heart problems at 59
Physical Exam:
5'1" 78.9 kg
HR 73 RR 18 121/54
alert and oriented, well- nourished
skin/HEENT unremarkable
neck supple
CTAB
RRR, no murmur
soft, NT, ND, + BS
warm, well-perfused extrems, no edema
1+ bilat. fem/PT/radials/ left PT
dopplerable right PT
Pertinent Results:
[**2184-5-5**] 06:38AM BLOOD WBC-11.1* RBC-3.29* Hgb-9.4* Hct-27.4*
MCV-83 MCH-28.5 MCHC-34.1 RDW-15.2 Plt Ct-319
[**2184-4-26**] 09:55AM BLOOD WBC-6.3 RBC-4.18* Hgb-11.4* Hct-33.2*
MCV-79* MCH-27.4 MCHC-34.4 RDW-15.2 Plt Ct-209
[**2184-4-26**] 09:55AM BLOOD Neuts-55.4 Lymphs-34.0 Monos-7.6 Eos-2.5
Baso-0.4
[**2184-5-5**] 06:38AM BLOOD Plt Ct-319
[**2184-5-5**] 06:38AM BLOOD UreaN-17 Creat-1.2* K-4.0
[**2184-5-4**] 03:40PM BLOOD ALT-48* AST-22 LD(LDH)-259* AlkPhos-193*
Amylase-38 TotBili-0.4
[**2184-5-4**] 03:40PM BLOOD Lipase-28
[**2184-5-4**] 03:40PM BLOOD Albumin-3.2*
[**2184-4-27**] 12:50PM BLOOD HCV Ab-NEGATIVE
Brief Hospital Course:
Admitted on [**4-26**] for cath and referred for CABG. Underwent CABG
x2 with Dr. [**Last Name (STitle) **] on [**4-27**]. Transferred to the CSRU in stable
condition on insulin and propofol drips. On nitroglycerin drip
on POD #1, had a short run of VT overnight and was extubated.
Chest tubes removed, off all drips, and transferred to the floor
on POD #2 to begin increasing her activity level. Foley,pacing
wires removed on POD #3, and gentle diuresis continued.
Developed sternal drainage on POD #5 and vanco/levofloxacin
started. Wound cultures were negative and drainage became
minimal. CLeared for discharge to home with VNA on POD #8. Will
have keflex for one week and return for wound check at one week.
Medications on Admission:
atrovent 2 puffs QID
pulmocort 2 puffs [**Hospital1 **]
singulair 10 mg daily
plavix 75 mg daily
metoprolol 50 mg [**Hospital1 **]
diovan/HCTZ 160/12.5 mg daily
nexium 40 mg daily
lorazepam 0.5 mg QHS prn
quinine sulfate 260 mg qHS prn
ASA 325 mg daily
lipitor 20 mg daily
lisinopril 5 mg daily
detrol LA 4 mg daily
restasis EMU 0.05% one gtt OU [**Hospital1 **]
preservision 1 tab [**Hospital1 **]
theratears nutrition 4 tabs daily
theratears eye drops
occuvit [**Hospital1 **]
Vit. E 200 IU daily
citrocal one tab daily
oscal 1000 units daily
Discharge Medications:
1. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Budesonide 200 mcg/Inhalation Aerosol Powdr Breath Activated
Sig: One (1) Aerosol Powdr Breath Activated Inhalation [**Hospital1 **] ().
4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours).
5. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q2H (every 2
hours) as needed.
Disp:*35 Tablet(s)* Refills:*0*
6. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
9. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 2 weeks.
Disp:*28 Packet(s)* Refills:*0*
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
13. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
Disp:*270 Tablet(s)* Refills:*0*
14. Keflex 500 mg Tablet Sig: One (1) Tablet PO four times a day
for 1 weeks.
Disp:*28 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
home health
Discharge Diagnosis:
s/p cabg x2
Coronary Artery Disease s/p PTCA
lipids
HTN
DM2
PVD
TIA
GERD
Fibromyalgia
Asthma
L ft melanoma
R carpal tunnel
disc surgery
hemoorhoidectomy
Discharge Condition:
Good.
Discharge Instructions:
Please take all medications as prescribed.
Call with fever, redness or draiange from incision or weight
gain more than 2 pounds in one day or five in one week.
Do not do any lifting > 10 lbs for 4 weeks.
Do not drive for 4 weeks.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 12817**] Follow-up
appointment should be in 2 weeks for general assessment, LFT
check (on statin), and review of medications.
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 1112**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 170**] Follow-up appointment
should be in 1 month
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. Phone:[**Telephone/Fax (1) 920**]
Date/Time:[**2184-7-19**] 1:45
Provider: [**Name10 (NameIs) **] STUDY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2184-7-19**]
10:00
Wound check on [**Wardname 836**] in one week
Completed by:[**2184-5-27**]
|
[
"V45.82",
"V10.82",
"424.0",
"250.00",
"401.9",
"427.89",
"440.21",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"39.61",
"36.15",
"36.11",
"37.22",
"99.05",
"99.04",
"88.72",
"89.69"
] |
icd9pcs
|
[
[
[]
]
] |
5077, 5120
|
2271, 2986
|
328, 376
|
5317, 5325
|
1623, 2248
|
5603, 6336
|
1310, 1347
|
3582, 5054
|
5141, 5296
|
3012, 3559
|
5349, 5580
|
1362, 1604
|
272, 290
|
404, 823
|
845, 1196
|
1212, 1294
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,238
| 134,936
|
44748
|
Discharge summary
|
report
|
Admission Date: [**2122-5-8**] Discharge Date: [**2122-5-11**]
Service: MEDICINE
Allergies:
Ciprofloxacin / Amiodarone / Procainamide / Quinidine
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
ICD shocks x 17 today
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 86 yoM w/ a h/o infarct related cardiomyopathy
and an EF of [**9-10**]% and VT s/p VT ablation and placement of
BiV-ICD + intrathroacic impedence monitor (optivol), atrial
fibrillation on coumadin, CKD, also new diagnosis of multiple
myeloma a few weeks ago presents to ER (initially OSH ER then
transferred to [**Hospital1 18**] ER) for 17 shocks today. His most recent
PPM interrogation revealed an increase in ventricular ectopy and
85 episodes of VT w/ rates 180-190 all successfully treated with
ATP. At this visit he was noted to be mildly volume overloaded
and his lasix dose was increased.
In the [**Hospital1 18**] ER initial VS were: T 97.2 HR 69 BP 101/60 RR 16 O2
sat: 98% on RA. The patients ICD was interrogated by the
cardiology fellow on call who stated it appears all shocks were
appropriate therapies for VT. The patient was given a 150mg IV
bolus of amiodarone and admitted to the CCU. VS prior to
transfer to the CCU were: HR 70 BP 109/65 RR 18 O2 sat 100% on
RA.
Currently feels well, no syncope, no lightheadedness, no SOB, no
DOE, no orthopnea or PND, no chest pain. no fevers / chills. In
general has felt more weak over past 1 month. no numbness or
paresthesias in lower extremities.
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. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
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:
# CAD s/p large anterior MI at age 36;
# 2 vessel CABG [**2101**] LIMA to LAD; SVG to OM
# NSTEMI [**10/2114**] s/p stent to native L circ.
# CHF with LV EF of 25%
# Ventricular Tachycardia: had pacemaker placed in [**2114**] for
primary prevention (MADIT criteria); had [**Hospital1 18**] hospitalization
[**3-26**] (started on amio; d/c'd due to "balance disorder/falls"),
started on procainamide [**12/2116**]; decreased from 1000mg tid to
500mg tid with level 7.2 on [**10-15**].
# s/p [**Company **] [**Last Name (un) **] pacer/defibrillator [**2116-12-31**] (Madit II
criteria)
# atrial flutter: recenty hospitalized at [**Hospital1 18**]
# CRI with baseline Cr in low 2 range
# ???L arm emolism; on coumadin since [**7-/2116**]
# B achilles tendon rupture [**12-24**] ciprofloxacin
# Prostate CA: s/p brachytherapy
# osteoarthritis (currently taking prednisone)
.
Social History:
retired; works as volunteer at local hospital. Remote smoking
history, no EtOH
Family History:
Father died with CAD; healthy son; daughter with [**Name2 (NI) 95740**]
Physical Exam:
Admission Exam
VS: T 96.3 HR 73 BP 122/58 RR 19 O2 sat 97% on RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 12 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. [**12-28**] HSM at the apex. No thrills, lifts.
No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. rales at L base.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal 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:
[**2122-5-8**] 07:35PM BLOOD WBC-8.3 RBC-5.05 Hgb-14.9 Hct-45.8 MCV-91
MCH-29.6 MCHC-32.6 RDW-15.1 Plt Ct-217
[**2122-5-10**] 02:14AM BLOOD WBC-8.4 RBC-4.71 Hgb-14.7 Hct-43.2 MCV-92
MCH-31.3 MCHC-34.1 RDW-15.4 Plt Ct-192
[**2122-5-8**] 07:35PM BLOOD PT-38.8* PTT-36.3* INR(PT)-3.9*
[**2122-5-9**] 05:03AM BLOOD PT-37.9* PTT-37.2* INR(PT)-3.8*
[**2122-5-10**] 02:14AM BLOOD PT-29.5* PTT-33.5 INR(PT)-2.9*
[**2122-5-8**] 07:35PM BLOOD Glucose-148* UreaN-106* Creat-2.7* Na-135
K-4.4 Cl-90* HCO3-34* AnGap-15
[**2122-5-9**] 05:03AM BLOOD Glucose-194* UreaN-102* Creat-2.5* Na-133
K-3.6 Cl-90* HCO3-31 AnGap-16
[**2122-5-10**] 02:14AM BLOOD Glucose-102* UreaN-104* Creat-2.9* Na-134
K-3.5 Cl-91* HCO3-31 AnGap-16
[**2122-5-8**] 07:35PM BLOOD CK-MB-34* MB Indx-21.7*
[**2122-5-8**] 07:35PM BLOOD cTropnT-0.31*
Brief Hospital Course:
86 year old male with infarct related cardiomyopathy, EF of
[**9-10**]% and VT s/p VT ablation and placement of BiV-ICD +
intrathroacic impedence monitor (optivol), atrial fibrillation
on coumadin, CKD, also new diagnosis of multiple myeloma a few
weeks ago admitted after having 17 ICD shocks.
1. Ventricular tachycardia s/p ICD shocks. His runs of
sustained and nonsustained monomorphic ventricular tachycardia
subsided once he was amiodarone loaded. He will be discharged
on amidoarone 400 mg po BID for 13 more days and taper to 200 mg
po qdaily thereafater.
2. Ischemic cardiomyopathy: LVEF of [**9-10**]%. CABG in [**2101**] with
LIMA to LAD and SVG to OM. DES to Lcx in [**2113**]. He was not on
antiplatelet therapy so aspirin 325 mg po qdaily was started.
He was continued on metoprolol succinate 25 mg po qdaily. He is
not on ACE-I likely due to rise in his creatinine from baseline
due to multiple myeloma. He is also not on statin as well but
probably appropriate given his age and comorbidities. He was
continued on home lasix 80 mg po qam and 40 mg po qpm. His
metalozone was switched to 2.5 mg QOD.
3. Atrial fibrillation. INR supratherapeutic on admission.
Restarted coumadin at lower dose of 1 mg po qdaily especially in
setting of starting amiodarone. Will follow up with PCP this
week for INR check. Continued on metoprolol XL 25 mg po qdaily
for rate control. Discharged on amiodarone 400 mg po BID for
rhythm control for 13 more days and taper to 200 mg po qdaily
thereafter. Will follow up with EP in one month.
4. Multiple Myeloma. Patient reports having had workup started
as outpatient with bone marrow biopsy and flow cytometry with
oncologist at [**First Name5 (NamePattern1) 745**] [**Last Name (NamePattern1) 18650**]. Follow up with oncologist.
5. Chronic Kidney Disease Stage 4 likely from multiple myeloma.
Follow up with PCP
6. Osteoarthritis/Gout: Continued on uloric and prednisone
Medications on Admission:
digoxin 0.125 three times a week
Lasix 60mg qam and 40 mg qpm (pt states he is taking 80qam and
40qpm)
metoprolol 25 mg daily
prednisone 5 daily
temazepam at night
warfarin
metolazone
Discharge Medications:
1. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
in the morning
.
2. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
in the evening.
3. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
4. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. febuxostat 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. temazepam 15 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime) as needed for insomnia.
7. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*90 Tablet(s)* Refills:*2*
8. warfarin 1 mg Tablet Sig: One (1) Tablet PO DAYS
([**Doctor First Name **],MO,TU,WE,TH,FR,SA).
9. metolazone 2.5 mg Tablet Sig: One (1) Tablet PO every other
day: leg edema.
10. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO twice a day
for 13 days: Take 400 mg twice per day until [**2122-5-23**]. Then take
200 mg per day thereafter. .
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] Area VNA
Discharge Diagnosis:
Primary Diagnosis
1. Ventricular tachcardia
2. Ischemic cardiomyopathy with EF of [**9-10**]%
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after experiencing multiple
ICD shocks for abnormal heart rhythm called ventricular
tachycardia. You were started on a medication called AMIODARONE
which helped suppress your abnormal rhythm.
FOLLOWING MEDICATION CHANGES WERE MADE TO YOUR MEDICAL REGIMEN
START AMIODARONE 400 mg by mouth twice a day for 13 more days
(end date:[**2122-5-23**]) then switch to 200 mg by mouth daily.
.
We have changed Metolazone from As Needed to Every Other Day
.
START ASPIRIN 325 mg by mouth daily
Followup Instructions:
Name:[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD
Specialty: Primary Care
Address: [**State 8536**], [**Apartment Address(1) 8537**], [**Location (un) **],[**Numeric Identifier 8538**]
Phone: [**Telephone/Fax (1) 40076**]
When: Thursday, [**5-14**] at 9:45am
|
[
"203.00",
"412",
"V45.02",
"428.22",
"V45.81",
"V58.61",
"427.31",
"428.0",
"414.8",
"V10.46",
"427.1",
"585.4",
"715.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.49"
] |
icd9pcs
|
[
[
[]
]
] |
8052, 8115
|
4884, 6816
|
281, 288
|
8253, 8253
|
4052, 4861
|
8947, 9236
|
3084, 3157
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6842, 7028
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8404, 8924
|
3172, 4033
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220, 243
|
316, 2076
|
8268, 8380
|
2098, 2971
|
2987, 3068
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,611
| 114,866
|
53084
|
Discharge summary
|
report
|
Admission Date: [**2195-1-12**] Discharge Date: [**2195-1-29**]
Date of Birth: [**2116-10-23**] Sex: F
Service: SURGERY
Allergies:
Morphine Sulfate / Iodine-Iodine Containing / Oxycodone /
Minocycline / Erythromycin Base / Dust & Pollen Filter Mask /
water, dove soap, seasonal allergies / water
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
nausea and vomitting
Major Surgical or Invasive Procedure:
Central line placment [**2195-1-17**]
Diagnostic paracentesis
PICC line
Nasogastric tube
History of Present Illness:
HISTORY OF PRESENTING ILLNESS
This patient is a 78 year old female who complains of
vomiting.
This patient is one-week status post right hemicolectomy for
a cecal volvulus. She's been having vomiting and retching
for the last several days. She went to the [**Hospital 620**] campus
where she had a KUB which showed: a 12 cm colon.
She has no real abdominal pain but is complaining of some
"heartburn".
She was given Cipro and Flagyl and sent. They also put a
Foley catheter in and found 500 cc of urine. No fevers or
chills. She actually denies abdominal pain. She has been
having difficulty urinating but denies any dysuria or any
hematuria.
Timing: Sudden Onset, Intermittent
Quality: Mostly retching,
Severity: 5 times in the last 24 hours
Duration: Several days,
Context/Circumstances: See above
Associated Signs/Symptoms: Decreased p.o. intake
Past Medical History:
PMH:
- rectocele and rectal prolapse s/p multiple surgeries (see
below)
- colonic adenomas s/p sigmoid colectomy [**2182**] (last colonoscopy
[**2192**], sigmoidoscopy [**2193**])
- diverticulosis
- hemorrhoids
- severe anxiety / depression
- osteopenia
- degenerative joint disease, planned for L hip surgery with
Dr.
[**Last Name (STitle) **] [**2195-1-13**]
- lumbar spondylosis
- chronic pain
- chronic constipation
- asthma
- syncope / vasovagal episodes
PSH:
- cholecystectomy [**2180**]
- sigmoid colectomy for tubobillous adenoma [**2182**]
- rectopexy and rectocele repair ([**Doctor Last Name 1120**] [**2191**])
- posterior colporraphy ([**Doctor Last Name **] [**2192**])
- removal of retained sigmoid suture ([**Doctor Last Name **] [**2193**])
Social History:
Former smoker, quit 25 years ago; no EtOH, no IVDU; lives with
husband. PCP is [**Last Name (NamePattern4) **]. [**Last Name (STitle) 67282**] ([**Hospital1 18**]).
Family History:
- father: deceased of colon cancer (age unknown), mother: CVA
and endometrial cancer, brother: lung cancer, DM and MI, son:
lung cancer
Physical Exam:
PHYSICAL EXAMINATION: upon admission: [**2195-1-17**]
Temp:99.2 HR:90 BP:132/83 Resp:16 O(2)Sat:95 Normal
Constitutional: Comfortable
HEENT: Extraocular muscles intact
Mucous membranes moist
Chest: Clear to auscultation
Cardiovascular: Normal first and second heart sounds
without murmur
Abdominal: Soft, Nontender without distention and with
clean-looking staple line
GU/Flank: No costovertebral angle tenderness
a Foley catheter is in a draining clear yellow urine.
Extr/Back: Mild edema on both sides
Neuro: Speech fluent
Psych: Normal mood
Physical examination upon discharge:
[**2195-1-29**]
General: Sitting in chair, alert and oriented, skin warm, dry,
pink
vital signs: t=98.6, hr=88, bp=130/90, resp. rate=20, oxygen
saturation room air=96%
CV: Ns1, s2, -s3, -s4
LUNGS: Diminished bases ( left >right)
ABDOMEN: Suture line clean and dry, no exudate, non-tender,
soft
EXT: Mild edema lower ext., + dp bil.
Pertinent Results:
[**2195-1-27**] 05:18AM BLOOD WBC-11.2* RBC-3.00* Hgb-8.8* Hct-25.4*
MCV-85 MCH-29.2 MCHC-34.4 RDW-14.0 Plt Ct-519*
[**2195-1-26**] 05:10AM BLOOD WBC-12.6* RBC-3.22* Hgb-8.9* Hct-27.3*
MCV-85 MCH-27.6 MCHC-32.6 RDW-14.0 Plt Ct-567*
[**2195-1-25**] 05:22AM BLOOD WBC-10.7 RBC-3.19* Hgb-9.0* Hct-27.1*
MCV-85 MCH-28.3 MCHC-33.4 RDW-13.9 Plt Ct-582*
[**2195-1-12**] 05:55PM BLOOD WBC-17.9*# RBC-4.53# Hgb-12.9# Hct-38.0#
MCV-84 MCH-28.5 MCHC-34.0 RDW-13.6 Plt Ct-590*#
[**2195-1-15**] 05:58AM BLOOD Neuts-80.3* Lymphs-13.0* Monos-4.3
Eos-2.0 Baso-0.5
[**2195-1-27**] 05:18AM BLOOD Plt Ct-519*
[**2195-1-23**] 05:33AM BLOOD PT-11.7 PTT-26.3 INR(PT)-1.0
[**2195-1-18**] 02:10AM BLOOD Fibrino-313
[**2195-1-17**] 05:32PM BLOOD Fibrino-385
[**2195-1-27**] 05:18AM BLOOD Glucose-149* UreaN-21* Creat-0.5 Na-138
K-3.5 Cl-107 HCO3-25 AnGap-10
[**2195-1-26**] 05:10AM BLOOD Glucose-128* UreaN-16 Creat-0.5 Na-136
K-3.4 Cl-103 HCO3-25 AnGap-11
[**2195-1-25**] 05:22AM BLOOD Glucose-186* UreaN-15 Creat-0.5 Na-137
K-4.2 Cl-106 HCO3-26 AnGap-9
[**2195-1-17**] 05:32PM BLOOD Glucose-240* UreaN-26* Creat-0.9 Na-137
K-3.8 Cl-100 HCO3-24 AnGap-17
[**2195-1-17**] 04:58AM BLOOD Glucose-163* UreaN-22* Creat-0.8 Na-130*
K-3.8 Cl-93* HCO3-30 AnGap-11
[**2195-1-17**] 01:30AM BLOOD Glucose-227* UreaN-19 Creat-0.8 Na-131*
K-3.5 Cl-94* HCO3-29 AnGap-12
[**2195-1-22**] 05:49AM BLOOD ALT-30 AST-19 AlkPhos-65 Amylase-9
TotBili-0.2
[**2195-1-18**] 02:10AM BLOOD ALT-183* AST-137* CK(CPK)-203* AlkPhos-69
TotBili-0.2
[**2195-1-17**] 05:32PM BLOOD ALT-211* AST-248* CK(CPK)-60 AlkPhos-76
TotBili-0.3
[**2195-1-18**] 09:04AM BLOOD CK-MB-6 cTropnT-0.02*
[**2195-1-18**] 02:10AM BLOOD CK-MB-8 cTropnT-0.03*
[**2195-1-17**] 05:32PM BLOOD CK-MB-3 cTropnT-0.01
[**2195-1-12**] 07:25AM BLOOD cTropnT-<0.01
[**2195-1-27**] 05:18AM BLOOD Calcium-8.0* Phos-3.2 Mg-2.1
[**2195-1-22**] 05:49AM BLOOD calTIBC-159* TRF-122*
[**2195-1-18**] 10:23AM BLOOD D-Dimer-[**Numeric Identifier **]*
[**2195-1-18**] 05:11PM BLOOD Type-ART pO2-92 pCO2-34* pH-7.48*
calTCO2-26 Base XS-2
[**2195-1-18**] 09:21AM BLOOD Type-ART pO2-142* pCO2-34* pH-7.48*
calTCO2-26 Base XS-3
[**2195-1-18**] 09:21AM BLOOD Glucose-91 Lactate-0.6
[**2195-1-18**] 03:33AM BLOOD Lactate-0.8
[**2195-1-17**] 06:14PM BLOOD Hgb-10.2* calcHCT-31
[**2195-1-12**]: EKG:
Sinus rhythm. Low voltage. Mild Q-T interval prolongation. ST-T
wave
abnormalities. Since the previous tracing of [**2194-12-30**] precordial
ST-T wave
abnormalities are more prominent. Clinical correlation is
suggested.
TRACING #1
[**2195-1-14**]: Abdominal cat scan:
IMPRESSION:
1. Mild dilation of the proximal and mid small bowel loops
measuring up to a maximum of 3.5 cm in diameter. There is no
definite discrete transition point in small bowel although
proximal bowel is somewhat more dilated than distal residual
small bowel. However, noting marked colonic dilatation on the
recent prior radiographs, which has improved, this evolution is
suggestive of an ileus. Small bowel obstruction is not entirely
excluded, however, and if it were confirmed, then ascites could
suggest considerable congestion or even potentially ischemia in
the appropriate clinical setting, although there is no bowel
wall thickening.
2. Moderate amount of ascites, new since the prior study, and
could be
secondary to fluid resuscitation/ cardiac / hepatic dysfunction.
Peritoneal inflammation with secondary ileus and ascites could
also be considered in the differential, noting substantial
ascites and ileus, which together could be seen with peritonitis
although the findings are non-specific. Although ascites does
not appear loculated, if clinical concern persists, then an
examination with intravenous contrast would be more sensitive
for the possibility of any potential early abscess formation.
3. Malpositioned nasogastric tube with a retrograde turn and
terminating in the distal esophagus.
4. Small exophytic left renal lesion; suggest follow-up
ultrasound evaluation
[**2195-1-15**]: Diagnostic paracentesis:
IMPRESSION: Successful, ultrasound-guided diagnostic and
therapeutic
paracentesis yielding 2.2 liters of reddish fluid
[**2195-1-16**]: Liver/gallbladder ultrasound:
IMPRESSION:
1. Patent hepatic vasculature, note is made that the midline
vessels are
obscured from view by overlying bowel.
2. Minimal ascites and a small right pleural effusion.
3. No liver lesion and no biliary dilatation.
[**2195-1-18**]: Chest x-ray:
IMPRESSION: Evidence for pulmonary vascular congestion. Left
pleural fluid.
Bilateral subsegmental atelectasis and possibly focal
consolidation. The
right internal jugular catheter terminates at the level of the
right atrium.
There is distended colon below the level of the diaphragm (see
accompanying
report)
[**2195-1-23**]: EKG:
Artifact is present. Sinus rhythm. Low voltage in the precordial
leads.
Compared to the previous tracing of [**2195-1-23**] limb lead voltage
has improved
marginally
[**2195-1-24**]: KUB:
FINDINGS: Moderate-to-severe intestinal distention with multiple
air-fluid
levels but no evidence of wall thickening. Given the multiple
overlays of
gas-filled bowel loops no change in caliber can be clearly
determined.
Therefore, CT is recommended. No evidence of free air. No safe
evidence of
pathological calcifications. Contrast material in the rectum
[**2195-1-24**]: Chest x-ray:
FINDINGS: The nasogastric tube that has newly been placed is in
the stomach.
A right internal jugular vein catheter projects into the basal
parts of the right atrium, the device should be pulled back by
approximately 7 cm.
Unchanged moderately distended segments of the colon. Subtle
bilateral areas of atelectasis at the lung base. Borderline size
of the cardiac silhouette without pulmonary edema.
[**2195-1-25**]: Chest x-ray:
FINDINGS: The patient has received a new PICC line. The line can
be followed over its entire course, the tip projects over the
right atrium, the line should be pulled back by approximately 4
cm to ensure position within the mid-to-low SVC. No evidence of
pneumothorax, the other monitoring and support devices are
unchanged. Mildly increasing colonic distention.
Brief Hospital Course:
78 year old female s/p right hemi-colectomy re-admitted to the
Acute Care Service with vomitting. Upon admission, she was made
NPO, given intravenous fluids, and had imaging studies of her
abdomen which showed an ileus and ascites. Because of her
abdominal distention and nausea, she had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-gastric tube
placed. A diagnostic paracentesis was done for the fluid
collection in her abdomen. It did not grow any bacteria. Her
fluid status was tenuous during this time and she did require
additional fluid to maintain an adequate urine output. In order
to maintain her nutritional staus, she was started on TPN on
[**1-16**] after a nutrition consult. On [**1-17**], she was transported to
the Intensive Care Unit after she sustained a PEA arrest vs.
vaso-vagal event. She was intubated and her cardiac enzymes
were cycled. Her EKG did not show any evidence of a myocardial
infarction. An echocardiogram showed possible antero-septal
hypokinesis with an EF> 50%. She was bronched with no evidence
of aspiration. Ultrasound was negative for DVT. She was
extubated within 24 hours and discharged from the Intensive Care
Unit.
Upon return to the floor, she had a follow-up GI consult who
recommended a bowel regimen to alleviate her constipation and
reduce her abdominal distention. Her [**Last Name (un) **]-gastric tube was
discontinued on [**1-22**] after she tolerated it being clamped.
She was started on clear liquids with the gradual advancement to
a regular diet. She did continue to have an elevated white blood
cell count and was found to have a urinary tract infection for
which she is currently on ampicillin until [**1-30**]. Because of her
colonic inertia, her narcotics were discontinued and she was
given mineral oil, reglan, and azithromycin with successful
passage of stool. Her abdominal distention has diminished and
she is tolerating a regular diet. Her TPN has been discontinued
on [**1-26**]. She has been evaluated by physical therapy and has been
seen by the social worker for additional emotional support.
She is preparing for discharge to a extended care facility
where she will be able to increase her strength and stamina
through physical therapy and ADL's. Her vital signs are stable
and she is tolerating a regular diet without complaint of
nausea, but her appetite is still diminished. Her foley catheter
is to gravity drainage. She has been followed by the
Nurtritionist who has made recommendations about her diet. She
has been ambulating with assistance.
Follow-up visit is recommended with her primary care provider
where she will need further investigation about the left renal
lesion. In addition to this, she will need to follow up with her
Dr. [**Last Name (STitle) 79**], who will make recommendations about the length of time
for azithromycin usage for colonic motility. She will need to
schedule an appointment with the Acute care service in 2 weeks.
Of note: MRSA +
Medications on Admission:
[**Last Name (un) 1724**]: albuterol 1-2 puffs inh QID prn, clonazepam 1mg PO BID,
compazine 5mg PO prn, flovent 110 mcg 3 puffs inh TID, Anusol
ointment prn, lidocaine 2% prn, Metrogel 1% prn, simvastatin
10mg
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) cc
Injection TID (3 times a day).
2. Cepacol Sore Throat + Coating 15-5 mg Lozenge Sig: One (1)
lozenger Mucous membrane every 4-6 hours as needed for throat
pain.
3. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as
needed for wheezing.
4. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
Two (2) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for back and chest pain .
5. azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
6. mineral oil Oil Sig: Thirty (30) ML PO EVERY OTHER DAY
(Every Other Day).
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
9. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
10. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
12. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
13. ampicillin 250 mg Capsule Sig: Two (2) Capsule PO Q6H (every
6 hours) for 1 days: 1 dose this pm, and 2 doses 1/28...then
d/c.
Disp:*6 Capsule(s)* Refills:*0*
14. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
15. calcium carbonate 250 mg Tablet, Chewable Sig: [**1-4**] Tablet,
Chewables PO three times a day: as needed for heartburn.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1036**] - [**Location (un) 620**]
Discharge Diagnosis:
Ileus
Post-operative ascites
Enterococcus urinary tract infection
PEA arrest
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 recently discharged from the hospital after you had a
portion of your bowel removed for a cecal vovulus. You were
discharged to a rehabilitation center but returned 3 days later
with inability to tolerate food and nausea. Since your
re-admission, you have had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-gastic tube placed to
allerviate your nausea. You also were noted to have a
collection of fluid in your abdomen which was cultured, did not
show any bacteria. Your bowels were slow to move, but since you
have been off narcotics, and with laxatives, you have
successfully moved your bowels. You have been able to tolerate a
diet. You are now preparing for discharge to a rehabiltation
facility with the following 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 resume all regular home medications and take any new
meds
as ordered, especially the bowel regimen which has been
prescribed
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2195-2-17**] 1:20
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1114**], M.D. Date/Time:[**2195-5-12**] 12:20 (please
reschedule this appointment so that your visit will be withing
the next 2-3 weeks. You will also need follow-up ultrasound for
the kidney lesion.
Please follow up with the Acute Care Service in 2 weeks, you can
schedule this appointment by calling #[**Telephone/Fax (1) 600**]. You will
also need ultra-sound follow-up for the kidney lesion was was
noted.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2195-1-29**]
|
[
"427.5",
"276.4",
"599.0",
"276.8",
"707.03",
"300.4",
"789.59",
"721.3",
"041.04",
"493.90",
"560.1",
"564.09",
"707.22",
"733.90",
"511.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"38.97",
"54.91",
"96.04",
"96.71",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
14709, 14786
|
9800, 12786
|
445, 536
|
14907, 14907
|
3622, 9775
|
16723, 17458
|
2517, 2658
|
13048, 14686
|
14807, 14886
|
12812, 13025
|
15092, 16700
|
2673, 2673
|
2695, 2697
|
385, 407
|
3259, 3603
|
564, 1516
|
2712, 3243
|
14922, 15066
|
1538, 2316
|
2332, 2500
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,758
| 129,324
|
22075+57280
|
Discharge summary
|
report+addendum
|
Admission Date: [**2196-9-9**] Discharge Date: [**2196-9-16**]
Date of Birth: [**2124-12-11**] Sex: M
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 10223**]
Chief Complaint:
UGIB
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
71 yo female w/ PMH significant for CAD, THN, MVR ([**Hospital3 9642**]),
and h/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **] Tear admitted to MICU on [**2196-9-9**] from OSH
for persistent UGIB (admitted to OSH [**9-3**] w/ blood tinged
vomitus and melena, with subsequent EGD revealing 3 [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] tears with fresh clot tx'd w/ injection of epi/BICAP x 3).
Pt initially started on heparin SS for MVR but d/c'd on [**9-10**].
Also started on AMP/GENT. Was transfused 3units prbcs in MICU.
Hct stable at 34 on MICU transfer. No further episodes of
hematemesis or melena. Denies n/v/d/sob/cp, as well as abd
pain/f/c/cough/lightheadedness.
Past Medical History:
HTN
CAD s/p CABG x 2
MVR w/ [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] [**2191**]
s/p CCY [**2195**]
h/o hernia repair
h/o mallor [**Doctor Last Name **] tear p CABG
h/o CHF
Social History:
Pt lives in [**Location 23171**], NC with wife; is visiting [**Location (un) 86**] for
daughter's wedding. Denies tobacco use; one drink EtOH qod.
Family History:
Non-contributory
Physical Exam:
VS: T=98.6 BP=152/68 HR=68 RR=19 02=99% (ra)
GEN: elderly man, lying in bed, speaking in full sentences, NAD
HEENT: PERRL OU, EOMI bilaterally, OP clear, MMM
LYMPH: No LAD
CV: JVP not visible, non-displaced PMI, RRR, mechanical HS, no
M/R/G
RESP: No accessory muscle use, no dullness to percussion, CTA
bilaterally, no w/r/r
ABD: Normo active BS, non-tender, no rebound, non-distended, no
masses, no organomegaly appreciated
EXT: no cyanosis/clubbing/edema
SKIN: no rashes
PULSES: dp/pt pulses 2+ bilaterally
NEURO: A&Ox3; CN II-XII intact bilat; sensation and motor exams
intact bilaterally
Pertinent Results:
[**2196-9-9**] 12:58PM BLOOD WBC-9.7 RBC-3.80* Hgb-11.2* Hct-31.9*
MCV-84 MCH-29.4 MCHC-35.0 RDW-14.4 Plt Ct-220
[**2196-9-9**] 10:25PM BLOOD WBC-10.8 RBC-3.17* Hgb-9.8* Hct-26.4*
MCV-83 MCH-30.8 MCHC-37.0* RDW-14.7 Plt Ct-161
[**2196-9-16**] 05:01AM BLOOD WBC-8.0 RBC-3.95* Hgb-11.8* Hct-33.5*
MCV-85 MCH-30.0 MCHC-35.4* RDW-14.3 Plt Ct-243
[**2196-9-9**] 12:58PM BLOOD Neuts-72.2* Lymphs-14.6* Monos-5.3
Eos-7.5* Baso-0.4
[**2196-9-9**] 12:58PM BLOOD PT-13.1 PTT-26.8 INR(PT)-1.1
[**2196-9-16**] 10:00AM BLOOD PT-13.6* PTT-38.1* INR(PT)-1.2
[**2196-9-9**] 12:58PM BLOOD Glucose-89 UreaN-23* Creat-1.2 Na-144
K-3.4 Cl-108 HCO3-25 AnGap-14
[**2196-9-16**] 05:01AM BLOOD Glucose-91 UreaN-21* Creat-1.1 Na-140
K-4.0 Cl-104 HCO3-27 AnGap-13
[**2196-9-9**] 12:58PM BLOOD ALT-55* AST-60* AlkPhos-66
[**2196-9-9**] 12:58PM BLOOD Calcium-9.3 Phos-2.1* Mg-1.9
[**2196-9-14**] 05:35AM BLOOD Calcium-9.1 Phos-3.2 Mg-1.9
[**2196-9-15**] 07:25AM BLOOD Triglyc-154* HDL-39 CHOL/HD-4.7
LDLcalc-112
*
CXR ([**2196-9-9**])
FINDINGS: The study is compared to previous examination of the
same day
earlier and shows continued application of the right IJ CVP
line. There is
left lower lobe partial atelectasis. The remainder of the lungs
are clear.
There has been some worsening the degree of left lower lobe
partial
atelectasis since the previous study. There is no evidence of
free intra-
peritoneal air. There is no evidence of mediastinal air to
suggest esophageal
perforation.
IMPRESSION: Right IJ line remains unchanged in position. Left
lower lobe
partial atelectasis appears to be slightly more pronounced at
this time. No
evidence of free intraperitoneal air or mediastinal air.
*
CT ABD ([**2196-9-10**])
1. No extraluminal air or contrast seen adjacent to the
esopahgus. The
distal esohpagus is enlarged. It is unclear whether this
represents a hiatal
hernia or is due to multiple attempted endoscopic [**Doctor First Name **]-[**Doctor Last Name **]
tear
ablations. No full thickness esophageal tear is present.
2. Small to moderate left-sided pleural effusion and a small
right pleural
effusion.
3. Two clips in the stomach, and one within the proximal small
bowel. These
could have been placed during multiple attempted endoscopic
procedures. No
evidence of oral contrast leak from the stomach.
*
CT CHEST ([**2196-9-10**])
1. No extraluminal air or contrast seen adjacent to the
esopahgus. The
distal esohpagus is enlarged. It is unclear whether this
represents a hiatal
hernia or is due to multiple attempted endoscopic [**Doctor First Name **]-[**Doctor Last Name **]
tear
ablations. No full thickness esophageal tear is present.
2. Small to moderate left-sided pleural effusion and a small
right pleural
effusion.
3. Two clips in the stomach, and one within the proximal small
bowel. These
could have been placed during multiple attempted endoscopic
procedures. No
evidence of oral contrast leak from the stomach.
Brief Hospital Course:
1) UGIB: [**3-14**] to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Tear appeared to be resolved after
clipping in ICU. Received 3 Units PRBCs in MICU. EGD on [**9-9**]
showed tears w/ ongoing bleeding and possible perf, however CT
did not reveal perf. Anti-coag was d/c'ed initially. IV
protonix and sulcrafate were continued. Diet was advanced to
solids. HCT was stable at around 33 after d/c from ICU. Stool
is no longer guaiac positive. GI and cardiology followed the
patient. Eventually, after >72 hours without acute bleeding,
anti-coag was restarted. Patient given coumadin 5 mg x 3 days,
then decreased to 3 mg.
*
2. MVR: pt w/ [**Hospital3 **] valve; restarted heparin after >72 hrs
w/o bleeding; also started coumadin at 5 mg x 3 days. Through
entire admission, there were no signs of TIA. Cardiology was
involved and approved pt could be d/c'd on lovenox until INR
becomes therapeutic. Lovenox started one day prior to d/c. Pt
was taught on use. Patient will go to [**Hospital 8125**] Hosp in [**Location (un) **] on
Sunday or Monday for INR check. Prescription for blood draws
was sent to [**Hospital 8125**] hospital. Results from [**Hospital 8125**] hospital will be
sent to me next week for adjustment of his coumadin dose as an
outpatient until he returns to NC on [**2196-9-24**].
*
3. HTN: initially, pt's toprol and accupril were held while
actively bleeding in ICU. After transfer from ICU, BP still
high (150's systolic). The patient's Accupril was increased to
20 mg po qd which heldped control his BP
*
4. CAD s/p CABG and MVR. Checked lipid panel in hospital. LCL
was 112. Patient had been on statin prior to bleed, but med
held in ICU. Pt restarted on statin at discharge, but PCP may
consider increasing dose.
*
5. BPH. Held Flomax; restarted on d/c.
*
6. Code: Full
*
7. DISPO. Pt's daughter to be married on Sat; Pt should be
stable for d/c on Friday. Will be in Mass until [**2196-9-24**], will
need INR checks after d/c before he returns to NC. Will need
f/u arranged with PCP (Dr. [**Last Name (STitle) 57727**] at [**Location (un) 23171**] Adult Medicine
[**Telephone/Fax (1) 57728**]).
Medications on Admission:
accupril 10 mg po qd
toprol 50 mg po qd
flomax 0.4 mg po qd
denadex 5 mg po qd
asa 81 mg po qd
Coumadin 3 mg po Q M,W,R,F,Sun; 4 mg po Q Tues/Sat
Discharge Medications:
1. Multivitamin Capsule Sig: One (1) Cap PO QD (once a day).
2. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO QD (once a day).
3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Quinapril HCl 10 mg Tablet Sig: Two (2) Tablet PO QD (once a
day).
5. Psyllium 58.6 % Packet Sig: One (1) Packet PO TID (3 times a
day) as needed for constipation.
6. Enoxaparin Sodium 60 mg/0.6mL Syringe Sig: Sixty (60) mg
Subcutaneous Q12H (every 12 hours) for 2 days.
Disp:*240 mg* Refills:*0*
7. Coumadin 3 mg Tablet Sig: One (1) Tablet PO QHS: Except
Tuesdays and Saturdays (take 4 mg on these days).
8. Coumadin 4 mg Tablet Sig: One (1) Tablet PO Qtuesday and
Qsaturday: Take 4 mg only on Tuesdays and Saturdays.
9. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*120 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Upper GI bleeding
Discharge Condition:
Stable
Discharge Instructions:
Please return to the emergency room if you experience vomiting
with blood or coffee grounds, or black stool or stool with red
blood. Also return to the emergency room if you experience
weakness, numbness, slurred speech, or difficulty with your
vision. Take all medications as prescribed. Return to [**Hospital 8125**]
Hospital on Monday for blood draw to have your INR level
checked. You should go to have this level checked at least once
a week until returning home to NC. Once returning to NC, you
should visit you primary care physician.
Followup Instructions:
Please follow up at [**Hospital 8125**] Hospital for blood draws (INR checks)
every week.
Please follow up with your Primary Care Physician within one
week of returning home to NC.
Name: [**Known lastname 10726**],[**Known firstname **] Unit No: [**Numeric Identifier 10727**]
Admission Date: [**2196-9-9**] Discharge Date: [**2196-9-16**]
Date of Birth: [**2124-12-11**] Sex: M
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9224**]
Chief Complaint:
UGIB
Major Surgical or Invasive Procedure:
EGD
Brief Hospital Course:
1) UGIB: [**3-14**] to [**First Name4 (NamePattern1) 9539**] [**Last Name (NamePattern1) **] Tear appeared to be resolved after
clipping in ICU. Received 3 Units PRBCs in MICU. EGD on [**9-9**]
showed tears w/ ongoing bleeding and possible perf, however CT
did not reveal perf. Anti-coag was d/c'ed initially. IV
protonix and sulcrafate were continued. Diet was advanced to
solids. HCT was stable at around 33 after d/c from ICU. Stool
is no longer guaiac positive. GI and cardiology followed the
patient. Eventually, after >72 hours without acute bleeding,
anti-coag was restarted. Patient given coumadin 5 mg x 3 days,
then decreased to 3 mg.
*
2. MVR: pt w/ [**Hospital3 10728**] valve; restarted heparin after >72 hrs
w/o bleeding; also started coumadin at 5 mg x 3 days. Through
entire admission, there were no signs of TIA. Cardiology was
involved and approved pt could be d/c'd on lovenox until INR
becomes therapeutic. Lovenox started one day prior to d/c. Pt
was taught on use. Patient will go to [**Hospital 10729**] Hosp in [**Location (un) 2089**] on
Sunday or Monday for INR check. Prescription for blood draws
was sent to [**Hospital 10729**] hospital. Results from [**Hospital 10729**] hospital will be
sent to me next week for adjustment of his coumadin dose as an
outpatient until he returns to NC on [**2196-9-24**].
*
3. HTN: initially, pt's toprol and accupril were held while
actively bleeding in ICU. After transfer from ICU, BP still
high (150's systolic). The patient's Accupril was increased to
20 mg po qd which heldped control his BP
*
4. CAD s/p CABG and MVR. Checked lipid panel in hospital. LCL
was 112. Patient had been on statin prior to bleed, but med
held in ICU. Pt restarted on statin at discharge, but PCP may
consider increasing dose.
*
5. BPH. Held Flomax; restarted on d/c.
*
6. Code: Full
*
7. DISPO. Pt's daughter to be married on Sat; Pt should be
stable for d/c on Friday. Will be in Mass until [**2196-9-24**], will
need INR checks after d/c before he returns to NC. Will need
f/u arranged with PCP (Dr. [**Last Name (STitle) 10730**] at [**Location (un) 10731**] Adult Medicine
[**Telephone/Fax (1) 10732**]).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Upper GI bleeding
Secondary Diagnosis: acute blood loss anemia
Discharge Condition:
Stable
Discharge Instructions:
Please return to the emergency room if you experience vomiting
with blood or coffee grounds, or black stool or stool with red
blood. Also return to the emergency room if you experience
weakness, numbness, slurred speech, or difficulty with your
vision. Take all medications as prescribed. Return to [**Hospital 10729**]
Hospital on Monday for blood draw to have your INR level
checked. You should go to have this level checked at least once
a week until returning home to NC. Once returning to NC, you
should visit you primary care physician.
Followup Instructions:
Please follow up at [**Hospital 10729**] Hospital for blood draws (INR checks)
every week.
Please follow up with your Primary Care Physician within one
week of returning home to NC.
[**First Name11 (Name Pattern1) 1811**] [**Last Name (NamePattern4) 9226**] MD [**MD Number(2) 9227**]
Completed by:[**2196-10-18**]
|
[
"530.7",
"414.00",
"285.1",
"401.9",
"V45.81",
"V43.3",
"V58.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"45.13",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
12007, 12013
|
9801, 11984
|
9772, 9778
|
12138, 12146
|
2157, 5071
|
12742, 13089
|
1499, 1517
|
7456, 8457
|
12034, 12034
|
7285, 7433
|
12170, 12719
|
1532, 2138
|
9728, 9734
|
350, 1099
|
12092, 12117
|
12053, 12071
|
1121, 1318
|
1334, 1483
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,003
| 111,981
|
11214
|
Discharge summary
|
report
|
Admission Date: [**2130-4-6**] Discharge Date: [**2130-4-18**]
Date of Birth: [**2070-8-26**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 974**]
Chief Complaint:
Splenic rupture
Major Surgical or Invasive Procedure:
[**2130-4-6**] Splenectomy
[**2130-4-14**] VAC placement
[**2130-4-17**] VAC replacement
History of Present Illness:
59 year old gentleman with known hepatitis C and who presented
to ED hypotensive and found to have hemoperitoneum. CT scan
revealed splenic blush.
He was taken to interventional radiology, but remained
tachycardiac and unstable with rising lactate and therefore was
taken to the operating room for emergency splenectomy.
Past Medical History:
Hepatitis C
Gallstones
Polysubstance abuse
Depression with suicidal ideation
psychotic with schizophrenic symptoms
s/p crushed elbow
s/p hernia repair
h/o withdrawal seizures
Social History:
He was currently at [**Hospital1 **]. Has h/o polysubstance abuse.
Family History:
Noncontributory
Physical Exam:
Upon admission to ED:
BP 142/86 HR 86 T 97.1 RR 16 O2 Sat 99%
Gen: No acute distress - A & O x3
HEENT:left post scalp lac ~2cm; PEARRLA
Cor: RRR
Chest: rhonci LLL
Abd: soft, NT
Pertinent Results:
[**4-5**] Abd CT: Multiple splenic lacs with multifocal active extrav
dr [**Last Name (STitle) **] pole, posterior mid-pole), subcapsular hematoma and
hemoperitoneum. No rib fractures.
[**4-5**] Head CT: no acute hemmorhage; left subgaleal hematoma, no fx
[**4-5**] C-spine CT: no acute fracture
[**4-6**] Angio: active bleed f/splenic a. Embolized w/coils and
thrombin
[**4-10**] RLE U/S: No DVT
[**4-12**] CT abd pelvis: Sm simple fluid in the post-splenectomy bed.
Sm
amount of pelvic fluid. No dehiscence. A 4.3 x 2 cm right groin
hematoma. LLL pneumonia?
[**2130-4-6**] 04:18PM LACTATE-3.5*
[**2130-4-6**] 04:05PM GLUCOSE-171* UREA N-14 CREAT-1.0 SODIUM-143
POTASSIUM-4.9 CHLORIDE-116* TOTAL CO2-18* ANION GAP-14
[**2130-4-6**] 04:05PM CALCIUM-9.3 PHOSPHATE-4.4 MAGNESIUM-2.5
[**2130-4-6**] 04:05PM WBC-19.92*# RBC-3.20* HGB-9.7* HCT-26.9*
MCV-84 MCH-30.2 MCHC-36.0*
[**2130-4-6**] 04:05PM PLT COUNT-89*
[**2130-4-6**] 04:05PM PT-16.6* PTT-35.5* INR(PT)-1.5*
[**2130-4-6**] 04:05PM FIBRINOGE-101*
Brief Hospital Course:
He was admitted to the Trauma Service and initially taken to
Interventional Radiology for embolization of splenic artery; he
became hemodynamically unstable and was then taken to the
operating for splenectomy. A liver wedge resection was also
performed. He received 9 units packed red cells (7 units prior
to going to OR) 4 units fresh frozen plasma and 1 unit platelets
given. Postoperatively, he was taken to the Trauma ICU where he
remained for several days with ongoing tachycardia and
hypotension; he required further crystalloid and blood products.
The tachycardia and hypotension did eventually resolve.
On [**4-7**] he was extubated, receiving PCA for pain control. His Hct
remained stable. He was transferred to the regular nursing unit.
He was noted with right leg swelling on [**4-10**] and underwent RLE
LENIS which was negative for deep vein thrombus.
Psychiatry was consulted given his history of substance abuse
and for Methadone taper. Per patient's request he wanted to
continue his taper while in the hospital until it was
discontinued and did not want to follow up with the [**Hospital 2514**]
clinic as an outpatient. He was also started on Remeron at hs
per recommendation of Psychiatry. He was given an appointment to
follow up with his outpatient mental health provider after
discharge.
On [**4-12**] he was noted with copious drainage from his abdominal
incision site; CT of his abd/pelvis were done to rule out
fascial dehiscence and none was noted. Hepatology was consulted
and made several recommendations for continuing the Lasix which
had already been started and to add, lactulose, spironolactone
and albumin. A wound VAC was applied on [**4-14**] and removed on
[**4-16**]. The wound continued to drain large amounts of ascitic
fluid and the VAC was replaced. Plans for discharge to home with
VAC were arranged. Instructions for follow up with the Liver
Center were provided to him.
He was evaluated by Physical therapy and was cleared for
discharge to home. Skilled nursing services were arranged for
providing wound care at home given the VAC dressing. Follow up
discharge instructions were provided to him.
Medications on Admission:
[**Last Name (un) 1724**]: Ativan 0.5, ?Klonopin 1mg QID, ?Methadone 120mg daily,
?Celexa 60mg daily
Discharge Medications:
1. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*0*
2. Risperidone 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*0*
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*0*
5. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day).
Disp:*qs ML(s)* Refills:*0*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
Disp:*45 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Splenic laceration - Grade III-IV
Ascites
Discharge Condition:
Hemodynamically stable, tolerating a regular diet, pain
adequately controlled.
Discharge Instructions:
It is important that you avoid being around people who have a
cold or the flu.
NO heavy lifting of greater than 10 lbs because of your
abdominal incision.
Your methadone was stopped while you were hospitalized. Do not
start taking methadone again unless told to do so by a
physician.
Return to the Emergency room if you develop any fevers, chills,
headaches, dizziness, chest pain, shortness of breath,
redness/drainage from your incision, nausea, vomiting, diarrhea
and/or any other symptoms that are concerning to you.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **], Trauma Surgery, next week for removal
of your staples and evaluation of your wound. Call [**Telephone/Fax (1) 6429**]
for an
appointment.
Follow up with Dr. [**Last Name (STitle) 7033**] in the Liver Center in the next [**1-6**]
weeks, call [**Telephone/Fax (1) 2422**] for an appointment.
Follow up with your primary care doctor in the next 1-2 weeks,
you will need to call for an appointment.
You also haven an appointment with [**Hospital1 1680**] Counseling in [**Location (un) 3786**]
on [**2130-5-1**] at 8:30am. Address is [**Street Address(2) 31724**],
[**Location (un) 3786**], Ma, [**Location (un) **]. Phone number: [**Telephone/Fax (1) 36058**]
Completed by:[**2130-5-5**]
|
[
"571.5",
"287.5",
"070.54",
"304.10",
"789.2",
"789.59",
"292.0",
"785.59",
"873.0",
"276.2",
"285.1",
"780.39",
"865.03",
"305.90",
"E888.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"50.12",
"86.59",
"39.79",
"88.49",
"41.5"
] |
icd9pcs
|
[
[
[]
]
] |
5372, 5430
|
2350, 4498
|
329, 421
|
5516, 5597
|
1308, 1504
|
6170, 6906
|
1072, 1089
|
4649, 5349
|
5451, 5495
|
4524, 4626
|
5621, 6147
|
1104, 1289
|
273, 291
|
449, 773
|
1513, 2327
|
795, 971
|
987, 1056
|
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