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2,025
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281
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Discharge summary
|
report
|
Admission Date: [**2133-7-29**] Discharge Date: [**2133-8-10**]
Date of Birth: [**2064-9-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
chest pain and shortness of breath
Major Surgical or Invasive Procedure:
Coronary angiogram
Intra-aortic balloon pump
Peritoneal dialysis
History of Present Illness:
68yo man w/ 3 vessel CAD, s/p STEMI w/ stenting of LAD ([**5-30**]),
NSTEMI w/ DES to LCx ([**6-30**]) and ESRD on Peritoneal dialysis who
p/w chest pain and shortness of breath. The CP is substernal,
sharp, radiating to lower neck, occurs both at rest & w/
activity. No palliative factors.
Past Medical History:
1. CAD (3VD, s/p STEMI [**5-30**] s/p BMS to LAD, complicated by
cardiogenic shock requiring balloon pump and intubation)
**Severe cardiomyopathy (EF 15%)
2. ESRD [**2-26**] PCKD on PD
3. Prostate Cancer treated with neoadjuvant hormonal therapy
followed by external beam radiation therapy
4. Anemia of CD
5. PVD with LE claudication (on plavix)
6. H/O GIB
Social History:
Former smoker, no EtOH. Lives with his wife.
Family History:
N/C
Physical Exam:
Afebrile, HR 100, BP 96/67, O2 96% on 2L NCT
Gen: alert, awake, oriented, mild distress
HEENT: increased JVP, no LAD, dry oral mucosa
Pulmonary: bibasilar crackles
Cardiac: sinus tach, Nml S2S2
Abd: soft, +BS, NTND, peritoneal catheter in place
Ext; 2+ lower ext edema
Pertinent Results:
[**2133-7-29**] 05:23PM GLUCOSE-89 UREA N-51* CREAT-11.2* SODIUM-131*
POTASSIUM-4.8 CHLORIDE-88* TOTAL CO2-26 ANION GAP-22*
[**2133-7-29**] 05:23PM CK(CPK)-58
[**2133-7-29**] 05:23PM cTropnT-2.3*
[**2133-7-29**] 05:23PM WBC-8.3 RBC-2.92* HGB-9.1* HCT-27.6* MCV-95
MCH-31.1 MCHC-32.9 RDW-21.3*
[**2133-7-29**] 05:23PM PT-12.1 PTT-19.7* INR(PT)-1.0
......
CTA CHEST W&W/O C &RECONS [**2133-7-29**] IMPRESSION:
1. Dilatation of the aortic root at 4.7 cm. No evidence of
aortic dissection, intramural hematoma or pulmonary embolism.
2. A small amount of fluid within the superior pericardial
recess consistent with a small pericardial effusio
3. Mild apical bullous emphysematous changes.
4. Small hiatal hernia.
5. Cholelithiasis without evidence of acute cholecystitis.
6. Small amount of intraabdominal ascites.
.....
ECG [**2133-7-29**]: Sinus rhythm at upper limits of normal rate. P-R
interval prolongation. Left anterior fascicular block.
Intraventricular conduction delay of a left bundle-branch block
type. Since the previous tracing of [**2133-7-18**] the rate is somewhat
slower and the QRS complex is wider. Clinical correlation is
suggested
.....
[**2133-7-30**] 09:15AM BLOOD Glucose-112* UreaN-58* Creat-12.2*
Na-125* K-7.0* Cl-86* HCO3-18* AnGap-28*
[**2133-7-30**] 09:15AM BLOOD CK-MB-23* MB Indx-15.0* cTropnT-1.98*
[**2133-7-30**] 10:27AM BLOOD Type-ART Rates-20/ Tidal V-600 PEEP-5
pO2-107* pCO2-43 pH-7.09* calTCO2-14* Base XS--16 -ASSIST/CON
Intubat-INTUBATED
.....
ECHO Study Date of [**2133-7-31**] Conclusions:
1. The left atrium is normal in size. The left atrium is
elongated.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated. There is severe global
left ventricular hypokinesis. Overall left ventricular systolic
function is severely depressed.
3. Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4.The aortic valve leaflets are mildly thickened. There is mild
aortic valve stenosis.
5.Mildly thickened mitral valve leaflets. Mild (1+) mitral
regurgitation is seen.
6.There is borderline pulmonary artery systolic hypertension.
7.There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2133-7-17**], no change.
Impression:No echocardiographic evidence of pulmonary embolus
seen.
.....
Brief Hospital Course:
Death Summary (please see hospital chart for further details):
The pt was admitted w/ CP and SOB as above. His admission ECG
was unchanged from prior. Cardiac enzymes were elevated, though
trending down. The morning following admission the pt felt
severe chest pain. Shortly thereafter he was found to be
bradycardic --> PEA cardiac arrest in the setting of
hyperkalemia. He received ACLS treatment, including sodium
bicarbonate, and regained normal rhythm and a blood pressure
(estimated resuscitation time <5minutes, pulseless time <20
seconds). He was taken to the cardiac cath lab, where both the
LAD and LCx stents were widely patent. He was treated for
hyperkalemia, and a balloon pump was inserted for cardiogenic
shock.
Though the pt was weaned off the IABP, his subsequent hospital
course was complicated. He was unable to be weaned off
mechanical ventilation (pt developed VAP) and had numerous other
complicating issues. Because of his very poor prognosis, the
pt's family decided to make him care and comfort measures only
on [**2133-8-9**]. The pt died with his family by his side on [**2133-8-10**]
at 2100.
Medications on Admission:
see chart
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Cardio-pulmonary arrest
Discharge Condition:
Deceased
Discharge Instructions:
none
Followup Instructions:
none
|
[
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"785.51",
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"285.9",
"410.72",
"276.7",
"V45.82",
"185",
"414.00",
"428.0"
] |
icd9cm
|
[
[
[]
]
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"54.98",
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"96.6",
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"96.72",
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,093
| 115,161
|
24121
|
Discharge summary
|
report
|
Admission Date: [**2137-5-12**] Discharge Date: [**2137-6-3**]
Date of Birth: [**2104-3-27**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
s/p rollover MVC
Major Surgical or Invasive Procedure:
ORIF zygoma, orbital floor, maxilla
Right radial fracture ORIF
Tracheostomy and G tube placement
Chest tube placement
Bolt placement
History of Present Illness:
25 yo male s/p MVC rollover, unresponsive at scene, +ETOH.
Failed attempts to intubate on the scene. Temporary airway
placed and pt brought to ED.
Past Medical History:
none
Social History:
+ ETOH
Family History:
NC
Physical Exam:
97.8 58 100/50 100%
Fast neg
DPL neg
GCS 3
multiple facial lacs, with full thickness lac on lower lip; fork
shaped chin lac; unstable mid-face; epistaxis, facial swelling,
CTAB, deformity left clavicle
RRR
Abd soft, bruising around abdomen
pelvis stable
Ext cool, mottled, superficial lacs +LLE
Pertinent Results:
CT abd/pel: 1) Grade 4 AAST liver laceration involving segments
5, 6, 7, and 8 of the liver, with evidence of active bleeding.
2) Laceration of upper pole of right kidney.
3) Large right-sided pneumothorax.
4) Left apical pneumothorax.
5) Right first posterior rib fractures.
6) Bilateral medial clavicular fractures.
7) Fracture through posterior acetabulum.
CT head: multiple facial fractures in maxilla and orbit; complex
numerous mandibular fractures
Right forearm fracture
CT head: No cervical spine fracture or malalignment is evident.
There is extensive soft tissue swelling in the neck, especially
on the left. Findings were discussed with Dr. [**Last Name (STitle) **]. At this
time (8 a.m.), he reports that the patient has a right
hemiparesis. No evidence of acute intracranial hemorrhage or
edema; There are no skull fractures, but there are numerous
facial fractures.
[**2137-5-12**] 06:03PM LACTATE-3.1*
[**2137-5-12**] 01:48PM UREA N-11 CREAT-1.1 SODIUM-145 POTASSIUM-4.0
CHLORIDE-109* TOTAL CO2-28 ANION GAP-12
[**2137-5-12**] 01:48PM HCT-40.6
[**2137-5-12**] 01:48PM PT-13.6 PTT-25.7 INR(PT)-1.2
[**2137-5-12**] 08:10AM GLUCOSE-114* UREA N-10 CREAT-1.1 SODIUM-147*
POTASSIUM-3.7 CHLORIDE-107 TOTAL CO2-26 ANION GAP-18
[**2137-5-12**] 08:10AM CALCIUM-7.1* PHOSPHATE-4.3 MAGNESIUM-1.5*
[**2137-5-12**] 08:10AM OSMOLAL-322*
[**2137-5-12**] 08:10AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2137-5-12**] 08:10AM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2137-5-12**] 05:20AM ALT(SGPT)-396* AST(SGOT)-355* CK(CPK)-625*
ALK PHOS-57 AMYLASE-231* TOT BILI-0.7
[**2137-5-12**] 05:20AM LIPASE-155*
[**2137-5-12**] 05:20AM CK-MB-21* MB INDX-3.4 cTropnT-0.30*
[**2137-5-12**] 05:20AM ETHANOL-134*
[**2137-5-12**] 04:00AM WBC-21.7* RBC-3.93* HGB-12.1* HCT-34.4*
MCV-87 MCH-30.8 MCHC-35.2* RDW-13.6
[**2137-5-12**] 02:29AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2137-5-12**] 02:29AM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2137-5-12**] 02:20AM ASA-NEG ETHANOL-229* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**5-19**]: Sputum: 1+ GNR
[**5-17**]: Sputum 1+ GNR
[**5-20**]: Blood Cx: GPC [**3-6**] coag neg
[**5-18**]: CSP 1+ PMNs/coag neg staph
[**5-17**]: JP: 3+ PMNs
[**5-19**]: cdiff neg
[**5-23**]: urine cx: neg
[**5-26**]: sputum: GNR 2+, GPC in prs 1+; resp cx GNR
Brief Hospital Course:
Pt arrived in trauma bay with GCS of 3. Multiple attempts to
intubate pt failed. LMA placed until pt brought to OR for trach.
No scans were initially performed on patient due to hemodynamic
instability. Pt brought immediately to OR for exploratory
laparotomy, BOLT, and trach. See results section for list of
traumatic injuries. CT chest showed large PTX for which a chest
tube was placed in the right apex. Pt underwent multiple
surgeries spanning 2 days. Exploratory lap negative for
significant findings. Pt tolerated the surgeries well. However,
the post operative course was complicated by O2 desaturation in
the PACU down to the low 80's. Xray did not show changes in
pneumothorax. Pt placed on NRB with adequate improvement of O2
sat. ICU stay complicated by + sputum cultures for GNR and high
fevers. Started on 3 antibiotic regimen therapy x 7 days and
improved. Pt improved on the floor, satting well on trach mask.
Floor stay complicated by delirium/altered mental status from
?etiology. White count was elevated. Patient remained afebrile,
urine negative. Sputum cultures positive for GPC and GNR on [**5-26**]
and started on Zosyn and Vanc. White count improved. Mental
status seemed to improve with decrease of ativan use and
antibiotics for presumed PNA (aspiration vs CAP). Pt was able to
sit without sitter, and plans made to discharge to rehab for
further care.
Medications on Admission:
none
Discharge Medications:
1. Bacitracin-Polymyxin B 500-10,000 unit/g Ointment Sig: One
(1) application to wounds Topical every six (6) hours.
Disp:*2 months* Refills:*0*
2. Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1)
Ophthalmic five times a day.
Disp:*2 months* Refills:*0*
3. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
every 4-6 hours as needed.
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**5-8**]
hours as needed.
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Enoxaparin Sodium 30 mg/0.3 mL Syringe Sig: One (1)
Subcutaneous Q12H (every 12 hours).
7. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 1-2 MLs
PO Q4H (every 4 hours) as needed.
8. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1)
ML Intravenous DAILY (Daily) as needed.
9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
10. Morphine Sulfate 8 mg/mL Syringe Sig: One (1) Injection Q4H
(every 4 hours) as needed for breakthrough pain.
11. H2O2 Sig: One (1) twice a day: Please give H2O2 rinses
for oral hygiene.
12. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Chlorhexidine Gluconate 0.12 % Liquid Sig: One (1) ML Mucous
membrane [**Hospital1 **] (2 times a day).
14. Haloperidol 5 mg Tablet Sig: One (1) Tablet PO twice a day.
Tablet(s)
15. Fentanyl 100 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
16. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
17. medications
Regular Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
0-50 [**2-3**] amp D50 [**2-3**] amp D50 [**2-3**] amp D50 [**2-3**] amp D50
51-120 0 0 0 0
121-140 2 2 2 2
141-160 4 4 4 4
161-180 6 6 6 6
181-200 8 8 8 8
201-220 10 10 10 10
221-240 12 12 12 12
241-260 14 14 14 14
261-280 16 16 16 16
[**Telephone/Fax (2) 61306**] 18 18
> 301 Notify M.D.
18. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
1) Grade 4 AAST liver laceration involving segments 5, 6, 7, and
8 of the liver, with evidence of active bleeding.
2) Laceration of upper pole of right kidney.
3) Large right-sided pneumothorax.
4) Left apical pneumothorax.
5) Right first posterior rib fractures.
6) Bilateral medial clavicular fractures.
7) Fracture through posterior acetabulum.
8) multiple facial fractures in maxilla and orbit; complex
numerous mandibular fractures
9) Right forearm fracture
10) There is extensive soft tissue swelling in the neck,
especially on the left.
Discharge Condition:
stable
Discharge Instructions:
1. Take all the medications as directed
2. Continue oral care with peridex and Peroxide rinses
3. Please take out the staples of head on [**Last Name (LF) 766**], [**2137-6-3**].
4. You need your antibiotics through your picc line daily.
5. Continue with physical therapy at the rehab
6. Continue using your eye drops
Followup Instructions:
1. Please follow up with oralmaxilofacial surgery clinic in
2.5-3 weeks by calling [**Telephone/Fax (1) 14288**] for an appointment. Ask for
the surgery resident on-call
2. Please call the plastic surgery clinic by calling
[**Telephone/Fax (1) 17687**] to schedule an appointment for any Friday in the
next 2-3 months if you have any cosmetic issues from your
surgery
3. You also should follow up with your primary care doctor in
the next few weeks. If you don't have one, you can call
[**Telephone/Fax (1) 250**] to schedule an appointment with physicians at the
[**Company 191**] here at [**Hospital1 18**].
4. You should also call the trauma clinic to schedule an
appointment by calling [**Telephone/Fax (1) 61307**] to schedule an appointment
in the next 10-14 days.
|
[
"807.01",
"813.21",
"810.00",
"860.0",
"E823.0",
"351.9",
"808.0",
"802.7",
"486",
"873.43",
"802.4",
"518.5",
"861.21",
"864.03",
"866.02",
"305.00",
"285.1",
"958.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"76.92",
"76.79",
"43.11",
"54.11",
"01.18",
"03.31",
"33.24",
"76.74",
"34.04",
"76.72",
"79.32",
"31.1",
"27.51",
"38.7"
] |
icd9pcs
|
[
[
[]
]
] |
7457, 7527
|
3613, 4994
|
330, 465
|
8114, 8122
|
1049, 1409
|
8488, 9266
|
709, 713
|
5049, 7434
|
7548, 8093
|
5020, 5026
|
8146, 8465
|
728, 1030
|
274, 292
|
493, 641
|
1536, 3590
|
663, 669
|
685, 693
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,871
| 104,383
|
22960
|
Discharge summary
|
report
|
Admission Date: [**2110-9-29**] Discharge Date: [**2110-10-10**]
Date of Birth: [**2052-12-5**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6180**]
Chief Complaint:
Shaking, fatigue
Major Surgical or Invasive Procedure:
none
History of Present Illness:
: 57yo M w/ PMH of progressive metastatic rectal cancer, DM and
HTN presented to the ER with worsening fatigue ("I don't have my
get-up-and-go"), diarrhea and LE edema. He was recently admitted
to [**Hospital1 18**] for pneumonia and given a course of levaquin for
treatment. He was discharged on [**9-20**], but continued taking
levaquin per his PCP up until today. His symptoms began
approximately 4 days ago, with increasing fatigue, decreased
energy and diarrhea (2 loose BM daily). He denies any
f/c/CP/SOB/dizziness/LH/weight changes/n/v/loss of appetite. On
arrival to the ER tonight, his T was 100, HR 180/104, HR 88, RR
24, and sats were 96% on RA. Exam was notable for guaiac
positive stool and yellow icteric sclera. Given his recent abx
use, the diarrhea was concerning for [**Last Name (LF) **], [**First Name3 (LF) **] cultures were
taken and labs drawn. His labs revealed a serum glu of 26 and
repeat FS was 20. He was given 1 amp D50 and ate his dinner,
with an improvement in his FS to 137. Repeat FS after that was
42 and then 26. He was given another amp of D50, then D51/2NS at
100/hr x1L, with improvement in his FS to 130s. He was started
on flagyl 500mg PO x1 for presumed C diff and blood cultures
were sent. His repeat FS were 55 and then 45. He was then
switched to a D10 gtt at 100/hr and he was transferred to the
[**Hospital Unit Name 153**] for further management of his hypoglycemia.
.
His prognosis was discussed with his primary oncologist and it
was felt that the course was indicative of limited reserve.
Palliative care was consulted and [**Hospital Unit Name 153**] team felt that the
discussion was moving toward CMO.
Past Medical History:
1. Onc history from OMR: Between [**Month (only) **]-[**2108-11-26**], Mr. [**Known lastname 16745**]
noticed blood in his stool and ongoing abdominal discomfort. In
[**2108-11-26**], he presented with acute worsening abdominal pain and
peritonitis. Radiological findings suggested large mass at the
rectosigmoid junction adhering to the bladder wall causing
cancerous colovesical fistula. During the surgical exploration,
colonoscopy was done which showed exophytic tumor w/ biopsy
positive for invasive adenocarcinoma. He then underwent
diverting colostomy. Repeat CEA showed increase in number
suggesting progression of the cancer. Further staging CT on
[**2109-1-31**] revealed 2 lesions in the liver suggestive of metastatis.
RUQ ultrasound showed portal vein thrombosis and he was started
and has completed coumadin. He received neoadjuvant chemotherapy
with FOLFOX and Avastin. Underwent resection of rectum with
colostomy, Cystoscopy and bilateral ureteral stent placement,
Cystoprostatectomy and urinary diversion into a colonic loop,
and Bilateral nephrostomy placement in [**8-30**]. He was on break
from chemotherapy from [**5-1**] to [**7-31**] but followup CT scans showed
significant progression of disease. He was started on single
[**Doctor Last Name 360**] weekly Irinotecan on [**2110-8-20**]. Patient missed his first
Erbitux dose on [**9-17**] because of nausea/abdominal discomfort.
.
Other PMHx:
2. IDDM
3. HTN
4. Portal vein thrombosis
Social History:
He is a widower and lost his wife in '[**94**], has 7 adult children.
Currently on disability, previously worked as a computer
engineer. Lives with girlfriend, with whom he has been
monogamous >2years. Last HIV test was 5 years ago-negative.
Tobacco: None
Alcohol: used to drink, stopped drinking 5 years ago.
Drugs: None
Family History:
No family hx of colon or prostate cancer
Physical Exam:
VS - T 100.1, BP 175/95, HR 78-85, RR 24-32, O2 sats 99% on RA
Gen: WDWN AfAm male in NAD, lying in bed.
HEENT: Sclera slightly icteric. PERRL, 3->2mm bilaterally. EOMI.
OP clear, no exudates or erythema. Neck supple, no evidence of
JVD.
CV: RR, normal S1, S2. No m/r/g.
Lungs: Decreased BS at R base, but otherwise clear, no crackles.
Abd: Soft, NTND. Has large midline scar, well healed. Has
colostomy bag in R middle quadrant w/ large amt of formed brown
stool + gas. Has urostomy bag in L middle quadrant. Ostomy pink,
nontender. Urine thick, yellow.
Ext: 2+ pitting edema in his feet bilaterally, but 2+ DP pulses
bilaterally. No c/c. No rashes. Skin dry.
Neuro: AAO x3. Has flat affect.
Pertinent Results:
[**2110-9-29**] 04:04PM LACTATE-2.0
[**2110-9-29**] 04:03PM GLUCOSE-26* UREA N-13 CREAT-0.6 SODIUM-135
POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-25 ANION GAP-14
[**2110-9-29**] 04:03PM ALT(SGPT)-87* AST(SGOT)-184* LD(LDH)-3096*
ALK PHOS-801* AMYLASE-53 TOT BILI-6.4*
[**2110-9-29**] 04:03PM ALT(SGPT)-87* AST(SGOT)-184* LD(LDH)-3096*
ALK PHOS-801* AMYLASE-53 TOT BILI-6.4*
[**2110-9-29**] 04:03PM ALBUMIN-2.5*
[**2110-9-29**] 04:03PM WBC-14.0* RBC-3.96* HGB-10.6*# HCT-31.9*
MCV-81* MCH-26.8* MCHC-33.3 RDW-21.5*
[**2110-9-29**] 04:03PM NEUTS-82* BANDS-0 LYMPHS-12* MONOS-5 EOS-0
BASOS-0 ATYPS-1* METAS-0 MYELOS-0
[**2110-9-29**] 04:03PM PT-16.8* PTT-28.0 INR(PT)-1.5*
[**2110-10-6**] 06:05AM BLOOD WBC-15.3* RBC-3.71* Hgb-9.3* Hct-28.9*
MCV-78* MCH-25.2* MCHC-32.3 RDW-22.4* Plt Ct-860*
[**2110-10-6**] 06:05AM BLOOD Plt Ct-860*
[**2110-10-6**] 06:05AM BLOOD Glucose-130* UreaN-77* Creat-2.3* Na-129*
K-5.3* Cl-93* HCO3-19* AnGap-22*
[**2110-10-6**] 06:05AM BLOOD ALT-143* AST-288* AlkPhos-549*
TotBili-13.1*
[**2110-10-6**] 06:05AM BLOOD Albumin-2.2* Calcium-8.9 Phos-6.0*
Mg-3.3*
[**2110-10-5**] 06:40AM BLOOD Hapto-558*
[**2110-10-7**] 07:00PM BLOOD TSH-1.8
.
Right LE doppler:
RIGHT LOWER EXTREMITY VENOUS ULTRASOUND: [**Doctor Last Name **]-scale and Doppler
son[**Name (NI) 1417**] of the right common femoral, superficial femoral, and
popliteal veins were performed. These demonstrate normal
augmentation, compressibility, flow and waveforms. No
intraluminal echogenic thrombus is identified.
IMPRESSION: No evidence of right lower extremity deep venous
thrombosis.
Brief Hospital Course:
57yo M w/ metastatic rectal cancer presents with fatigue,
diarrhea, and persistent hypoglycemia.
.
1. RECTAL CANCER: The majority of problems that the patient
experienced while inpatient were thought to be due to advanced
metastatic disease. Initially the patient was evaluated for
hospice care, but the patient expired prior to this being
arranged.
.
2. HYPOGLYCEMIA/Hyperglycemia - The patient was initially
admitted with severe hypoglycemia that has now resolved. The
initial cause is likely a combination of decreased metabolism of
insulin with possible infection (now resolved). Pt was treated
with antibiotics at first, but discontinued as pt was afebrile
without localizing symptoms. For the management of his
hypoglycemia, pt was managed in the ICU and required dextrose
IV. Eventually, the glucose level was improved and he was
transfered to the medicine floors. He was kept off insulin
intially. Then small doses of glargine were started, but pt
began to have hypoglycemia and the lantus was discontinued.
.
3. Liver Failure: Pt with significant elevation of LFTs over
last weeks which was likely due to invasive process with cancer.
Continues to be elevated. Pt likely with progression of liver
disease as a result of liver metastases.
- RUQ u/s showed echogenic liver consistent with history of
multiple hepatic metastasis. No ductal dilation.
- LFT elevation limits opportunities for chemotherapy.
.
4. Renal failure- pt has increasing BUN, creatinine. Likely
hepatorenal syndrome and due to metastatic disease.
.
5. Thrush: pt continues to have oral symptoms. Will add
peridex, keep on nystatin.
.
6. DIARRHEA: Per pt, somewhat at baseline. Unclear if changed.
Stool cultures negative.
.
7. HTN: Metoprolol.
.
8. LE EDEMA: New issue for the patient. He has had increasing
swelling while inpatient. He had some relief with
spironolactone.
.
In last days of hospitalization the patient's mental status
declined such that it was impossible to take PO meds or eat. He
was made comfort measures only and given medications to limit
pain. The patient expired in the hospital.
Medications on Admission:
Atenolol 100mg PO QD
Hydrochlorothiazide 25mg PO QD
Glargine 35u SC QHS
Levofloxacin 500mg PO QD - last dose on day of admission
Percocet 5-325 mg PO every 4-6 hours prn x 10 pills
Discharge Medications:
Pt expired
Discharge Disposition:
Expired
Discharge Diagnosis:
End-stage Metastatic rectal cancer
Secondary
Hypoglycemia
Discharge Condition:
Deceased
Discharge Instructions:
Deceased
Followup Instructions:
Deceased
|
[
"401.9",
"250.80",
"250.00",
"572.4",
"V58.67",
"197.7",
"V10.06",
"112.0",
"198.89"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8614, 8623
|
6248, 8347
|
333, 340
|
8725, 8735
|
4637, 6225
|
8792, 8803
|
3865, 3907
|
8579, 8591
|
8644, 8704
|
8373, 8556
|
8759, 8769
|
3922, 4618
|
277, 295
|
369, 2026
|
2048, 3509
|
3525, 3849
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,625
| 151,058
|
38861
|
Discharge summary
|
report
|
Admission Date: [**2130-1-17**] Discharge Date: [**2130-1-24**]
Date of Birth: [**2061-7-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2130-1-18**] - Coronary artery bypass graft x5: Left internal mammary
artery to left anterior descending artery and saphenous vein
grafts to posterior descending artery and diagonal artery and
saphenous vein sequential grafting to obtuse marginal 1 and 2.
History of Present Illness:
This 68 year old white male presented to his primary care doctor
with atypical chest pain. A stress teast in [**2129-12-16**] was
positive and he underwent an elective cardiac cath the day of
trnasfer which showed tight left main and
three vessel disease. He was transferred from [**Hospital1 **] to
[**Hospital1 18**] for urgent revescularization.
Past Medical History:
Diabetes mellitus type 2
Hypertension
hyperlipidemia
Rt inguinal hernia repair 30 years ago
kidney stones
Social History:
Race: Caucasian
Last Dental Exam: 3 weeks ago, needs to complete a root canal
Lives with: wife, no children
Occupation: retired electrician
Tobacco: never
ETOH: quit 30 years ago
Family History:
non-contributory
Physical Exam:
Admission:
Pulse: 66 Resp: 14 O2 sat: 95
B/P Right: 139/76 Left: 128/63
Height: 5'[**30**]" Weight: 170 lbs
General: no acute distress
Skin: Dry [x] intact [x] healed incision from hernia right groin
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur none
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] no palpable masses
Extremities: Warm [x], well-perfused [] Edema none - legs
slight
mottling Varicosities: None []
Neuro: alert and oriented x3 non focal
Pulses:
Femoral Right: cath site - mink closure device Left: +2
DP Right: +1 Left: +1
PT [**Name (NI) 167**]: +1 Left: +1
Radial Right: +2 Left: +2
Carotid Bruit Right: no bruit Left: no bruit
Pertinent Results:
Admission
[**2130-1-17**] 06:29PM BLOOD WBC-6.0 RBC-5.33 Hgb-15.5 Hct-46.3 MCV-87
MCH-29.1 MCHC-33.4 RDW-13.5 Plt Ct-220
[**2130-1-17**] 06:29PM BLOOD Glucose-150* UreaN-20 Creat-1.0 Na-140
K-3.9 Cl-101 HCO3-28 AnGap-15
[**2130-1-17**] 06:18PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2130-1-17**] 06:18PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.032
[**2130-1-17**] 06:29PM PT-10.5 PTT-23.2 INR(PT)-0.9
[**2130-1-17**] 06:29PM PLT COUNT-220
[**2130-1-17**] 06:29PM %HbA1c-9.4*
[**2130-1-17**] 06:29PM ALBUMIN-4.6 CALCIUM-9.8 PHOSPHATE-3.0
MAGNESIUM-2.1
[**2130-1-17**] 06:29PM LIPASE-34
[**2130-1-17**] 06:29PM ALT(SGPT)-23 AST(SGOT)-25 LD(LDH)-182 ALK
PHOS-92 AMYLASE-35 TOT BILI-0.5
[**2130-1-17**] 06:29PM GLUCOSE-150* UREA N-20 CREAT-1.0 SODIUM-140
POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-28 ANION GAP-15
Discharge
[**2130-1-23**] 05:10AM BLOOD WBC-6.0 RBC-3.24* Hgb-9.6* Hct-29.0*
MCV-90 MCH-29.7 MCHC-33.2 RDW-14.3 Plt Ct-227
[**2130-1-23**] 05:10AM BLOOD Plt Ct-227
[**2130-1-23**] 05:10AM BLOOD Glucose-147* UreaN-15 Creat-1.1 Na-137
K-4.9 Cl-101 HCO3-31 AnGap-10
[**2130-1-17**] Carotid Duplex Ultrasoound
Right ICA with no stenosis .
Left ICA stenosis <40%.
[**2130-1-18**] ECHO
Prebypass:
No atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thicknesses are normal. Overall left
ventricular systolic function is mildly depressed (LVEF= 45-50
%). Right ventricular chamber size and free wall motion are
normal. There are simple atheroma in the descending thoracic
aorta. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild to moderate
([**12-17**]+) mitral regurgitation is seen. There is no pericardial
effusion. Dr. [**Last Name (STitle) **] was notified in person of the
results on [**2130-1-18**] at 1030am
Post bypass:
Patient is A paced and receiving an infusion of phenylephrine.
Biventricular systolic function is unchanged. Mild mitral
regurgitation present. Aorta is intact post decannulation.
Brief Hospital Course:
Mr. [**Known lastname 21056**] was admitted to the [**Hospital1 18**] on [**2130-1-17**] for surgical
management of his coronary artery disease. He was worked up in
the usual preoperative manner including a carotid duplex
ultrasound which showed no significant disease.
On [**2130-1-19**], Mr. [**Known lastname 21056**] was taken to the Operating Room where he
underwent coronary artery bypass grafting to five vessels.
Please see operative note for details. In summary he had: Left
internal mammary artery to left anterior descending artery and
saphenous vein grafts to posterior descending artery and
diagonal artery and saphenous vein sequential grafting to obtuse
marginal 1 and 2 as well as endoscopic harvesting of the greater
saphenous vein. His bypass time was 87 minutes with a crossclamp
of 75 minutes. He tolerated the operation well and was
transferred from the operating room to the cardiac surgery
intensive care unit in stable condition.
Over the next 24 hours, Mr. [**Known lastname 21056**] [**Last Name (Titles) 5058**] neurologically intact
and was extubated. His beta blockade, aspirin and statin were
resumed. All tubes lines and drains were removed according to
cardiac surgery protocol. Post-operatively he remained
hyperglycemic and was kept in the ICU for insulin regulatuion.
[**Last Name (un) **] followed him for this. His oral hyperglycemic agents
were discontinued and Lantus and Humalog insulin were utilized
for glycemic control. He remained hemodynamically stable. He
developed rapid atrial fibrillation for which Amiodarone was
given intravenously. He did convert to sinus rhythm shortly
thereafter. He was transferred from the intensive care unit to
the step down floor on Post operative day 5.
He continued to progress and was disacharged on POD 6.
Medications on Admission:
Glyburide 10mg twice a day
Norvasc 5mg daily
Simvastatin 60mg daily
Lisinopril 20mg twice a day
Atenelol 50mg daily
Metformin 500mg three times a day
Vit D. 1 tab daily
Centrum 1 tab daily
ASA 81 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:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
3. Diabetes supplies
Glucometer, Blood glucose Testing strips, Lancets
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
5. Simvastatin 40 mg Tablet Sig: 1.5 Tablets PO once a day: 60
mg daily .
Disp:*45 Tablet(s)* Refills:*0*
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day:
please take 200mg twice a day for 7 days then decrease to 200mg
once daily until follow up with cardiologist .
Disp:*37 Tablet(s)* Refills:*0*
9. Lopressor 50 mg Tablet Sig: 1.5 Tablets PO twice a day: 75 mg
twice a day.
Disp:*90 Tablet(s)* Refills:*0*
10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
11. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
12. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) as needed for right arm phlebitis for 7 days: right
arm phlebitis .
Disp:*28 Capsule(s)* Refills:*0*
13. sliding scale
Fingerstick QACHSInsulin SC Fixed Dose Orders
Breakfast
Glargine 25 Units
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Humalog Humalog Humalog Humalog
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
0-70 mg/dL Proceed with hypoglycemia protocol Proceed with
hypoglycemia protocol Proceed with hypoglycemia protocol Proceed
with hypoglycemia protocol
71-99 mg/dL 0 Units 0 Units 0 Units 0 Units
100-140 mg/dL 6 Units 6 Units 6 Units 0 Units
141-180 mg/dL 9 Units 9 Units 9 Units 0 Units
181-220 mg/dL 12 Units 12 Units 12 Units 3 Units
221-260 mg/dL 14 Units 15 Units 14 Units 4 Units
261-300 mg/dL 15 Units 15 Units 15 Units 5 Units
301-360 mg/dL 16 Units 16 Units 16 Units 6 Units
Instructons for NPO Patients: if npo use bedtime scale
14. Insulin Glargine 100 unit/mL Solution Sig: Twenty Five (25)
units Subcutaneous once a day.
Disp:*qs qs* Refills:*0*
15. Humalog 100 unit/mL Solution Sig: per sliding scale insulin
units Subcutaneous before each meal and bedtime : pleae cover
based on sliding scale .
Disp:*qs qs* Refills:*2*
16. Insulin Syringe MicroFine 0.3 mL 28 x [**12-17**] Syringe Sig: One
(1) syringe Miscellaneous ac and hs for humalog, once daily for
lantus .
Disp:*150 syringe * Refills:*2*
17. Glucose Gel 40 % Gel Sig: One (1) PO as needed as needed
for hypoglycemia .
Disp:*qs qs* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
coronary artery disease, s/p coronary artery bypass graft x5
Diabetes mellitus type 2
Hypertension
hyperlipidemia
s/p inguinal herniorraphy
kidney stones
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating, gait steady
Sternal pain managed with percocet prn
Sternal wound CDI, no drainage or erythema
Right forearm with erythema no drainage improving - on Keflex
for 7 days for phlebitis
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month 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**]
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2130-2-20**] 1:00
Primary Care Dr. [**Last Name (STitle) 11427**] on Thursday, [**2130-1-26**] 12:00pm
([**Telephone/Fax (1) 8058**])
Please call to schedule appointments
Cardiologist Dr. [**Last Name (STitle) 8051**] in [**12-17**] weeks
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule before discharge
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2130-1-24**]
|
[
"413.9",
"414.01",
"414.2",
"427.31",
"250.00",
"458.29",
"V13.01",
"401.9",
"997.1",
"272.4",
"451.82",
"E878.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.14",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
9383, 9442
|
4369, 6161
|
330, 592
|
9640, 9867
|
2180, 4346
|
10408, 11022
|
1315, 1334
|
6417, 9360
|
9463, 9619
|
6187, 6394
|
9891, 10385
|
1349, 2161
|
280, 292
|
620, 972
|
994, 1102
|
1118, 1299
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,923
| 183,448
|
53777
|
Discharge summary
|
report
|
Admission Date: [**2157-6-2**] Discharge Date: [**2157-6-17**]
Date of Birth: [**2094-3-28**] Sex: F
Service: MEDICINE
Allergies:
latex
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
- bronchoscopy
- rigid bronchoscopy with Y-stent placement
History of Present Illness:
This is a 63 year old female presenting with a chief complaint
of shortness of breath.
Ms [**Known lastname 13143**] has a history of stage I lung cancer which was wedge
resected in [**2153**]. Just prior to this diagnosis, she also was
diagnosed with pulmonary embolism for which she was
anticoagulated. Between [**2153**] and [**2157**], she has had continued
respiratory events which are described in detail below and lead
to her current hospitalization. She also has a diagnosis of
COPD with a 20 pack year smoking history (she quit many years
ago).
Over the past four years, she has been dealing with intermittent
periods of shortness of breath. This has been worked up by
various physicians who have referred her complaints to multiple
diagnoses, including COPD, asthma, and most recently,
tracheobronchomalacia. Her pulmonologist near [**Location (un) 5583**]
performed bronchoscopy early in [**2157**] and diagnosed this
condition. In [**2157-3-2**], she underwent stent placement
given TBM; between [**Month (only) 956**] and [**Month (only) 547**], she tolerated the stent
with initial improvement in her breathing, however, over the
last several weeks, she has started to make increasing
secretions with daily cough. In early [**Month (only) 547**], given advancing
symptoms, her stent was removed and significant laryngeal edema
was identified. She was started on steroids which have been
tapered over the past three weeks; she finished her steroid
course 2 days ago. Now, since stopping the steroids, she has
developed increasing wheezing over the past 24 hours. She
presented to [**Hospital **] clinic on morning of this admission for
consideration of repeat stent placement. However, given
respiratory rate of 30, saturations near 92% on ambulation, she
was sent to the ED for respiratory distress; she was started on
nebulizers amd required BiPap initially. She was started on
solumedrol. A chest x-ray was obtained which reveals surgical
scarring on the left secondary to her wedge resection, but no
other acute process.
.
At time of transfer to the MICU, she is weaned off BiPAP and
tolerating a non-rebreather with good saturations.
Past Medical History:
GERD
TBM
HTN
PE [**2151**]
stage I lung cancer left upper lobe, s/p thoracotomy wedge
resection [**2153**]
s/p CCY
s/p achilles tendon repair right
bilat carpal and cubital tunnel repair
chronic headaches
s/p cervical fusion
chronic low back pain
anxiety
depression
Social History:
Lives at home
Occupation:Operations supervisor, not working these days
Smoking history; Quit 10pk year. occasional alcohol
Family History:
CAD, COPD, Lung CA
Physical Exam:
Admission exam
VS: temp 98, RR 14, O2 sat 97% on NRB, pulse 103
Ms [**Known lastname **] is sitting up in bed with nonbreather in place, with
no difficulty with air movement and exhibiting no signs of
respiratory distress. She does pause after long sentences to
breathe. She is pleasant, alert, and oriented to person, place,
and time.
Cardiovascularly her JVP is normal. Her heart is regular rhythm
with a slightly tachycardic rate.
Pulmonary exam is surprisingly free of wheeze or rales.
Abdomen is soft, nontender, and nondistended with normoactive
bowel sounds.
Extremities are free of rash and edema
Discharge exam
98.3 151/58 87 18 98% ra
GENERAL - caucasian female, overweight, in NAD, comfortable
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTAB, breathing comfortably
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**6-4**] throughout, sensation grossly intact throughout, steady gait
Pertinent Results:
Admission labs
[**2157-6-2**] 05:20PM BLOOD WBC-11.5* RBC-4.92 Hgb-14.3 Hct-44.5
MCV-90 MCH-29.1 MCHC-32.2 RDW-13.7 Plt Ct-319
[**2157-6-2**] 05:20PM BLOOD Neuts-54.3 Lymphs-37.3 Monos-4.8 Eos-2.7
Baso-1.0
[**2157-6-2**] 05:20PM BLOOD Glucose-99 UreaN-24* Creat-1.0 Na-141
K-4.0 Cl-104 HCO3-24 AnGap-17
[**2157-6-2**] 05:20PM BLOOD Calcium-9.9 Phos-3.6 Mg-2.1
Discharge labs
[**2157-6-17**] 07:45AM BLOOD WBC-10.9 RBC-4.05* Hgb-11.7* Hct-37.2
MCV-92 MCH-28.8 MCHC-31.4 RDW-14.1 Plt Ct-248
[**2157-6-17**] 07:45AM BLOOD Glucose-88 UreaN-25* Creat-0.9 Na-139
K-4.0 Cl-103 HCO3-24 AnGap-16
Studies
CXR [**2157-6-2**]: Linear opacities in the left mid lung are suggestive
of scarring. Surgical chain sutures also seen suggesting prior
resection. There is obscuration of the left lateral
costophrenic angle compatible with prominent fat identified on
CT. Elsewhere, the lungs are clear without confluent
consolidation. The cardiomediastinal silhouette is within
normal limits. Anterior lower cervical and upper thoracic
spinal fixation hardware is identified. The osseous structures
are otherwise grossly unremarkable. IMPRESSION: No definite
acute cardiopulmonary process.
.
CT trachea [**2157-6-3**]:
1. No tracheal narrowing or evidence of tracheobronchomalacia.
2. Mucosal irregularity posterior tracheal wall could be
inflammation or
artifact from recently removed tracheal stent.
3. Normal postoperative appearance of left lung following
subtotal resection from the lingula.
.
Spirometry [**2157-6-13**]:
Pulmonary Report SPIROMETRY, LUNG VOLUMES, DLCO Study Date of
[**2157-6-13**] 8:43 AM
SPIROMETRY 8:43 AM Pre drug Post drug
Actual Pred %Pred Actual %Pred %chg
FVC 2.36 3.00 79 2.60 87 +10
FEV1 1.75 2.19 80 1.89 86 +8
MMF 1.35 2.50 54 1.32 53 -2
FEV1/FVC 74 73 102 73 100 -2
LUNG VOLUMES 8:43 AM Pre drug Post drug
Actual Pred %Pred Actual %Pred
TLC 3.88 4.87 80
FRC 1.88 2.78 68
RV 1.60 1.87 85
VC 2.32 3.00 77
IC 2.00 2.10 96
ERV 0.28 0.91 31
RV/TLC 41 38 107
He Mix Time 0.00
DLCO 8:43 AM
Actual Pred %Pred
DSB 16.96 18.53 92
VA(sb) 3.91 4.87 80
HB 11.90
DSB(HB) 17.84 18.53 96
DL/VA 4.56 3.80 120
.
Bronchoscopy [**2157-6-13**]:
The flexible bronchoscope was introduced for airway inspection.
The vocal cords moved normally. A lesion was identified on the
left vocal cord. The scope was advanced to perform airway
inspection. Right airways appeared normal to the segmental
level, left airways were noted for a surgically absent left
upper lobe. Dynamic airway maneuvers were then performed, with
the following findings: proximal trachea - moderate collapse;
mid-trachea - severe collapse; distal trachea - mild collapse;
RMS - moderate collapse; [**Hospital1 **] - mild to moderate collapse; LMS -
mild collapse. The scope was removed, and the procedure
completed.
Impression: 63yo F with chronic cough and paroxysms of wheezing,
diagnosis of tracheobronchomalacia with failed tracheal stent at
an outside hospital admitted for wheezing. Flexible bronchoscopy
with dynamic airway maneuvers was performed today. Severe
tracheomalacia at the level of the proximal and mid-trachea.
none
.
Rigid bronchoscopy [**2157-6-15**]:
Rigid bronchoscopy and flexible bronchoscopy with deployment of
Dumon Y stent for tracheobronchomalacia. Stent size was a
16x13x13 with a 5cm proxima limb, 1.5cm to RMS and 3cm to LMS.
Balloon dilation tot he LMS needed for complete unfolding of the
stent. This was complicated by LMS partial mucosa tear non
communicating with the mediastinum by bronchoscopic direct
visualization asssessment. No other complications.
Brief Hospital Course:
Ms [**Known lastname **] is a 63yoF with h/o stage I lung cancer sp wedge
resected in [**2153**], PE [**2151**] asthma/COPD, possible
trachobronchomalacia, who p/w SOB, hypoxia, and wheeze. This has
been a longstanding issue for her, over several years, though
worse more recently. It has intermittently been diagnosed as
asthma, COPD, and most recently tracheomalacia. In this
admission we diagnosed severe tracheomalacia, and mild asthma,
as well as significant anxiety, as the primary contributors to
her symptoms.
.
# Dyspnea - When she first presented, she was wheezing and in
respiratory distress, and went to the MICU. She briefly required
CPAP. She had recently completed a steroid [**Last Name (LF) 15123**], [**First Name3 (LF) **] airway
inflammation was thought to be the cause, and she was restarted
on steroids again. CXR was unremarkable. CT trachea showed no
evidence of tracheobronchomalacia. She had 1-2 episodes of
wheezing, tachypnea with facial flushing. She would de-sat to
low 90s during these episodes but did not have major episodes of
hypoxia. ENT evaluated pt with laryngoscopy and did not feel
that this was consistent with vocal cord dysfunction. She
underwent bronchoscopy that showed severe upper tracheomalacia.
Please [**Last Name 788**] problem specific notes below:
.
# Tracheomalacia: she thus had a Y-stent placed on [**6-15**]. Her
breathing improved after this intervention, in terms of
wheezing, but she then developed problems with managing
secretions. She required respiratory therapy to do deep
nasopharyngeal suctioning [**1-31**] x/day after stent placement, and
this relieved the obstruction. She will continue on mucinex, and
standing duonebs to help manage her airways. She will need Q6H
hypertonic saline. One of these saline nebulizer treatments
should be in the middle of the night (2-5am), to help deal w/ AM
secretions. Because of her difficulty w/ managing secretions,
she was sent to pulmonary rehab. She will f/u in Interventional
Pulmonary clinic, to see if tracheoplasty is a viable option for
her.
.
# Asthma: she had PFT's (prior to stent placement), that were
suggestive of mild asthma. She will be continued on standing
duonebs for now (per tracheomalacia / stent) and symbicort. Her
steroids will be tapered over 2 weeks.
.
# Depression/anxiety: we thought anxiety contributed to her SOB
and attacks, though certainly does not explain them entirely.
Increased her citalopram to 20mg daily (from 10), and changed
ativan to klonapin TID, with an additional 1mg klonapin TID PRN
anxiety.
.
# Lasix: she is on lasix for unclear reasons. We held this the
entirety of her admission, and did not get volume overloaded. It
was restarted at discharge, but if it seems that it is making
her secretions thicker, should be stopped.
.
# Hypertension - held metoprolol to see if that made any
difference w/ SOB, but it did not so we restarted it
.
# Hyperlipidemia - continued simvastatin
.
# s/p stage I lung cancer - resected
.
# history of pulmonary embolus - several years ago, likely in
setting of underlying malignancy, now resected, off
anticoagulation
.
# GERD - continued omeprazole
.
# Code Status - full
.
=====================
TRANSITIONAL ISSUES
# Will f/u with IP in ~1 week for further management of her
severe tracheomalacia
# At discharge, she should be set up to have home suction and
yankaur device at home
# She will need Q6H hypertonic saline. One of these saline
nebulizer treatments should be in the middle of the night
(2-5am), to help deal w/ AM secretions
Medications on Admission:
simvastatin 40 mg pm
metoprolol tartrate 50"
diphenhydramine 50 mg daily
citalopram 10'
furosemide 80'
vit D 50,000 u weekly
glimepiride 2 mg'
lorazepam 1 mg tid
hydrocodone-apap 5-500 [**1-31**] Q6 hrs prn
symbicort [**Hospital1 **]
albuterol nebs or MDI
sucralfate 1 G qid prn
Discharge Medications:
1. Home suction and yankaur device
Dispense 1 home suction device, 10 yankaur devices.
2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO twice
a day.
4. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Lasix 80 mg Tablet Sig: One (1) Tablet PO once a day.
6. Vitamin D3 2,000 unit Tablet Sig: One (1) Tablet PO once a
day.
7. glimepiride 2 mg Tablet Sig: One (1) Tablet PO once a day.
8. Symbicort 80-4.5 mcg/actuation HFA Aerosol Inhaler Sig: Two
(2) Inhalation twice a day.
9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours).
10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as
needed for SOB or Wheeze.
11. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
12. clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
13. clonazepam 1 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for anxiety.
Disp:*90 Tablet(s)* Refills:*0*
14. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
15. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
16. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
17. calcium carbonate 500 mg calcium (1,250 mg) Capsule Sig: One
(1) Capsule PO twice a day.
18. Vitamin D3 1,000 unit Capsule Sig: One (1) Capsule PO once a
day.
19. guaifenesin 600 mg Tablet Extended Release Sig: Two (2)
Tablet Extended Release PO twice a day.
20. prednisone 10 mg Tablet Sig: take 3 tablets for 4 days, then
2 tablets for 5 days, then 1 tablet for 5 days, then stop Tablet
PO DAILY (Daily).
21. hypertonic saline (3% NaCl) nebulizer, 3cc QID. One should
be in the middle of the night (2-5am)
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Transitional Care and Rehabilitation
Discharge Diagnosis:
- tracheomalacia
- asthma
- anxiety
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 **],
You were admitted for respiratory distress. We found that you
have a condition called tracheomalacia. This means that your
trachea (airtube) is softer than normal, and is prone to
collapsing. For this, you received a stent in your trachea.
We also found that you have asthma. You will need nebulizer
treatments for this. You were started on steroids, and will
[**Known lastname 15123**] off of them over 2 weeks.
You will also need a saline nebulizer 4 times daily. One of
those times should be in the middle of the night (2-5am). Try to
cough up any secretions you may have afterwards, before going to
bed.
We have also made several changes to your medications
** START prednisone [**Known lastname 15123**] [steroid] over 2 weeks
** START guiafenesin (mucinex) [help with airway secretions]
** START hypertonic saline nebulizer. Use 4 times daily. 1 of
those times should be between 2am-5am.
** START albuterol/ipratropium nebulizer [open airways]
** INCREASE citalopram to 20mg daily (from 10mg) [anxiety
control]
** STOP lorazepam [anxiety medication]
** START clonazepam [stronger anxiety med], take 3 times daily,
and 3 additional times if you need extra
** START omeprazole [anti-acid] while you are on prednisone. You
can stop after you are off the prednisone.
** START calcium/vitamin D for bone health
Followup Instructions:
You will follow up with the [**Hospital1 18**] Interventional Pulmonary
Clinic in about 1 week. You will be contact[**Name (NI) **] by them. If you do
not hear from them within 2-3 days, call ([**Telephone/Fax (1) 17398**]
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2157-6-30**] at 11:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6543**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
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"V10.11",
"300.00",
"E870.4",
"311",
"276.3",
"934.1",
"493.22",
"276.2",
"530.81",
"519.19",
"V15.82",
"V12.55",
"478.6",
"998.2",
"E912"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.23",
"31.42",
"33.22",
"96.05"
] |
icd9pcs
|
[
[
[]
]
] |
13763, 13843
|
7938, 11473
|
285, 346
|
13923, 13923
|
4302, 7915
|
15478, 16016
|
2991, 3012
|
11802, 13740
|
13864, 13902
|
11499, 11779
|
14106, 15455
|
3027, 4283
|
226, 247
|
374, 2543
|
13938, 14082
|
2565, 2834
|
2850, 2975
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,169
| 119,073
|
15436
|
Discharge summary
|
report
|
Admission Date: [**2148-3-12**] Discharge Date: [**2148-3-13**]
Date of Birth: [**2068-8-25**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
cardiogenic shock
Major Surgical or Invasive Procedure:
Arterial Line placement
History of Present Illness:
79 F with insulin-dependent diabetes, CAD, PVD, s/p rt CEA in
fairly good health had abdominal discomfort and generally
feeling unwell for approximately 2 weeks. She states that she
has been feeling "tired and weak", staying in bed for most of
those two weeks. Denies any CP, Sob, N/V/D. Her daughter visited
her 2 days ago and reports that her mother was c/o mild
periumbilical abdominal aching, no N/V/D and appeared to be
dizzy.
.
Her family brought her to the [**Location (un) **] ED. In the ED, she was
pale diaphoretic and c/o of abd pain. Abd was found to be benign
but she had new EKG changes with ST elevations in anterior leads
and cardiac enzyme elevations: Trop 7.02, Ck 200's, MB 47. BP
mid 90's. Left IJ placed. She received approx 4l IVF for
hypotension and then developed pulmonary edema. BNP 1854. She
was diagnosed with cardiogenic shock and transfered to the CCU.
.
In the CCU, she was on neo at 40mcg per kg with improvement of
SBp to 97. An echo revealed an EF of 20%. Due to low BP, she was
also placed on dobutatime. She subsequently became very
tachycardic and was switched to dopamine. In addition, she was
found to have a leukocytosis of 40,000 but had already been
started on Ceftriaxone given hx of UTI's.
Past Medical History:
PAST MEDICAL HISTORY:
Hypertension
Status post R carotid endarterectomy in [**2145**]
Status post L second ray amputation for osteomyelitis in [**2141**]
IDDM
.
Cardiac History:
CABG: none
Percutaneous coronary intervention: none
Pacemaker/ICD placed: none
Social History:
No tobacco or etoh history. Widowed. Lives alone; meals on
wheels and daughter helps with cooking/cleaning. Manages her
own ADL's. Worked in bank before retirement.
.
Family History:
N/A
Physical Exam:
Admission:
VITALS: Temp 98.6 BP 99/49 HR 109 SaO2 87% on RA, 96% 6L NC
GEN: ill appearing, pale and clammy
HEENT: minimally elevated JVP 2-3cm
CVS: RRR, no MRG, minimally displace PMI
RESP: mildly labored breathing, no acessory muscle use, no
crackles but dull at LLL with egophany
ABD: soft NT/ND, NABS
EXT: no edema, cold clammy, diaphoretic
Neuro: AOx2, drowsy but answering questions appropriately
.
Discharge: expired
Pertinent Results:
CXR: Cardiomegaly with moderate-to-severe pulmonary edema and
bilateral pleural effusion indicates congestive heart failure.
.
Echo: EF 25-20%
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. There is moderate to severe regional left ventricular
systolic dysfunction with septal/anterior hypokinesis/akinesis
and apical akinesis. Right ventricular chamber size is normal.
with focal hypokinesis of the apical free wall. The aortic valve
leaflets (3) are mildly thickened. There is no aortic valve
stenosis. The mitral valve leaflets are mildly thickened. Mild
(1+) mitral regurgitation is seen. There is a
trivial/physiologic pericardial effusion.
.
ABG:
[**2148-3-12**] 01:56PM BLOOD Type-ART pO2-88 pCO2-31* pH-7.32*
calTCO2-17* Base XS--8
[**2148-3-12**] 09:03PM BLOOD Type-ART FiO2-95 pO2-107* pCO2-27*
pH-7.22* calTCO2-12* Base XS--15 AADO2-568 REQ O2-90 Intubat-NOT
INTUBA
[**2148-3-12**] 10:15PM BLOOD Type-MIX pH-7.18*
[**2148-3-12**] 11:39PM BLOOD Type-ART pO2-81* pCO2-27* pH-7.17*
calTCO2-10* Base XS--17
[**2148-3-13**] 12:57AM BLOOD Type-ART pO2-94 pCO2-40 pH-7.10*
calTCO2-13* Base XS--16
[**2148-3-13**] 02:27AM BLOOD Type-ART FiO2-100 pO2-83* pCO2-30*
pH-7.20* calTCO2-12* Base XS--14 AADO2-626 REQ O2-98 -ASSIST/CON
Intubat-INTUBATED
.
Lactate
[**2148-3-12**] 01:56PM BLOOD Lactate-1.6
[**2148-3-12**] 09:03PM BLOOD Lactate-1.7
[**2148-3-12**] 10:15PM BLOOD Lactate-1.8
[**2148-3-12**] 11:39PM BLOOD Lactate-2.9*
[**2148-3-13**] 12:57AM BLOOD Lactate-2.9*
[**2148-3-13**] 02:27AM BLOOD Lactate-4.3*
.
Cardiac Enzymes
[**2148-3-12**] 02:06PM BLOOD CK-MB-49* MB Indx-15.4* cTropnT-3.31*
[**2148-3-13**] 02:11AM BLOOD CK-MB-37* MB Indx-19.3* cTropnT-3.43*
[**2148-3-12**] 02:06PM BLOOD ALT-34 AST-58* LD(LDH)-455* CK(CPK)-318*
AlkPhos-51 TotBili-0.3
[**2148-3-12**] 08:42PM BLOOD CK(CPK)-226*
[**2148-3-13**] 02:11AM BLOOD CK(CPK)-192*
.
Chem 7
[**2148-3-12**] 02:06PM BLOOD Glucose-108* UreaN-74* Creat-2.6*# Na-139
K-5.2* Cl-109* HCO3-18* AnGap-17
[**2148-3-12**] 08:42PM BLOOD Glucose-217* UreaN-81* Creat-2.8* Na-137
K-5.6* Cl-107 HCO3-11* AnGap-25*
[**2148-3-13**] 02:11AM BLOOD Glucose-258* UreaN-84* Creat-3.1* Na-140
K-6.3* Cl-106 HCO3-11* AnGap-29*
.
CBC
[**2148-3-12**] 02:06PM BLOOD Hypochr-NORMAL Anisocy-2+
Poiklo-OCCASIONAL Macrocy-1+ Microcy-NORMAL Polychr-OCCASIONAL
Ovalocy-OCCASIONAL Schisto-OCCASIONAL
[**2148-3-12**] 02:06PM BLOOD Neuts-91* Bands-1 Lymphs-5* Monos-3 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-1*
[**2148-3-12**] 02:06PM BLOOD WBC-52.7*# RBC-3.46* Hgb-11.0* Hct-33.0*
MCV-95# MCH-31.7# MCHC-33.2 RDW-15.4 Plt Ct-333
[**2148-3-13**] 02:11AM BLOOD WBC-70.1* RBC-3.60* Hgb-11.1* Hct-35.3*
MCV-98 MCH-30.9 MCHC-31.5 RDW-15.3 Plt Ct-536*#
Brief Hospital Course:
79 year old female vasculopath, IDDM with acute anterior MI, EF
20% in cardiogenic shock with pulmonary edema and leukocytosis.
.
# Cardiogenic shock: The patient was admitted from OSH diagnosed
with cardiogenic shock with BP 99/40 on levophed. Her AMI was
presumed to be completed with q waves as well as STE in V1-V4
although it was unclear if her [**Name (NI) **] had peaked. Over the course
of the next 16 hours, her CK's trended down. Because she was
initially stable, with presumed completed infarct and because of
her elevated creatinine, she was not taken for PCI immediately.
An echo was performed showing EF 20-30%, severe regional left
ventricular systolic dysfunction with septal/anterior
hypokinesis/akinesis and apical akinesis. A CXR showed
significant pulmonary edema. Echo and CXR as well as EKG and CE
c/w AMI indicated that the patient was most likely in
cardiogenic shock. She was started on a heparin drip for
anterior wall akinesis. She was also started on a lasix drip.
She was initially continued on levophed. As her mental status
and BP declined, milrinone was added to levophed. 1-2 hours
after starting milrinone her BP declined further to 80/30 with
MAP's in 40's, lactate started rising and her urine output fell
despite lasix. Milrinone and lasix were then discontinued.
Dopamine was initiated, but was soon discontinued when she
became tachycardic to HR 120's. Vasopressin was then initiated
in addition to levophed. During this time period, her pH fell
from 7.32 to 7.1 and her lactate rose from 1.6 to 4.3. As
pressors and ionotropes did not appear to be sufficient to
maintain her perfusion, it was decided to take the patient to
the cath lab for PCI and balloon pump. Initially, the family had
decided that they would be comfortable with a short trial of
aggressive measures but that the pt "did not want to live on
machines". Just prior to taking the patient to the cath lab, her
family made the decision not to pursue catheterization or a
balloon pump. They requested that she be made CMO. Pressors were
stopped. The patient died shortly thereafter.
.
# Respiratory Distress: On admission, the patient was in mild
respiratory distress and slightly hypoxic. After settingly in
and receiving morphine, the patient was comfortable on NC. A CXR
was obtained showing pulmonary edema likely [**12-23**] cardiogenic
shock. She received several lasix boluses and was then put on a
lasix drip. For several hours, she appeared relatively
comfortable, but as her mental status declined and blood
pressure fell, she became hypoxic and required increasing
amounts of oxygen and a NRB. She was also tachypnic. She
appeared to be increasing respiratory distress, with an ashen,
cyanotic appearance. Her ABG's showed a metabolic acidosis with
respiratory compensation. When her pH fell to 7.2, it was
decided to semi-electively intubate her with agreement of her
family. After she was make CMO, pressors were stopped.
Initially, the family requested that she remain intubated so
that she would not be "gasping for air". However, after seeing
the patient intubated and off pressors, they decided to have her
extubated. A morphine drip was started. Fentanyl and Versed were
discontinued. The patient was extubated and died.
.
# Leukocytosis: At the OSH, the patient's WBC was 33 with a left
shift. Her WBC count trended up from 33 to 55 to 70. Intially,
it was thought that with a leukocytosis of 33, that she could be
having an inflammatory reaction secondary to MI. There was no
evidence of infection w/o fever or focal symptoms. At the OSH,
she had been empirically started on Ceftriaxone despite normal
UA given a history of frequent UTI's. Her blood pressure and
leukocytosis remained unchanged despite Ceftriaxone. She was
re-cultured here but was not continued on any antibiotics as her
presentation was thought to be consistent with cardiogenic shock
and not concerning for sepsis. As her WBC rose, it seemed less
likely that a leukocytosis of 70 was due to AMI. A review of
the OSH records, revealed a lab report stating that there were
"rare Auer rods" suggestive of AML. A blood smear was sent, but
the patient was made CMO. After discussing the leukocytosis with
her family, they requested an autospy to evaulated for an
hematologic disturbance.
.
# Metabolic acidosis: The patient's pH fell throughout the night
from 7.31 t0 7.1 with CO2 31->27 and bicarb 18->11, AG 17->25
suggestive of an evolving mixed gap and non-gap metabolic
acidosis. Intially, she had a non-gap acidosis likely due to
acute renal failure. She was admitted on an insulin drip, but
there was no report of DKA. Her blood glucose was 120's, no
glucose or significant urine or serum ketones making DKA
unlikely. A serum beta-hydroxybutyrate level was sent, but was
pending. As perfusion decreased and lactate rose, it became
clearer that the AG metabolic acidosis was likely due to lactic
acidosis.
.
# Communication:
HCP son [**Name (NI) **]: cell [**0-0-**], home [**Telephone/Fax (1) 44790**]
Daughter: cell [**Telephone/Fax (1) 44791**], home [**Telephone/Fax (1) 44792**]
Medications on Admission:
Nifedical 50
Cozaar 50
Metoprolol 50
Asa 81
Insulin TID
Lumigan eye gtt
Alphagan eye gtt
Cosopt eye gtt
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Cardiogenic Shock
Acute Anterior Myocardial Infarction
Leukocytosis (unclear etiology)
Discharge Condition:
expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
[
"518.5",
"414.01",
"428.0",
"428.23",
"410.11",
"584.5",
"785.51",
"250.00",
"401.9",
"443.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
10617, 10626
|
5353, 10435
|
332, 357
|
10756, 10765
|
2569, 5330
|
10817, 10823
|
2106, 2111
|
10589, 10594
|
10647, 10735
|
10461, 10566
|
10789, 10794
|
2126, 2550
|
275, 294
|
385, 1621
|
1665, 1902
|
1918, 2090
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,107
| 161,958
|
8879
|
Discharge summary
|
report
|
Admission Date: [**2152-9-1**] Discharge Date: [**2152-9-5**]
Date of Birth: [**2067-11-11**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Codeine / Bactrim / IV Dye, Iodine Containing
Contrast Media
Attending:[**First Name3 (LF) 602**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Intubation [**Date range (1) 21081**]
Bronchoscopy
History of Present Illness:
The patient's history was primarily reconstructed from reports
from [**Hospital3 **] and OMR, since she arrived in
extremis. The patient has a history of COPD, CHF, atrial
fibrillation (refuses anticoagulation), history of colon cancer,
and recurrent pneumonias. The patient had been experiencing 24
hours of worsening acute repiratory distress. The patient
further experienced fever, chills, and a cough productive of
sputum. Her oxygen saturations dropped into the high 60s, so the
rehab facility did bag breathing for her overnight.
.
In the ED, the patient arrived tachypneic to the 40s, using her
accessory muscles,and saturating in the 80s. Her EKG evidently
showed sinus tachycardia. A chest X-ray demonstrated complete
opacification of the left lung. The patient had appropriate
mental status to be asked her code status; she agreed to be
intubated. The patient then nderwent rapid sequence intubation
successfully, then was sedated with propofol. During her stay in
the ED, the patient spiked a fever to 101.4; because of her
already suspected pneumonia, she was started on vancomycin,
cefepime, azithromycin. The patient has an operational power
PICC and peripheral in place for access. Her vital signs were HR
89 RR 23 stauration of 97% (ventilator settings not known), BP
101/59.
Past Medical History:
1) Diastolic congestive heart failure (NYHA class IV)
2) Atrial fibrillation (refuses coumadin)
3) Symptomatic bradycardia status post VDD pacemaker in [**11/2143**]
4) Obstructive sleep apnea (on CPAP at 8-10 cm of H2O)
5) Coronary artery disease
6) Hyperlipidemia
7) Hypertension
8) Colon cancer s/p resection
9) COPD (on O2 2-4 liters at home)
10) Bronchiectasis
11) GERD
12) Pulmonary hypertension
13) Anemia
14) Pneumonia ([**2145**])
15) Acute respiratory failure in [**3-/2144**] and again in [**3-/2145**]
16) History of methicillin resistant Staphylococcus aureus in
her
sputum following hernia repair and again in [**3-/2145**] with
documented pneumonia
.
Past surgical history:
1) Status post hernia repair.
2) Status post appendectomy.
3) Status post total abdominal hysterectomy.
4) Status post back surgery.
5) Status post right total hip
Social History:
Lives in [**Location 686**]. Worked as a printer many years ago. Not
married and does not have any children. No family in the area.
Uses a walker or wheelchair at baseline. Patient is quite
independent, and she manages her finances, cooks, and cleans
herself. She is accompanied to the supermarket. Patient quit
smoking >25 years ago. Drinks one whiskey a week. No illicit
drug use.
Family History:
Sister has endometriosis and breast cancer
Physical Exam:
Admission Physical Exam:
Vitals: T: 97.3 BP: 106/73 P: 88 R: 18
General: Intubate, sedated
HEENT: Sclera anicteric, oropharynx clear
Neck: Supple, no lymphadenopathy
Lungs: Bronchial breath sounds on left; clear on right
CV: S1, S2, no murmurs auscultated
Abdomen: Soft, non-tender, bowel sounds positive
GU: Foley catheter
Ext: Warm, well perfused, 1+ pulses
.
Discharge Physical Exam:
Vitals: T: 96.8 BP: 142/75 P: 95 R: 20 90% on 4L
General: conversant, calm
HEENT: Sclera anicteric, oropharynx clear
Neck: Supple, no lymphadenopathy
Lungs: scattered rhonchi and basilar crackles on right;
decreased breath sounds on left.
CV: RRR, S1, S2, no M/R/G
Abdomen: Soft, non-tender, bowel sounds positive
Ext: Warm, well perfused, 1+ pulses
NEURO: CN II-XII grossly intact; 4-/5 strength in right hip
flexor, otherwise 5/5 strength throughout. Sensation grossly
intact.
Pertinent Results:
[**2152-9-1**] 03:40PM BLOOD WBC-19.1*# RBC-3.65* Hgb-11.7* Hct-35.5*
MCV-97 MCH-32.0 MCHC-33.0 RDW-13.8 Plt Ct-218
[**2152-9-1**] 03:40PM BLOOD Neuts-84* Bands-3 Lymphs-9* Monos-2 Eos-1
Baso-0 Atyps-0 Metas-1* Myelos-0
[**2152-9-5**] 04:28AM BLOOD WBC-10.5 RBC-2.92* Hgb-9.1* Hct-27.3*
MCV-93 MCH-31.2 MCHC-33.4 RDW-14.5 Plt Ct-271
[**2152-9-1**] 03:40PM BLOOD Glucose-217* UreaN-17 Creat-1.0 Na-138
K-3.5 Cl-96 HCO3-25 AnGap-21*
[**2152-9-5**] 04:28AM BLOOD Glucose-101* UreaN-11 Creat-0.6 Na-144
K-4.0 Cl-110* HCO3-25 AnGap-13
[**2152-9-1**] 03:52PM BLOOD Lactate-7.0*
[**2152-9-3**] 01:49AM BLOOD Lactate-1.0
[**2152-9-1**] 04:10PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.023
[**2152-9-1**] 04:10PM URINE Blood-MOD Nitrite-NEG Protein-100
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG
[**2152-9-1**] 04:10PM URINE RBC-26* WBC-69* Bacteri-FEW Yeast-NONE
Epi-15 RenalEp-<1
MICRO:
[**2152-9-1**] 8:40 pm URINE Source: CVS.
**FINAL REPORT [**2152-9-2**]**
Legionella Urinary Antigen (Final [**2152-9-2**]):
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.
[**2152-9-1**] 6:19 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE.
GRAM STAIN (Final [**2152-9-1**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2152-9-4**]):
Commensal Respiratory Flora Absent.
SERRATIA MARCESCENS. ~1000/ML.
Piperacillin/tazobactam sensitivity testing available
on request.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
SERRATIA MARCESCENS
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
FUNGAL CULTURE (Preliminary):
YEAST.
.
IMAGING:
[**2152-9-1**] CXR - IMPRESSION: Severely limited examination secondary
to motion. Complete opacification of the visualized left
hemithorax with associated leftward mediastinal shift most
compatible with left lung collapse with possible effusion.
[**2152-9-1**] CXR (after bronch) - ETT ends 1.2 cm above the carina and
could be retracted by 1-2cm. There is improved aeration in the
left upper lobe post-bronchoscopy. Extensive parenchymal
opacities and left basal opacification persist.
[**2152-9-3**] R HIP - Again noted is severe osteoarthritis with marked
narrowing of the joint space with subchondral cyst formation,
sclerosis, and spurring. On this limited study, I see no
evidence of fracture or dislocation. Distal femoral internal
fixation rod is noted.
Brief Hospital Course:
This is an 84-year-old woman with a history of COPD,
bronchiectasis, obstructive sleep apnea, pulmonary hypertension,
and diastolic congestive heart failure admitted to the MICU with
respiratory failure requiring intubation for mucous plugging and
pneumonia.
# Respiratory failure: The patient was admitted in respiratory
distress and intubated. Based on imaging, the patient has a
pneumonia with mucus plugging that took away function of her
left lung. She was started on vancomycin and cefepime, with
added azithromycin for atypicals. The patient underwent
bronchoscopy on day of admission with suctioning of copious
secretions. After bronchoscopy, the patient's left lung showed
significant improvement on chest X-ray. The patient remained
intubated for 2 days with continued suctioning of secretions.
Secretions diminished and the patient was extubated on day 3 of
admission. Following extubation, BAL returned positive for
Serratia species. Her antibiotic coverage was narrowed to
ceftriaxone and she should continue on this antibiotic alone
until [**9-9**]. Blood cultures remained negative from [**9-1**] but were
still pending at time of discharge. She will likely need
aggressive pulmonary toilet at rehab if she were to mucous plug
again potentially including chest PT, saline neb treatments,
in/exsufflation, or nasotracheal suctioning.
# Urinary tract infection: The patient was admitted with
urinalysis suggestive of infection, with pyuria and large
leukocyte esterase. Urine culture was not checked, but given
that the patient improved clinically it is felt that the patient
likely did not have a true UTI. If the patient develops symptoms
c/w UTI a UA and urine culture should be checked.
# COPD: The patient's home regimen includes albuterol, Advair,
and tiotropium. Albuterol and ipratroprium were used in the ICU
while intubated.
# Diastolic heart failure: The patient is NYHA class III, but
with preserved ejection fraction. The patient's home
spironolactone and torsemide were held on admission given
possible sepsis picture. On day 3 of admission, the patient was
restarted on her home dose of torsemide. On discharge she was
restarted on her home dose of spironolactone.
.
# Coronary artery disease: The patient was continued on aspirin
and simvastatin therapy throughout admission
.
# Right leg pain - Chronic. However, there was new concern for
the degree of pain while the patient was intubated. Patient
underwent right hip x-ray that showed severe OA, with no
evidence of fracture or dislocation. She was started on
morphine 2mg IV q4hrs prn pain and fentanyl patch at home dose
of morphine. Pain improved.
#Code status: Full code
Medications on Admission:
1. albuterol sulfate 1.25 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation every four (4) hours as needed for shortness
of breath or wheezing.
2. azelastine 137 mcg Aerosol, Spray Sig: Two (2) sprays Nasal
twice a day.
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
sprays Nasal once a day.
5. fluticasone-salmeterol 100-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. gabapentin 400 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
7. morphine 60 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO twice a day.
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. potassium chloride 10 mEq Tablet Extended Release Sig: One
(1) Tablet Extended Release PO twice a day.
10. primidone 50 mg Tablet Sig: Two (2) Tablet PO at bedtime.
11. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Inhalation once a day.
14. torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
15. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: Two (2) Tablet, Chewable PO DAILY (Daily).
16. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
17. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
18. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. ferrous gluconate 240 mg (27 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
20. 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.
21. cefepime 1 gram Recon Soln Sig: One (1) gram Injection Q12H
(every 12 hours) for 9 days: To finish on [**2152-8-13**].
22. vancomycin 500 mg Recon Soln Sig: Five Hundred (500) mg
Intravenous Q 12H (Every 12 Hours) for 9 days: To finish on
[**2152-8-13**].
23. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
2. 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.
3. azelastine 137 mcg Aerosol, Spray Sig: Two (2) sprays Nasal
twice a day.
4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
sprays Nasal once a day.
6. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: Two (2) Tablet, Chewable PO Q 24H (Every 24 Hours).
7. Advair Diskus 100-50 mcg/dose Disk with Device Sig: One (1)
inhalation Inhalation twice a day.
8. gabapentin 800 mg Tablet Sig: One (1) Tablet PO three times a
day.
9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
10. primidone 50 mg Tablet Sig: Two (2) Tablet PO at bedtime.
11. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
12. spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a
day.
13. CeftriaXONE 1 gm IV Q24H
14. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
16. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
17. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
18. Morphine Sulfate 2-4 mg IV Q4H:PRN agitation/pain
hold for somnolence or RR<10
19. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
20. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO BID (2 times a day) as needed for agitation.
21. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
22. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
23. torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
24. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Respiratory failure requiring intubation
Mucous plugging
Serratia pneumonia
Urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to [**Hospital1 69**] for
further evaluation of respiratory distress, productive cough,
and fevers and found to have a pneumonia, mucous plugging, and a
urinary tract infection. You needed to be placed on a breathing
machine to help your breathing while your pneumonia was being
treated and needed a procedure called a bronchoscopy to help
clear out some mucous from your lungs. You will be discharged
to [**Hospital 100**] Rehab where your breathing can continue to be
monitored and you can finish your antibiotic course.
You should continue all of your previous medications in addition
to a course of IV antibiotics (ceftriaxone daily until [**2152-9-9**]).
Followup Instructions:
Please follow-up with all of your outpatient appointments listed
below:
Department: MEDICAL SPECIALTIES
When: TUESDAY [**2152-11-7**] at 10:30 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 612**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2152-12-20**] at 10:30 AM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2152-12-20**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], 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
|
[
"482.83",
"519.19",
"427.31",
"414.01",
"715.95",
"428.32",
"494.1",
"401.9",
"518.81",
"428.0",
"V10.05",
"V43.64",
"327.23",
"599.0",
"V88.01",
"530.81",
"272.4",
"V45.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"33.24",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
14662, 14728
|
7588, 10267
|
341, 394
|
14872, 14872
|
3967, 6744
|
15753, 16700
|
3020, 3065
|
12515, 14639
|
14749, 14851
|
10293, 12492
|
15048, 15730
|
2427, 2593
|
3105, 3442
|
6780, 7565
|
294, 303
|
422, 1716
|
14887, 15024
|
1738, 2404
|
2609, 3004
|
3467, 3948
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,187
| 186,869
|
22176+57289
|
Discharge summary
|
report+addendum
|
Admission Date: [**2146-7-3**] Discharge Date: [**2146-7-25**]
Date of Birth: [**2075-8-10**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Codeine / Benzodiazepines
Attending:[**First Name3 (LF) 14037**]
Chief Complaint:
fever, respiratory distress, altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
70 year-old man with history of dementia (attributed to
Korsakoff??????s syndrome, [**2-23**] prior alcohol abuse), COPD, and CHF
who was sent to the [**Hospital1 18**] ED from [**Hospital3 **] home.
Patient has had variable refusal vs. inability to talk for last
week. Seen in [**Hospital1 18**] ED on [**2146-6-22**] for agitation and subsequent
lethargy, found to be hypernatremic (Na 148). Sent back to NH
after discussion with PCP, [**Name10 (NameIs) **] [**Name11 (NameIs) 57893**] and patient, who all
thought his MS was at baseline. This morning he was found
acutely short of breath and diaphoretic with diminished
responsiveness. He was found to have a WBC count of 20, sodium
of 155, temp of 104, and a heart rate of 150. In the emergency
department, initial attempts at LP and head CT were not
successful given the agitation of the patient. On prior
admissions, he had been sedated, but on one occasion, suffered
respiratory failure as a result, and was therefore not sedated
on this presentation for this reason. He was given 2 grams of
CTX IV for meningitis dosing, as well as one gram of IV
vancomycin. His heart rate slowed to approx. 110 with removal of
restraints, and when allowed to rest. He was subsequently LP'd.
The 3rd and 4th tubes were notable for xanthochromia.
Past Medical History:
1. Organic personality disorder with negative head CT in [**4-25**]
2. Dementia/Korsakoff's psychosis (attributed to history of
alcohol abuse), with agitation and hallucinations
3. COPD: on chronic predisone 5mg tid, s/p previous intubation
in the setting of percocet OD
4. CAD
5. CHF: EF 70%, chronic bilaterally LE edema
6. Hyptertension
7. Gastroesophageal Reflux Disease
8. H/O VRE (per OMR records)
9. Urinary incontinence
Social History:
Lives in [**Hospital3 **] home in [**Location (un) 583**]. History of
percocet overdose and severe alcohol abuse.
Family History:
Unknown
Physical Exam:
VS: Tm: 104.8 Tc: 102.6 HR 99 BP 134/91 RR 27 SaO2
95% 2L NC
General: elderly man, agitated, moaning, not verbally
responsive, though does react to voices and pain
HEENT: PERRL, bilateral scleral injection with greenish
exudates on R, MM dry
Chest: Rose and fell with equal size, shape and symmetry,
decreased breath sounds throughout, no rales or wheezes
Cardiac: tachycardic, regular rhythm, crisp S1 and S2
Abd: soft, no rebound or guarding, nontender to palpation
Ext: no cyanosis, clubbing or edema, radial and DP pulses
palpable bilaterally
Skin: No lesions, rashes or discoloration
Neuro: Not verbally responsive, tardive dyskinesias of
tongue/mouth, moving all 4 extremities equally, withdraws to
pain, toes downgoing bilaterally
Pertinent Results:
[**2146-7-3**] 08:45AM BLOOD WBC-19.9* RBC-5.34 Hgb-15.1 Hct-47.1
MCV-88 MCH-28.3 MCHC-32.2 RDW-15.0 Plt Ct-340
[**2146-7-6**] 06:21AM BLOOD WBC-8.9 RBC-4.19* Hgb-12.4* Hct-37.1*
MCV-89 MCH-29.6 MCHC-33.4 RDW-15.1 Plt Ct-223
[**2146-7-8**] 12:18PM BLOOD WBC-14.7*# RBC-4.13*# Hgb-12.1*#
Hct-35.3* MCV-86# MCH-29.3 MCHC-34.2# RDW-15.1 Plt Ct-256
[**2146-7-4**] 06:36AM BLOOD Neuts-85.9* Lymphs-10.6* Monos-3.4
Eos-0.1 Baso-0.1
[**2146-7-4**] 06:36AM BLOOD PT-13.9* PTT-25.9 INR(PT)-1.3
[**2146-7-3**] 08:45AM BLOOD Glucose-139* UreaN-34* Creat-2.4*#
Na-155* K-4.0 Cl-117* HCO3-20* AnGap-22*
[**2146-7-4**] 09:50AM BLOOD Glucose-130* UreaN-25* Creat-0.9 Na-153*
K-3.6 Cl-124* HCO3-14* AnGap-19
[**2146-7-8**] 04:04AM BLOOD Glucose-130* UreaN-16 Creat-0.6 Na-142
K-3.0* Cl-112* HCO3-22 AnGap-11
[**2146-7-3**] 12:20PM BLOOD CK(CPK)-254*
[**2146-7-6**] 07:55PM BLOOD CK(CPK)-1602*
[**2146-7-7**] 06:08AM BLOOD CK(CPK)-1287*
[**2146-7-6**] 07:55PM BLOOD CK-MB-13* MB Indx-0.8 cTropnT-0.04*
[**2146-7-7**] 06:08AM BLOOD CK-MB-13* MB Indx-1.0 cTropnT-0.02*
[**2146-7-3**] 08:45AM BLOOD Albumin-4.2 Calcium-9.8 Phos-1.7*# Mg-1.7
[**2146-7-5**] 05:50AM BLOOD Calcium-8.5 Phos-2.2* Mg-1.9
[**2146-7-8**] 04:04AM BLOOD Calcium-8.0* Phos-2.4* Mg-2.2
[**2146-7-3**] 09:23AM BLOOD Type-ART Rates-/30 FiO2-10 pO2-123*
pCO2-29* pH-7.40 calHCO3-19* Base XS--4 Intubat-NOT INTUBA
Vent-SPONTANEOU
[**2146-7-7**] 08:45AM BLOOD Type-ART pO2-74* pCO2-24* pH-7.50*
calHCO3-19* Base XS--2
##
CXR [**7-3**]:
Probable left lower lobe opacity. Please obtain lateral view for
complete evaluation.
##
CXR [**7-6**]:
Compared with [**2146-7-4**], there is no evidence of CHF. The lungs
now appear grossly clear of active infiltrates.
.
GRAM STAIN (Final [**2146-7-19**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Final [**2146-7-21**]):
OROPHARYNGEAL FLORA ABSENT.
STAPH AUREUS COAG +. MODERATE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # 190-6941G
[**2146-7-18**].
Brief Hospital Course:
70 year-old man with history of dementia (attributed to
Korsakoff??????s syndrome, [**2-23**] prior alcohol abuse), COPD, and CHF
initially presented to [**Hospital1 18**] ED [**7-3**] from [**Hospital3 **]
home. He initially had been found to have WBC count of 20, Na of
155, T 104, HR 150; also found acutely short of breath and
diaphoretic and minimally responsive. In the emergency
department, initial attempts at LP and head CT were unsuccessful
given the patient's agitation. He was given 2 grams of CTX IV
for meningitis dosing, as well as one gram of IV vancomycin. His
heart rate slowed to approx. 110 with removal of restraints, and
when allowed to rest. He was subsequently LP'd 2 hrs after Abx
were given.
.
The patient's mental status improved somewhat over his stay on
the medical floor as his sodium trended downward to 145 with
free water repletion. He was treated empirically for an
aspiration PNA (seen on CXR) with levo/flagyl and his
temperatures subsequently decreased to 99. The MICU was
consulted originally for muscle rigidity and an elevated CK of
1287. He continued to complain of dyspnea with hypoxia. He was
transferred to the MICU [**7-7**] for concern of Neuroleptic
Malignant Syndrome and for nursing issues.
.
In the MICU, the patient's fever curve and respiratory status
were observed. Psychiatry was consulted and did not feel that
the etiology of his fevers was secondary to NMS as he had been
tapered on haldol and then stopped prior to admission and fevers
and that his mental status improved on the floor while off all
neuroleptics. Recommended treating agitation with Zyprexa. His
hypoxia was stable with chest X-rays that revealed no
cardiopulmonary disease. His metronidazole was discontinued and
his levofloxacin continued. His mental status remained stable,
alert but groaning and minimally responsive.
.
The patient was called out to the floor on [**2146-7-9**], where he
continued to be hypoxic with a slightly decreasing pO2 (from 62
to 56). He spiked a fever to 103.6. His metronidazole was
restarted. Given a concern for PE, a femoral line was placed and
CTA performed which revealed no PE and stable RLL infiltrate.
On the floor he continued to be tachynpneic and grunting while
awake. He was sent back to the MICU on [**2146-7-12**], for
"respiratory distress" and nursing.
.
Neurology saw the patient on his second transfer to the MICU and
felt that his history of his med exposures was not consistent
with NMS. Their impression was that his encephalopathy was more
likely toxic-metobolic, due to a combination of pneumonia and
hypoxia, (and perhaps recent increase in steroids). Recommended
stopping Zyprexa as it can cause extrapyramidal side effects and
restarting Seroquel (as patient had been treated with it prior
to admission). His respiratory distress was felt to be more
likely psychiatric in origin, as he improved while sleeping and
his symptoms did not seem to be related to his level of hypoxia.
A TTE revealed R to L shunting and mild pulm HTN. Chest CT was
negative for AVM's. He was called out to the floor on [**7-15**]. An
NG tube was placed for tube feedings and medications. He was
transitioned from Zyprexa to Seroquel and trazadone for
agitation, with the reasoning that his respiratory status would
improve once he was back on his full psych regimen. On
transfer, his mental status had improved. He was intermittently
yelling and moaning, but could also respond to questions and
have conversations.
.
While on the floor, pt's mental status seemed to slowly return
to the baseline initially, but then his agitation continued to
increase as he tried to pull out iv lines, NGT and facial mask
for O2 supplement, requiring almost constant nursing care.
Finished a course of Flagyl and levofloxacin for pneumonia but
his WBC continued to trend up. Sputum cx was obtained which grew
moderate MRSA. Vanco 1g [**Hospital1 **] thus was started and WBC started to
trend down. However, pt continued to be tachypneic with
increased work of breathing and decreasing O2 sats which was
believed to be related with his psych problems and constantly
pulling his facial mask. Pt continued to be more agitated,
pulling his NGT and refusing another NG replacement, requiring
constant nursing care. Swallowing evaluation consulted, and pt
failed profoundly. After talking with the pt, pt wished no more
aggressive treatment including PEG or NGT but wanted to be fed
and be comfortable. At this point, his guardian and family were
called to have a family meeting to discuss about code status and
whether to continue aggressive treatment. At the meeting,
everybody agreed that it's best for pt to keep him comfortable
as he wished and changed his code status to DNR/DNI. A
palliative care nurse was notified, and she gave appropriate
counseling to pt's guardian and family. All aggresive
treatments including vanco, solumedrol, prophylactic meds were
discontinued as well as checking labs. Pt was started on
morphine drip, ativan, and haldol for comfort and delirium. At
pt's wish, also started full liquid puree diet as pt tolerated,
and the guardian and family members agreed.
Medications on Admission:
quetiapine (Seroquel) 100 [**Hospital1 **]
buspirone (BuSpar) 20 [**Hospital1 **]
gabapentin (Neurontin) 100 TID
metoprolol (Lopressor) 25 TID
montelukast (Singulair) 10mg QD
haloperidol (Haldol) stopped [**2146-7-1**]
ipratropium (Atrovent) MDI
albuterol MDI
fluticasone (Flovent) 110 [**Hospital1 **]
salmeterol (Serevent)
prednisone ?15mg QOD
aspirin 325 mg daily
potassium chloride 20 mEq daily
trazadone 100 mg QHS and 50 QID:PRN
pantoprazole (Protonix) 40 mg [**Hospital1 **]
furosemide (Lasix) 20 mg QD (since [**6-22**], on 40mg QD prior)
Discharge Medications:
1. Morphine 10 mg/mL Solution Sig: Two (2) mg Intravenous q2hr:
via CADD pump through PICC line.
Disp:*20 vials* Refills:*2*
2. Morphine 10 mg/mL Solution Sig: One (1) mg Intravenous q15
min: via CADD through PICC line for pain or shortness of breath.
Disp:*20 vials* Refills:*2*
3. medicine
Haldol Gel 4mg/ml
Sig: apply 4mg TD q6 hrs.
Dispense: q.s for 1 week
Refill: 2
4. Scopolamine Base 1.5 mg Patch 72HR Sig: One (1) Transdermal
q72hrs/prn as needed for secretions.
Disp:*10 patches* Refills:*3*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 57894**] Home - [**Location (un) **]
Discharge Diagnosis:
1. MRSA aspiration pneumonia
2. Dementia
3. CHF
4. COPD
5. CAD
6. HTN
7. GERD
Discharge Condition:
Fair
Discharge Instructions:
O2 via nasal cannula for comfort.
Oral suction as needed for secretion.
Followup Instructions:
With your PCP as needed
Name: [**Known lastname 10766**],[**Known firstname **] Unit No: [**Numeric Identifier 10767**]
Admission Date: [**2146-7-3**] Discharge Date: [**2146-7-25**]
Date of Birth: [**2075-8-10**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Codeine / Benzodiazepines
Attending:[**First Name3 (LF) 4709**]
Addendum:
With his guardian's agreement, pt was scheduled to be discharge
to [**Hospital6 10768**] Home for hopice care on [**2146-7-23**]. However,
given pt's Nasal MRSA screen (prelim) came back positive for
moderate growth of S. aureus for MRSA, he required a single room
at the nursing home. However, there was no single room available
at the nursing home at that time, so pt stayed in the hospital,
waiting on placement. The patient was kept comfortable with
morphine drip, ativan, suctioning of secretions, oxygen, and
haldol for comofort the until the night he expired on [**2146-7-25**].
The patient was discharged to home (to family) and NOT to [**Hospital 10769**] Home, so please disregard what's written on
discharge dispositon and facility.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 10768**] Home - [**Location (un) 4415**]
Discharge Diagnosis:
1. Methicillin resistant Staph aureus aspiration pneumonia
2. Dementia
3. Congestive heart failure
4. Chronic obtructive pulmonary disease
5. Coronary artery disease
6. Hypertension
7. Gastroesophageal reflux disease
Discharge Condition:
Expired
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4710**] MD [**MD Number(1) 4274**]
Completed by:[**2146-9-3**]
|
[
"584.9",
"496",
"428.30",
"428.0",
"530.81",
"V09.0",
"276.0",
"401.9",
"294.8",
"276.2",
"507.0",
"482.41",
"294.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"03.31",
"00.14",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
12990, 13070
|
5214, 10370
|
351, 357
|
13331, 13496
|
3075, 5191
|
11820, 12967
|
2273, 2282
|
10967, 11473
|
13091, 13310
|
10396, 10944
|
11724, 11797
|
2297, 3056
|
261, 313
|
385, 1674
|
1696, 2125
|
2141, 2257
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,042
| 192,603
|
36811
|
Discharge summary
|
report
|
Admission Date: [**2166-6-27**] Discharge Date: [**2166-7-1**]
Date of Birth: [**2100-2-5**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
Cerebellar Mass
Major Surgical or Invasive Procedure:
[**6-29**]: Stereotactic 3rd Ventriculostomy
History of Present Illness:
66 yo female w/ PMHx sig for metastatic uterine sarcoma, breast
ca s/p R mastectomy who presents with two days of dizziness and
double vision found to have a large enhancing right cerebellar
mass and smaller enhancing cortical lesions on brain MRI. The
patient has noticed double vision over the last two
days as well as unsteadiness with falling to the right. She
called her oncologist and went to an PSH where imaging revealed
her new CNS metastases. She was given a dose of Decadron and
transferred to [**Hospital1 18**] for further management.
Past Medical History:
R breast ca s/p mastectomy '[**45**], [**Last Name (un) **] (s/p mastectomy in
[**2155**]), uterine sarcoma with mets to abdomen and probably lung
s/p
TAH, XRT, and currently treated with chemotherapy, hx
cryptogenic
organizing pneumonitis
Social History:
widowed, former ppd x 34 years quit four years ago. occ ETOH.
Family History:
Non-contributory
Physical Exam:
On Admission:
Vitals: T 97.7; BP 147/93; P 81; RR 16;
General: lying in bed NAD
HEENT: NCAT, moist mucous membranes
Neck: supple
Pulmonary: CTA b/l
Cardiac: regular rate and rhythm, with no m/r/g
Carotids: no blood flow murmur
Abdomen: soft, nontender, non distended, normal bowel sounds
Extremities: no c/c/e.
Neurological Exam:
Mental status: Awake, alert, attentive. Fluent speech with no
paraphasic errors. Adequate comprehension. Follows
simple and multi-step commands.
Cranial Nerves:
I: Not tested
II: PERRL, 4-->2mm with light.
III, IV, VI: EOMI. no nystagmus.
V, VII: facial sensation intact, facial strength
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: SCM [**6-3**]
XII: Tongue midline without fasciculations.
Motor: Normal bulk. Normal tone. No pronator drift.
Delt Tri [**Hospital1 **] WE WF FE FF IP QD Ham DF PF [**Last Name (un) 938**] EDB
C5 C7 C6 C8 L2 L3 L4-S1 L4 L5 L5
RT: 5 5 5 5 5 5 5 5 5 5 5 5 5 5
LEFT: 5 5 5 5 5 5 5 5 5 5 5 5 5 5
Sensation: intact light touch.
Reflexes: Bic T Br Pa Ac
Right 2 2 2 2 2
Left 2 2 2 2 2
Toes downgoing bilaterally.
Coordination: R sided dysmetric on FNF, heel to shin intact.
Exam on Discharge:
Alert, oriented to person, place and date. PERRL. Full strength
and power throughout upper and lower extremities. There is a
slight right sided pronator drift noted. Wound is clean dry and
intact without erythema/drainage
Pertinent Results:
Labs on Admission:
[**2166-6-27**] 01:00AM BLOOD WBC-24.0* RBC-3.25* Hgb-10.0* Hct-30.6*
MCV-94 MCH-30.8 MCHC-32.7 RDW-19.4* Plt Ct-379
[**2166-6-27**] 01:00AM BLOOD Neuts-89* Bands-3 Lymphs-4* Monos-1*
Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-1* NRBC-1*
[**2166-6-27**] 01:00AM BLOOD Hypochr-NORMAL Anisocy-1+
Poiklo-OCCASIONAL Macrocy-1+ Microcy-OCCASIONAL
Polychr-OCCASIONAL Ovalocy-OCCASIONAL Stipple-OCCASIONAL
[**2166-6-27**] 11:51AM BLOOD Hypochr-OCCASIONAL Anisocy-2+ Poiklo-1+
Macrocy-2+ Microcy-NORMAL Polychr-1+ Ovalocy-OCCASIONAL
Stipple-1+ Tear Dr[**Last Name (STitle) 833**]
[**2166-6-27**] 01:00AM BLOOD PT-13.1 PTT-20.2* INR(PT)-1.1
[**2166-6-27**] 01:00AM BLOOD Glucose-166* UreaN-9 Creat-0.7 Na-140
K-4.8 Cl-104 HCO3-23 AnGap-18
[**2166-6-27**] 01:00AM BLOOD Calcium-9.6 Phos-4.4 Mg-2.1
Labs on Discharge:
[**2166-7-1**] 05:20AM BLOOD WBC-18.6* RBC-3.21* Hgb-10.1* Hct-30.5*
MCV-95 MCH-31.4 MCHC-33.1 RDW-18.9* Plt Ct-389
[**2166-7-1**] 05:20AM BLOOD PT-12.5 PTT-20.8* INR(PT)-1.1
[**2166-7-1**] 05:20AM BLOOD Glucose-148* UreaN-27* Creat-0.9 Na-139
K-4.7 Cl-103 HCO3-24 AnGap-17
[**2166-7-1**] 05:20AM BLOOD Calcium-9.3 Phos-3.5 Mg-2.2
Imaging:
CT Chest/Abdomen/Pelvis [**6-28**]:
TECHNIQUE: MDCT axial images were obtained from the thoracic
inlet to the
symphysis pubis with the administration of IV contrast. Coronal
and sagittal reformations were obtained.
CT OF THE CHEST WITH IV CONTRAST: The heart and pericardium are
unremarkable, without pericardial effusion. Few scattered
mediastinal lymph nodes are not pathologically enlarged. The
great vessels are within normal limits. Minimal atherosclerotic
coronary artery calcifications are noted. There is centrilobular
emphysema, with numerous bilateral metastatic lesions scattered
throughout the lungs. There is a mass in the right upper lobe
which measures 7.1 cm x 5.9 cm (3:18), that is heterogeneous in
appearance, with areas of necrosis. The largest lesion in the
right lower lobe is a bilobed mass or two adjacent masses, which
measure approximately 5.4 cm x 4.0 cm. The largest lesion in the
left lower lobe (3:29) measures 2.8 cm x 2.4 cm, and the largest
lesion in the left upper lobe measures 2.2 cm x 1.9 cm. No
pleural effusion or pneumothorax is identified.
CT OF THE ABDOMEN WITH IV CONTRAST: The liver is diffusely low
in
attenuation, consistent with fatty infiltration. There are
scattered rounded hypodensities in the right lobe, with an
exophytic lesion arising from the inferior right lobe (3:68),
measuring 2.2 cm, suspicious for a metastatic lesion. The
gallbladder, spleen, pancreas, and left adrenal gland are
normal. The kidneys demonstrate slightly lobulated contours,
which could reflect sequela from prior insult, but are otherwise
unremarkable. There is a heterogeneous lobulated large mass
arising from the right adrenal gland which measures 8.4 cm
craniocaudad x 5.0 cm transverse. Additional heterogeneous
masses are seen within the periportal region, with a mass
measuring approximately 3.0 cm x 2.8 cm (3:62). The stomach,
small bowel, and large bowel are unremarkable. Adjacent to the
stomach antrum in the peritoneal fat is a lobulated irregular
mass, which
measures approximately 5.4 cm x 6.0 cm (3:70). There are
scattered nodules
throughout the peritoneum, with one adjacent to the transverse
colon (3:56) measuring 9 mm, as well as irregular mass posterior
to the right psoas muscle (3:70) measuring 3.0 cm x 1.9 cm. No
free air or free fluid is identified.
CT OF THE PELVIS WITH IV CONTRAST: The urinary bladder and
rectum are
unremarkable. Patient is status post hysterectomy. There is an
irregular
hypodense lesion in the expected location of the right adnexa
(3:96), which measures 2.7 cm x 2.6 cm. This could reflect the
right ovary. Alternatively, this could represent a metastatic
lesion. No pelvic free fluid or adenopathy is identified.
OSSEOUS STRUCTURES: There are diffuse osseous metastases, with
scattered
sclerotic foci seen within the pelvis as well as scattered
throughout the
vertebral column (predominantly thoracic). Additionally, there
are wedge
compressions at the T7 and T8 vertebral bodies, of uncertain
chronicity.
Sclerotic foci are also present within bilateral ribs,
compatible with
metastatic lesions. Incompletely assessed sclerotic focus also
seen in the
right humeral head.
IMPRESSION:
1. Widespread metastatic disease, including innumerable
bilateral pulmonary masses, as well as probable hepatic lesion,
right adrenal mass, and nodules/masses scattered throughout the
peritoneum and mesentery.
2. Diffuse sclerotic osseous metastasis with wedge compressions
of T7 and T8 of uncertain chronicity.
MRI Head [**6-30**]:
Comparison is made with MRI performed at [**Hospital 1474**] Hospital on
[**2166-6-26**].
FINDINGS:
There is a tract in the right frontal lobe relating to recent
3rd
ventriculostomy. Multiple enhancing supra- and infratentorial
lesions are
stable including a large lesion in the right cerebellum with
significant mass effect on the fourth ventricle. Some of the
lesions appear to be
leptomeningeal, particularly in the left frontal lobe.
The ventricles are stable in size and configuration. There is a
small amount of pneumocephalus. There is no evidence for acute
ischemia. There is suggestion of multiple calvarial enhancing
lesions which could represent metastatic disease.
IMPRESSION:
Changes from right frontal craniotomy reportedly for a third
ventriculostomy. Unchanged intracranial metastatic disease
including the largest lesion in the right cerebellum with
significant mass effect on the fourth ventricle. There is
ventriculomegaly which is unchanged.
Brief Hospital Course:
66F who presented with diplopia and vertigo, with PMH of known
significant metastatic disease. Head CT was done with revealed
intracranial pathology. She was then taken to the Operating
room for CSF diversion procedure. Post-operatively she was
monitored overnight in the ICU. She was transferred out of the
ICU to NSURG floor on [**6-30**] with an intact neurological
examination. Palliative care was also consulted to assist the
disposition planning with her family. Patient had previously had
oncologic treatment in [**Last Name (LF) 1474**], [**First Name3 (LF) **] plans for further
treatment(to include WBR) we also arranged in [**Hospital1 1474**]. She was
seen on [**6-30**] by PT and they determined that she would be
appropriate for discharge to home with physical therapy. She
was discharged as such on [**7-1**], with follow up appointments
scheduled with Dr. [**Last Name (STitle) 83168**] and instructions to be in touch with
Dr.[**Name (NI) 12757**] office for surgical follow up. She was also given
a CD of the images performed during this hospitalization.
Medications on Admission:
omeprazole 40mg, bactrim SS q day, Fosamax q week, Prednisone 15
mg q day, Feosol 300 mg q day.
Discharge Medications:
1. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*120 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*30 Capsule(s)* Refills:*0*
3. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Cerebellar and right cortical brain mass
Discharge Condition:
Neurologically Stable
Discharge Instructions:
General Instructions/Information
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair 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 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?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office in [**8-8**] days (from your date of
surgery) for removal of your sutures and a wound check. This
appointment can be made with the Nurse Practitioner. Please
make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite
a distance from our office, please make arrangements for the
same, with your PCP.
??????An appointment has been made for you with your prior
oncologist, Dr. [**Last Name (STitle) 65126**], for [**7-8**], at 10:30am. Their address
is: [**Hospital1 **] [**Hospital1 **], [**Numeric Identifier 60185**]. Phone: ([**Telephone/Fax (1) 83169**]
Fax: [**Telephone/Fax (1) 83170**].
Completed by:[**2166-7-1**]
|
[
"197.7",
"198.5",
"V10.42",
"745.5",
"348.4",
"197.0",
"V10.3",
"496",
"197.6",
"198.3",
"198.7",
"331.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"02.2"
] |
icd9pcs
|
[
[
[]
]
] |
10333, 10388
|
8518, 9598
|
333, 380
|
10473, 10497
|
2869, 2874
|
12252, 12967
|
1323, 1341
|
9745, 10310
|
10409, 10452
|
9624, 9722
|
10521, 12229
|
1356, 1356
|
1688, 1688
|
278, 295
|
3690, 8495
|
408, 961
|
1853, 2607
|
2626, 2850
|
2888, 3671
|
1703, 1837
|
983, 1225
|
1241, 1307
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,388
| 157,998
|
50578
|
Discharge summary
|
report
|
Admission Date: [**2185-7-29**] Discharge Date: [**2185-8-8**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1561**]
Chief Complaint:
malignant pleural effusion
Major Surgical or Invasive Procedure:
L video-assisted thoracoscopy and talc pleurodesis
History of Present Illness:
The patient is a delightful 93- year-old woman who was recently
diagnosed with stage 3A lung cancer. This was diagnosed and
treated with a vats wedge node
dissection. We elected not to treat her with postoperative
adjuvant therapy. She has recently developed dyspnea and was
found to have a left pleural effusion which on aspiration
demonstrated malignancy. She subsequently recurred with dyspnea
and therefore we admitted her for talc pleurodesis.
Past Medical History:
PMHX:
1) CAD s/p anterior wall MI - stent in OM1 in '[**78**]
2) Ischemic cardiomyopathy with EF 35%
3) Pacemaker for sick sinus syndrome
4) HTN
5) TIAs
6) DVTs
7) osteoporosis; thoracic compression fracture.
8) small cell lung ca (dx [**4-14**]; wide resection; decision against
chemo)
Social History:
.
SOCIAL HISTORY: She had been a one to one and a half pack a day
smoker for 15 years, but she quit 50 years ago. Denies ETOH.
She has been quite active and continued to swim at least up
through the recent
problem.
Family History:
.
FMH: sister with breast cancer. + CAD
Physical Exam:
NAD
RRR
decreased lung sounds on left, CTA-R
s/nt/nd
no c/c/e
Pertinent Results:
[**2185-7-29**] 06:10PM BLOOD Glucose-95 UreaN-21* Creat-0.9 Na-135
K-4.9 Cl-93* HCO3-35* AnGap-12
[**2185-8-2**] 12:50PM BLOOD Glucose-106* UreaN-38* Creat-2.2* Na-133
K-5.2* Cl-101 HCO3-26 AnGap-11
[**2185-8-6**] 05:15AM BLOOD Glucose-85 UreaN-28* Creat-0.9 Na-141
K-4.7 Cl-107 HCO3-26 AnGap-13
Brief Hospital Course:
Ms. [**Known lastname 12163**] went to the OR under the care of Dr. [**Last Name (STitle) 952**].
Please see his operative note for detail. On POD #1, it was
noted that Ms. [**Known lastname 12163**] had low urine output. She had lost IV
access and was unable to receive IV fluids. A left subclavian
central line was placed. Her creatinine was 1.6, indicating
that she was in acute renal failure, likely secondary to a
pre-renal state given a FeNa of <1%. She was given IV hydration
but continued to fail to produce any urine. By POD #2, she was
averaging only 0-5cc/hour overnight. She was transferred to the
ICU for placement of a Swan-Ganz to assess fluid status and
closer monitoring. Finally, Ms. [**Known lastname 12163**] received and responded
to Lasix to increase her urine output. Her anterior left chest
tube was pulled on POD #3.
A renal consult was also obtained and followed Ms. [**Known lastname 12163**]
closely.
Her posterior left chest tube was pulled on POD #4 and she was
transferred to the floor in stable condition. The remainder of
her hospital course was uneventful. Her central line was pulled
on POD#7/ By the time of discharge on on POD #8, she was
tolerating a regular diet, had good urine output with a normal
creatinine, and had good pain control.
She was discharged to rehab in good condition.
Medications on Admission:
Lipitor 20mg po daily
Fosamax 35mg qweek
Flonase
Lisinopril 10mg po daily
Discharge Medications:
1. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
Disp:*90 Tablet, Chewable(s)* Refills:*2*
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Vicodin 5-500 mg Tablet Sig: One (1) Tablet PO every [**3-16**]
hours.
Disp:*30 Tablet(s)* Refills:*2*
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*60 Tablet(s)* Refills:*0*
8. Alendronate 35 mg Tablet Sig: One (1) Tablet PO QFRI (every
Friday).
Disp:*4 Tablet(s)* Refills:*2*
9. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
mL Injection TID (3 times a day).
Disp:*90 mL(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 30191**] - [**Location (un) 22287**]
Discharge Diagnosis:
acute renal failure
recurrent malignant pleural effusion
s/p L VATS/talc pleurodesis [**7-15**]
small cell lung CA
s/p LLL wedge resection [**4-14**]
CAD s/p MI (EF 35%)
osteoporosis
HTN
TIAs
Discharge Condition:
Stable
Discharge Instructions:
If you have difficulty breathing, chest pain, persistent
nausea/vomiting, fevers/chills, or redness/oozing at incision
sites, Call Dr.[**Name (NI) 1816**] office [**Telephone/Fax (1) 170**].
Followup Instructions:
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 15108**], MD Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2185-8-30**] 11:00
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Where: CLINICAL CTR. - 9TH FL.
THORACIC SURGERY Date/Time:[**2185-8-30**] 11:30
Completed by:[**2185-8-8**]
|
[
"V10.11",
"584.9",
"414.8",
"401.9",
"V45.01",
"V45.82",
"733.00",
"424.0",
"197.2",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.92",
"89.64",
"38.93",
"34.09"
] |
icd9pcs
|
[
[
[]
]
] |
4378, 4454
|
1854, 3195
|
302, 355
|
4690, 4699
|
1533, 1831
|
4938, 5317
|
1395, 1436
|
3319, 4355
|
4475, 4669
|
3221, 3296
|
4723, 4915
|
1451, 1514
|
236, 264
|
383, 834
|
856, 1144
|
1179, 1379
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,047
| 118,573
|
32158
|
Discharge summary
|
report
|
Admission Date: [**2153-11-29**] Discharge Date: [**2154-1-10**]
Date of Birth: [**2079-7-17**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Trovafloxacin / Albuterol
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
nausea
Major Surgical or Invasive Procedure:
CABG x3 (SVG>LAD, SVG>DIAG, Y from diag >Distal Cx) with open
chest [**11-29**], closed chest [**12-3**]
History of Present Illness:
74 yo F s/p recent stent placement. Plavix was dc'd after she
developed a GI bleed. She developed nausea on [**11-29**]. She ruled in
for STEMI at OSH and was taken to cath lab, where she coded on
the table.
Past Medical History:
CAD with ostial LCX 90% lesion per cath on [**2153-8-8**] with
successful BMS
HTN
Hyperlipidemia
CVA 4 yrs ago with R scotoma
esophageal ulcer.
+ GERD
+ Asthma/Emphysema, home O2 not required
osteoporosis
R carpal tunnel surgery
.
Cardiac Risk Factors: - Diabetes, + Dyslipidemia, + Hypertension
.
Cardiac History: CABG: NONE
.
Percutaneous coronary intervention, in [**8-4**] anatomy as follows:
One vessel CAD with 90% ostial LCx stenosis s/p BMS
.
Pacemaker/ICD: NONE
Social History:
Patient lives with husband in [**Name (NI) 487**]. Quit smoking 11 yrs
ago, smoked 1ppd since age 14. Social EtOH, no recreational
drugs
Family History:
Family history is significant for mother who died from
alcoholism at age 50. Father died at age 62 of unknown cause.
No early death.
Brief Hospital Course:
IABP was placed in the cath lab. She was taken emergently to the
operating room where she underwent a CABG x 3. While in the
operating room she also underwent endoscopy which showed
esophagitis, clotted blood and duodentitis, but no active
bleeding, and her right femoral vein was repaired. She was
transferred to the ICU with her chest open on milrinone,
epinephrine, levophed, vasopressin and amiodarone. She was given
vanocmycin perioperatively for her open chest. Her pressors were
weaned slowly. She was seen by ID to evaluate need for
antibiotics. She was taken back to the operating room on [**12-3**]
where her chest was closed. HIT antibody was negative. IABP was
weaned and removed and epi was weaned to off on [**12-4**]. Her
ventilator was weaned but she had no cuff [**Last Name (LF) 3564**], [**First Name3 (LF) **] she remained
intubated, was given steroids, and was extubated to BiPAP on
[**12-6**]. She developed serous sternal drainage, and remained on
vancomycin. She developed atrial fibrillation and was started on
amiodarone and coumadin. She developed a small area of necrosis
at the distal end of her incision. She developed a fever,
increased white count and hypotension, her antibiotic coverage
was broadened to vanco and zosyn and her sternal incision was
opened and packed at the distal end. She was restarted on
levophed. A line tip culture grew yeast and she was started on
fluconazole. She was seen by opthamology and there were no signs
of fungal eye infection. A VAC dressing was placed to her
sternal wound. On [**12-14**] she fell after attempting to get out of
bed herself. Head CT was negative. She continued to require
BiPAP. A dobhoff was placed for tube feeding. Sternal wound grew
[**Female First Name (un) **]. On [**12-19**] she was reintubated for respiratory failure and
left lung collapse. Bronchoscopy showed mucous plug in left main
bronchus. She was again extubated to BiPap on [**12-21**]. She again
required` intubation but refused despite repiratory distress.
She eventually agreed to bronchoscopy on [**12-24**] which showed
malacia and tenacious secretions that plugged bronchoscope, and
she required intubation to clear secretions. During intubation
her blood pressure dropped and she lost her pulse. She was
resuscitated. She failed spontaneous breathing trial.
Thoracentesis on [**12-28**] for 1 liter serosnaguinous fluid. Seen by
thoracic surgery for ? of hemothorax. Chest tube was placed for
400 cc old blood. Tracheostomy and PEG tube placed on [**1-4**]. She
was started on a lasix drip and then transitioned to IV laasix
and zarozolyn. Bronchoscopy on [**1-8**] ahowed thick clear
secretions bilaterally. BAL sent at that time gram stain
negative. Patient was changed back to pressure support
ventilation after bronchoscopy. She remained hemodynamically
stable and on [**1-10**] was transferred to rehab at [**Last Name (un) 8612**] in
[**Location (un) **].
Medications on Admission:
actonel 35 qwk, advair 500/50", ASA 325', Cardizem 360',
Clarinex 5 prn, coumadin stopped, clonazepam 0.5 prn, iron 325',
fish oil 1200', neurotin 300", lipitor 80', lunesta 3',
olmesartan-HCTZ 1 tablet', omprazole 20', plavix stopped,
primidone 50', Spiriva 2p', Toprol xl 25', Xopenex 1p", vit E
Discharge Medications:
1. Acetaminophen 325 mg Tablet [**Location (un) **]: 1-2 Tablets PO every six (6)
hours as needed for temperature >38.0.
2. Docusate Sodium 100 mg Capsule [**Location (un) **]: One (1) Capsule PO BID (2
times a day).
3. Atorvastatin 80 mg Tablet [**Location (un) **]: One (1) Tablet PO HS (at
bedtime).
4. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [**Location (un) **]: [**11-28**]
Drops Ophthalmic PRN (as needed).
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Month/Day (2) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
6. Magnesium Hydroxide 400 mg/5 mL Suspension [**Month/Day (2) **]: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
7. Chlorhexidine Gluconate 0.12 % Mouthwash [**Month/Day (2) **]: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
8. Ferrous Sulfate 300 mg/5 mL Liquid [**Hospital1 **]: One (1) PO DAILY
(Daily).
9. Ascorbic Acid 90 mg/mL Drops [**Hospital1 **]: One (1) PO DAILY (Daily).
10. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
11. Folic Acid 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
12. Aspirin 81 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
13. Metolazone 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily):
give 30 min prior to lasix.
14. Furosemide 10 mg/mL Solution [**Last Name (STitle) **]: Forty (40) mg Injection
DAILY (Daily): give 30 min after zaroxolyn.
15. Fluticasone 110 mcg/Actuation Aerosol [**Last Name (STitle) **]: Four (4) Puff
Inhalation [**Hospital1 **] (2 times a day).
16. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Hospital1 **]: 6-8 Puffs
Inhalation Q4H (every 4 hours) as needed for when on vent.
17. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization [**Hospital1 **]:
One (1) ML Inhalation Q6 ().
18. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1) ml
Injection TID (3 times a day).
19. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: 0.5 Tablet PO BID (2
times a day).
20. Fluconazole in Dextrose(Iso-o) 200 mg/100 mL Piggyback [**Hospital1 **]:
One Hundred (100) mg Intravenous once a day for 4 weeks.
21. Citalopram 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
22. Insulin Glargine 100 unit/mL Solution [**Hospital1 **]: Ten (10) units
Subcutaneous once a day.
23. Insulin Regular Human 100 unit/mL Solution [**Hospital1 **]: sliding
scale Injection four times a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] [**Hospital 75232**] Rehab
Discharge Diagnosis:
CAD now s/p CABG
cardiogenic shock
sternal wound infection
fungemia
ventilator dependent respiratory failure
PMH: Asthma, Emphysema, Anemia, GERD, anxiety, smoker, Carpal
tunnel, ^chol, HTN, Afib
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 or driving until follow up with
surgeon.
Followup Instructions:
Dr. [**Last Name (STitle) **] after discharge from rehab.
Dr. [**First Name (STitle) **] 2 weeks after discharge from rehab(call [**Telephone/Fax (1) 1504**]
to schedule appointment)
Cardiologist after discharge from rehab
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2154-1-10**]
|
[
"518.5",
"410.71",
"492.8",
"272.0",
"427.31",
"401.9",
"998.59",
"117.9",
"996.72",
"414.01",
"997.1",
"785.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"96.71",
"00.40",
"43.11",
"99.20",
"37.61",
"45.13",
"00.66",
"34.79",
"34.91",
"37.22",
"38.93",
"88.56",
"96.72",
"31.1",
"33.23",
"96.6",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
7308, 7377
|
1471, 4395
|
299, 406
|
7617, 7627
|
7926, 8271
|
1313, 1448
|
4743, 7285
|
7398, 7596
|
4421, 4720
|
7651, 7903
|
253, 261
|
434, 643
|
665, 1140
|
1156, 1297
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,151
| 173,203
|
42616
|
Discharge summary
|
report
|
Admission Date: [**2173-1-16**] Discharge Date: [**2173-2-12**]
Date of Birth: [**2093-1-14**] Sex: F
Service: CARDIOTHORACIC
Allergies:
morphine / Oxycodone / tramadol
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
replacement of ascending aorta/hemiarch(28 mm Dacron tube graft)
using deep hypothermic circulatory arrest,Aortic valve
replacement(23-mm [**Doctor Last Name **] Magna Ease) [**2173-1-16**]
Chest closure [**2173-1-18**]
Percutaneous tracheostomy.
Placement of percutaneous endoscopic gastrotomy tube.
History of Present Illness:
This 80 year old female with hypertension awoke with chest pain
that radiated to her back. It was associated with numbness of
both legs. She was seen at
[**Hospital3 **]. A CT scan was suggestive of Type A dissection of
the
aorta and she was transferred for further evaluation. She
denied chest
pain or leg numbness on arrival here. She denied abdominal pain,
lower
extremity pain or difficulty moving extremities.
Past Medical History:
hypertension, depression, anemia, hard of hearing,
COPD, 2 hip replacements,
hysterectomy
Social History:
the patient lives in [**Location (un) 5503**], MA with her
daughter. She smokes approximately [**12-7**] PPD, but used to smoke 1
PPD for at least 10 years. She drinks no alcohol. There are
two
dogs and two cats at home.
Family History:
Some members of family died of cardiomyopathy > 55yrs
Physical Exam:
Pulse: Resp: O2 sat:98% trach mask 50%
B/P Right: 130/70 Left:
Height: Weight: 54 kg
Five Meter Walk Test #1_______ #2 _________ #3_________
General:NAD, alert, cooperative, follows instruction
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x] high palate
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally []few scattered rhonchi
Heart: RRR [x] Irregular [] Murmur [x] soft early systolic
murmur, no diastolic murmur heardgrade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [] _____
Varicosities: None []
Neuro: Grossly intact [x] oriented x3, moves all extremities,
follows commands
Pulses:
Femoral Right: +2 Left:+2
DP Right: +1 Left:+1
PT [**Name (NI) 167**]: +1 Left:+1
Radial Right: +2 Left:+2
Carotid Bruit Right: none Left:none
Pertinent Results:
[**2173-2-11**] 12:07AM BLOOD WBC-11.3*# RBC-3.04* Hgb-8.9* Hct-26.7*
MCV-88 MCH-29.4 MCHC-33.4 RDW-18.0* Plt Ct-346
[**2173-2-2**] 02:23AM BLOOD Neuts-81.2* Bands-0 Lymphs-12.0*
Monos-5.9 Eos-0.2 Baso-0.6
[**2173-2-11**] 12:07AM BLOOD Plt Ct-346
[**2173-2-11**] 12:07AM BLOOD Glucose-109* UreaN-17 Creat-0.9 Na-139
K-3.5 Cl-106 HCO3-24 AnGap-13
[**2173-2-11**] 12:07AM BLOOD Amylase-67
[**2173-2-11**] 12:07AM BLOOD Calcium-8.7 Phos-3.2 Mg-2.0
[**2173-2-11**] 11:06AM BLOOD Type-ART Temp-37.3 pO2-69* pCO2-34*
pH-7.50* calTCO2-27 Base XS-3 Intubat-NOT INTUBA
[**2173-2-10**] PCXR
Left lower lobe retrocardiac opacity consistent with almost
collapse of the
left lower lobe has worsened. Right lower lobe opacities are
likely
atelectasis are unchanged. There is mild pulmonary edema. There
is no
pneumothorax. Sternal wires are aligned. Left PICC tip is in the
lower SVC.
Right peripheral inserted catheter tip is in the axilla.
Mediastinal widening
is unchanged. Tracheostomy tube is in standard position. Small
left pleural
effusion is unchanged.
[**1-27**] TTE:
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium or left atrial appendage. Overall left
ventricular systolic function is normal (LVEF>55%). There are
nonmobile complex (>4mm) atheroma in the descending thoracic
aorta. A well seated bioprosthetic aortic valve prosthesis is
present. No masses or vegetations are seen on the aortic valve.
There is evidence of an echolucent space posterior to the aortic
valve bioprosthesis with diffuse thickening around the aortic
root. There is no flow appreciated in the space. These findings
were already present on post-op TEE dated [**2173-1-16**], although
less prominent and are most likely c/w post-op changes. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Physiologic mitral regurgitation is seen
(within normal limits). Tricuspid regurgitation is present but
cannot be quantified. There is no pericardial effusion.
IMPRESSION: No evidence of valvular vegetations or abscesses. A
well seated bioprosthetic aortic valve prosthesis is present.
[**2173-2-11**] 12:07AM BLOOD WBC-11.3*# RBC-3.04* Hgb-8.9* Hct-26.7*
MCV-88 MCH-29.4 MCHC-33.4 RDW-18.0* Plt Ct-346
[**2173-1-16**] 12:10PM BLOOD WBC-12.4* RBC-4.15* Hgb-11.4* Hct-35.4*
MCV-85 MCH-27.5 MCHC-32.2 RDW-15.8* Plt Ct-399
[**2173-2-11**] 12:07AM BLOOD Glucose-109* UreaN-17 Creat-0.9 Na-139
K-3.5 Cl-106 HCO3-24 AnGap-13
[**2173-1-24**] 04:44AM BLOOD Glucose-112* UreaN-26* Creat-0.8 Na-140
K-4.1 Cl-104 HCO3-26 AnGap-14
[**2173-1-22**] 02:35AM BLOOD Glucose-126* UreaN-27* Creat-0.8 Na-144
K-3.2* Cl-105 HCO3-30 AnGap-12
[**2173-1-17**] 12:30AM BLOOD Glucose-118* UreaN-12 Creat-0.6 Na-138
K-4.8 Cl-109* HCO3-25 AnGap-9
[**2173-1-16**] 12:10PM BLOOD Glucose-105* UreaN-15 Creat-0.7 Na-135
K-3.6 Cl-103 HCO3-24 AnGap-12
[**2173-2-7**] 05:46AM BLOOD ALT-35 AST-39 AlkPhos-104 Amylase-171*
TotBili-0.3
[**2173-2-12**] 03:01AM BLOOD WBC-8.6 RBC-3.01* Hgb-9.1* Hct-26.8*
MCV-89 MCH-30.1 MCHC-33.8 RDW-18.0* Plt Ct-328
[**2173-2-12**] 03:01AM BLOOD Glucose-124* UreaN-16 Creat-0.7 Na-141
K-3.4 Cl-107 HCO3-26 AnGap-11
[**2173-2-12**] 03:01AM BLOOD Calcium-9.1 Phos-2.7 Mg-2.0
Brief Hospital Course:
The patient was admitted on [**2173-1-16**] with a type A dissection.
She went urgently to the OR and underwent AVR tissue valve and
replacement of the ascending aorta. She arrived to the unit with
an open chest due to bleeding. She was hemodynamically stable
and weaned from vasoactive medications quickly, she was kept
paralyzed and sedated because of the open chest. She was a-paced
for heart block. She had poor oxygenation and remained fully
vented initially. She returned to the OR for chest closure on
[**1-18**] and tolerated the proceedure well. Post op she was
hypertensive and slow to wake. She developed postoperative renal
failure with creatinine to 4.5, but recovered and her creatinine
fell to normal levels.
Oxygenation was again a problem despite diuresis. She awoke
slowly and once awake she was very anxious and confused which
continued her whole hospital course. Precedex was initially used
to treat her anxiety, she has a significant pre-op history of
anxiety and depression and was on Ativan and Elavil. Precedex
was eventually weaned and she was transitioned to Ativan and PRN
Haldol. This worked for a period but her mental status was still
an issue and gerontology was consulted who recommeded starting
low dose Seroquel combined with Ativan.
She was very difficult to wean from the ventilator and she self
extubated on POD #4 but was reintubated a few hours later due to
respiratory distress and hypoxia. She extubated again on [**1-23**]
and was reintubated 48hrs later. Her BAL grew out Serratia and
Proteus and she was placed on Vancomycin/Cefepime/Zosyn.
Leukocytosis soon followed and a line tip grew out [**Female First Name (un) 564**] for
which she was placed on course of Micafungin.
She was again extubated on [**1-28**] and continued with aggressive
pulmonary management. She was seen by ENT for coarse upper
airway sounds and wheeezing. She was found to have significant
glottal edema and thick secretions. Oral care and humitification
were maximized, no steroids were given. She failed several of
her speech and swallow exams and therefore tube feeds were
continued.
She was noted to have elevated amylase/lipase but was
asymptomatic and they eventually returned to baseline. She
continue to be hyppertensive and meds were adjusted as needed.
She also had episodes of PAF and was started on amiodarone and
Coumadin. Her rhythm stabilized and she the Coumadin was
discontinued.
She was diuresed to below her pre-op weight and was started on
free water bolusues for hypernatremia which has resolved. Chest
tubes and pacing wires were discontinued without complications.
She transferred to the floor eventually on POD # 22 [**2-6**]. While
on the floor her anxiety continued to be a problem. [**Name (NI) 92172**] and
Ativan were adjusted. She was seen by ENT again for f/u
examination and while her glottal edema had resolved she was
noted to have a concerning amount of dessicated secrections on
her vocal cords and was at a very high risk of obstructing her
airway. The decision was made to have her return to the CVICU
for bronch. However, prior to transferring the patient developed
acute respiratory distress and decreased breath sounds on left
side. She was therefore emergently intubated on the floor and
transferred to CVICU.
She then underwent an urgent brochoscopy which revealed a large
amount of thick/dry copious secretions. On POD #25 she underwent
trach and PEG. She tolerated the proceedures the well. Her
anxiety improved and was managed with both Ativan and prn
Haldol. She was screened for rehab and on POD 27 she was
discharged to [**Hospital 5503**] Rehab Hospital in good condition with
appropriate follow up instructions.
Of note during her hospitalization her hearing according the
patient and her family appeared much worse. She is baseline hard
of hearing in her right ear. ENT evaluated the right ear and
found there to be a large amount of impacted cerumen with a
portion of the hearing aid imbedded in it. She was started on
Colace tid to the effected ear for 3 days and was then irrigated
afterwards. The foreign body was removed, and the patient will
remain on otic antibiotics x 5 days.
Medications on Admission:
Elevil 50mg HS, ASA 81mg daily, ativan 1mg tid/prn, lopressor
25mg daily, lisinopril 5mg daily, losartan ?, proair 2
puffs/prn, Spiriva daily
Discharge Medications:
1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. ipratropium bromide 0.02 % Solution [**Hospital **]: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezes.
3. metoprolol tartrate 50 mg Tablet [**Hospital **]: One (1) Tablet PO TID
(3 times a day).
4. ipratropium bromide 17 mcg/actuation HFA Aerosol Inhaler [**Hospital **]:
Six (6) Puff Inhalation QID (4 times a day).
5. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler [**Hospital **]:
4-6 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing.
6. acetaminophen 650 mg/20.3 mL Solution [**Hospital **]: [**12-7**] PO Q4H (every
4 hours) as needed for pain.
7. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
8. haloperidol 0.5 mg Tablet [**Last Name (STitle) **]: 0.5 mg PO TID (3 times a day):
noon, 5p and 10p.
9. fluticasone 110 mcg/actuation Aerosol [**Last Name (STitle) **]: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
10. heparin (porcine) 5,000 unit/mL Solution [**Hospital1 **]: 5000 (5000)
units Injection TID (3 times a day).
11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezes.
12. multivitamin Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
13. amlodipine 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
14. senna 8.8 mg/5 mL Syrup [**Hospital1 **]: Five (5) ml PO BID (2 times a
day) as needed for Constipation.
15. aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
16. docusate sodium 50 mg/5 mL Liquid [**Hospital1 **]: One Hundred (100) mg
PO BID (2 times a day).
17. heparin, porcine (PF) 10 unit/mL Syringe [**Hospital1 **]: 1-2 MLs
Intravenous PRN (as needed) as needed for line flush.
18. ofloxacin 0.3 % Drops [**Hospital1 **]: Three (3) Otic TID (3 times a
day) for 5 days.
19. sodium chloride 0.65 % Aerosol, Spray [**Hospital1 **]: [**12-7**] Sprays Nasal
[**Hospital1 **] (2 times a day) as needed for nasal congestion.
20. sodium chloride 3 % Solution for Nebulization [**Hospital1 **]: One (1)
ML Inhalation Q4H (every 4 hours).
21. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette [**Hospital1 **]: Two
(2) Drop Ophthalmic TID (3 times a day) as needed for while
sedated.
22. insulin regular human 100 unit/mL Solution [**Hospital1 **]: One (1)
Injection ASDIR (AS DIRECTED): see attached sliding scale.
23. ciprofloxacin 0.3 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic TID
(3 times a day) for 5 days: 3 drops to RIGHT EAR TID x 5 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] [**Hospital **] Hospital - [**Location (un) 5503**]
Discharge Diagnosis:
Type A aortic dissection
s/p repair Type A dissection.
postoperative Respiratory insufficiency.
hypertension
depression
chronic obstructive pulmonary disease
s/p total hip replacements
s/p hysterectomy
Discharge Condition:
Alert x2, restless and agitated at times, MAE, non focal
Ambulates with assistance
Sternal pain managed with oral analgesics
Sternal woumd CDI
Trach site CDI
Peg site CDI
No edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call 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:
Surgeon Dr. [**Last Name (STitle) **] (for Dr. [**Last Name (STitle) 914**], [**Telephone/Fax (1) 170**]) on Thursday,
[**2173-3-18**], 1pm
Please call to schedule appointments on discharge from rehab
Primary Care Dr. [**First Name (STitle) **] ([**Telephone/Fax (1) 92173**]
Cardiologist Dr. [**Last Name (STitle) 40510**] [**Telephone/Fax (1) 40420**]
Pulmonology Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 9674**]
ENT Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1728**] [**Telephone/Fax (1) 92174**]
Completed by:[**2173-2-12**]
|
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30,460
| 100,328
|
2169
|
Discharge summary
|
report
|
Admission Date: [**2162-12-28**] Discharge Date: [**2163-1-9**]
Date of Birth: [**2114-8-16**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Morphine
Attending:[**First Name3 (LF) 6021**]
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
Central line placement
PICC line placement
History of Present Illness:
48yo male with AIDS related [**Doctor Last Name 11579**] Lymphoma with CNS
involvement s/p cycle 2 of R-IVAC (discharged [**12-24**]) developed
chills, then checked temperature; noted fever to 100.5 at home
and so presented to the ED. Denied cough, SOB, HA, urinary sx,
CP, N/V/D/C.
.
ED Course: Febrile to 101.2, initially BP normal but fell to
70/30, HR tachycardic up to 150's. Code sepsis called. Initial
labs significant for: lactate 3.3->4.3, WBC 0.1 w/ 17% PMNs, Hct
27.4, platelets 27->13. UCX, Blood Cx drawn. UA negative, CXR
showed no acute cardiopulmonary process. RIJ CVL placed. CVP =
8. Given cefepime/vancomycin. Started on levophed, titrated up;
eventually dopamine added. He received one unit of pRBC's.
.
Regarding his Burkitt's Lymphoma: Diagnosed in [**2162-10-2**] w/
BM bx [**10-18**]. CODOX and intrathecal cytarabine started on [**10-20**]. On
[**10-21**], MRI demonstrated progressive CNS disease and he commenced
whole brain XRT x 5 fractions of radiation (completed [**10-27**]).
He was admitted from [**12-16**] through [**12-24**] for his second cycle of
R-IVAC. Mr. [**Known lastname **] received rituximab on [**2162-12-16**], and his IVAC
was started on [**12-17**]. He also received intrathecal liposomal
cytarabine on [**2162-12-22**]. G-CSF was started on [**2162-12-23**]. During
that admission he reported numbness of his left shoulder as well
as bilateral fingertip numbness, thought to be due to
vincristine-induced peripheral neuropathy, not a central process
(MR [**First Name (Titles) **] [**Last Name (Titles) 11580**]). The patient was sent home with
dexamethasone 4 mg PO bid x 2.5 days to complete a 5-day course.
Plan is for 3 cycles each of CODOX (2 with Rituxan) and R-IVAC.
Past Medical History:
ONCOLOGIC HISTORY:
He was initially admitted on [**10-14**] with ten days of increasing
axillary adenopathy, fevers, chills, and night sweats. An
inguinal lymph node biopsy was non-diagnostic and the diagnosis
was confirmed on bone marrow biopsy performed on [**10-18**]. He was
transferred to OMED service and commenced on CODOX and received
intrathecal cytarabine on [**10-20**]. On [**10-21**], MRI demonstrated
progressive CNS disease and he commenced WBXRT on [**10-22**]. He
received five fractions of radiation and completed therapy on
[**10-27**]. He developed tumor lysis with renal insufficiency
following chemotherapy, but this resolved with supportive care.
He has now received CODOX, R-IVAC, and R-CODOX. We are planning
3 cycles each of CODOX (2 with Rituxan) and R-IVAC.
.
PAST MEDICAL HISTORY:
1. Burkitt's Lymphoma as described above.
2. HIV as above, diagnosed in [**5-/2159**] thought to be contracted
from an MSM contact after which he developed a viral-like
syndrome. Has never been on HAART.
3. Left V1/V2 trigeminal zoster without ocular involvement in
[**6-/2160**]
4. Viral orchitis in left testicle at age 15; testicle is
chronically shrunken, "mushy", and tender, per patient
5. Chronic low back pain from herniated disc noted several yrs
ago
6. Depression/Anxiety
7. HBcAb and HBsAb (+) (HBsAg neg)
8. s/p cholecystectomy in [**2145**]
9. Chronic anisocoria (per patient) with R>L
Social History:
He works for a small company doing computer programming. He
denies tobacco use. Has used marijuana in the past, but
denies IV drug use. He uses occasional alcohol, though none
since his diagnosis.
Family History:
He reports that his father died of an MI in his 50s. His mother
has diabetes. His sister has had zoster.
Physical Exam:
Physical Exam:
VS - T99.0F, BP 116/61, HR 98, RR 15, Sat 99%RA
GENERAL - Comfortable, no acute distress
HEENT - Dry mucus membranes. Right eyelid droop.
NECK - No cervical lymphadenopathy. No
LUNGS - CTA bilaterally
HEART - RRR normal S1/S2, no m/r/g
ABDOMEN - Soft, NT, NT, + bowel sounds
EXTREMITIES - Trace edema bilaterally
SKIN - No rashes
NEURO - Alert, oriented x 3, conversational
Brief Hospital Course:
ASSESSMENT/PLAN: 48yo male with AIDS related [**Doctor Last Name 11579**] Lymphoma
with CNS involvement s/p cycle 2 of R-IVAC admitted with sepsis
and pancytopenia.
.
# Sepsis/ Febrile neutropenia: GNR and methicillin resistant
staph aureus on [**5-5**] blood cultures previously requiring pressors
and course in [**Hospital Unit Name 153**]. Source unclear. Urine cx negative, CT sinus
negative. TTE revealed no evidence of endocarditis with EF
50-55% and mild global systolic dysfunction likely secondary to
sepsis. TEE not completed due to thrombocytopenia. Patient
initially treated with cefepime and vancomycin. As sensitivities
returned, coverage switched to Cipro and vancomycin. Vancomycin
initially dosed by level in setting of acute renal failure. As
renal function improved dosing switched to 1 gram q 12 hours.
PICC line was placed and patient was sent home to complete 3
week course of cipro and 4 weeks total of vancomycin with follow
up by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1075**] from Infectious Disease. Given scripts to
have weekly lab surveillance for Vancomycin including
chemistries and vancomycin levels.
.
# Acute renal failure: urine lytes consistent with prerenal
cause. FeNA 1%. Given IV fluids with improvement. However did
not return to baseline at time of discharge.
.
# Altered mental status: Noted slowing and parkinsonian type
features yesterday. Sent for CT head, revealed subdural
hematomas. Seen by neurosx who felt evacuation not necessary.
Neurology consulted also completed and felt no need for
antiseizure meds at this time. Blood pressure was kept below 140
systolic and repeat CT head showed no progression. Platelets
maintained above 60 and significantly improved prior to
discharge. Parkinsonian features were not completely
attributable to small subdural hematomas. Therefore seroquel
discontinued as patient had cogwheel rigidity which can be a
side effect of seroquel.
.
# C difficile colitis: Stool C difficile toxin positive. Started
on course of flagyl for total of 14 days. However per ID
curbside, patient should be treated for four weeks along with
vancomycin. Therefore, Dr. [**First Name (STitle) **] was contact[**Name (NI) **] regarding
appropriate duration of therapy in order to extend the total
course of antibiotics.
.
#Pancytopenia: [**3-5**] recent chemo and complicated by sespis. Hct
drifts downwards w/o transfusions, bone marrow not producing
retics ANC increased with Neupogen and discontinued when count
rose above 1000.
.
# Oral herpes: Treated with topical acyclovir.
.
#AIDS: Cont home ARV therapy
.
#Hyperglycemia: Insulin SS. Sugars improved as patient recovered
from sepsis.
.
# Full
Medications on Admission:
Acyclovir 400 mg PO q12hr
Ranitidine 150 mg PO BID
Sertraline 100 mg daily
Levofloxacin 500 mg daily x 10 days
Neupogen 480 mcg daily x 10 days
ATRIPLA [**Telephone/Fax (3) 567**] mg once daily
Mirtazapine 15 mg PO qhs -> 7.5 since he was constantly hungry
Ambien CR 12.5 mg qhs
Compazine 5-10mg q 6-8 hours PRN
Zofran 4 mg q 8 hrs
Benadryl 50 mg qhs PRN- not taking- > nasal congestion
Lorazepam 0.5-1 mg q 6 hr PRN
Discharge Medications:
1. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
Intravenous every twelve (12) hours: Last day: [**2163-1-28**].
Disp:*41 units* Refills:*0*
2. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours): Last day: [**2163-1-11**]
.
Disp:*6 Tablet(s)* Refills:*0*
3. Outpatient Lab Work
WEEKLY LABS:
CBC, BUN/Cr, LFTs, Vanco trough (goal = 20)
FAX to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1075**] ([**Hospital **] CLINIC) at [**Telephone/Fax (1) 432**].
(All questions regarding outpatient antibiotics should be
directed to the infectious disease R.Ns. at ([**Telephone/Fax (1) 11581**] or to
[**Name8 (MD) 11582**] MD in when clinic is closed.)
4. Heparin Flush 10 unit/mL Kit Sig: Two (2) mL Intravenous once
a day.
Disp:*30 flushes* Refills:*1*
5. Saline Flush 0.9 % Syringe Sig: [**6-10**] mL6 Injection SASH and
PRN.
Disp:*60 * Refills:*2*
6. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
7. Efavirenz 600 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1) Tablet
PO DAILY (Daily).
9. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
10. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
13. Fentanyl 12 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
Disp:*5 Patch 72 hr(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
PRIMARY:
Bacteremia
Hypotension
Febrile neutropenia
Mucositis
Hyperglycemia
SECONDARY:
HIV/AIDS
Burkitt's lymphoma
Hepatitis B core/surface ab positive
Anxiety
Depression
Eczema
Low back pain/muscle spasm
Discharge Condition:
Hemodynamically stable, afebrile
Discharge Instructions:
You were admitted to the hospital because you had an infection
in the blood. This is probably because you recently had
chemotherapy and your immune system was compromised. You were
treated with antibiotics and required a brief stay at the ICU
for closer care and monitoring. You seem to be recovering so
you will be discharged and will finish the remaining course of
antiobiotics as an outpatient.
You will be on Vancomycin until [**2163-1-28**]. You will be on
Ciprofloxacin until [**2163-1-11**]. Remember to have your blood work
checked every week while you are getting these antibiotics.
Details:
*** WEEKLY LABS ***
CBC, BUN/Cr, LFTs, vanco trough (goal = 20) FAX'ed to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1075**]
([**Hospital **] Clinic) at [**Telephone/Fax (1) 432**]. (All questions regarding
outpatient antibiotics should be directed to the infectious
disease R.Ns. at
If you have fevers or chills, please call your doctor
immmediately. If you have chest pain or shortness of breath, or
if there are any symptoms concerning to you, seek medical
attention immediately or go to the nearest Emergency Department.
Followup Instructions:
Please follow up with Dr. [**First Name8 (NamePattern2) 916**] [**Last Name (NamePattern1) **] within 1 week. Please
call ([**Telephone/Fax (1) 11583**]
.
Please follow up with Infectious Disease Clinic:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2163-1-28**]
9:30
Please follow up with your PCP [**Name Initial (PRE) 176**] 2 weeks:
[**Last Name (LF) **],[**First Name3 (LF) **] C. [**Telephone/Fax (1) 2393**]
|
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[
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,200
| 126,823
|
24517
|
Discharge summary
|
report
|
Admission Date: [**2150-4-27**] Discharge Date: [**2150-5-18**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Thoracentesis x 2. Midline placement for access.
History of Present Illness:
This is a [**Age over 90 **] yo F presenting with increasing shortness of
breath, hypoxemia, and pleural effusion. The patient was
hospitalized at [**Hospital1 18**] from [**Date range (1) 19627**] after she presented with a
noted L pleural effusion on CXR (done at her PCP's office),
cough, and DOE for 2 weeks prior. She was treated with
levofloxacin from [**Date range (1) 61971**] for presumed CAP. She had perhaps
mild improvement in symptoms initially, but her SOB and DOE have
worsened. She reports that she feels SOB at rest, and has been
unable to perform any activities. At baseline, up until 1.5
weeks ago, the pt was going to her pool for water aerobic
classes 3 times a week. She has a continued non-productive
cough, increased fatigue, and stable 2 pillow orthopnea. She
notes she is unable to speak without feeling SOB. She notes
increased weight of 145 lbs from her baseline of 130 lbs (unsure
over what time period this weight gain has been), and 8 months
of increasing abdominal girth. She has had no fevers, chills,
anorexia, palpitations, chest pain, syncope, nightsweats, or
abdominal pain. She presented to her PCP today with increased
shortness of breath and hypoxia, noted to be satting 87-88% RA.
She was referred to the ER for further management.
.
In the ED, the pts vitals were: T 97.2 HR 80 BP 132/62 RR 22 Sat
94% 3 L NC. CXR showed an increased L effusion. She received CTX
1 gm IV x1 and azithromycin 500 mg pox1.
.
ROS:
-Constitutional: []WNL []Weight loss-no, weight gain
[x]Fatigue/Malaise []Fever-no []Chills/Rigors-no
[]Nightsweats-no []Anorexia-no
-Eyes: [x]WNL []Blurry Vision []Diplopia []Loss of Vision
[]Photophobia
-ENT: [x]WNL []Dry Mouth []Oral ulcers []Bleeding gums/nose
[]Tinnitus []Sinus pain []Sore throat
-Cardiac: []WNL []Chest pain []Palpitations []LE edema
[x]Orthopnea/PND [x]DOE
-Respiratory: []WNL [x]SOB []Pleuritic pain []Hemoptysis
[x]Cough
-Gastrointestinal: []WNL []Nausea []Vomiting []Abdominal pain
[x]Abdominal Swelling []Diarrhea []Constipation []Hematemesis
[]Hematochezia []Melena
-Heme/Lymph: [x]WNL []Bleeding []Bruising []Lymphadenopathy
-GU: [x]WNL []Incontinence/Retention []Dysuria []Hematuria
[]DIscharge []Menorrhagia
-Skin: [x]WNL []Rash []Pruritus
-Endocrine: []WNL []Change in skin/hair [x]Loss of energy
[]Heat/Cold intolerance
-Musculoskeletal: [x]WNL []Myalgias []Arthralgias []Back pain
-Neurological: [x] WNL []Numbness of extremities []Weakness of
extremities []Parasthesias []Dizziness/Lightheaded []Vertigo
[]Confusion []Headache
-Psychiatric: [x]WNL []Depression []Suicidal Ideation
-Allergy/Immunological: [x] WNL []Seasonal Allergies
Past Medical History:
# Atrial fibrillation
# HTN
# Glaucoma
# h/o TIAs
# Spinal stenosis
# Peripheral [**Date range (1) 1106**] disease s/p right SFA angioplasty and
stent on [**2148-2-29**] for right footnumbness and pain
# GERD
# Aortic Stenosis: Valve area in [**2147**] was 1.1 with a peak
Social History:
She is divorced, lives in this retirement community. Smoking
history (less than a pack per day) for >20 years, but quit over
in the early 80s. Has a glass of wine with dinner. Walks with a
cane. Up until 1.5 weeks ago was going to water aerobics classes
3 times a week.
Family History:
Her mother died at 79 of cardiac issues. Her father died at 66
of an MI. She had a sister who died at 92 of old age. She has 4
brothers; two are deceased from old age.
Physical Exam:
Appearance: dyspneic, unable to complete full sentences, sitting
up in bed
Vitals: T 95.4 axillary, BP 133/79 P 76 R 24 Sat 93% 4 L NC
Eyes: EOMI, PERRL, conjunctiva clear but pale, noninjected,
anicteric, no exudate
ENT: Moist
Neck: No JVD, no LAD
Cardiovascular: irreg irreg, grade [**1-30**] late peaking SEM at LUSB
and LLB, soft S2
Respiratory: diminished breath sounds and dullness to percussion
1/2 up L lung, R lung is CTA, no wheezing, no ronchi
Gastrointestinal: soft, non-tender, +distension, no
hepatosplenomegaly, normal bowel sounds
Musculoskeletal/Extremities: no clubbing, no cyanosis, no joint
swelling, no edema in the bilateral extremities
Neurological: Alert and oriented x3, +short term memory
deficit--unable to remember her daughter's phone numbers, unable
to remember my name, fluent speech
Integument: warm, no rash, no ulcer
Psychiatric: appropriate, pleasant
Hematological/Lymphatic: No cervical, supraclavicular, axillary
LAD
Discharge: afebrile, VSS on [**1-28**] L oxygen by nasal canula
elderly, NAD, alert/oriented x3
Heart irregular, rate 80s
Lungs clear on right, diminished left to mid lung
Abd -- soft, [**Last Name (un) 17066**]
Ext -- midline right arm, minimal edema all ext
Pertinent Results:
[**2150-4-27**] 11:36AM WBC-8.4 RBC-4.38 HGB-12.7 HCT-37.4 MCV-85
MCH-29.0 MCHC-34.1 RDW-14.5
[**2150-4-27**] 11:36AM NEUTS-74.1* LYMPHS-16.9* MONOS-7.0 EOS-1.7
BASOS-0.3
[**2150-4-27**] 11:36AM PLT COUNT-297.
.
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2150-5-18**] 06:50AM 11.4* 3.34* 9.7* 29.6* 89 29.1 32.8 15.2
228
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
[**2150-4-27**] 11:36AM 74.1* 16.9* 7.0 1.7 0.3
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2150-5-18**] 06:50AM 228
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2150-5-18**] 06:50AM 105 31* 1.9* 135 4.2 98 28 13
ESTIMATED GFR (MDRD CALCULATION) estGFR
[**2150-5-12**] 05:15AM Using this1
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2150-5-13**] 07:00AM 28 24 178 57 0.4
CPK ISOENZYMES proBNP
[**2150-4-27**] 11:36AM 6784*1
BNP ADDED [**4-27**] @ 16:28
REFERENCE VALUES VARY WITH AGE, SEX, AND RENAL FUNCTION;AT 35%
PREVALENCE, NTPROBNP VALUES; < 450 HAVE 99% NEG PRED VALUE;
>1000 HAVE 78% POS PRED VALUE;SEE ONLINE LAB MANUAL FOR MORE
DETAILED INFORMATION
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2150-5-18**] 06:50AM 10.1 4.4 2.0
HEMATOLOGIC calTIBC VitB12 Folate Ferritn TRF
[**2150-5-15**] 02:50AM 280 90 215
ADDED CHEM 7:37AM
PITUITARY TSH
[**2150-4-30**] 10:30AM 2.4
FOL TSH ADDED [**4-30**] @ 13:24; MODERATELY HEMOLYZED SPECIMEN
THYROID PTH
[**2150-5-10**] 07:55AM 10*
PROTEIN AND IMMUNOELECTROPHORESIS PEP IgG IgA IgM IFE
[**2150-5-4**] 01:40PM TWO TRACE 1 776 116 182 TRACE MONO2
EKG:
atrial fibrillation, nl axis, biphasic T wave in I/AVL,II,
nonspecific
.
RETROPERITONEAL LIMITED US [**2150-4-27**]:
There is a large left pleural effusion. There is no ascites.
Surveillance views of the spleen and left kidney are
unremarkable. The liver is incompletely imaged.
IMPRESSION: Large left pleural effusion without ascites.
.
TTE [**2150-4-28**]:
The left atrium is moderately dilated. The left ventricular
cavity is unusually small. Due to suboptimal technical quality,
a focal wall motion abnormality cannot be fully excluded. Left
ventricular systolic function is hyperdynamic (EF>75%). The
estimated cardiac index is normal (>=2.5L/min/m2). There is no
resting left ventricular outflow tract gradient, but the
gradient increased with the Valsalva manuever into the mild
range. Right ventricular chamber size and free wall motion are
normal. There is a mobile, linear density which is ill-defined
but seen in the proximal main pulmonary artery (2 cm x 0.cm)
which may represent mass or thrombus (best seen in clips 37, 39,
42) . The aortic valve leaflets are moderately thickened. There
is moderate aortic valve stenosis (valve area 1.0 cm2). Trace
aortic regurgitation is seen. There is severe mitral annular
calcification. There is moderate thickening of the mitral valve
chordae. There is moderate functional mitral stenosis (mean
gradient 7 mmHg) due to extensive mitral annular calcification.
Mild (1+) mitral regurgitation is seen. [Due to acoustic
shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The left ventricular inflow
pattern suggests impaired relaxation. The pulmonary artery
systolic pressure could not be determined. The pulmonic valve
leaflets are thickened. There is a trivial pericardial effusion.
IMPRESSION: Suboptimal image quality. Possible proximal
pulmonary artery mass versus thrombus. Moderate aortic stenosis.
Moderate functional mitral stenosis from extensive mitral
annular calcifications. Small left ventricular cavity with
hyperdynamic systolic function and inducible left ventricular
outflow tract gradient.
Compared with the prior study (images reviewed) of [**2148-1-11**],
the severity of aortic stenosis has slightly progressed. Mitral
stenosis is now present. The pulmonary artery pressure could not
be estimated on this study. A pulmonary artery density is now
seen.
.
CTA CHEST W&W/O C&RECONS [**2150-4-28**]:
There are no abnormalities identified in the proximal pulmonary
artery that could correspond to the finding described in the
echocardiogram. and no filling defects in pulmonary artery
branches.
A 19 x 11 mm retrosternal soft tissue mass surrounds the left
internal mammary artery (3:41); it is unchanged compared to
prior study [**2150-4-18**].
Over ten days the large non hemorrhagic left large pleural
effusion and
atelectasis of the lingula and left lower lobe have all
increased. In the
anterior segment of the right upper lobe, the 18mm wide cluster
of one
dominant and several smaller branching nodules was 13 mm
previously.
No right pleural effusion. Heart size is normal. Pericardial
effusion is
minimal. Coronary arteries contain atherosclerotic
calcifications.
Calcifications are identified in the mitral annulus and aortic
valve. Thoracic aorta is normal in size, with atherosclerotic
calcifications and mural plaques, some ulcerated. The aorta
diameter increases slightly at the level of the diaphragmatic
hiatus to 30 x 29 mm.
Limited images of the upper abdominal organs are unremarkable.
OSSEOUS STRUCTURES: Degenerative changes in spine. No worrisome
lytic or
sclerotic bone lesions.
IMPRESSION:
1. No abnormality in the main pulmonary arteries to explain the
finding
described in the echocardiogram.
2. Negative examination for pulmonary embolism.
3. Interval increase in size of the non-hemorrhagic left large
pleural
effusion.
4. Interval worsening of atelectasis of the left lower lobe and
lingula.
5. Interval increase in size of the nodular opacity and
surrounding satellite
nodules, right upper lobe, either growing mucoid impaction or
focal infection.
.
CXR PA/Lateral [**2150-4-30**]:
Small-to-moderate left pleural effusion is unchanged. Adjacent
left lower
lobe opacity probably represents atelectasis, less likely
reexpansion
pulmonary edema. There is no pneumothorax. Cardiomediastinal
contours are
unchanged. Right lung remains clear.
IMPRESSION: Stable left pleural effusion and likely associated
left basilar atelectasis. No pneumothorax.
.
CT CHEST W/O CONTRAST [**2150-4-30**]:
Compared to [**2150-4-28**] there is interval decrease in left
pleural effusion which is currently small to moderate
accompanied by atelectasis (at least partially rounded) in the
left lower lobe. The effusion is nonhemorrhagic measuring up to
5 Hounsfield units. The right middle lobe consolidation, 3:30
and the subpleural areas of consolidation in the lingula has
slightly increased in the interim, thus might represent areas of
atelectasis, although infectious process cannot be excluded as
well as malignancy given a short-term dating back only to [**4-18**], [**2149**]. There are no new abnormalities seen within the lungs
and the airways are patent to the level of subsegmental bronchi
bilaterally except for most likely mucus impaction in the left
lower lobe bronchi.
The mediastinal lymph nodes are not pathologically enlarged
based on the size criteria, stable and might represent reactive
changes. Extensive
calcifications of the aortic valve and coronary arteries are of
unknown
clinical significance. The heart is not enlarged and there is no
pericardial effusion. Extensive calcifications of the aorta are
noted as well as areas of mural thrombus and potential focal
area of small dissection at the level of the aortic arch. The
evaluation of the descending aorta demonstrates an aneurysmatic
dilatation of the aorta at the level of the hiatus up to 3 cm.
The imaged portion of the upper abdomen demonstrates partially
imaged biliary sludge, a relatively small but again partially
imaged right kidney and aortic calcifications and otherwise is
unremarkable within the limitation of the non-enhanced study
that was not designed for evaluation of intra-abdominal
pathology.
Significant calcifications of the mitral annulus are present.
There are no bone lesions worrisome for malignancy. Extensive
degenerative
changes are noted in the thoracic spine.
.
CT ABDOMEN/PEL W/O CONTRAST:
IMPRESSION:
1. No lymphadenopathy to explain pleural tap findings.
2. Hypodensity in the pancreatic tail, incompletely evaluated on
this non IV contrast scan. If patient's renal function improves,
IV contrast enchanced. MRCP or CT should be performed. This
finding is unlikely to represent lymphoma but could represent a
pancreatic tumor.
3. Pleural effusions and basilar atlectesis, left more than
right.
4. Sigmoid diverticulosis without diverticulitis.
5. Equivocal thickening of posterior wall of stomach, likely
fluid. Attention to this region on follow-up is recommended.
.
Flow cytometry on pleural fluid from [**2150-4-29**]:
RESULTS:
Three color gating is performed (light scatter vs. CD45) to
optimize lymphocyte yield.
B cells demonstrate a monoclonal lambda light chain restricted
population. They co-express pan-B cell markers CD19, along with
CD5 (dim, variable) and HLA-DR. [**Last Name (STitle) 20282**] do not express any other
characteristic antigens including CD10, FMC-7, CD23 or CD138.
CD20 expression is dim-to-absent. These abnormal B-cells
comprise approximately 8% of total analyzed events.
T cells comprise 80% of lymphoid gated events and express mature
lineage antigens.
INTERPRETATION
Immunophenotypic findings are consistent with involvement by a
Lambda-restricted B cell lymphoproliferative disorder, with
aberrant coexpression of CD5 (dim, variable). CD20 is almost
absent.
Review of cytospin preparation showed a predominant population
of small mature lymphocytes, with fewer scattered larger
atypical plasmacytoid cells. Correlation with clinical and
radiologic findings to assess any other mass lesion with
possible biopsy may be contributory in further
subclassification. In the absence of a mass lesion, a repeat
pleural fluid analysis with cell block preparation for
additional immunohistochemical workup may be contributory.
Findings discussed with Dr. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] and Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 4762**].
.
MRI abdomen [**2150-5-10**]:
MRCP: There is a moderate left pleural effusion and associated
atelectasis of
the lower portion of the right lung, incompletely imaged. There
is nodular
thickening of the left postero-medial pleural.
Liver is essentially unremarkable. There is no intrahepatic
biliary ductal
dilation. The gallbladder is unremarkable. The CBD is not
dilated. The
pancreas is normal in signal intensity and morphology. While the
examination
is slightly limited by motion and the lack of IV contrast, there
is no
evidence of a focal pancreatic lesion, particularly in the tail.
There is no
pancreatic ductal dilation.
The spleen is normal in size. The adrenal glands are
unremarkable. There is
no hydronephrosis of the kidneys. The right kidney is atrophic,
measuring
approximately 6.5 cm in length. There are cystic lesions which
are
hyperintense on T2-weighted images at the lower pole of the left
kidney,
likely representing cysts. The abdominal aorta is normal in
caliber, with
some ectasia. No mesenteric or retroperitoneal lymphadenopathy
is seen in the
abdomen.
As noted on recent CT, the gastric wall appears thickened in the
fundus and
proximal body of the stomach. Small and large bowel loops are
unremarkable.
No ascites.
Multiplanar imaging provided multiple perspectives.
IMPRESSION:
1. Slightly limited exam, but no evidence of a focal pancreatic
lesion. The
finding on CT may have been related to fat infiltration in the
pancreatic tail
parenchyma and/or volume averaging.
2. Thickening of the gastric fundus. Lymphoma is not excluded,
though the
differential diagnosis of gastric wall thickening is broad.
Recommend
correlation with endoscopy and biopsy at the fundus.
3. Moderate left pleural effusion, with nodular thickening of
the left pleura
posteromedially.
4. Atrophic right kidney.
.
CXR [**2150-5-11**]:
FINDINGS: In comparison with study of [**2150-5-4**], there has been
some further
increase in pleural fluid in the left hemithorax. This may be
associated with
mild shift of the mediastinum to the right.
The right lung is clear.
Pleural fluid cytology:
Pleural fluid:
SUSPICIOUS FOR MALIGNANT CELLS.
Numerous lymphocytes, suspicious for involvement by
patient's known lymphoproliferative disorder; (see note.)
Note: The lymphocytes are polymorphic and appear similar to
the patient's prior pleural fluid specimen C09-[**Numeric Identifier 61972**]. Some
cells display nuclear irregularities and some appear
binucleate. See also corresponding studies performed on
prior pleural fluids (S09-[**Numeric Identifier 61973**] and S09-[**Numeric Identifier 37469**].)
Brief Hospital Course:
This is a [**Age over 90 **] year old lady who presented with increasing
shortness of breath and an enlarging left pleural effusion. Work
up revealed a B cell lymphoproliferative disorder.
.
# Dyspnea/Hypoxemia: Multifactorial in a patient with new
malignant effusion (lymphoma) and episodes of acute diastilic
heart faliure with flash pulmonary edema. Initially pt was
requiring 5-6 L NC to maintain sats in the mid 90s. Patient
underwent thoracentesis and removal of approximately 1400 ml of
serous appearing fluid, final cytology with malignant cells,
likely lymphoma. Her oxygenation improved to mid 90s on 2 L NC.
She underwent another subsequent therapeutic thoracentesis
prior to her discharge. Studies were consistent with exudate and
flow cytometry was consistent with a B cell lymphoproliferative
process. Hematology/Oncology was consulted. (see below). Her
CT was concerning for right upper lobe nodules, but these
nodules were felt to be mucoid impaction. Patient remained
afebrile and without elevated white count throughout her stay
her. Her PPD was normal. She has outpatient pulmonary follow up
as scheduled to assess for reaccumulation of pleural effusion.
He diastolic heart failure was treated with rate control and
diuresis.
.
# Lymphoma: Flow cytometry on the pts initial pleural fluid
specimen was consistent with a B cell lymphoma. It was felt the
pt had lymphoplasmacytic lymphoma, marginal zone lymphoma, MALT
lymphoma, or primary effusion lymphoma. The oncology team was
consulted and steps were taken to try to delineate what kind of
lymphoma the patient had to determine prognosis and treatment
options. CT abd/pel did not show any lymphadenopathy. A repeat
thoracentesis was done to obtain fluid for a pathology cell
block. Unfortunately the results of this were not helpful in
definitively characterizing the lymphoma. Bone marrow biopsy was
performed on [**2150-5-11**], however there was only aspirate and no
definite tissue for pathology from that specimen. MRI abdomen
was performed on [**5-10**] to further evaluate the pts pancreatic
hypodensity on CT, and to evaluate for any lymph nodes that
could be biopsied. MRI abdomen commented on gastric fundus
thickening, concerning for MALT lymphoma. EGD with gastric
fundus biopsy was discussed, but Ms. [**Known lastname 25989**] preferred to wait
for further workup as an outpatient, as she did not want to
undergo further invasive evaluation. Also explained that given
pts chronic kidney failure, history of TIAs, atrial
fibrillation, O2 requirement, advanced age, moderate aortic
stenosis, and PVD (so likely CAD), pt is at high risk for a
procedure. A more reasonable approach may be repeat bone marrow
biopsy, to be discussed as an outpatient with Dr. [**Last Name (STitle) **] in
an outpatient oncology follow up appointment on [**2150-5-25**].
.
# Diastolic heart failure and valvular disease: Patient had
evidence of diastolic heart failure with poor forward flow. She
was given periodic diuresis as needed. TTE revealed diastolic
CHF with inducible LV outflow gradient.
.
# Atrial Fibrillation: Patient has a history of atrial
fibrillation and has been anti-coagulated on coumadin. On [**5-13**]
she developed severe hypoxia and was also noted to be in rapid
ventricular response. Following a thoracentesis she reverted
back to NSR. Notably, patient also developed sinus pauses of up
to 12-13 seconds with witnessed syncope. She was evaluated by
cardiology/EP and a pacemaker was placed on [**2150-5-14**]. This
episode likely reflected tachy-brady syndrome. Following
pacemaker placement she again went into RVR and this time
dropped her pressures to the 70's-90's systolic. She was
transferred to the CCU where she was loaded with amiodarone.
Lopressor was initially held during amiodarone load and then
restarted at 12.5 mg TID and titrated to 25 mg po TID prior to
discharge. She was transitioned to oral amiodarone 400 mg [**Hospital1 **] x
1 week, 200 mg [**Hospital1 **] x 1 week and then 200 mg daily x 1 week. She
is chronically anticoagulated on coumadin at home. This was
held during part of her stay for invasive procedures. On
discharge, given her history of TIA/stroke, we recommend IV
heparin gtt (previously theraputic on 800 units/hr) while
awaiting possible repeat bone marrow biopsy on [**2150-5-25**]. After
that procedure, coumadin can be re-initiated at her previous
dosing, which is 3 mg qhs on MWF and 2 mg on STThSunday.
.
# Tachy-Brady Syndrome: As noted above, patient developed
significant sinus pauses requiring pacemaker placement. Device
was placed without complications. She received 4 doses of
Vancomycin for prophylaxis. She will need to follow up in device
clinic on [**2150-5-21**].
.
# Acute on Chronic kidney failure: Initial creatinine was
elevated at 2.3, with baseline of 1.7-1.9. This was felt to be
due to a component of poor foward flow/CHF. Her creatinine
normalized with gentle diuresis.
.
# Pancreatic tail hypodensity: Noted on CT abdomen. MRI abdomen
showed no pancreatic tail mass, so likely it was artifact noted
on CT scan.
.
# Hypertension: Patient was continued on home regimen of
amlodipine and metoprolol. HCTZ was stopped in the setting of
hypercalcemia.
.
# Hypercalcemia: Pts calcium was elevated at 11-12. Her HCTZ and
calcium supplements were stopped. PTH was checked and was low at
10. This indicates likely malignancy-related hypercalcemia. Pt
was given pamidronate 30 mg IV x1 on [**5-11**]. She will need her
calcium levels monitored and may require periodic pamidronate.
.
# Chronic aortic dissection: Noted on CT of the lungs with
'extensive calcifications of the aorta noted as well as areas of
mural thrombus and potential focal area of small dissection at
the level of the aortic arch'. Discussed with [**Month/Year (2) 1106**], and this
is NOT an acute aortic dissection, but rather just a chronic
finding from choleterol plaques.
.
# ?Clot vs tumor on TTE: TTE commented on possible tumor vs. PE
in the pulmonary artery. CTA was performed and showed no
pulmonary artery abnormality.
.
# Peripheral [**Month/Year (2) 1106**] disease: Continued atorvastatin and
aspirin 325mg daily. She was continued on Neurontin for
neuropathic pain.
.
# Contact: [**Name (NI) **], daughter and HCP [**Telephone/Fax (1) 61968**], [**Telephone/Fax (1) 61969**]
.
She was discharged to the [**Hospital 100**] Rehab MACU for IV heparin and
pulmonary rehab.
Medications on Admission:
Norvasc-atorvastatin 5mg-10 mg daily
Neurontin 100 mg in the morning and 300 mg in the evening
HCTZ 12.5 mg daily
Toprol 50 mg daily
Protonix 40 mg daily
Coumadin 3 mg four days a week and 4 mg three days a week
Ambien 10 mg at bed
ASA 325 mg daily
Discharge Medications:
1. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
10. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QAM (once
a day (in the morning)).
11. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4H
(every 4 hours) as needed for Pain.
12. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
13. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
16. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for insomnia.
17. Heparin
Patient needs to be on heparin drip, running at 800 units an
hour, till her INR becomes therapeutic (between 2 and 3).
Target PTT while on heparin is 60 to 80. Her PTT needs to be
checked every 8 hours to make sure that the PTT is therapeutic.
18. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
19. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 1 weeks: start [**2150-5-23**].
20. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 4 days.
21. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): to begin on [**2150-5-30**].
22. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Five (5) ML
Intravenous PRN (as needed) as needed for line flush.
23. Sodium Chloride 0.9 % 0.9 % Syringe Sig: Five (5) ML
Injection Q8H (every 8 hours) as needed for line flush.
24. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO
every eight (8) hours.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary:
Left pleural effusion
Lymphoma
Right upper lobe lung nodules
Diastolic heart failure
Moderate aortic stenosis
Functional mitral stenosis
Acute on chronic kidney disease
.
Secondary:
Atrial fibrillation
Discharge Condition:
Improved shortness of breath, back to baseline per patient.
Saturating 93-96% on room air while resting on [**1-28**] liters by
nasal canula. Saturation decreases to 89 while walking and 88%
while sleeping. Hemodynamically stable.
Discharge Instructions:
You were admitted to [**Hospital1 69**] with
shortness of breath. You were found to have a left pleural
effusion. Your pleural fluid was drained and found to be caused
by a lymphoma. You were evaluated by Hematology/Oncology. They
performed a bone marrow biopsy with the results pending at the
time of discharge. You need to follow up with You need out
patient follow up by your primary care doctor.
.
Please take the medications as written. You need to be on
heparin drip until your INR (warfarin's blood thinning levels)
are therapeutic (between 2 and 3).
.
Please keep all of the follow up appointments as mentioned
below.
.
If you develop chest pain, shortness of breath, fever or any
other concerning symptoms, please call your primary care doctor
or go to the nearest Emergency Department.
Followup Instructions:
1. Oncology: Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD
Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2150-5-25**] 11:00 to discuss further
workup of lymphoma.
.
2. Pulmonary: You have a follow up appointment with a lung
specialist, Dr. [**Last Name (STitle) **] on Monday, [**6-8**] at 8:30 AM. You
will need to get a Chest Xray prior to that. Please show up to
the radiology department at 8:00 AM to get the chest Xray prior
to the appointment. The telephone number to reach their office
is [**Telephone/Fax (1) 3020**].
3. Cardiology follow up: Provider: [**Name10 (NameIs) 676**] CLINIC
Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2150-5-21**] 2:30
.
Other previously scheduled appointments are:
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2150-9-8**] 11:15
Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2150-9-14**]
1:30
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2150-9-14**] 2:10
|
[
"518.89",
"585.3",
"577.9",
"428.33",
"427.31",
"427.81",
"428.0",
"530.81",
"441.00",
"202.80",
"275.42",
"403.90",
"584.9",
"396.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.72",
"41.31",
"37.83",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
27007, 27073
|
17798, 24227
|
269, 321
|
27328, 27563
|
5005, 17775
|
28412, 28971
|
3582, 3753
|
24526, 26984
|
27094, 27307
|
24253, 24503
|
27587, 28389
|
3768, 4986
|
28982, 29557
|
222, 231
|
349, 2975
|
2997, 3277
|
3293, 3566
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,047
| 135,570
|
4569+55588
|
Discharge summary
|
report+addendum
|
Admission Date: [**2126-6-6**] Discharge Date: [**2126-6-14**]
Date of Birth: [**2052-5-13**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Codeine
Attending:[**Doctor Last Name 10493**]
Chief Complaint:
dyspnea, melena
Major Surgical or Invasive Procedure:
Colonoscopy
Endoscopy (EGD)
History of Present Illness:
74 year-old woman on anticoagulation w/ lovenox with a history
of bilateral PEs dx [**2126-5-14**], CRI, and CHF who now presents with
melena x 1 day and sob. She is s/p admit to medical service w/
?progression of PE/ increased clot burden. At that time, she
presented w/ sob that quickly resolved spontaneously, but
CTA/LENI's showed bilateral PEs/high clot burden. It was thought
that patient may have failed her coumadin that was dosed [**2126-5-14**]
on initial presentation of PE (dx'd by v/q scan). Heme was
consulted and recommended high dose lovenox at 1.5 mg/kg [**Hospital1 **]
(see their consult note). Pt was d/c home on this yesterday.
.
Pt reports returning from the hospital yesterday, doing well w/o
dyspnea, until this am when she noticed very dark brown stools,
slightly looser than normal. She denied any hematochezia. She
had normal stools yesterday and has never had melena before.
Denies abdominal pain, but notes increased heartburn over the
past several days, which is relieved with Tums. This am, with
black stool, she noted shortness of breath, no change from her
d/c, which resolved during transport to the hospital. In the ED,
another black stool was accompanied by faintness, diaphoresis,
and pallor with ambulation. She was unable to cooperate with
orthostatics due to her symptoms. Given protonix, ordered for 2
units of prbc's for hct drop 35-->27. Denies palpitations or
prior sx of orthostasis. Pt noted HTN this am, with SBP approx
170, associated with dyspnea.
On last admission, was felt to have failed coumadin and
therefore was discharged on Lovenox at 1.5mg/kg [**Hospital1 **]. No factor
Xa levels available.
ROS: negative for CP, abdominal pain palpitations, fever,
chills, dizziness. +sore throat since hospitalization.
Past Medical History:
1. Bilateral pulmonary emboli, diagnosed on [**5-14**], on lovenox
2. s/p IVC filter, [**6-4**]
3. Bipolar disease
4. CRI secondary to lithium toxicity, with baseline creatinine
1.4-1.9
5. Mild congestive heart failure with EF 45-50% in [**5-/2126**]
6. Chronic back pain
7. Hypothyroidism
8. Osteoporosis
9. Choledochoduodenostomy [**2126-4-3**] for ampullary stricture and
re-hospitalized from [**Date range (1) 19423**] for diarrhea.
10. Gastric banding ([**2098**])
11. Cholecystectomy ([**2098**])
12. Diverticulosis
13. LBBB
Social History:
She lives with her son. Non-[**Name2 (NI) 1818**]. She denies EtOH consumption.
Family History:
Non-contributory
Physical Exam:
VS: T 99 HR 99-103, BP 89/69, repeated at 100/66, SaO2 98%/RA
GEN: some pallor, o/w comfortable, alert & oriented
HEENT: anicteric, nontraumatic
CHEST: CTA b/l, no r/r/w
CV: RRR, slightly tachycardic, no m/r/g
ABD: soft, nontender, nondistended, BS+, liver edge 2cm below
costal margin
EXT: large, indurated hematoma in right thigh, tender to touch,
no bruit; no tracking into back; 1+ pitting edema, 1+ right DP
BACK: no back tenderness, no bruising
rectum: grossly positive, melena
NEURO: intact exam, good historian, alert and oriented x 3
Pertinent Results:
[**2126-6-6**] 10:20PM WBC-9.5 RBC-3.32* HGB-8.3* HCT-27.5* MCV-83
MCH-24.9* MCHC-30.1* RDW-17.3*
[**2126-6-6**] 10:20PM NEUTS-77.3* LYMPHS-19.7 MONOS-2.7 EOS-0.3
BASOS-0.1
[**2126-6-6**] 10:20PM PLT COUNT-395
[**2126-6-6**] 09:30PM WBC-10.6 RBC-3.63* HGB-9.2* HCT-30.7* MCV-85
MCH-25.3* MCHC-30.0* RDW-17.0*
[**2126-6-6**] 09:00PM CALCIUM-7.9* PHOSPHATE-3.8 MAGNESIUM-1.8
IRON-57
[**2126-6-6**] 01:15PM GLUCOSE-141* UREA N-43* CREAT-1.9* SODIUM-139
POTASSIUM-4.6 CHLORIDE-103 TOTAL CO2-24 ANION GAP-17
[**2126-6-6**] 01:15PM WBC-9.6 RBC-4.31 HGB-10.6* HCT-34.9* MCV-81*
MCH-24.5* MCHC-30.3* RDW-16.9*
-------------------
CXR ([**6-6**]): IMPRESSION: No acute cardiopulmonary process.
.
Abd CT : IMPRESSION:
1. Large right thigh/groin hematomas. No retroperitoneal
hemorrhage
identified.
2. IVC filter in place.
3. Otherwise, overall stable appearance of the abdomen and
pelvis compared to the exam of [**2126-5-4**].
.
ECHO [**6-4**]: mild symmetric LVH, mildly depressed EF. Resting
regional wall motion abnormalities include anteroseptal and
apical HK. Right ventricular systolic function is borderline
normal. The ascending aorta is mildly dilated. The aortic arch
is mildly dilated. Mild (1+) mitral regurgitation is seen. The
left ventricular inflow pattern suggests impaired relaxation.
There is a trivial/physiologic pericardial effusion. Compared
with the prior study (tape reviewed) of [**2126-5-16**], right
ventricular cavity size is now smaller and free wall motion is
improved.
.
R groin u/s ([**6-6**]): IMPRESSION: Large right groin hematoma.
R groin u/s ([**6-11**]): IMPRESSION: Right groin hematoma is
decreased in size. No evidence of a pseudoaneurysm.
.
colonoscopy ([**6-10**]): Grade 2 internal hemorrhoids, diverticulosis
of the sigmoid colon, transverse colon and distal ascending
colon, no evidence of active gastrointestinal bleeding.
EGD ([**6-10**]): Previous gastroenterostomy of the stomach. The
efferent limb was explored until the distal gastroenterostomy
anastomosis was found. Bilious secretions were seen around the
anastomotic site. Again, no blood or ulcers were detected. There
was no blood or anastomic ulcers visualized in the gastric
pouch. Otherwise normal egd to gastroenterostomy
Brief Hospital Course:
Impression: 74yo woman w/ recent PEs and presumed coumadin
failure on high-dose LMWH in setting of CRI initially admitted
to MICU with melena and concern for UGIB and large right thigh
hematoma, now stable.
.
Hospital course is detailed below by problem:
.
1. Melena: Pt was admitted with melena, noted to have a Hct drop
of 34->27 in the setting of lovenox treatment for DVT/PEs. She
was admitted to the MICU, where she was transfused and her
anticoagulation was discontinued. On [**2126-6-10**], she had a
colonoscopy and EGD which showed no bleeding source. Meanwhile,
the pt's melena resolved. On discharge, she is no longer having
any melena.
.
2. Thigh hematoma: While in the MICU, the patient was noted to
have a rapidly expanding hematoma in her right thigh. The
vascular surgery team was called to evaluate it; after 15mins of
pressure, the bleeding halted. Pt was transfused (see above). On
discharge, the hematoma is diffusing and improving. She had an
ultrasound that showed a hematoma, then a repeat u/s showing it
as much smaller with no pseudoaneurysm.
.
3. PE/DVT: The patient had been on lovenox 80mg sq [**Hospital1 **] at home
when she began to bleed. All anticoagulation (including aspirin)
was thus stopped for her hospitalization. Since she had an IVC
filter, it was considered safe to keep her off the lovenox. She
did not experience any symptoms of PE. Given her history of PEs
and DVTs, the hematology team recommended beginning lovenox and
coumadin after 1 more week without anticoagulation. On [**2126-6-18**],
she should begin lovenox 1mg/kg renally dosed (70mg) sc bid as
well as coumadin 10mg po x 1 dose. On [**2126-6-19**], the coumadin
should be changed to 5mg po qd and maintained with goal INR [**1-17**].
The lovenox should be discontinued 48hrs after coumadin is
therapeutic to goal INR of [**1-17**]. Please check an INR qday
beginning on [**2126-6-18**].
.
4. ARF: During her hospitalization, the pt's Cr rose to 2.2 but
resolved with blood and fluids.
.
Medications on Admission:
1. Levothyroxine Sodium 112 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
6. Fluvoxamine Maleate 50 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
7. Benztropine Mesylate 0.5 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QSUN (every
Sunday).
10. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Enoxaparin Sodium 80 mg/0.8 mL Syringe Sig: Eighty (80) mg
Subcutaneous Q12H (every 12 hours) for 6 weeks.
Disp:*90 syringes* Refills:*0*
Discharge Medications:
1. Levothyroxine Sodium 112 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Fluvoxamine Maleate 50 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
5. Benztropine Mesylate 0.5 mg Tablet Sig: One (1) Tablet PO
once a day.
6. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Coumadin 10 mg Tablet Sig: One (1) Tablet PO once for 1
doses: Please give on [**2126-6-18**].
11. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day:
Begin [**2126-6-19**]. Titrate to goal INR [**1-17**].
12. Enoxaparin Sodium 30 mg/0.3 mL Syringe Sig: One (1)
Subcutaneous once a day: Begin on [**2126-6-18**]. Continue 48hrs after
INR reaches goal [**1-17**].
13. Enoxaparin Sodium 40 mg/0.4mL Syringe Sig: One (1)
Subcutaneous once a day: Begin on [**2126-6-18**]. Continue for 48hrs
after INR reaches goal [**1-17**].
14. Alendronate 70 mg Tablet Sig: One (1) Tablet PO qSun.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 620**]
Discharge Diagnosis:
GI bleed
Right thigh hematoma
Discharge Condition:
Good
Discharge Instructions:
Continue your medicines as prescribed. Call your doctor if you
have any blood in your stools, or black, tarry stools, if you
have any difficulty breathing, lightheadness, dizziness, chest
pain, or new bruising. You are being started on coumadin to thin
your blood and will need to have your coumadin levels checked
frequently.
Followup Instructions:
Call Dr.[**Name (NI) 19421**] office ([**Telephone/Fax (1) 10492**]) for an appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**] MD, [**MD Number(3) 10495**]
Name: [**Known lastname 3165**],[**Known firstname **] Unit No: [**Numeric Identifier 3166**]
Admission Date: [**2126-6-6**] Discharge Date: [**2126-6-14**]
Date of Birth: [**2052-5-13**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Codeine
Attending:[**Doctor Last Name 3167**]
Addendum:
Pt noted to have R arm cellulitis at site of IV after discharge.
Was started on clindamycin 300mg po q6hours for 7 day course.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 176**] Of [**Location (un) 407**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 3168**] MD, [**MD Number(3) 3169**]
Completed by:[**2126-6-14**]
|
[
"428.0",
"296.7",
"244.9",
"459.0",
"311",
"562.10",
"584.9",
"285.1",
"578.9",
"453.8",
"455.0",
"415.19"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"45.23",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
11408, 11643
|
5652, 7648
|
298, 328
|
10302, 10308
|
3388, 5629
|
10683, 11385
|
2791, 2809
|
8801, 10128
|
10249, 10281
|
7674, 8778
|
10332, 10660
|
2824, 3369
|
243, 260
|
356, 2121
|
2143, 2676
|
2692, 2775
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,259
| 184,115
|
21775
|
Discharge summary
|
report
|
Admission Date: [**2109-10-14**] Discharge Date: [**2109-11-5**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Fever/chills
Major Surgical or Invasive Procedure:
(1) [**2109-10-15**] Left Video-assisted thoracoscopy converted to Left
thoracotomy with decortication of Left Lung
(2) [**2109-10-25**] Bronchoscopy
(3) [**2109-10-27**] Bronchoscopy
(4) Left Lung TPA Fibrinolysis [**2109-10-19**], [**2109-10-20**], and [**2109-10-21**]
History of Present Illness:
This is a 82 year old female who was transferred from [**Hospital 40796**] after being hospitalized for 6 days for presumed
pneumonia. She had presented at the outside hospital with
several days of fevers and chills. On admission there she had a
white blood cell count of 18,000. A Chest CT on [**2109-10-13**]
demonstrated a left multi-loculated empyema. She was treated
with Levofloxacin at the outside hospital and then switched to
Clindamycin/Zithromax/Zosyn after infectious disease
consultation. On admission to [**Hospital1 18**] the patietn denies shortness
of breath or productive cough. She denies feeling febrile or
having chills.
Past Medical History:
Hypertension
Diabetes Mellitus
Mitral Valve Prolapse
Anemia of Chronic Disease
Bronchiectasis
Diverticulitis
Social History:
The patient lives at home with her husband. She denies ever
smoking or drinking alcohol.
Family History:
non-contributory
Physical Exam:
ON admission [**10-14**]:
v/s 56.8 kg, 98.4, 94, 133/50, 22, 96% on 2 liters
Gen: no acute distress, resting comfortably, alert, oriented to
place and time
Neuro: CN 2-12 grossly intact
HEENT: moist mucous membranes, PERRLA, no icterus
CV: regular rate and rhythm, no murmurs
Pulm: Significant rhonchi on the Left
Abdomen: soft, non-tender/non-distended, + bowel sounds
Extr: no edema
*
ON transfer to medicine service [**11-2**]:
PE: vitals- T 96.7, BP 123/42, RR 28, O2 96% on 3L O2,
gen: sitting up in bed, alert, non-cooperative w/ questions of
orientation "i know where i am"
HEENT: EOMI. PERRLA. OP clear
neck: supple, no jvd, no bruits
Pulm: ronchi b/l lower lobes. coarse upper breath sounds; L old
central line site, dressed w/ gauze: c/d/i.
CV: RRR. nl s1/s2. no m/r/g
ABD: soft, nt, nd. well-healing left thoracotomy site
EXT: 1+ pedal edema. left superficial ulcer w/ serous drainage;
sacral stage II decubitus ulcer packed w/ duoderm
Neuro: confused,agitated, non-cooperative w/ exam. [**4-17**] motor
strength.
*
Pertinent Results:
[**2109-10-14**] 09:14PM BLOOD WBC-18.3* RBC-3.67* Hgb-10.6* Hct-30.6*
MCV-83 MCH-28.8 MCHC-34.7 RDW-13.9 Plt Ct-457*
[**2109-10-22**] 06:25AM BLOOD WBC-30.4* RBC-2.91* Hgb-8.2* Hct-25.1*
MCV-86 MCH-28.3 MCHC-32.8 RDW-14.6 Plt Ct-634*
[**2109-10-23**] 06:25AM BLOOD WBC-22.7* RBC-3.58* Hgb-10.0* Hct-29.9*
MCV-83 MCH-28.1 MCHC-33.7 RDW-14.9 Plt Ct-599*
[**2109-10-28**] 03:07AM BLOOD WBC-12.6* RBC-4.14* Hgb-12.0 Hct-35.1*
MCV-85 MCH-29.0 MCHC-34.2 RDW-15.3 Plt Ct-355
[**2109-10-15**] 06:50PM BLOOD PT-13.4 PTT-25.8 INR(PT)-1.1
[**2109-10-16**] 05:58AM BLOOD PT-12.7 PTT-25.3 INR(PT)-1.0
[**2109-10-28**] 03:07AM BLOOD PT-12.1 PTT-28.9 INR(PT)-0.9
[**2109-10-14**] 09:14PM BLOOD Glucose-170* UreaN-26* Creat-0.8 Na-132*
K-4.6 Cl-97 HCO3-26 AnGap-14
[**2109-10-16**] 05:58AM BLOOD Glucose-73 UreaN-19 Creat-0.7 Na-135
K-4.5 Cl-102 HCO3-26 AnGap-12
[**2109-10-21**] 06:05AM BLOOD Glucose-39* UreaN-22* Creat-0.7 Na-137
K-4.5 Cl-98 HCO3-30* AnGap-14
[**2109-10-27**] 04:40AM BLOOD Glucose-99 UreaN-11 Creat-0.6 Na-133
K-4.6 Cl-91* HCO3-30* AnGap-17
[**2109-10-28**] 03:07AM BLOOD Glucose-90 UreaN-15 Creat-0.6 Na-134
K-3.7 Cl-91* HCO3-34* AnGap-13
[**2109-10-14**] 09:14PM BLOOD ALT-15 AST-11 AlkPhos-88 TotBili-0.6
[**2109-10-14**] 09:14PM BLOOD Calcium-9.0 Phos-2.2* Mg-1.7
[**2109-10-16**] 05:58AM BLOOD Calcium-8.3* Phos-2.9 Mg-2.4
[**2109-10-27**] 04:40AM BLOOD Calcium-8.7 Phos-2.3* Mg-1.8
[**2109-10-28**] 03:07AM BLOOD Calcium-8.6 Phos-3.4 Mg-2.5
ENDOCRINOLOGY:
[**2109-10-20**] 04:25PM BLOOD TSH-2.8
[**2109-10-15**] 06:40AM BLOOD %HbA1c-7.8*
RESPIRATORY:
[**2109-10-25**] Bronchoscopy: Left lower lobe full of thick mucoid
secretions which were sent for microbiology, trachea with normal
anatomy and some secretions, left upper lobe washed with washing
sent for pathology, thick secretions in the right lower lobe
[**2109-10-27**] Bronchoscopy: Patent trachea, thick mucous plug
obstructing the left mainstem bronchus (removed and sent for
culture), patent left upper lobe, purulent secretions in left
lower lobe, patent right mainstem/upper lobe/ lower lobe
RADIOLOGY:
[**2109-10-18**] Chest CT:
1) Status post placement of two left-sided chest tubes, which
are appropriately placed within the pleura. There has been
interval decrease in the degree of loculated pleural fluid,
although a significant amount remains with some irregular
thickening of the pleural space/fluid.
2) A spiculated lung mass is now seen at the left lung apex,
with enlargement of AP window and precarinal lymph nodes. These
findings are highly suspicious for malignancy.
3) Significant bilateral lower lobe bronchiectasis, with
endoluminal secretions. There has been interval endoluminal
obstruction of the right lower lobe bronchus due to secretions,
with some degree of atelectasis as well as a small pleural
effusion which has developed in the interval.
Further Studies:
*ECHO [**10-25**]- EF 60%, normal walls, mild PA HTN (30mmHg), no
effusion, no vegetations
*CT Chest [**10-28**]- patchy opacities assymm in both lungs, most
suggestive of multi-focal pna, bulky intrathoracic
lymphadenopathy, irregular pleural thickening adjacent to left
mediastinum with nodular left diaphramatic pleural thickening. ?
[**1-14**] malignant process; moderate pericardial effusion;
intermediate L. adreanal lesion. L.sided pleural efusion has
decreased in interval with improved aeration of l. lung. R
effusion has slightly worsened.
*L ARm u/s ([**2109-10-31**])- no evidence of DVT
*CXR [**11-1**]- b/l effusions, multifocal pna
*CXR [**11-2**]- No significant interval change in the bilateral
pneumonia
MICROBIOLOGY:
[**2109-10-15**] Intraoperative swab: STREPTOCOCCUS MILLERI
[**2109-10-21**] Blood Culture: negative
[**2109-10-25**] Bronchial lavage culture: Gram Negative Rods, Yeast
[**2109-10-25**]:Bronchial Washings: Klebsiella Oxycota- pan sensitive
Brief Hospital Course:
Brief Overview of Hospital Course:
82 y/o female with chronic b/l lower lobe bronchiectasis with
frequent LLL pneumonia. Originally admitted to OSH on [**2109-10-8**]
for LL pna. she was treated with clindamycin, zosyn,
azithromycin. Had CT chest on [**2109-10-12**], which showed loculated
pleural effusions. She also had a thoracentesis performed at OSH
which was c/w exudative effusion. She was transferred to [**Hospital1 18**]
for VATS decortication which was done on [**2109-10-15**] by the thoracic
surgery service. Initial culture of empyema grew out rare strep
milleri which was treated w/ IV PCN G. The pt had a persistent
leukocytosis despite tx w/ abx. She was evaluated for repeat
thoracentesis w/ U/S on [**2109-10-22**] but no tappable fluid was seen.
She underwent bronchoscopy on [**2109-10-25**] for diagnosis of LUL
lesion seen on repeat CT scan. Left upper lobe was washed with
washing sent for pathology. This showed atypical squamous cells
(uncertain significance-needs biopsy for further evaluation). At
the same time, the left lower lobe was found to be full of thick
mucoid secretions which were sent for microbiology. These grew
out 2+ GNR's. Antibiotic regimen was changed to levofloxacin and
meropenem on [**2109-10-27**].
On [**10-29**], she developed acute increased work of breathing and
inability to clear her respiratory secretions , so she was
intubated emergently and transferred to MICU. At that time,
surgery did not feel that any further surgical intervention was
indicated. While in MICU [**Date range (3) 57198**] she was treated with
aggressive pulmonary toilet. Vanco was started for emperic MRSA
coverage. Final cultures from [**10-25**] bronchoscopy returned as
Klebsiella pan-sensitive, so she was weaned to Levofloxacin.
Meropenem and Vanco were discontinued. She was extubated on
[**10-31**]. She Remained afebrile on Levo/PCN G and was able to
maintain O2 sats on 3 Liter O2 via NC, so she was transferred to
the general medicine service on [**2109-11-2**].
On the medicine service, she continued to have some difficulty
clearing her secretions. She was continued on aggressive chest
physical therapy in addition to accapella valve and percussive
vest. This helped to clear her secretions, and she has had no
further episodes of desaturations or respiratory distress. She
has progressed well with decreasing productive cough and
secretions. She has remained afebrile and well-appearing on PCN
G IV and Levofloxacin. She will need to complete her antibiotic
regimen with a total of 21 days of Levo (last day=[**2109-11-18**]) and 6
week total course of PCN G (last day =[**2109-11-25**]). As for her
respiratory status, she has been maintained at 4 L O2 via nasal
canula to maintain O2 sats >93%. This is the level she is on
upon discharge. She may be weaned down to room air as long as
she is able to maintain her O2 sats at [**Last Name (un) 57199**] than 93%. In
addition, she should continue to have chest PT for her thick
secretions, since this will be a chronic issue from her
bronchiectasis.
A brief problem based plan is outlined below:
1) Bronchiectasis/Pneumonia: Multilobar pna w/ persistent
secretions. Bronchial washings from [**10-25**] grew klebsiella
oxytoca pan-sensitive. Per ID, she will need Levofloxacin (day
1= [**10-29**]) for total of 21 day course (Last day will be [**11-18**]).
She will need continued aggressive pulmonary toilet to clear
secretions. O2 via NC to maintain O2 sats>93%. Guaifenesin as
necessary to decrease cough.
2)Empyema: VATS decortication w/ culture positive for Strep
Milleri. Treated with IV PCN. Per ID, needs 6 week total course
of PCN G. Last day = [**2109-11-25**].
3)Volume overload: She was noted to have 1+ pedal edema and
elevated JVP on admission to the medicine service, so we gave
her 20mg IV lasix for a goal of -500 to -1000 cc over night. She
was -800cc over a 24 hour period. For the next 24 hour period we
allowed her to self-diurese, which she did with good effect. She
was negative one liter for the day [**11-4**]. She does not likely
need ongoing diuresis, since her ECHO showed no evidence of CHF
(no systolic or diastolic dysfunction). Her edema is likely
secondary to low albumin/poor nutrition in combination with
deconditioning. Her right upper extremity edema is secondary to
IV infiltration. An extremity ultrasound was performed and was
negative for clot. She has had good resolution of edema,
although it will likely take another week or two before she is
euvolemic. Please monitor strict in's and out's and daily
weights to help assess her volume status. Encouraging daily
adequate nutrition and physical therapy will also help.
4)HTN: Her blood pressure has been well-controlled on Valsartan
and Atenelol.
5)Pyuria: Moderate bacteria on U/A [**11-1**], however final urine
cultures were negative. Foley catheter is now discontinued. No
further antibiotic changes necessary.
6)LUL mass- Cytology from the Left upper lung mass was
non-diagnostic. A follow-up lung biopsy will be deferred to the
outpatient setting. She may have a repeat CT scan in 3 months.
7) DMII- We re-started her on glyburide 5mg qday and this may be
tapered up as necessary for glycemic control.
8) FEN: She passed her video swallow study and was maintained on
a diabetic/cosistent carbohydrate diet with supplemental vitamin
C and zinc. We also added sugar free shakes for increased
nutritional support given her low albumin.
9) Prophylaxis: For prophylaxis, we used [**Male First Name (un) 14261**], PPI, bowel
regimen, HOB at 60 degrees, fall precautions and Heparin SQ.
Once she is ambulating she will no longer need sub-cutaneous
heparin.
10)Access: Right arm PICC for IV antibiotic delivery.
11)Communications: [**Name (NI) 57200**] son [**Name (NI) **]: [**Telephone/Fax (1) 57201**]; [**Name2 (NI) **] [**Name (NI) **]:
[**Telephone/Fax (1) 57202**]
12)Code: Full Code- discussed at family meeting [**2109-11-2**]
Medications on Admission:
ON admission:
Glyburide 10 mg oral [**Hospital1 **]
Norvasc 5 mg Oral Daily
Atenolol 50 mg oral [**Hospital1 **]
Digoxin 0.125 mg oral daily
Diovan/Hydrochlorothiazide 80/12.5 mg oral daily
NO Known Drug Allergies
Discharge Medications:
1. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
ml Injection TID (3 times a day).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours).
4. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
5. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical QID
(4 times a day) as needed.
6. Lidocaine HCl 5 % Ointment Sig: One (1) Appl Topical QID (4
times a day) as needed for groin pain.
7. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
8. Guaifenesin 600 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO bid ().
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
10. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
12. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
13. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
14. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
15. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet Sig: One
(1) Packet PO TID (3 times a day).
16. Trazodone HCl 50 mg Tablet Sig: 0.5 Tablet PO HS (at
bedtime) as needed.
17. Valsartan 80 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
18. Glyburide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
19. Penicillin G Pot in Dextrose 2,000,000 unit/50 mL Piggyback
Sig: Two (2) MU Intravenous Q4H (every 4 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
(1) Left Empyema- s/p VATS; organism: strep milleri
(2) Hypertension
(3) Chronic Anemia
(4) Diabetes II
(5) Multifocal Pneumonia- oranism: Klebsiella
(6) Left upper lobe mass- non-specific cytology washings, needs
further follow up as outpatient.
Discharge Condition:
Good. Improved respiratory status-- requires chest physical
therapy and suctioning for secretions. Afebrile and
hemodynamically stable on current antibiotic regimen. PICC for
delivery of IV Penicillin.
Discharge Instructions:
1. Please contact the office or come to the emergency room with
any worsening shortness of breath or chest pain, drainage from
your incision, fever >101.0, pain not improved with pain
medications. Do not drive while taking narcotics. Please take
all medications as prescribed. Call with any questions
2. You should record your blood sugars and blood pressure
regularly to help your physician with optimal Diabetes and
hypertension management.
3.We recommend a repeat lung CT in 3 months to re-evaluate the
status of the left upper lobe lung mass. This may be followed-up
through your PCP.
Followup Instructions:
1.Please follow-up with Dr. [**Last Name (STitle) **] on [**2109-11-20**] at 12:15pm; You may
call to confirm your appointment at [**Telephone/Fax (1) 37283**].
2.Please f/u with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 175**] in thoracic surgery on
[**2109-11-21**] at 2:30pm. [**Hospital 23**] Clinic-[**Location (un) 24**]. You may call to
confirm your appointment at [**Telephone/Fax (1) 170**].
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
|
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"494.0",
"793.1"
] |
icd9cm
|
[
[
[]
]
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[
"34.51",
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icd9pcs
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[
[
[]
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,470
| 180,444
|
38364
|
Discharge summary
|
report
|
Admission Date: [**2201-6-18**] Discharge Date: [**2201-6-24**]
Date of Birth: [**2117-11-24**] Sex: M
Service: NEUROLOGY
Allergies:
Penicillins / Novocain
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
nausea/vomiting, L arm weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname **] is a 83yo R handed man with HTN, [**Hospital **] transferred
from [**Hospital **] hospital with subacute L PICA infarction. He was
initially transferred to the Neurosurgery service out of a
concern for a possible hemorrhage, however on review of the
imaging, there is no evidence for hemorrhage or edema in need of
neurosurgerical intervention.
As per the neurosurgery admission note, the patient patient
reports carrying his daughters dog into the car around 6pm 4
days
ago when he noted the sudden onset of intense nausea, "dry
heaves," as well as dizziness and feeling unsteady on his feet.
He sat down in his daughter's car and was unable to be moved and
he was then taken via EMS to [**Hospital **] Hospital. There he noted
his
left arm "felt numb." The patient was admitted to the hospital
for evaluation of mild RUQ pain. Abdominal CT revealed
cholithiasis and no cholecystitis. A mass at the bladder trigone
was noted. Given the pt's protracted N/V and left arm symptoms
an
MRI brain was performed today at 2pm. Study revealed subacute L
PICA infarct. MRA was degraded by motion, there is a R dominant
vertebral artery. L vert not visualized.
The patient notably reports focal left neck tenderness. He is
otherwise without diplopia, headache, difficulty producing or
comprehending speech. His gait is quite unsteady and he has not
been walking since admission to [**Hospital1 **] four days ago.
On gen ROS, denies fever, chills, night sweats or weight loss.
He has continued nausea and poor appetite. He denies CP and SOB.
He does report L shoulder pain.
Past Medical History:
Hypertension
BPH
carpal tunnel- s/p L release
Social History:
Married, lives with his wife and daughter, he is a
retired computer engineer who worked on hardware for Compaq,
never smoker, rare ETOH, no illicit or IV drug use.
Family History:
both parents lived "long lives" and died in old age.
Physical Exam:
PHYSICAL EXAM:
O: T: 98 BP: 130/80 HR: 66 R: 14 O2Sats: 100% 2LNC
Gen: WD/WN, comfortable, NAD.
HEENT: NCAT
Neck: Supple, focal L posterior neck tenderness. No carotid
bruits bilaterally.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT (NO RUQ TENDERNESS), BS+
Extrem: Warm and well-perfused. 2+ symmetric radial pulses.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date. Names [**Doctor Last Name 1841**]
backwards without difficulty
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, he has R
beating nystagmus with L gaze only.
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. there is slight L
pronator drift, he has a L hemiparesis, weakness of L delt, Tri,
FE, FA [**3-30**]. Full strength biceps. L IP, H, TA [**3-30**]. Full at
Quadriceps. R side is [**4-29**] throughout.
Coordination: slow, clumsy L hand movements
(dysdiadochokinesia).
dysrhythmic L foot tapping. dysmetria on L FNF. No clear
abnormality with heel knee shin bilaterally.
Sensation: Intact to light touch. Does not fully cooperate with
propioception testing, but intact to gross movements. pinprick
intact.
Reflexes: B T Br Pa Ac
Right 0 0 0 0 0
Left 1 1 1 1 0
Toes downgoing bilaterally
Gait: deferred.
Pertinent Results:
[**2201-6-20**] 06:30AM BLOOD WBC-6.8 RBC-4.41* Hgb-12.8* Hct-38.7*
MCV-88 MCH-29.1 MCHC-33.1 RDW-13.2 Plt Ct-295
[**2201-6-19**] 12:29AM BLOOD WBC-9.4 RBC-4.33* Hgb-13.3* Hct-38.1*
MCV-88 MCH-30.7 MCHC-34.8 RDW-13.3 Plt Ct-261
[**2201-6-20**] 06:30AM BLOOD Neuts-79.9* Lymphs-13.9* Monos-3.5
Eos-2.4 Baso-0.3
[**2201-6-20**] 06:30AM BLOOD Plt Ct-295
[**2201-6-20**] 06:30AM BLOOD PT-12.5 PTT-30.2 INR(PT)-1.1
[**2201-6-19**] 11:45AM BLOOD ESR-87*
[**2201-6-21**] 01:30PM BLOOD ESR-80*
[**2201-6-20**] 06:30AM BLOOD Glucose-128* UreaN-24* Creat-1.4* Na-139
K-3.4 Cl-104 HCO3-27 AnGap-11
[**2201-6-22**] 01:10PM BLOOD Glucose-82 UreaN-28* Creat-1.3* Na-140
K-3.9 Cl-105 HCO3-23 AnGap-16
[**2201-6-22**] 01:10PM BLOOD TotProt-6.1* Albumin-3.7 Globuln-2.4
Calcium-8.7 Phos-3.8 Mg-2.0
[**2201-6-19**] 11:45AM BLOOD %HbA1c-5.6 eAG-114
[**2201-6-19**] 11:45AM BLOOD Triglyc-93 HDL-73 CHOL/HD-2.8 LDLcalc-114
[**2201-6-19**] 11:45AM BLOOD CRP-248.5*
[**2201-6-21**] 01:30PM BLOOD CRP-117.2*
UPEP/SPEP both normal
[**Doctor First Name **] positive with very low titer 1:80
Imaging:
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 mild hypokinesis of
the distal septum and apex. The remaining segments contract
normally (LVEF = 55%). No masses or thrombi are seen in the left
ventricle. Doppler parameters are most consistent with Grade I
(mild) left ventricular diastolic dysfunction. There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The ascending aorta is mildly
dilated. The aortic arch is mildly dilated. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Mild (1+) aortic regurgitation is seen. Mild (1+)
mitral regurgitation is seen. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
IMPRESSION: No left ventricular thrombus seen. Mild regional
left ventricular systolic dysfunction, c/w CAD. Mild aortic and
mitral regurgitation. Dilated thoracic aorta.
TEE:
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium or left atrial appendage. No atrial septal
defect is seen by 2D or color Doppler. The left ventricle is not
well seen. There are complex (>4mm) atheroma in the aortic arch.
There are simple atheroma in the descending thoracic aorta. The
aortic valve leaflets (3) are mildly thickened. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is no
pericardial effusion.
IMPRESSION: Suboptimal image quality secondary to hiatal hernia.
No LA/LAA thrombus seen. No PFO/ASD at rest or with maneuvers.
Complex (>4mm, nonmobile) atheroma in the aortic arch and simple
plaque in the descending aorta.
CXR:
The lungs are hyperinflated and the diaphragms are flattened,
consistent with
COPD. There is mild-to-moderate cardiomegaly. The aorta is
slightly
unfolded. There is a moderate-sized hiatal hernia. There are
small bilateral
pleural effusions seen on the lateral view posteriorly. No CHF.
Doubt focal
infiltrate. Minimal bibasilar atelectasis. Probable small
calcified
granuloma in the right mid zone measuring approximately 3.5 mm
and overlying
the right fifth anterior rib. Degenerative changes of the
thoracic spine are
noted. Possible minimal anterior wedging of several lower
thoracic vertebral
bodies is suggested, unlikely to be acute.
IMPRESSION:
1) Background COPD.
2) Small bilateral effusions posteriorly. Doubt acute
infiltrate.
3) Moderate- sized hiatal hernia.
Head CT/CTA:
HEAD CT: There is a hypodense lesion in the left cerebellar
hemisphere
causing effacement of the fourth ventricle, consistent with
acute left
cerebellar infarct with history of left PICA. There is no
evidence of
hemorrhage, edema, mass effect, elsewhere in the brain. The
ventricles and
sulci are normal in caliber and configuration. The basal
cisterns are patent.
Visualized paranasal sinuses and mastoid air cells are clear.
CTA:
Neck CTA: There is a normal three-vessel aortic arch. The
origins of both
common carotid and vertebral arteries are normal. The cervical
common carotid
arteries are normal. The right vertebral artery is dominant and
the left
vertebral artery is developmentally hypoplastic. The cervical
portion of the
internal carotid arteries and vertebral arteries are normal.
Head CTA: The hypoplastic left vertebral artery gives off the
left posterior
inferior cerebral artery, just before it enters the dura (3:194)
and appears
unremarkable. The attenuated left vertebral artery continues on
to form the
basilar artery. The right vertebral artery supplies the major
flow of the
basilar system. The basilar artery and the major intracranial
branches are
normal, without evidence of occlusion or flow-limiting stenosis
or aneurysm
formation. The intracranial portion of both internal carotid
arteries and
their major branches are normal in their course without evidence
of occlusion,
stenosis, or aneurysm formation.
The thyroid gland is enlarged, left lobe greater than right. The
hypoattenuating left lobe nodule measures 3.7 x 3.1 cm.
IMPRESSION:
1. Cerebellar infarct in the territory of left PICA, with mild
mass effect on
the fourth ventricle and effacement of the cerebellar folia. No
evidence of
herniation.
2. No vascular occlusion, significant flow limiting stenosis or
aneurysm
greater than 2 mm identified in the CTA.
3. Enlarged nodular thyroid gland, involving the left lobe
greater than right,
needs further evaluation with a thyroid ultrasound.
US abd/gall bladder:
FINDINGS: Note is made that this is a limited study due to the
patient's body
habitus. The liver shows no focal or textural abnormality. No
biliary
dilatation is seen and the common duct measures 0.2 cm. The
portal vein is
patent with hepatopetal flow. A small amount of sludge and
several small
gallstones are seen moving within the lumen of the gallbladder.
There is no
gallbladder wall thickening and no pericholecystic fluid is
identified. The
pancreas is obscured from view by overlying bowel. The spleen is
unremarkable
and measures 9.2 cm. There is no hydronephrosis. The right
kidney measures
9.2 cm and the left kidney measures 9.1 cm. A small parapelvic
cyst is seen
in the left kidney measuring 0.9 cm. No AAA is identified. No
ascites is
seen in the abdomen.
IMPRESSION: Small amount of sludge and several small gallstones
within the
gallbladder, but no son[**Name (NI) 493**] signs of cholecystitis.
Brief Hospital Course:
The patient was initially admitted with nausea, vertigo and
difficulty with gait. He was also noted to have significant
difficulty coordinating the movement of your left arm. You were
first sent to [**Hospital **] Hospital. The patient was also
complainting of abdominal pain. At the OSH he was evaluted for
mild RUQ pain -> an abdominal CT revealed no cholecystitis.
There was a question of a small mass in the bladder trigone
although it was not clear and he will need urology workup as an
outpatient. Given the protracted symptoms of nausea and
vomiting he had an MRI which revealed a L SCA infarct. As a
result of this he was transferred to the [**Hospital1 18**]. He was
initially transferred to the neurosurgery service, however based
on his findings he was sent to the neurology service.
At [**Hospital1 18**] we further evaluated the patient to find the underlying
cause of the stroke. Based on a complaint of neck pain we
obtained a CTA to help evaluate possible dissection, however no
evidence of dissection was seen. There was a enlarged nodular
thyriod gland, that will need a thyroid ultrasound as an
outpatient. His thyroid function was normal.
We kept the patient on telemetry and did not notice any atrial
fibriliation. There was an echo cardiogram of his heart which
did not note any source of thrombus. A TEE was obtained which
showed no LA/LAA thrombus seen. No PFO/ASD at rest or with
maneuvers. Complex (>4mm, NON-mobile) atheroma in the aortic
arch and simple plaque in the descending aorta.
The patient had elevated inflammatory markers including an ESR
of 80 and a CRP as high as 250 which came down to 117. It is
not clear why these are elevated, he did not appear to have an
underlying infection. He had mutiple negative blood cultures,
and no fevers or evidence of underlying infectious processes.
He had a normal chest x-ray and a normal UA. He had a normal
SPEP and UPEP. He has a positive [**Doctor First Name **] but with a very low titer.
He will need these inflammatory markers checked when he returns
to clinic.
The secondary stroke risk factors were also checked. The
hgba1c = 5.6. The LDL was 117 and he was started on a statin.
In addition based on his initial complaint of abdominal pain he
had normal liver enzymes as well as a normal ultrasound of the
liver and gall bladder.
Neuro
- given his intracranial stenosis and risk of stroke he will
maintain on plavix
- he will not be started on coumadin given his current falls
risk
CV
- c/w statin
- c/w Diltiazem Extended release 180mg daily
Urology
- will need f/u for question of a bladder mass as an outpatient
- the patient is not scheduled for any chemotherapy in the next
week, this area will need workup first
Thyroid
- normal TFTs, however abnormal enlargement of thyroid seen on
CT will need re-eval with thyroid U as an outpatient
Medications on Admission:
Diltiazem Extended release 180mg daily
Aspirin 325mg daily
Nitroglycerin sublingual PRN (does not use)
Multivitamin
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Diltia XT 180 mg Capsule,Degradable Cnt Release Sig: One (1)
Capsule,Degradable Cnt Release PO once a day.
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Multivitamin Capsule Sig: One (1) Capsule PO once a day.
5. Famotidine 20 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) as needed for constipation.
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Cerebellar infarct - Left Superior Cerbellar Artery
Discharge Condition:
MS: awake, alert, interactive, axox3. Language intact, repition
intact, comprehension intact, recalls [**1-28**] at 5 min
CN: on left gaze left beating nystagmus, o/w EOMI, PERRL, face
symmetric, facial [**Last Name (un) 36**] intact
Motor: mild weakness at left deltoid, 5-/5 at hamstring
bilaterally. Appears weaker on left but given coordination
problems does not often give full effort.
no drift
[**Last Name (un) **]: no deficits to LT, mild pinprick and vibration loss at
feet, slight 2 point discrimination on left hand
[**Last Name (un) **]: dysmetria on FNF and HKS on left side. Overshoot and
increased cerebellar rebound on L
Gait: unable to stand, needs two person assist to walk, very
unsteady.
Discharge Instructions:
You were transferred from an outside hospital after you were
found to have a sub-acute left sided stroke in an area of your
brain called the cerebellum. This part of the brain is
responsible for coordination and balance and it has made it
dififcult to coordinate the use of your left hand as well as
walk. A stroke in this area is often caused by a clot from
another area. We attempted to find an underlying cause of your
stroke. You were on telemetry and it did not show any irregular
rhythms. You had a echo-cardiogram of your heart which did not
show any clots. You had a trans-esophageal echo of your heart
which was also normal. You also had elevated inflammatory
markers (they are called ESR and CRP). While these can happen
after stroke they were higher than we usually see post stroke.
You did not have an underlying infection, no infections in the
urine or chest x-ray. We checked an measure of proteins in your
blood called an SPEP/UPEP which were normal. You secondary
stroke risk factors were also checked. A test of your blood
sugar was normal (hgba1c = 5.6). A test of your cholesterol was
slighlty high (LDL=117) and you were placed on a cholesterol
lowering medication.
In addition you had an initial complaint of abdominal pain. You
had normal enzymes and an ultrasound of your liver and gall
bladder which was normal. It was also noted that you have a
slighlty enlarged thyroid gland that should be followed as an
outpatient with an ultrasound.
Please take all medications as prescribed. Please make all
follow up appointments. If you have any acute worsening of your
symptoms or new symptoms (new weakness, difficulty with
language) please call your doctor or return to the nearest
emergency room.
Followup Instructions:
Please follow up with
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2201-9-1**] 2:00
[**Hospital1 18**] [**Hospital Ward Name **] - [**Hospital Ward Name **] 8.
Please follow up with your PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 56498**]
upon discharged from rehab
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
[
"728.87",
"440.0",
"496",
"600.00",
"781.3",
"V15.88",
"553.3",
"414.01",
"401.9",
"596.8",
"272.4",
"790.95",
"241.0",
"719.7",
"789.01",
"790.1",
"434.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
14429, 14501
|
10717, 13577
|
317, 324
|
14597, 15308
|
4105, 7767
|
17092, 17605
|
2215, 2270
|
13744, 14406
|
14522, 14576
|
13603, 13721
|
15332, 17069
|
2300, 2631
|
245, 279
|
352, 1947
|
2946, 4086
|
7776, 10694
|
2646, 2930
|
1969, 2017
|
2033, 2199
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,532
| 146,875
|
17853+56899
|
Discharge summary
|
report+addendum
|
Admission Date: [**2144-2-25**] Discharge Date: [**2144-3-26**]
Date of Birth: [**2083-9-14**] Sex: F
Service: CARDIOTHOR
HISTORY OF PRESENT ILLNESS: The patient is a 60 year old
diabetic woman with a history of atypical chest pain with
recent presentation with congestive heart failure in [**2144-1-18**], now admitted after transfer from an outside hospital
with near syncope. She reports being on diuretics for CHF
and was having a routine chest x-ray on [**2-19**] when she
collapsed. She was found to be dehydrated and had pre-renal
azotemia. She was admitted at that time and rehydrated. ETT
done was positive for anterior lateral as well as inferior
ischemia. Transferred to [**Hospital1 188**] at that time for cardiac catheterization. Please see
cath report for full details. She was found to have a
totally occluded RCA, 65% left main, some circumflex disease
and some distal LAD disease.
PAST MEDICAL HISTORY: Significant for type 2 diabetes
mellitus on insulin, fibromyalgia, anemia, obesity,
congestive heart failure with diastolic dysfunction,
restrictive lung disease, dyslipidemia, cataracts, gastritis.
MEDICATIONS ON ADMISSION: Prevacid 30 mg q.d., Glucophage
1000 mg b.i.d., amitriptyline 50 mg q.h.s., Neurontin 900 mg
q.h.s., hydrocodone 5/500 q.d. p.r.n., [**Doctor First Name **] 60 mg b.i.d.,
albuterol nebs p.r.n., Flovent two puffs b.i.d., lorazepam
0.5 to 1 mg p.r.n., aspirin 325 q.d., Effexor 10 mg q.d.,
enalapril 5 mg q.d., Lasix 40 mg b.i.d., Aldactone 25 mg
t.i.d., multivitamin one q.d., FiberCon q.d., calcium 600 mg
q.d., nystatin 5 cc swish and swallow q.i.d., Toprol 25 mg
q.d.
PHYSICAL EXAMINATION: Vital signs were heart rate in the 70s
sinus rhythm, blood pressure 116/70, respiratory rate 16.
Lungs decreased anterior laterally with no wheezing. Neck
was supple, no JVD. Heart regular rate and rhythm, distant
heart sounds, no murmurs, gallops or rubs appreciated.
Extremities without bleeding, trace dorsalis pedis pulses, 1+
lower extremity edema. Neuro alert and oriented times three.
Moves all extremities, 5/5 strength.
HOSPITAL COURSE: As stated previously, the patient was
admitted and went for cardiac catheterization. Please see
cath report for full details. In summary, the cath report
showed an EF of 50%. Left main 60%. LAD 80% with diffuse
disease. Circumflex 60%. RCA totally occluded proximally
with left to right collaterals from LAD. Following cath CT
surgery was consulted. Patient was seen by CT surgery and
accepted for surgery. On [**2-28**] she was brought to the
operating room. Please see the operative report for full
details. In summary, patient had coronary artery bypass
grafting times three with LIMA to LAD, saphenous vein graft
to OM and saphenous vein graft to RCA. She tolerated the
operation and was transferred from the operating room to the
cardiothoracic intensive care unit. At the time of transfer
patient had mean arterial pressure of 82, CVP 19, PAD 22.
Heart rate was sinus rhythm at 84 beats per minute. She had
Neo-Synephrine 1 mcg per kg per minute and propofol 30 mcg
per kg per minute.
The patient had a poor cardiac index upon arrival in the
CSRU. At that time she was initially given fluids without
response. She was started on dobutamine with minimal
response. Dobutamine was switched to milrinone with good
effect. Patient did well over the next 24 hours. On
postoperative day two patient's cardiac function had
significantly improved. Milrinone was slowly weaned off.
Sedation was also minimized. Patient's ventilatory status
continued to need support. She was switched from IMV
ventilation to pressure support ventilation and slowly weaned
from the ventilator as well. On postoperative day three all
cardioactive IV medications had been weaned to off. Patient
was awake and was ventilating with minimal support from the
ventilator. She was successfully extubated on the morning of
postoperative day three.
Over the next several days the patient remained in the
intensive care unit. Neurologically she was oriented,
however, she remained very lethargic and her respiratory
status merited continuous monitoring. Therefore, she
remained in the intensive care unit. Hemodynamically she
remained stable at that time. On postoperative day six
patient's neurologic status had improved sufficiently and she
was transferred to the floor for continued postoperative care
and cardiac rehabilitation. Patient was slow to progress
once on [**Hospital Ward Name 121**] 2, which is the cardiac surgery recovery floor.
Ten days after surgery she was noted to have redness in the
area of the distal sternal incision with minimal surrounding
erythema. In addition, her leg wounds were noted to have
minimal erythema as well. She was started on Kefzol for both
these wounds. Legs were elevated when she was not
ambulating. Despite these measures, the wounds continued to
worsen. The chest wound developed increasing erythema with
an area of dry eschar at the distal pole. The lower
extremities remained edematous with mild erythema surrounding
the saphenous vein graft sites.
Simultaneously a syncope workup was begun. The patient was
seen by neurology and she had carotid ultrasound done.
Neurology recommendations were outlined and followed.
Carotid ultrasound showed right internal carotid stenosis of
60% to 69% and left carotid stenosis of less than 40%. In
addition, [**Hospital **] clinic was consulted for treatment of
patient's diabetes. On postoperative day 12 with the wounds
continuing to deteriorate, plastic surgery was asked to
consult on patient's chest wounds. It was the feeling of the
plastics consult that the erythema of the chest wall was due
to ischemia and that cellulitis was secondary. They had
decided at that time to pursue conservative treatment,
continuing patient's antibiotics, however, at that time they
were changed to Levaquin and vancomycin, despite the fact
that plastic surgery felt it was a sterile dehiscence.
Over the next two weeks the patient remained hospitalized,
waiting for her chest wound to develop and declare itself.
It remained an area of dry eschar. By the end of the second
week a 4 cm x 2 cm area had opened on the right lateral side
of the chest wound with fibrinous drainage from that wound
margin. The total area of the wound was about 4 cm x 9 cm of
dry eschar with another 4 to 5 cm of erythema surrounding the
wound. Neurologically patient remained alert and oriented.
Cardiovascularly patient remained hemodynamically stable.
From a pulmonary standpoint patient had good air exchange
with good oxygen saturation. From an infectious disease
standpoint, to this point patient has been culture negative
and afebrile with normal white blood cell count. She remains
on vancomycin and Levaquin with adequate vancomycin levels.
From a GI standpoint patient is tolerating a diabetic cardiac
diet with blood glucoses in normal range on metformin, NPH
insulin and Humalog sliding scale.
It has been discussed between plastic surgery and
cardiothoracic surgery that appropriate care at this point
would be to allow patient to go to a rehabilitation setting
where she can continue her cardiac rehabilitation while
awaiting her sternal wound to further deteriorate, at which
point she will be sharp debrided +/- flap and skin graft
closure by plastic surgery. On post-op day 26 it was decided
that patient could be transferred to rehabilitation while
continuing her antibiotics, waiting for her wound to further
dehisce, at which time she will be reconstructed by plastic
surgery.
At the time of transfer the patient's physical exam is as
follows. Vital signs are temperature of 98.4, heart rate 94
sinus rhythm, blood pressure 123/58, respiratory rate 18, O2
92% in room air. Weight preoperatively was 111.2 kg, at
discharge is 108.3 kg. Alert and oriented times three.
Moves all extremities, follows commands. Respiratory clear
to auscultation bilaterally, diminished somewhat on the left.
Heart regular rate and rhythm, S1, S2, no murmur. Sternum
with positive click, has an area of eschar that is
approximately 9 x 6 cm in the distal [**11-22**] of her chest wound,
open on the right side 4 cm in length 1 to 2 cm open with
fibrinous versus purulent drainage in that area. There is
approximately 3 to 4 cm of surrounding erythema. Abdomen is
soft, nondistended, nontender, normoactive bowel sounds.
Extremities have 3 to 4+ pedal edema. Left leg saphenous
vein graft site with minimal erythema, however, very tender
to touch.
Lab data white count 6.0, hematocrit 27.6, platelets 320.
Sodium 138, potassium 3.6, chloride 100, CO2 28, BUN 12,
creatinine 1.0, glucose 75. Vancomycin level peak 25.7,
trough 10.3.
DISCHARGE MEDICATIONS:
1. Enteric coated aspirin 325 mg q.d.
2. Combivent two puffs q.four hours.
3. Flovent two puffs b.i.d.
4. Metformin 1000 mg b.i.d.
5. NPH insulin 14 units in the a.m., 12 units in the p.m.
6. Humalog sliding scale.
7. Atorvastatin 10 mg q.d.
8. Multivitamin one tab q.d.
9. Levofloxacin 500 mg q.d.
10. Vancomycin 1250 mg q.24 hours, please check peak and
trough after the third dose.
11. Elavil 25 mg q.h.s.
12. Venlafaxine XR 37.5 mg q.d.
13. Lasix 40 mg b.i.d.
14. Heparin 5000 units subcutaneously b.i.d.
15. Vitamin C 500 mg b.i.d.
16. Metoprolol 50 mg b.i.d.
CONDITION ON DISCHARGE: Stable.
FOLLOWUP: She is to have followup with Dr. [**Last Name (STitle) 1537**] in two to
four weeks. Follow up with Dr. [**Last Name (STitle) 13797**] in the plastic
surgery division whenever the wound further dehisces and
needs sharp debridement. Follow up with her primary care
provider following discharge from rehabilitation.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Name8 (MD) 415**]
MEDQUIST36
D: [**2144-3-25**] 13:15
T: [**2144-3-25**] 13:22
JOB#: [**Job Number 49519**]
Name: [**Known lastname 9187**], [**Known firstname 9188**] Unit No: [**Numeric Identifier 9189**]
Admission Date: [**2144-2-25**] Discharge Date: [**2144-3-27**]
Date of Birth: [**2083-9-14**] Sex: F
Service:
ADDENDUM TO DISCHARGE SUMMARY:
The patient was initially scheduled for discharge on [**2144-3-26**]; however, secondary to difficulty with regards to
procuring a rehabilitation bed, the patient's discharge was
delayed for approximately 25 hours.
The patient was subsequently discharged to an extended care
facility on [**2144-3-27**], with instructions for follow-up.
Please see previously dictated Discharge Summary for
Discharge Medications and Discharge Instructions.
DR.[**Last Name (STitle) **],[**First Name3 (LF) 63**] 02-248
Dictated By:[**Last Name (NamePattern1) 9133**]
MEDQUIST36
D: [**2144-3-27**] 14:17
T: [**2144-3-27**] 17:11
JOB#: [**Job Number 9190**]
|
[
"458.0",
"682.2",
"E878.2",
"998.59",
"599.0",
"414.01",
"428.0",
"424.0",
"411.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"39.61",
"88.56",
"89.68",
"36.12",
"38.93",
"37.23",
"88.53"
] |
icd9pcs
|
[
[
[]
]
] |
8766, 9341
|
1179, 1650
|
2124, 8743
|
1673, 2106
|
172, 929
|
952, 1152
|
9366, 10929
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,703
| 188,566
|
39191
|
Discharge summary
|
report
|
Admission Date: [**2194-5-28**] Discharge Date: [**2194-6-10**]
Date of Birth: [**2131-6-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Esophageal Cancer
Major Surgical or Invasive Procedure:
[**2194-5-28**]:
1. [**First Name9 (NamePattern2) 12351**] [**Doctor Last Name **] esophagectomy.
2. Buttressing of intrathoracic anastomosis with
pericardial fat pad.
3. Surgical laparoscopic jejunostomy.
4. Therapeutic bronchoscopy.
5. Diagnostic esophagoscopy.
History of Present Illness:
Mr. [**Known lastname 28221**] is a 62 years old gentleman with newly diagnosed
Adenocarcinoma of the GE junction. He has had a long history of
reflux, lasting for ten years, on management for the last eight
years with Nexium and other acid blockers. He was first found to
have Barrett's esophagus, short segment, six years ago. He is
being followed by EGD routinely. Last EGD done at the beginning
of [**2194-3-27**] in
[**State 1727**] he was found to have high-grade dysplasia with a question
of intramural adenocarcinoma in his Barrett's segment. Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], has confirmed the presence of at least
intramucosal adenocarcinoma. He is being admitted for
[**First Name9 (NamePattern2) 12351**] [**Doctor Last Name **] esophagectomy.
Past Medical History:
Crohn's disease, stable on Pentasa
Dyslipidemia
Hypertension
GERD
Iron Deficiency Anemia
Atrial Fibrillation on Coumadin,
Multinodular goiter.
Social History:
Drinks two beers a day and does not smoke tobacco
Family History:
Positive for a mother who died at age [**Age over 90 **] with colon cancer.
Physical Exam:
VS: 98.2 HR: 70 afib BP: 110/4 Sats: 98% RA
General: 62 year-old male sitting in chair no apparent distress
HEENT: normcephalic, voice mildly hoarse, mucus membranes moist
Neck: supple no lymphadenopathy
Card: irregular normal S1,S2
Resp: decreased breath sounds on right faint crackles left lower
lobe
GI: bowel sounds positive, abdomen soft non-tender/non-distended
Extr: warm no edema
Incision: abdominal site clean dry intact, margins well
approximated.
R. VATs site clean dry intact no erythema
Skin: left forearm mild edema, erythema
Neuro: awake, alert, oriented. moves all extremities
Pertinent Results:
[**2194-6-9**] WBC-9.4 RBC-3.08* Hgb-9.1* Hct-28.4 Plt Ct-660*
[**2194-6-6**] WBC-17.1* RBC-3.22* Hgb-10.1* Hct-30.7* Plt Ct-462*
[**2194-6-4**] WBC-16.6*# RBC-3.46* Hgb-10.9* Hct-32.9 Plt Ct-459*
[**2194-6-3**] WBC-8.1 RBC-3.29* Hgb-10.3* Hct-31.7 Plt Ct-335
[**2194-6-2**] WBC-8.8 RBC-3.19* Hgb-10.1* Hct-30.1 Plt Ct-317
[**2194-5-29**] WBC-7.7 RBC-3.13* Hgb-9.8* Hct-29.6 Plt Ct-231
[**2194-5-28**] WBC-11.6*# RBC-3.22* Hgb-10.5* Hct-31.2 Plt Ct-227
[**2194-6-10**] Glucose-118* UreaN-14 Creat-0.6 Na-136 K-4.3 Cl-103
HCO3-26
[**2194-6-9**] Glucose-116* UreaN-15 Creat-0.6 Na-138 K-3.7 Cl-105
HCO3-25
[**2194-6-6**] Glucose-147* UreaN-24* Creat-0.7 Na-136 K-3.9 Cl-101
HCO3-23
[**2194-6-3**] Glucose-126* UreaN-22* Creat-0.7 Na-143 K-3.7 Cl-109*
HCO3-26
[**2194-6-2**] Glucose-141* UreaN-22* Creat-0.6 Na-142 K-4.0 Cl-111*
HCO3-25
[**2194-5-29**] Glucose-137* UreaN-19 Creat-0.7 Na-137 K-4.0 Cl-106
HCO3-22
[**2194-5-28**] Glucose-162* UreaN-18 Creat-0.7 Na-138 K-4.5 Cl-105
HCO3-21
[**2194-5-31**] ALT-419* AST-119* AlkPhos-50 TotBili-0.6
[**2194-6-10**] INR(PT)-1.5* [**2194-6-9**] INR(PT)-1.4* [**2194-6-8**]
INR(PT)-1.2*
[**2194-6-7**] INR(PT)-1.2* [**2194-6-5**] INR(PT)-1.3* [**2194-6-5**]
INR(PT)-1.2*
Esophagus: [**2194-6-3**]: FINDINGS: Thin barium contrast passes
freely through the proximal esophagus into the gastric pull-up,
with no evidence of leak or obstruction. Progression into the
small bowel is within normal limits.
CXR:
[**2194-6-8**] opacity in the right mid and lower zones, consistent
with pleural
effusion and underlying collapse and/or consolidation. There is
minimal
blunting of the left costophrenic angle and some atelectasis at
the left lung base. No CHF.
[**2194-6-6**]: New right mid and lower lung zone opacities consistent
with aspiration or pneumonia.
[**2194-6-2**]:Decrease of the left retrocardiac opacity with mild
residual atelectasis. Slight increase of a moderate left pleural
effusion.
[**2194-6-1**]: Right chest tube remains in place. There is no evident
pneumothorax. Right subcutaneous emphysema has improved.
Cardiomediastinal contours are unchanged with evidence of pull
through. NG tube is in unchanged position with tip at the level
of the hemidiaphragm. Left lower lobe consolidation has
worsened, could be atelectasis but superimposed infection cannot
be totally excluded. Small left pleural effusion is unchanged.
[**2194-5-29**]: Cardiomediastinal contours are unchanged. Patient has
been extubated. NG tube and right chest tube remain in place.
There is no pneumothorax or enlarging pleural effusions. Left
lower lobe aeration have improved. Right lower lobe opacity
consistent with atelectasis has minimally worsened. There is
minimal right chest wall subcutaneous emphysema.
Chest CT [**2194-6-4**]:
1. No evidence of PE to the subsegmental levels.
2. 46 x 47 mm chest wall collection inferior to the right
scapula may
represent a fluid collection. Although non-enhancing, an
infection in this
region is a consideration. Neighboring subcutaneous emphysema is
present.
Minimally rim-enhancing subjacent pleural loculations are seen,
which are also suggestive of an infectious process.
3. Wedge shaped hypodensity within the superior/medial aspect of
the spleen is most likely a small infarct.
4. Small bilateral pleural effusions, with some loculations at
the right base, accompanied by neighboring compressive
atalectasis.
5. status post esophagectomy with gastric pullup. the
anastamoses appear
intact, however, further evaluation is limited due to lack of
oral contrast at this level.
[**2194-6-5**]: Lower Extremity Dopplers
Occlusive thrombus is seen within the two left peroneal veins in
the left calf. No vascular flow is detected on color Doppler
imaging. The remainder of the vessels demonstrate normal flow,
compression and augmentation. Note is made that the peroneal
veins could not be identified in the right calf.
IMPRESSION: Deep vein thrombosis in the left peroneal veins.
Cultures: [**6-4**]/`0 BC x 2 no growth, sputum no growth
Brief Hospital Course:
Mr. [**Known lastname 28221**] was admitted on [**2194-5-28**] for an uncomplicated [**First Name9 (NamePattern2) 12351**]
[**Doctor Last Name **] esophagectomy. Buttressing of intrathoracic anastomosis
with pericardial fat pad. Surgical laparoscopic jejunostomy.
Therapeutic bronchoscopy. Diagnostic esophagoscopy. He
transferred to SICU intubated in stable condition with Right CT
and JP drain in place. He was successfully extubated on
[**2194-5-29**].
Respiratory: aggressive pulmonary toilet, nebs and chest PT and
ambulation he titrated off supplemental oxygen with room air
oxygen saturations 98%.
Chest tube and JP was removed following the esophagus study
which was negative for anastomotic leak.
Chest films: he was followed by serial chest films with showed
bilateral atelectasis and small left lower lobe effusion. On
[**2194-6-5**] his chest film
Cardiac: He remained in atrial fibrillation 70-80 rate control
on IV Lopressor. On [**2193-6-3**] he was converted to his home dose
Toprol XL 25 mg daily. Blood pressure stable 100-120's.
GI: NGT was removed on POD4. Abdomen mildly distended,
non-tender. With rectal suppository his bowel function returned
with decrease abdominal distention. No episode of diarrhea his
Pentasa was restarted.
Nutrition: POD1 tube feeds were slowly titrated to goal of 60
mL/hr and maintained on IV fluids until tube feed goal obtained.
Fingerstick blood sugars were 100-136.
Renal; Foley removed 0/08/10. He was volume overloaded gently
diuresis with IV Lasix. His renal function remained normal with
good urine output. His electrolytes were replete as needed. He
was discharged home with 4 days of Lasix 40 mg and Kcl 20 mEq
with instruction for daily weights and to contact his PCP should
he require further treatment.
Heme: HCT stable at 29-31. His warfarin 5mg daily was restarted
[**2194-6-3**] for atrial fibrillation. On [**2194-6-5**] he had lower
extremity Doppler which showed Deep vein thrombosis in the left
peroneal veins. He was given 7.5 mg Warfarin [**6-9**] & 15, 5 mg on
[**6-11**]& 17. Discharged INR [**6-10**] 1.5. He will follow-up with his
PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 39450**] for warfarin management starting Friday [**6-13**].
ID: On [**2194-6-4**] he spike a fever of 102 with leukocytosis 16.6
peak 19.3. A Chest CT was done (see report) and pan cultured
which was all negative. Chest X-ray showed aspiration
pneumonia. He was started on IV Vancomycin and Zosyn x 5 days
then changed to Cipro & Flagy for 7 days on discharge. He had
no further fevers.
IV access: Right PICC line was placed for antibiotics
administration. It was removed on [**2194-6-10**].
Pain: Dilaudid/Bupivacaine epidural with good pain control was
managed by the acute pain service. On [**2194-6-3**] he converted to
PO pain medication with good control.
Neuro: no neuro events or concerns during this hospitalization.
Disposition: He was seen by physical therapy who deemed him safe
for home. He will follow-up with Dr. [**First Name (STitle) **] as an outpatient and
Dr. [**Last Name (STitle) 39450**] for his warfarin management.
Medications on Admission:
Atorvastatin 10 mg daily, Lansoprazole 30 mg twice daily,
Mesalamine 1000 mg q8H, Metoprolol Succinate 25 mg [**Hospital1 **], Warfarin
5 mg daily except 2.5 mg M-Th-Sat
Discharge Medications:
1. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
[**Hospital1 **]: One (1) Tablet Sustained Release 24 hr PO twice a day.
2. Warfarin 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO Once Daily at 4
PM: then 2.5 mg on M-Th-Sat.
3. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] every twelve (12) hours.
4. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Last Name (STitle) **]: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain.
Disp:*400 ML(s)* Refills:*0*
5. Atorvastatin 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
6. Mesalamine 500 mg Capsule, Sustained Release [**Last Name (STitle) **]: Two (2)
Capsule, Sustained Release PO every eight (8) hours.
7. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve [**Last Name (STitle) **]: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours.
Disp:*8 Tablet, Rapid Dissolve(s)* Refills:*2*
8. Sertraline 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
9. Iron 325 mg (65 mg Iron) Tablet [**Last Name (STitle) **]: One (1) Tablet PO every
twelve (12) hours.
10. Ciprofloxacin 750 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a
day for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
11. Flagyl 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO every eight (8)
hours for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
12. Furosemide 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QAM for 4
days.
Disp:*4 Tablet(s)* Refills:*0*
13. Potassium Chloride 20 mEq Packet [**Last Name (STitle) **]: Four (4) PO QAM for 4
days: take with lasix.
Disp:*4 packets* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
smmc visiting nurses
Discharge Diagnosis:
Crohn's disease, stable on Pentasa
Dyslipidemia
Hypertension
GERD
Iron deficiency anemia
Atrial fibrillation on Coumadin
Multinodular goiter
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 sputum production
-Difficulty or painful swallowing.
-Nausea, vomiting, diarrhea. Take antinausea medication if
needed
-Call immediately if feeding tube falls out. Please bring it
with you to the hospital.
-NOTHING DOWN FEEDING TUBE UNLESS IT IS IN LIQUID FORM
-Sit up in chair for all meals. Remain sitting or standing for
30-45 minutes after eating. Eat small frequent meals.
Warfarin 7.5mg tonight 5 mg WED & THURS. Friday Blood draw and
follow-up with Dr. [**Last Name (STitle) 39450**] for further warfarin dosing
-Daily Weights: keep a log and bring it with you to the
hospital.
-Lasix 40 mg x 4 days with 20mEq of potassium. If you continue
to have lower extremity edema please follow-up with Dr.
[**Last Name (STitle) 39450**] for further diuretics
Followup Instructions:
Follow-up with Dr. [**First Name (STitle) **] [**0-0-**] Date/Time:[**2194-6-24**] 11:00
on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical Center, [**Location (un) 24**]
Chest X-Ray [**Location (un) 861**] Radiology Department 30 minutes before
your appointment
Follow-up with Dr. [**Last Name (STitle) 39450**] [**Telephone/Fax (1) 86780**] for further Warfarin
dosing. Friday
Completed by:[**2194-6-11**]
|
[
"530.85",
"530.81",
"V58.61",
"276.2",
"507.0",
"151.0",
"453.42",
"401.9",
"241.1",
"427.31",
"272.4",
"280.9",
"V12.79"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.6",
"40.3",
"44.13",
"33.23",
"46.39",
"43.99"
] |
icd9pcs
|
[
[
[]
]
] |
11490, 11541
|
6434, 9576
|
339, 608
|
11726, 11726
|
2391, 6411
|
12812, 13244
|
1682, 1760
|
9797, 11467
|
11562, 11705
|
9602, 9774
|
11877, 12789
|
1775, 2372
|
282, 301
|
636, 1432
|
11741, 11853
|
1454, 1599
|
1615, 1666
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,816
| 154,321
|
40061
|
Discharge summary
|
report
|
Admission Date: [**2157-5-23**] Discharge Date: [**2157-6-6**]
Date of Birth: [**2115-6-15**] Sex: M
Service: MEDICINE
Allergies:
Cefepime / Chlorhexidine
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
hypoxemia, cough
Major Surgical or Invasive Procedure:
diagnostic paracentesis
diagnostic and therapeutic paracentesis
History of Present Illness:
This is a 41 year old M with a PMH significant for diabetes,
HCV, ESRD on HD, EtOH cirrhosis (last drink in [**9-21**])c/b ascites
and severe malnutrition. He is not listed for transplant
secondary to his malnurtition. He has had a cough and fever for
the past several days and he was noted to be hypoxemic to the
80s on room air at dialysis. He was noted to have a new RLL
infiltrate with elevated WBC count.
.
In the ED, his initial vitals were 98.2 78 108/75 24 97% 10 L
NRB
.
Cultures were sent and he was given vanc/ceft/levaquin. lactate
2.2. He was admitted to the ICU for pneumonia.
.
He has a history of dysphagia [**3-16**] vocal cord dysfunction and was
not approved for po intake on last discharge. however, he was
reevaluated by speech and swallow at rehab and was clear for
thin liquids.
Past Medical History:
- Type II diabetes
- Grade II esophageal varices
- Portal hypertensive gastropathy
- EtOH and hepatitis C cirrhosis
- "Asthma"
- Allergic Rhinitis
Social History:
Smokes 1PPD.
EtOH abuse (unclear amounts) until [**2156-9-12**].
Family History:
Noncontributory
Physical Exam:
97.8 81 118/76 18 96% 4L NC
Gen: thin, NAD
HEENT:left eyelids fused, NG tube
CV: RRR no m/g/r
Pulm: Crackles bilateral bases
Abd: Soft, Non-tender, Bowel sounds present, moderate ascites
Ext: Trace edema BLE
Neuro: no asterixis
Pertinent Results:
[**2157-5-23**] 12:15PM BLOOD WBC-14.4*# RBC-3.21* Hgb-11.2* Hct-32.4*
MCV-101* MCH-34.9* MCHC-34.5 RDW-17.2* Plt Ct-65*
[**2157-5-23**] 12:15PM BLOOD Neuts-84* Bands-3 Lymphs-5* Monos-6 Eos-2
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2157-5-23**] 12:15PM BLOOD PT-24.0* PTT-40.1* INR(PT)-2.3*
[**2157-5-23**] 12:15PM BLOOD Glucose-54* UreaN-24* Creat-2.0* Na-135
K-3.8 Cl-98 HCO3-33* AnGap-8
[**2157-5-23**] 12:15PM BLOOD ALT-17 AST-37 AlkPhos-142* TotBili-1.5
[**2157-5-23**] 12:15PM BLOOD Calcium-7.7* Phos-3.3# Mg-1.6
[**2157-5-23**] 12:38PM BLOOD Lactate-2.2*
CXR: bibasilar opacities
[**2157-6-3**] Video Swallow study
IMPRESSION:
1. Normal oropharyngeal swallowing videofluoroscopy.
Brief Hospital Course:
Mr. [**Known lastname 88075**] was a 41 year old man with diabetes, HCV, & EtOH
cirrhosis, ESRD on HD that presented with Klebsiella pneumoniae
pneumonia secondary to aspiration.
#. Klebsiella pneumoniae pneumonia
Patient presented from rehab with fever, cough, and relative
hypoxia. In the ER, he was placed unnecessarily on a
non-rebreather mask on admission requiring a brief stay in the
MICU for less than 24 hours. CXR did not show discrete
infiltrate but multi-focal airspace disease present from likely
aspiration. He also had leukocytosis. After initiation of
broad-spectrum antimicrobial therapy with vancomycin, zosyn, and
levofloxacin ([**5-23**] - [**5-27**]), he became afebrile and did not
have an oxygen requirement. His antibiotics were narrowed to
ceftriaxone ([**Date range (1) 88082**]) and he completed a 7-day antibiotic
course with resolution of resipratory symptoms.
# Abdominal pain
Patient reporting RUQ abdominal pain associated with nausea
during hospitalization. Physical exam significant for an
enlarged abdomen from ascites. RUQ did not suggest hepatobiliary
process such as gallbladder disease. Subsequently, a therapeutic
paracentesis was performed with alleviation of the pain.
# Malnutrition/Failure to thrive:
The patient is failing to thrive secondary to poor nutrition and
underlying hepatic disease. He was continued on tube feeds (see
discharge diet). Speech and swallow evaluated patient and
recommended STRICT NPO given the location of his pneumonia and
his high risk for aspiration. The patient was frustrated but
understood the reasons and rationale. He underwent filler
injection to larynx at MEEI durring admission with subsequent
improvent in phonation and aspiration risk profile. Subsequent
video swallow study did not reveal evidence or risk of
aspiration. He was discharged on a thin liquid and soft solid
diet in addition to tube feeding.
# Alcohol and HCV cirrhosis:
Complicated by ascites, grade II esophageal varices, and hepatic
encephalopathy. He did not display encephalopathy during
hospitalization given effective route by NGT ensuring medication
administration. He was continued on lactulose and flagyl with
the latter replacing rifaximin, which has resulted in tube feed
clogs. SBP prophylaxis was held while on broad spectrum
antibiotics but continued at discharge rifaximin replaced with
flagyl because it can clog the tube. He was also continued on
nadolol for portal hypertension and grade II varices.
#. Depression and Anxiety
He was continued on paxil and remeron.
#. End-Stage Renal Disease on HD:
He was mantained on HD as an inpatient and will continue on TTS
schedule.
# Phonation:
Patient has been evaluated by ENT in past with vocal cord issues
resulting in muffled voice. He underwent filler injection to
larynx at MEEI durring admission with subsequent improvent in
phonation and aspiration risk profile. He should follow-up with
ENT as an outpatient.
#. Asthma:
He was continued on fluticasone and albuterol nebulizers. If he
should have recurrent pneumonia, his inhaled steroid dose should
be decreased.
#. Lower Back Pain:
He was continued on oxycodone as needed for back pain.
#. Diabetes Mellitus Type 2
He was continued on sliding scale insulin.
#. Neurotrophic Corneal Abrasion:
His left eye appears white. He has outpatient follow-up with an
oculoplastic surgeon.
Medications on Admission:
aranesp with mon hd
docusate liquid [**Hospital1 **]
mirtazipine 7.5 hs prn
flagyl 500 [**Hospital1 **]
paxil 40 daily
lactulose 20gm [**Hospital1 **]
trazodone 25 hs prn
nadolol 20 daily on non hd days
zofran 4mg po q4h prn
duonebs q6 prn
flovent 220 [**Hospital1 **]
cipro eye drops 2 drops os q4
erythromycin oint daily both eyes
tylenol prn
afrin prn
magic mouthwash prn
mvi liq daily
maalox qq4h prn
artificial tears prn
oxycodone 20 q4 prn
xanax 0.5mg before hd
reg ins sliding scale `
sarna lotion
guafenisin syrup q6 prn
nexium 40 daily
Discharge Medications:
1. Nebulizer
Home nebulizer
Dx: Pneumonia
2. [**Hospital 485**] Hospital Bed
Patient has a medical condition which requires positioning of
the body that is not fesiable in an ordinary bed to alleviate
pain
Dx: Hepatic Cirrhosis, severe malnutirition, pneumonia
3. Nutren 2.0
Tubefeed Nutren 2.0 at 55cc/hr continuous with 50 ml water
flushed every six hours. Tube feeds should be run at 65cc/hr on
dialysis days and held for time at dialysis.
4. mirtazapine 15 mg Tablet [**Hospital **]: 0.5 Tablet PO HS (at bedtime).
Disp:*15 Tablet(s)* Refills:*2*
5. lactulose 10 gram/15 mL Syrup [**Hospital **]: Thirty (30) ML PO BID (2
times a day).
Disp:*qs * Refills:*2*
6. fluticasone 110 mcg/Actuation Aerosol [**Hospital **]: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*qs * Refills:*2*
7. erythromycin 5 mg/gram (0.5 %) Ointment [**Hospital1 **]: One (1)
Ophthalmic DAILY (Daily).
Disp:*qs * Refills:*2*
8. aminocaproic acid 25 % Solution [**Hospital1 **]: One (1) PO every [**5-18**]
hours as needed for bleeding gums.
Disp:*qs * Refills:*2*
9. nadolol 20 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO 4X/WEEK
([**Doctor First Name **],TU,TH,SA).
Disp:*120 Tablet(s)* Refills:*2*
10. rifaximin 550 mg Tablet [**Doctor First Name **]: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
11. ciprofloxacin 500 mg Tablet [**Doctor First Name **]: One (1) Tablet PO once a
day.
Disp:*60 Tablet(s)* Refills:*2*
12. insulin regular human 100 unit/mL Solution [**Doctor First Name **]: 1-10 units
Injection ASDIR (AS DIRECTED): Please see attached sliding
scale.
Disp:*qs * Refills:*2*
13. ipratropium-albuterol 18-103 mcg/Actuation Aerosol [**Doctor First Name **]: [**2-13**]
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
Disp:*qs * Refills:*2*
14. paroxetine HCl 10 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
15. lansoprazole 30 mg Capsule, Delayed Release(E.C.) [**Month/Day (2) **]: One
(1) Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
16. Nephrocaps 1 mg Capsule [**Month/Day (2) **]: One (1) Capsule PO once a day.
Disp:*30 Capsule(s)* Refills:*2*
17. oxycodone 10 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO every four (4)
hours for 9 days.
Disp:*54 Tablet(s)* Refills:*0*
18. alprazolam 0.5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO before
dialysis.
Disp:*4 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA Care [**Location (un) 511**]
Discharge Diagnosis:
Primary: Klebsiella pneumoniae pneumonia, ascites, severe
malnutrition, failure to thrive
Secondary: Alcoholic and Hepatitis C cirrhosis, depression, End
stage renal diseas, neurotrophic corneal abrasion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Mr. [**Known lastname 88075**],
You were admitted to the hospital after aspirating food at your
rehabilitation facility. You were evaluated and treated by the
medicine service. You were found to have a bacterial pneumonia.
You received antibiotics and your symptoms improved. You also
received tube feeding. You were transported to [**State 88083**] where you reveived injections for your vocal
cord dysfunction which improved your voice and swallowing. You
were maintained on your dialysis schedule while admitted to the
hospital and will continue this as an outpatient. Please take
your medications as prescribed and keep your outpatient
appointments.
.
Please review your medications carefully as you have not been
home in quite some time and there may be significant changes
from your home medications. Please only take the medications
ordered from this hospital stay and review all your medications
at your next appointment with your liver specialist and primary
care doctor.
Followup Instructions:
Name: [**Doctor Last Name **],PURVA
Address: 75 SOCKANOSSET CROSSROAD, [**Last Name (un) **],[**Numeric Identifier 88084**]
Phone: [**Telephone/Fax (1) 88085**]
Appt: [**6-13**] at 9:45am
Department: TRANSPLANT
When: WEDNESDAY [**2157-6-22**] at 2:40 PM
With: TRANSPLANT [**Hospital 1389**] CLINIC [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Name: [**Last Name (LF) 9328**],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital **] INFIRMARY
Address: [**Doctor Last Name 18227**], [**Location (un) **],[**Numeric Identifier 18228**]
Phone: [**Telephone/Fax (1) 18229**]
Appt: [**6-22**] at 9:15am
Department: OPHTHALMOLOGY ([**Hospital 13128**] Oculoplastics)
When: MONDAY [**2157-7-18**] at 9:15 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 88080**], M.D. [**Telephone/Fax (1) 32768**]
Building: [**Location (un) 31373**], Massachussetts Eye and Ear Infirmary, [**Last Name (NamePattern1) 88081**], [**Location (un) 86**], MA
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
|
[
"507.0",
"070.54",
"724.2",
"285.9",
"585.6",
"300.4",
"261",
"493.00",
"787.20",
"456.21",
"572.3",
"482.0",
"478.5",
"V45.11",
"537.89",
"789.59",
"250.00",
"783.7",
"371.89",
"571.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"39.95",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
8920, 8983
|
2461, 5820
|
301, 367
|
9231, 9231
|
1752, 2438
|
10415, 11663
|
1468, 1485
|
6415, 8897
|
9004, 9210
|
5846, 6392
|
9409, 10392
|
1500, 1733
|
245, 263
|
395, 1199
|
9246, 9385
|
1221, 1369
|
1385, 1452
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,976
| 105,333
|
46831
|
Discharge summary
|
report
|
Admission Date: [**2167-12-29**] Discharge Date: [**2168-1-7**]
Date of Birth: [**2105-6-4**] Sex: F
Service: [**Year (4 digits) 662**]
Allergies:
Haldol / Darvon / Keppra
Attending:[**First Name3 (LF) 1674**]
Chief Complaint:
Altered mental status, ? hematemesis
.
PCP: ?Dr. [**Last Name (STitle) **], [**Hospital1 **] Community Health
Major Surgical or Invasive Procedure:
intubation
central venous line attempt
arterial line
History of Present Illness:
62yoF with h/o EtOH/Hep C cirrhosis, psychotic, seizure d/o
(none x many years), multiple admission for GI bleeds (portal
gastropathy, grade 4 rectal varices) who now presents from rehab
with altered mental status and ?hematemesis. She has been at
acute rehab from [**12-26**] and was reportedly doing well until early
this morning when she was found to be somnolent/lethargic. There
is some verbal report of perhaps hematemesis although amount and
frequency is unknown (not documented on transfer paperwork). She
was, thus, taken directly to [**Hospital1 18**] ED for further evaluation and
management. Per verbal rehab report, she had been receiving all
of her medications as prescribed upon discharge; it is unclear
if she had been having regular BMs. No report of increased
cough, BRBPR, but additional ROS unclear.
.
Of note, she was admitted [**Date range (1) 99376**] for GI bleed. An EGD on
[**2167-12-19**] showed portal gastropathy only without any evidence of
active bleeding. There was no evidence of varices.
.
Prior to her most recent hospitalization, she was admitted
[**Date range (1) 99375**] for a signficant LGIB s/p TIPS at which time she
presented with black stools, lethargy, and confusion. Hospital
course in [**11/2167**] was complicated by respiratory failure [**2-13**] to
nosocomial pneumonia and pulmonary edema transiently requiring
intubation.
.
In the ED, initial vitals revealed T 101.2 BP 178/113 HR 137 RR
24 O2 sat 100%. She was noted to have BRB in her mouth without
any obvious source of bleed within the oral cavity. She was
noted to have altered mental status and was intubated for airway
protection in this setting. A CT head was performed and read is
pending. She received octreotide 50mcg IV x1, protonix 40mg IV
x1, vitamin K 10mg SC x1, 2 units of FFP. Additionally, she
received ceftazidime 1g IV x1, flagyl 500mg IV x1, and
vancomycin 1g IV x 1. It appears that blood culture x1 was
collected, but not UA/culture.
.
Abdominal U/S in the ED demonstrated interval decrease in the
proximal, mid and distal TIPS velocity, but did show normal
wall-to-wall flow was noted within the TIPS and the main portal
vein and its branches. The TIPS device demonstrates abnormal
pulsatile flow suggesting the presence of possible right heart
failure.
.
Pt admitted to the ICU [**1-1**] for further management of her
altered mental status (s/p intubation for airway protection),
SIRS and probable sepsis and ? GIB. After uneventful 1d course
with improved MS (alert, oriented x2) pt transferred back to
floor [**1-2**].
.
ROS: Unable to obtain from patient.
Past Medical History:
1) Iron deficiency anemia
2) GI bleed - presumed secondary to hemorrhoids, s/p TIPS; also
w/ known portal gastropathy
3) Sigmoid diverticulosis
4) Schatzki's ring
5) Duodenal polyps and duodenitis
6) MGUS
7) ?Etoh/ HCV cirrhosis followed by Dr. [**Last Name (STitle) 497**]
8) Psychotic disorder
9) polysubstance abuse - etoh, cocaine, marijuana
10) COPD
11) ?? h/o Complex partial seizures
Social History:
History of tobacco and EtOH abuse. She is originally from
[**State 3908**], and changed her name when she became a practicing
Muslim. She worked as an administrative assistant when she was
younger, but is now on SSDI (for schizophrenia and seizure
disorder, per pt, both now quiescent). She was most recently
discharged to rehab on [**2167-12-26**].
Family History:
Mother: asthma, grandmother with diabetes, HTN. No family
history of liver disease or bleeding disorders. Great aunt with
epilepsy.
Physical Exam:
VS: Temp: 99.9 BP: 146/86 HR: 89 NSR RR: 15 O2sat 100%
GEN: Intubated, sedated.
HEENT: Pupils equal, 2.5mm, minimally reactive to light,
+scleral icterus, blood in OP with ?small anterior tongue
laceration
NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no
carotid bruits, no thyromegaly or [**Date Range **] nodules
RESP: Anteriorly w/ rhonchorus BS likely transmitted from upper
airway, no wheezes
CV: RRr, S1 and S2 wnl, no m/r/g appreciated
ABD: nd, +b/s, soft, nt, no masses, no appreciable ascites
EXT: 1+ dorsal hand edema b/l and dorsal foot edema b/l, 2+ DP
and PT pulses b/l
SKIN: no rashes
NEURO: Unable to assess CN II-XII. Pt. unable to cooperate w/
full neuro exam given mental status/sedation. Downgoing toes
b/l.
RECTAL: Guaiac + brown stool per ED eval.
Pertinent Results:
[**2167-12-29**] 06:30AM PT-18.4* PTT-48.9* INR(PT)-1.7*
[**2167-12-29**] 06:30AM PLT COUNT-124*#
[**2167-12-29**] 06:30AM NEUTS-87.3* LYMPHS-8.3* MONOS-3.0 EOS-1.0
BASOS-0.3
[**2167-12-29**] 06:30AM WBC-12.1* RBC-3.21* HGB-10.5* HCT-30.9*
MCV-96 MCH-32.9* MCHC-34.2 RDW-17.6*
[**2167-12-29**] 06:30AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2167-12-29**] 06:30AM ALBUMIN-2.4* CALCIUM-9.1 PHOSPHATE-4.0
MAGNESIUM-1.5*
[**2167-12-29**] 06:30AM CK-MB-NotDone cTropnT-0.14*
[**2167-12-29**] 06:30AM LIPASE-82*
[**2167-12-29**] 06:30AM ALT(SGPT)-37 AST(SGOT)-54* CK(CPK)-68 ALK
PHOS-83 AMYLASE-101* TOT BILI-5.2*
[**2167-12-29**] 06:30AM GLUCOSE-117* UREA N-33* CREAT-1.5* SODIUM-139
POTASSIUM-3.9 CHLORIDE-106 TOTAL CO2-22 ANION GAP-15
[**2167-12-29**] 06:44AM HGB-10.9* calcHCT-33
[**2167-12-29**] 06:44AM LACTATE-1.7
[**2167-12-29**] 06:51AM GLUCOSE-107*
[**2167-12-29**] 06:51AM TYPE-ART PO2-304* PCO2-33* PH-7.50* TOTAL
CO2-27 BASE XS-3
[**2167-12-29**] 06:53AM AMMONIA-105*
[**2167-12-29**] 09:44AM PT-17.9* PTT-50.6* INR(PT)-1.6*
[**2167-12-29**] 09:44AM HCT-26.4*
[**2167-12-29**] 11:10AM HGB-9.7* calcHCT-29
[**2167-12-29**] 11:10AM TYPE-ART PO2-521* PCO2-37 PH-7.43 TOTAL
CO2-25 BASE XS-1
[**2167-12-29**] 12:00PM URINE MUCOUS-MANY
[**2167-12-29**] 12:00PM URINE MUCOUS-MANY
[**2167-12-29**] 12:00PM URINE RBC-7* WBC-52* BACTERIA-FEW YEAST-NONE
EPI-0
[**2167-12-29**] 12:00PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-MOD
[**2167-12-29**] 12:00PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.013
[**2167-12-29**] 12:00PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2167-12-29**] 12:00PM URINE OSMOLAL-449
[**2167-12-29**] 12:00PM URINE HOURS-RANDOM UREA N-504 CREAT-65
SODIUM-92
[**2167-12-29**] 06:28PM HCT-24.6*
[**2167-12-29**] 06:39PM TYPE-ART PO2-474* PCO2-35 PH-7.50* TOTAL
CO2-28 BASE XS-4
[**2167-12-29**] 07:45PM CK-MB-NotDone cTropnT-0.10*
[**2167-12-29**] 07:45PM CK-MB-NotDone cTropnT-0.10*
[**2167-12-29**] 07:45PM CK(CPK)-42
[**2167-12-29**] 10:30PM HCT-23.8*
[**2167-12-29**] 10:44PM O2 SAT-99
[**2167-12-29**] 10:44PM TYPE-ART PO2-180* PCO2-25* PH-7.50* TOTAL
CO2-20* BASE XS--1
Discharge labs:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW
Plt Ct
[**2168-1-6**] 06:00AM 6.9 2.38* 7.4* 23.0* 97 31.0 32.1 18.9*
118*
BASIC COAGULATION (PT, PTT, INR)
[**2168-1-6**] 06:00AM 21.0*1 57.6* 2.0*
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2168-1-6**] 06:00AM 102 19 1.1 135 4.9 104 23 13
ENZYMES & BILIRUBIN ALT AST AlkPhos TotBili
[**2168-1-6**] 06:00AM 21 31 68 3.4*
.
EKG: Sinus tachycardia to rate 136. Nml axis, nml intervals.
Poor R wave progression. TW flattening V1, ?TW inversion V2.
.
Repeat EKG in ICU: NSR rate 84, nml intervals and axis. TWI in
II, III, aVF (new), TW flattening in V1-V2, TWI V3-V6 (all old
though more pronounced from prior).
.
[**2167-11-28**] Echo:
-Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF 60-70%).
-The right ventricular cavity is dilated.
-Right ventricular systolic function appears depressed.
-The ascending aorta is mildly dilated.
-There is no aortic valve stenosis. Mild (1+) aortic
regurgitation is seen.
-The mitral valve appears structurally normal with trivial
mitral regurgitation. There is no mitral valve prolapse.
-There is moderate pulmonary artery systolic hypertension.
-There is no pericardial effusion.
.
Imaging:
[**2167-12-29**] CXR: Diffuse course linear opacities likely sequelae of
aspiration pneumonitis. No significant change from prior
([**2167-12-19**]).
.
[**2167-12-29**] Liver U/S:
1. Interval decrease in the proximal, mid and distal TIPS
velocity. Six-week followup is recommended to ensure the
stability of the TIPS function.
2. Normal wall-to-wall flow was noted within the TIPS and the
main portal vein and its branches demonstrate appropriate flow.
3. The TIPS device demonstrates abnormal pulsatile flow
suggesting the presence of possible right heart failure.
4. Small bilateral pleural effusion is noted.
.
[**2167-12-29**] CT head : No evidence of acute intracranial process.
Left-sided NGT in place; R>L opacification of nasal passage &
visualized nasopharynx. Mild mucosal thickening in right
maxillary sinus.
.
EEG: encephalopathy, no e/o seizure activity
.
Studies:
[**2167-12-19**] EGD:
1. Schatzki's ring
2. Erythema and congestion in the stomach body and fundus
3. Erythema and congestion in the first part of the duodenum
compatible with duodenitis
4. Otherwise normal EGD to second part of the duodenum
.
[**2167-11-25**] Colonoscopy: Grade 4 internal & external hemorrhoids.
Brief Hospital Course:
62yoF with h/o EtOH/hepC cirrhosis presents with altered mental
status, fever, blood in mouth, ? hematemesis. In the MICU,
patient was intubated for airway protection given altered mental
status. On transfer to floor, patient still confused but
returning towards baseline on lactulose and started on IV
antibiotics for GNR in urine and sputum and GPC in prs/clusters
in sputum. She received one unit of blood for decreased Hct
thought to be [**2-13**] oropharyngeal bleeding, etiology unclear, but
stabilized bleeding after extubation. Liver service is
involved, no endoscopy indicated at this time.
.
HOSPITAL COURSE BY PROBLEM:
.
# Altered mental status: The patient was admitted from rehab
with altered mental status. She was intubated for airway
protection in the ED. Per extended care facility she has been
taking lactulose and rifaximin although he hepatic
encephalopathy could be contributing as the ammonia on
presentation was 105 which is higher than previously (50-80, but
? in setting of encephalopathy). She was continued on lactulose
and refamixin during her hospital stay. Although the patient has
a history of seizures ( she is not on any medication?) and did
present with possible tongue trauma and oral bleeding, an EEG
was performed which did not show any seizure activity. Utox was
negative making drug abuse unlikely despite recent history of
crack cocaine abuse. CT head negative for bleed/acute
intracranial process. She did receive empirc coverage for
meningitis in the ED with ceftazadine and Vanco given fever on
presentation although she did not have any meningeal symptoms.
Meningitis was later thought to be less likely. A CXR was
performed to evaluated for PNA as a possible cause of AMS and
was found to be unchanged from prior. A CT chest did not
pulmonary edema but no focal infiltrate suggestive of PNA. SBP
was also thought to be unlikely without ascites on ultrasound of
the abdomen and without abdominal tenderness. Evaluation of
her TIPS showed decreased flow but per the hepatology team a
revision of TIPS would likely worsen her encephalopathy. She was
ultimately found to have a enterobacter UTI and was initially
started on Zosyn and Vanc. The enterobacter was then found to be
resistant to Zosyn - Sensitive to cefepime and Meropenem only-
and she was switched to Cefepime. Her mental status improved to
baseline. She had repeat U/A on 12.24 that showed clearance of
infection. Plan for 14d course for complicated UTI/PNA, for 6
more days on d/c. Hepatology followed and decided against
reevaluation of TIPs given clinical improvement with lactulose
and treatment of UTI.
.
# Fever: WBC count elevated to 12.1 with 87% neutrophils. Was
febrile on presentation to ED concerning for infection.
Additionally she was tachycardic to 130s. She was admitted to
the ICU for SIRS and s/p intubation. at least meets criteria for
SIRS and likely even sepsis (source not yet clear). Her fever ws
found to be due to a UTI described above and resolved with
antibiotics. Notably, sputum gram stain did show GPC's and
GNR's, but only GNR's grew on culture; clinically the patient
did not appear to have pneumonia. She was only kept on Cefepime
as well as vanc for sputum MRSA given her improvement for
treatment of her UTI/PNA, as above
.
# Respiratory: Patient reportedly not in respiratory distress on
presenation, but rather intubated for airway protection given
severely depressed mental status. She was never hypoxic in the
ICU or on the floor. CXR does show reticular opacities stable
from most recent CXR previously billed as aspiration
pneumonitis. CT showed pulmonary edema and she was given lasix
IV, then transitioned to pre-admission diuretics.
.
# ?upper GI bleed: HCT trending down and +blood removed form
oropharynx. Patient with known grade 4 rectal varices however
guaiac + brown stools. Also recent EGD showed e/o portal
gastropathy, but w/o e/o varices. She was started on octreotide
in ED for ? variceal bleed. Blood in NGT looks old so perhaps
old from recent bleed/EGD. Other blood in mouth bright red and
perhaps from tongue/mouth trauma.
- q8h hcts
- a-line placed; CV line attempt failed
- Appreciated liver involvement
- [**Hospital1 **] PPI
.
# Bleeding: Patient was found to have oozing in posterior
throat, central line and PICC site after transfer to the floor.
She did not appear to have uremia with a normal BUN. Her PTT was
elevated and her platelets were decreased. She had received PPx
heparin and heparin flush through PICC last night and her PLT
have trended down although not by 50%. She was evaluated for HIT
- a HIT Ab was sent and was negative. Heparin administration was
discontinued. She was also given FFP for elevated PTT and
likelihood of liver dysfunction.
- was given 1 U pRBCs on [**1-3**] and another on 12.27 day of
discharge with stable hct of ~21-23 at discharge. Goal hct >21.
.
# Elevated troponin: Normal CK and CK-MB. Troponin elevated to
0.14 (up from previous baseline even in setting of CRI), now
trending down. Given dilated, hypokinetic RV, may be elevated in
the setting of failure. Does have poor R wave progression on EKG
which is old as are, EKG now back at baseline.
.
# EtOH/Hep C cirrhosis: Platelets 124 and within previous
baseline. Coags in the ED revealed INR of 1.7 which is also c/w
baseline. Albumin 2.6 on [**12-25**] (not sent in ED). AST mildly
elevated, ALT, alk phos normal. T.bili elevated to 5.2 which is
actually slightly down from baseline. MELD of 22 on admission.
- continue lactulose and rifaximin po
- held lasix/sprinolactone initially, then restarted, but on day
of discharge had hyponatremia to 128. Pt. thought to be
hypovolemic, so diuretics discontinued and given 1U pRBCs
- will follow up in first week of [**Month (only) **] with Dr. [**Last Name (STitle) 497**] to
determine whether diuretics need to be restarted
.
# Acute on CRF: Appears to have had progessively worsening
function since spring, [**2167**]. Currently within most recent
baseline. Etiology not entirely clear. It does not appear to
have been worked up previously although there has been ? HRS on
old d/c notes. No other clear e/o cryoglobulinemia, but does
have hep C. FEUrea 35.7%, borderline prerenal on [**12-29**]; lasix
held for the past 2 days so unlikely to be pre-renal still.
Patient has not been hypotensive, making ATN unlikely. Urine eos
positive but sparse and no peripheral eosinophilia or rash,
making AIN equivocal; however, the patient was on Zosyn which
could cause AIN.
- cryoglobulin levels negative
- C3, C4 levels wnl
- will f/u with Dr. [**Last Name (STitle) 1366**] in renal as outpt.
.
# Anemia: High normal MCV, elevated RDW. Baseline fluctuates
somewhat, but generally runs mid-upper 20s to low 30s. Of note,
hct was 30.9 on presentation from 28.9 upon discharge on [**12-26**].
As above, likely secondary to chronic GI sources (portal
gastropathy, hemorrhoids).
-continue [**Hospital1 **] Hct monitoring
- pt likely transfusion dependent to certain extent; transfuse
to maintain Hct >21 or if acute drop, e/o bleeding
-continue iron supplementation
.
# H/O seizure d/o: No documented history of seizures while at
[**Hospital1 **]. Has been off antiepileptic meds per OMR notes since at least
[**2165**]. Given AMS and tongue trauma, ? postictal although seems
less likely given has yet to clear.
- EEG negative for seizure
.
# COPD: Rhonchorus BS anteriorly likely transmitted from upper
airway. Without e/o bronchospasm on exam currently.
- Continue albuterol/ipratropium MDI via ETT prn
.
# Psychotic disorder: Schizophrenia per pt. in old notes. Not on
any neuroleptic meds. Appears to have received olanzapine on
prior admissions. Has "allergy" to haldol.
- olanzapine prn started with olanzapine in evenings standing.
.
# F/E/N: Replete lytes PRN. NPO.
.
# PPx: Bowel regimen, PPI, sq Heparin
.
# Access: PICC
.
# Code Status: Full
.
# Communication: Daughter [**First Name4 (NamePattern1) 4850**] [**Last Name (NamePattern1) 99377**] [**Telephone/Fax (1) 99373**],
[**Telephone/Fax (1) 99378**]
D/c'd to [**Hospital1 **] [**1-7**] with instructions to follow lytes and hct
and for PT.
Medications on Admission:
1. Rifaximin 400 mg tid
2. Lactulose 30 ML PO TID-QID; titrate to 4 BMs daily
3. Nystatin 5 ML PO QID prn
4. Ipratropium Bromide nebs q6h
5. Albuterol Sulfate nebs q6h prn
6. Pantoprazole 40 mg PO daily
7. Furosemide 20 mg PO daily
8. Spironolactone 50 mg daily
9. Ferrous Sulfate 325 mg PO daily
Discharge Medications:
1. Rifaximin 200 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO TID (3 times a
day).
2. Lactulose 10 gram/15 mL Syrup [**Month/Year (2) **]: Thirty (30) ML PO QID (4
times a day).
3. Ferrous Sulfate 300 mg/5 mL Liquid [**Month/Year (2) **]: Five (5) ml PO DAILY
(Daily).
4. Albuterol 90 mcg/Actuation Aerosol [**Month/Year (2) **]: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for SOB, cough, wheezing.
5. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Month/Year (2) **]: Two (2)
Puff Inhalation QID (4 times a day) as needed for SOB, cough,
wheezing.
6. Olanzapine 5 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2 times a
day) as needed for agitation.
7. Olanzapine 5 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO HS (at
bedtime).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Month/Year (2) **]: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
9. Cefepime 1 gram Recon Soln [**Month/Year (2) **]: Five Hundred (500) mg
Intravenous once a day for 5 days.
10. Vancomycin in Dextrose 1 gram/200 mL Piggyback [**Month/Year (2) **]: One (1)
gram Intravenous Q 24H (Every 24 Hours) for 5 days.
11. Ensure Plus Liquid [**Month/Year (2) **]: Two (2) bottles PO three times a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary Diagnoses
1) Hepatic Encephalopathy
2) UTI
3) Pneumonia
4) Altered Mental Status
5) anemia
secondary diagnoses:
1) Iron deficiency anemia
2) GI bleed - presumed secondary to hemorrhoids, s/p TIPS; also
w/ known portal gastropathy
3) Sigmoid diverticulosis
4) Schatzki's ring
5) Duodenal polyps and duodenitis
6) MGUS
7) ?Etoh/ HCV cirrhosis followed by Dr. [**Last Name (STitle) 497**]
8) Psychotic disorder
9) Remote polysubstance abuse - etoh, cocaine, marijuana
10) COPD
11) Complex partial seizures
Discharge Condition:
good, tolerating pos, satting well on RA, afebrile, sitting in
chair with assist
Discharge Instructions:
You came to the hospital due to a change in your mental status
as well as blood in your mouth. You were in the ICU for part of
your hospital stay due to concern for your mental status and
breathing, and you were found to have both a respiratory and
urinary tract infection for which you are being treated.
Additionally, your mental status is altered due to your liver
disease. Please take antibiotics as prescribed for 6 more days
and continue lactulose and rifaxamin, titrated to [**3-15**] loose
bowel movements per day.
Please call your physician or return to the hospital for any of
the following: bright red blood per rectum, black, tarry
stools,chest pain, shortness of breath, inability to tolerate
food, fever >101 or other concerns.
Followup Instructions:
You have the following appointments which you should attend
Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2168-1-15**] 2:20
Provider: [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**], M.D. Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2168-1-18**] 9:00
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**]
|
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15,524
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5656
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Discharge summary
|
report
|
Admission Date: [**2178-3-8**] Discharge Date: [**2178-3-20**]
Date of Birth: [**2129-10-27**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Penicillins
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
48yoW with h/o ESLD [**3-6**] EtOH cirrhosis, Crohn's disease, chronic
kidney disease, transfered from [**Hospital3 **] on [**3-8**] for persistent
MRSA bacteremia
Major Surgical or Invasive Procedure:
Admitted with PICC
Femoral HD catheter placement
History of Present Illness:
48yoW with h/o ESLD [**3-6**] EtOH cirrhosis, Crohn's disease,
chronic kidney disease, who was admitted to [**Hospital3 417**]
Hospital [**2178-2-18**] with liver failure, acute renal failure and
hyponatremia, and is transferred now to [**Hospital1 18**] with persistant
MRSA bacteremia.
.
The patient was initially referred to [**Hospital3 417**] ED [**2178-2-18**]
from her primary care physician's office for evaluation of
elevated LFTs, confusion, ARF (Cr 3.4), and hyponatremia (Na+
124). At that time she complained of SOB and productive cough.
She was transferred to the ICU [**2178-3-3**] with hypotension (BP
65/40) and treated for urosepsis after E.coli grew in her urine.
She was treated with initially ceftriaxone and then aztreonam.
Hypotension was treated initially with Neosynephrine, and then
levophed. Baseline SBP 80s. Hospital course also complicated by
LLL pneumonia. She then developed a MRSA bacteremia. Exam was
significant for pericardial rub, and echo showed a
small-moderate effusion. No vegetations were seen on TTE
[**2178-3-1**], but she was treated for endocarditis with
vancomycin/gentamicin. A TEE was not done due to concern for
causing a variceal bleed. EF was 60-65%. On the gentamicin her
creatinine rose from 1.0 to 3.8. On [**2178-3-2**] she had a single
burst of non-sustained Afib. Hospital course was also
complicated by hypokalemia requiring repletion. Surveillance
blood cultures were persistantly positive for MRSA, most
recently [**2178-3-5**], despite therapeutic doses of vancomycin.
Additionally the LLL infiltrate enlarged on CXR. Abdominal U/S
on [**2178-3-2**] showed hepatosplenomegaly, ascites, and reversed flow
in the portal vein. On [**2178-3-4**] she had a urine culture that grew
enterococcus. She was transferred on Levophed via PICC line in
left A/C vein.
.
Hospital course also complicated by indecision regarding code
status. She was initially DNR/DNI, then full code, then reverted
to DNR/DNI status prior to transfer.
.
On presentation now she complains of chest pain when coughing,
and cough productive of brown sputum. She denies SOB. She c/o
midepigastric abdominal pain and low back pain, which is her
baseline. She denies headache, dizziness, confusion, vision
changes, nausea, vomiting, diarrhea, constipation.
Past Medical History:
COPD
Crohn's disease
Liver failure d/t alcoholic cirrhosis c/b portal HTN, esophageal
varices
Sciatica
Osteoarthritis
Chronic kidney disease
Social History:
lives with her son. daughter serves as her HCP. on disability
+Tob use; +EtOH use; denies illicit drug use
Most recent drink was the day prior to hospitalization. she
denies having a h/o withdrawals. drinks 1pint vodka daily.
Family History:
Father - h/o EtOH abuse, d. Alzheimer' dz at 64yrs
Mother - alive, had stroke at 67yrs
Brother - EtOH abuse
MGM - EtOH abuse
Physical Exam:
T 97.2 HR 69 BP 93/36 RR 33 95%3Lnc Wt 94kg pulsus <10
GEN: alert, speaking full sentences, appropriate, NAD
HEENT: icteric sclera, PERRL (2->1mm), conjunctiva pale, OP
clear, MMdry
Neck: supple, no LAD, JVP 11cm
CV: PMI nondisplaced, regular rate, murmer vs rub, II/VI supine,
III/VI sitting
Resp: left basilar crackles, no rhonchi, no wheeze. no egophany.
Abd: +BS, soft, ttp RUQ, +fluid wave, +caput
Ext: 3+pitting edema BLE to thigh, 2+ DPs and radial pulses, no
splinter hemorrhage, [**Last Name (un) 1003**] or Osler lesions, fingers clubbed
Neuro: A&Ox3, CN II-XII intact, no asterixis, strength 5/5
throughout, sensation intact to touch, coordination intact FTN
Skin: jaundiced
Pertinent Results:
Admission Labs:
[**2178-3-8**] 09:57PM GLUCOSE-143* UREA N-59* CREAT-3.6*
SODIUM-130* POTASSIUM-3.4 CHLORIDE-99 TOTAL CO2-18* ANION GAP-16
[**2178-3-8**] 09:57PM estGFR-Using this
[**2178-3-8**] 09:57PM ALT(SGPT)-31 AST(SGOT)-75* LD(LDH)-225 ALK
PHOS-214* AMYLASE-78 TOT BILI-28.1* DIR BILI-21.0* INDIR BIL-7.1
[**2178-3-8**] 09:57PM LIPASE-100*
[**2178-3-8**] 09:57PM ALBUMIN-2.2* CALCIUM-8.0* PHOSPHATE-5.1*
MAGNESIUM-2.3
[**2178-3-8**] 09:57PM URINE HOURS-RANDOM UREA N-424 CREAT-61
SODIUM-18 TOT PROT-33 PROT/CREA-0.5*
[**2178-3-8**] 09:57PM URINE OSMOLAL-316
[**2178-3-8**] 09:57PM WBC-16.1*# RBC-3.04* HGB-11.1* HCT-30.8*
MCV-101*# MCH-36.5*# MCHC-36.0*# RDW-16.7*
[**2178-3-8**] 09:57PM NEUTS-82.7* LYMPHS-8.6* MONOS-3.7 EOS-4.6*
BASOS-0.4
[**2178-3-8**] 09:57PM ANISOCYT-1+ MACROCYT-3+
[**2178-3-8**] 09:57PM PLT COUNT-115*#
[**2178-3-8**] 09:57PM PT-15.7* PTT-37.9* INR(PT)-1.4*
[**2178-3-8**] 09:57PM URINE COLOR-Amber APPEAR-Hazy SP [**Last Name (un) 155**]-1.008
[**2178-3-8**] 09:57PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-MOD UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2178-3-8**] 09:57PM URINE RBC-[**4-6**]* WBC-[**12-22**]* BACTERIA-FEW
YEAST-MOD EPI-[**4-6**]
[**2178-3-8**] 09:57PM URINE EOS-NEGATIVE
.
Labs closest to time of Death:
[**2178-3-16**] 03:45AM BLOOD WBC-14.8* RBC-2.34* Hgb-8.5* Hct-24.6*
MCV-105* MCH-36.3* MCHC-34.5 RDW-17.9* Plt Ct-106*
[**2178-3-16**] 09:46AM BLOOD Glucose-342* UreaN-22* Creat-1.6* Na-128*
K-3.9 Cl-95* HCO3-20* AnGap-17
[**2178-3-16**] 09:46AM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2178-3-16**] 09:46AM BLOOD Calcium-8.8 Phos-2.4* Mg-2.2
[**2178-3-16**] 03:58AM BLOOD Type-[**Last Name (un) **] pO2-48* pCO2-44 pH-7.38
calTCO2-27 Base XS-0
.
MICRO:
Urine culture with yeast.
Blood cultures Negative
.
IMAGING:
CXR:
AP UPRIGHT PORTABLE CHEST X-RAY: There is a ill-defined opacity
within the left lower lobe consistent with patient's known
pneumonia in this region. The cardiac silhouette is difficult to
evaluate. The mediastinal and hilar contours appear within
normal limits. There is a small right pleural effusion. A left
PICC catheter terminates in the upper SVC. Cholecystectomy clips
in the right upper quadrant.
IMPRESSION: Left lower lobe consolidation consistent with
patient's known pneumonia. Small right pleural effusion.
.
Abd Ultrasound:
FINDINGS: This was a technically difficult examination and was
performed portably. The liver is heterogenous in echotexture and
is of increased echogenicity. It is shrunken and the appearances
are consistent with cirrhosis. There is evidence of ascites. The
flow in the main portal vein is reversed and is centrifugal. The
flow in the main hepatic artery reaches velocities of 80 cm/sec,
but there is a normal waveform and the resistive index is 0.77.
The flow in the right anterior portal vein is centripetal and
the flow in the right posterior portal vein is centrifugal. The
left portal vein is not well visualized. Normal waveforms are
seen in the right and left hepatic arteries. The flow in the
left hepatic vein, right hepatic vein and middle hepatic vein is
normal. No intrahepatic bile duct dilatation. The CBD measures
0.48 cm.
IMPRESSION: Technically difficult examination in a patient with
cirrhotic liver with ascites with reversed flow seen in the
portal veins. Ascites
.
ECHO:
Conclusions:
The left atrium is moderately dilated. The right atrium is
moderately dilated. 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 are mildly thickened. There is moderate
aortic valve stenosis (area 0.8-1.19cm2) Mild to moderate ([**2-3**]+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen. There is
a small pericardial effusion.
.
MRI Abdomen:
FINDINGS: The liver is shrunken and nodular, consistent with the
given history of cirrhosis. Within the limits of the
examination, no focal mass lesion is seen. A mild-moderate
amount of ascites fluid is seen, primarily adjacent to the
liver. The pancreas is diffusely atrophic. Adrenal glands are
unremarkable. The spleen and kidneys also appear unremarkable.
A serpiginous structure showing flow voids is seen in the right
paraaortic/retroperitoneal region, with suggestion of
communication between the superior mesenteric vein and the renal
vein, probably representing a porto-systemic shunt.
IMPRESSION: Right-sided vascular structure, probably
representing a porto- systemic shunt between the SMV and the
right renal vein. No renal mass seen within the limits of this
noncontrast examination.
Brief Hospital Course:
48 y/o female with h/o end stage liver disease, EtOH abuse,
COPD, Crohn's disease, and chronic kidney disease, transferred
from OSH with MRSA bacteremia, liver failure, acute renal
failure, LLL pneumonia, enterococcus UTI, and hypotension. Her
hospital course is as follows:
.
Cirrhosis w/acute hepatitis: Patient was admitted with likely
EtOH cirrhosis given her known history and lab data
(discriminate score >32). Liver service cwas consulted. She
remained coagulopathic with elevated LFTs and
hyperbilirubinemia. She was also encephalopathic. We treated
her supportively with lactulose, rifamixin. We held her
propranolol given her hypotnesion requiring pressors. US was
negative for PV thrombosis, though there was reversal of flow.
A diagnostic paracentesis was unsuccessfully attempted. She was
also started on pentoxyfylline for presumed EtOH hepatitis, as
well as octreotide and midodrine for possible HRS.
Nevertheless, given her multiple issues, she continued to
decompensate. She was [**Hospital 22626**] transferred to the liver
service after a final decision was made to make her comfort
measures only.
.
ARF on CKD: Her baseline creatinine was unknown but per report
creatinine was 1.0 prior to initiation of gentamicin. She had
no h/o large volume paracentesis. She had been hypotensive
requiring pressors, including vasopressin, raising the concern
for pre-renal azotemia vs ATN. HRS was also considered given
her decompensated liver failure. Renal was consulted and
initiated CVVH after placing a femoral HD cath. However, after
she was made CMO all interventions were withdrawn.
.
MRSA bacteremia: Her source was unknown but was being treated
for endocarditis given persistant bacteremia despite therapeutic
doses of vancomycin at OSH. ID was consulted. She was started
on gent in addition to vanco. There were no positive cultures
here. TEE was not done given concern for causing variceal bleed;
however, EGD did not demonstrate varices. Worsening LLL
pneumonia on CXR at OSH could have been source of infection.
There was also a concern that her pericardial effusion might be
infected/purulent pericarditis. Spinal abscess or
thrombophlebitis was also considered. Multiple imaging studies
were performed without clear source of infection (see above).
Her antibiotics were stopped once the patient was made CMO.
.
Hypotension: It was unclear what degree of hypotension this
represented as patient's baseline SBP reported to be in the 80s.
However she was clearly septic at OSH. Sepsis, severe
infection, ESLD were thought involved. She was maintained on
levophed, neosynephrine, and vasopressin during her MICU stay.
Octreotide and midodrine were also started (see above).
However, these interventions were stopped once she was made CMO.
.
Tachycardia/chest pain: Patient had an episode of A fib w/ RVR
[**2178-3-15**]; likely [**3-6**] to fluid shifts w/ CVVHD and cardiac
irritation from levophed. Echo at OSH showed normal EF, LA
slightly enlarged. She was asymptomatic during event, cardiac
enzymes were flat. Levophed was changed to neo and pt bolused
fluid. She converted to NSR after 1-2hrs. She remained
tachycardic but looked to be in MAT.
.
MS changes: Patient was not oriented, and she was unclear that
she understood who made decisions for her. Psych evaluated her
and determined that she did not have capacity to make her own
decisions. There were multiple family meetings to discuss goals
of care. Palliative care also helped faciliate this decision
making process. She remained disoriented, likely secondary to
hepatic encephalopathy, infection, hyponatremia, and ARF.
.
Hyponatremia: It was thought to be hypervolemic hyponatremia
given her ESLD. It improved with fluid restriction
.
Code/End of Life Issues: Her code status continually fluctuated
during her admission, between full code and DNR/DNI. However,
after extensive family meetings and palliative care involvement,
the decision was made to make her CMO
.
Once the patient was CMO, she was transferred to the
[**Doctor Last Name 3271**]-[**Doctor Last Name **] service. There were no lab draws. She was put on
a morphine drip and appeared comfortable. She was pronounced
dead at 7AM on [**2178-3-20**]. Cause of death likely end stage liver
disease and infection. The family was notified. They did not
request an autopsy.
Medications on Admission:
Percocet 1-2tabs Q4hr prn
Protonix 40mg [**Hospital1 **]
Loratadine 10mg daily
Singulair 10mg dialy
Vistaril 25mg TID prn
Lomotil 2mg TID prn
Actos 15mg daily
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Cardiopulmonary arrest
End Stage Liver Disease
Crohn's Disease
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
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45,671
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1866
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Discharge summary
|
report
|
Admission Date: [**2166-1-30**] Discharge Date: [**2166-2-6**]
Date of Birth: [**2104-1-10**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5141**]
Chief Complaint:
hemetemesis
Major Surgical or Invasive Procedure:
esophagogastroduodenoscopy
History of Present Illness:
This is 62F with HCV and alcohol use, with known cirrhosis and
hepatocellular carcinoma, no prior history of GI bleeding, on
warfarin, who presents with multiple episodes of vomiting blood
today. Having dark green stools. No belly pain, CP, SOB. Had an
EGD [**2165-11-22**] that showed no esophageal varices, but did show
portal gastropathy.
Pt was recently admitted [**2165-11-21**] for abdominal pain, n/v/d, and
increased fatigue and was diagnosed with HCC covering most of
the left lobe of her liver. She was also found to have splenic,
portal vein, and SMV thrombosis (without evidence of ischemia)
and was started on warfarin during that admission. She was
started on omeprazole for GERD symptoms and treated for an
uncomplicated E. coli UTI at that time.
In the ED, initial VS were: T98.1 HR 113 BP 88/62 RR 16 sat
100%. Pt was guaiac negative. NG lavage did not clear after
500 cc, returned bright red blood. She was started on
octreotide and pantoprazole drips. She was typed and crossed
for 4 units. GI was consulted, pt was intubated per GI rec. She
received IV vit K 10 mg. She received 1 L NS prior to arrival
and 3 L in the ED.
.
On arrival to the MICU, vitals were T 98.9 HR 103 BP 129/79 RR
15 sat 100% on 100% FIO2 assist ventilation. She received 4
units FFP. Pt denied pain.
.
Review of systems: unable to obtain
Past Medical History:
Hepatitis C with established cirrhosis on biopsy in [**2153**], was a
nonresponder to 6 months of interferon/ribaviron
Diabetes Mellitus type 2
Hypertension
Prior ETOH abuse
Social History:
Lives with son Celo who helps care for her, not married.
- Tobacco: smoked [**12-23**] ppdx50 years, now smoking [**12-24**] ppd
- Alcohol: active EtOH use; drank "a lot" in the past, now
drinks 2-3 times per week, last drink was Friday 6 days ago
- Illicits: IVDU in [**2123**]
Family History:
mother died of uterine cancer, father died of MI, grandfather
with lung cancer. no family history of blood clots.
Physical Exam:
On admission:
Vitals: T: 98.1 BP: 124/74 P: 97 R: 18 O2: 100%
General: Intubated, sedated, NG tube in place, retching
HEENT: Sclera anicteric
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Coarse breath sounds superiorly, no wheezes, rales,
rhonchi anteriorly
Abdomen: soft, non-tender, non-distended, bowel sounds present
GU: + foley, small amount of yellow urine
Ext: warm, well perfused, no clubbing, cyanosis or edema
Neuro: opens eyes to voice, follows commands.
Discharge PE
pt stable at time of discharge
Pertinent Results:
[**2166-1-30**] 11:30PM HCT-40.0#
[**2166-1-30**] 06:46PM GLUCOSE-127* UREA N-19 CREAT-0.9 SODIUM-144
POTASSIUM-4.0 CHLORIDE-111* TOTAL CO2-17* ANION GAP-20
[**2166-1-30**] 06:46PM CK-MB-3 cTropnT-0.12*
[**2166-1-30**] 06:46PM CALCIUM-6.8* PHOSPHATE-3.2 MAGNESIUM-0.7*
[**2166-1-30**] 06:46PM WBC-8.3 RBC-3.13*# HGB-9.6*# HCT-29.3*#
MCV-94 MCH-30.8 MCHC-32.9 RDW-14.9
[**2166-1-30**] 02:05PM LIPASE-39
[**2166-1-30**] 02:05PM PT-62.7* PTT-57.4* INR(PT)-6.3*
[**2166-1-30**] 02:05PM ALBUMIN-3.6
Micro
[**2166-1-31**] 5:02 pm URINE Source: Catheter.
**FINAL REPORT [**2166-2-1**]**
URINE CULTURE (Final [**2166-2-1**]): NO GROWTH.
EGD [**1-30**]: Impression: Varices at the lower third of the esophagus
No active bleeding,ulcers or esophagitis
Blood in the fundus
Mosaic appearance in the fundus and stomach body compatible with
mild bleeding portal gastropathy
No evidence of ulcers, varices or active bleeding
Normal mucosa in the first part of the duodenum and second part
of the duodenum
No evidence of active bleeding, varices or ulcers
Otherwise normal EGD to third part of the duodenum
CXR [**2-2**]: The patient was extubated in the meantime interval.
Heart size and mediastinum are unremarkable but there is
interval development of interstitial pulmonary edema, associated
with bilateral pleural effusions, small, but appear to be
increased since the prior study. The worsening in the right
lower lung although most likely associated with edema, can
potentially represent interval development of right lower lobe
pneumonia. Attention to this area on the subsequent radiographs
is recommended and if clinical symptoms of pneumonia are
present, it should be treated as pneumonia.
CT Heead [**2-4**]: FINDINGS: There is no evidence of hemorrhage,
edema, mass, mass effect, or infarction. The ventricles and
sulci are normal in size and configuration. The basal cisterns
are patent. There are prominent cerebellar fovea related to
cerebellar volume loss. There is preservation of [**Doctor Last Name 352**]-white
matter differentiation. The visualized paranasal sinuses,
mastoid air cells, and middle ear cavities are clear. The soft
tissues are unremarkable. IMPRESSION: No evidence of hemorrhage
or mass effect.
Discharge and Pertinent Labs
[**2166-2-6**] 06:15AM BLOOD WBC-9.2 RBC-4.65 Hgb-13.9 Hct-41.5 MCV-89
MCH-30.0 MCHC-33.5 RDW-16.3* Plt Ct-168
[**2166-2-6**] 06:15AM BLOOD Glucose-92 UreaN-7 Creat-0.7 Na-140 K-4.2
Cl-107 HCO3-21* AnGap-16
[**2166-2-5**] 06:20AM BLOOD Glucose-106* UreaN-6 Creat-0.7 Na-140
K-3.9 Cl-108 HCO3-20* AnGap-16
[**2166-2-4**] 09:40PM BLOOD Na-139 K-3.9 Cl-105
[**2166-2-4**] 06:41PM BLOOD Glucose-169* UreaN-7 Creat-0.7 Na-133
K-5.2* Cl-103 HCO3-17* AnGap-18
[**2166-2-6**] 06:15AM BLOOD Calcium-7.6* Phos-1.5* Mg-1.2*
[**2166-2-5**] 06:20AM BLOOD Calcium-7.0* Phos-1.8* Mg-1.5*
[**2166-2-4**] 06:41PM BLOOD Calcium-7.3* Phos-2.2* Mg-2.0
[**2166-2-4**] 06:40AM BLOOD Albumin-3.1* Calcium-7.2* Phos-0.9*
Mg-1.2*
[**2166-2-3**] 07:25AM BLOOD Calcium-7.3* Phos-1.0* Mg-1.3*
[**2166-2-2**] 06:50AM BLOOD Calcium-7.3* Phos-1.5* Mg-1.2*
[**2166-2-1**] 04:11AM BLOOD Calcium-7.8* Phos-2.0* Mg-2.1
Brief Hospital Course:
62 yo woman with cirrhosis, HCV and EtOH use, HCC diagnosed
[**11/2165**] on palliative chemo, no prior history of EGD or GI
bleeding, on warfarin with INR 6.3, presenting with hematemesis.
# Upper GI bleed: Likely gastric bleeding given portal
gastropathy, no varices on [**2165-11-22**] EGD. Elevated INR could
cause profuse bleeding from other sources. Differential also
includes ulcer, [**Doctor First Name **]-[**Doctor Last Name **] tear, variceal bleed. The patient
was started on octreotide and ppi drip. She was given Vitamin K
and 4 units FFP. She was intubated for airway protection. She
was scoped by GI who found 50cc of blood in the stomach. She was
extubated and called out to the floor.
# Cirrhosis--From HCV, EtOH. No hx of encephalopathy, pt not on
rifaximin or lactulose at home.
No hyponatremia, no ascites. Plt 187.
# HCC--stable. Sorafenib is associated with elevated INR,
hemorrhage, and benefit is unclear in this case. Portal vein
thrombosis is likely associated with tumor, no role for
anticoagulation going forward.
-pt will continue sorafenib after discharge
-pt should not resume warfarin
-discuss goals of care with pt
# EtOH--Pt still drinking, per GI note recently drinking [**1-24**]
times per week, last drink was Friday 6 days ago. Watch for
signs of withdrawal in next 24-48 hrs.
-CIWA scale, 10 mg valium PRN
-thiamine, folate, MVI
# Troponin elevation--Likely demand ischemia in the setting of
tachycardia. Pt had inverted T waves in 1 and aVL between ED
and floor, [**11/2165**] ECGs without T wave inversions. Pt is not
eligible for heparin. Denied chest pain prior to intubation.
-cycle troponins--consider TTE if marked troponin elevation
# U/A--+ for bacteria. Will assess for symptoms once pt is
awake.
# DM2--regular insulin sliding scale while inpatient, will be
discharged to resume her metformin 500mg [**Hospital1 **]
# HTN--hold home lisinopril while inpatient in setting of GI
bleed, restarted just before discharge
Once stable, the patient was sent to the floor. She received a
total of 5 days on the octreotide drip for her UGIB. She was
transitioned from an IV protonix drip to IV protonix 40mg [**Hospital1 **]
and then PO protonix 40mg [**Hospital1 **]. Her diet was advanced slowly to a
regular diet which she tolerated well.
She was difficult to wean off oxygen, so a CXR was obtained.
Although she had pleural effusions on both side and mild
pulmonary edema, her UOP picked up and lasix was not given. She
was eventually weaned off of oxygen, and will not require oxygen
at discharge.
It was difficult to maintain adequate levels of her
electrolytes, mostly magnesium and phosphorus. They were checked
and repleted daily.
She also had a mild headache for several days, so a head CT was
ordered. The CT did not show any acute intracranial process, and
no bleeds were seen.
She was started on her home lisinopril on [**2-4**] after titrating
her on captopril. Physical therapy evaluated her and felt that
she should go to rehab.
She should continue her sorafenib once at rehab. The son should
have this medication, and can provide it for the patient to
take. She will not continue warfarin after discharge.
A PCP followup appointment should be arranged by the rehab just
before her discharge from rehab.
Medications on Admission:
cyclobenzaprine 10 mg qHS prn
folic acid-vit b6-vitb12
hydroxyzine 10 mg tid PRN itching
lisinopril 10 mg daily
metformin 500 mg [**Hospital1 **]
omeprazole 20 mg [**Hospital1 **]
warfarin 1 mg daily
thiamine 100 mg daily
tylenol for abdominal pain
sorafenib since [**2166-1-3**]
Discharge Medications:
1. 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*
2. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
3. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. cyclobenzaprine 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times
a day) as needed for muscle spasms.
7. dextromethorphan-guaifenesin 10-100 mg/5 mL Liquid Sig: Five
(5) ML PO Q6H (every 6 hours) as needed for cough.
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
10. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
11. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 2 days.
12. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. sorafenib 200 mg Tablet Sig: Two (2) Tablet PO twice a day:
The son should have this medication and it should be started
while she is at rehab once available.
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name 3504**] ridge and Rehabilitation - [**Location (un) 86**]
Discharge Diagnosis:
Upper GI bleed
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname **],
You were admitted to [**Hospital1 18**] for workup of bloody vomiting. This
was due to an upper gastro-intestinal bleed. You spent several
days in the intensive care unit for treatment of your bleed, and
once you were stable you were transferred to the floor for
further management.
An esophagogastroduodenoscopy was completed during your stay.
Evidence of previous bleeding was seen on this study. You were
started on a proton pump inhibitor and octreotide for treatment.
You were also given antibiotics for prophylaxis.
Since you had a significant bleed, your coumadin was held during
your admission. You will not continue this after discharge.
Medications:
Start Protonix 40mg twice a day
Stop Coumadin
You should attend the followup appointments listed below.
Thank you for allowing us at the [**Hospital1 18**] to participate in your
care.
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2166-2-14**] at 11:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6050**], MD [**Telephone/Fax (1) 8770**]
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 [**2166-2-14**] at 11:30 AM
With: DR. [**First Name8 (NamePattern2) 2801**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: LIVER CENTER
When: MONDAY [**2166-3-10**] at 11:50 AM
With: [**Name6 (MD) 1382**] [**Name8 (MD) 1383**], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"571.2",
"305.00",
"V58.61",
"572.3",
"537.89",
"155.0",
"456.1",
"250.00",
"401.9",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
11032, 11137
|
6147, 9434
|
315, 344
|
11196, 11196
|
2931, 6124
|
12254, 13185
|
2234, 2351
|
9765, 11009
|
11158, 11175
|
9460, 9742
|
11347, 12231
|
2366, 2366
|
1701, 1720
|
264, 277
|
372, 1681
|
2381, 2912
|
11211, 11323
|
1742, 1918
|
1934, 2218
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,545
| 121,577
|
4595
|
Discharge summary
|
report
|
Admission Date: [**2147-8-30**] Discharge Date: [**2147-9-8**]
Date of Birth: [**2070-7-24**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3948**]
Chief Complaint:
Respiratory Distress
Major Surgical or Invasive Procedure:
BAL
History of Present Illness:
Mr. [**Known lastname 9381**] is a 77 y/o man with PMH notable for NSCLC (diagnosed
[**2145**]) s/p cyberknife radiation therapy, interstitial lung
disease, and COPD who presents with worsening respiratory
distress. He notes worsening difficulty with breathing for the
past four days. Denies fever but endorses chills last night.
Denies increased sputum production but endorses small amount of
blood-tinged sputum for past four days. Increased cough,
especially in the evenings with laying down.
.
In the ED, initial vitals T 102.8 rectally, HR 130, BP 125/59, R
, 51% on home 2L NC. Oxygen saturations improved to 100% on NRB,
and pulse improved to 90s-100s. Blood cultures were sent X 2.
The patient was treated with ceftriaxone 1 g IV, vancomycin 1 g
IV, and levofloxacin 750 mg IV. He was also treated with
dexamethasone 10 mg IV given his chronic steroid use and tylenol
1 g PO for fever. He received 3 L NS. From the ED, the patient
was taken to the bronchoscopy suite for bronchoscopy and BAL.
Bronchoscopy demonstrated blood in the left airways, which only
partially cleared with irrigation. BAL was performed with
results pending.
.
On arrival to the ICU, the patient reports less work of
breathing compared to earlier today. He denies any chest pain,
abdominal pain, nausea, or vomiting. He endorses travel to
[**State 108**] last winter but no other travel, including to [**Location (un) **].
Works on his boat occasionally where there are seagulls.
.
ROS: Endorses chills last night. No fevers/sweats. Denies sore
throat, nasal congestion, headache. No orthopnea or PND. No
abdominal pain, diarrhea, constipation. No burning with
urination or change in urine color. No blood in urine. No lower
leg edema.
Past Medical History:
RUL NSLC s/p cyberknife treatment [**9-26**]
interstitial lung disease
emphysema
CKD, baseline Cr. 1.7-2
GOUT
hypertension
GERD
esophageal stricture s/p dilatation
Social History:
He lives with his wife in [**Name2 (NI) **] [**Name (NI) 19501**]. No children. He is
retired factory worker from a rubber factory. He has a
50-pack-year history of smoking and quit 8 years ago. He has
significant asbestos exposure due to his factory work with
rubber. Previously in the Navy. Drinks 4-5 beers per day. No
illicits. No children.
Family History:
Mother with cancer (unknown type). Brother with leukemia
Physical Exam:
vs: T 96.6, BP 146/81, P 102, RR 25, 94% 3L at rest, 78%
w/activity
gen: alert, oriented, mild respiratory distress, wearing NRB
mask
heent: PERRL, EOMI, sclerae anicteric, MM slightly dry, no
lymphadenopathy in the neck
lungs: crackles in mid-lung to base L>R, no wheezing, no
dullness to percussion, symmetric expansion
CV: tachycardic but regular, no appreciable murmur
abd: soft, nondistended, nontender to palpation, firm mass in
pelvis palpable 6 cm about pelvic brim which is nontender
ext: no peripheral edema, DP pulses 2+ bilaterally
skin: dry patches with scaling across forehead, legs, arms,
multiple tattoos
neuro: Moving all extremities without difficulty, face
symmetric, speech clear
psych: appropriately answering questions
Pertinent Results:
WBC 12.7 (66%N, 1% bands, 14% lymphs, 15% monos, 4% atypicals)
Hct 38.3
Plt 192,000
lactate 2.3
LDH 557
PT 13.8 PTT 23.7 INR 1.2
Na 137, K 4.8, Cl 97, HCO3 24, BUN 36, Cr 2, glucose 95
CK 56, MB not done, trop 0.01
.
CXR: The wedge-shaped triangular parenchymal opacity in the
right mid zone has further decreased in size. There is interval
increase in the interstitial markings seen throughout the left
mid and lower zones, more pronounced since the prior
examination. The appearances in the left lung may represent
infectious etiology vs. a less likely possibility of a rapid
progression of interstitial lung disease. A CT chest would be
helpful for further evaluation.
.
EKG: sinus rhythm at 90, normal axis, inverted T wave in V1
(old), T wave flattening V2, upsloping T wave in V2-5 (old)
.
Chest CT ([**8-30**]): Since [**2147-5-6**] and [**2147-7-4**] diffuse
ground-glass opacity and intralobular reticulations throughout
the left lung and right upper lobe is new; the profusion is much
less in the right lower lobe with relative sparing of subpleural
parenchyma. Longstanding fibrotic interstitial lung disease,
mostly on the right and mostly in right lower lobe is otherwise
unchanged.
IMPRESSION: 1. New diffuse ground-glass opacity with
intralobular reticulation in the left lung and right upper lobe,
less in the right lower lobe could be due to [**Year (4 digits) **], diffuse
infection, or acute exacerbation of interstitial lung disease.
If the prior interstitial lung disease was due to asbestos, this
is
not the expected course of that disease. Acute exacerbation of
UIP, NSIP, or AIP would be more likely. 2. Right perihilar
radiation fibrosis 3. Prior granulomatous exposure.
Chest CT [**2147-9-5**]:
IMPRESSION:
1. Improvement of left lung ground-glass and reticulation, not
yet back
to baseline of [**2147-7-4**].
2. Improving enlarged 15-mm prevascular lymph node, decreased
from 24 mm.
3. Otherwise unchanged in 6-day interval.
PICC line [**2147-9-4**]: FINDINGS:
There is a left PICC with tip in the upper superior vena cava.
Brief Hospital Course:
77 y/o man with known interstitial lung disease and prior NSCLC
s/p radiation therapy admitted with respiratory distress and
hypoxia.
.
# Respiratory distress: The patient has underlying interstitial
lung disease with baseline oxygen requirement though clearly he
is much worse than baseline. Differential initially included
infection (bacterial, including PCP or [**Name9 (PRE) 10540**], viral, or fungal);
congestive heart failure; vasculitis (pulmonary-renal syndromes
such as Wegener's or Goodpasture's versus pulmonary syndromes
such as lupus or Churg-[**Doctor Last Name 3532**]). Other considerations included
BOOP/COP, acute eosinophilic pneumonia and hypersensitivity
pneumonitis. Less likely was an acute worsening of underlying
lung disease as that would be atypical for UIP.
Elevated LDH in setting of chronic steroid use without PCP
prophylaxis was certainly concerning for PCP. [**Name10 (NameIs) **] visible
on BAL was concerning for diffuse alveolar damage. Cell
counts/diff, cytology, and cultures from BAL were unremarkable.
High resolution chest CT scan demonstrated new, diffuse
ground-glass opacity with intralobular reticulation in the left
lung and right upper lobe, less in the right lower lobe. These
findings were thought to be due to [**Name10 (NameIs) **], diffuse
infection, or acute exacerbation of interstitial lung disease.
Acute exacerbation of UIP, NSIP, or AIP remained in the
differential. [**Doctor First Name **], ANCA, legionella urinary antigen, BAL for AFB
and PCP DFA were negative, negative beta-glucan and
galactomanan. Complement levels were within normal limits. CBC
differential failed to demonstrate a peripheral eosinophilia.
Upon presentation to the MICU, the patient was begun on HCAP
treatment with vancomycin, cefepime, and levofloxacin. Vanc was
stopped on [**9-1**]. Levofloxacin and cefepime were continued with
plan for 8-day course of treatment (day 1=[**8-30**]). He was covered
for PCP with treatment dose bactrim and 1mg/kg IV steroids.
Bactrim changed to prophylaxis dose on [**9-5**] based on negative
beta-glucan/galactomannan and smere. From [**Date range (1) 19502**], he was
given 3 days of 1g/day solumedrol. He was kept on a face mask
with goal saturations >88-90%. He continued to desat to the low
80s with minimal movement. Upon transfer to the floor his oxygen
requirements were increased from his basline. He is [**Age over 90 **]% on
3Liter via nasal cannula, desat to 78% on 3L with activity on 6L
his sats 91%. Physical therapy recommended inpatient pulmonary
rehab.
# Urinary retention: On arrival to the MICU, the patient had
distended bladder evident on examination. A foley was placed and
kept in place at the patient's request and because of his
frequent desats with minimal movement. Foley d/c'd on [**9-5**]. He
voided 300cc without difficulty.
.
# Chronic renal insufficiency: Patient's meds were renally
dosed. He maintained his baseline creatinine of 1.6. On [**9-4**],
he developed hyperkalemia to 6.1 which was responsive to
kayexelate in the setting of bactrim use and CKD.
# Hypertension: As the patient remained normotensive, his HCTZ
was held.
Upon discharge he was hemodynamically stable. He will follow-up
with Dr. [**Last Name (STitle) **] in 2 weeks.
Medications on Admission:
advair 250/50 inhaler [**Hospital1 **]
spiriva 18 mcg daily
asa 81 mg daily
allopurinol 300 mg daily
hctz 12.5 mg once daily
prilosec 20 mg daily
prednisone 10 mg daily
albuterol prn
Home oxygen 2 Liters
Discharge Medications:
1. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 7 days: decrease dose by 10 mg every 7 days.
2. Azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) as needed for Pulmonary vasculitis.
Disp:*30 Tablet(s)* Refills:*1*
3. Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO DAILY
(Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Calcium-Cholecalciferol (D3) 500 (1,250)-400 mg-unit Tablet
Sig: One (1) Tablet PO once a day.
10. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY MONDAY THRU FRIDAY (): Prophylaxis.
11. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) Inhalation once a day.
12. Serevent Diskus 50 mcg/Dose Disk with Device Sig: One (1)
Inhalation twice a day.
13. Oxygen
Home oxygen 2-4L via nasal cannula maintains sats > 90%
14. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: 2.5/3ml Inhalation every 4-6 hours as needed
for wheezing/dyspnea.
15. Ipratropium Bromide 0.02 % Solution Sig: 0.2mg/ml
Inhalation Q6H (every 6 hours).
16. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
17. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
18. Regular Insulin Sliding Scale
Fingerstick QACHSInsulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
71-149 mg/dL 0 Units 0 Units 0 Units 0 Units
150-199 mg/dL 2 Units 2 Units 2 Units 2 Units
200-249 mg/dL 4 Units 4 Units 4 Units 4 Units
250-299 mg/dL 6 Units 6 Units 6 Units 6 Units
300-349 mg/dL 8 Units 8 Units 8 Units 8 Units
350-399 mg/dL 10 Units 10 Units 10 Units 10 Units
19. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 245**] [**Location (un) 1514**]
Discharge Diagnosis:
1) NSCLCA (right puplmonary nodule) S/P CyberKnife) complicated
by localized radiation pneumonitis
2) Interstitial lung disease "pulmonary fibrosis" (?
Asbestosis)chronic respiratory failure
3) Chronic renal insufficiency (baseline 1.6-2.0)
4) Hypertension
5) GERD
6) History of esophageal stricture S/P dilatation
Discharge Condition:
decondition
Discharge Instructions:
Call Dr.[**Name (NI) 14679**] office [**Telephone/Fax (1) 10084**] if experience: fever,
chills, increased shortness of breath, chest pain or cough
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 828**] [**Name11 (NameIs) 829**], MD Phone:[**0-0-**]. Please call
for an appointment in 2 weeks.
Completed by:[**2147-9-12**]
|
[
"788.20",
"V10.11",
"274.9",
"518.84",
"276.7",
"508.0",
"530.81",
"515",
"530.3",
"305.01",
"403.90",
"492.8",
"585.9",
"909.2",
"253.6",
"786.3",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
11252, 11323
|
5581, 8841
|
341, 346
|
11682, 11695
|
3496, 5558
|
11892, 12062
|
2661, 2719
|
9095, 11229
|
11344, 11661
|
8867, 9072
|
11719, 11869
|
2734, 3477
|
281, 303
|
374, 2093
|
2115, 2281
|
2297, 2645
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,973
| 187,914
|
53857
|
Discharge summary
|
report
|
Admission Date: [**2150-3-2**] Discharge Date: [**2150-3-8**]
Date of Birth: [**2095-2-14**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: A 55-year-old male with a
history of multiple myeloma status post autologous BMT
[**2149-10-7**] and chronic hepatitis B, who is admitted
for five days of jaundice, dark urine, and malaise.
Apparently, he stopped his adefovir approximately 4-5 weeks
prior to admission, which had been maintaining his chronic
hepatitis B from replicating. He was also on lamivudine,
which he had been taking. Otherwise, his most recent course
was complicated by strongyloides infection to be found after
his autologous BMT, which he was treated with ivermectin.
He was seen in a clinic in [**First Name4 (NamePattern1) 651**] [**Last Name (NamePattern1) **], where he was noted to
be grossly jaundiced, and was seen by his own physician the
next day upon where he was transferred to [**Hospital1 346**] for further evaluation and admitted
to the Bone Marrow Transplant service. He was on the
transplant service for two days until he was found to have a
pantransaminitis and extreme hyperbilirubinemia, where upon
he went into fulminant liver failure, and was transferred to
the ICU.
PAST MEDICAL HISTORY:
1. Multiple myeloma diagnosed in [**11/2147**] treated with
autologous BMT and with a prednisone/thalidomide cycles.
2. Hepatitis B for many years.
ALLERGIES: There was no known drug allergies.
MEDICATIONS PRIOR TO ADMISSION:
1. Lamivudine.
2. Ivermectin.
3. Tylenol.
4. Adefovir which had been stopped for several weeks.
FAMILY HISTORY: No family history of any pertinent disease.
SOCIAL HISTORY: Patient worked as a cook prior to diagnosis
of myeloma. Denies smoking, drinking, or using IV drugs. He
is married with two children. Lives in JP. He is also
primarily Mandarin speaking Chinese.
REVIEW OF SYSTEMS: No fevers, chills, abdominal pain,
nausea, vomiting, chest pain, shortness of breath,
hematochezia, dysuria, weight loss.
PHYSICAL EXAMINATION: Upon admission, patient was noted to
be in no acute distress, was overtly jaundiced with icteric
sclerae. His neck was supple without any lymphadenopathy.
His lungs are clear to auscultation bilaterally. Heart
examination was regular rate and rhythm without any murmurs
appreciated. The abdominal examination was soft, nontender,
and nondistended. His extremities were strong throughout
without any edema.
ADMISSION LABORATORY WORK: Significant for normal white
count, hematocrit of 44, platelets of 84. Liver enzymes have
an ALT of 2,093, AST of 3,000, total bilirubin of 30 with a
direct fraction being 22.
He had a right upper quadrant ultrasound which revealed no
stones, a slightly edematous gallbladder wall, but otherwise
a patent cystic and common bile duct.
HOSPITAL COURSE: [**Hospital **] hospital course was complicated
by fulminant hepatitis and complete liver failure. He was
continuously transfused with FFP for three days, and his
platelets were also transfused that involved a DIC picture
for which he was treated for a gram-positive coccus
bacteremia with ceftriaxone and Vancomycin empirically. His
coma worsened, and he developed severe acidosis. He also
received several red cell transfusions in addition to FFP,
platelets, and factor VII-A on three separate occasions.
Decision was made with Neurosurgery in consult with
Hepatology service to place an ICP bolt to monitor his
intracranial pressure to treat his brain edema with mannitol
boluses. Patient was not a liver transplant candidate. This
is going to be done with the hopes that we could temporize
through his severe illness and allow him to recover his
synthetic function. However, the patient soon bled into his
bolt site requiring urgent trip to the OR after CT revealed a
subdural hematoma with a midline shift and a blown pupil.
Hematoma was evacuated. FFP was continued. The patient went
into renal failure. Whether this is due to primary hepatic
renal syndrome or due to biliary sludge, is unclear, however,
it eliminated our only therapeutic options, decreasing his
ICP at that time. He became volume overloaded due to the
continuous coagulation factors and transfusions required to
maintain his ability to clot and became a difficult patient
to oxygenate requiring significantly high FIO2s and PEEP as
high as 20 cm of water. Despite this, his oxygenation
remained poor and his intracranial pressure continued to
rise. He became hypotensive and dopamine was started, and
eventually Renal was consulted for CVVH to help ultrafiltrate
the fluid that he was receiving as his kidneys were no longer
functioning.
On [**2150-3-8**], after lengthy discussion with the
neurosurgeons, Hepatology service, Renal service, and the ICU
team, the patient was made do not resuscitate and eventually
placed on comfort measures only, and care was withdrawn in
accordance to family's wishes. Patient expired shortly after
he was extubated.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], M.D. [**MD Number(1) 292**]
Dictated By:[**Last Name (NamePattern1) 4791**]
MEDQUIST36
D: [**2150-3-8**] 17:41
T: [**2150-3-9**] 04:50
JOB#: [**Job Number 110503**]
|
[
"286.7",
"570",
"070.20",
"286.6",
"584.9",
"577.0",
"432.1",
"276.6",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.95",
"39.95",
"01.24",
"99.07",
"45.13",
"38.93",
"99.05",
"01.18",
"99.06"
] |
icd9pcs
|
[
[
[]
]
] |
1590, 1635
|
2812, 5243
|
1476, 1573
|
2018, 2794
|
1872, 1995
|
154, 1225
|
1247, 1444
|
1652, 1852
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,380
| 115,694
|
14911
|
Discharge summary
|
report
|
Admission Date: [**2154-10-25**] Discharge Date: [**2154-10-30**]
Service: CCU
HISTORY OF PRESENT ILLNESS: This is an 84-year-old gentleman
with a history of severe coronary artery disease status post
coronary artery bypass graft x2, recent admission to [**Hospital1 1444**] for ST elevation myocardial
infarction on [**2154-10-12**], moderate aortic stenosis,
congestive heart failure, and chronic renal insufficiency,
admitted again on [**2154-10-25**] for failure to thrive
secondary to decompensated congestive heart failure.
On admission, patient appeared very cachectic and fluid
overloaded. Swan Ganz catheter revealed CVP pressure of 22,
PA systolic and diastolic pressures of 68/26, with capillary
wedge pressure of 30. He was started on dobutamine and
dopamine drip and was aggressive diuresed with Lasix.
After a long discussion with patient and his family, decision
was made to continue medical management, but not to pursue
any invasive interventions including valvuloplasty for the
aortic stenosis. His code status was changed to DNR/DNI.
However, despite aggressive medical management, the patient
arrested around 10 pm on [**2154-10-30**] after a run of
V-T which turned into torsade V-fib. When on the on-call
house staff was called to examine the patient, the patient
had already been in cardiopulmonary arrest. Death was
pronounced and family was informed. The family declined a
postmortem examination.
DIAGNOSES: Cardiac arrest, coronary artery disease, aortic
stenosis, congestive heart failure, chronic renal
insufficiency.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 4786**]
Dictated By:[**Last Name (NamePattern1) 225**]
MEDQUIST36
D: [**2154-11-5**] 15:20
T: [**2154-11-11**] 08:57
JOB#: [**Job Number **]
|
[
"429.3",
"250.00",
"427.41",
"414.01",
"783.7",
"428.0",
"424.1",
"397.0",
"424.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
118, 1866
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9,058
| 187,101
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49908
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Discharge summary
|
report
|
Admission Date: [**2182-2-3**] Discharge Date: [**2182-2-9**]
Date of Birth: [**2128-8-14**] Sex: F
Service: MEDICINE
Allergies:
Zoloft / Tetracyclines / Prozac / Paxil / Darvocet A500
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Admit for Cath
Major Surgical or Invasive Procedure:
Cardiac and Lower extemity catheterization with relook [**2182-2-6**]
History of Present Illness:
Ms. [**Known lastname 104253**] is a 53 year old woman with history of CABG,
mechanical AVR and MVR, hx of severe PVD s/p PTA??????s, being
referred for both cardiac and RLE angiography on Wednesday
[**2182-2-6**]. She has a history of prior retroperitoneal bleed with
last cath. She had had a long history of symtoms of claudication
with ambulation. She has had LE angiography in the past that has
demonstrated several LE blockages.
.
She states that at baseline, she can typically walk
approximately one block before she has to rest. She stated that
a few days ago, she had experienced some dull chest pain at rest
that lasted a few minutes. It was not associated with any SOB,
nausea, or diaphoresis.
.
On [**2-6**] patient taken for LE and coronary angiography. Patient
had a complicated procedure that led to her transfer to the CCU.
During the cath, patient developed a LCFA dissection. The LCFA
was ballooned using an approach from the right. Patient also was
found to have a proximal RCA lesion that was stented using a
BMS. She was also found to have a LMCA lesion that was not
intervened upon. Several hours post intervention, patient
complained of pain in LLE and was unable to move her foot.
Patient's foot was cold and did not have any pulses. She was
taken for re-look and was found to have an embolus in the
popliteal artery. Patient had an embolectomy and a stent placed
in the popliteal artery. She was started on a heparin gtt and
was taken to the CCU for back pain, delirium, nausea. She
recieved pain meds, lorazepam and now feels better. She dropped
her oxygen satutations and her CXR showed possible pulm edema
and got furosemide 10 mg IV x 1 at 12am, to which she has
diuresed well.
.
Pt is now transferred back to floor. Patient denies any nausea,
vomiting, diarrhea, CP.
Past Medical History:
Cardiac Risk Factors: (-)Diabetes, (+)Dyslipidemia,
(+)Hypertension
.
Cardiac History:
CABG, in [**9-/2179**] anatomy as follows:
1. left internal mammary artery to left anterior descending
artery
2. saphenous vein grafts to right coronary artery
3. saphenous vein grafts to obtuse marginal artery
4. saphenous vein grafts to diagonal artery
Aortic Valve Replacement (19mm St. [**Male First Name (un) 923**] Mechanical), Mitral
Valve Replacement (27mm St. [**Male First Name (un) 923**] Mechanical), Aortic Root
Enlargement with Pericardial Patch
.
Percutaneous coronary intervention:
1. Silverhawk atherectomy of the left SFA/PFA origin on
[**2180-3-6**]
2. PTA was performed on the PFA origin on [**2180-3-6**]
3. Acculink stent in [**Doctor First Name 3098**] on [**2179-9-21**]
4. Protege stent in the L SFA on [**2179-6-21**]
5. Atherectomy and angioplasty of RSFA on [**2179-5-20**]
.
Other Past History:
1. Hypertension.
2. Hyperlipidemia.
3. Peripheral [**Date Range 1106**] disease status post bilateral lower
extremity SFA revascularization by Dr. [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **]
- [**2-24**] ABIs: 0.82 and 1.05 on the right and left respectively,
remaining stable with exercise. She has triphasic waveforms
throughout with exception of monophasic right DP. Her PVRs are
maintained at 16 bilaterally at the metatarsal level. Duplex
results reveal elevated velocities at proximal aspect of stents
bilaterally (248 and 305 cm/sec, respectively) consistent with
50% narrowing.
- [**2179-4-12**] ABIs: Right: 0.55, decreasing to 0.15 with exercise.
Left: 0.41, decreasing to 0.21 with exercise. Impression: Left
iliofemoral arterial disease, right SFA disease, possible left
SFA disease, bilateral infrapopliteal arterial disease.
- [**2179-5-20**] right SFA atherectomy and angioplasty (Dr. [**First Name (STitle) **]
- [**2180-2-3**]-ABIs as below
4. Coronary artery disease, status post CABG x4 in [**2179-9-19**],
under the care of Dr. [**Last Name (STitle) **].
5. Rheumatic heart disease with AR and MR, s/p AVR/MVR in
[**2179-9-19**].
6. Cardiomyopathy: [**2178-2-27**] admission to [**Hospital1 18**] [**Location (un) 620**] with
CHF, cardiomyopathy, EF = 25%. Etiology unclear; repeat echo
[**2178-3-31**] EF = 55%.
7. Asymptomatic bilateral carotid artery disease status post
[**Doctor First Name 3098**] stent, under the care of Dr. [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **] prior to
cardiac surgery in [**2179-9-19**].
8. Congenital hip dysplasia status post left total-hip
replacement
9. Chronic back pain
10. Status post appendectomy
11. Status post cholecystectomy
Social History:
The patient is married and has a 26 year-old daughter. She lives
in [**Hospital1 189**]. She used to work as a nursing assistant in ALF but
had to retire due to back/hip pain. Has recently been working in
retail but that is on hold until she completes cardiac rehab.
Smoked 1 ppd x 36 years, quit at age 50. Occasional EtOH.
Family History:
Mother: CAD, hypercholesterolemia, MI in 50s, breast cancer.
Fater: DM2, CVA.
Siblings: Healthy.
Physical Exam:
VS - 97.7, 120/43, 62, 18, 93%RA
Gen: Oriented x3. Mood, affect appropriate.
HEENT: PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis
of the oral mucosa. No xanthalesma.
Neck: No JVP
CV: RR, loud S1, load S2 with IV/VI SEM. No thrills, lifts. No
S3 or S4.
Chest: 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 inguinal hematomas bilaterally. No bruit on R.
L femoral soft bruit. BLE warm, well perfused.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
Pertinent Results:
[**2-6**] C Cath
COMMENTS:
1. The right femoral artery sheath ws exchanged for a 6 french
short
sheath. An omniflush catheter was advanced over an angled glide
wire,
over the [**Doctor Last Name 534**] to the LCFA. Angiography revealed a patent CFA
with the
previous dissection site widely patent. The LSFA stent was
widely patent
and the left popliteal artery was occluded and reconstituted
aftet
approximately 40 mm. The AT and PT were patent to the foot.
2. We planned to export the thrombus from the left popliteal
artery and
laser if needed. A 6 French [**Last Name (un) 12297**] sheath was advanced over the
[**Doctor Last Name 534**] to
the contralateral SFA. The lesion was crossed with an angled
glide wire
and then a spartacore wire. A 4.0 spider filter was used for
distal
protection. Thrombectomy was preformed with the export cathether
with
retrieval of thrombus but little improvment angiographically.
Atherectomy with a 1.4 mm laser at 45/30 was preformed without
return of
flow. The lesion was then dilated with a 4.0 x 60 mm amphirion
balloon.
A 5.0 x 80 mm Zilver stent was deployed in the left popliteal
artery
and was post dilated with a 4.0 x 80 mm amphirion balloon.
Final
angiography revealed no residual stenosis in the stent and no
dissection. The DP had a distal cut off though the PT was widely
patent.
3. Right femoral arteriotomy site was closed with a 6 French
Angioseal
device.
FINAL DIAGNOSIS:
1. Acute limb ischemia.
2. Successful thrombectomy, laser atherectomy, PTA and stenting
of the
Left popliteal artery.
[**2-6**] C Cath
COMMENTS:
1. Coronary angiography in this right-dominant system revealed:
--the LMCA had a proximal 70% tubular lesion with flow into the
LCX and
competitive flow into the LAD.
--the LAD was patent with competitive flow to the diagonal and
LAD from
a patent [**Female First Name (un) 899**] graft.
--the LCX was a non-dominant vessel with moderate diffuse
disease.
There is tenting of a small OM from the occluded SVG graft.
--the RCA was a dominant vessel with origin 90% lesion.
2. Arterial conduit angiography revealed the LIMA-LAD graft to
be
widely patent. Venous conduit angiography revealed the SVG-RCA,
SVG-OM,
and SVG-Diag grafts to be occluded. This was confirmed by
supravalvular
aortography.
3. Supravalvular aortography confirmed occlusion of the
SVG-RCA,
SVG-OM, and SVG-Diag grafts.
4. Upon access in the LCFA dissection was noted with preserved
flow.
The EIA had moderate diffuse disease proximal to the previous
SFA stent.
The REIA had a tubular 70% lesion with the RSFA having a
proximal 90%
lesion above the previous stent.
5. Limited resting hemodynamics revealed severe arterial
systolic
hypertension, with SBP 202 mmHg.
6. We first palnned to fix the Right external iliac artery. We
exchanged
the left CFA sheath for a 6 French Balken sheath. The lesion was
crossed
with a steel core wire to the Right popliteal artery. A 7.0 x
80 mm
protege stent was deployed in the REIA and was post dilated with
a 6.0 x
60 mm Admiral balloon. We then advanced a 6.0 x 20 mm
angiosculpt
balloon to the proximal RSFA and dilated the lesion at moderate
pressure. Final angiography revealed no residual stenosis in the
stent
and a 10% residual in the SFA.
7. We then turned our attention to the Right coronary artery.
Successful
PTCA and stenting of the ostial RCA with a 4.0 x 15 mm VISION
BMS which
was deployed at 17 ATM. Final angiography revealed no residual
stenosis
in the stent, no dissection and TIMI III flow. (See PTCA
comments)
8. We then turned our attention to the LCFA dissection. We
accessed t he
RCFA and placed a 6 French Balken sheath to the contralateral
LCIA. A
angled glide wire was left in the L SFA. Angiography confirned a
retrograde dissection. The Left CFA was closed with a 6 French
Mynx
device but flow diminished. The [**Female First Name (un) 7195**] and the LCFA were t hen
dilated
with a 6.0 x 60 admiral balloon to 5 ATMs. Final angiography
revealed a
10% residual, a contained dissection with preserved flow.
FINAL DIAGNOSIS:
1. Native three-vessel CAD
2. Patent LIMA-LAD
3. Occluded SVG-RCA, SVG-Diag, and SVG-OM grafts.
4. Dissection in LCFA with preserved flow.
5. Moderate diffuse disease in [**Female First Name (un) 7195**]; tubular 70% stenosis in
REIA and
90% stenosis in R SFA.
6. Severe systemic arterial systolic hypertension.
7. Successful stenting of the REIA and PTA of the RSFA.
8. Successful PTCA and stenting of the ostial RCA.
9. Successful PTA of teh LCFA dissection.
10. Successful closure of LCFA access site with Mynx closure
device.
[**2-6**] KUB
IMPRESSION: Incompletely visualized abdomen; however, visualized
portion
appears normal. Indistinct left lung base, better characterized
on
accompanying chest radiograph.
[**2-7**] Femoral U/S
IMPRESSION:
1. No evidence of hematoma, pseudoaneurysm or AV fistula.
2. No son[**Name (NI) 493**] evidence of foreign object in the right common
femoral
artery. A possible angioseal device is seen in the superficial
tissues
superficial to the right CFA.
[**2182-2-9**] 08:16AM BLOOD WBC-7.6 RBC-3.84* Hgb-7.4* Hct-26.6*
MCV-69* MCH-19.2* MCHC-27.7* RDW-26.2* Plt Ct-177
[**2182-2-8**] 09:20AM BLOOD Hct-26.4*
[**2182-2-8**] 04:45AM BLOOD WBC-8.6 RBC-3.56* Hgb-7.0* Hct-23.4*
MCV-66* MCH-19.6* MCHC-29.9* RDW-26.9* Plt Ct-196
[**2182-2-7**] 05:38AM BLOOD WBC-12.2* RBC-4.28 Hgb-8.2* Hct-27.4*
MCV-64* MCH-19.3* MCHC-30.1* RDW-24.5* Plt Ct-216
[**2182-2-9**] 03:55PM BLOOD PT-22.7* PTT-70.6* INR(PT)-2.2*
[**2182-2-9**] 08:16AM BLOOD Plt Ct-177
[**2182-2-9**] 08:16AM BLOOD PT-21.4* PTT-102.2* INR(PT)-2.0*
[**2182-2-8**] 04:45AM BLOOD Plt Ct-196
[**2182-2-8**] 04:45AM BLOOD PT-16.4* PTT-83.5* INR(PT)-1.5*
[**2182-2-4**] 06:43AM BLOOD calTIBC-459 Hapto-<20* Ferritn-9.1*
TRF-353
[**2182-2-4**] 06:43AM BLOOD Triglyc-84 HDL-45 CHOL/HD-2.8 LDLcalc-63
Brief Hospital Course:
53 year old woman with history of CABG, mechanical AVR and MVR,
hx of severe PVD s/p PTA??????s, s/p BMS to prox RCA and LCFA
dissection, with REIA and L popliteal stenting.
.
#. CAD: Patient is s/p CABG with triple vessel disease, and
with lower extremity [**Month/Day/Year 1106**] disese. CP free, but coronaries
were looked. During the procedure, patient was found to have a
tight left main that was supplying a diagonal (likely D1) that
was not intervened upon. The LMCA had a proximal 70% tubular
lesion with flow into the LCX and competitive flow into the LAD
that was patent. The RCA was a dominant vessel with origin 90%
lesion that was successfully stented with BMS. The LMCA was not
intervened upon.
- Continue ASA, BB, Statin
- Continue [**Month/Day/Year **]-I
- Continue Plavix 75mg daily
.
#PVD: Stable. During the cath, patient developed a LCFA
dissection. The LCFA was ballooned using an approach from the
right. Several hours post intervention, patient complained of
pain in LLE and was unable to move her foot. Patient's foot was
cold and did not have any pulses. She was taken for re-look and
was found to have an embolus in the popliteal artery. Patient
had an embolectomy and a stent placed in the popliteal artery.
She was started on a heparin gtt and was taken to the CCU for
back pain, delirium, nausea. Patient recovered after one night
in the CCU. Patient has a soft L femoral bruit that was likely
from the dissection, and was confirmed by ultrasound. There was
no evidence of AV fistula. Patient's BLE are warm with 2/2
pulses present.
.
#. Pump: Patient is euvolemic on exam. She has a history of AV
and MVR and has been on coumadin at home. Patient was started on
a heparin drip and warfarin was held prior to procedure. On
discharge, patient's INR was 2.2, with goal 2.5-3.5. Patient is
to follow up with PCP for INR check.
- Cont coumadin 5mg
- Follow INR as outpatient
.
#. Rhythm: NSR.
- Monitor on tele
.
#. Hyperlipidemia: Continue pravastain
.
Medications on Admission:
Plavix 75mg daiy
HCTZ 12.5mg daily
Hydromorphone 2mg QID
Ipratropium Bromide [**Hospital1 **]-QID
Lisinopril 30mg daily
Lopressor 100mg [**Hospital1 **]
Omeprazole 20mg daily
Oxycontin 80mg [**Hospital1 **]
Pravastain 40mg daily
Coumadin 3-5mg/day
ASA 81mg daily
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Lisinopril 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
6. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO TID (3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
7. Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: Two (2)
Tablet Sustained Release 12 hr PO Q8H (every 8 hours).
8. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: Please adjust according to your INR.
10. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: One (1)
Inhalation twice a day.
11. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- Coronary Artery Disease
- Peripheral [**Hospital1 1106**] disease
- Hypertension
Discharge Condition:
Afebrile, Vitals Stable
Discharge Instructions:
You were hospitalized because you needed to have a lower
extremity and cardiac catheterization. You had a stent placed
in your proximal right coronary artery and another placed in an
artery in your right and left lower extremities.
Please continue to take plavix. Your dose of aspirin has been
increased to 325mg daily.
Your INR is 2.2 on discharge. Please continue to adjust your
coumadin dose based on your home INR machine. Please make an
appointment to see Dr. [**Last Name (STitle) **] and to have your INR officially
checked on Wednesday.
Please call Dr.[**Name (NI) 3101**] office to make an appointment to see
him in [**1-23**] weeks.
You were also found to be anemic, please continue to take Iron
supplements. Please consider having a screening colonoscopy as
an outpatient.
Followup Instructions:
Please call Dr. [**Last Name (STitle) 12103**] office to make an appointment within 1
week. Please tell his office that you need your INR checked on
Wednesday. His number is [**Telephone/Fax (1) 4775**]
Please call Dr.[**Name (NI) 3101**] office to make a follow up appointment.
His number is [**Telephone/Fax (1) 62**]
Completed by:[**2182-3-5**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
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[
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275, 291
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429, 2226
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4916, 5243
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
946
| 183,564
|
26865+57516
|
Discharge summary
|
report+addendum
|
Admission Date: [**2120-4-12**] Discharge Date: [**2120-5-14**]
Date of Birth: [**2040-3-16**] Sex: M
Service: MEDICINE
Allergies:
Iodine; Iodine Containing
Attending:[**First Name3 (LF) 297**]
Chief Complaint:
The patient is an 80 year old man with a history of
poliomyelitis as a child, new onset atrial fibrillation, and
recent GI bleed now presenting with respiratory failure. The
patient problems began in late [**Month (only) 956**] when he presented to his
Cardiologist with increased shortness of breath and was found to
be in rapid afib and congestive heart failure. He went for a
cardiac catheterization at the time which showed severe LAD
disease. The cath procedure was complicated by a presumed
reaction to the contrast dye. He was noted to have a bilateral
pneumonia and was started on doxycycline. The patient was
discharged home later afebrile and on warfarin and lasix. He
epresented about a week later to the hospital, febrile and with
hematemesis and BRBPR--his bp was 80/38 with a HR of 125; INR
was 6.2. He was found to have bleeding jejunal diverticulas and
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **] tear--both of which were surgically corrected.
He underwent a head ct for "sundowning" which was normal by
report. He remained intubated, febrile, was started on vanco,
cefepime and flagyl and transferred to [**Hospital1 18**] for further care.
Major Surgical or Invasive Procedure:
Percutaneous Tracheostomy
History of Present Illness:
This is a 80 year old male with recent admit to [**Hospital 108**] hospital
[**2120-3-18**] due to acute dyspnea. He has a new onset A- fib, CHF,
S/P jejunal resection on [**2120-4-5**], for bleeding diverticulae.
Transferred from [**Hospital 108**] hospital for failure to wean from vent.
Since being at [**Hospital1 18**], he has remained intermittantly febrile
(fever curve has improved). He is noted by the nursing staff to
intermittanly follow simple commands, moving all extremities,
and has become agitated at times requiring ativan, fentanyl,
haldol and more recently seroquel. He gets ativan 1 mg tid
standing, fentanyl patch in addition to prn's of those. His
respiratory status has remained tenuous and has been diagnosed
with atypical pneumonia vs. early ARDs. He was transferred to
the surgical service of [**Hospital1 18**] on [**2120-4-12**] for failure to wean
from vent. He was febrile and hypotensive after transfer, and
pressors were started. The pressors were weanted and he was felt
to be in ARDS. He was trached on [**4-17**] and has had generally not
been able to be weaned since that time. He has completed courses
of empiric antibiotics. He has been slowly getting better since
that time, and is being transferred to the MICU service [**2120-5-9**]
for failure to wean from the ventilator.
Past Medical History:
Past Medical History:
-s/p appendectomy
-h/o polio as a child; wife tells me he was diagnosed in the
[**2064**]'s during the polio epidemic; had a headache at the time; no
weakness or diarrhea
-recent new atrial fibrillation
-h/o recent pneumonia
Social History:
Social History:
-married and lives with wife
-no tobacco or alchol use
-worked as a machinist
Family History:
Family History:
-father had a stroke at 90
-mother died of old age
-no h/o neuromuscular problems
Physical Exam:
V: Tm 99.2 115/52 (98/45-146/75) 82 (66-83)
SIMV/PS 450x23 [**10-27**] 40% 7.38/50/183 breathing at 36 PIP 25 Plat
29 (yesterday)
I/O 990/970 (urine)
Gen: no apparent distress.
HEENT: OP clear, MM dry
Neck: no JVD
Resp: clear bilaterally
CV: irreg, tachy normal S1s2 no murmurs
Abd: soft NTND midline incision well healed.
Ext: SCD's in place. No cyanosis, clubbing, edema
Neuro: Responsive to voice. Denies pain.
Pertinent Results:
[**2120-4-13**] 12:58AM BLOOD WBC-9.2 RBC-3.91* Hgb-11.6* Hct-33.4*
MCV-86 MCH-29.5 MCHC-34.6 RDW-15.2 Plt Ct-123*
[**2120-4-13**] 12:58AM BLOOD Neuts-80.3* Lymphs-13.4* Monos-3.3
Eos-1.8 Baso-1.1
[**2120-4-13**] 12:58AM BLOOD PT-16.0* PTT-29.3 INR(PT)-1.5*
[**2120-5-9**] 01:45AM BLOOD Ret Aut-2.8
[**2120-4-13**] 12:58AM BLOOD Glucose-98 UreaN-26* Creat-1.1 Na-137
K-4.0 Cl-100 HCO3-28 AnGap-13
[**2120-4-13**] 12:58AM BLOOD ALT-20 AST-28 LD(LDH)-500* AlkPhos-98
TotBili-1.3
[**2120-4-14**] 01:30AM BLOOD Lipase-21
[**2120-4-28**] 09:03PM BLOOD proBNP-[**Numeric Identifier 66114**]*
[**2120-4-14**] 01:30AM BLOOD Calcium-7.0* Phos-2.9 Mg-1.8
[**2120-4-22**] 01:32AM BLOOD calTIBC-124* TRF-95*
[**2120-5-1**] 02:17PM BLOOD Hapto-316*
[**2120-4-22**] 05:57PM BLOOD TSH-2.5
[**2120-4-22**] 05:57PM BLOOD Cortsol-13.9
.
Histoplasma Ag neg
ADENOVIRUS PCR neg
LEGIONELLA PNEUMOPHILA ANTIBODY neg
MYCOPLASMA PNEUMONIAE ANTIBODY IGM neg
CHLAMYDIA PNEUMONIAE ANTIBODY PANEL neg
MYCOPLASMA PNEUMONIAE ANTIBODY, IGG pos
.
[**2120-4-14**] BAL no growth and neg cytology
[**2120-4-22**] LP negative for infection and cytology
[**2120-4-30**] BRONCHOALVEOLAR LAVAGE no growth and neg cytology
[**2120-4-30**] 9:46 am Rapid Respiratory Viral Screen & Culture
[**2120-5-10**] Rapid Respiratory Viral Antigen Test: negative
VIRAL CULTURE CYTOMEGALOVIRUS-LIKE CYTOPATHIC EFFECT
.
[**5-13**] PCXR
Mild interstitial pulmonary edema has improved over the past
five days. Moderate cardiomegaly persists. There is no focal
pulmonary abnormality to suggest pneumonia. Feeding tube ends in
the proximal jejunum. Tracheostomy tube is canted in the trachea
and should be evaluated clinically to determine the position is
acceptable. There is no pleural effusion or pneumothorax.
.
[**5-8**] CXR: global interstitial abnormality, low lung volumes
.
[**5-7**] EKG
Atrial fibrillation with a controlled ventricular response.
Delayed R wave
transition. Downsloping ST segment depressions in leads V4-V6
suggest the
possibility of lateral ischemia. Compared to the previous
tracing of [**2120-4-29**] the rate is diminished and the downsloping ST
segment depressions in the lateral precordial leads are slightly
more prominent. Clinical correlation is suggested.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
80 0 72 320/355.71 0 -4 -118
.
[**5-1**] ECHO: EF60%/2+MR/1+TR
.
[**4-25**] CT Chest:
1. Bilateral ground-glass opacities, fibrotic changes, pleural
effusions and possible lower lobe consolidations. These findings
may be consistent with ARDS.
2. No evidence of pulmonary embolism within the limitations of
the study.
.
[**4-24**] US L LE: Left lower extremity DVT extending from the common
femoral vein to the popliteal vein.
.
[**4-4**] TTE=EF60%, mild TR/MR; (Cath=30%stenosis LAD, mod-severe
MR, EF 41%)
.
[**4-23**] EEG: No actual sharp or epileptiform discharges were seen.
No electrographic seizures were recorded. This EEG is most
consistent with an encephalopathy.
.
[**4-22**] CT Head:
No intracranial hemorrhage. No evidence of a major vascular
territory acute infarct
.
[**4-15**] Upper ext U/S negative for DVT
Brief Hospital Course:
The patient is an 80 year old man with a h/o recent onset atrial
fibrillation, GI bleed, and ARDS now presents with continued
respiratory failure. His neurologic exam demonstrates
obtundation--perhaps related to multiple sedating meds. His head
ct shows 2 hypodensities in the right cerebellum that may be
new. The neurologic differential for respiratory insufficency
would include: muscle- critical illness myopathy; NMJ:
myasthenia [**Last Name (un) 2902**], nerve: AIDP (had reflexes), critical illness
polyneuropathy; cord: high cervical cord injury (does not seem
paraparetic); anterior [**Doctor Last Name 534**] cell- AlS, west [**Doctor First Name **], enteroviruses
(does have h/o questionable h/o polio). Impression is for a
non-neurologic cause of his respiratory failure (pna, ards). Pt
secondary to His respiratory failure underwent tracheostomy on
[**4-17**]/5.
.
#) Respiratory failure - Patient was trached [**4-17**]. Now
oxygenating and ventilating adequately. Increased secretions but
afebrile, [**3-15**] CXR with improved edema and no PNA. Large amount
of measured dead space contributing to difficulty weaning.
******Continue high fat and low-carb diet to avoid worsening
tachypnea, Pco2*******
Goal is to gradually decrease pressure support 18/5->15/5 as
tolerated on [**5-14**]. Continue nebs prn. Increased cuff pressures
to 35 so tracheostomy tube was changed [**5-14**].
.
#) Hyprenatremia - Patient developed hypernatremia of unclear
etiology. Possibly secondary to Na retention. Continuing TF with
free H20 boluses with good results.
.
#) Encephalopathy and agitation - d/ced standing haldol, use
sparingly PRN. Minimize sedation for now and AVOID BENZOS or
narcotics. Patient mental status clearing, able to follow voice
commands (squeeze hand and wiggle toes).
.
#) Left leg DVT - Holding coumadin on [**5-14**] due to
supratherapeutic INR. No PE on CTA. Restart coumadin once INR<3
for goal of 2.0-3.0 for at least 6 months.
.
#) H/o CHF - Echo EF60%/2+MR/1+TR with PA diastolic
hypertension.
.
#) Atrial fibrillation - supratherapeutic INR initially upon
transfer to MICU. Resumed coumadin [**5-10**] with goal INR 2.0-3.0
for afib. Coumadin was held on [**4-24**] due to upratherapeutic INR.
Resume coumadin when INR<3.0. Continued metoprolol for rate
control.
.
#) FEN - Continued insulin sliding scale. Low-carboohydrate tube
feeds.
.
#) Prophylaxis - Continued prevacid, bowel regimen,
supratherapeutic INR.
.
#) access - d/ced A line [**5-14**], dobhoff
.
#) precautions - for VRE colonization
.
#) code - full, discussed [**5-9**] with wife
.
#) communication - with wife
.
#) PT/OT - seen by PT, encourage OOB to chair and
strength-building
.
#) dispo - to rehab.
Medications on Admission:
-seroquel 25 mg [**Hospital1 **] (started today)
-metoprolol
-ativan 0.5-1 mg q4hr prn
-levofloxacin
-fentanyl patch
-haloperidol 0.5-1 qhs prn
-nebs
-insulin sc
-fentanyl 12.5-25 mcg iv q2hr prn
-protonix
.
.
Meds on transfer from SICU:
Lansoprazole Oral Suspension 30 mg NG DAILY
Acetaminophen (Liquid) 325 mg PO Q4-6H:PRN
Magnesium Sulfate 2 gm / 100 ml D5W IV PRN
Albuterol-Ipratropium [**1-22**] PUFF IH Q6H
Metoprolol 50 mg PO TID
Albuterol 6 PUFF IH Q4H:PRN
Midazolam HCl 0.5 mg IV Q1H: PRN
Artificial Tear Ointment 1 Appl OU PRN
Miconazole Powder 2% 1 Appl TP TID:PRN
Calcium Gluconate 2 gm / 100 ml D5W IV PRN
Nystatin Oral Suspension 5 ml PO QID:PRN
Digoxin 0.25 mg IV DAILY Start: [**2120-4-24**]
Oxycodone-Acetaminophen Elixir [**5-29**] ml PO Q4-6H:PRN
Haloperidol 10 mg PO BID
Potassium Chloride 40 mEq / 100 ml SW IV PRN
Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN
Warfarin 5 mg PO DAILY
Insulin SC (per Insulin Flowsheet) Sliding Scale
.
Previous antibiotics:
vanco (stopped [**5-2**])
flagyl (stop [**4-18**])
Discharge Medications:
1. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1)
Appl Ophthalmic PRN (as needed).
2. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q4-6H
(every 4 to 6 hours) as needed.
3. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff
Inhalation Q4H (every 4 hours) as needed.
4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
5. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-22**]
Puffs Inhalation Q6H (every 6 hours).
6. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO DAILY (Daily).
7. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
9. Insulin Regular Human 100 unit/mL Solution Sig: PER SLIDING
SCALE Injection ASDIR (AS DIRECTED).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed.
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
12. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed: 10ml NS followed by
1ml of 100 Units/ml heparin (100 units heparin) each lumen Daily
and PRN. Inspect site every shift .
13. Coumadin 1 mg Tablet Sig: HOLDING Tablet PO at bedtime:
Please resume coumadin when INR<3.0 with goal INR of 2.0-3.0.
Will need to be anticoagulated for 6 months until [**2120-10-24**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Hospital1 **]
Discharge Diagnosis:
primary diagnosis:
ARDS
secondary diagnosis:
Atrial fibrillation (since [**2-26**])
CHF EF 60% 2+MR (last echo [**5-1**]) PHTN
DVT right leg this hospitalization
H/o polio in childhood
Discharge Condition:
good
Discharge Instructions:
Please take medications as prescribed.
Please keep follow-up appointments.
If you have any worsening respiratory distress, change in mental
status, fevers/chills or any other worrying symptoms, please
[**Name6 (MD) 138**] your MD.
Current vent settings: CPAP w/ & w/o PS
Pressure support level: 15 cm/h2o PEEP: 5 cm/h2o FIO2: 40 %
Continue with high-fat, low carbohydrate tube feeds given Vd/Vt
of .68
Followup Instructions:
Please schedule an appointment to see your primary care
physician [**Name Initial (PRE) 176**] 1 week of discharge.
Completed by:[**2120-5-14**] Name: [**Known lastname 11564**],[**Known firstname **] J Unit No: [**Numeric Identifier 11565**]
Admission Date: [**2120-4-12**] Discharge Date: [**2120-5-14**]
Date of Birth: [**2040-3-16**] Sex: M
Service: MEDICINE
Allergies:
Iodine; Iodine Containing
Attending:[**First Name3 (LF) 1225**]
Addendum:
Additional procedures:
Lumbar puncture [**4-22**]
Bronchoscopy [**4-14**], [**4-30**]
[**5-14**] Flexible bronchoscopy performed and tracheostomy tube
switched to 8 biovona.
Please follow cuff pressure and keep < 25mmHg. The 8 Portex
requred pressures of 35mmHg to maintain a seal and the
bronchoscopy showed focal malacia at the cuff site prompting the
change to the 8 [**Last Name (un) 11566**].
[**5-14**] vent 7.48/29/126 PS 18/5 FiO2 0.4 Tv 480 MV 17.3
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2215**] Northeast - [**Hospital1 1947**]
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 1226**] MD [**Last Name (un) 1227**]
Completed by:[**2120-5-14**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
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[
[
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13937, 14178
|
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1487, 1514
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12483, 12490
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3808, 6772
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12944, 13914
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3276, 3359
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10723, 12155
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12274, 12274
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12514, 12921
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3374, 3789
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246, 1449
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1542, 2858
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6781, 6910
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12320, 12462
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12293, 12299
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2902, 3131
|
3163, 3244
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,837
| 177,389
|
32596
|
Discharge summary
|
report
|
Admission Date: [**2109-11-24**] Discharge Date: [**2109-12-1**]
Date of Birth: [**2079-2-3**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
cardiac catherization
central line (Cordis) placement with Swan-Ganz
History of Present Illness:
30 YOM with no pmh, p/w to OSH on [**11-23**] with mid-sternal CP,
[**10-12**] in severity in the setting of cocaine and alcohol use. He
also was taking Klonopin (not prescribed to him, obtained from
friends) the days prior to presentation. In OSH ED, his initial
vitals were 38 128 120/67 24 98% on 15L NRB 97.5kg. He was
noted to have STE in the anterior leads on the ECG. He had an
episode of seizure like activity and went into PEA which after
CPR converted to torsade/VF. He was given 4g of Magnesium and
was shocked back to normal rhythm. Total time was approx. 15
minutes. He also recieved 6mg Ativan, 324 ASA, lidocaine bolus,
integrillin load and gtt, heparin load and gtt, and was placed
on nitro gtt. He has a L tibial osteo-line. FSG was 210.
Other pertinent labs were: Na of 145, K 3.5, HCO3 18, Ca 9.8,
creatinine 1.5, Glucose 176, WBC 21.6, Hct 47.8, CK 382, MB 3.7,
trop 0.01, toxic screen was negative.
.
On transfer to [**Hospital1 18**] ED, he was noted to: 103 99/73 16 100% NRB.
He was given phentolamine x1, sent to cath lab. He was noted
to have a a prox. LAD thrombus with complete occlusion that
resolved with suction.
.
On review of systems, s/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:
1. CARDIAC RISK FACTORS: Diabetes (-), Dyslipidemia (-),
Hypertension (-)
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY: none.
Social History:
-Tobacco history: yes
-ETOH: yes
-Illicit drugs: yes
Family History:
+ father and sister - protein S deficiency, father had early
strokes in his 40's, HTN.
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
GENERAL: WDWN, in NAD. disoriented.
HEENT: NCAT, bloody sclera. PERRL, EOMI. Conjunctiva were pink,
no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 8 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
.
Pertinent Results:
[**2109-11-29**] 06:04AM BLOOD WBC-10.0 RBC-3.91* Hgb-11.9* Hct-34.4*
MCV-88 MCH-30.4 MCHC-34.6 RDW-14.2 Plt Ct-250
[**2109-11-24**] 04:29AM BLOOD Neuts-90.0* Lymphs-7.2* Monos-2.5 Eos-0
Baso-0.3
[**2109-11-29**] 06:04AM BLOOD PT-18.2* PTT-52.4* INR(PT)-1.6*
[**2109-11-29**] 06:04AM BLOOD Glucose-98 UreaN-19 Creat-1.0 Na-137
K-4.1 Cl-102 HCO3-22 AnGap-17
[**2109-11-29**] 06:04AM BLOOD CK(CPK)-5435*
[**2109-11-28**] 06:29AM BLOOD ALT-48* AST-133* LD(LDH)-1103*
CK(CPK)-9112* AlkPhos-37* TotBili-0.8
[**2109-11-26**] 03:02PM BLOOD CK(CPK)-8561*
[**2109-11-25**] 08:26PM BLOOD CK(CPK)-4287*
[**2109-11-24**] 08:11AM BLOOD ALT-128* AST-811* CK(CPK)-[**Numeric Identifier **]*
AlkPhos-46 TotBili-1.4
[**2109-11-24**] 04:29AM BLOOD CK(CPK)-7946*
[**2109-11-29**] 06:04AM BLOOD CK-MB-5
[**2109-11-26**] 01:54AM BLOOD CK-MB-11* MB Indx-0.2
[**2109-11-25**] 06:43AM BLOOD CK-MB-58* MB Indx-1.3 cTropnT-12.07*
[**2109-11-24**] 03:59PM BLOOD CK-MB-315* MB Indx-3.6
[**2109-11-24**] 04:29AM BLOOD CK-MB-493* MB Indx-6.2* cTropnT-22.18*
[**2109-11-29**] 06:04AM BLOOD Calcium-8.7 Phos-4.6* Mg-2.2
[**2109-11-24**] 08:11AM BLOOD Triglyc-61 HDL-31 CHOL/HD-4.9 LDLcalc-110
LDLmeas-109
.
c cath
COMMENTS:
1- Selective coronary angiography of this right-dominant system
demonstrated acute thrombotic occlusion of the proximal LAD and
TIMI 0
flow throuhghout the LAD system beyong the occlusion. The LCX
and RCA
were free from angiographic disease.
2- Limited resting hemodynamic assessment showed markedly
elevated
left-sided filling pressures (mPCWP 25 mmHg), normal right-sided
filling
pressures (RVEDP 5 mmHG), mild pulmonary HTN (36/26 mmHg) and
preserved
cardiac output (5.3 L/min) and cardiac index (2.5 L/min/m2).
3- Successful percutaneous thrombectomy of the LAD and diagonal
with
restoration of TIMI 3 flow. Final angiography showed no stenotic
lesions
at the thrombus site. No dissection or distal emboli.
4- Successful deployment of a 6 French Angioseal to the RCFA.
.
FINAL DIAGNOSIS:
1. Complete thrombotic occlusion of the proximal LAD.
2. Successful percutaneous thrombectomy of the LAD and diagonal
branch
3. Successful deployment of a 6 French Angioseal closure device
.
TTE
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. There is severe regional
left ventricular systolic dysfunction with akinesis of the mid
to distal anterior wall, anterior septum and lateral wall. The
basal anterior and anteroseptal, distal inferior and
inferolateral segments are hypokinetic. A left ventricular
thrombus cannot be excluded. There is no ventricular septal
defect. Right ventricular chamber size and free wall motion are
normal. The number of aortic valve leaflets cannot be
determined. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. The pulmonary artery
systolic pressure could not be determined. There is a
trivial/physiologic pericardial effusion.
.
IMPRESSION: Severe focal LV systolic dysfunction consistent with
large LAD territory infarction. No significant valvular
abnormality seen. EF 20%
Brief Hospital Course:
In brief, this is a 30 year old man with history of cocaine
abuse who presented with STEMI and found to have a LAD thrombus.
His STEMI was associated with cocaine and ETOH use. He is
currently s/p thrombectomy. His post cath course was
complicated by cardiogenic shock and a Swan-Ganz was placed for
monitoring. His shock improved with furosemide diuresis and
afterload reduction with ACEI. He was also noted to have mild
respiratory distress that was atributed to a combination of
pulmonary edema and atelectasis. Also, the patient experienced
two episodes of emesis while hospitalized and there was concern
for aspiration pneumonia. He was empirically treated with
levofloxacin and metronidazole. His respiratory status improved
with these interventions. Post catheterization the patient was
mantained on therapeutic anticoagulation with heparin gtt and
bridged to warfarin. The reason for this intervention was his
low EF of 20% with anterior/apical akinesis and subsequent
concern for LV thrombosis. Of note, upon initial presentation
to OSH ED, he experienced a cardiac arrest with torsades de
pointes/VF, which was treated with defibrillation and magnesium.
He remained in sinus rhythm during this hospitalization. Given
his ETOH abuse he was maintained on a diazepam scale for
withdrawl symptoms. The medical regimen on discharge includes
ASA, metoprolol, lisinopril, clopidogrel, atorvastatin,
epleronone, furosemide and warfarin. He was strongly advised to
abstain from cocaine and alcohol abuse in order to prevent
further morbitity. Dr. [**Last Name (STitle) **], the patient's PCP, [**Name10 (NameIs) **] notified
via email of this hospitalization.
Medications on Admission:
N/A
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): for one month.
Disp:*30 Tablet(s)* Refills:*0*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Eplerenone 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: 0.5 Tablet Sustained Release 24 hr PO QAM (once a day (in
the morning)).
Disp:*15 Tablet Sustained Release 24 hr(s)* Refills:*0*
7. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4
PM.
Disp:*90 Tablet(s)* Refills:*0*
8. Lisinopril 5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
- ST-elevation myocardial infarction
- acute systolic heart failure
- cardiogenic shock
Secondary Diagnoses:
- substance abuse
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
You were seen at [**Hospital1 18**] for heart attack complicated by shock and
fluid in the lungs. You were hospitalized in the intensive care
unit for several days, during which time we were able to improve
your breathing and heart function.
At discharge, your heart function is at approximately one-third
of normal from your heart attack. We believe your heart attack
was likely due to your substance abuse. In the future, it is
vitally important that you abstain completely from all illicit
drugs as well as smoking. You will need to continue to follow
up with a cardiologist regularly as well as your primary
physician in order to adjust your medications. These
medications are very important in order to preserve your
remaining heart function.
You will need to weigh yourself daily in order to assess for
fluid retention. If you gain greater than [**2-5**] lbs. suddenly,
notify your PCP as this could indicate your heart failure is
worsening.
The following medications have been changed:
ADDED aspirin for your heart
ADDED atorvastatin for your heart
ADDED plavix for your heart
ADDED eplerenone for your heart
ADDED furosemide to remove excess fluid
ADDED lisinopril for your heart
ADDED metoprolol succinate for your heart
ADDED warfarin to prevent blood clots
Please DO NOT TAKE your warfarin today. Start tomorrow
([**2109-12-2**]). Take all other medications as prescribed.
If you experience fevers, shortness of breath, chest pain, or
any other symptoms that concern you, please contact your PCP or
go to the Emergency Room.
Followup Instructions:
You will need to follow up with your primary care physician, [**Last Name (NamePattern4) **].
[**Last Name (STitle) **], in one week. At that time, you will need to have your
blood checked to see if it is appropriately thinned from the
warfarin. This medication may need to be adjusted. You can
contact his office at [**Telephone/Fax (1) 1144**] to set up an appointment.
You will need to follow up with Dr. [**Last Name (STitle) **] for your cardiology
follow-up. This follow up is being scheduled for you. You will
be contact[**Name (NI) **] with the date of your appointment. If you are not
notified within 3-4 days as to the date of your appointment,
please [**Telephone/Fax (1) 62**] to set up an appointment in [**3-6**] weeks.
Completed by:[**2109-12-1**]
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424, 2115
|
9381, 9469
|
9545, 9652
|
2337, 2344
|
2137, 2211
|
2360, 2416
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,158
| 100,066
|
52735
|
Discharge summary
|
report
|
Admission Date: [**2129-3-4**] Discharge Date: [**2129-3-6**]
Date of Birth: [**2053-6-30**] Sex: F
Service: MEDICINE
Allergies:
Iodine-Iodine Containing / Ace Inhibitors
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
RCA dissection
Major Surgical or Invasive Procedure:
Cardiac Catheterization with placement of 4 bare metal stents
Intra-operative (catheterization) trans-esophageal
echocardiogram
History of Present Illness:
75 y/oF with hypertension, HL and exertional angina who
initially presented for elective cardiac catheterization c/b RCA
dissection, being transferred to the CCU for further management.
.
Briefly, patient complained of exertional angina for several
weeks. She described chest discomfort radiating to jaw while
walking on treadmill or riding exercise bike vigorously. Also
experianced dyspnea and chest discomfort while walking up 1
flight of stairs. Symptoms always resolved with rest. Exercise
stress test on [**2129-2-14**] was concerning for ischemia: after 8
minutes on [**Doctor First Name **] protocol, peak HR of 116 (80% predicted for
age), patient developed recurrent angina and EKG showing 0.5mm
ST depressions in infero-lateral leads. Given positive stress
test, patient was referred for elective coronary
catheterization.
.
This morning, he underwent coronary catheterization which showed
calcification in coronary arteries with diffuse disease in RCA
with proximal 90% stenosis and distal 60-80% stenosis. The
catheterization was complicated by an RCA dissection with
retrograde extention to the right sinus of valsalva. She
received four bare metal stent to the RCA: 2 overlapping distal,
1 non-overlapping proximal, and 1 ostial integrity stents.
Following ostial stent depolyment, contrast was no longer seen
flowing into the sinus. Post-catheterization TEE showed
unchanged AI, functioning leaflets and no pericadial effusion.
She was transfered to the CCU in stable condition.
.
On arrival to the CCU, she endorsed mild left sided chest and
jaw pain that had significantly improved compared to what she
had experienced in the cath lab. She endorsed comfortably
breathing and denied other complaints.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable chest pain as per HPI; she
denied paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
- moderate AI, moderate MR
3. OTHER PAST MEDICAL HISTORY:
- Left Breast Cancer s/p Mastectomy in [**2103**]
- GERD
- Hemorrhoids
- Pneumonia x2 (in [**2097**]'s)
- Hiatial Hernia
- S/p Hysterectomy
- Osteopenia
- s/p Tonsillectomy
- s/p Adenoidectomy
- s/p Appendectomy
Social History:
Retired, lives with husband. [**Name (NI) **] very active lifestyle, going to
gym daily
- Tobacco history:
- ETOH: drinks approx 4oz red wine daily
- Illicit drugs: denies
Family History:
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
- Mother: died at age 83 of CHF
- Father: died in 80s of CVA
Physical Exam:
Admission Exam:
VS: T=98.4 BP=127/80 HR=93 RR=14 O2 sat=100% on 2L
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 8cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, systolic murmur loudest at apex. No thrills, lifts.
LUNGS: left mastectomy scar noted. Resp were unlabored, no
accessory muscle use. CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Discharge Exam:
Tc 98.0, Tm 98.4, BP 128-146/49-68, HR 58-88, RR 16-18, Sats
95-99% 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 8cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, systolic murmur loudest at apex. No thrills, lifts.
LUNGS: CTAB
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits. 2+ pulses in radial/DP
Pertinent Results:
Admission Labs ([**2129-3-4**]):
Hct-32.2*
Glucose-218* UreaN-17 Creat-0.6 Na-134 K-3.8 Cl-99 HCO3-23
AnGap-16
Calcium-9.5 Phos-3.7 Mg-2.1
[**2129-3-4**] 04:09PM BLOOD CK(CPK)-69
[**2129-3-5**] 06:00AM BLOOD CK(CPK)-98
[**2129-3-4**] 04:09PM BLOOD CK-MB-4 cTropnT-<0.01
[**2129-3-5**] 06:00AM BLOOD CK-MB-5 cTropnT-LESS THAN
.
Imaging:
Intra-operative TEE ([**2129-3-4**]):
Conclusions
No atrial septal defect is seen by 2D or color Doppler. The left
ventricle is not well seen but overall left ventricular systolic
function is normal (LVEF>55%). There are simple atheroma in the
aortic arch. A mobile density is seen in the aortic sinus at the
right coronary cusp consistent with an intimal flap/aortic
dissection.the flap extends minimally above the sinus of
Valsalva.The aortic valve leaflets (3) are mildly thickened.
Mild to moderate ([**12-12**]+) aortic regurgitation is seen. Moderate
(2+) mitral regurgitation is seen. There is no pericardial
effusion.
IMPRESSION: Dissection flap at the right coronary sinus, largely
contained within the sinus of Valsalva. Preserved global LV
systolic function with mild to moderate aortic regurgitation and
moderate mitral regurgitation.
.
CTA of chest ([**2129-3-4**]):
FINDINGS: Trace pericardial sluid is noted. There is multivessel
coronary
arterial calcification and mitral annular calcifications.
Density in the right coronary artery is compatible with known
stent. The proximal RCA appears low attenuation centrally, but
assessment is limited by overlying stent and non-gated study.
Close to the origin of the RCA, a minimal linear mural
irregularity at the
proximal aorta is seen (4,58), which likely represents a small
focal
dissection as noted at time of coronary angiogram. No distal
propagation is seen.
Some calcification at the left anterolateral papillary muscles
is noted
(6,61). This is likely due to prior ischemia.
The pulmonary arterial tree is opacified without evidence of
pulmonary
embolism.
There is no mediastinal, hilar, or axillary lymphadenopathy by
CT size
criteria. With the exception of trace bibasilar dependent
atelectases , the lungs are clear. Central airways remain
patent.
Limited subdiaphragmatic evaluation demonstrates hyperdense
material within the gallbladder, compatible with vicarious
excretion of contrast status post recent cardiac
catheterization. A tiny hiatal hernia may be present. The left
adrenal gland is mildly prominent, without focal nodularity.
A small non-specific 7mm hypodensity is seen at the dome of the
right hepatic lobe (4,68), too small to characterize.
BONE WINDOW: No focal concerning lesion. Mild multilevel
thoracic
spondylosis is present. Mild levoconvex thoracic curvature is
noted.
IMPRESSION:
1. Tiny linear irregularity at the aortic root adjacent to the
RCA origin
compatible with known tiny dissection. No propagation seen.
2. Apparent opacification of the RCA proximally may be
artifactual related to stent and non-gated study, but clinical
correlation is advised.
3. Coronary calcification and small area of calcification at the
tip of
anterolateral papillary muscle.
.
Cardiac Cath ([**2129-3-4**]): Report not yet finalized
.
Discharge Labs:
[**2129-3-6**] 08:35AM BLOOD WBC-7.2 RBC-3.77* Hgb-11.8* Hct-32.7*
MCV-87 MCH-31.2 MCHC-36.0* RDW-12.6 Plt Ct-299
[**2129-3-6**] 08:35AM BLOOD Glucose-119* UreaN-17 Creat-0.6 Na-137
K-4.0 Cl-102 HCO3-24 AnGap-15
[**2129-3-6**] 08:35AM BLOOD Calcium-9.5 Phos-3.6 Mg-2.0
Brief Hospital Course:
ASSESSMENT AND PLAN
Mrs. [**Known lastname **] is a 75 year-old woman with HTN, HLD and exertional
angina s/p elective cardiac catheterization c/b RCA dissection
with placement of 4 BMS in the RCA.
# Coronaries: Patient has known CAD identified on cardiac cath
[**3-4**] now s/p RCA dissection during cardiac catheterization and
placement of 4 BMS to RCA. Patient received integrillin during
procedure. Chest pain has significantly improved. Discussed with
patient importance of avoiding valsalva or manuvers that
increase intra-thoracic pressure. CTA report not finalized but
per radiology wet read no significant dissection still noted
post-proceedure although contrast timing sub-optimal for
evaluation. Before CTA pt received premedication with benadryl,
prednisone, and mucomyst/IV hydration. Nitro gtt was weaned off
and cardiac enzymes were stable. Pt will be continued on ASA
indefinitely and will need to take plavix 75 mg daily for at
least 1 month. Plan will be for repeat CTA 2-3 weeks after
discharge to re-evaluate RCA dissection. Pt will follow-up with
Dr. [**Last Name (STitle) **] in outpatient setting.
# Pump: Patient has no know CHF symptoms. LVEF was not obtained
durring TEE performed in cath lab. Patient has remained
hemodynamically stable during hospitalization.
# RHYTHM: Patient was in sinus rhythm. She has no known
dysrhythmia. Was monitored on Tele in the CCU and then on the
floor but no signficiant arrhythmias noted.
# HTN: Patient with Hx of HTN on only metoprolol as home BP med.
Day after cath pt was started on 25mg daily of losartan for
better BP control and metoprolol increased from 50 mg po tid to
200 mg po daily.
# HLD: Patient takes rosuvastatin 20mg daily at home and was on
atorvastatin 80mg while admitted. She was discharged on her home
regimen of rosuvastatin 20 mg po daily.
#Code: Full (confirmed with patient)
Medications on Admission:
- ciprofloxacin 250 mg [**Hospital1 **] prn UTI
- hydrocortisone acetate - 25 mg Suppository - 1 rectally up to
tid
prn irritation and pressure
- metoprolol tartrate 50mg [**Hospital1 **]
- omeprazole 20 mg Capsule, Delayed Release(E.C.) daily
- rosuvostatin 20 mg daily
- vitamin C 500 mg daily
- ASA 81 mg daily
- calcium carbonate- vitamin D3 500 mg (1,250 mg)-400 U Tablet
daily
- geriatric MVI w/iron 1tab daily
- magnesium 250mg 4 tabs daily
Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. metoprolol succinate 200 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
7. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO once a day.
8. calcium carbonate-vitamin D3 500 mg(1,250mg) -400 unit Tablet
Sig: One (1) Tablet PO once a day.
9. geriatric multivit w/iron-min Tablet Sig: One (1) Tablet
PO once a day.
10. magnesium 250 mg Tablet Sig: Four (4) Tablet PO once a day.
11. hydrocortisone acetate 25 mg Suppository Sig: One (1)
Rectal once a day as needed for irritation and pressure .
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Coronary artery disease
Coronary artery dissection
Secondary:
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after a small tear in one of
your coronary arteries occurred during your cardiac
catheterization. To help stabilize the artery and to open up
your coronaries which were found to have some narrowings, 4 bare
metal stents were placed in your coronary arteries. Your chest
pain improved significantly the next day and a CT scan of your
chest showed no worsening of the tear in your artery.
You were started on plavix 75 mg daily and Aspirin 325 mg daily.
You must take the plavix every day for at least the next month
and take the aspirin daily indefinitely in order to help keep
your stents from clotting. It is very important that you take
these medications every day otherwise you are at risk for clots
forming in your stents. We also increased your metoprolol dose
and started a new blood pressure medication called losartan to
help keep your blood pressure in a good range. You will
follow-up with Dr. [**Last Name (STitle) **] and will likely get a repeat CT scan or
your heart in [**1-13**] weeks.
The following changes were made to your medications:
- Metoprolol dose increased to metoprolol XL 200 mg by mouth
once daily
- Added Losartan 25 mg by mouth once daily for blood pressure
- Added clopidogrel (Plavix) 75mg by mouth daily for at least
the next month - it is very important that you do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 11014**]s of this medication. Please talk with Dr. [**Last Name (STitle) **] about when
it is ok to stop taking this medication.
- Increased Aspirin dose from 81 mg daily to 325mg by mouth
daily
- Continue your other home medications
You should refrain from lifting weights greater than 20 pounds
for 1 month after your hospital discharge.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] in [**12-12**] weeks. Please call her office to
make sure that you have an appointment. The number to call is
[**Telephone/Fax (1) 4105**]. You will likely have a repeat CT scan of your
heart in [**1-13**] weeks.
You should refrain from lifting weights greater than 20 pounds
for 1 month after your hospital discharge.
|
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5,032
| 128,624
|
43806
|
Discharge summary
|
report
|
Admission Date: [**2176-2-17**] Discharge Date: [**2176-2-19**]
Date of Birth: [**2141-12-3**] Sex: F
Service: MEDICINE
Allergies:
Doxycycline / Ibuprofen
Attending:[**First Name3 (LF) 23753**]
Chief Complaint:
Rash
Major Surgical or Invasive Procedure:
desensitization to penicillin ([**2176-2-17**])
PICC line placement/removal
History of Present Illness:
This is a 34 year old woman with recent diagnosis of syphilis
who presents to the ED with a 1 day history of rash. She was
diagnosed with syphilis on [**2176-1-23**] on routine blood work at
[**Hospital1 **]/gyn dept by Dr. [**Last Name (STitle) 1729**]: she had a positive RPR of 1:256
as well as negative HepB sAG and Ab, neg HIV, and neg HCV. She
was put on doxycycline due to penicillin allergy of unclear
etiology. She had taken almost 2 weeks of treatment, but
developed a rash last night on her arms and torso (not
palms/soles) which became worse and pruritic today after a walk
outside. She came to the ED.
.
In the ED, she was noted to have a petechial rash believed to be
secondary to drugs. She was given 50 mg benadryl. However, given
her recent diagnosis of syphilis, ID was consulted who
recommended changing from doxycycline to penicillin. Given her
history of rash, she was admitted to the MICU for penicillin
desensitization. En route to the ED, she was noted to have
systolic blood pressures in the 80's which resolved with
administration of fluids, and she was given empiric levofloxacin
after blood cultures were obtained.
.
ROS: She reports a rash as per HPI which is pruritic. She has
had a headache since 2 weeks ago, slightly before taking the
doxycycline. It is bilateral, like a band around the head, [**6-18**],
not associated with photophobia, neck stiffness, or vision
changes. Tylenol makes it better. She also complains of some
"rib pain" in her abdomen from about the same time, which is
[**2179-7-20**] but only lasts minutes. Her doctors [**Name5 (PTitle) 2771**] it to
gastritis. All other ROS negative.
Past Medical History:
childhood asthma
Social History:
Denies alcohol use, single with two children ages 14 and 18.
Used crack up until 4 months ago but denies since then and now
lives at [**Location (un) 94115**], a drug rehab center. Last
sexual activity 18 months ago. Believes she contracted syphilis
from a rape 10 years ago.
Family History:
noncontributory
Physical Exam:
V: T97 P69 BP 99/62 R10
Gen: no apparent distress
HEENT: PERRLA, EOMI, OP clear
Neck: no LAD
Resp: CTA bilaterally no wheeze
CV: RRR nl s1s2 no MGR
abd: soft NTND +BS no organomegaly
Ext: no edema
Skin: petechial light red nonblanching rash, not raised, over
inner aspects of arms and both legs. Scattered rash over stomach
but not back. Petechia separated by few centimeters each.
Pertinent Results:
[**2176-2-17**] 12:24PM BLOOD WBC-5.9 RBC-4.09* Hgb-12.7 Hct-36.7
MCV-90 MCH-31.0 MCHC-34.5 RDW-13.5 Plt Ct-386
[**2176-2-17**] 12:24PM BLOOD Glucose-91 UreaN-19 Creat-0.8 Na-140
K-4.2 Cl-105 HCO3-23 AnGap-16
[**2176-2-19**] 05:40AM BLOOD Calcium-9.2 Phos-4.4 Mg-2.1
Brief Hospital Course:
Ms. [**Known lastname 94116**] new rash was deemed to be a drug rash secondary
to her doxycycline use, so this was discontinued. Since she
failed [**Last Name (LF) 94117**], [**First Name3 (LF) **] infectious disease consultation recommended that
she be desensitized to penicillin for treatment of her late
latent syphilis. She was admitted to the MICU overnight for
monitoring and tolerated the desensitization process
uneventfully. She was then called out to the floor and
continued on IV penicillin q4h to avoid re-sensitization. The
plan was for her to complete a 14-day course of IV penicillin so
that her total course of treatment would be 4 weeks (which would
empirically treat for neurosyphilis).
.
For discharge, since she had no insurance, her only option for
continuing outpatient IV antibiotics was to go to the [**Hospital **]
Hospital. She was adamant that she would not go there and was
unwilling to even consider staying in-house for the duration of
therapy. The drug rehab shelter where she had been staying,
Women's Hope, is unable to take people with IV catheters and
also does not have the capacity to administer medications. Due
to the patient's refusal of her only options for receiving IV
penicillin, the infectious disease team recommended that she
take a 3-week course of azithromycin. The ID team and primary
team both stressed to the patient that this is an *unproven* and
very likely *inferior* treatment for her syphilis. Furthermore,
the risks of developing the neurologic, cardiac, and other
severe manifestations of late syphilis were explained to the
patent, and she demonstrated understanding of these risks. She
will follow up with her PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], who is aware of the
above plan. She should have repeat RPR titers checked to
evaluate efficacy of therapy.
.
If she were to need penicillin products again in the future, she
would need to repeat the desensitization process.
Medications on Admission:
doxycycline
tylenol prn headache
Discharge Medications:
1. Azithromycin 500 mg Tablet Sig: Four (4) Tablet PO once a
week for 2 doses: take first dose (4 tablets) on [**2176-2-26**]
.
take second dose (4 tablets) on [**2176-3-4**].
Disp:*8 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
primary diagnosis: late latent syphilis, penicillin allergy
(status-post desensitization)
Discharge Condition:
stable
Discharge Instructions:
You were admitted to the hospital for desensitization to
penicillin, but you were not willing to go to the [**Hospital1 **] to
complete your course of IV penicillin. We are sending you home
with 2 doses of azithromycin with the understanding that this is
*not* proven therapy. It is extremely important that you follow
up with Dr. [**Last Name (STitle) **] and have your titers re-drawn.
.
Please take all medications as prescribed. Please attend all
follow up appointments.
.
If you experience high fevers, shortness of breath, loss of
consciousness, chest pain, or other concerning symptoms, then
you need to seek medical attention.
Followup Instructions:
Please see Dr. [**Last Name (STitle) **] at [**Hospital1 **] on Thursday [**2176-3-7**] for
followup. Her office's phone number is [**Telephone/Fax (1) 3581**].
|
[
"096",
"276.52",
"693.0",
"E930.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.12"
] |
icd9pcs
|
[
[
[]
]
] |
5399, 5405
|
3111, 5083
|
290, 368
|
5539, 5548
|
2820, 3088
|
6234, 6399
|
2386, 2403
|
5167, 5376
|
5426, 5426
|
5109, 5144
|
5572, 6211
|
2418, 2801
|
246, 252
|
396, 2037
|
5445, 5518
|
2059, 2077
|
2093, 2370
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,173
| 113,458
|
38887
|
Discharge summary
|
report
|
Admission Date: [**2195-4-21**] Discharge Date: [**2195-4-27**]
Date of Birth: [**2126-6-27**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest Burning
Major Surgical or Invasive Procedure:
[**2195-4-21**] Coronary Artery Bypass Graft Surgery with Left internal
mammory artery -> Left anterior descending artery, Reverse
saphenous vein graft --> obtuse marginal and Reverse saphenous
vein graft to right coronary artery
History of Present Illness:
68 year old female with symptoms of exertional chest burning and
shortness of breath. She had + stress test and was referred for
cardiac catheterization to further evaluate which showed
coronary artery disease.
Past Medical History:
Hypertension
Dyslipidemia
Diabetes Mellitus
thyroid nodule- last u/s- size stable
polpyectomy during colonoscopy- benign
Past Surgical History:
s/p tonisillectomy
Social History:
Lives with:husband
Occupation:retired
Tobacco: quit 3 years ago, [**7-23**] cigs/day x 45 years
ETOH: denies
Recreational drugs: denies
Family History:
Father died of MI age 71, Mother with heart problems, 2 sisters
s/p MI, brother s/p stent
Physical Exam:
Pulse:51 Resp:16 O2 sat:96%RA
B/P Right:167/63 Left: 165/
Height:4'[**96**]" Weight:64.9kg (143 lbs)
General:
Skin: Dry [x] intact [x] 5mm raised erythematous papule with
crust on bilateral cheeks
HEENT: PERRLA [] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur II/VI SEM LUSB, III/VI HSM
RUSB
Abdomen: Soft [x] non-distended [x] non-tender [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: nd Left: nd
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: - Left: -
Pertinent Results:
[**2195-4-27**] 05:10AM BLOOD Hct-32.1*
[**2195-4-26**] 05:45AM BLOOD WBC-9.6 RBC-3.98* Hgb-11.3* Hct-33.9*
MCV-85 MCH-28.5 MCHC-33.4 RDW-14.0 Plt Ct-402
[**2195-4-21**] 01:20PM BLOOD WBC-20.0*# RBC-3.87*# Hgb-11.2*#
Hct-32.0*# MCV-83 MCH-29.0 MCHC-35.1* RDW-13.7 Plt Ct-310
[**2195-4-21**] 12:24PM BLOOD WBC-12.2*# RBC-2.77*# Hgb-7.9*#
Hct-23.1*# MCV-83 MCH-28.5 MCHC-34.2 RDW-13.7 Plt Ct-222
[**2195-4-26**] 05:45AM BLOOD Plt Ct-402
[**2195-4-21**] 01:20PM BLOOD PT-13.1 PTT-26.9 INR(PT)-1.1
[**2195-4-27**] 05:10AM BLOOD Glucose-119* UreaN-18 Creat-0.6 Na-136
K-4.8 Cl-101 HCO3-27 AnGap-13
[**2195-4-21**] 01:20PM BLOOD UreaN-12 Creat-0.5 Cl-117* HCO3-25
[**2195-4-27**] 05:10AM BLOOD Mg-2.2
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: 55% to 60% >= 55%
Findings
LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.
LEFT VENTRICLE: Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Simple atheroma in
descending aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
TRICUSPID VALVE: Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications.
Conclusions
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:
A-Paced, low dose Neo.
Normal biventricular systolic fxn.
Trace MR, no AI. Aorta intact.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2195-4-21**] 12:22
Sinus rhythm. Consider inferior myocardial infarction of
indeterminate age
but baseline artifact in the inferior leads makes assessment
difficult.
Low precordial lead QRS voltage is non-specific. Lateral
precordial lead
ST-T wave changes are non-specific. Clinical correlation is
suggested.
Since the previous tracing of [**2195-4-15**] sinus bradycardia is
absent and
lateral precordial lead ST-T wave changes are seen but baseline
artifact
in the inferior leads makes comparison of these leads difficult.
Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
88 172 92 380/429 48 -1 -41
Brief Hospital Course:
Admitted same day surgery and underwent coronary artery bypass
graft surgery. See operative report for full details. She
received cefazolin for perioperative antibiotics. Post
operatively she was transferred to the intensive care unit for
management. In the first twenty four hours she was weaned from
sedation, awoke neurologically intact and was extubated without
complications. She remained in the intensive care unit post
operative day one due hypotension and was started on vasoactive
medications. She was transfused 2 units of packed red blood
cells for a hematocrit of 24 and low blood pressure on
postoperative day 2 and improved. She was transferred to the
floor later on post operative day 2. Physicial therapy worked
with her on strength and mobility. She continued to progress
and was ready for discharge home with services on post operative
day six.
Medications on Admission:
Atenolol 25mg po daily
Lisinopril 5mg po daily
Metformin 500mg po daily
Simvastatin 20mg po daily
ASA 81 mg po daily
Calcium Carbonate-Vit D 1 tab po daily
Ergocalciferol-400 unit capsule po daily
Glucosamine chondroitin 1 capsule po daily
MVI 1 tab po daily
Omega-3 fatty acids 1 cap po daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
7. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 5
days.
Disp:*10 Tablet(s)* Refills:*0*
8. Metformin 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Centrus Home Care
Discharge Diagnosis:
Coronary Artery Disease s/p CABG
Hypertension
Dyslipidemia
Diabetes Mellitus type 2
thyroid nodule
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with Ultram prn
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month, and while taking
narcotics
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Please call to schedule appointments
Surgeon Dr [**Last Name (STitle) 914**] in 4 weeks [**Telephone/Fax (1) 170**] [**5-26**] at 1:30 PM
Primary Care Dr [**Last Name (STitle) 54049**] [**Name (STitle) **] in [**1-17**] weeks
Cardiologist Dr [**First Name8 (NamePattern2) 19118**] [**Last Name (NamePattern1) 23705**] in [**1-17**] weeks
Completed by:[**2195-4-27**]
|
[
"285.9",
"518.0",
"041.04",
"241.0",
"458.29",
"599.0",
"272.4",
"250.00",
"414.2",
"401.9",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"36.12",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
7609, 7657
|
5270, 6144
|
334, 566
|
7800, 7894
|
1997, 5247
|
8433, 8802
|
1163, 1255
|
6488, 7586
|
7678, 7779
|
6170, 6465
|
7918, 8410
|
972, 993
|
1270, 1978
|
281, 296
|
594, 806
|
828, 949
|
1009, 1147
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,764
| 166,769
|
47629
|
Discharge summary
|
report
|
Admission Date: [**2198-6-23**] Discharge Date: [**2198-6-27**]
Date of Birth: [**2121-8-5**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor First Name 3290**]
Chief Complaint:
melena
Major Surgical or Invasive Procedure:
None
History of Present Illness:
76 yo M with Hx of CAD s/p MI c/b VF arrest s/p BIV ICD, CABGx4,
sCHF (EF of 10%), IDDM, COPD, CLL, stage II-III CKD, LV thrombus
(on coumadin) admitted for melena and hypotension. Patient was
recently seen in ER [**2198-6-21**] for BRBPR and left AMA after
receiving 1 liter bolus of IVF. At initial presentation on [**6-21**]
HCT 40 (baseline). He subsequently saw his Urologist, who told
him to return to the ED, which he did the evening of [**2198-6-23**]. Pt
states that he never had BRBPR, but did have several days of
melanotic stool. Denies lightheadedness, palpitations, syncope,
fatigue, decreased exercise tolerance. He has never had melena
prior to the past week. Denies EtOH, NSAIDs, hematemesis or h/o
liver disease.
.
In the ED, initial VS:
T 97.9 HR 98 BP 108/50 RR 16 O2 Sat 94%
Labs notable for HCT 39.5 and INR 3.4. Per ED s/o, GI was
notified of his presentation and recommended no scope overnight.
He was given Protonix 40mg IV and admitted to the [**Hospital Unit Name 153**].
.
On arrival to the MICU, patient's VS:
T 98 BP 99/60 HR 80 RR 18 O2 Sat 97% RA
Pt states that he feels in his USOH, came to the ED because his
Urologist encouraged him to do so.
Past Medical History:
-CAD s/p MI c/b V-fib arrest, s/p CABG x 4, s/p ICD
-CHF, EF 20% (last ECHO [**12-24**] w/ diffuse hypokinesis along the
distribution of the left anterior descending artery, likely with
ventricular aneurysm)
-LV clot on coumadin
-IDDM
-Hypercholesterolemia
-S/p inguinal hernia repair
-CLL, dx in [**2189**]
-PVD with RLE claudication
-Lipoma
-Elevated CK on statin
-s/p eye injury as child with limited vision in R eye
-hematuria x 1.5 months
PMH:
COPD
HTN
CAD
CHF with EF 10%
AICD
HLD
DVT/PE
MIx2 s/p CABGx5 in [**2183**]
Diabetes
CLL in [**2189**]
hematuria
pacemaker/AICD [**2183**]
Social History:
The patient lives alone in [**Location (un) 669**]. He is retired. He worked as
an oil company supervisor. He has ten children. He is divorced.
He does not smoke at this time, however, he has a distant
smoking history of more than a pack a day for 18 years. Does not
drink alcohol. Denies IVDU or recreational DU. Served in the
military in [**Country 10181**], was an army tanker, he is fluent in Korean.
Family History:
The patient is unsure how his parents died. He
thinks that it is due to diabetes mellitus and stroke. The
patient has 10 children, a brother and a sister who he states
are
healthy.
No h/o of GU disease or cancers
Physical Exam:
Vitals: T 98 BP 99/60 HR 80 RR 18 O2 Sat 97% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP 5cm above the RA, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops, distant heart sounds, no appreciable S3 + S4.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: R eye esotropia, otherwise CN II-XII intact, non focal
RECTAL: Stool grossly melanotic, guiac +
Pertinent Results:
ADMISSION LABS:
[**2198-6-23**] 09:54PM GLUCOSE-250* NA+-137 K+-4.6 CL--97 TCO2-29
[**2198-6-23**] 09:50PM GLUCOSE-278* UREA N-62* CREAT-2.4* SODIUM-140
POTASSIUM-4.2 CHLORIDE-99 TOTAL CO2-26 ANION GAP-19
[**2198-6-23**] 09:50PM ALT(SGPT)-28 AST(SGOT)-38 ALK PHOS-107 TOT
BILI-0.6
[**2198-6-23**] 09:50PM LIPASE-50
[**2198-6-23**] 09:50PM ALBUMIN-3.5 CALCIUM-8.5 PHOSPHATE-2.6*
MAGNESIUM-2.6
[**2198-6-23**] 09:50PM WBC-17.9* RBC-4.03* HGB-12.4* HCT-39.5*
MCV-98 MCH-30.8 MCHC-31.5 RDW-13.4
[**2198-6-23**] 09:50PM NEUTS-60.2 LYMPHS-33.7 MONOS-4.6 EOS-1.0
BASOS-0.5
[**2198-6-23**] 09:50PM PLT COUNT-355#
[**2198-6-23**] 09:50PM PT-35.4* PTT-37.9* INR(PT)-3.4*
DISCHARGE LABS:
MICRO:
IMAGING:
CXR [**2198-6-23**]
IMPRESSION:
1) Upper zone redistribution, unchanged. Doubt overt CHF.
2) Mild bibasilar atelectasis, which is new. No frank
consolidation.
3) ICD device. Stable cardiomegaly. Calcifications along left
ventricular
wall suggestive of prior infarct -- see also abdominal CT from
[**2197-9-29**].
4) Stable prominence of hila - ? pulmonary hypertension.
[**2198-6-27**] 10:45AM BLOOD WBC-14.4* RBC-3.71* Hgb-11.2* Hct-36.1*
MCV-97 MCH-30.1 MCHC-31.0 RDW-13.2 Plt Ct-366
[**2198-6-27**] 10:45AM BLOOD PT-19.0* INR(PT)-1.8*
Brief Hospital Course:
# GIB: Patient presented melena of several days duration that
had occured during the previous week. Last bowel movement was
three days prior to admission. Patient had presented to the ED
on [**2198-2-19**] complaining of melena for which he received a 1 liter
bolus of saline and then left against medical advice. The
patient returned at the urging of his urologist. Hematocrit at
baseline on admission. Etiology unlcear; patient denies alcohol
or NSAID use. He further denies abdominal pain and has no
history of liver disease. The patient was started on protonix
[**Hospital1 **] and his heparin was held. He was placed on telemetry
monitoring and hematocrit was trended. The patient was seen and
evaluated by GI who felt that the bleeding was likely secondary
to elevated INR. His hematocrit remained stable, but he
continued to have dark stool that was intermittently mildly
guiaiac positive during the last couple of days of his hospital
stay. He was greatly bothered by the fact that his stool was
still dark. He was offered colonoscopy but after discussion with
his PCP refused it as an inpatient.
# Leukocytosis: Most likely cause is known CLL given chronicity
of this finding and absence of infectious symptoms. There were
no signs or symptoms of infection; UA was normal and CXR was
without any acute pulmonary processes.
.
# Acute on Chronic Renal Failure: Unclear precipitant, though
empirically would favor pre-renal process superimposed on
chronic DM, HTN related renal injury given is clinically dry.
The patient was given careful fluid resuscitation due to chronic
heart failure.
# DM: Patient was placed on insulin sliding scale while in the
hospital.
# CAD: Patient has significant cardiac history with coronary
artery dsiease s/p MI complicated by V-fib arres, s/p CABGx4,
s/p ICD. He was continued on his home Aspirin and Atorvastatin.
Metoprolol, lisiopril and lasix were initially held due to
concern for bleeding causing hypotension and acute renal
failure.
# Hypophosphatemia: Patient's phosphorus level was found to be
low on the day of discharge; patient had left hospital by the
time the lab value had returned. He was called at home and
prescribed two packets of neutraphos for him to take.
# CHF: Patietn has ischemic cardiomyopathy LVEF 10% s/p ICD. He
was carefully volume repleted. His home dose of metoprolol,
lisinopril and lasix were initially held due to concern for
blood loss causing hypotension and ARF.
Transitional Issues:
Medications on Admission:
ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - 2 HFA(s)
inhaled
every six (6) hours as needed for SOB
ATORVASTATIN [LIPITOR] - 20 mg Tablet - 1 Tablet(s) by mouth
once
daily
ERGOCALCIFEROL (VITAMIN D2) - 50,000 unit Capsule - one
Capsule(s) by mouth weekly
FAMOTIDINE - 20 mg Tablet - 1 (One) Tablet(s) by mouth once a
day
at night
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250 mcg-50 mcg/Dose
Disk
with Device - 1 inhaled twice a day
FUROSEMIDE - 40 mg Tablet - 1 Tablet(s) by mouth daily
INSULIN GLARGINE [LANTUS] - 100 unit/mL Solution - 36 units once
a day every morning
LISINOPRIL - 20 mg Tablet - 1 (One) Tablet(s) by mouth once a
day
METOPROLOL SUCCINATE - 50 mg Tablet Extended Release 24 hr - 1
Tablet(s) by mouth once a day
NIACIN - 1,000 mg Tablet Extended Release - 1 Tablet(s) by mouth
once a day
OXYCODONE - 5 mg Tablet - 1 tab(s) by mouth q4-6 as needed for
pain for pain not relieved with tylenol/motrin. do not take with
alcohol or if operating motor vehicles.
PHENAZOPYRIDINE - 200 mg Tablet - 1 Tablet(s) by mouth three
times a day as needed for urethral pain may turn urine [**Location (un) 2452**].
SYRINGE (DISPOSABLE) - Syringe - as needed
TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule,
w/Inhalation Device - 1 capsule INH Daily Please teach patient
to
use. Contents of each capsule should be inhaled twice.
WARFARIN - 5 mg Tablet - 0.5 (One half) to 1 (One) Tablet(s) by
mouth once a day
Medications - OTC
ASPIRIN - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by
mouth every evening
BLOOD SUGAR DIAGNOSTIC [ONE TOUCH ULTRA TEST] - Strip - Please
use as directed three times a day Please provide appropriate
strips for OneTouchUltra II system
DOCUSATE SODIUM - 100 mg Capsule - 1 Capsule(s) by mouth three
times a day while taking narcotics to prevent constipation
INSULIN SYRINGE-NEEDLE U-100 [BD SAFETYGLIDE INSULIN SYRINGE] -
29 gauge X [**11-20**]" Syringe - as directed qd and prn
Discharge Disposition:
Home
Discharge Diagnosis:
Upper GI bleed
CHF
LV thrombus
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with black stools. We found that your stools
had a small amount of blood. We started you on a medicine
called omeprazole (a PPI) to reduce the acid in your stomach.
You met with the gastroenterologists who offered you a procedure
called an endoscopy, but in consultation with your primary care
doctor you decided not to have this done. Your red blood cell
count in your body was unchanged, meaning that you were losing a
very small amount of blood from your stomach.
Per Dr[**Name (NI) 100626**] request, we have scheduled a follow up
with you with the hematologist [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] so that you may
discuss your CLL (elevated white blood cell count)
Followup Instructions:
Department: [**Hospital3 249**]
When: MONDAY [**2198-7-2**] at 2:35 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 73069**], MD [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2198-7-26**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], MD [**Telephone/Fax (1) 9645**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: WEST [**Hospital 2002**] CLINIC
When: WEDNESDAY [**2198-7-4**] at 2:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 21927**], MD [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
|
[
"496",
"V58.61",
"414.00",
"585.3",
"275.3",
"440.21",
"578.1",
"428.0",
"V12.59",
"V12.51",
"414.8",
"V45.81",
"412",
"204.10",
"584.9",
"458.9",
"V45.02",
"250.00",
"428.22",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9272, 9278
|
4794, 7260
|
311, 318
|
9368, 9368
|
3514, 3514
|
10264, 11280
|
2576, 2792
|
9299, 9347
|
7308, 9249
|
9519, 10241
|
4211, 4771
|
2807, 3495
|
7282, 7282
|
265, 273
|
346, 1526
|
3530, 4194
|
9383, 9495
|
1548, 2137
|
2153, 2560
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,592
| 191,451
|
6842
|
Discharge summary
|
report
|
Admission Date: [**2196-9-12**] Discharge Date: [**2196-9-16**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
Colonoscopy
History of Present Illness:
HPI: 85f with HTN, CAD, PUD, diverticulosis, hepatic cysts
presents with two hours of brbpr associated with clots. She'd
been in her normal state of health, feeling well when she
developed rectal bleeding starting at 3pm on day of admission;
it was her first episode ever, with no prior GI bleeds. She had
a second episode at home, then came into the ED where she denied
chest pain, dyspnea, abdominal pain, cramping, nausea/vomiting;
she had experienced a few brief episodes of lightheadedness
without syncope. In the ED, she was hemodynamically stable with
a hematocrit of 32, near her baseline. She had an NG-lavage
that was negative for both blood and clot. She passed two more
bloody bowel movements and about an hour to two hours later
dropped her systolic bp to the 80's, though this responded to
IVF. Her repeat hct at the time of the BM was 35, and a recheck
4hours later after IVF was down to 27, for which she was given
one unit of pRBCs. Given her ongoing bleeding, the GI fellow
recommended a tagged-RBC scan, that did not show evidence of
bleeding at 90min. At the time of admission to the MICU, she
denied lightheadedness, chest pain, dyspnea, abdominal pain,
n/v. Her only complaint was of pain at the site of the NG-tube.
Past Medical History:
1. Hypothyroidism
2. H/O E. Coli Sepsis ([**4-/2194**])
3. HTN
4. H/O Bronchitis
5. Hepatic Cystadenoma S/P Resection ([**2184**])
6. Cholangitis S/P Stenting
7. PUD (Duodenum)
8. TAH/BSO
9. DJD
10. CAD (2VD s/p DES to D1)
Social History:
Lives at an [**Hospital3 **] facility in [**Location (un) 583**], moved to U.S.
from rural [**Country 651**] 40 years ago. No tobacco, no EtOH history.
Family History:
No known liver, gall bladder, lung or heart disease. No known
cancers.
Physical Exam:
PE: t 97.0, bp 132/50, hr 68, rr 14, spo2 100%ra
gen- pleasant, elderly female, looks younger than age, functions
fairly well, non-tox, nad
heent- anicteric, op clear with mmm
cv- rrr, s1s2, no m/r/g
pul- no resp distress, moves air well, no w/r/r
abd- soft, nt, nd, nabs, no hsm, well-healed old [**Doctor First Name **] scars
extrm- puffy hands but otherwise no edema, warm/dry
nails- no clubbing, no pitting/color changes/indentations
neuro- a&ox3, no focal cn/motor deficits
Pertinent Results:
137 105 27 121 AGap=15
4.8 22 0.9
CK: 237 MB: 11 MBI: 4.6 Trop-*T*: 0.02
ALT: 14 AP: 74 Tbili: 0.3 Alb:
AST: 28 LDH: Dbili: TProt:
[**Doctor First Name **]: 76 Lip: 57
.
Iron: 39
calTIBC: 289
Ferritn: 109
TRF: 222
.
74
11.0 \ 11.1 / 279
/ 32.0 \
N:78.5 L:14.6 M:4.2 E:1.7 Bas:0.9
PT: 12.2 PTT: 28.5 INR: 1.1
.
ECG: NSR, nl axis, normal intervals, mild laa, no q's or st-t
changes, no significant change from prior.
.
[**9-12**] Tagged RBC Scan:
No active GI bleeding identified.
.
ADDENDUM: After an 8 hour delay, additional serial imaging of
the abdomen was obtained for 30 minutes. Static anterior and
left lateral views were also obtained. There was no evidence of
active gastrointestinal bleeding.
.
[**9-12**] colonoscopy:
Diverticulosis of the ascending colon, transverse colon,
descending colon and sigmoid colon. Normal mucosa in the colon.
Otherwise normal colonoscopy to cecum.
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the ICU due to transient hypotension in
the ED.
.
1) hypotension- patient arrived in MICU6 w/ blood hanging and 2
PIV. she was hemodynamically stable in the ICU, w/ sbps running
in the 110s-130s. on discharge the patient's bp was systolic 160
and her antihypertensives had been re-started.
.
2) GIB- felt to be likely lower given neg NGL in ED. Due to
ongoing dk red output via rectum patient underwent tagged RBC
scan to attempt to localize source. no source was seen. pt was
again sent to nuclear approx 8 hours later due to ongoing
bleeding. again no source was seen. on HD2,the patient
underwent colonoscopy which showed stigmata of prior bleed at
one diverticular site, but no active bleeding. following the
procedure the patient's hct was stable at approx 33 over the
next 30 h. she is discharged w/ f/u at [**Hospital 191**] clinic on Thursday.
.
3) cad- w/o CP or ecg changes in house. on discharge the
patient was re-started on losartan, metoprolol, and amlodipine.
.
4) fen- patient was tolerating regular diet on discharge.
Medications on Admission:
-Metoprolol 50mg [**Hospital1 **]
-Amlodipine 2.5mg daily
-Losartan 25mg daily
-Levothyroxine 75mcg daily
-Ursodiol 300mg [**Hospital1 **]
-Darvocet prn
Discharge Medications:
1. Levothyroxine 25 mcg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
2. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
3. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
4. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Amlodipine 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
1) GI Bleed, likely diverticular
2) CAD
3) htn
Discharge Condition:
all vitals are stable
Discharge Instructions:
Please take all your medications and follow up on all your
appointments. Please report to the ED or to your physician if
you have worsening abdominal pain, dark colored stools, nausea,
vomiting, dizziness or any other concerns.
.
You should not take aspirin until instructed to do so by your
PCP.
Followup Instructions:
Please make an appointment to see Dr. [**First Name (STitle) **], your primary care
physician [**Last Name (NamePattern4) **] [**1-11**] weeks.
.
Provider: [**Name10 (NameIs) 13228**] [**Name11 (NameIs) 13229**], [**First Name3 (LF) **] Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2196-12-13**] 9:30
Provider: [**Name10 (NameIs) 475**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 474**], M.D. Phone:[**Telephone/Fax (1) 1989**]
Date/Time:[**2196-12-28**] 3:00
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2196-9-22**] 2:30
|
[
"414.01",
"285.1",
"562.12",
"244.9",
"276.52",
"401.9",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
5358, 5364
|
3525, 4612
|
266, 280
|
5455, 5479
|
2577, 3502
|
5824, 6426
|
1990, 2062
|
4816, 5335
|
5385, 5434
|
4638, 4793
|
5503, 5801
|
2077, 2558
|
221, 228
|
308, 1558
|
1580, 1804
|
1820, 1974
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
83,532
| 180,932
|
37135
|
Discharge summary
|
report
|
Admission Date: [**2120-2-20**] Discharge Date: [**2120-2-28**]
Date of Birth: [**2072-1-11**] Sex: M
Service: MEDICINE
Allergies:
Azithromycin / Gadopentetate Dimeglumine / Morphine Sulfate /
Keflex / Iodine-Iodine Containing
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
Cardiac catheterization
Central line placement and removal
PICC line placement
History of Present Illness:
Mr. [**Known lastname 83669**] is a 48 year-old man with dilated
cardiomyopathy (EF 25%) on coumadin, s/p ICD in [**2117**], HTN, CKD
(baseline Cr 1.3-1.6) and asthma who presents with syncope.
.
The patient was recently discharged on [**2120-2-11**] for acute on
chronic CHF after receiving aggressive diuresis. He then
continued to develop abdominal discomfort, nausea and vomitting,
and he was unable to keep his medications down. He then
developed worsening coughing spells, and it was in the setting
of a severe coughing spell when he had a witnesssed syncopal
event for about 7 seconds. Per the patient's mother, the patient
was pale and cyanotic. He quickly recovered and was sent to the
ER who admitted him to the cardiology service.
.
On the cardiology service his abdominal pain, nausea, vomitting
was felt to be secondary to congestive hepatopathy, his cough
due to CHF vs asthma, and his syncope was felt to be secondary
to a coughing spell leading to increased intra-abdominal
pressures and therefore reduced preload in the setting of
low-output state. His ICD interrogation was negative for any
events. He was aggressively diuresed with a net 10 liters
negative since admission. He underwent RHC for milrinone trial,
which proved to be successful. His mean PCW went from 30 to 22,
and his Fick C.I. went from 1.72 to 2.79.
.
On the floor he is complaining of a frontal headache. He denies
weakness, speech/vision problems, seizures, nausea, vomitting,
unilaterality, photophobia/phonophobia. He denies chest pain or
shortness of breath. He also gives a several month history of
significant BRBPR. He had a colonoscopy for this in [**2117**] which
showed polyps that were removed. He recently saw GI who felt his
bleeding was likely due to internal hemorrhoids or a fissure and
referred him to colorectal surgery, who he has not yet seen.
.
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. 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,
paroxysmal nocturnal dyspnea, ankle edema, palpitations.
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, -Dyslipidemia, +Hypertension
2. CARDIAC HISTORY: Non-ischemic dilated cardiomyopathy; EF 20%
(etiology Takotsubo vs. alcohol-induced per OMR review)
--On coumadin for dilated LV
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: Percutaneous coronary
intervention, in [**6-9**] without evidence of coronary disease
-PACING/ICD: AICD placement [**2118-10-26**]
3. OTHER PAST MEDICAL HISTORY:
- Asthma
- Depression
- GERD
- Chronic kidney disease, baseline creatinine 1.3
- s/p Achilles repair
Social History:
He lives with his children, not married. Originally from PR,
former correctional officer x 25 years, on disability x2 years
since cardiomyopathy diagnosis. No ETOH x 2 years. History of
recreational cocaine, last used 3 years ago. No tobacco use.
Family History:
Father (74 years; valve replacement + CABG 8 months ago)
Mother (68 years; diabetes, hypertension).
3 brothers (hypertension, asthma).
5 children (5-23 years; asthma).
Colon cancer in maternal grandmother and 2 maternal aunts.
Physical Exam:
ADMISSION EXAM
T: 98, 118/57, hr 77. rr 18 100% ra. 248kg.
Gen: Obese male, appears tired, NAD, AAOx3
Neck: JVP pulsatile at the mandible.
Heart: RR, nl s1 s2, s3. no murmurs.
Lungs: CTABL
Abd: obese, very ttp in right quadrant, rebound +, guarding +,
left side not ttp.
Ext: 1+ lower extremity edema.
.
DISCHARGE EXAM
S 97.9 114/70 (100-120/50-65) 74 18 100/RA Wt 105.9 (106 <--109
Orthostatic VS - HR & BP stable
GEN male lying in bed in NAD, comfortable-appearing AAOx3
HEENT: NCAT MMM neck supple JVP 5
Heart: RRR, nl s1 s2; no murmurs
Lungs: decreased rales, good aeration and expansion, no apparent
respiratory distress
Abd: soft obese nontender nondistended NABS
Ext: no edema
Pertinent Results:
ADMISSION LABS
[**2120-2-20**] 01:30PM BLOOD WBC-5.8 RBC-3.87* Hgb-10.3* Hct-31.1*
MCV-80* MCH-26.7* MCHC-33.1 RDW-15.5 Plt Ct-172
[**2120-2-20**] 01:30PM BLOOD Neuts-73.1* Lymphs-18.2 Monos-8.1 Eos-0.2
Baso-0.4
[**2120-2-20**] 01:30PM BLOOD PT-55.5* PTT-43.9* INR(PT)-5.5*
[**2120-2-20**] 01:30PM BLOOD Glucose-135* UreaN-26* Creat-1.6* Na-125*
K-4.1 Cl-90* HCO3-26 AnGap-13
[**2120-2-20**] 01:30PM BLOOD ALT-101* AST-60* AlkPhos-108 TotBili-1.1
[**2120-2-20**] 01:30PM BLOOD cTropnT-<0.01
[**2120-2-20**] 09:43PM BLOOD cTropnT-<0.01
[**2120-2-20**] 09:43PM BLOOD Lipase-10
[**2120-2-20**] 01:30PM BLOOD Calcium-9.3 Phos-3.8 Mg-2.1
.
IRON STUDIES
[**2120-2-23**] 06:47PM BLOOD calTIBC-363 Ferritn-34 TRF-279 Iron-48
.
DISCHARGE LABS
[**2120-2-28**] 05:00AM BLOOD WBC-4.3 RBC-3.96* Hgb-10.3* Hct-31.2*
MCV-79* MCH-26.2* MCHC-33.2 RDW-15.6* Plt Ct-175
[**2120-2-28**] 05:00AM BLOOD PT-12.6* PTT-25.5 INR(PT)-1.2*
[**2120-2-28**] 05:00AM BLOOD Glucose-98 UreaN-21* Creat-1.2 Na-129*
K-4.6 Cl-92* HCO3-28 AnGap-14
[**2120-2-28**] 05:00AM BLOOD Calcium-9.0 Phos-3.2 Mg-1.9
.
[**2-20**] ADMISSION EKG - NSR 76
Sinus rhythm with ventricular premature beats. Borderline P-R
interval
prolongation. Low limb lead voltage. There is somewhat late R
wave
progression. Since the previous tracing probably no significant
change.
.
[**2-20**] ADMISSION CXR
FRONTAL AND LATERAL CHEST RADIOGRAPH: The lungs are clear. There
is no focal consolidation or pneumothorax. There is no vascular
congestion or pleural effusions. Mediastinal and hilar contours
are within normal limits.
Moderately severe cardiomegaly is unchanged compared to prior
examination. An AICD generator overlies the left chest wall. The
lead appears intact,
terminating in the expected location of the right ventricle.
IMPRESSION: Moderate-to-severe cardiomegaly consistent with
history of known cardiomyopathy. No pulmonary edema, pleural
effusion, or focal consolidation to suggest pneumonia.
.
[**2-20**] ADMISSION CT HEAD
NON-CONTRAST HEAD CT: There is no hemorrhage, mass, mass effect,
or acute
large territorial infarction. There is no shift of the usually
midline
structures. The suprasellar and basilar cisterns are widely
patent. The
ventricles and sulci are normal in size and configuration.
[**Doctor Last Name **]-white matter differentiation is preserved throughout. There
is a moderate soft tissue thickening in the subcutaneous tissues
of the left occiput, which is unchanged from prior examination.
No acute hematoma or skull fracture is identified.
The visualized paranasal sinuses and mastoid air cells are well
aerated.
IMPRESSION: No acute intracranial process.
.
[**2-21**] CT ABD/PELVIS
ABDOMEN:
The lung bases are clear without focal lesion. There is moderate
cardiomegaly. A pacemaker wire terminates in the right
ventricle, unchanged.
The heart is otherwise unremarkable. The pleura and pericardium
are intact
without effusion.
Evaluation of intra-abdominal organs is limited by lack of IV
contrast.
Within these limitations, the liver appears unremarkable without
focal or
diffuse abnormality. The gallbladder is normal. No intra- or
extra-hepatic
bile duct dilatation. The pancreas appears within normal limits.
The spleen
appears unremarkable. Bilateral adrenal glands are normal.
Bilateral kidneys are unremarkable.
The esophagus and stomach are normal. The small and large bowel
are normal in course and caliber. Oral contrast reaches the
rectum. Colonic diverticulosis is present without evidence of
diverticulitis. The appendix is normal and filled with air.
A small amount of fluid is present in perisplenic and
perihepatic regions.
Mild thickening of bilateral Gerota's fascia, bilateral lateral
conal fascia, and mesentery are present. No pathologically
enlarged retroperitoneal or mesenteric lymph nodes. No
pneumoperitoneum or abdominal wall hernia. Small scattered
calcifications are present of bilateral common iliac arteries.
PELVIS: The bladder is normal. Dystrophic calcifications of the
prostate are present. No pathologically enlarged pelvic wall or
inguinal lymph nodes. A small amount of pelvic fluid is present.
OSSEOUS STRUCTURES: Mild degenerative changes are present at
several levels
of the thoracolumbar spine with osteophytosis. No focal lytic or
sclerotic
lesions concerning for malignancy. No acute fractures.
IMPRESSION:
1. Within the limitations of this non-contrast study, no acute
abdominal
organ pathology is appreciated. No evidence of bowel ischemia or
obstruction.
2. Small amount of intraabdominal and pelvic fluid with mild fat
and
mesenteric stranding may be due to fluid overload.
3. Moderate cardiomegaly.
4. Colonic diverticulosis without diverticulitis.
.
[**2-23**] CARDIAC CATHETERIZATION
COMMENTS:
1. Limited resting hemodynamics revealed significantly elevated
biventricular filling pressures (RVEDP 22mmHg and mean PCW
30mmHg).
There was moderate pulmonary artery hypertension at rest with
mild
elevation in PVR (58/11mmHg with 211 dynes*sec*cm-5). The
cardiac output
and index were depressed (3.8 L/min and 1.7 L/min/m2). After a
milrinone
bolus the PCW dropped to 22mmHg mean and mean PA dropped to
36mmHg. The
cardiac output and index improved significantly (6.2 L/min and
2.8
L/min/m2).
FINAL DIAGNOSIS:
1. Moderate systolic and diastolic ventricular dysfunction.
2. Moderate secondary pulmonary venous hypertension.
3. Marked improvement in systolic function with milrinone.
.
[**2120-2-26**] FLUOROSCOPY-GUIDED PICC LINE PLACEMENT
IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided
double-lumen PICC line placement via the right brachial vein.
Final internal length is 40 cm, with the tip positioned in the
distal SVC. The line is ready to use.
Brief Hospital Course:
48M with idiopathic dilated cardiomyopathy (EF 25%, on coumadin
& s/p ICD placement), HTN, CKD (baseline Cr 1.3-1.6) & asthma
who presents with syncope, found to be in acute-on-chronic heart
failure.
.
#) ACUTE-ON-CHRONIC SYSTOLIC HEART FAILURE
Underlying exacerbation of chronic heart failure [**2-1**] known
idiopathic cardiomyopathy likely explanation for numerous
presenting symptoms including syncope, abdominal pain, and
dyspnea. Last echo [**8-/2119**] showed LVEF = 25%. He was admitted in
the setting of low output heart failure, leading to increased
intra-abdominal pressures causing congestive
hepatopathy/abdominal pain/RUQ tenderness. Abdominal distension
also thought to contribute to syncope. Cardiac output and wedge
pressure significantly improved after milrinone infusion. In the
ICU he was maintained on milrinone at a rate of 0.5 mcg/hr and
transferred to the floor on this stable dose. Torsemide 80mg
daily was restarted; he was discharged on milrinone and
torsemide. Heart failure specialists had honest discussions with
the patient about his long-term prognosis; he will continue to
be followed closely in heart failure clinic at [**Hospital1 18**] and will
continue work-up for potential heart transplant at [**Hospital1 3278**]/[**Hospital1 336**].
.
#) CONGESTIVE HEPATOPATHY
Patient presented w/a tender enlarged liver, most likely
secondary to vascular congestion. Team initially consider portal
venous thrombosis (exonerated by negative RUQ U/S on [**2120-2-3**]),
alcoholic hepatitis, viral hepatitis (but negative viral
screen), and/or hemachromatosis (iron studies negative).
Ultrasound demonstrated some fatty infiltration suggestive of
either alcoholic hepatitis or NASH. Tender hepatomegaly resolved
after initiation of milrinone and diuresis for 3 kg.
.
#) CHRONIC MICROCYTIC ANEMIA
MCV 80 suggestive of anemia [**2-1**] iron-deficiency and/or chronic
inflammation. Iron studies wnl.
.
#) ANTICOAGULATION
Patient on coumadin 5 mg QD for lifelong prevention of atrial
thrombus, given his dilated cardiomyopathy. His INR was
initially elevated (likely in the setting of worsening heart
failure/inflammation) so coumadin was decreased to 3 mg QD.
Given total of 7 mg vitamin K on [**2-22**] and [**2-23**] to reverse INR
prior to cardiac catheterization (for milrinone trial);
thereafter, his coumadin was restarted but INR continued to be
low due to persistent effects of large dose vitamin K.
Discharged on coumadin 5 mg QD. Expect gradual rise in INR even
without coumadin dose increase.
.
TRANSITIONAL ISSUES
1. Follow-up heart failure symptoms, Dr. [**First Name (STitle) 437**] to modify medical
management PRN
2. Heart transplant workup at [**Hospital1 **] (needs PFTs, not able to
obtain here)
3. Follow-up any issues surrounding home milrinone infusion, any
ectopy
4. Trend Hct.
Medications on Admission:
1. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for wheezing.
2. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. esomeprazole magnesium 20 mg Capsule, Delayed Release(E.C.)
Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day.
4. fluticasone 110 mcg/actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
5. hydrocortisone acetate 25 mg Suppository Sig: One (1)
suppository Rectal at bedtime: please take under direction of
your PCP.
6. losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
8. montelukast 4 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day.
9. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: Take as directed by the coumadin clinic.
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. torsemide 20 mg Tablet Sig: Four (4) Tablet PO once a day.
13. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
Two (2) Tablet, ER Particles/Crystals PO once a day: please take
with breakfast.
14. spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a
day.
15. codeine sulfate 15 mg Tablet Sig: One (1) Tablet PO at
bedtime as needed for cough.
Disp:*15 Tablet(s)* Refills:*0*
16. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
Disp:*60 Capsule(s)* Refills:*0*
17. Anecream 4 % Cream Sig: One (1) application Topical twice a
day as needed for pain: apply to affected area twice daily as
needed.
8. multivitamin Tablet Sig: One (1) Tablet PO once a day.
Discharge Medications:
1. milrinone in D5W 200 mcg/mL Piggyback Sig: 0.5 mcg/kg/min
Intravenous INFUSION (continuous infusion): Weight 106kg.
Disp:*QS mcg/kg/min* Refills:*2*
2. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. esomeprazole magnesium 20 mg Capsule, Delayed Release(E.C.)
Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day.
4. losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
6. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. torsemide 20 mg Tablet Sig: Four (4) Tablet PO once a day.
Disp:*120 Tablet(s)* Refills:*2*
10. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) puff Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 disc* Refills:*2*
11. Singulair 4 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day.
12. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day.
13. hydrocortisone acetate 25 mg Suppository Sig: One (1)
suppository Rectal at bedtime: under direction of your PCP.
14. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation four times a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Diabetes
Dyslipidemia
Hypertension
Non-ischemic dilated cardiomyopathy
Chronic systolic heart failure
Chronic kidney disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 83669**],
You were admitted to the hospital with worsening heart failure.
You had a cardiac catheterization that showed you would benefit
from milrinone. You were started on a milrinone drip, with
improvement in your heart's pump function. You were also
diuresed for 6 liters of fluid.
You will continue to receive milrinone at home - an infusion
company will continue to instruct you and your family on home
use of milrinone.
We made the following changes to your medications:
STOPPED FLOVENT INHALER
STOPPED POTASSIUM SUPPLEMENTS
.
STARTED ADVAIR INHALER, 1 PUFF DAILY
.
YOU SHOULD CONTINUE TO TAKE:
TORSEMIDE 80 MG DAILY
SPIRONOLACTONE 25 MG DAILY
LOSARTAN 25 MG DAILY
TOPROL XL 50 MG DAILY
SINGULAIR 4 MG DAILY
ALBUTEROL INHALER AS BEFORE
5 MG COUMADIN DAILY UNTIL INSTRUCTED BY [**Hospital **] CLINIC
CELEXA 40 MG DAILY
ESOMEPRAZOLE 20 MG DAILY
COLACE 100 MG [**Hospital1 **]
DAILY MULTIVITAMIN
RECTAL SUPPOSITORIES
Please review the attached medication list with your doctor at
your next appointment.
Followup Instructions:
Department: [**Hospital3 249**]
When: WEDNESDAY [**2120-3-6**] at 10:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD. [**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 doctor as part of
your transition from the hospital back to your primary care
provider. [**Name10 (NameIs) 616**] this visit, you will see your regular primary
care doctor in follow up.
YOU SHOULD HAVE LABS CHECKED (CHEM7) AT THIS PCP [**Name9 (PRE) **]
APPOINTMENT NEXT WEEK.
Department: CARDIAC SERVICES
When: MONDAY [**2120-3-11**] at 9:30 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
You will be contact[**Name (NI) **] by [**Name (NI) 3278**] Medical Center's Heart Transplant
program with an appointment in the near future. If you do not
hear from them, please call Dr.[**Name (NI) 3536**] office or discuss this
issue with him at your follow-up appointment. [**Hospital1 3278**] will arrange
for PFTs.
|
[
"585.9",
"493.90",
"403.90",
"570",
"425.4",
"311",
"V53.32",
"428.0",
"428.23",
"790.92",
"285.9",
"578.1",
"V58.61",
"780.2",
"530.81",
"573.8",
"416.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.49",
"37.23",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
16308, 16379
|
10289, 13111
|
372, 453
|
16548, 16548
|
4574, 6564
|
17762, 19089
|
3627, 3855
|
14939, 16285
|
16400, 16527
|
13137, 14916
|
9808, 10266
|
16699, 17179
|
3870, 4555
|
2902, 3213
|
17208, 17739
|
325, 334
|
481, 2794
|
6573, 9791
|
16563, 16675
|
3244, 3346
|
2816, 2882
|
3362, 3611
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,816
| 153,529
|
10592
|
Discharge summary
|
report
|
Admission Date: [**2181-6-22**] Discharge Date: [**2181-7-14**]
Date of Birth: [**2126-10-24**] Sex: M
Service: OMED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6169**]
Chief Complaint:
Fever and hypotension.
Major Surgical or Invasive Procedure:
status post skin biopsy of left scapular region
status post placement of Hickman catheter
status post insertion and removal of right internal jugular
central venous catheter.
status post insertion and removal of right arm midline
History of Present Illness:
FULL CODE
NKDA
CC:[**CC Contact Info 34829**]
54 yo with MDS (requiring PRBC QOwk, plt transfusion in the
several weeks perceding admission; [**12-17**] BMbx w/ increased blasts
(23% on aspirate)) who presents to clinic [**6-22**] w/ 2days of fever
(T102), chills. Recently completed 4 wk course of augmentin for
L thigh folliculitis. ROS +diarrhea. In clinic found to be in AF
RVR 150-160s w/ SBP70's responsive to fluid bolus x1. Initial
labs showed WBC 0.2 (0 pmn).
Past Medical History:
PMH:
Myelodysplastic syndrome
Hypertension
Remote history of kidney stones
Social History:
Lives at home with wife. Formerly employed in
engineering/sales. Lives with wife in [**Name (NI) 6151**]. No children.
No EtOH
No Tobacco
Physical Exam:
Physical examination on presentation, blood pressure 90/60,
responded to one liter of fluids. Heart rate 150 with regular
rate. Temperature 101.5. A well-developed, well-nourished
male,
acutely ill with shaking chills. O2 sat on room air are 98%.
He
is tachypneic. HEENT, sclerae are anicteric pupils equal and
reactive to light. Mouth, there are no oral lesions. Lungs,
clear. Heart, tachypneic, regular rate. Abdomen, nontender.
Spleen tip at the left sternal border. Bowel sounds are
present,
no rebound. Extremities, lower extremity petechiae. No
cyanosis, clubbing or edema.
Pertinent Results:
[**2181-6-22**] 9:50 am BLOOD CULTURE
**FINAL REPORT [**2181-6-27**]**
AEROBIC BOTTLE (Final [**2181-6-25**]):
ENTEROBACTER CLOACAE.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
172-7782S
([**2181-6-22**]).
ANAEROBIC BOTTLE (Final [**2181-6-27**]):
ENTEROBACTER CLOACAE.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
172-7782S
([**2181-6-22**]).
[**2181-6-22**] 8:40 am BLOOD CULTURE
**FINAL REPORT [**2181-6-26**]**
AEROBIC BOTTLE (Final [**2181-6-25**]):
REPORTED BY PHONE TO [**Doctor First Name 34830**],[**Doctor Last Name **] -7F- @ 20:20 [**2181-6-22**].
ENTEROBACTER CLOACAE. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
ENTEROBACTER CLOACAE
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
GENTAMICIN------------ <=1 S
LEVOFLOXACIN----------<=0.25 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
ANAEROBIC BOTTLE (Final [**2181-6-26**]):
ENTEROBACTER CLOACAE.
IDENTIFICATION AND SENSITIVITIES PERFORMED FROM AEROBIC
BOTTLE.
[**2181-6-26**] 7:35 am urine/serology
**FINAL REPORT [**2181-6-27**]**
Legionella Urinary Antigen (Final [**2181-6-27**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
-----------------
[**2181-7-10**] 9:30 am SPUTUM Site: INDUCED
GRAM STAIN (Final [**2181-7-10**]):
<10 PMNs and >10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2181-7-12**]):
HEAVY GROWTH OROPHARYNGEAL FLORA.
IMMUNOFLUORESCENT TEST FOR PNEUMOCYSTIS CARINII (Final
[**2181-7-10**]):
PNEUMOCYSTIS CARINII NOT SEEN.
NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2181-7-11**]):
ORDERED [**Numeric Identifier 34831**].
NO FUNGAL ELEMENTS SEEN.
RADIOLOGY Final Report
CT CHEST W/O CONTRAST [**2181-7-6**] 4:11 PM
CT CHEST W/O CONTRAST
IMPRESSION:
1) No significant interval change in extensive, ill-defined,
diffuse nodular and patchy opacities which are predominantly
distributed within both upper lobes. These findings in this
neutropenic patient are most suggestive of an infectious
etiology with invasive aspergillosis high on the differential.
The radiographic differential diagnosis also includes other
fungal infections, PCP, [**Name10 (NameIs) 34832**] emboli, cryptogenic organizing
pneumonitis, and less likely, vasculitis.
2) Stable mediastinal lymphadenopathy.
3) Small bilateral pleural effusions, slightly decreased in size
since the prior study.
4) Tiny non-obstructing right renal calculus.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) **] [**First Name8 (NamePattern2) 8843**] [**Location (un) **]
DR. [**First Name (STitle) 7204**] [**Name (STitle) 7205**]
Approved: SAT [**2181-7-7**] 2:23 PM
Cardiology Report ECHO Study Date of [**2181-7-3**]
Conclusions:
The left atrium is mildly dilated. Left ventricular wall
thicknesses are
normal. The left ventricular cavity size is normal. Overall left
ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and
free wall motion are normal. The aortic root is mildly dilated.
The ascending
aorta is moderately dilated. The aortic valve leaflets (3)
appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is
mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the findings of the prior study (tape reviewed) of
[**2181-6-25**],
there is no significant change.
No vegetations seen (but cannot exclude).
Electronically signed by [**First Name4 (NamePattern1) 553**] [**Last Name (NamePattern1) **], MD on [**2181-7-3**] 19:14.
[**Location (un) **] PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **].
RADIOLOGY Final Report
CT ABD W&W/O C [**2181-7-2**] 11:57 AM
CT ABD W&W/O C; CT PELVIS W/CONTRAST
IMPRESSION:
1) Small bilateral pleural effusions and bibasilar
infiltrates/opacities.
2) Small right renal stone without obstruction.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7832**]
Approved: WED [**2181-7-4**] 3:13 PM
RADIOLOGY Final Report
RUQ ULTRASOUND: The gallbladder is unremarkable without evidence
of stones, sludge, or gallbladder wall edema. There is no
intrahepatic or extrahepatic biliary ductal dilatation. The
common bile duct is normal in size, measuring 3 mm. Son[**Name (NI) 493**]
[**Name2 (NI) 515**] sign was not ellicited.
IMPRESSION: Unremarkable right upper quadrant ultrasound.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) **] [**First Name8 (NamePattern2) 8843**] [**Location (un) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7832**]
Approved: SUN [**2181-7-1**] 9:11 AM
--------------------
RADIOLOGY Final Report
CT CHEST W/O CONTRAST [**2181-6-30**] 10:17 AM
IMPRESSION:
1. Multiple, ill-defined, irregularly marginated pulmonary
nodules throughout both lungs, predominantly within both upper
lobes, which have not significantly changed since the prior
study. These findings, again, are most suggestive of an
infectious etiology. The diffuse distribution of these lesions
less likely favors [**Month/Day/Year 34832**] emboli.
2. Continued bibasilar atelectasis/consolidation with small
bilateral pleural effusions, not significantly changed in size
since the prior study.
3. Stable mediastinal lymphadenopathy.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) **] [**First Name8 (NamePattern2) 8843**] [**Location (un) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7832**]
Approved: SUN [**2181-7-1**] 9:11 AM
[**Hospital1 69**]
[**Location (un) 86**], [**Telephone/Fax (1) 15701**]
Pathology Examination
DIAGNOSIS:
Skin, left back, punch biopsy:
Superficial and mid-dermal perivascular lymphocytic infiltrate
with upper dermal red blood cell extravasation (see note.)
Note: No atypical cells or granulomatous inflammation is seen. A
single microscopic aggregate of neutrophils is focally noted in
the papillary dermis. Special stains for bacteria (Brown and
Brenn) and fungi (PAS) are negative. The infiltrate is
pauci-inflammatory and nonspecific, raising the possibilities of
a systemic hypersensitivity reaction or reaction to treatment.
Clinical correlation is recommended. If clinical concern for a
infection disseminated to the skin persists, biopsy of another
lesion may be further informative.
Cardiology Report ECHO Study Date of [**2181-6-25**] Conclusions:
1.The left atrium is moderately dilated
2.The left atrium is elongated. Left ventricular wall
thicknesses are normal.
The ventricular cavity size is normal. There is normal left
ventricular
function..
3. Right ventricular chamber size is normal. There is possible
mild global
right ventricular free wall hypokinesis.
4.The ascending aorta is mildly dilated.
5.The aortic valve leaflets (3) appear structurally normal with
good leaflet
excursion and no aortic regurgitation. 6.The mitral valve
appears structurally
normal with trivial mitral regurgitation.
7.There is no pericardial effusion.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD on [**2181-6-25**]
22:14.
[**Location (un) **] PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **].
([**Numeric Identifier 34833**])
RADIOLOGY Final Report
US EXTREMITY NONVASCULAR LEFT [**2181-6-25**] 4:36 PM
US EXTREMITY NONVASCULAR LEFT
Reason: PT WITH RED HOT AREA ON LUE, R/O ABSCESS
[**Hospital 93**] MEDICAL CONDITION:
54 year old man with neutropenia, fever, cellulitis. Please
evaluate cellulitis on left arm for abscess.
REASON FOR THIS EXAMINATION:
r/o abscess
INDICATION: Neutropenia, fever, cellulitis. Rule out abscess.
LIMITED LEFT UPPER EXTREMITY ULTRASOUND: Imaging of the left
upper extremity in the area of erythema and swelling shows no
evidence of fluid collections to indicate an abscess. There is
edema of the soft tissues.
IMPRESSION: No abnormal fluid collections to indicate an abscess
identified.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Name (STitle) **]
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 21884**]
Approved: WED [**2181-6-27**] 11:30 PM
-------------------
RADIOLOGY Final Report
CTA CHEST W&W/O C &RECONS [**2181-6-24**] 7:27 PM; CT 150CC NONIONIC
CONTRAST
Reason: eval for pna, PE, CHF
Contrast: OPTIRAY
IMPRESSION:
1. Suboptimal visualization of the pulmonary arterial segmental
and subsegmental levels. However, no pulmonary embolism is
identified within the main pulmonary arterial trunk and main
branches.
2. Multiple diffuse bilateral pulmonary nodules, predominantly
within the upper lobes, which given the patient's
immunocompromised state are most concerning for an infectious
process such as fungal disease. [**Month/Day/Year **] emboli, metastatic
disease, and pulmonary edema are much less likely considered in
the differential.
3. Bibasilar atelectasis/consolidation with small bilateral
pleural effusions, right greater than left.
4. Mediastinal lymphadenopathy.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) **] [**First Name8 (NamePattern2) 8843**] [**Location (un) **]
DR. [**First Name8 (NamePattern2) 7722**] [**Last Name (NamePattern1) 7723**]
Approved: MON [**2181-6-25**] 8:20 AM
[**2181-6-22**] 04:20PM LD(LDH)-194 CK(CPK)-137
[**2181-6-22**] 04:20PM CK-MB-2 cTropnT-<0.01
[**2181-6-22**] 04:20PM PHOSPHATE-1.7*
[**2181-6-22**] 08:40AM GLUCOSE-131* UREA N-18 CREAT-1.5* SODIUM-134
POTASSIUM-3.7 CHLORIDE-98 TOTAL CO2-23 ANION GAP-17
[**2181-6-22**] 08:40AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2181-6-22**] 08:40AM URINE HEMOSID-NEGATIVE
Brief Hospital Course:
Mr. [**Known lastname 34834**] was admitted to BMT [**6-22**] and started on cefipime,
vanco, and LVQ x1 dose (changed to cipro 400iv [**Hospital1 **] on [**6-23**]).
Aerobic and anaerobic BCx from [**6-22**] grew out [**3-18**] GNR enterobacter
cloacae(pan sensitive) and UCx w/ GNR and enterobacter. Admitted
to ICU after repeat episode of AF RVR (130-150) w/ BP 90's, 90%
2L, placed on 100% NRB w/ spo2 hi 90's; following 1L bolus-->
SBP 100's. Hct 20.8 (from 25 in AM) w/ new HA--> NCHCT w/o
evidence of ICH. CVL placed, then removed ~2wks later secondary
to persistant fevers and a concern for it as a source of
infection
Abx start dates:
1. ID: Febrile neutropenia
A.Urosepsis with +[**Last Name (un) **] and +Blood cultures for enterobacter
now negative x many days. [**3-18**] GNR (enterobacter) on [**2181-6-22**]
BCx. UCx that day enterobacter and diptheriods. BCx enterobacter
pansensitive. Abx were switched to ciprofloxacin and meripenem
providing double coverage for gram (-) organisms. TTE did not
show valvular lesions. Labs showed elevated d-dimer at 2257, but
also elevated haptoglobin at 396, fibrinonogen 430, suggesting
generalized inflammation without DIC.
B.Multiple diffuse bilateral pulmonary nodules,
predominantly within the upper lobes, most concerning for an
infectious process such as fungal disease, but also may be c/w
GNR [**Date Range 34832**] emboli. Sputum and repeat chest CT's did not offer
putative etiology. Required non-rebreather for a number of days
in ICU, but eventually weaned to 8 L nasal canulae and over the
course of 2 weeks, to room air; his oxygen saturation at
discharge was 95% on RA. A TTE on [**7-3**] showed no valvular
lesions. An abdominal CT to assess for hepatic infection was
normal. Repeat chest CTs have shown no change in the pulmonary
nodules, but resolving effusion and resolving lymphadenopathy.
Induced sputum with gram stain showed heavy growth of
oropharyngeal flora, (-)prelim nocardia cx, (-)PCP [**Last Name (NamePattern4) **], (-)prelim
fungal cx, (-)fungal KOH prep.
C.Folliculitis: Derm biopsy of follicular plaque on back.
GRAM STAIN: no pmns, no microorgranism. No fungus. No AFB.
Nocardia cx negative. Enterobacter cloacae isolated. Per derm
unlikely lymphoma cutis. Most likely hypersensitivity to infxn c
gnrs, ecthyma gangrenosum, Sweet's syndrome, or medications.
Has been regressing on antibiotics.
D.Cellulitis on left upper arm/shoulder. Despite regressing
over during the course of antibiotics, the region displayed some
fluctuance on exam. An ultrasound exam was negative, and the
regional infection was considered by the medical and infectious
disease teams to be well sequested.
E. The right internal jugular central venous line was
pulled, but fevers persisted, and the catheter tip yielded no
significant growth.
F. Persistent fevers: Although Mr. [**Known lastname 34834**] showed marked
clinical improvement over the course of admission, he remained
febrile. Danazol, neupogen, and vancomycin were discontinued as
potential causes of medication-induced fever, considering that
meropenem was providing adequate gram positive coverage. After
multiple sources were ruled out (endocarditis, medications, line
infection, etc.),he was started on low dose steriods, prednisone
10 mg qd, with resolution of fevers. It was felt that underlying
myelodysplastic syndrome may be a source of his persistent
fever. The patient was therefore discharged to home in good
condition on prednisone 10mg qd, tylenol 500mg qd, ciprofloxacin
500mg [**Hospital1 **], caspofungin 35 mg qd, meropenem 2000mg [**Hospital1 **] in
addition to the other listed medications. Caspofungin was used
after ambisome resulted in a conjugated bilirubinemia and
voriconazole resulted in elevation of transaminase levels.
2. Pulm: Mr. [**Known lastname 34835**] pulmonary infection was compounded by a
component of CHF. The pulmonary infectious workup is listed as
above in Infectious Disease section. With a lasix diuresis, his
pleural effusions, 3+ pitting leg edema to the thighs, and
positive fluid balance all corrected.
3. Heme-Onc: MDS w/ pancytopenia (hct 26-28 baseline) increased
blasts on BMbx [**12-17**] (none in periphery) On danazol, aransep,
desyrel (ferritin >[**2176**]); receiving prbc qowk, plt transfusions
intermittently in last several months. Received transfusions to
keep HCT >25 and plts >10 (>50 if bleeding).
4. GI: The initial course of ambisome resulted in an elevated
direct bilirubin level. RUQ U/S and Abdominal CT without liver
lesions/obstruction. Was then started on voriconazole until
liver transaminases trended up. Now on caspofungin with liver
enzymes trending down towards normal.
5. A fib with RVR: likely [**1-15**] bactermia (ruled out for MI, nl
TSH), resolved after dilt 20 IV x 2, then dilt po 30 qid.
Dilt d/c on [**6-27**] and on low dose metoprolol. in sinus rhythm.
6. HTN: on meds at home with baseline bps in 100s per patient.
In hospital, on metoprolol but transitioned back to home
medications on discharge. Leg cuff BP's because L arm
cellulitis, R arm midline.
8. Renal/F/E/N: Small renal stone in pole of R kidney Fluids
were d/c on [**6-28**] as pt looks like in pulm edema (with lower
extremity edema). Given lasix 40 mg iv qd and then prn for
diuresis.
9. Diabetes: No abnormal FSBGs.
10. Prophylaxis: pepcid and pneumoboots. Serax for sleep
11. Access: Surgery placed R internal jugular CVL [**6-29**].
Transfused platelets for above 50K for line to be placed. Right
midline placed [**7-10**] after right IJ d/c'd [**7-9**] secondary to
?fever source. Double-lumen Hickman placed [**2181-7-13**] by surgery
before discharge but visualized by PA/LAT to be in L
brachiocephalic. Pulled by surgery on day of d/c after
platelets given pre-procedure. Will arrange as outpatient to
obtain Hickman, although may return as inpatient for one night
to give blood or plt transfusion.
12. Disposition: To home in stable condition on antibiotics,
tylenol, and prednisone 10 mg qd. Antibiotics will be
discontinued based on radiologic resolution of the pulmonary and
dermatologic conditions. Will receive visiting nursing to set
up with home infusions of antibiotics.
Medications on Admission:
Atenolol 12.5 mg qd
danazol 200 mg p.o. t.i.d.
Aranesp 200 mg subcu q. weekly
Nexium 40 mg daily.
Discharge Medications:
INTRAVENOUS TREATMENTS/MEDICATIONS
meropenem [**2176**] mg IV bid
caspofungin 35 mg IV once daily
OTHER MEDICATIONS
ciprofloxacin 500 mg po bid
atenolol 12.5 mg po qd
esomeprazole 40 mg po qd
neutra-Phos 1 packet tid prn low Ph; will be directed further in
clinic.
tylenol 500 mg po each day at 6pm
prednisone 10 mg po each daily
serax 10 mg po qhs prn insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
Myelodysplastic syndrome
Enterobacter cloacae bacteremia
Pulmonary and skin nodules consistent with infectious etiology
Cellulitis
Discharge Condition:
Stable.
Discharge Instructions:
Please call your physician if you have shortness of breath,
difficulty breathing, lightheadedness, worsening skin infection,
bleeding, or fevers.
Please take antibiotics, including iv and oral according to the
prescriptions. A visiting healthcare agency will help you set
up the iv medications.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 6175**], MD Where: [**Hospital6 29**]
HEMATOLOGY/BMT Phone:[**Telephone/Fax (1) 3237**] Date/Time:[**2181-7-16**] 1:30
|
[
"238.7",
"038.3",
"682.3",
"117.9",
"284.8",
"486",
"704.8",
"686.09",
"995.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.05",
"99.04",
"86.11",
"86.09",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
19607, 19613
|
12830, 19070
|
335, 566
|
19788, 19797
|
1953, 4114
|
20142, 20342
|
19219, 19584
|
10513, 10618
|
19634, 19767
|
19096, 19196
|
19821, 20119
|
1339, 1934
|
4147, 6293
|
273, 297
|
10647, 12807
|
594, 1066
|
10203, 10476
|
1088, 1164
|
1180, 1324
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,479
| 106,256
|
34773
|
Discharge summary
|
report
|
Admission Date: [**2152-7-23**] Discharge Date: [**2152-7-29**]
Date of Birth: [**2098-3-31**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Motrin / Ibuprofen / Shellfish Derived
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2152-7-23**] Placement of IABP
[**2152-7-25**] Urgent CABG x 4 on IABP(LIMA to LAD, SVG to DIAG, SVG to
OM, SVG to PDA)
History of Present Illness:
Mr. [**Known lastname 79662**] is a 54 year old male with history of coronary
artery disease since [**2147**]. Approximately one week prior to
admission, he was experiencing intermittent chest pain. He
eventually presented to [**Hospital3 **] ED. EKG showed ST elevations
in v2-v4. He ruled in for acute MI with elevated troponins. He
was urgently taken to the cath lab which revealed critical three
vessel coronary artery disease. He was started on intravenous
therapy and transferred to the [**Hospital1 18**] for urgent surgical
revascularization.
Past Medical History:
Coronary Artery Disease - s/p PCI/stenting to LAD in [**2147**]
Hypertension
Dyslipidemia
Social History:
Active smoker. Occasional ETOH. Currently lives with his wife.
Family History:
Denies premature coronary disease.
Physical Exam:
Admission
Vitals: 132/80, 85, 16
Slightly obese male in no acute distress
Oropharyx benign
Neck supple, no JVD
Lungs clear to auscultation bilaterally
Heart regular rate and rhythm, normal s1s2, no murmur or rub
Abdomen benign
Extermities warm without edema
Neurologically intact, no focal deficits noted
Distal pulses 2+, no carotid or femoral bruits noted
Discharge
VS T98 HR88SR BP 130/84 RR 16 O2sat 100-RA
Gen NAD
Neuro A&O, nonfocal exam
CV RRR, no murmur. Sternum stable incision CDI
Pulm dimminished bases bilat
Abdm soft, NT/+BS
Ext warm, 1+ edema bilat. Left SVG sites w/steris CDI
Pertinent Results:
[**2152-7-23**] 05:05PM BLOOD WBC-13.2* RBC-4.45* Hgb-13.2* Hct-38.1*
MCV-86 MCH-29.7 MCHC-34.7 RDW-12.3 Plt Ct-217
[**2152-7-23**] 05:05PM BLOOD PT-13.2 PTT-37.1* INR(PT)-1.1
[**2152-7-23**] 05:05PM BLOOD Glucose-124* UreaN-9 Creat-0.9 Na-133
K-3.7 Cl-97 HCO3-28 AnGap-12
[**2152-7-23**] 05:05PM BLOOD ALT-38 AST-76* CK(CPK)-668* AlkPhos-65
Amylase-30 TotBili-1.5
[**2152-7-23**] 05:05PM BLOOD CK-MB-59* MB Indx-8.8* cTropnT-0.48*
[**2152-7-25**] 07:19AM BLOOD %HbA1c-5.3
[**2152-7-27**] 04:15PM BLOOD WBC-10.4 RBC-3.62* Hgb-10.7* Hct-31.7*
MCV-88 MCH-29.5 MCHC-33.7 RDW-12.0 Plt Ct-153
[**2152-7-27**] 04:15PM BLOOD Plt Ct-153
[**2152-7-26**] 06:17AM BLOOD PT-13.6* PTT-28.2 INR(PT)-1.2*
[**2152-7-27**] 04:15PM BLOOD Glucose-112* UreaN-13 Creat-0.9 Na-137
K-3.7 Cl-97 HCO3-28 AnGap-16
[**2152-7-23**] EKG:
Sinus rhythm. ST segment elevation in the anteroseptal leads
suggestive
of myocardial infarction.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
79 154 88 358/391 40 2 52
[**Known lastname **],[**Known firstname **] P [**Medical Record Number 79663**] M 54 [**2098-3-31**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2152-7-26**] 1:09
PM
[**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG CSRU [**2152-7-26**] SCHED
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 79664**]
Reason: ?ptx after CT removal
[**Hospital 93**] MEDICAL CONDITION:
54 year old man with
REASON FOR THIS EXAMINATION:
?ptx after CT removal
Final Report
CHEST RADIOGRAPH
INDICATION: Followup.
COMPARISON: [**2152-7-25**].
As compared to the previous examination, the mediastinal and
pleural drains
have been removed. The patient has also been extubated. The
pre-existing
small left-sided pleural effusion and the associated
retrocardiac atelectasis
have slightly increased in extent. Otherwise the chest
radiographic
appearance is unchanged. The Swan-Ganz catheter is in unchanged
position.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**]
Approved: WED [**2152-7-26**] 4:37 PM
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 79665**] (Complete)
Done [**2152-7-25**] at 8:45:34 AM 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: [**2098-3-31**]
Age (years): 54 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Chest pain. Coronary artery disease. Left
ventricular function. Preoperative assessment.
ICD-9 Codes: 440.0
Test Information
Date/Time: [**2152-7-25**] at 08:45 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 168**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW5-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.0 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 4.6 cm
Left Ventricle - Fractional Shortening: *-0.15 >= 0.29
Left Ventricle - Ejection Fraction: >= 55% >= 55%
Aorta - Annulus: 2.2 cm <= 3.0 cm
Aorta - Sinus Level: *3.7 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 3.0 cm <= 3.0 cm
Aorta - Ascending: *3.7 cm <= 3.4 cm
Aorta - Descending Thoracic: 2.1 cm <= 2.5 cm
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Normal regional LV systolic function. Overall normal LVEF
(>55%).
RIGHT VENTRICLE: Moderately dilated RV cavity. Mild global RV
free wall hypokinesis.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Trace
AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial
MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
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.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PRE-BYPASS
No atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. Regional left ventricular wall motion is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). The right ventricular cavity is moderately dilated
with mild global free wall hypokinesis. The aortic valve
leaflets (3) are mildly thickened. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen.
POST BYPASS
There is preserved left ventricular systolic function. The RV is
still moderately enlarged but now with normal systolic function.
The study is otherwise unchanged from prebypass.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2152-7-25**] 10:58
Brief Hospital Course:
Mr. [**Known lastname 79662**] was admitted to the cardiac surgical service. Given
his critical coronary artery disease, he was brought to the
cardiac cath lab where an IABP was successfully placed without
complication. Surgery was delayed for several days given recent
Plavix dose, and he continued to remain pain free on intravenous
therapy. On [**7-25**], Dr. [**Last Name (STitle) **] performed four vessel
coronary artery bypass grafting. For surgical details, please
see seperate dictated operative note. Following the operation,
he was brought to the CVICU for invasive monitoring. Within 24
hours, he awoke neurologically intact and was extubated without
incident. On postoperative day one, the IABP was weaned and
removed without complication. He maintained stable hemodynamics
and transferred to the SDU on postoperative day two. The
remainder of his postoperative course was uneventful, on POD4 he
was discharged home with visiting nurses.
Medications on Admission:
Transfer meds: IV Heparin, Plavix, IV Nitro, Aspirin, Atenolol,
Lescol
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*14 Tablet(s)* Refills:*0*
2. Lescol 40 mg Capsule Sig: One (1) Capsule PO once a day.
Disp:*30 Capsule(s)* Refills:*2*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every six (6) hours as needed for pain.
Disp:*15 Tablet(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Potassium Chloride 10 mEq Tablet Sustained Release Sig: One
(1) Tablet Sustained Release PO once a day for 7 days.
Disp:*7 Tablet Sustained Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Coronary Artery Disease s/p CABG
Preoperative Acute ST Elevation MI
Hyperlipidemia
HTN
History of LAD stent [**2147**]
Discharge Condition:
good
Discharge Instructions:
Shower daily, no baths or swimming
No creams, lotions, powders to incisions
No driving
No lifting more than 10 pounds for 10 weeks
Take all medications as prescribed
report any weight gain of greater than 3 pounds a week
Followup Instructions:
Dr.[**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]) in 4 weeks
Dr.[**First Name4 (NamePattern1) 4597**] [**Last Name (NamePattern1) 5017**] in [**1-9**] weeks
Dr.[**First Name8 (NamePattern2) **] [**Name (STitle) 4922**] in [**1-9**] weeks
Completed by:[**2152-8-1**]
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icd9cm
|
[
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1149, 1213
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,743
| 158,028
|
23728+57372+57374
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2134-8-2**] Discharge Date: [**2134-8-15**]
Date of Birth: [**2071-1-2**] Sex: F
Service: [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: This is a 63 year-old woman with
a history of necrotizing pancreatitis with multiple
pseudocysts. The patient has undergone percutaneous drainage
after biliary obstruction. The patient had a PTC catheter, a
G tube, a J tube. She was discharged to rehabilitation
recently and returned to the [**Hospital1 188**] with a history of fever, increasing white count,
abdominal distention with some abdominal pain. The patient
had a previous blood culture that was positive for the
Vancomycin resistant enterococcus in [**2134-6-9**]. She was C
difficile positive in [**2134-4-9**]. Recently the patient
does not have any fevers, denies chills, denies rigors. Has
had increasing diarrhea. The patient received Zosyn and
linezolid while at rehabilitation and recently began vomiting
profusely with abdominal pain and fever.
PAST MEDICAL HISTORY: Is consistent with diabetes type 2,
hypertension, rosacea and a right lower lobe nodule that was
seen on a previous CT scan two months ago.
PAST SURGICAL HISTORY: Is consistent with a total abdominal
hysterectomy and a tonsillectomy.
PAST MEDICATIONS: Have been Imodium, Nystatin, octreotide,
cholestyramine, atenolol, bupropion, diltiazem and Zantac.
SOCIAL HISTORY: The patient has been a social worker in the
[**Name (NI) 531**] system helping indigent individuals for many many
years. She lives alone. She has two sons and a daughter who
she is very close with.
PHYSICAL EXAMINATION: On admission the patient's temperature
si 100.1. Her heart rate is 120. Her blood pressure was
165/70, her respiratory rate is 20 and her oxygen saturation
is 90% on room air. She is awake, alert and oriented x3. She
is in sinus tachycardia. There are no murmurs, rubs or
gallops. The patient's chest is clear to auscultation
bilaterally. The patient's abdomen is distended although she
is nontender. The patient's gastric tube is to drainage. She
has a T tube that is capped. There are two [**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 12828**]
with milky white fluid. The patient has a PTC tube as
previously mentioned that was capped and also has a J tube.
The patient is heme negative.
The patient had a CT scan. The impression on the CT scan on
admission was very extensive pneumatosis affecting the entire
bowel including the small and large bowel to the level of the
rectum. This was associated with gas in the mesenteric
vasculature and portal vein. There is free fluid and
mesenteric fat stranding. There is an unchanged mass in the
right lower lobe. There are heterogenous bilateral
enhancement of both kidneys. Close follow up of renal
function is recommended, as these functions show she may have
some impending renal failure. The findings re strongly
suggestive of necrotic bowel in this patient with markedly
elevated white count and lactic acidosis. Patency of the
superior and inferior mesenteric arteries and branch of the
superior mesenteric vein together with involvement of bowel
segment and multiple vascular territories, and flattening of
the inferior vena cava suggest dehydration and hypovolemia as
the cause of these findings.
LABORATORY DATA: On admission were the following: White
blood cell count of 33.1, hematocrit of 37.3, platelets of
611. The patient's serum sodium was 140, potassium was 2.9,
chloride was 107, bicarbonate was 17, BUN was 27 and the
creatinine was 1.3. The blood sugar was 264. The anion gap
was 16. Patient had a KUB that showed massively dilated loops
of small bowel and transverse colon.
PROCEDURES PERFORMED: The patient had a right radial
arterial line placed on admission. The patient also had a
pulmonary artery catheter placed through a triple lumen
catheter in the right internal jugular vein. Patient had
multiple IVs placed to optimize her fluid resuscitation.
HOSPITAL COURSE: A concise summary of the [**Hospital 228**] hospital
course is the following: On hospital day 1 the patient was
started on broad spectrum antibiotics with linezolid,
levofloxacin and Flagyl. She was transferred to the surgical
Intensive Care Unit where procedures including a right radial
arterial line and a right internal jugular triple lumen
catheter with placement of the pulmonary artery catheter were
performed. The patient tolerated these procedures well.
Please see the procedure notes for further detail. The
patient was resuscitated overnight. She was followed very
closely in the Intensive Care Unit for sepsis. She was made
Do Not Resuscitate by her family. Overnight the patient was
afebrile. Her vital signs were stable. Her white blood cell
count was trending down. On admission it was 35. On hospital
day 2 it was 25. Her creatinine also trended down from 1.3 on
admission to 1.1. The patient's cultures - blood, urine,
sputum and cultures from all drains were sent off.
Additionally her J tube, G tube, PTC tubes and [**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 1662**]
drains were all put to gravity. The patient was started on
total parenteral nutrition for IV fluid hydration and made
n.p.o. during her resuscitation. In addition, the patient
also got normal saline for volume replacement. On hospital
day 3 the patient continued to improve. She was afebrile. Her
vital signs were stable. She was maintained on a heparin drip
to monitor her blood sugar. She was continued on
levofloxacin, Flagyl and linezolid. She was still n.p.o. Her
abdomen was distended but nontender. Her Swan Ganz catheter
numbers all continued to improve. Her gas also improved. Her
white blood cell count which had been 25 on the day prior was
now 13. Her creatinine also trended down from 1.9 the day
prior to 0.9. The patient was awake, alert and oriented. She
was in some minus sinus tachycardia. She did not have any
vomiting or diarrhea. Her electrolytes were monitored very
closely and her fluid resuscitation was continued. Her IV
fluids were decreased to 80 to 100 and the patient continued
to do very well.
On postoperative day 4 the patient continued to do much
better. She was advanced on her total parenteral nutrition
with glutamine. Her J tube again continued to be to gravity.
Her abdomen was mildly distended. She remained afebrile with
vital signs stable. The patient had no events and was
continued on her antibiotics on hospital day 5 and she had no
events. She slept well overnight. Her nasogastric tube was
continued. There no evidence of sepsis at this time. However,
her antibiotics were continued and she continued to do much
better. Her white blood cell count was trending down and
nutrition consult was ordered at this time in order to assess
calorie counts and monitor her nutrition while in the
hospital in anticipation of a potentially prolonged hospital
stay. Physical therapy also visited with the patient to
improve her range of motion and her strength training while
in the hospital. The patient was able to ambulate with a
walker. She was alert, awake and oriented, pleasant and
cooperative per the objective findings of the physical
therapist. On hospital day 6 the patient had no events. She
was doing well. It should be noted that the patient was
transferred to the regular floor on day 4 from the Intensive
Care Unit because she was doing much better. The patient
continued on her total parenteral nutrition. Her insulin was
adjusted to cover for her increasing blood glucose. The
patient continued to work well with physical therapy. She was
continued on her antibiotics.
On hospital day 7 the patient continued on her antibiotics,
levofloxacin, Flagyl and linezolid. The patient reported no
change in her condition. She was out of bed to chair with
assistance, on her own. The patient was afebrile. Vital signs
were stable. Blood sugar was somewhat difficult to control as
fingersticks were in the low 200s. Total parenteral nutrition
was continued and all of her drains were continued to
gravity. On hospital day 8 the patient continued to do very
well. She was continued to be n.p.o. Her antibiotics were
continued. There were no major changes. She just continued to
improve and do better and better each day. It should be noted
the [**Initials (NamePattern4) 228**] [**Last Name (NamePattern4) 1661**] [**Last Name (NamePattern1) 1662**] drains actually had fallen out
and her wounds were now draining. We had an ostomy nurse
consult. The ostomy nurse came and put two ostomy bags on the
patient's skin to where the [**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 1662**] drains had
previously been draining out the patient's skin. The patient
tolerated this very well. However, one of the ostomy bags was
difficult to maintain intact. A dry sterile dressing was
applied to the left upper quadrant where one of the [**First Name8 (NamePattern2) 1661**]
[**Last Name (NamePattern1) 12828**] had previously been.
On hospital day 9 the patient continued on her levofloxacin,
Flagyl and linezolid. She continued to be n.p.o. She was
afebrile. Her vital signs were stable. The [**Last Name (un) **] Diabetes
Center saw the patient on hospital day 10. They decided to
increase the insulin in her bag of her total parenteral
nutrition to 60 units and to continue IV insulin for the time
being to maintain the patient's glucose control. On hospital
day 10 the patient had a low grade temperature of 100.1. She
remained afebrile. Her vital signs were stable. She had a CT
scan of her abdomen. The CT scan showed no pneumatosis at
this time. It showed multiple pseudocysts which had been
either the same on admission or improved and some thickening
of her ascending and transverse colon that was really
unchanged or slightly improved from her admission CT on [**2134-8-2**]. On hospital day 11 the patient had no events. She
was again afebrile. Her vital signs were stable. She was
continued on her antibiotics. She maintained her n.p.o.
status with IV fluids and total parenteral nutrition. Her
electrolytes were repleted and all drains were kept to
gravity.
The vascular surgery service consulted the patient on
hospital day 12. The previous CT scan showed an iliac vein
deep venous thrombosis that was in the left side that had
been there since [**2134-6-9**] which was initially found on
the CT at that time. The patient was recommended to go to the
operating room for an inferior vena cava filter. The vascular
staff came and saw the patient. That was Dr. [**Last Name (STitle) **]. Her
films were reviewed. The patient had a procedure. She
understood the risks and decided to proceed with it. On
hospital day 11 the patient was doing very well. She had
tolerated her IVC filter very well on the previous day. Her
antibiotics were continued. She continued to be made n.p.o.
All drains were to gravity. The patient was afebrile and
vital signs were stable. On hospital day 13 the patient had
no events. She was followed by both the vascular surgery
staff and the [**Last Name (un) **] Diabetes Center. Physical therapy saw
the patient and worked with her. She had no acute events and
was doing well on hospital day 13. Her central line was
removed. A PICC line was placed so that the patient could
continue her antibiotics and her TPN. The patient had a
double lumen PICC line placed in anticipation that she would
be going to rehabilitation. Her J tube fell out and was
replaced with a stitch. Patient was afebrile with afebrile
with vital signs stable. She was up out of bed and ambulated.
On hospital day 14 the patient was afebrile. Her vital signs
were stable. The patient continued on her levofloxacin,
Flagyl and linezolid. This was day 14 of 154. This was the
last day patient was to get antibiotics. We were following
all laboratories. The patient's urine which initially had
grown out Serratia marcescens which was sensitive to
everything was treated via this 14 day course of antibiotics.
The patient's blood cultures never showed any growth. The
patient's stool culture was negative for C difficile and
negative for Campylobacter and negative for Salmonella and
Shigella. The patient's urine culture did show some yeast.
Patient was given a dose of Diflucan for that supposed
infection. On hospital day 15 the patient had no events. Her
antibiotics were discontinued. She had expressed a desire to
go to a rehabilitation facility in the [**Location 60615**] so
that she could be close to her children. Since the patient
had had a long course of necrotizing pancreatitis the patient
will be discharged to rehabilitation.
She will be discharged on all of her medications in the
hospital. The patient will be continued on her Dilaudid 1 mg
IV q 4 to 6 hours p.r.n., her insulin sliding scale. The
patient will be discharged on octreotide acetate 100 mcg
subcutaneously q 8 hours, metoprolol 7.5 mg IV q 6 hours,
Anzemet 12.5 mg IV q 8 hours p.r.n., miconazole powder 2% 1
application applied p.r.n., Protonix 40 mg IV q 12 hours.
Patient also gets artificial tears 1 to 2 drops in both eyes
p.r.n. The patient has been getting TPN with standard central
solution. The volume is 2 liters. The amino acid grams per
day is 120 grams per day. The dextrose is 340 grams per day.
The fat is 40 grams per day and the total K calories per day
is 2,000. Patient's diet is n.p.o.
Laboratories have been ordered daily. Electrolytes have been
ordered while the patient has been n.p.o. on TPN.
DISCHARGE DIAGNOSIS: Necrotizing pancreatis with multiple
pseudocysts and intra-abdominal infection.
DISCHARGE MEDICATIONS: Are previously described.
FOLLOW UP PLANS: The patient will need to follow up with Dr.
[**Last Name (STitle) **] in two weeks upon discharge. The patient should call
Dr.[**Name (NI) 2829**] office in order to schedule a follow up
appointment. The phone number is [**Telephone/Fax (1) 1231**].
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: To rehabilitation in [**State 531**] City.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**MD Number(2) 11162**]
Dictated By:[**Last Name (NamePattern1) 18027**]
MEDQUIST36
D: [**2134-8-15**] 18:11:39
T: [**2134-8-15**] 20:56:09
Job#: [**Job Number 60616**]
Name: [**Known lastname 11055**],[**Known firstname 194**] Unit No: [**Numeric Identifier 11056**]
Admission Date: [**2134-8-2**] Discharge Date: [**2134-8-25**]
Date of Birth: [**2071-1-2**] Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2083**]
Addendum:
Ms. [**Known lastname **] remained on [**Hospital Ward Name **] 10 awaiting a rehabilitation
facility that would accept her while on TPN. During that time,
her PICC line needed to be replaced on [**2134-8-18**]. She has also
been complaining of right lower extremity pain. She was placed
on neurontin via G-tube and dilaudid 0.5-2mg q2-3hr for pain,
which has alleviated her pain. Patient has been otherwise
clinically stable and will now be transferred to a rehab
facility in Valhala, NY (8/15/5). She will need to have an
outpatient chest and abdominal CT before follow-up with Dr.
[**Last Name (STitle) **] on [**2134-9-24**].
Chief Complaint:
Acute Pancreatitis
Major Surgical or Invasive Procedure:
IVC filter placement ([**2134-8-12**])
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Skilled Nursing Rehab
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2084**] MD [**MD Number(2) 2085**]
Completed by:[**2134-8-23**] Name: [**Known lastname 11055**],[**Known firstname 194**] Unit No: [**Numeric Identifier 11056**]
Admission Date: [**2134-8-2**] Discharge Date: [**2134-8-25**]
Date of Birth: [**2071-1-2**] Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2083**]
Addendum:
Patient has been clinically stable during the remainder of her
admission. She has not complained of pain and has required
minimal changes in her TPN contents, as guided by her
electrolyte status. She has been awaiting rehab facility
placement and is stable for discharge today [**2134-8-25**] to [**State 2625**].
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Skilled Nursing Rehab
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2084**] MD [**MD Number(2) 2085**]
Completed by:[**2134-8-25**]
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] |
icd9pcs
|
[
[
[]
]
] |
16310, 16581
|
15292, 15333
|
13896, 15217
|
13578, 13874
|
13473, 13554
|
3983, 13451
|
1185, 1377
|
1616, 3965
|
15234, 15254
|
181, 997
|
1020, 1161
|
1394, 1593
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,149
| 148,557
|
9650
|
Discharge summary
|
report
|
Admission Date: [**2116-6-6**] Discharge Date: [**2116-6-11**]
Date of Birth: [**2036-10-16**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 465**]
Chief Complaint:
hypotension and bradycardia
Major Surgical or Invasive Procedure:
unsuccessful R IJ placement, R femoral venous line placement and
removal
History of Present Illness:
81 yo F with AF, CAD, HTN, who was at home. She c/o SOB and
called her son who called 911. Per the ED, the pt's daughter
thinks that she may have taken an extra dose of her BB on
inspection of her med box. On arrival to OSH, HR 40's in slow
AF. BP dropped there and she was started on dopamine after IVFs
were not helpful. For her possible BB tox, she was given d50,
insulin, ca gluconate, and glucagon. She was sent to [**Hospital1 **] for
possible transcutaneous pacing. On arrival here, her BP was in
the 60's, but then improved with IVFs. Dopa was weaned. A right
IJ was attempted but air was aspirated on needle insertion. A
right femoral line was placed instead. A CXR was neg for PTX.
Admitted to the MICU for bradycardia and hypotension.
.
Past Medical History:
HTN, DM, CAD s/p MI, AF, vascultitis/arthritis (on chronic
prednisone), chronic renal insuff (cr 1.3 in [**1-/2116**])
Social History:
lives with son/daughter, former [**Name2 (NI) 1818**], quit for several years
Family History:
NC
Physical Exam:
Upon arrival to ICU:
temp 99, BP 152/70, HR 92, R 22, O2 96% on 2L
Gen: NAD
HEENT: PEERL, EOMI
Neck: elevated neck veins
CV: irreg irreg
Chest: diffuse exp crackles
Abd: +BS, soft, ntnd
Groin: right fem in place
Ext: no edema
Neuro: follows commands, oriented to person, time, not place
Pertinent Results:
Labs:
[**2116-6-6**] 12:10AM WBC-18.7*# RBC-2.99* HGB-8.9* HCT-27.5*
MCV-92 MCH-29.9 MCHC-32.5 RDW-16.7*
[**2116-6-6**] 12:10AM PLT COUNT-213
[**2116-6-6**] 12:10AM NEUTS-90.9* BANDS-0 LYMPHS-5.5* MONOS-3.4
EOS-0.1 BASOS-0.1
[**2116-6-6**] 12:10AM PT-18.2* PTT-26.7 INR(PT)-1.7*
[**2116-6-6**] 12:10AM GLUCOSE-223* UREA N-25* CREAT-1.7* SODIUM-139
POTASSIUM-5.1 CHLORIDE-107 TOTAL CO2-16* ANION GAP-21*
[**2116-6-6**] 12:10AM CK(CPK)-46
[**2116-6-6**] 12:10AM CK-MB-NotDone cTropnT-<0.01
.
Imaging:
[**2116-6-5**]: CXR - The cardiac silhouette is upper limits of normal.
There are dense intramural aortic calcifications. The
mediastinal and hilar contours are otherwise within normal
limits. The pulmonary vasculature is prominent. There is no
pneumothorax. The lungs are clear without consolidations or
effusions. The surrounding soft tissue and osseous structures
demonstrate loss of height of a lower thoracic vertebral body.
.
[**2116-6-6**]: CT torso -
1. No evidence of hematoma within the chest or retroperitoneum
or groin.
2. Small bilateral pleural effusions, with increased ground
glass opacity are most consistent with mild pulmonary edema.
Focal tree-in-[**Male First Name (un) 239**] opacities in the right lower lobe could
represent fluid or mucus impacted bronchi, or possibly
aspiration.
3. 1 cm left upper lobe pulmonary nodule was seen on prior
examination in [**2114**] and is unchanged, consistent with a benign
lesion.
4. 6 mm left lower lobe pulmonary nodule has not been imaged
previously should be followed with chest CT in [**3-17**] months to
confirm stability.
5. Cholelithiasis, without evidence of cholecystitis.
6. Extensive widespread vascular calcification.
7. Heterogenous thyroid with multiple nodules. Thyroid
ultrasound is recommended for further evaluation.
Brief Hospital Course:
In brief, the patient is a 79F with hx of afib, CAD, HTN, DM who
presented from home with suspected BB overdose, hypotension and
bradycardia. Her hospital course was subsequently complicated by
shortness of breath secondary to pulmonary edema in the setting
of hypertension and presumed community acquired pneumonia, and
acute anemia.
.
# Hypotension due to unintentional ingestion of extra dose of
beta blocker and calcium channel blocker. Given glucagon in ER;
on arrival to MICU, HR and BP stable. Her heart rate rapidly
normalized and was restarted on her home dose medications for
blood pressure and rate control. Given her significant response
to (per history) relatively small overdose of metoprolol leading
to significant bradycardia, she could be at risk for tachy-brady
syndrome and may benefit from follow-up with her cardiologist
for discussion of medication titration or pacemaker. This was
the first episode of taking medication incorrectly, and in
discussion with her daughter, she normally does very well with
using a pill box. Her daughter will monitor her use of
medications, and continue using the pill box. If any further
memory problems recur, then an evaluation for cognitive
dysfunction would be warranted.
.
# Shortness of breath: On HD#2, BP meds were held in setting of
hypotension, bradycardia. The patient's HR rose and BP elevated
leading to possible flash pulm edema. The patient received a NTG
drip and lasix with notable improvement. She ruled-out for MI
and had no ischemic EKG changes. She was able to wean down her
supplemental oxygen needs prior transfer from the ICU. There
was a possible RLL consolidation so empiric antibiotics were
started for community acquired pneumonia. Her home CHF regimen
was gradually re-introduced after holding her ACEi with concern
for her renal function.
.
# ARF: On presentiation her Cr had increased above her baseline.
This was felt secondary to to the transient hypotension from
the medication overdose as above. The creatinine began to
recover as her blood pressure normalized.
.
# Anemia: The patient had an asymptomatic Hct drop with no clear
evidence for bleeding source (stools OB-, CT torso no evidence
of hematoma from RIJ attempt or R fem line attempt), also no
evidence of hemolysis given unchanged MCV and RDW. Her
hematocrit started to trend up without intervention.
.
# afib: chronic, restart coumadin at lower dose than home given
that she is now on levaquin. rate control as above.
.
# Gout: patient had a very mild flare of gout symptoms in both
of her feet. She was started on prednisone 20mg qdaily, and
should be titrated down over the course of [**1-14**] weeks. She is
continued on allopurinol which she used at baseline. A once
daily dose of colchicine may help control this flare once her
prednisone is stopped. She became hyperglycemic on this higher
dose, and therefore will have to have her fingersticks carefully
monitored as she is tapered off.
Medications on Admission:
1. Allopurinol 200 mg daily
2. Atorvastatin 40 mg PO DAILY
3. Boniva 150 mg qmonth
4. Cartia XT 120 mg PO BID
5. Cyanocobalamin 50 mcg PO DAILY
6. Escitalopram Oxalate 10 mg PO DAILY
7. FoLIC Acid 1 mg PO DAILY
8. Glucophage 500 mg daily
9. Lisinopril 40 mg daily
10. PredniSONE 1 mg PO DAILY
11. Toprol XL 100 mg daily
12. TraZODONE HCl 50 mg PO HS:PRN
13. Warfarin 2 mg PO DAILY
Discharge Medications:
1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
4. Cartia XT 120 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
5. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
Disp:*30 Capsule(s)* Refills:*2*
8. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
9. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
10. Prednisone 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
12. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Please taper over 1-2 weeks.
13. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day
for 1 months.
14. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
15. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
16. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
17. Insulin sliding scale
Discharge Disposition:
Extended Care
Facility:
[**Hospital 11851**] Healthcare - [**Location (un) 620**]
Discharge Diagnosis:
primary: inadvertent beta blocker overdose
secondary:
- atrial fibrillation
- HTN,
- DM,
- CAD s/p MI,
- arthritis (on chronic prednisone),
- chronic renal insuff (cr 1.3 in [**1-/2116**])
Discharge Condition:
stable
Discharge Instructions:
You were admitted with a very low heart rate and blood pressure
after taking too many blood pressure medicines. You also had a
flare of your gout in both feet for which you were started on a
higher dose of prednisone to be titrated down over the course of
two weeks.
Followup Instructions:
Please be sure to follow up with:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 7721**] VASCULAR LMOB (NHB) Date/Time:[**2116-10-20**]
2:30pm
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2116-10-20**] 3:00pm
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
|
[
"447.6",
"584.9",
"E855.6",
"585.9",
"427.89",
"274.9",
"412",
"971.3",
"403.90",
"486",
"428.0",
"427.31",
"V58.65"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"00.17"
] |
icd9pcs
|
[
[
[]
]
] |
8325, 8409
|
3609, 6561
|
342, 417
|
8643, 8652
|
1775, 3586
|
8967, 9396
|
1448, 1452
|
6993, 8302
|
8430, 8622
|
6587, 6970
|
8676, 8944
|
1467, 1756
|
275, 304
|
445, 1195
|
1217, 1337
|
1353, 1432
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,972
| 163,116
|
17253
|
Discharge summary
|
report
|
Admission Date: [**2152-6-18**] Discharge Date: [**2152-6-20**]
Date of Birth: [**2110-8-25**] Sex: M
Service: MICU [**Location (un) **]
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 48340**] is a 41-year-old
male transferred from [**Hospital6 **] with hemoptysis
in the setting of large cell lung cancer invading into his
airway. At [**Hospital6 **], the patient had presented
on the [**6-17**] with sudden shortness of breath and
hemoptysis. He just had radiation treatment that day. He
had decreasing O2 saturations and chest x-ray showing right
upper lobe cavitary lesion with surrounding opacification.
The patient was intubated. At the [**Hospital6 **]
Intensive Care Unit, the patient ran temperatures up to 101
and white count up to 23. He was treated with levofloxacin
and Flagyl for postobstructive pneumonia. The patient also
had a hematocrit drop from 32 to 23 and was transfused packed
red blood cells and fluid resuscitated. Bronchoscopy at
[**Hospital6 **] showed the right main stem mass
extending into the trachea with large clot distally.
He was transferred to [**Hospital1 69**]
for repeat bronchoscopy and stent placements.
PAST MEDICAL HISTORY:
1. PPD positive from [**2148**], however, he has had negative
acid-fast smears presumably secondary to a vaccination in
Europe.
2. Large cell lung cancer presented in [**2152-2-9**] with
hemoptysis.
3. XRT and chemotherapy.
4. The patient has metastasis to the left humerus based on
previous bone scan.
MEDICATIONS ON ADMISSION:
1. Versed drip.
2. Morphine prn.
3. Fentanyl drip.
4. Levofloxacin.
5. Flagyl.
6. Zantac.
7. Albuterol and Atrovent nebulizers.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is not married. Lives with his
brother and kids, although recently is living on his own. He
is a smoker since the [**2129**].
FAMILY HISTORY: He came to the US from Poland in [**2147**].
ADMISSION PHYSICAL EXAMINATION: Temperature 98.8, blood
pressure 112/66, heart rate 101, respiratory rate 25, pulse
oximetry is 100%. The patient was sedated in no apparent
distress. The pupils are constricted and reactive
bilaterally. Bilateral breath sounds anteriorly with rhonchi
invented sounds. Cardiac regular, rate, and rhythm,
tachycardic, no murmur. Abdomen is positive bowel sounds,
soft, nontender, nondistended. He is guaiac negative per
[**Hospital6 **] Emergency Department. Extremities:
The patient was moving all extremities and no edema.
Multiple dark brown 1 cm round lesions were noted on his
anterior legs and right shoulder. Neurologic examination is
nonfocal.
LABORATORIES ON ADMISSION: Sodium of 138, potassium 4.1,
chloride 105, bicarb 21, BUN 10, creatinine 0.5, and glucose
96. White count was 12.1, hematocrit 25.8, platelet count of
394. Coags were normal.
ELECTROCARDIOGRAM: The patient was in sinus rhythm with a
tachycardia, no acute ST changes.
The patient was maintained in the MICU on the ventilator with
Fentanyl and Versed sedation. He was stable status post
transfer. The patient then underwent high resolution lung CT
scan and airway tracheal CT scan prior to Interventional
Pulmonology procedure. On Monday, the [**2-20**], the
patient was taken to the operating room by the Interventional
Pulmonary team, his larynx was examined to be within normal
limits. Tumor tissue was visualized in the distal trachea on
the right lateral wall with narrowing of the lumen to about
50%. No endobronchial lesions in the left lung airway were
noted. There was extensive tumor tissue in the right lung
airways with narrowing of the lumen to 20-30%. A cavitary
lumen opens into the right mainstem bronchus. A dynamic
Y-stent [**62**] mm in size was placed in the distal trachea during
the procedure of less than 50 mL of blood were lost.
The patient tolerated the procedure without complications.
The evening following the procedure, the patient was
extubated without any difficulty. The patient had no
complications overnight and on Tuesday, [**2-21**], the
patient was stable. His family was present and talking with
the patient. He did complain of some anxiety and was given
some Ativan. The patient is to be transferred back to [**Hospital6 11241**] for definitive home care and further
oncological treatments.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To [**Hospital6 **].
DISCHARGE DIAGNOSIS: Nonsmall cell lung cancer invading into
airway.
DISCHARGE MEDICATIONS:
1. Flagyl.
2. Levofloxacin.
3. Famotidine.
4. Tylenol prn.
5. Ativan prn.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**]
Dictated By:[**Last Name (NamePattern1) 2215**]
MEDQUIST36
D: [**2152-6-20**] 11:20
T: [**2152-6-20**] 11:25
JOB#: [**Job Number 48341**]
|
[
"485",
"162.3",
"518.81",
"197.3",
"198.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.05",
"33.23",
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
1873, 1929
|
4458, 4806
|
4386, 4435
|
1531, 1698
|
1952, 2625
|
187, 1179
|
2640, 4289
|
1201, 1505
|
1715, 1856
|
4314, 4364
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,532
| 109,486
|
25775
|
Discharge summary
|
report
|
Admission Date: [**2189-9-2**] Discharge Date: [**2189-9-17**]
Date of Birth: [**2144-6-5**] Sex: M
Service: SURGERY
Allergies:
Penicillins / Lisinopril / Ace Inhibitors
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
ESRD
Major Surgical or Invasive Procedure:
[**2189-9-3**] renal transplant
[**2189-9-16**] Tunnelled HD line
History of Present Illness:
45 y.o. M with ESRD who presents for renal transplant. He has no
recent h/o infections or interval changes in health. He has had
no fever/chills, nausea, vomiting, change in bowel habits,
travel outside of country, exposure to sick contacts. [**Name (NI) **] has not
had any recent changes in his medication regimen and was
dialyzed this am where they removed approx 4-4.5 liters. He
takes a daily 81mg ASA tab which he did not take today. Past
history is significant for CAD, MI with CABG and was cleared by
cardiology for transplant. He has been npo since 10am.
Past Medical History:
Coronary Artery Disease s/p Myocardial Infarction, End-Stage
Renal Disease on Hemo-dialysis, Hypertension, GERD
Hypercholesterolemia, HIV+, Asthma, Gastroesophageal Reflux
Disease, Neuropathy, Lung nodules, Anemia, +VRE in past, s/p
Appendectomy, s/p Tonsillectomy, s/p Tracheostomy x 2, h/o Deep
Vein Thrombosis, Hyperparathyroidism, Anal HPV,
PSH: CABG, appy, tonsillectomy, R AVF, HD catheter placements
Social History:
Attorney. Lives with roommates. Has a partner. Quit smoking 6
years ago. Drinks a glass of wine on occasion. Denies drug use.
Family History:
CAD in many relatives but not at a young age.
Physical Exam:
A&O, pleasant, cooperative, NAD
HEENT: sclera non-icteric/non-injected, eomi/perrl, mmm,
oropharynx clear
Resp: coarse BS with wheezes on upper lung fields bilaterally,
no crackles/rubs, R tunnelled HD catheter. Site c/d/i
CV: RRR, no murmurs
ABD: S/NT/ND, BS +, obese, small umbilical hernia
Ext: no clubbing, venous stasis disease bilateral lower
extremities, no apparent lesions/ulcers, 2+ edema bilateral
lower extremities
Pertinent Results:
[**2189-9-16**] 06:40AM BLOOD WBC-6.2 RBC-2.52* Hgb-8.1* Hct-23.8*
MCV-95 MCH-32.1* MCHC-33.9 RDW-16.5* Plt Ct-255
[**2189-9-17**] 06:20AM BLOOD PT-12.8 PTT-24.9 INR(PT)-1.1
[**2189-9-15**] 06:00AM BLOOD Glucose-143* UreaN-79* Creat-8.9*# Na-133
K-4.7 Cl-95* HCO3-23 AnGap-20
[**2189-9-16**] 06:40AM BLOOD Glucose-110* UreaN-94* Creat-10.5*#
Na-133 K-5.0 Cl-96 HCO3-23 AnGap-19
[**2189-9-17**] 06:20AM BLOOD Glucose-112* UreaN-105* Creat-11.1*
Na-132* K-5.5* Cl-95* HCO3-20* AnGap-23*
[**2189-9-14**] 07:04AM BLOOD ALT-22 AST-17 AlkPhos-67 TotBili-0.4
[**2189-9-17**] 06:20AM BLOOD Calcium-8.5 Phos-8.8* Mg-2.5
[**2189-9-16**] 06:40AM BLOOD calTIBC-238* Ferritn-592* TRF-183*
[**2189-9-2**] 05:00PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE
[**2189-9-15**] 06:00AM BLOOD tacroFK-11.0
[**2189-9-16**] 06:40AM BLOOD tacroFK-13.9
Brief Hospital Course:
On [**2189-9-2**] he received a cadaveric renal transplant from a high
risk donor (given social history of donor. Discussed with
recipient)placed in the right retroperitoneum. Surgeon was Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**]. Induction immunosuppression consisted of cellcept,
solumedrol and ATG (usually simulect given per HIV/transplant
protocol), but due to higher PRA of 38%, he received ATG 150mg
intraop. The case was difficult due to the patients size. Please
see operative report for complete details. The kidney pinked up
and made a small amount of urine. The kidney was biopsied and
bled a significant amount. Stasis was achieved with Argon. There
was a small subcapsular hematoma. Postop in PACU he was
hypotensive, tachycardic and unable to be extubated and
transferred to the SICU for care. A Levophed drip was used. ID
was consulted
Intraop, he spiked a temperature to 104 and became hypotensive
most likely from ATG reaction vs infection. He received
Vancomycin and Levaquin perioperatively and was pancultured for
this fever. Urine culture from [**9-2**] grew >100,000 colonies of
E.coli pan-sensitive. ID was consulted and felt that fever most
likely due to ATG than infectious etiology and recommended broad
spectrum antibiotics (vanco/aztreonam and flagyl).
A renal transplant US was done which was significantly limited
due to patient body habitus and intubated status preventing
adequate breathhold. Doppler waveforms within the upper, inter,
and lower pole demonstrated brisk systolic upstroke and
diastolic flow with slightly elevated RIs of greater than 0.8.
Additionally, waveforms in the renal hila, which were difficult
to obtain, demonstrated diminished diastolic flow. Numerous
attempts to identify flow within the transplant main renal vein
were unsuccessful. CVVHD was begun for hyperkalemia (7.7)and
delayed graft function on pod 1.
He was extubated and transferred out of the SICU to the med-[**Doctor First Name **]
unit.
Nephrology followed him and tailored HD accordingly. The
tunnelled HD line that was present preoperatively was removed
and replaced with a L IJ temporary HD line. This temporary line
was very positional and uncomfortable during HD and was
subsequently replaced on [**9-14**]. Again this catheter was exchanged,
but did not work during HD on [**9-16**] requiring removal. A L
subclavian tunnelled HD line was successfully placed on [**9-16**]. He
received HD on [**9-16**].
A renal transplant biopsy was performed on [**9-9**]. The pathology
report on the biopsy was negative for cellular and humoral
rejection. The differential diagnosis included obstruction, drug
nephrotoxicity, and especially "acute tubular necrosis." The
small focus of interstitial neutrophils raised the possibility
of an infectious process. There was considerable chronic (donor)
vascular disease.
For immunosuppression, he remained on cellcept 1gram [**Hospital1 **],
steroid taper to prednisone 25mg qd and prograf [**Hospital1 **]. Prograf
required up titration to as high as 22mg [**Hospital1 **] to achieve trough
levels of 9.4. This unusually high dosage was due to interaction
with his HAART medication. The decision was made to give prograf
15mg q 8 hours as it was difficult to get obtain appropriate
troughs on [**Hospital1 **] dosing and to avoid high peaks and prevent
vasoconstriction. Prograf was dosed at 6am, 2pm and 10pm.
The abdominal incision continued to ooze large amounts of old
bloody fluid from a hematoma. The incision was opened on [**9-13**] and
a vac was placed. Vac outputs averaged 1 liter per day of
serosanguinous.
Urine output continued to be low averaging 50-100cc/24 hours.
Creatinine ranged between 8.5 and 10.5 decreasing due to
dialysis.
Hematocrit trended down to 24 (from preop 35.6) and remained
stable. Epogen was administered at HD. Iron studies revealed a
ferritin of 592, tsf 183 and cal TIBC 238.
Physical therapy evaluated and recommended rehab. He will be
transferred to [**Hospital **] Rehab Hospital with continuation of HD
and lab monitoring q Monday and Thursday. Labs results should be
fax'd immediately when available to the [**Hospital 1326**] Clinic attn:
[**Name6 (MD) 5036**] [**Name8 (MD) 5039**], RN coordinator. Immunosuppression should only
be adjusted by the Transplant Center.
Medications on Admission:
abacavir 300mg [**Hospital1 **], lamivudine 50mg po qd, efavirenz 600mg qd,
albuterol mdi prn, atorvastin 20mg qd, lomotil 1 tab prn quid,
cymbalta ? dose, [**Doctor First Name 130**] prn, advair ? dose, atrovent 1 puff
[**Hospital1 **],lopressor 100mg [**Hospital1 **], asa 81 qd, requip 2mg qd,
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: sliding scale
Injection four times a day.
Disp:*1 vial* Refills:*2*
2. syringes Sig: One (1) syringe four times a day: supply 28
gauge low dose insulin syringes U 100.
Disp:*1 box* Refills:*2*
3. One Touch Ultra 2 Kit Sig: One (1) kit Miscellaneous four
times a day.
Disp:*1 kit* Refills:*2*
4. Lancets,Ultra Thin Misc Sig: One (1) lancets
Miscellaneous four times a day: follow sliding scale.
Disp:*1 box* Refills:*2*
5. One Touch Ultra Test Strip Sig: One (1) In [**Last Name (un) 5153**] four
times a day.
Disp:*1 box* Refills:*2*
6. Alcohol Wipes Pads, Medicated Sig: One (1) Topical four
times a day.
Disp:*1 box* Refills:*2*
7. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
11. Efavirenz 200 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily).
12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
13. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
14. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed.
15. Prednisone 5 mg Tablet Sig: Five (5) Tablet PO DAILY
(Daily).
16. Lamivudine 10 mg/mL Solution Sig: 2.5 ml PO DAILY (Daily).
17. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
18. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO 2X/WEEK
(MO,TH).
19. Abacavir 300 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
20. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
21. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
22. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection [**Hospital1 **] (2 times a day).
23. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
24. Ropinirole 1 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
25. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
26. Oxycodone 5 mg Tablet Sig: 5-10 Tablets PO Q4H (every 4
hours) as needed for pain.
27. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed.
28. Tacrolimus 5 mg Capsule Sig: Three (3) Capsule PO Q 8H
(Every 8 Hours): administer at 6am, 2pm and 10pm.
29. Outpatient Lab Work
Labs every Monday and Thursday for cbc, chem 10, and trough
prograf level
Fax labs to [**Telephone/Fax (1) 697**] attn: [**Name6 (MD) 5036**] [**Name8 (MD) 5039**], RN coordinator
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
ESRD
HIV
s/p Cadaveric Renal Transplant
Delayed graft function
UTI, E.coli
Incision wound
Anemia
Discharge Condition:
good
Discharge Instructions:
Please call the transplant clinic at [**Telephone/Fax (1) 673**] for fever >
101, chills, nausea, vomiting, diarrhea, inability to take or
keep down medications, increased abdominal pain, increased
drainage from abdominal wound vac, increased urine output
Monitor the incision for increased drainage, redness or bleeding
Continue VAC dressing changes every 72 hours
Continue Hemodialysis every Tuesday-Thursday & Saturday
Labs every Monday and Thursday
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2189-9-21**] 2:30
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] TRANSPLANT SOCIAL WORK
Date/Time:[**2189-9-22**] 10:30
Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2189-9-22**] 11:20
Provider: [**Name10 (NameIs) **],[**First Name4 (NamePattern1) 1575**] [**Last Name (NamePattern1) 1105**] [**Telephone/Fax (1) 14167**] Call to schedule
appointment
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 819**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 673**] Call to schedule
appointment
Completed by:[**2189-9-17**]
|
[
"285.21",
"356.9",
"998.11",
"276.7",
"599.0",
"041.4",
"E878.0",
"403.91",
"493.90",
"585.6",
"996.81",
"272.0",
"998.12",
"458.29",
"412",
"V45.81",
"414.00",
"530.81",
"042"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.18",
"38.95",
"55.23",
"55.69",
"54.12",
"39.95",
"00.93",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
10516, 10595
|
2925, 7247
|
304, 372
|
10736, 10743
|
2065, 2902
|
11244, 12006
|
1556, 1603
|
7594, 10493
|
10616, 10715
|
7273, 7571
|
10767, 11221
|
1618, 2046
|
260, 266
|
400, 965
|
987, 1395
|
1411, 1540
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,605
| 141,891
|
29792+57660
|
Discharge summary
|
report+addendum
|
Admission Date: [**2155-1-2**] Discharge Date: [**2155-1-13**]
Date of Birth: [**2099-9-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
DOE
Major Surgical or Invasive Procedure:
[**2155-1-6**] Three Vessel Coronary Artery Bypass Grafting(left
internal mammary artery to left anterior descending with vein
grafts to diagonal and obtuse marginal) and Mitral Valve
Replacement utilizing a 33 millimeter Mosaic Porcine Valve.
History of Present Illness:
55 yo M with DOE starting in early [**Month (only) **] and progressing over
the month. Cath at [**Hospital1 **] with 3vd and 3+MR, transferred for
CABG/MVR.
Past Medical History:
cardiomyopathy
MR
CAD
T&A
Social History:
married, lives with spouse
works full time as salesman
no etoh, no tob
Physical Exam:
On admission
Neuro grossly intact
Lungs CTA bilat
RRR 2/6 systolic murmur
Abdomen benign
Pertinent Results:
[**2155-1-13**] 06:50AM BLOOD WBC-9.8 RBC-4.02* Hgb-11.4* Hct-34.0*
MCV-85 MCH-28.4 MCHC-33.6 RDW-14.4 Plt Ct-420
[**2155-1-13**] 06:50AM BLOOD PT-14.4* PTT-41.3* INR(PT)-1.3*
[**2155-1-13**] 06:50AM BLOOD Glucose-124* UreaN-25* Creat-1.1 Na-135
K-4.8 Cl-100 HCO3-26 AnGap-14
Brief Hospital Course:
Mr. [**Known lastname **] was transferred from MWMC for consideration of
CABG/MVR. He was seen in consultation by heart failure who
recommended echocardiogram, pulmonary consult for ? of
sarcoidosis seen on chest CT, diuresis and cardiac MRI if able.
He received a PA catheter on [**2155-1-3**]. He was seen in
consultation by pulmonology for his ? of sarcoid who recommended
follow up CT scan after he was diuresed. He was cleared for
surgery by dentistry. He was taken to the operating room on
[**2155-1-6**] where he underwent a CABG x 3 and mitral valve
replacement with a 33mm mosaic porcine valve. He was transferred
to the SICU in critical but stable condition on milrinone,
epinephrine, phenylephrine and propofol. His epi and neo were
weaned off by POD #1. He was extubated on POD #1. His milrinone
was slowly weaned over the next several days and was turned off
on POD #6. His PA cath was dc'd and he was transferred to the
floor. He was ready for discharge home on POD #7.He will follow
up with his pulmonologist in 4 weeks with a CT scan.
Medications on Admission:
coreg, lisinopril, asa
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
4. 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*
5. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*0*
6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Telephone/Fax (1) 71300**]
Discharge Diagnosis:
Coronary Artery Disease, Cardiomyopathy, Congestive Heart
Failure, Mitral Regurgitation - s/p CABG and MVR
Discharge Condition:
Good.
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for at least one month. No lifting more
than 10 lbs for at least 10 weeks from the date of surgery.
Monitor wounds for signs of infection. Please call with any
concerns or questions.
Followup Instructions:
Dr. [**Last Name (STitle) 1290**] 4-5 weeks
Dr. [**Last Name (STitle) 5874**] 2-3 weeks
Dr. [**Last Name (STitle) 70409**] (Pulmonologist) with CT scan Chest in 1 month
Completed by:[**2155-1-13**] Name: [**Known lastname **],[**Known firstname 11991**] Unit No: [**Numeric Identifier 11992**]
Admission Date: [**2155-1-2**] Discharge Date: [**2155-1-13**]
Date of Birth: [**2099-9-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 674**]
Addendum:
Mr. [**Known lastname **] has systolic heart failure with an LVEF of 15-30%.
Discharge Disposition:
Home With Service
Facility:
[**Telephone/Fax (1) 11993**]
[**Doctor Last Name **] [**Last Name (Prefixes) **] MD [**MD Number(1) 681**]
Completed by:[**2155-1-22**]
|
[
"276.2",
"423.9",
"135",
"428.20",
"414.8",
"424.0",
"414.01",
"517.8",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.15",
"35.23",
"36.12",
"88.72",
"89.64",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
4435, 4631
|
1276, 2329
|
281, 527
|
3460, 3468
|
976, 1253
|
3786, 4412
|
2402, 3226
|
3330, 3439
|
2355, 2379
|
3492, 3763
|
866, 957
|
238, 243
|
555, 713
|
735, 762
|
778, 851
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,903
| 167,457
|
19877
|
Discharge summary
|
report
|
Admission Date: [**2183-11-2**] Discharge Date: [**2183-11-17**]
Date of Birth: [**2127-8-15**] Sex: M
Service:
ADMITTING DIAGNOSIS: Status post fall.
DISCHARGE DIAGNOSIS:
1. Fall
2. Ethyl alcohol intoxication
3. Ethyl alcohol withdrawal
4. Traumatic brain injury
5. Intubation secondary to traumatic brain injury
OPERATIVE PROCEDURES: Intubation
HISTORY OF PRESENT ILLNESS: The patient is a 56 year old
male with a past medical history significant for
hypertension, prostate hypertrophy, L5-S1 disc herniation and
bilateral lower extremity claudication, left greater than
right.
PAST SURGICAL HISTORY: 1. Appendectomy; 2. Umbilical
hernia repair
MEDICATIONS AT HOME: Lescol and Doxazosin 4 mg once a day
and Aspirin.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Examination on admission revealed the
patient was agitated and combative with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2611**] coma scale
of 13. He had dried blood in both nares. His face was
stable. His oropharynx had dried blood in it. His heart was
regular. His lungs were clear. His abdomen was soft,
nontender, nondistended. His lower extremities were warm
with an abrasion over the left lateral thigh. He had
palpable pulses bilaterally. His rectal was heme negative,
guaiac heme negative, normal tone. His pelvis was stable.
His back revealed no stepoff and no deformities. He was
moving all extremities well.
LABORATORY DATA: On admission his hematocrit was 34.7, his
creatinine was .8, his lactate was 1.5, his urinalysis was
negative. His serum toxicology was positive for an ethyl
alcohol of 161. His amylase was 73.
His studies on admission revealed a negative chest x-ray and
a negative pelvis film. His cervical spine computerized
tomography scan was negative. His abdomen and pelvis
computerized tomography scan revealed aspiration in the right
lower lobe, otherwise negative. His gala films were
negative. His head computerized tomography scan revealed a
nondisplaced occipital bone fracture with pneumocephalus, a
left temporal contusion with subarachnoid hemorrhage, a right
temporal bone fracture, a sphenoid sinus fracture and blood
in the temporomandibular joint.
HOSPITAL COURSE: The patient was seen and evaluated in the
Emergency Department by the Trauma Team, given his brain
injury he was admitted to the Intensive Care Unit and
Neurosurgery was consulted. An A-line was placed. He
underwent a four vessel angiogram on hospital day #2 given
the proximity of his fractures to the carotid and vertebral
foramen. The four vessel angiogram was negative. Given his
agitation and tachycardia, it was felt that the patient was
going into withdrawal. He was therefore started on a CIWA
protocol. On [**2183-11-4**], given the fact that his
mental status seemed to be slightly decreased and that he was
not following commands, Neurosurgery recommended a stat head
computerized tomography scan. The patient was intubated for
this examination given the fact that we were not able to
adequately sedate him and protect his airway at the same time
for the computerized axial tomography scan, the computerized
axial tomography scan revealed a large amount of frontal
edema. He was started on Mannitol on hospital day #3. Given
the fact that he was getting Mannitol and had not had an ICP
monitor, this issue was revisited with Neurosurgery. They
decided to discontinue the Mannitol. He seemed to be
improving slightly and they felt that his prognosis was
favorable. Also of note, an Otorhinolaryngology consult was
obtained for his fractures near the skull base and near the
auditory canal. They recommended antibiotics for the fluid
in his sinuses but no further in-hospital workup. Of note,
during the [**Hospital 228**] hospital stay the family expressed that
they did not want the patient to be a full code and thus he
was made Do-Not-Resuscitate, Do-Not-Intubate. They also
stated that they knew that their father would not want to be
on any sort of life support or have his life prolonged if he
were to be anything but normal. The Intensive Care Unit Team
and Trauma Team and the Neurosurgery Team felt that the
patient had made some progress and it was not reasonable to
withdraw care, and thus an Ethics Consult was obtained. It
was decided that the patient would be Comfort-Measures-Only,
that his intravenous fluids be discontinued, and he would be
allowed to eat and drink if he was hungry or thirsty but that
he would receive no further medications and would be made
hospice. This plan was enacted, however, the patient did
continue to improve to the point where he was following
commands and able to eat at discharge. Physical therapy felt
that he had good potential for rehabilitation and thus on
hospital day #17, [**2183-11-17**], the patient was
discharged to rehabilitation in stable condition.
MEDICATIONS ON DISCHARGE: None.
FOLLOW UP: The patient should follow up with Neurosurgery
for any further issues with his brain injury.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) **]
Dictated By:[**Last Name (NamePattern1) 4985**]
MEDQUIST36
D: [**2183-11-17**] 12:51
T: [**2183-11-17**] 13:06
JOB#: [**Job Number 53701**]
|
[
"276.5",
"348.5",
"276.0",
"461.9",
"780.6",
"E880.9",
"291.81",
"801.21",
"303.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.91",
"96.6",
"88.41",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
194, 377
|
4927, 4934
|
2259, 4900
|
705, 794
|
636, 683
|
4946, 5311
|
817, 2241
|
406, 612
|
154, 173
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,585
| 167,198
|
53877
|
Discharge summary
|
report
|
Admission Date: [**2102-3-22**] Discharge Date: [**2102-3-28**]
Service: ORTHOPAEDICS
Allergies:
Penicillins / Sulfa(Sulfonamide Antibiotics) / Tetracycline /
Neurontin / IV Dye, Iodine Containing Contrast Media
Attending:[**First Name3 (LF) 8587**]
Chief Complaint:
Left open tibial shaft fracture s/p mechanical fall
Major Surgical or Invasive Procedure:
Washout and debridement of the open fracture, operative
treatment of left tibia shaft fracture with intramedullary nail,
and closed treatment of the left fibula fracture without
manipulation.
History of Present Illness:
88F with aortic insufficiency, COPD, RA on
prednisone/methotrexate, on coumadin for DVT who was admitted at
2 AM on [**3-22**] for an open mid-shaft spiral tibia fracture
sustained after twisting her ankle while getting into bed. The
patient does not recall the exact mechanism of injury but states
that had no head strike and no LOC.
Past Medical History:
-HTN
-COPD
-Hypercholesterolemia
-Aortic insufficiency
-Rheumatoid arthritis
-TIA
-Thrombophlebitis of LE, on coumadin
-Diverticulosis
-Spinal stenosis
-GERD
-Hiatal hernia
-Acute gastritis
-Osteoporosis
-Urinary incontinence
-Appendectomy
-Cholecystectomy
-L breast biopsy
-Urinary incontinence
-Lactose intolerance
Social History:
Pt lives alone, walks with a walker. Smokes [**11-21**] ppd x10 yrs, no
etoh, illicits.
Family History:
NC
Physical Exam:
AVSS, NAD, AOx3
CV: RRR
PULM: Non-labored breathing
MSK:
BUE skin clean and intact
No tenderness, deformity, erythema, edema, induration or
ecchymosis
Arms and forearms are soft
No pain with passive motion
R M U [**Month/Day (2) 2189**]
EPL FPL EIP EDC FDP FDI fire
2+ radial pulses
LLE with bivalve cast in place
Incision is clean/dry/intact with mild erythema and ecchymosis,
No edema, drainage, or fluctuance
Peri-incisional tenderness appropriate to post-op exam, no
induration or ecchymosis
Thighs and legs are soft
No pain with passive motion at knee or ankle
Saph Sural DPN SPN MPN LPN [**First Name9 (NamePattern2) 2189**]
[**Last Name (un) 938**] FHL GS TA PP Fire
1+ PT and DP pulses
Contralateral extremity examined with good range of motion,
SILT, motors intact and no pain or edema
Pertinent Results:
[**2102-3-28**] 05:47AM BLOOD WBC-7.0 RBC-3.45* Hgb-10.0* Hct-31.5*
MCV-91 MCH-29.0 MCHC-31.8 RDW-15.2 Plt Ct-165
[**2102-3-28**] 05:47AM BLOOD Glucose-78 UreaN-19 Creat-0.8 Na-142
K-3.9 Cl-106 HCO3-28 AnGap-12
[**2102-3-28**] 05:47AM BLOOD Calcium-8.5 Phos-2.4* Mg-1.7
Brief Hospital Course:
88F with aortic insufficiency, COPD, RA on
prednisone/methotrexate, on coumadin for DVT who was admitted at
2 AM on [**3-22**] for an open mid-shaft spiral tibia fracture
sustained after twisting her ankle while getting into bed. The
patient does not recall the exact mechanism of injury but states
that had no head strike and no LOC.
She was admitted to the Orthopaedic Trauma Service for repair of
an open mid-shaft spiral tibia fracture . The patient was taken
to the OR and underwent an uncomplicated washout and debridement
of the open fracture, operative treatment of left tibia shaft
fracture with intramedullary nail, and closed treatment of the
left fibula fracture without manipulation.
The patient tolerated the procedure without complications, was
extubated without difficulty and was transferred to the PACU in
stable condition. Please refer to the operative report for
details of the case. However while in the PACU she became
hypotensive with a pressor requirement and was transferred to
the ICU post op for management. She responded well to PRBC
transfusion and to pressor and her BP had improved on arrival to
the ICU. Pressors were turned off at 3 PM on the day of surgery
([**2102-3-24**]) and she remained stable for the remainder of her
hospitalization. During her hospitalization she was also noted
to have a decrease in platelet count, workup revealed that she
was HIT antibody NEGATIVE and her platelet count stabilized and
slowly began to increase.
Post operatively pain was controlled with IV pain medication
with a transition to PO pain meds once tolerating POs. The
patient tolerated diet advancement without difficulty and made
steady progress with PT, however was found to benefit most from
discharge to rehab.
Weight bearing status: Weight bearing as tolerated in bivalve
cast .
The patient received peri-operative antibiotics as well as
Lovenox for DVT prophylaxis. The incision was clean, dry, and
intact without evidence of erythema or drainage; and the
extremity was NVI distally throughout. The patient was
discharged in stable condition with written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient will be continued on chemical DVT
prophylaxis for 4 weeks post-operatively. All questions were
answered prior to discharge and the patient expressed readiness
for discharge.
The patient's PCP was informed of this admission and the need to
restart coumadin as an outpatient. [**First Name4 (NamePattern1) 501**] [**Last Name (NamePattern1) **]-[**Doctor Last Name **] at the
[**Hospital3 **] associated with the patient's PCP (Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]) has been informed of her admission and treatment
course. She can be reached at [**Telephone/Fax (1) 110522**] regarding management
of the patient's coumadin.
Medications on Admission:
*cyanocobalamin (vitamin B-12) 1,000 mcg daily
*aspirin 81 mg Tab Oral
*Boniva 150mg q 30 days
*hydrochlorothiazide 25 daily
*lisinopril 10 daily
*Combivent 18 mcg-103 mcg/actuation Aerosol Inhaler Inhalation
2 puffs Aerosol(s) Four times daily
*Prilosec 20 mg q AM
*Remeron 7.5 q HS
*Coumadin 1.25ng x 2d (w,sa); 2.5mg x 5d
*meclizine -- 25 mg PRN vertigo
*folic acid 1mg daily
*Calcium 600 mg q TID
*prednisone 10 mg daily
*methotrexate sodium-not filled since novemember-12.5 mg weekly
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
2. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO Q6H (every 6 hours) as needed for Dyspepsia.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
5. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO BID (2 times a day) as needed for Constipation.
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
7. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID (3 times a day).
8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. ipratropium-albuterol 18-103 mcg/actuation Aerosol Sig: [**11-21**]
Puffs Inhalation Q6H (every 6 hours).
10. enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Syringe
Subcutaneous QPM (once a day (in the evening)) for 4 weeks.
Disp:*28 Syringe* Refills:*0*
11. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 1687**] - [**Location (un) 745**]
Discharge Diagnosis:
Left open midshaft spiral tibia fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
******SIGNS OF INFECTION**********
should experience severe pain, increased swelling, decreased
sensation, difficulty with movement; fevers >101.5, chills,
redness or drainage at the incision site; chest pain, shortness
of breath or any other concerns.
-Wound Care: You can get the wound wet/take a shower starting
from 3 days post-op. No baths or swimming for at least 4 weeks.
Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment. No dressing is needed
if wound continued to be non-draining.
******WEIGHT-BEARING*******
Left lower extremity: Weight bearing as tolerated in bivalve
cast
******MEDICATIONS***********
- Resume your pre-hospital medications.
- You have been given medication for your pain control. Please
do not operate heavy machinery or drink alcohol when taking this
medication. As your pain improves please decrease the amount of
pain medication. This medication can cause constipation, so you
should drink 8-8oz glasses of water daily and take a stool
softener (colace) to prevent this side effect.
-Medication refills cannot be written after 12 noon on Fridays.
*****ANTICOAGULATION******
- Take Lovenox for DVT prophylaxis for 4 weeks post-operatively.
******FOLLOW-UP**********
Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**9-3**] days
post-operation for evaluation and staple/suture removal. Call
[**Telephone/Fax (1) 1228**] to schedule appointment upon discharge.
Please follow up with your PCP regarding this admission and any
new medications/refills.
Physical Therapy:
Left lower extremity: Weight bearing as tolerated in bivalve
cast
Treatments Frequency:
Site: bilat arms
Description: ecchymosis over entire arm, weaping serous fluid.
*skin tear to Right upper arm dressed with adaptik and DSD
wrapped in Kerlix**
Care: Kerlix wraps prn
Site: Coccyx
Description: stage 2 pressure ulcer
Care: Mepilex q3days and prn
Site: LLE
Description: ORIF
Care: [**Hospital1 **]-valve cast in place, wound beneath to be dressed with
xeroform, ABD pads and loosely placed ace wrap.
Followup Instructions:
Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**9-3**] days
post-operation for evaluation and staple/suture removal. Call
[**Telephone/Fax (1) 1228**] to schedule appointment upon discharge.
Please follow up with your PCP regarding this admission and the
need to restart coumadin as an outpatient.
Completed by:[**2102-3-28**]
|
[
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"788.30",
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"424.1",
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"458.29",
"287.5",
"553.3",
"496",
"285.1",
"790.92",
"401.9",
"E927.0",
"V12.51",
"275.41",
"276.8",
"V58.65",
"271.3",
"714.0",
"305.1",
"733.00",
"823.32"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.66",
"79.36"
] |
icd9pcs
|
[
[
[]
]
] |
7284, 7362
|
2531, 5390
|
378, 572
|
7446, 7446
|
2237, 2508
|
9765, 10140
|
1399, 1403
|
5931, 7261
|
7383, 7425
|
5416, 5908
|
7629, 7885
|
1418, 2218
|
9238, 9304
|
9326, 9742
|
287, 340
|
7897, 9220
|
600, 937
|
7461, 7605
|
959, 1278
|
1294, 1383
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,760
| 112,895
|
2132
|
Discharge summary
|
report
|
Admission Date: [**2139-8-3**] Discharge Date: [**2139-8-7**]
Date of Birth: [**2079-8-6**] Sex: M
Service: MEDICINE
Allergies:
Iron
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
Nausea, Vomiting, Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname **] is a 59 year old male with PMH significant for CKD s/p
renal transplant, DM-II, chronic pancreatitis, HCV without
cirrhosis, and HTN who was admitted earlier this afternoon for
nausea, emesis and abdominal pain felt to be due to an acute on
chronic pancreatitis flare-up. Patient explains that he had
several non-bloody emesis episodes and nausea for about 5 hrs
leading up to admission. Also several episodes of diarrhea
(non-bloody). He also had more intense epigastric area pain
after eating a meal yesturday afternoon. States recent ETOH use
was 4-5 days ago.
He states his abd pain is similar to his prior episodes of
pancreatitis. No fevers, chills, CP, SOB, H/A,
numbness/weakness/tingling. In the ED this morning his initial
VS were: T99 HR67 BP227/66 18 100 % on RA. Lipase was 148, Cr
was 1.8 (near usual baseline), AST 41/ALT 21. He was given GI
cocktail, maalox, IV morphine, PO zofran and IV compazine. He
was also given 50 mg oral metoprolol and 1L IVF. He had missed
his AM dose of metoprolol today.
.
When he arrived to the medical floor he had 215/90, HR 80, RR18,
100% on RA. On exam, He was alert, fully oriented and without
headache / visual changes. Neurologically intact. Abd pain well
controlled with percocet x 1. On the floor, patient's BP range
was: 150-210/80-98. He was given 5 mg metoprolol IV, 50 mg PO
metoprolol, 10 mg IV labetalol and 20 mg IV labetalol. His SBP
remained 189-214 with these interventions. Transfer to MICU was
initiated for better BP control.
On arrival to the [**Hospital Unit Name 153**], initial vs were: T98.6F, P80,
BP195/79,RR 15 O2 sat 100% RA. Patient was given additional 10mg
Labetolol IV and BPs came down to 180s systolic range.
Past Medical History:
1. ESRD s/p Renal Transplant [**6-/2135**] (baseline Cre 1.8-2.5)
- complicated by CMV Viremia
2. Erectile Dysfunction
3. Hx of detached retina - [**2132**], surgically repaired
4. h/o infected sebaceous cyst
5. Pancreatitis -chronic
6. Diabetes Mellitus Type II - on Insulin
7. h/o Knee arthritis
8. h/o Hepatitis C - followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11455**] ([**Hospital1 2177**])
9. Hypertension - controlled on metoprolol
Social History:
Home: Lives alone in apartment on [**Location (un) **] avenue. On
disability, not currently working.
EtOH: Had [**1-31**] pint hard liquor 2 days PTA. Denies any other EtOH
use since [**Month (only) 547**]. Notes drank regularly ([**1-31**] pint to pint until
mid 90s, when decreased dramatically). No history of withdrawl
noted by patient.
Drugs: Denies illicits.
Tobacco: Denies
Family History:
Mother - Type 2 Diabetes Mellitus, hypertension
Father - Type 2 Diabetes Mellitus
Physical Exam:
Vitals: T 98.6F, P80, BP195/79,RR 15 O2 sat 100% RA.
General: Alert, oriented, somewhat slow speech at times
ncomfortable. Slightly irritable.
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear
Neck: supple, no LAD and JVP 8cm
Lungs: Clear to auscultation bilaterally.
CV: Regular rate and rhythm, tachycardic, normal S1 + S2. No
murmurs, rubs, gallops.
Abdomen: soft, tender over mid-epigastrium. Normoactive BS. No
rebound tenderness or guarding. No organomegaly. Refused rectal
exam.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: No sensation deficits to light touch. CNs [**3-13**] in tact.
[**6-3**] UE and LE strength. No tremors. No asterixis. Gait
assessment deferred.
GU: no foley
Pertinent Results:
CBC
[**2139-8-3**] 06:15AM BLOOD WBC-11.3*# RBC-4.96 Hgb-11.1* Hct-35.7*
MCV-72* MCH-22.4* MCHC-31.1 RDW-15.3 Plt Ct-142*
[**2139-8-4**] 03:57AM BLOOD WBC-6.6 RBC-5.46 Hgb-12.2* Hct-40.1
MCV-73* MCH-22.4* MCHC-30.5* RDW-15.3 Plt Ct-160
[**2139-8-3**] 06:15AM BLOOD Plt Ct-142*
[**2139-8-4**] 03:57AM BLOOD Plt Ct-160
[**2139-8-6**] 04:31PM BLOOD WBC-4.0 RBC-4.10* Hgb-9.3* Hct-30.7*
MCV-75* MCH-22.6* MCHC-30.1* RDW-15.5 Plt Ct-116*
[**2139-8-7**] 11:00AM BLOOD WBC-4.8 RBC-4.37* Hgb-9.6* Hct-32.4*
MCV-74* MCH-22.0* MCHC-29.7* RDW-15.6* Plt Ct-179#
CHEM 7
[**2139-8-3**] 06:15AM BLOOD Glucose-97 UreaN-25* Creat-1.8* Na-142
K-4.1 Cl-107 HCO3-20* AnGap-19
[**2139-8-4**] 03:57AM BLOOD Glucose-124* UreaN-20 Creat-1.4* Na-135
K-5.9* Cl-100 HCO3-21* AnGap-20
[**2139-8-6**] 05:45AM BLOOD Glucose-137* UreaN-54* Creat-2.5*# Na-136
K-4.8 Cl-101 HCO3-26 AnGap-14
[**2139-8-6**] 04:31PM BLOOD Glucose-159* UreaN-51* Creat-2.3* Na-137
K-4.8 Cl-105 HCO3-17* AnGap-20
[**2139-8-7**] 11:00AM BLOOD Glucose-170* UreaN-41* Creat-1.9* Na-142
K-4.1 Cl-108 HCO3-25 AnGap-13
OTHER LABS
[**2139-8-3**] 06:15AM BLOOD ALT-21 AST-41* AlkPhos-86 TotBili-0.6
[**2139-8-3**] 06:15AM BLOOD Lipase-148*
[**2139-8-6**] 05:45AM BLOOD Lipase-153*
[**2139-8-4**] 03:57AM BLOOD tacroFK-4.7*
[**2139-8-7**] 11:00AM BLOOD tacroFK-PND
Brief Hospital Course:
Brief Hospital Course
Mr. [**Known lastname **] is a 59yo male with h/o CKD s/p renal transplant, and
DM-II who was admitted with an acute flare of chronic
pancreatitis and HTN urgency, also found to have acute on
chronic renal failure improved back to baseline with hydration.
#Acute on chronic pancreatitis: Unclear whether this is a new
flare or residual sx prior flare last week, which never fully
resolved. [**Month (only) 116**] have been in setting of eating large bolus of meat
(possible outdated) on [**8-2**], prior to admission.
- Pain well controlled on percocet 1-2 mg q4h PRN throughout
admission.
- Tolerating full diet without issue by the time of discharge.
- No hx of bloody emesis on this admission.
- Pt reports that he has pain clinic appt next Wednesday.
- Diarrhea and nausea resolved on admission.
#Hypertensive urgency: Patient has had chronic elevated BPs in
the 170-190s range (systolic).
- Was briefly in ICU on this admission for hypertensive urgency
(SBPs 215-220, uncontrolled by PO metoprolol, IV metoprolol and
IV labetalol) No neurologic or visual changes at any time.
- Received additional dose of IV labetalol as well as amlodipine
in the ICU, with SBP down to < 160.
- On the floor, pressures were well controlled (SBP < 150, and
generally 120s-140s) on oral metoprolol 50 mg po bid and
amlodipine 5 mg po qd.
- Patient instructed to continue PO metoprolol and amlodipine on
discharge.
# Acute on chronic renal failure: Patient with baseline renal
function with Cr 1.8, during hospital found to have acute
worsening of Cr up to 2.5 on [**2139-8-6**] thought to be prerenal in
setting of being NPO and having flare of pancreatitis.
- Given 1L bolus and Cre down to 2.3 on recheck on [**2139-8-6**].
afternoon.
- Given 2L fluids overnight with return of Cre to baseline value
of 1.9 upon discharge.
#h/o ESRD, s/p transplant: Likely had renal failure secondary to
HTN although patient seems to be limited historian in this
Medical Center, Dr. [**First Name (STitle) **].
-continued Prednisone 2.5mg daily
-continued Mycophenolate Mofetil 750 mg PO DAILY
-continued Tacrolimus 1 mg PO QPM / 2 mg PO QAM
-has followup appointment with Dr. [**First Name (STitle) **] at [**Hospital1 2177**] on discharge
#DM-II: Longstanding history of type II diabetes.
- HbA1c=6.1%
- QID fingersticks with SSI
- Home glargine restarted once patient was taking full POs.
#Alcohol Abuse: Patient strongly denied use between prior
discharge and current admission. Had CIWA scale in the MICU but
did not require ativan. No e/o withdrawal on exam, so CIWA scale
was d/c'd without issue.
#Recent GI Bleed: Recent coffee-ground emesis on prior
admission. He could have possible varices given his HCV and ETOH
history although no documented cirrhosis. Also may be gastritis
related as he has h/o GERD. Hct stable on this admission;
refused EGD on prior admission and rectal exam on this
admission.
- HCt stable at patient's baseline on this admission
- Patient agreed to consider outpt EGD -- he will discuss with
his [**Hospital1 2177**] PCP.
[**Name Initial (NameIs) **] PPI dose was increased to 40 omeprazole [**Hospital1 **].
# IV access/blood draws: Of note, patient with difficult access.
We were able to obtain an antecubital R PIV during this
admission (although in past has had PICC lines, we wanted to
avoid this due to infection risk). Phlebotomy was challenging,
but when MD order allowed patient to be drawn on left side where
patient had his old fistula, phlebotomy was able to obtain blood
from left hand.
Medications on Admission:
Insulin SC (per Insulin Flowsheet)
Morphine Sulfate 2-4 mg IV Q6H:PRN abdominal pain
Metoclopramide 10 mg IV Q6H:PRN nausea
Pantoprazole 40 mg IV Q24H gastritis
Mycophenolate Mofetil 750 mg PO DAILY
PredniSONE 2.5 mg PO/NG DAILY
Tacrolimus 1 mg PO QPM
Tacrolimus 2 mg PO QAM
Metoprolol Tartrate 50 mg PO/NG [**Hospital1 **]
Discharge Medications:
1. Prednisone 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
Disp:*120 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
5. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO QAM (once a
day (in the morning)).
6. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO QPM (once a
day (in the evening)).
7. Mycophenolate Mofetil 250 mg Capsule Sig: Three (3) Capsule
PO DAILY (Daily).
8. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
9. Insulin Glargine 100 unit/mL Cartridge Sig: Twenty Two (22)
UNITS Subcutaneous at bedtime.
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 6-8 hours as needed for abdominal pain : Please contact
your primary care provider who normally prescribes this
medication for any refills.
Disp:*0 Tablet(s)* Refills:*0*
11. Humalog 100 unit/mL Cartridge Sig: Four (4) UNITS
Subcutaneous WITH EVERY MEAL.
12. Outpatient Lab Work
Please have CHEM7 panel and CBC drawn on [**2139-8-10**]. Results should
be faxed to Dr. [**Doctor Last Name 11456**] at [**Telephone/Fax (1) 11454**].
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Acute pancreatitis
Secondary Diagnoses:
Acute on chronic renal failure
Hypertensive urgency
End-Stage Kidney Disease, status-post kidney transplant
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure to participate in your care. You were
diagnosed with hypertension and pancreatitis. When you came into
the hospital you had abdominal pain similar to your prior
episodes of pancreatitis. When you arrived on the Medical Floor,
your blood pressure was very high (as high as 215 systolic). You
were given several medications but your blood pressure remained
high. Therefore you were transferred to the medical intensive
care unit, where your blood pressure was controlled with
labetalol, metoprolol, and amlodipine. Subsequently, on the
medical floor, your blood pressure remained well controlled on
oral metoprolol and oral amlodipine. Your abdominal pain was
controlled with Percocet. Your diet was slowly advanced until
you were tolerating a full diet by the time of your discharge.
You should avoid alcohol and foods that trigger worsening of
your pancreatitis.
.
Please note the following changes to your medications:
MEDICATIONS ADDED:
Amlodipine 5 mg by mouth every day
MEDICATION DOSE CHANGES:
Dose increased to Omeprazole 40 mg by mouth twice a day.
MEDICATIONS REMOVED:
None
.
Thank you for allowing us to participate in your care.
Followup Instructions:
You have an appointment with your Primary Care Physician (Dr.
[**Doctor Last Name 11456**]) on [**8-12**] at 3:45 PM.
At this appointment, please discuss your blood pressure
medications and the risk factors that may cause or worsen your
pancreatitis. Please mention the new dose of omeprazole, which
has been increased. You should also discuss the possibility of
having an upper endoscopy as an outpatient procedure.
-------
You have an appointment with your Renal Transplant Doctor, Dr.
[**First Name (STitle) **] at [**Hospital6 **] on [**8-19**] at 8:20AM.
At this appointment, please discuss your kidney function and
your current transplant drug regimen.
|
[
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"607.84",
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"250.00",
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"577.0",
"V42.0",
"070.70",
"584.9",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10413, 10419
|
5144, 8686
|
295, 301
|
10631, 10631
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3816, 5121
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,647
| 186,958
|
3564
|
Discharge summary
|
report
|
Admission Date: [**2188-5-4**] Discharge Date: [**2188-5-7**]
Date of Birth: [**2106-1-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
82 yo male presented to outside hospital with chest pain. CT
done suspicious for Type A aortic dissection. Scan also showed
ascending and arch aneurysm, arch hematoma, and hemopericardium.
Transferred here emergently for surgical evaluation.
Past Medical History:
mitral regurgitation s/p MV repair [**2175**]
CVA
PVD s/p right fem-[**Doctor Last Name **] BPG
chronic renal failure ( baseline 1.9)
Atrial fibrillation
s/p AAA repair with left renal artery bypass
CAD
HTN
hyperlipidemia
Social History:
no ETOH or tobacco
Lives with spouse
Family History:
mother and father died of congenital heart disease
Physical Exam:
Pulse:78 Resp: O2 sat:98%
B/P Right:120/80 Left: 90/50
Height: Weight:
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM []
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ []
Extremities: Warm [x], well-perfused [] Edema Varicosities:
None
[]
Neuro: Grossly intact
Pulses:
Femoral Right: +3 Left:+3
Pertinent Results:
IMPRESSION:
1. Type A aortic dissection originating from the aortic root
near the origin
of the right coronary artery, extending through the ascending
aorta to
terminate proximal to the origin of the right innominate artery.
There is
aneurysmal dilatation of the ascending aorta and thoracic arch
with extensive
mural thrombus and atheromatous ulceration. A small amount of
hemopericardium
is associated.
2. Extensive atherosclerotic calcifications and mural thrombus
involving an
aneurysmally dilated abdominal aorta, with the infrarenal aorta
measuring up
to 3.8 cm. Ectasia of the common iliac arteries bilaterally and
aneurysmal
dilatation of the right common femoral artery to 2.4 cm.
3. Extensive colonic diverticulosis without acute
diverticulitis.
4. Cholelithiasis without acute cholecystitis.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3904**]
DR. [**First Name8 (NamePattern2) **] [**Name (STitle) **]
Approved: MON [**2188-5-5**] 8:27 AM
Imaging Lab
Conclusions
The left atrium is markedly dilated. No left atrial
mass/thrombus seen (best excluded by transesophageal
echocardiography). The right atrium is markedly dilated. The
right atrial pressure is indeterminate. There is moderate
symmetric left ventricular hypertrophy with normal cavity size
and regional/global systolic function (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The aortic
valve leaflets are mildly thickened (?#). There is mild aortic
valve stenosis (valve area 1.2-1.9cm2). Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] There is a small inferolateral
pericardial effusion.
If clinically indicated, a follow-up study be laboratory
son[**Name (NI) 16272**] may be able to better clarify the severity of
aortic stenosis.
Electronically signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2188-5-5**] 13:21
Brief Hospital Course:
Admitted after evaluation in emergency room. Detailed discussion
held with family given extremely high risk for surgery. Elected
for medical management. Admitted to CVICU for monitoring and
blood pressure management. He was then transferred to the floor
for pain management and palliative care consult. On hospital day
three while walking with physical therapy he had pain in upper
chest and throat. Pain continued to persist adn after
discussing it with him, morphine was given for pain.
He passed away shortly there after with daughter at his side.
Medications on Admission:
captopril 25 mg TID
advair prn
allopurinol 300 mg daily
digoxin 0.125 mg daily
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Type A aortic dissection
s/p MV repair [**2175**]
s/p AAA repair/left renal artery bypass
atrial fibrillation
chronic renal failure ( baseline 1.9)
CVA
PVD s/p right fem-[**Doctor Last Name **] BPG
CAD
HTN
hyperlipidemia
Discharge Condition:
deceased
Completed by:[**2188-5-7**]
|
[
"V12.54",
"562.10",
"272.4",
"441.01",
"427.31",
"568.81",
"585.9",
"403.90",
"443.9",
"E942.6",
"424.0",
"574.20",
"427.89"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4373, 4388
|
3690, 4243
|
286, 293
|
4653, 4691
|
1412, 3667
|
879, 931
|
4409, 4632
|
4269, 4350
|
946, 1393
|
236, 248
|
321, 564
|
586, 809
|
825, 863
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,084
| 110,031
|
698+699
|
Discharge summary
|
report+report
|
Admission Date: [**2182-9-16**] Discharge Date: [**2182-9-20**]
Date of Birth: [**2107-2-27**] Sex: M
Service:
NOTE - An addendum will be dictated when the patient is
discharged.
HISTORY OF PRESENT ILLNESS: The patient is a 75 year old
male with a past medical history significant for coronary
artery disease, diabetes and chronic renal insufficiency,
admitted to Coronary Care Unit following cardiac
catheterization for ventilatory support and Intensive Care
Unit monitoring. The patient originally presented to an
outside hospital the morning of admission complaining of
chest pain and symptoms of congestive heart failure. An
electrocardiogram showed a new left bundle branch block. He
was then transferred to [**Hospital6 256**]
for emergent cardiac catheterization. The patient went
immediately to the Catheterization Laboratory upon arrival.
Catheterization showed three vessel coronary artery disease,
patent graft, left internal mammary artery to the left
anterior descending, patent saphenous vein graft to the
posterior descending artery and patent saphenous vein graft
to obtuse marginal 1. It was significant for increased right
and left filling pressures. Angioplasty was then performed
on the aortoiliac bypass graft, left circumflex coronary
artery with failed angioplasty of obtuse marginal 1. The
patient developed significant respiratory distress following
catheterization and was ventilated for ventilatory support
with transfer to the Coronary Care Unit on a ventilator.
PAST MEDICAL HISTORY: Coronary artery disease status post
coronary artery bypass graft redo, three vessels in [**2159**],
four vessels in [**2170**], diabetes mellitus times 13 years,
chronic renal insufficiency with baseline creatinine 2.3,
prostate cancer diagnosed in [**2171**] refractory to hormone
therapy followed by Dr. [**Last Name (STitle) **], gout, depression, anemia,
congestive heart failure with unknown ejection fraction.
SOCIAL HISTORY: History of tobacco use, 30 pack years, quit
in [**2158**], occasional alcohol.
HOME MEDICATIONS:
1. Calcitriol .25 mcg q. day
2. Calcium acetate 657 mg t.i.d.
3. Docusate 100 mg b.i.d.
4. Epogen 10,000 units subcutaneous q. Thursday
5. Felodipine 5 mg q. day
6. Iron 325 mg t.i.d.
7. Fluoxetine 20 mg q. day
8. Glipizide 5 mg q. AM
9. Hydralazine 40 mg b.i.d.
10. Hydroxyzine 25 mg b.i.d.
11. Metoprolol 25 mg t.i.d.
12. Omeprazole 40 mg q. day
13. Senna two tablets b.i.d.
14. Simvastatin 20 mg q. day
15. Allopurinol 50 mg q. day
16. Isosorbide mononitrate 60 mg q. day
17. Lasix 60 mg b.i.d.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs, temperature
96, heartrate 60, blood pressure 179/57, oxygen saturation
100% on 30% FIO2, weight 108 kg. General: Elderly male in
no acute distress. Head, eyes, ears, nose and throat, pupils
equal, round and reactive to light and accommodation.
Oropharynx clear. Neck supple. No lymphadenopathy. Chest
clear to auscultation anteriorly, no wheezes. Heart, regular
rhythm, II/VI systolic murmur at the lower left sternal
border with no radiation. Abdomen, soft, nontender,
nondistended, positive bowel sounds. Extremities, 1+ edema.
Pulses dopplerable bilaterally. Venous stasis changes
bilaterally. Neurological, intubated, sedated. Moves
extremities times four.
LABORATORY DATA: White blood count 15.8, hematocrit 29.8,
platelets 228. Sodium 142, potassium 4.7, chloride 111,
bicarbonate 18, BUN 86, creatinine 5.0, glucose 138. Calcium
8.7, magnesium 1.7, phosphorus 4.6. Chest x-ray:
Cardiomegaly, mild congestive heart failure.
Electrocardiogram, sinus rate at 80, left bundle branch
without ST changes.
HOSPITAL COURSE: Cardiovascular - Ischemia, the patient with
a history of coronary artery disease, transferred from an
outside hospital for emergent cardiac catheterization
following new left bundle branch block at an outside
hospital. During catheterization, the patient underwent
percutaneous transluminal coronary angioplasty to the left
circumflex with serial percutaneous transluminal coronary
angioplasty of obtuse marginal 1. Following catheterization
he was maintained on a statin, Plavix, and Aspirin. He was
initially on a nitroglycerin drip which was then converted
over to p.o. He was also started on Hydralazine and titrated
up on a beta blocker. This was subsequently converted to
Carvedilol. The patient did not have any further episodes of
chest pain or ischemia during the hospitalization.
Pump, the patient with congestive heart failure Class 4. The
patient underwent echocardiogram following cardiac
catheterization which showed an ejection fraction of 30 to
40% and severe hypokinesis inferiorly and posteriorly along
with 1+ mitral regurgitation and impaired ventricular
relaxation. Immediately following catheterization the
patient was diuresed on a Natrecor drip. He was quickly
weaned off of this and titrated over to daily intravenous
Lasix. He was initially started on beta blocker and later
converted over to Carvedilol which he tolerated well. He was
also started on Hydralazine and put back on his
nitroglycerin. He continued to receive prn Lasix for
symptoms of fluid overload.
Rhythm, the patient remained in sinus rhythm and was
monitored on Telemetry throughout his hospital course.
Pulmonary - The patient was intubated following cardiac
catheterization for respiratory distress following minimal
diuresis with Natrecor drip. The patient was quickly weaned
off of the ventilator and successfully extubated without any
complications. He did not require any additional oxygen
requirements throughout the hospitalization and had no
symptoms of respiratory distress.
Infectious disease - The patient developed leukocytosis and
diarrhea during hospitalization and a stool sample was
positive for Clostridium difficile toxin. He was started on
Vancomycin therapy for treatment of Clostridium difficile
colitis. His symptoms of diarrhea improved following
initiation of antibiotic therapy.
Renal - The patient with chronic renal insufficiency with
baseline creatinine of 2.3. At admission, his creatinine was
acutely elevated up to 5.0, thought to be due to dye load
during catheterization. He was aggressively hydrated and his
creatinine trended down. He briefly bumped his creatinine
due to hypovolemia during his diarrhea but this resolved with
hydration. He was eventually put back on his daily Lasix
dose for maintenance.
Fluids, electrolytes and nutrition - The patient's volume
status and electrolytes were followed throughout admission.
He received multiple electrolyte repletions.
Heme - Anemia, the patient with baseline anemia believed due
to chronic renal insufficiency. He was continued on iron and
Epogen per his home regimen. He required transfusion of 2
units of packed red blood cells during the hospitalization.
His acute drop was thought to be following his
catheterization procedure. He responded appropriately to the
transfusions and remained hemodynamically stable.
Endocrine - Patient with diabetes mellitus. His Glipizide
was held initially and he was placed on sliding scale
insulin. Following resumption of the regular diet he was
converted back to home medicines.
Prophylaxis - The patient was maintained on subcutaneous
heparin and proton pump inhibitor throughout his
hospitalization.
Code status - The patient was a full code throughout the
hospitalization.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: Home.
DISCHARGE DIAGNOSIS:
1. Myocardial infarction with cardiac catheterization
2. Congestive heart failure
3. Acute and chronic renal failure
DISCHARGE MEDICATIONS/FOLLOW UP INSTRUCTIONS: Will be
dictated in an addendum to this discharge summary.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. [**MD Number(1) 5211**]
Dictated By:[**Last Name (NamePattern1) 5212**]
MEDQUIST36
D: [**2182-9-20**] 15:06
T: [**2182-9-20**] 16:22
JOB#: [**Job Number 5213**]
Admission Date: [**2182-9-16**] Discharge Date: [**2182-9-29**]
Date of Birth: [**2107-2-27**] Sex: M
Service: CCU
ADDENDUM: The current summary will cover hospital stay from
[**2182-9-20**] through [**2182-9-29**].
1. GASTROINTESTINAL BLEED: The patient developed
progressive throat and esophageal pain and had an episode of
hematemesis in which he vomited approximately 500 cc of
blood. GI was consulted. The patient had an EGD which
showed esophagitis consistent with likely ischemic changes.
The patient was intubated for the EGD and transferred to the
ICU for closer monitoring. He was started on a Pantoprazole
drip. Following several days of the drip, he was transferred
over to p.o. Pantoprazole and his diet was slowly advanced.
He did not have any further episodes of hematemesis and his
throat discomfort resolved.
2. RENAL FAILURE: The patient was admitted with baseline
chronic renal insufficiency and symptoms of uremia over the
previous three months. During the hospitalization, he had an
acute bump in his creatinine thought to be ATN from
catheterization dye load. Renal consulted and the patient
was started on dialysis on [**2182-9-24**]. He underwent
several hemodialysis sessions to remove excess fluid and then
was started on a regimen of hemodialysis three times each
week. The patient tolerated dialysis well.
3. ACUTE CORONARY SYNDROME: The patient had a non-ST
elevation MI on [**2182-9-21**]. Given his acute GI
bleed, he was not a candidate for anticoagulation and instead
was managed medically. He was established on a regimen of
Carvedilol, Captopril, hydralazine, and Isordil and was also
started on aspirin. The plan is to start the patient on
Plavix when he is further out from his GI bleed. His cardiac
medications were titrated up as tolerated throughout his
hospitalization.
4. INFECTIOUS DISEASE: The patient was treated for C.
difficile colitis with a ten day regimen of Flagyl. He also
developed an Enterococcus UTI and was successfully treated
with Levaquin.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: The patient was discharged to
rehabilitation.
DISCHARGE DIAGNOSIS:
1. Non-ST elevation myocardial infarction.
2. Cardiac catheterization.
3. Chronic renal insufficiency with acute renal failure
requiring hemodialysis.
4. Clostridium difficile colitis.
5. Urinary tract infection.
6. ischemic esophagitis.
DISCHARGE MEDICATIONS:
1. Docusate 100 mg b.i.d.
2. Fluoxetine 20 mg q.d.
3. Hydroxyzine 25 mg b.i.d.
4. Simvastatin 20 mg q.d.
5. Isosorbide dinitrate 20 mg t.i.d.
6. Aspirin 81 mg q.d.
7. Viscous lidocaine 2% 20 ml t.i.d. p.r.n.
8. Pantoprazole 40 mg p.o. q. 12 hours.
9. Calcium acetate 1,334 mg p.o. t.i.d. with meals.
10. Carvedilol 50 mg p.o. b.i.d.
11. Sliding scale insulin.
12. Lisinopril 20 mg p.o. q.d.
13. Metoclopramide 5 mg IV q. eight hours p.r.n.
14. Metronidazole 500 mg t.i.d. times one week.
FOLLOW-UP PLANS: The patient is to follow-up with primary
care doctor in one week. Follow-up with GI in two weeks for
repeat EGD.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5214**]
Dictated By:[**Last Name (NamePattern1) 5212**]
MEDQUIST36
D: [**2182-9-29**] 01:48
T: [**2182-9-29**] 14:20
JOB#: [**Job Number 5215**]
|
[
"414.02",
"416.0",
"584.9",
"008.45",
"414.01",
"585",
"599.0",
"428.0",
"410.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"88.42",
"99.20",
"00.13",
"88.56",
"37.23",
"45.13",
"39.95",
"36.01",
"99.15",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
10432, 10930
|
10164, 10409
|
3674, 7408
|
2075, 2604
|
10948, 11305
|
228, 1520
|
2619, 3656
|
1543, 1960
|
1977, 2057
|
10069, 10143
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,091
| 164,694
|
54418
|
Discharge summary
|
report
|
Admission Date: [**2101-6-7**] Discharge Date: [**2101-9-18**]
Date of Birth: [**2063-6-13**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7934**]
Chief Complaint:
Respiratory arrest
Major Surgical or Invasive Procedure:
Central Line Placement
Transjugular liver biopsy
History of Present Illness:
HPI - This is a 37 y/o male with relapsed AML, s/p unrelated
unmatched alloBMT day +59, course c/b VRE bacteremia ([**7-14**]),
aspergillus lung infection in [**2099**], GVHD, recent stay in [**Hospital Unit Name 153**]
for sepsis of unclear etiology (although grew pseudomonas and
enterococcus from pus from foley catheter) on long-standing
broad-spectrum abx, who was transferred to the ICU this
afternoon s/p code blue for respiratory arrest.
This afternoon, the patient was sitting in his chair and was
noted to become hypotensive from a lying to sitting position
(SBP drop to 70's) and suddenly unresponsive with hypoxia on 4L,
with sats of 80's on NRB. He was emergently intubated on the
floor and was started on Neo for a brief time when SBP's fell to
the 50's s/p intubation and sedation. By the time he arrived to
the ICU (approx 10 min later), his SBP had improved to the 90's
and he was weaned off the Neo gtt.
At the time of intubation, he was noted to have brown, copious
secretions at the back of his throat, requiring suctioning.
Past Medical History:
1)ONCOLOGY HX -
- presented in [**7-30**] w/ new R sided neck discomfort, swelling,
fevers
- WBC in ED showed 20 K, 74% atypicals
- BM bx (sternal aspirate) showed AML FAB M2
- recieved induction w/ idarubicin and cytarabine, then hiDAC x2
- repeat BM bx showed complete remission
- admitted [**2100-12-6**] for autoBMT, conditioned w/
busulfan/cytoxan
- thrombocytopenia in [**1-31**] -> BM negative in [**2-28**]
- relapsed AML in [**3-31**] (94% blasts on smear)
- treated w/ MEC (last day [**2101-4-22**])
- prolonged neutropenia -> never recovered his counts
- BM at day 16 empty, then showed relapse in [**5-31**]
- admitted on [**2101-6-7**] with sepsis (VRE bacteremia)
- disease progressed
- went for unmatched, unrelated mini-alloBMT on [**2101-7-14**]
(conditioned w/ TBI, pentastatin)
- post-transplant course complicated by grade IV GVHD of gut,
skin, liver
-[**7-30**]: new right sided neck discomfort with fevers, painful
swelling
-WBC in ED showed 20 K, 74% atypicals
-BM bx (strenal aspirate) FAB M2
-recieved idarubicin and cytarabine
- Repeat BM bx showed complete remission
2. Left thigh furuncle s/p surgical debridement was on
daptomycin, metronidazole, and cipro.
3. DM 1, insulin dependent, on lantus
4. VRE bacteremia
Social History:
He works in the real estate business and plans on going into
appraisals. He lives in [**Location 15427**] and is engaged. He has one
daughter from his prior marriage. He smoked 2 packs of
cigarettes per day prior to his diagnosis but is currently not
smoking. He does not drink alcohol.
Family History:
No known history of leukemias or other cancers within the
family. His father had heart disease and multiple sclerosis. His
mother has type 1 diabetes.
Physical Exam:
VS - T 95.7, BP 99/53, HR 76, RR 16, SaO2 97%/AC 900 x 16, FiO2
100%, PEEP 5
General: Obese male in respiratory distress, mentating enough to
say "help me".
HEENT: Sclera + significant icterus, tears are icteric. Pupils
small, but equal and reative bilaterally. OP clear, MM dry. ETT
in place.
Neck: Could not appreciate any JVD. No LAD.
CV: RRR, nl S1, S2, no m/r/g.
Pulm: dullness at bases b/l, with few anterior wheezes.
Abd: soft, obese, NT/ND. few BS.
Extrem: + anasarca. 2+ radial pulses, but weakly palpable DP
pulses bilaterally.
Neuro: moves all four extremities, sedated but opens voice to
tactile stimuli.
Pertinent Results:
Microbiology:
[**9-7**] - CMV negative
[**9-1**] - blood cx negative
[**8-31**] - urine cx negative
[**8-31**] - blood cx negative
[**8-29**] - blood cx negative
[**8-28**] - foley cath pus enterococcus/pseudomonas
GRAM STAIN (Final [**2101-8-28**]): 2+ PMNs, 4+ GNRs, 1+ GPC pairs.
[**8-22**] - CMV VL negative
[**8-18**] - HCV VL negative
[**8-18**] - HBV VL <60
[**8-16**] - duodenal tissue cx (prelim) negative for CMV
[**8-16**] - cath tip cx negative
[**8-15**] - CMV VL negative
[**8-8**] - CMV VL negative
[**8-6**] - C diff cx negative
[**8-4**] - C diff cx negative
[**8-4**] - stool viral cx negative
Relevant Imaging:
[**2101-7-27**] RUQ US: This study is somewhat limited by patient body
habitus. The liver demonstrates diffuse increase in
echogenicity consistent with fatty infiltration. No focal
hepatic lesions are identified. There is no intra- or
extra-hepatic biliary ductal dilatation. The common duct
measures 6 mm. The gallbladder contains shadowing stones and
sludge, but
there is no evidence of wall thickening, or pericholecystic
fluid. There is no ascites. Limited views of the right kidney
demonstrate no hydronephrosis. There is appropriate hepatopetal
portal vein blood flow.
[**2101-8-4**] Colonoscopy: scattered areas of ereythema throughout the
colon
[**2101-8-7**] CT Abdomen/pelvis: Diffuse wall thickening and luminal
narrowing of the entire large and small bowel, with segments of
small bowel demonstrating an intramural low attenuation rim;
these findings are suggestive of graft versus host disease given
the history of allogenic [**Month/Day/Year 3242**]. Other differential considerations
include other microvasculopathies and/or hypovolemic state. No
free intraperitoneal air.
Distended stomach with no contrast seen to pass past the antrum;
a delayed KUB could be obtained to ensure passage of barium and
exclude gastroparesis or obstruction.
Ground glass and tree-in-[**Male First Name (un) 239**] opacities involving the right
middle lobe and left lower lobes. Small bilateral pleural
effusions. Small pericardial effusion. 4-mm focal nodule at the
left lung base with a ground glass halo. Findings are
nonspecific, but most suggestive of an infectious process.
Cholelithiasis.
[**2101-8-16**] EGD: Erythema and nodularity in the whole duodenum
compatible with duodenitis (biopsy) Biopsies were taken from the
duodenum for viral culture and histology Otherwise normal EGD to
second part of the duodenum
[**2101-8-26**]: Duplex doppler US liver: Moderately distended
gallbladder with sludge and stones, but gallbladder wall
thickening not as prominent on today's study. Cholecystitis is
not currently suspected, but if clinical suspicion persists or
increases, repeat ultrasound and/or HIDA scan can be performed.
Diminished flow within proximal left portal vein, with flow
distally.
[**2101-8-29**] CT abdomen: Diffuse ill-defined patchy pulmonary
opacities are diffuse infection versus asymmetric pulmonary
edema. There are enlarging and moderate bilateral pleural
effusions. New small fluid in the abdomen and pelvis secondary
to third spacing. Evaluation of the bowel is limited given lack
of IV contrast, but bowel wall thickening is again seen
suggestive of graft versus host disease.
[**9-12**] CXR - pulmonary edema, improved from CXR on [**2101-8-30**]
Brief Hospital Course:
A/P: Patient is a 38yo male w/ DM, relapsed AML neutropenic,
with acute respiratory failure
1. Respiratory distress/arrest: Pt emergently intubated on the
floor due to acute respiratory failure. Etiology for respiratory
arrest on admission continues to remain unclear, possible acute
worsening of pleural effusions secondary to GVHD versus
infection. Additionally mucous plugging versus aspiration
pneumonia should also be considered. Pt does have pleural
effusions on cxray but after [**Date Range 3242**] at this time is recommending
not to tap. Pt underwent bronchoscopy and continues to be
unrevealing for etiology, BAL cultures are NGTD. PCP and
legionella negative. He was continued on IV Methylprednisolone.
Pt was continued on broad spectrum antibiotics-Daptomycin,
Meropenem, Micofungin, and Vancomycin. The antibiotics were
slowly peeled off as the family progressed to comfort measures
only.
2. Hypotension: This was intermittent, occurring prior to
respiratory arrest and after intubation. Likely [**1-27**] aspiration
prior to arrest and [**1-27**] sedation. No clear infectious source
identified. Continued on broad spectrum antibiotics but were
d/c'ed as family came to decision to withdraw care. He was
intermittenly treated with Albumin, fluids, and Lasix since the
housestaff team was unsure about his volume status, despite him
being extremely edematous on exam.
3. Altered Mental Status: The patient did not wake from
sedation, despite being off off all sedation. The morning prior
to his death, pt went into vfib arrest, likely hypoxic for
approximately 10 minutes resulting in anoxic brain [**Month/Day (2) **].
4. Hyperbilirubinemia: The most likely cause of this conjugated
hyperbilirubinemia is acute hepatic GVHD. Pt underwent a
transjugular liver biopsy, as per hepatology, but there was not
enough tissue sample to analyze. He also likely has a component
of hemolysis giving rise to indirect bilirubinemia [**1-27**]
mismatched allo. He was continued on Cyclosporing during his
stay, with close monitoring of the drug levels.
5. AML - Given mismatched alloBMT, has low grade hemolysis
contributing to his hyperbilirubinemia. He remained anemic and
thrombocytopenic during his stay in the [**Hospital Unit Name 153**] requiring multiple
RBC and platelet transfusions. [**Hospital Unit Name 3242**] followed him closely. He was
continued on empiric antibiotic therapy, Cyclosporine, and IV
steroids. The cyclosporine levels were followed closely.
6. GVHD: Likely affecting both the gut and liver - ongoing, with
intermittent GI bleed. He was continued on Cyclosporine, IV PPI
and sucralfate for his GI regimen.
7. Anemia/Thrombocytopenia: Likely [**1-27**] mismatched alloBMT, ACD,
and ongoing GIB. He required multiple RBC and platelet
transfusions.
8. DM: Continued on insulin in TPN along with ISS. .
9. F/E/N - TPN, NPO. Replete lytes prn.
10. Ppx - PPI, pneumoboots, bowel regimen, HOB at 30 degrees
11. Access - Right IJ Quad, R arterial radial line.
12. Communication - with pt, pt's girlfriend/HCP [**Name (NI) 1356**]
([**Telephone/Fax (1) 111400**])
Pt passed away on [**2101-9-18**] from respiratory failure after the
family decided to change code status to CMO. Full autopsy was
done.
Medications on Admission:
Tacrolimus suspension 2mg PO BID
Quetiapine 25mg PO QHS
Caphasol 30mL MM QID
Sucalfate 1gm PO QID
Nifedipine 10mg PO Q8
RISS + 15u Lantus QHS
Ambisome 500mg IV Q24
Metoprolol 25mg PO BID
Mycophenolate 750mg IV QAM (7), 500mg Qnoon (15), 750mg PO QPM
(23)
Fentanyl patch 75mcg TP Q72
Ursodiol 300mg PO QAM, 600mg PO QPM
Dental gel 1 app TP [**Hospital1 **]
Clotrimazole 1 troc PO QID
Mg, KPhos, Ca, KCl sliding scales
Methylprednisolone 50mg IV Q12
Cyclosporine cont infusion 180mg IV QD
Ciprofloxacin 250mg IV Q12 (started [**8-28**])
Daptomycin 450mg IV Q24 (started [**8-29**])
Lasix 40mg IV x1 on [**2101-8-28**]
Discharge Medications:
Pt died on [**2101-9-18**]
Discharge Disposition:
Home
Discharge Diagnosis:
Respiratory failure
Hepatic failure
AML
Discharge Condition:
Pt died on [**2101-9-18**]
Discharge Instructions:
Pt died on [**2101-9-18**]
Followup Instructions:
Pt died on [**2101-9-18**]
|
[
"V09.80",
"250.00",
"578.9",
"695.89",
"288.0",
"518.81",
"573.8",
"293.0",
"428.0",
"117.3",
"205.00",
"682.6",
"996.85",
"079.89",
"486",
"599.7",
"V58.67",
"584.9",
"790.7",
"728.89",
"401.9",
"427.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"92.29",
"41.05",
"99.15",
"88.47",
"41.31",
"38.93",
"00.92",
"45.16",
"45.25",
"33.24",
"50.11",
"99.05",
"48.24",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
11151, 11157
|
7196, 8592
|
335, 385
|
11241, 11269
|
3855, 4468
|
11344, 11373
|
3049, 3202
|
11100, 11128
|
11178, 11220
|
10460, 11077
|
11293, 11321
|
3217, 3836
|
275, 297
|
4486, 7173
|
413, 1459
|
8607, 10434
|
1481, 2728
|
2744, 3033
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,241
| 145,151
|
31984
|
Discharge summary
|
report
|
Admission Date: [**2194-10-16**] Discharge Date: [**2194-10-19**]
Date of Birth: [**2126-4-11**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization with stent placement
History of Present Illness:
This patient is a 68 year old male patient with a history of
HTN, TIAs and carotid stenosis who presents after developing
sudden onset of at 230pm today while he was the passenger in a
car. He was at rest, not exerting himself. He developed
shortness of breath and nausea, and the pain spread down left
arm with some numbness in his fingers. The pain lasted several
hours. EMS was called and he was taken to the [**Hospital1 46**] ER where he
was found to have 2mm ST elevation 2, 3, AVF and left bundle
branch block.
.
He was transferred to [**Hospital1 18**] cath lab for emergent cath with BMS
to the RCA. He has transient bradycardia following line wire
placement. On admission to CCU he was without chest pain, SOB,
palpatations.
.
At baseline, patient denies ever having chest pain in the past,
denies palpatations, shortness of breath, is able to climb
stairs and exert himself without shortness of breath.
.
ROS: patient has hx of multiple TIAs with no residual losses.
denies hx of stroke DVT, PE, cough, bloody [**Last Name (un) 74934**]. Patient
comlains of numbness in fingers occassionally, both left and
right.
Past Medical History:
HTN: patient treated, but med dc/ed due to frequent episodes of
Hypotension
Nephrolithiasis, s/p lithotripsy
Hernia repair in the 60s
Carotid stenosis, unknown degree
Recurrent TIAs, initially on Aspirin, recurrent, then started on
Coumadin; last in [**Month (only) 547**] this year; no residual neurological
deficit
Social History:
- 40 pack years tobacco use. 1ppd x 40 years. quit last week.
- admits to binge drinking occasionally (?1/week), and 1-2 beers
every night, has never had seizures.
- at baseline ambulatory, able to ambulate 2 flights of stairs
without problems, independent in ADLs
Family History:
- Father died of "cancer" in his 80s, Mother with heart
problems, died at age 70, first MI in 60s, no h/o sudden death
Physical Exam:
VS: T 97.0, BP 114/66, HR 76, RR 14, O2 97 % on 4L
Gen: middle aged male in NAD. Oriented x3.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, MM dry. adentulous
Neck: Supple with non elevated JVP. No bruits auscultated
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3.
Chest: unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi. Some coarse sounds at base.
Abd: Obese, NTND, No HSM or tenderness. No abdominial bruits.
Ext: No c/c/e. No femoral bruits bl. Groin with 4inch hematoma.
Left arm swollen from shoulder to wrist. small demarcated area
of erythema on antecubital fossa at site of previous IV. pulses
palpable, warm.
pulses
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Pertinent Results:
.
ECHO: [**10-17**]
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. There is mild regional
left ventricular systolic dysfunction with basal
inferior/inferolateral akinesis (probable distribution of the
RCA). The remaining segments contract normally (LVEF = 45%).
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The pulmonary
artery systolic pressure could not be determined. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Suboptimal image quality. Mild regional left
ventricular systolic dysfunction, c/w CAD. No
clinically-significant valvular disease.
.
[**10-17**]
Carotid ECHO
IMPRESSION:
1. No significant ICA stenosis bilaterally (graded as less than
40% bilaterally).
2. Indirect findings suggesting an element of right vertebral
artery stenosis proximal to the area of interrogation.
.
[**2194-10-16**]
UE doppler
IMPRESSION: No evidence of deep venous thrombosis.
.
[**2194-10-16**] 07:01PM CK(CPK)-879*
[**2194-10-16**] 07:01PM CK-MB-146* MB INDX-16.6* cTropnT-1.94*
Brief Hospital Course:
68 yo man with inferior STEMI, hemodynamically stable.
.
STEMI/CAD: pt with ST elevations in II, III, AVF and positive
cardiac enzymes. chest pain resolved. Patient taken directly to
cath from OSH and recieved BMS to RCA. He was on Integrillin for
18hours post cath. On Nitro gtt, which was titrated off quickly
post cath. PAtient was started on Plavix 75 daily, ASA 325,
simvastatin 80, Lisinpril 2.5 daily, atenolol 25 daily. No
recurrence of CP after cath. Will follow up with Cardiolgist at
[**Hospital3 **].
.
Bradycardia: while in cath lab, normal HR since. RCA lesion,
distal to artery to AV node. Pt normotensive since, tolerating
BBlocker and ACE.
.
LE arm swelling: left arm larger than right, no pain, warm. has
history of numbness in b/l fingers. LE ultrasound shows noC|DVT
.
Hx of TIA: No residual deficits. no carotid stenosis. Patient
now on plavix and aspirin, so no need for coumadin in addition
to this.
Medications on Admission:
Home meds:
Coumadin 2.5/5 every other day
ASA
.
Transfer MEDICATIONS:
plavix 300 mg Bolus
Plavix 75 mg PO daily
s/p Heparin bolus 1555
heparin gtt at 1000/hr (turned off prior to cath)
zofran 8mg at
morphine 4mg
asa 325mg in ER
integrillin being started by [**Location (un) **]
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*0*
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
STEMI
Secondary
Hypertension
Discharge Condition:
Stable, chest pain free
Discharge Instructions:
1. You were admitted from an outside hospital with a myocardial
infarction, or a "heart attack." You were taken emergently to
the catheterization lab and it was found that one of your
coronary arteries was blocked. You had a stent placed to this
coronary artery. You also had a carotid ultrasound to evaluate
the arteries that supply your brain. It was found that your
carotid arteries are patent and without evidence of occlusion.
.
2. The following medication changes were made during your
hospital stay:
a) Coumadin was discontinued as you are now on plavix and
aspirin which serve as blood thinners to decrease your risk of
stroke.
b) Plavix and high dose aspirin were started. It is imperative
that you take both of these medications to minimize the risk of
your stent occluding.
c) You were also started on simvastatin, lisinopril and atenolol
for your heart.
.
If you have any of the following symptoms, you should return to
the ED or see your PCP:
[**Name10 (NameIs) **] pain, difficulty breathing, palpitations, or any other
serious concerns.
Followup Instructions:
You will receive a phone call from your PCP's office for an
appointment. You should schedule your appointment and see your
PCP [**Last Name (NamePattern4) **] 5 to 7 days. PCP: [**Name10 (NameIs) 39360**], [**Name11 (NameIs) **] [**Telephone/Fax (1) 36604**].
.
It it important that you obtain a referral to a cardiologist
from your PCP. [**Name10 (NameIs) **] should follow up with a cardiologist in the
next 2 to 3 weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
Completed by:[**2194-10-19**]
|
[
"414.01",
"416.8",
"V58.61",
"443.0",
"401.9",
"V12.54",
"410.41",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.06",
"88.56",
"00.66",
"00.40",
"37.23",
"99.20",
"00.45"
] |
icd9pcs
|
[
[
[]
]
] |
6511, 6517
|
4488, 5414
|
328, 375
|
6598, 6624
|
3163, 4465
|
7729, 8317
|
2167, 2287
|
5743, 6488
|
6538, 6577
|
5440, 5488
|
6648, 7706
|
2302, 3144
|
278, 290
|
5510, 5720
|
403, 1529
|
1551, 1869
|
1885, 2151
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,478
| 199,963
|
21915
|
Discharge summary
|
report
|
Admission Date: [**2101-8-23**] Discharge Date: [**2101-9-8**]
Date of Birth: [**2031-3-6**] Sex: M
Service: CSURG
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
70 year old white male with a history of CAD with increasing
episodes of chest tightness.
Major Surgical or Invasive Procedure:
CABGx3 (LIMA->LAD, SVG->PDA, SVG->ramus) [**2101-8-29**]
History of Present Illness:
This 70 year old white male has a history of CAD and had been
cathed in [**2096**]. He needed intervention at that time, but was
waiting for the drug eluting stents. He has been followed by
Dr. [**Last Name (STitle) 11493**] who felt he needed a new cath as he was having
increasing chest tightness. He was admitted for the cooling
study. He reportedly was turned down for a CABG in [**2096**] because
of obesity.
Past Medical History:
CAD
NIDDM
HTN
Hypercholesteremia
CRI
CHF
Anemia
s/p pacemaker placement for SSS
Retinopathy- s/p laser [**Doctor First Name **] x 3
Chronic LE edema
Social History:
He lives alone, does not smoke cigarettes, and does not drink
alcohol.
Family History:
+CAD
Physical Exam:
Gen: Obese, elderly, white male in NAD
Afeb, HR 60, BP 114/68, RR 10, 280 lbs.
HEENT: N/C, A/T, EOMI, PERLA, oropharynx benign.
Neck: Supple, FROM, no lymphadenopathy or thyromegaly, carotids
2+=bilat.
Lungs: Clear to A+P
CV: RRR w/out R/G/M
Abd: obese, soft, nontender, without masses or
hepatosplenomegaly.
Ext: Bilat. LE edema with venouse stasis changes. Pulses 1+ =
bilat.
Neuro: non-focal.
Pertinent Results:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2101-9-8**] 07:05AM 9.8 3.58* 11.3* 33.7* 94 31.6 33.5 15.1
309
BASIC COAGULATION Plt Ct
[**2101-9-8**] 07:05AM 309
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2101-9-8**] 07:05AM 113* 101* 3.2* 137 4.7 95* 27 20
ANTIBIOTICS Vanco
[**2101-9-8**] 07:05AM 16.1*
Brief Hospital Course:
The patient was admitted on [**2101-8-23**] and was enrolled in the
cooling study for renal protection during cardiac cath. He had
an MI by enzymes on admission. He had the catheterization on
[**8-25**] and it revealed: a 50-60% stenosis of the LAD, 90% diagonal
lesion, 80% proximal LCX stenosis, and a 90% RCA lesion. His EF
is 20%. During the cath. he became hypotensive and bradycardic
and required atropine and dopamine. He had an IABP placed and
cardiac surgery was consulted for high risk CABG. He then
developed ologuric renal failure and responded to high doses of
lasix.
On [**2101-8-29**] he underwent CABGx3 with LIMA to the LAD, SVG to the
PDA and ramus. He was transferred to the CSRU on Epi, Lido, and
Propofol in stable condition. He had some bleeding on the post
op night and required 3U PRBC, 2 of platelets, and 1 of cryo.
He had decreased urine output and was started on a lasix drip
and natracor. He continued to require these drips for several
days and remained intubated until POD#3. His creat. was between
3.2 and 4, but he continued to have adequate urine output. His
IABP was d/c'd on POD#1. He slowly improved and was transferred
to the floor on POD#7. He developed cellulitis on his L leg and
has been treated with vanco. He continued to progress and was
discharged to rehab on POD# 10.
Medications on Admission:
Glipizide 10 mg. PO qd
Hydralazine 10 mg. PO qd
Coreg 6.25 mg. PO qd
FeSO4 325 mg. PO qd
MVI 1 PO qd
NTG patch
Lasix 80 mg. PO qd
ASA 81 mg. PO qd
Plavix 75 mg PO qd
Colace 100 mg. PO BID
Zocor 20 mg. PO qd
Discharge Medications:
1. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day) for 5 days: Then decrease to Amiodorone 400 mg PO
qd for 1 week, then decrease to 200 mg PO qd.
2. Glipizide 5 mg Tablet Sig: Two (2) Tablet PO QD (once a day).
3. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QD (once a day).
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
8. Lasix 40 mg Tablet Sig: 1.5 Tablets PO three times a day.
9. Vancomycin HCl 10 g Recon Soln Sig: One (1) gram Intravenous
PRN (as needed) as needed for level <15 for 2 weeks.
10. Zocor 20 mg Tablet Sig: One (1) Tablet PO once a day.
11. Ferrous Sulfate 325 (65) mg Capsule, Sustained Release Sig:
One (1) Capsule, Sustained Release PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 25759**] & Rehab Center - [**Location (un) **]
Discharge Diagnosis:
Coronary artery disease.
NIDDM
CHF
HTN
Hypercholesterolemia
CRI
Retinopathy
SSS-s/p pacer placement
Discharge Condition:
Good.
Discharge Instructions:
Follow medications on discharge instructions.
You may not drive for 4 weeks.
You may not lift more than 10 lbs. for 3 months.
You should shower, let water flow over wounds, pat dry with a
towel.
Followup Instructions:
Make an appointment with Dr. [**Last Name (STitle) 11493**] for 1-2 weeks.
Make an appointment with Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] 1 week.
Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks.
Completed by:[**2101-9-8**]
|
[
"682.6",
"584.9",
"V45.01",
"E878.2",
"998.11",
"424.0",
"272.0",
"428.0",
"V70.7",
"998.59",
"250.00",
"285.9",
"414.01",
"401.9",
"410.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.52",
"39.95",
"88.56",
"99.05",
"00.13",
"36.15",
"37.23",
"99.04",
"37.61",
"39.61",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
4664, 4750
|
1981, 3305
|
357, 416
|
4894, 4901
|
1575, 1958
|
5144, 5406
|
1138, 1144
|
3562, 4641
|
4771, 4873
|
3331, 3539
|
4925, 5121
|
1159, 1556
|
228, 319
|
444, 861
|
883, 1034
|
1050, 1122
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,336
| 100,849
|
15362
|
Discharge summary
|
report
|
Admission Date: [**2151-1-10**] Discharge Date: [**2151-1-19**]
Date of Birth: [**2082-4-16**] Sex: F
Service: MEDICINE
Allergies:
Demerol / Percocet / Sulfamethoxazole / Thorazine / Codeine /
Loperamide / macrolides
Attending:[**First Name3 (LF) 4891**]
Chief Complaint:
Ureteral stone
Major Surgical or Invasive Procedure:
Interventional radiology placed right percutaneous nephrostomy
tube
History of Present Illness:
Ms. [**Known lastname **] is a 68 year old female with PMH HTN,
Hyperlipidemia, CAD, is transferred from [**Hospital 8125**] [**Hospital 6136**]
Hospital for hypotension and sepsis after presenting with
nausea/vomiting and flank pain and found to have a large right
uretral stone.
.
According to the patient, she was experiencing nausea/vomiting
with bilateral flank pain and "tightness" radiating to the groin
(she is unable to assign another quality to the pain). The pain
was constant and became progressively worse over 2 days, she
developed confusion on the day of admission. She presented to
[**Hospital 8125**] hospital where she was hypotensive to SBP 80-90 and
tachycardic to 120, she was given 3L IVNS and started on
peripheral phenylephrine. Initial labs were remarkable for WBC
60 with 40% bands, Creatinine 3.3 (baseline unknown though last
in [**Hospital1 18**] records is 0.5 in [**2141**]), AST 70, ALT 50, INR 1.3,
Lactate 4.5. She had a CT head which was negative for acute
hemorragic stroke, CT abdomen/pelvis revealed bilateral
nephrolithiasis with a 5mm stone located in the right ureter
without evidence of hydronephrosis. She was given Zosyn 3.73g
IV, Vanco 1gm IV, Magnesium 1gm, Zofran 4mg IV and Morphine 4mg
IV. Given hypotension and sepsis, she was transported by
[**Location (un) **] to [**Hospital1 18**] for further workup.
.
Patient was received in the ED on phenylephrine with initial
vitals
HR 120, BP 123/67 RR 28, 98% on NRB, 89% on RA. A right IJ CVL
was placed with initial CVP 7-10. She was given another 3L IVNS
(total 6L IVNS including those given at OSH), and phenylephrine
was weaned with SBP 110/50. Labs were remarkable for WBC 43.1,
94% PMN, Plt 132, BUN/Cr 37/3.0, K 3.0, HCO3 20, with AG 15, mg
1.5, Lactate 2.4, TropT: 0.09, CK 119, UA was grossly positive
with 140 WBCs and 20 RBC. She again became hypotensive to 98/56,
CVP 15mmHg, Phenylephrine was resumed. O2 saturation remained
mid 90's on NRB, attempts to wean were unsuccessful. Urology was
consulted who recommended clinical stabilization prior to
intervention and admission to the [**Hospital Ward Name **]. She was given
magnesium 2g prior to transfer.
.
On arrival to the ICU, she reports chest "tightness" that she
feels when she needs to use her pumps for asthma, stating that
the pain is different from her anginal equivalent which is back
pain. She reports that the abdominal/flank pain was alleviated
by morphine at [**Hospital 8125**] hospital and has not returned.
Past Medical History:
Past Medical History:
- Myocardial infarction [**2137**] at [**Hospital1 2025**], by report no intervention
performed
- Stroke [**2137**] no residual
- Breast CA s/p BL lumpectomy, no chemo/radiation
- Hyperlipidemia
- Hypertension
- Degenerative joint disease
- Asthma
PAST SURGICAL HISTORY:
- Appendectomy
- TAH BSO
- Cervical spine fusion
- Lumpectomy
Social History:
Lives with husband in [**Name (NI) **], daughter [**Name (NI) 717**] is nearby and
involved in her care.
- Tobacco: Never smoker
- Alcohol: Denies
- Illicits: Denies
Family History:
Mother: breast cancer in 60's
Grandmother: Breast cancer in 60's
Father: Coronary artery disease first MI at age 51
Physical Exam:
Admission Physical Exam:
Vitals: T: BP:97/55 P:114 R:24 O2: 93% 50% face tent
General: Eyes closed, opens to command, wearing NRB mask. Alert,
oriented to person, city:[**Location (un) **].
HEENT: Sclera anicteric, mucous membs dry, false upper/lower
teeth
Neck: Right IJ in place, left EJ, no lymphadenopathy. Unable to
assess JVP.
Lungs: Clear anteriorly, left sided inspiratory rales, decreased
breath sounds at the base on the right
Back: TTP at LEFT costal margion, no TTP at RIGHT costal
margion.
CV: Tachycardic, regular rate, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Well healed surgical scar midline and in RLQ, soft,
non-tender, non-distended, bowel sounds present, mild TTP on LLQ
with no rebound tenderness
GU: Foley in place
Ext: Warm, well perfused, no peripheral edema.
Discharge Physical Exam:
VS: Tc 98.5, Tm 98.9, BP 108-143/54-71, HR 76-93, RR 18, O2 sat
96% RA
GEN: well-appearing woman in no acute distress, comfortable
HEENT: PERRL, EOMI, sclerae anicteric
NECK: supple, no LAD, no JVD
PULM: fine bibasilar crackles, no wheezes
CARD: RRR, nl s1 and s2, no murmurs
ABD: +BS, well-healed surgical scar midline and in RLQ, soft,
non-tender, non-distended, no hepatosplenomegaly
EXT: warm, well-perfused, no edema
NEURO: AOx3, CN II-XII grossly intact, moving all extremities
Pertinent Results:
[**Hospital1 18**] [**2151-1-10**]
144 109 37 AGap=18
------------< 97
3.0 20 3.0
43.1 >10.6/30.8< 132
Trop-T: 0.09
Microbiology:
Blood culture ([**2151-1-10**]) x 2- no growth to date, pending
Urine culture ([**2151-1-10**])-
GRAM STAIN - UNSPUN (Final [**2151-1-11**]):
GRAM STAIN PERFORMED ON UNSPUN SPECIMEN.
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
URINE CULTURE (Final [**2151-1-13**]):
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
____________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
IMAGING:
CT Head [**Hospital 8125**] hospital [**2151-1-10**]- Negative head CT
CT Abdomen/pelvis [**Hospital 8125**] hospital [**2151-1-10**]
1. Bilateral nephrolithiasis 7mm calculus in the proximal right
ureter with no significant
2. Colonic diverticulosis without diverticulitis
3. bilateral lower lung consolidation which is non-specific
4. fat deposition in the liver
EKG: Sinus tachycardia at 120 bpm, normal axis, no pathologic Q
waves, and 1mm STD in v3-v6, compared with tracing [**2142-1-4**]
tachycardia and STD are new (Medicine PGY2 read).
Portable Chest Xray [**2151-1-10**]
IMPRESSION: Right IJ central venous catheter tip in a low
position.
Retraction by at least 6 cm is advised for more appropriate
positioning.
Persistent mild vascular congestion and bibasilar atelectasis.
Portable Chest Xray [**2151-1-10**]
Right internal jugular line has been pulled back to the distal
SVC. Mild
edema still present in both lungs along with mild cardiomegaly
and mediastinal vascular engorgement. More discrete
consolidation in the right lower lung, where there is also a
clear atelectasis, and in the infrahilar left lower lobe could
be due to concurrent pneumonia.
TTE [**2151-1-11**]
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. Left ventricular wall thickness, cavity
size, and global systolic function are normal (LVEF>55%). Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. There is no ventricular septal defect.
Right ventricular chamber size and free wall motion are normal.
The ascending aorta is mildly dilated. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. 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 mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
Portable Chest Xray [**2151-1-11**]:
Right internal jugular line tip is currently low, at the level
of the right
atrium and should be pulled back approximately 2.3 cm. There is
interval
placement of the right nephrostomy, partially imaged. Pulmonary
edema is
still present, although minimally improved since the prior
study. Right
middle lobe atelectasis and left retrocardiac density with air
bronchogram
persist, highly worrisome for pneumonia.
Portable Chest Xray [**2151-1-12**]:
There is no change in the position of the right internal jugular
line but
there is interval progression of pulmonary edema. Bibasilar in
particular
left lower lobe consolidations are unchanged.
Portable Chest Xray [**2151-1-12**]:
Right supraclavicular central venous line has been withdrawn to
the level of the superior cavoatrial junction. No mediastinal
widening. A heterogeneous opacification predominantly in the
perihilar left lung and right lung base and in the infrahilar
left lower lobe has improved, probably representing asymmetric
edema in most locations and atelectasis in the left lower lobe,
which is relatively unchanged. Small left pleural effusion is
presumed. Heart size is normal. No pneumothorax.
Discharge labs:
[**2151-1-19**] 07:35AM BLOOD WBC-8.8 RBC-3.93* Hgb-11.5* Hct-34.1*
MCV-87 MCH-29.2 MCHC-33.6 RDW-14.2 Plt Ct-436
[**2151-1-19**] 07:35AM BLOOD Glucose-98 UreaN-8 Creat-0.9 Na-137 K-4.0
Cl-100 HCO3-30 AnGap-11
Brief Hospital Course:
Primary Reason for Hospitalizaiton:
68F with PMH of HTN, HL, [**Hospital **] transferred from OSH for
hypotension and sepsis, and found to have large R ureteral
stone, diagnosed with urosepsis.
Active Diagnoses:
# Urosepsis: Patient was found to have large 5.3mm stone in
right proximal ureter, now s/p right-sided nephrostomy tube
placement by IR. Blood cultures were obtained in ICU, all NGTD.
Urine cx grew pan-sensitive e. coli. She was originally on
vanc/zosyn, but was narrowed to cipro after urine culture came
back. Pain was initially controlled wit oxycodone, then with
tylenol prn; zofran prn nausea. Continue cipro for until stone
is retreived. At discharge, patient was scheduled for an
appointment with Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] retrieve stone in OR on [**1-27**]. Per
IR, patient can be discharged with nephrostomy care manual, Dr. [**Name (NI) 44614**] office will schedule f/u with IR to remove tube after
stone is removed in surgery.
# Acute Kidney Injury: Baseline creatinine unknown however last
measurement in [**2141**] at [**Hospital1 18**] was 0.5. On presentation to the
ICU, patient's Cr was 3.0, but trended down to 0.7, which is
near baseline, at the time of discharge. Lisinopril was held in
the ICU but restarted on the floor when Cr normalized. Most
likely cause of [**Last Name (un) **] is ATN from hypotension/sepsis. Patient was
informed at discharge not to take Ibuprofen due to [**Last Name (un) **].
# Hypoxia: Patient was extremely hypoxic on admission to the ICU
requiring face mask ventilation. Patient was never intubated.
Hypoxia was thought to be secondary to pulmonary edema in the
setting of aggressive volume resuscitation. BNP was 9568 on
admission, suggesting heart failure, but TTE in ICU showed
normal EF>55% and essentially normal cardiac function, despite
MI in [**2137**] s/p CABG. Thus, BNP elevation most likely secondary
to hypervolemia and myocardial stretch. Patient was still
requiring 2L NC on transfer to the floor and still has crackles
in bilateral lower lung fields. She was diuresed with IV lasix
and was breathing well on room air at the time of discharge.
# Coronary Artery Disease: Patient with reported history of
myocardial infarction in [**2137**] with cardiac cath at [**Hospital1 2025**] and no
stents placed. EKG remarkable for STD in pre-cordial leads which
is likely rate-related. Troponin 0.09 in the setting of Cr 3.0
on admission. Repeat CK-MB and trops have remained flat, so
likely a result of demand ischemia from sepsis. Although
troponin continued to rise very slowly in the days after she was
sent to the floor, CK-MB remained flat, thus low suspicion for
ACS. Patient denied chest pain throughout admission.
# Hypertension: Patient was hypotensive in the ICU, was fluid
resuscitated and on pressors. Blood pressure normalized and was
transferred to the floor. Patient was reinitiated on diltiazem
in ICU and blood pressure remained in the 130s on transfer to
the floor. She was later also started on lisinopril when her
renal function normalized. On the day of discharge, SBP ran low
into mid-80s, likely from high dose of antihypertensives in the
setting of recent sepsis and weight loss. She was not
orthostatic, but bolused 250cc fluids. Upon discharge, her SBP
was 100s-110s and she felt fine walking with walker, no
lightheadedness. Patient will f/u with PCP/NP a few days after
discharge to ensure she is still on the right BP regimen.
Chronic Diagnoses:
# Asthma: No wheezes on exam throughout admission. Patient was
maintained on nebs prn and Zafirlukast 20 mg Daily (home
medication).
#Neuropathy: Patient reports history of bilateral lower ext
neuropathy, not diabetes related, for which she takes Neurontin
at home. Neurontinw as initially held due to renal dysfunction,
but restarted when Cr normalized.
Transitional Issues:
# Patient discharged with nephrostomy tube worksheet and receive
nephrostomy care assistance from visiting nurse.
# Patient will continue Ciprofloxacin until she gets her stone
retreived.
# Patient has OR appointment with Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] [**1-27**] for stone
retrieval.
# Patient will follow up with PCP regarding BP management and if
she needs further diuresis.
# Dr.[**Name (NI) 10529**] secretary will help patient schedule IR appointment
to remove nephrostomy tube. Patient provided with IR phone
number in case she has questions.
# Communication: Patient, daughter [**Name (NI) 717**] [**Telephone/Fax (2) 44615**]c,
[**Telephone/Fax (2) 44616**]h
# Code: Full code (confirmed with pt [**2151-1-13**])
Medications on Admission:
Diltiazem ER 300 mg Daily
Neurontin 800 mg TID
Lisinopril 5 mg Daily
Zafirlukast 20 mg Daily
Ibuprofen 800 mg TID
Beclomethasone dipropionate 80 mcg/Actuation Aerosol Inhaler
Inhalation 2 Puffs [**Hospital1 **]
Discharge Medications:
1. gabapentin 800 mg Tablet Sig: One (1) Tablet PO three times a
day.
2. zafirlukast 20 mg Tablet Sig: 1-2 Tablets PO once a day.
3. beclomethasone dipropionate 80 mcg/Actuation Aerosol Sig: Two
(2) puffs Inhalation twice a day.
4. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 9 days: Please take two tablets/day until
[**2151-1-24**] for a total of 14 day course.
Disp:*11 Tablet(s)* Refills:*0*
5. diltiazem HCl 180 mg Tablet Extended Release 24 hr Sig: One
(1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA of [**Hospital3 **] Inc.
Discharge Diagnosis:
Urosepsis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure taking vare of you at [**Hospital1 827**]. You were admitted with urosepsis, hypotension,
and a stone was found blocking your ureter. You were treated in
the intensive care unit for two days, where a neprhostomy tube
was placed in your right kidney to drain your urine. You will
follow-up with urology to remove the stone and with
interventional radiology to take the tube out. When your blood
pressure had normalized and you were seen by physical therapy,
we felt you were safe to go home.
Please note the following changes have been made to your
medications:
- Please START taking Ciprofloxacin and continue taking it until
you are told to stop after you follow-up with Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] get the
stone retrieved from your ureter.
- Please STOP taking Lisinopril as your blood pressure has been
low in the days preceding discharge
- Please DECREASE your dose of Diltiazem to 180mg daily as your
blood pressure has been low in the days preceding discharge
- Please STOP taking lisinopril as your blood pressure was low
before discharge
** When you follow up with your PCP [**Last Name (NamePattern4) **] [**1-22**], please discuss
whether you should restart these medications.
- Please STOP taking Ibuprofen unti you kidney function
normalizes. You can discuss this issue when you follow-up with
your PCP.
[**Name Initial (NameIs) **] Please take oxycodone 5mg every 6 hours as needed for pain
- Please take a bowel regimen (docusate and senna) for as long
as you are on oxycodone to prevent constipation
** Please come to the ED if you feel short of breath, as you may
have accumulated fluid in your lungs again.
** Please make sure you get assistance when you get up and
especially when you get in and out of cars.
Followup Instructions:
Please follow up with the following appointments:
Name: [**First Name8 (NamePattern2) 5627**] [**Last Name (NamePattern1) **], NP
Location: [**Hospital1 **] HEALTHCARE - [**Location (un) 8720**]
Address: 15 [**Doctor Last Name 8721**] BROTHERS WAY,[**Apartment Address(1) 8722**], [**Location 8723**],[**Numeric Identifier 8724**]
Phone: [**Telephone/Fax (1) 8725**]
Appointment: Friday [**2151-1-22**] 10:40am
Name: Dr. [**Last Name (STitle) **]
[**Last Name (STitle) **]: SURGICAL SPECIALTIES/ UROLOGY
When: [**2151-1-27**] at 8:30 AM (10:00 AM procedure)
With: UROLOGY UNIT [**Telephone/Fax (1) 164**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
** This will be a procedure in the operating room to remove the
stone in your ureter. You will need to arrive at 8:30am for a
10:00 procedure. Please do not eat or drink anything after
midnight of the day of procedure.
Dr.[**Name (NI) 10529**] office will schedule you with an appointment with
Interventional Radiology after they remove your stone.
Interventional Radiology will take out your nephrostomy tube
when you no longer need it after the urology surgery. If you do
not hear from Interventional Radiology after , you can reach [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 6745**] at ([**Telephone/Fax (1) 44617**].
***A nephrostomy tube care sheet has been included with your
discharge paperwork. This caresheet will include information on
how to clear and care for your tube, the date it was inserted,
as well as the contact information to people to get in touch
with regarding questions.***
Completed by:[**2151-1-20**]
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74,092
| 129,955
|
38814
|
Discharge summary
|
report
|
Admission Date: [**2195-4-14**] Discharge Date: [**2195-4-21**]
Service: MEDICINE
Allergies:
Iodine-Iodine Containing
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
Abdominal aortic aneurysm
Pericardial tamponade
Major Surgical or Invasive Procedure:
Endovascular repair of abdominal aortic aneurysm on [**2195-4-14**].
Pericardiocentesis on [**2195-4-16**].
History of Present Illness:
This is an 85 year old gentleman with a recently diagnosed very
large abdominal aortic aneurysm. He moved from [**State 4565**]
approximately five years ago. Many of
his records are there and unobtainable. In [**2179**], he apparently
had a cardiac arrest. He survived that and underwent
angioplasty and stress testing since then. He has also had two
carotid endarterectomies approximately 10 years ago, again
details are unknown. A year ago, he had evidence of
pericardial effusion that required a pericardiocentesis at [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] Hospital. The etiology to this is unknown.
Past Medical History:
HTN, MI, COPD, kidney stones, smoker, hypothyroidism, not on any
of his medication.
Social History:
He smokes one pack of cigarettes a day. He lives alone. Son
[**Name (NI) **] ([**Telephone/Fax (1) 86148**]) is HCP and closest relative.
Family History:
No family history of premature coronary disease or sudden death.
Physical Exam:
Admission Baseline:
He was alert and oriented.
His weight is 135 pounds. His blood pressure: 130/80, Pulse is
50/min. Neck supple.
No carotid bruits.
Palpation of the heart reveals normally placed PMI, normal S1,
S2, no murmurs, rubs or gallops. Respiratory effort is
adequate.
Lungs are clear to auscultation bilaterally. Abdomen was
nontender. I did not feel for his aneurysm. Extremities showed
no cyanosis, clubbing, or edema. Distal pulses are absent.
Inspection and palpation of skin is normal. The gait and muscle
tone are normal.
On Medicine Floor:
PHYSICAL EXAMINATION:
VS: T= 98.2 BP= 157/80 HR= 49 RR= 18 O2 sat= 97% RA
GENERAL: elderly male lying in bed watching TV in NAD. Responds
appropriately, hard of hearing.
HEENT: Sclera anicteric. PERRL 3-->2mm, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple, JVP not elevated.
CARDIAC: Irregular rhythm with rare premature beats,
bradycardic, normal S1, S2. No murmurs/rubs/or gallops. Distant
heart sounds. No S3 or S4. LLL not dull (neg [**Last Name (un) **] sign).
LUNGS: No accessory muscle use. Course rhonchi diffusely. Minor
wheezes.
ABDOMEN: Soft/NT/ND. No HSM or tenderness. Pos BS.
EXTREMITIES: No clubbing/cyanosis/edema. No pain in bilateral
femoral area. Cath site right inguinal area clean,
nonerythematous, nonedematous. DP/PT 2+ bilat.
SKIN: Skin flaking arms bilat. Ecchymoses overlying triceps
bilat. No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
[**2195-4-14**] 07:50PM GLUCOSE-131* UREA N-15 CREAT-1.0 SODIUM-139
POTASSIUM-3.1* CHLORIDE-106 TOTAL CO2-23 ANION GAP-13
[**2195-4-14**] 07:50PM ALT(SGPT)-9 AST(SGOT)-22 ALK PHOS-41
AMYLASE-52 TOT BILI-0.9
[**2195-4-14**] 07:50PM LIPASE-13
[**2195-4-14**] 07:50PM WBC-5.0 RBC-3.48* HGB-11.3* HCT-32.9*#
MCV-94# MCH-32.4* MCHC-34.3 RDW-17.1*
[**2195-4-14**] 07:50PM WBC-5.0 RBC-3.48* HGB-11.3* HCT-32.9*#
MCV-94# MCH-32.4* MCHC-34.3 RDW-17.1*
Admission chemistry ([**2195-4-14**])
138 105 16
3.2 23 1.0 < 101
Ca 7.6 Phos 2.4 Mg 2.1
Thyroid labs
([**2195-4-14**]) TSH 99 T4 4.4
([**2195-4-17**]) T3 49 Free T4 0.72
([**4-14**] to [**2195-4-21**])
Crit 25.5 --> 33 --> 37
WBC 5.0 --> 8.2 ---> 5.1
Plts 92 --> 107 --> 116
CK 429 --> 907 ---> 593
Trop 0.05 ([**2195-4-14**]) --> 0.06 --> 0.07 --> 0.09 --> 0.10 --> 0.11
--> 0.12 --> 0.08 ([**2195-4-18**])
UA ([**2195-4-20**]) Neg nitrites, neg leuks, 21-50 RBCs
Pericardial fluid ([**2195-4-16**]) WBC 55 RBC 45 Poly 0 Lymph 3
Mono 0 Macro 92 Other 5
Time Taken Not Noted Log-In Date/Time: [**2195-4-16**] 4:52 pm
FLUID RECEIVED IN BLOOD CULTURE BOTTLES
Fluid Culture in Bottles (Preliminary):
VIRIDANS STREPTOCOCCI.
VANCOMYCIN Sensitivity testing performed by Sensititre.
VIRIDANS STREPTOCOCCI. SECOND MORPHOLOGY.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
VIRIDANS STREPTOCOCCI
|
VANCOMYCIN------------ <=1 S
Aerobic Bottle Gram Stain (Final [**2195-4-18**]):
GRAM POSITIVE COCCI IN CHAINS.
Discharge chemistry (latest as of [**4-21**])
137 100 18
3.8 22 1.0 < 70
Ca 7.7 Phos 2.4 Mg 2.1
Echo ([**4-16**]):
The estimated right atrial pressure is 0-5 mmHg. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is mildly depressed (LVEF= 45 %). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. The mitral valve leaflets are mildly
thickened. There is a large pericardial effusion. There is brief
right atrial diastolic collapse. There is significant,
accentuated respiratory variation in mitral valve inflows,
consistent with impaired ventricular filling. There is also
inconsistent very brief right ventricular diastolic collapse.
Compared with the images of the prior study (images reviewed) of
[**2195-4-2**], the size of the pericardial effusion has increased
and there are echo signs for early tamponade (however, estimated
right atrial pressure is low, which indicate low circulatory
volume. This may accentuate the echocardiographic signs of
tamponade).
Repeat echo ([**4-16**]):
There is a trivial/physiologic pericardial effusion.
Compared with the prior study (images reviewed) of [**2195-4-16**],
large pericardial effusion is no longer present.
CXR ([**4-16**]):
IMPRESSION: Interval extubation without complication. Persistent
prominence of the cardiac silhouette related to known
pericardial effusion.
Brief Hospital Course:
Four days before AAA repair, Mr. [**Known lastname 19837**] had a thallium stress
test at [**Hospital3 26615**] Hospital which found no evidence of ischemia
or infarct and borderline left ventricular systolic function
with an ejection fraction of 50%. He was aymptomatic at
admission on [**2195-4-14**] and underwent AAA repair the same day,
which was complicated by an episode of hypotension/bradycardia
responsive to requiring some atropine and neosynephrine, IV
fluids, and two units of PRBCs. He was kept intubated overnight
and extubated the next morning. TSH done post procedure was 99
uIU/mL with T4 4.4ug/dL. Known hypothyroid but he had apparently
stopped taking his medications.
On [**4-16**], patient developed shortness of breath, BNP 784,
diuresed with IV lasix with some improvement; required 2L O2.
Echo was obtained and showed worsening pericardial effusion from
[**4-2**] with possible tamponade physiology. Cardiac enzymes were
also cycled for vomiting. Troponins were 0.05/ 0.06/ 0.07. Known
to have pericardial effusion preoperatively. BNP 784, diuresed
with IV lasix with some improvement; required 2L O2. Echo was
obtained and showed worsening pericardial effusion from [**4-2**]
with possible tamponade physiology. Cardiology was consulted and
recommended percardiocentesis and deferral of further
diuresis.Cardiology was consulted and recommended
percardiocentesis and deferral of further diuresis. Mr. [**Known lastname 19837**]
was given gentle IVF to limit tamponade physiology and taken for
pericardiocentesis and pericardial drain placement. During the
procedure, he breifly became hypotensive and bradycardic,
responsive to 500 cc bolus; thought to be vagal episode at
sheath insertion. RA mean 6mmHg, RVEDP 8, wedge 12. BP 140 > 87
> 140s. HR 70s > 40s > 70s. Removal of 460 cc serous fluid.
Repeat ECHO afterwards with improvement.
.
Mr. [**Known lastname 19837**] arrived at the CCU with no complaints. No chest pain.
No PND, orthopnea. Reports that at baseline, he can walk around
his 2 acre property that is limited primary due to pain in his
legs attributed to his PVD. He also has noted some proximal
weakness in his lower extremities over the past few months.
while in the CCU, psychiatry consulted and found patient to lack
capacity due to poor insight/judgement. He stayed in the CCU
[**2195-4-16**] to [**2195-4-18**], when he transfered to general medicine
floor.
.
On the floor, the pericardia fluid culture returned with Strep
viridans sensitive to vancomycin. However, he showed no signs of
systemic infection (afebrile to 98.1, hemodynamically stable,
low-normal WBCs, clinically looked well, and denied any pain or
other complaints). The culture result was considered
contaminant, so vancomycin was discontinued after briefly
starting him on it. On the floor, he intermittently refused all
treatment (food, vital signs, blood draws, telemetry). He did
permit some physical exams. His catheterization site was clean,
dry, and intact throughout stay on medicine floor. There were
family meetings on [**4-19**] and [**2195-4-20**] with son and HCP [**Name (NI) **], who
was aware of the dilemma due to patient lacking capacity. With
assistance of [**Name (NI) **] team, social work, case management, and
son [**Name (NI) **], plan was made for patient to be discharged to country
[**Doctor Last Name **] rehab hospital in [**Location (un) **], MA.
Medications on Admission:
- aspirin 81 mg a day
- patient reports that he was not taking any other medications
as
prescribed
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours.
4. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*2*
6. Prednisone 50 mg Tablet Sig: 1 tablet 13hours prior to CT
scan, 1 tablet 7 hours prior to CT scan and 1 tablet 1 hr prior
to CT scan Tablet PO as directed for 3 doses: this is given as
prophylaxis given your iodine allergy.
Disp:*3 Tablet(s)* Refills:*0*
7. Benadryl 25 mg Capsule Sig: Two (2) Capsule PO once, one hour
prior to your CT scan for 1 doses: due to your contrast dye
allergy.
8. Outpatient Lab Work
Blood labs for [**2195-4-24**]:
TSH, TT4, FT4, T3 uptake
9. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
Country Rehabilitation and Nursing Center - [**Location (un) 5028**]
Discharge Diagnosis:
x Abdominal aortic aneurysm
x Pericardial effusion
Discharge Condition:
Good
Responds appropriately
Ambulate as tolerated
Discharge Instructions:
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? Do not stop Aspirin unless your Vascular Surgeon instructs you
to do so.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
What to expect when you go home:
It is normal to have slight swelling of the legs:
?????? Elevate your leg above the level of your heart (use [**1-7**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
?????? Drink plenty of fluids and eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
?????? After 1 week, you may resume sexual activity
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate
?????? No driving until you are no longer taking pain medications
?????? Call and schedule an appointment to be seen in [**3-10**] weeks for
post procedure check and CTA
What to report to office:
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or
incision)
?????? Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office. If bleeding does not stop, call 911 for
transfer to closest Emergency Room.
Followup Instructions:
1. Get bloodwork drawn on [**2195-4-24**] (thyroid tests: TSH, TT4, FT4,
T3 uptake). We are giving you a prescription for this. Please
fax results to your PCP's office at [**Telephone/Fax (1) 86149**].
2. You have a follow-up appt with endocrinology:
Tuesday [**4-28**] at 11am Dr [**First Name8 (NamePattern2) **] [**Name (STitle) **], [**Hospital1 **]
Hospital, [**Hospital Unit Name 1825**] 1 [**Telephone/Fax (1) 1803**].
3. You have an appointment with Dr. [**Last Name (STitle) **] in Vascular
Surgery on [**5-21**] at [**Hospital1 **]. First you will
get a CT scan at 11:30am, then have your appointment at 1:15pm.
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2195-5-21**] 11:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 2625**]
Date/Time:[**2195-5-21**] 1:15
** because you have an allergy to iodine/ contrast dye, you will
need to have a prednisone and benadryl prep prior to the scan.
please see the prescriptions attached and take the prednisone
and benadryl as prescribed prior to the scan **
4. Will need follow up with your primary care physician, [**Last Name (NamePattern4) **].
[**First Name (STitle) 1661**], for monitoring TFT and to ensure compliance. Call
[**Telephone/Fax (1) 79522**] before you are discharged from the rehabilitation
facility to make that appointment.
5. You might consider making an appointment with a geriatric
psychiatrist at [**Hospital1 **]. [**First Name (Titles) **] [**Last Name (Titles) **] team was
consulted on your care, and would be happy to evaluate and treat
any concerns you or family members have about mood or behavior,
as an outpatient. Phone ([**Telephone/Fax (1) 6846**].
Completed by:[**2195-4-21**]
|
[
"305.1",
"458.29",
"401.9",
"441.4",
"V10.83",
"414.01",
"423.3",
"423.9",
"414.8",
"492.8",
"412",
"244.9",
"280.9",
"V15.81",
"428.0",
"443.9",
"294.8",
"V13.01",
"427.89",
"428.22"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.21",
"39.71",
"37.0"
] |
icd9pcs
|
[
[
[]
]
] |
10780, 10875
|
6236, 9631
|
280, 390
|
10970, 11022
|
2911, 6213
|
13513, 15297
|
1337, 1404
|
9781, 10757
|
10896, 10949
|
9657, 9758
|
11046, 12933
|
12959, 13490
|
1419, 1985
|
2007, 2892
|
193, 242
|
418, 1055
|
1077, 1163
|
1179, 1321
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,265
| 198,632
|
42367
|
Discharge summary
|
report
|
Admission Date: [**2194-12-30**] Discharge Date: [**2195-1-8**]
Date of Birth: [**2142-7-25**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 9965**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
52F w/ PMH of hypothyroidism who presented to [**Hospital1 **] ED yesterday
with shortness of breath and cough. She reports a 2 wk history
of new-onset shortness of breath, cough and dyspenea with
exertion which has worsened significantly. The cough is
productive with yellow sputum. She initially saw her PCP and
was prescribed what sounds like a 5d course of azithromycin,
which finished on [**12-25**], but had no improvement of her
symptoms. She reports the most comfortable position is sitting
upright because lying down provokes her cough. She has had
occasional subjective fevers. She also reports one month of
increasing ankle edema.
.
At [**Hospital3 **] ED, she was found to be hypoxic to the 80's.
CTA chest showed "early ARDS vs multifocal PNA innumerable tree
in [**Male First Name (un) 239**] opacities". She received solumedrol, ceftriaxone,
azithromycin, and nebs. She was then transferred to [**Hospital1 18**] ED on
a non-rebreather for possible ICU admission.
In the [**Hospital1 18**] ED, initial vitals were: 97.5F, HR 90, 131/58, RR
24, sat 94% 15L Non-Rebreather. She was on 6 L NC, but desated
to 88% so she was restarted on a nonrebreather and transferred
to the ICU for persistent hypoxia.
EKG: Rate 88, sinus rhythm, normal axis, no ST segment changes
.
On arrival to the ICU, her vitals were 97.0F, HR 103, 92% on
facemask -> 98% on non-rebreather
.
Review of systems:
Intermittnent subjective fevers. No chills, night sweats, recent
weight loss or gain. Denies headache. Reports some mucus from
nostrils. Reports cough, dyspnea as per HPI. Denies chest pain,
chest pressure, palpitations. 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. Reports some ankle edema x 1
month.
Past Medical History:
Hypothyroidism
Total hysterectomy in [**2162**] for menorrhagia
Social History:
worked for 30 years in electronics assembly plants. She mainly
soldered, cut and crimped cables, but was also exposed to
molding plastic and silicon motherboards. She then worked for
the last year in an air force base in the kitchen. Pt lives with
her mother in [**Name (NI) 730**]. Pt has 1 dog and 2 cats. No birds. Had not
travelled or had international visitors. Does not garden or work
with dirt. Has a leaky roof over her bathroom and ~ 1 x 1 foot
square of black mold on her bathroom wall.
- Tobacco: never
- Alcohol: rare
- Illicits: none
- Sex: not sexually active
Family History:
no signficiant history of lung disease, cancer, heart disease,
or other illnesses. Has two healthy siblings, and her mother is
also healthy.
Physical Exam:
Vitals: T: 36.1 BP: 153/95 P: 103 R:26 O2: 92% facemask -> 96%
non-rebreather
General: Obese middle-aged woman, alert, oriented, no acute
distress
HEENT: PERRL, Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: coarse breath sounds, insp. crackles bilaterally, but R >
L. ?egophany on R
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: obese, 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. 1+
edema in bilateral ankles.
Pertinent Results:
CBC: WBCs 9.7, Hct 34.3, Plt 423.
BNP 69
LDH 300
Lactate 1.9
Chem 7: Na 143, k 4.4, cl 101, hco3 31, bun 7, cr 0.7, glu 193.
AG 11.
ABG on facemask: 7.49/42/60/33 lactate 1.2.
.
Micro:
None available.
.
Images:
CT chest w/ contrast: diffuse tree-and-[**Male First Name (un) 239**] opacities
bilaterally. ? nodular lesion on R lung.
.
EKG: Rate 88, sinus rhythm, normal axis, no ST segment changes
Brief Hospital Course:
52F w/ PMH of hypothyroidism who presented to [**Hospital1 **] ED yesterday
with shortness of breath and cough. She reports a 2 wk history
of new-onset shortness of breath, cough and dyspenea with
exertion which has worsened significantly.
.
# Hypoxemic respiratory distress: On admission the differential
diagnosis was felt to be very broad and included infectious,
autoimmune, and toxic etiologies. Given her 2 weeks of symptoms
of cough and fevers - in combination with her CT findings of
tree and [**Last Name (LF) 239**], [**First Name3 (LF) **] infectious etiology seems more likely. Although
she did not respond to a one week course of azithromycin, her
symptoms and chest imaging are more consistent w/ atypical
rather than a typical staph/strep pneumonia. Patient does work
on an airforce base, but usually in the kitchen, and she states
that she had a negative PPD skin test. Pt does not have any
exotic exposures, but mold hypersensitivity is a possibility
given her leaky roof and mold in her bathroom (her beta glucan
and galactomannan returned negative). Her industrial exposure
may also have caused some baseline lung dysfunction, but the
onset of her symptoms is acute and CT does not show the
typically nodular appearance of silicosis or beryllium. Pt did
not have a flu vaccination this year, but symptoms are atypical
for flu - she was also ultimately negative on nasopharyngeal
swab for respiratory viruses. Urine legionella was also
negative; induced sputums X3 were negative for acid fast
bacteria. Pt may have an autoimmune or vasculitic process, but
again appearance on CT is not typical for this, and she has no
personal or family history of autoimmune disorders. The patient
was initially treated with ceftriaxone and azithromycin and then
narrowed to just levofloxacin. She was intially on nonrebreather
and could not be weaned without desaturations to 85-88%. She was
trialed on nasal CPAP and tolerated this well, with O2
saturations 93-94%. The patient's HIV antibody and HIV viral
load were negative. Her histoplasma negative and
hypersensitivity panel was negative and quantiferon gold was
negative. She was able to wean down to 5L NC and stable for
transfer to the floor. On the floor she was seen by pulmonary
who felt her presentation was most likely secondary to
infection. At the time of discharge her resting sats were normal
but ambulatory sats dropped to the high 80s. She was discahrged
on oxygen with plans for out-patient PCP and pulmonary
[**Name9 (PRE) 702**]. She completed her full 8 day course of levaquin.
.
# Hypothyroidism: Stable
- The patient was continued on home 100mcg of levothyroxine
Medications on Admission:
Levothyroxine 100mcg daily
NKDA
Discharge Disposition:
Home
Discharge Diagnosis:
hypoxic respiratory distress/bronchiolitis likely seconday to
pulmonary infection
Discharge Condition:
The patient has a stable mental status and is ambulatory with
oxygen.
Discharge Instructions:
You were admitted with shortness of breath, low oxygen and a
likely lung infection. Your oxygen level has improved but you
will still need oxygen at home. You should follow-up with your
appointments as attached. Your PCP and pulmonary doctors [**First Name (Titles) **] [**Name5 (PTitle) 91760**] when you can go off oxygen.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **]
Address: [**Location (un) **] STE 213C, [**Location (un) 10068**],[**Numeric Identifier 10069**]
Phone: [**Telephone/Fax (1) 79586**]
Appointment: Friday [**2195-1-16**] 9:45am
Department: PULMONARY FUNCTION LAB
When: MONDAY [**2195-2-2**] at 3:40 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: MONDAY [**2195-2-2**] at 4:00 PM
With: DR. [**Last Name (STitle) **] / DR. [**Last Name (STitle) 611**] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"244.9",
"278.00",
"V85.43",
"518.82",
"466.19",
"782.3"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6852, 6858
|
4125, 6770
|
312, 318
|
6984, 7056
|
3703, 4102
|
7429, 8221
|
2905, 3048
|
6879, 6963
|
6796, 6829
|
7080, 7406
|
3063, 3684
|
1752, 2206
|
265, 274
|
346, 1733
|
2228, 2294
|
2310, 2889
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,825
| 143,219
|
20827
|
Discharge summary
|
report
|
Admission Date: [**2199-8-19**] Discharge Date: [**2199-8-24**]
Date of Birth: [**2140-12-10**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
pericardiocentesis
History of Present Illness:
58 yo female s/p MVR (mechanical)/ TV repair/ASD closure on [**7-16**]
with Dr. [**Last Name (STitle) **]. Was doing well until three days ago when she
developed chest pain across her incision. Presents from ER for
evaluation and management of angina and subtherapeutic INR
(1.6). Further work up revealed a pericardial effusion. She was
admitted to cardiac surgery service for pericardiocentesis and
anticoagulation.
Past Medical History:
-s/p Mitral Valve Replacement (#27mm St.[**Male First Name (un) 923**]
Mechanical)/Tricuspid Valve repair (#28mmEdwards ring)/Atrial
Septal Closure-[**2199-7-10**]
-Hypertension
-Hyperlipidemia
-Rheumatic fever as a child
-Atrial fibrillation
-Diabetes Type II
-Tubal ligation
-Arthritis
-Mitral stenosis s/p mitral valvuloplasty
-Trisuspid regurgitation
-Pulmonary hypertension
-Arthritis
-Gastric ulcer [**2197**]-GI bleed per pt
Social History:
Occupation:retired Last Dental Exam - edentulous
Lives with: spouse [**Name (NI) **] Asian
Tobacco:denies ETOH denies
Family History:
mother - stroke and MI in her 50s, died in her 70s
Physical Exam:
98.2 T 109/78 HR 93 RR 18
99% RA sat 58" 52 kg
AAO x 3
CTAB
[**Last Name (un) **], valve click present
sternum stable
mediastinal incision c/d/i
hepatomegaly
Pertinent Results:
[**2199-8-19**] 09:31PM GLUCOSE-160* UREA N-22* CREAT-1.0 SODIUM-126*
POTASSIUM-4.5 CHLORIDE-92* TOTAL CO2-21* ANION GAP-18
[**2199-8-19**] 09:31PM ALT(SGPT)-14 AST(SGOT)-29 LD(LDH)-311*
CK(CPK)-73 ALK PHOS-102 TOT BILI-0.7
[**2199-8-19**] 09:31PM CK-MB-NotDone cTropnT-<0.01
[**2199-8-19**] 09:31PM ALBUMIN-3.9 MAGNESIUM-1.7
[**2199-8-19**] 09:31PM WBC-10.4 RBC-4.01* HGB-10.1* HCT-31.8*
MCV-79* MCH-25.3* MCHC-31.9 RDW-15.2
[**2199-8-19**] 09:31PM PLT COUNT-467*
[**2199-8-19**] 09:31PM PT-19.7* PTT-42.3* INR(PT)-1.8*
[**2199-8-19**] 02:50PM PT-18.1* PTT-30.5 INR(PT)-1.6*
Findings
PERICARDIUM: Effusion circumferential. No RA or RV diastolic
collapse.
GENERAL COMMENTS: Emergency study performed by the cardiology
fellow on call.
Conclusions
The effusion appears circumferential. No right atrial or right
ventricular diastolic collapse is seen.
PRELIMINARY REPORT developed by a Cardiology Fellow. Not
reviewed/approved by the Attending Echo Physician.
[**Name10 (NameIs) 55496**] assigned to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], MD, Interpreting
physician
[**2199-8-24**] 07:00AM BLOOD WBC-8.1 RBC-3.52* Hgb-8.7* Hct-27.4*
MCV-78* MCH-24.6* MCHC-31.6 RDW-15.9* Plt Ct-402
[**2199-8-24**] 07:00AM BLOOD PT-25.8* PTT-89.2* INR(PT)-2.5*
Brief Hospital Course:
Admitted [**8-19**] with work up for chest pain. She ruled out
Myocardial Infarction. INR subtherapeutic at 1.6 for a
mechanical Mitral Valve Replacement. Anticoagulation with
Heparin was initiated. Hyponatremia also noted at 126 and free
water restriction instituted. Chest cat scan and Echo showed
large circumferential pericardial effusion. [**8-20**]
Pericardiocentesis performed. Drain discontinued the following
day with minimal drainage. Transthoracic echo after drain
discontinued = Overall left ventricular systolic function is low
normal (LVEF 50-55%). There is no ventricular septal defect.
with mild global free wall hypokinesis. A bileaflet mitral valve
prosthesis is present. The mitral prosthesis appears well
seated, with normal leaflet/disc motion and transvalvular
gradients. No mitral regurgitation is seen. There is a
trivial/physiologic pericardial effusion. The remainder of her
admission course was essentially uneventful. Mrs.[**Known lastname **] [**Known lastname **] was
kept until her INR level was therapeutic for her mechanical
valve. [**8-24**] she was ready for discharge to home with INR
level=2.5. She is to resume [**Hospital 197**] clinic with Dr.[**Last Name (STitle) **], on
Mon. [**8-26**], to follow Coumadin dosing. All follow up appointments
were advised.
Medications on Admission:
lasix 20 mg daily
ASA 81 mg daily
coumadin 1 mg daily
lisinopril 40 mg daily
glipizide 5 mg daily
colace 100 mg [**Hospital1 **]
lopressor 50 mg [**Hospital1 **]
KCL 20 mEq daily
pantoprazole 40 mg daily
pravastatin 80 mg daily
Discharge Medications:
1. Aspirin 81 mg [**Hospital1 8426**], Delayed Release (E.C.) Sig: One (1)
[**Hospital1 8426**], Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 [**Hospital1 8426**], Delayed Release (E.C.)(s)* Refills:*2*
2. Glipizide 5 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO DAILY (Daily).
Disp:*60 [**Hospital1 8426**](s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Pravastatin 20 mg [**Hospital1 8426**] Sig: Four (4) [**Hospital1 8426**] PO HS (at
bedtime).
Disp:*120 [**Hospital1 8426**](s)* Refills:*2*
5. Pantoprazole 40 mg [**Hospital1 8426**], Delayed Release (E.C.) Sig: One
(1) [**Hospital1 8426**], Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 [**Hospital1 8426**], Delayed Release (E.C.)(s)* Refills:*2*
6. Metoprolol Tartrate 50 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO BID
(2 times a day).
Disp:*60 [**Hospital1 8426**](s)* Refills:*2*
7. Warfarin 1 mg [**Hospital1 8426**] Sig: Five (5) [**Hospital1 8426**] PO Once Daily at 4
PM for 2 days: take on Sun:[**8-25**] and Mon:[**8-26**].
Disp:*10 [**Month/Year (2) 8426**](s)* Refills:*0*
8. Warfarin 1 mg [**Month/Year (2) 8426**] Sig: [**Name8 (MD) **] MD [**First Name (Titles) 8426**] [**Last Name (Titles) **] once a day:
Dr.[**Last Name (STitle) **] following INR/Coumadin dosing. INR goal=>2.5.
Disp:*120 [**Last Name (STitle) 8426**](s)* Refills:*2*
9. Ascorbic Acid 500 mg [**Last Name (STitle) 8426**] Sig: One (1) [**Last Name (STitle) 8426**] PO BID (2
times a day).
Disp:*60 [**Last Name (STitle) 8426**](s)* Refills:*2*
10. Ferrous Sulfate 325 mg (65 mg Iron) [**Last Name (STitle) 8426**] Sig: One (1)
[**Last Name (STitle) 8426**] PO DAILY (Daily).
Disp:*60 [**Last Name (STitle) 8426**](s)* Refills:*2*
11. Folic Acid 1 mg [**Last Name (STitle) 8426**] Sig: One (1) [**Last Name (STitle) 8426**] PO DAILY (Daily).
Disp:*60 [**Last Name (STitle) 8426**](s)* Refills:*2*
Discharge Disposition:
Home with Service
Discharge Diagnosis:
pericardial effusion
s/p MVR/TV repair/closure ASD [**6-25**]
chronic A Fib
hypertension
hyperlipidemia
childhood rheumatic fever
NIDDM
osteoarthritis
pulm. hypertension
[**2197**] gastric ulcer bleed
Discharge Condition:
good
Discharge Instructions:
no lifting greater than 10 pounds for 5 more weeks
no lotions, creams, powders or ointments on incision
call for fever greater than 100, redness, drainage, or weight
gain of 2 pounds in 2 days or 5 pounds in one week
shower daily and pat incision dry
Followup Instructions:
***Coumadin dosing per Dr.[**Last Name (STitle) **] ([**Telephone/Fax (1) 41652**], please call for
follow up/Lab draw for INR on Monday [**8-10**] Clinic
see Dr. [**Last Name (STitle) **] in [**2-19**] weeks
see Dr. [**Last Name (STitle) **] in [**2-19**] weeks [**Telephone/Fax (1) 170**]
Completed by:[**2199-8-24**]
|
[
"790.92",
"V43.3",
"401.9",
"250.00",
"285.9",
"276.1",
"789.1",
"429.4",
"427.31",
"716.90",
"420.90",
"V58.83",
"423.3",
"416.0",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.21",
"37.0"
] |
icd9pcs
|
[
[
[]
]
] |
6602, 6621
|
3024, 4325
|
332, 352
|
6866, 6873
|
1705, 3001
|
7173, 7496
|
1454, 1506
|
4603, 6579
|
6642, 6845
|
4351, 4580
|
6897, 7150
|
1521, 1686
|
282, 294
|
380, 799
|
821, 1255
|
1271, 1438
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,716
| 158,787
|
48872
|
Discharge summary
|
report
|
Admission Date: [**2146-12-4**] Discharge Date: [**2147-1-31**]
Date of Birth: [**2077-11-4**] Sex: F
Service: MEDICINE
Allergies:
Plavix / Heparin Agents
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
ataxia/unsteady gait, transferred to MICU for further eval and
treatment of evolving stroke.
Major Surgical or Invasive Procedure:
intubation & bronchoscopy
liver biopsy
Left internal jugular central venous catheter placement
Right radial arterial catheter placement
bone marrow biopsy
tracheostomy placement
History of Present Illness:
This is a 72 yo F with h/o DM, OSA, right hemispheric CVA in the
past, ?seizure disorder admitted on [**2146-12-4**] with chief complaint
of ataxia and unsteady gait. Patient reportedly woke up to go to
the kitchen and felt dizzy and unsteady on her feet. She hit her
head against her bed room door without falling, no LOC. She
vomitied twice, no blood. She then called her sister to bring
her into the hospital. On admission she had left lateral
nystagmus, increased tone thoughout, brisk reflexes, weakness
noted in left arm and leg suggestive UMN pattern. Prior neuro
exams only suggestive of mild left hand weakness after CVA [**2144**].
CT performed in the ED showed a 5 mm hypodensity in the right
basal ganglia. She then began to have work finding difficulty
during her hospital stay and now is progressively more
inattentive, less responsive, non verbal. Neurology evaluation
feels this is an evolving embolic CVA. MRI showed occlusion of
the R ICA with watershed infarction in the right hemisphere on
[**12-4**]. Repeat MR today showed extension of the right infarct with
multiple other small watershed infarcts in the thalmus and left
hemisphere. The patient also presented with pancytopenia making
anticoagulation difficult. The decision to initiate heparin
therapy had been postponed however was started on the evening of
transfer given her worsening symptoms.
.
In addition, she was noted to have a nodule on a CXR performed
in the ED, CT of the chest showed multiple nodules concerning
for either infection vs. malignancy. CT abd/pelvis showed
hpodensities in the liver and spleen with multiple lymph nodes
however no mass. She is up-to-date with her age appropriate
cancer screening. As stated above, she was noted to be
pancytopenic suggesting a possible underlying bone marrow
process. In [**4-26**] her plts were ~400 however on admission they
were 30-40's. Her Hct was 41 in [**2141**] then low 30's starting in
[**11-25**]. Her WBC count started to trend down in [**11-25**] as well.
.
She was transfered to the MICU for monitoring given initiation
of anticoagulation in the setting of thrombocytopenia as well as
for tight BP control.
.
ROS (per records), she denied any CP, SOB, palpitations, HA,
vision changes or weakness. She reported some chronic neck
stiffness that is unchanged. The patient travelled to [**Country 480**]
from 12/3-23/06 but did not participate in any risky behavior.
She was on an organized tour to South [**Last Name (LF) 480**], [**First Name3 (LF) 16465**] and [**Country 3399**]
and ate in restaurants, drank bottled water. She took malaria
ppx with Malarone (atovaquone/ plaquenil) for 10 days but then
lost it. She received oral typhoid vaccine before the trip. She
denies any mosquito bite or contact exposures to animals. Of
note, she reported a positive TB test in the past (15 yrs and 5
yrs ago) but never recieved treatment.
Past Medical History:
1)Diabetes mellitus - diet controlled
2)OSA - on BiPAP 12/8
3)Cataract in the left eye
4)CVA/TIA (positive MRI) - right frontal with L arm/hand
hemiparesis; etiology likely moderate degree stenosis of the ICA
in the cavernous region, stable on recent CTA
5)Asthma
6)Hypercholesterolemia
7)Seizure? - L arm involuntary movements [**2144**]
8)Recent colonoscopy in [**2144**] with single sessile 4-5 mm
non-bleeding polyp of benign appearance, s/p removal.
mammography yearly unremarkable.
9)Sickle trait
Social History:
Lives alone in [**Location (un) 86**]. Supportive family nearby. Remote history
of tobacco use. One-two glasses of alcohol per week. Retired,
used to work in a post office. Currently works in a graft group,
making gloves and hats for poor kids. Denies recent sexual
intercourse.
Family History:
Diabetes in son, sister, and brother. [**Name (NI) **]-[**Name2 (NI) **] with
epilepsy. [**Name (NI) **] brother with ? lung cancer. Uncle with TB
Physical Exam:
On Admission:
VS: 101.4 Tm (101) 148/79 107 22 98 RA
GEN: tracks with eyes, minially following commands, lying in
bed, NAD
HEENT: OP clear, moist, anicteric, PERRL, EOMI, no nystagmus
NECK: supple, no JVD
LUNGS: coarse breath sounds, no rales or wheezing
CVS: nl S1 S2, RRR, distant, no m/r/g appreciated
ABD: soft, NT, ND, BS diminished
EXT: warm, 2+ dp pulses, no edema
NEURO: Awake, does not follow commands or respond to questions,
squeezes hands b/l 4+/5 strength, moving b/l LE, increased tone
throughout, toes equivocal/withdraws, unable to elicit reflexes
b/l knees, no clonus
Pertinent Results:
IMAGING:
[**12-4**] CT w/out contrast:
No acute intracranial hemorrhage. Left subcutaneous hematoma.
Persistent prominence of the ventricles, unchanged since prior
study. 5 mm hypodensity in the right basal ganglia, either cyst
or prior infarct.
.
CXR [**12-4**]
2.5 cm and 8 mm nodular opacities projecting over right mid
lung,
highly concerning for malignancy. Dedicated chest CT is
recommended to further evaluate these findings.
.
CT Chest w/out contrast
1. Multiple consolidations and ill-defined nodules and numerous
small nodules mostly in centrilobular distribution. The finding
is most likely representing infectious process, likely bacterial
infection, however, given the appearance, possibilities of
fungal infection or tuberculosis infection should be considered.
2.Given the liver lesion and lymphadenopathy described below,
some of the nodules especially larger nodules can represent
metastasis if there is underlying malignancy. Please correlate
clinically, and please closely follow after appropriate
treatment.
3. Bilateral axillary and right paratracheal lymphadenopathy,
also
concerning for malignancy.
4. Multiple hypodense liver lesions, only partially visualized,
of unknown origin however is strongly worrisme for metastasis
from underlying malignancy such as colon or breast cancer.
Please correlate clinically, and please perform dedicated
abdominal imaging such as ultrasound or contrast enhanced CT if
renal function permits.
.
EKG [**12-4**] NSR
.
MRA Brain [**12-4**]:
Occlusion of the right ICA with watershed infarction in the
right
hemisphere. Occlusion or severe stenosis of the left vertebral
artery.
.
CTA Head & Neck [**12-6**]
Complete occlusion of the right internal carotid artery. Patent,
but diminutive left vertebral artery.
.
TTE [**12-7**]: EF >55%, 1+ MR. [**First Name (Titles) **] [**Last Name (Titles) **] vegetations seen.
.
CTA Abd/Pelvis [**12-6**]
No clear primary malignancy. With the constellation of findings
of multiple pulmonary nodules, ill-defined liver and splenic
lesions, and lymphadenopathy, metastatic disease cannot be
excluded. However, infectious etiology such as TB could explain
these findings. An MRI of the liver is recommended for further
characterization of the liver lesions.
.
MR [**Name13 (STitle) 430**] [**12-8**]
1. There is unknown total occlusion of the right internal
carotid artery. There is some flow in the right MCA, primarily
from the anterior communicating artery and right A1 segment,
which appears to be small. The current study extends further
superiorly showing enlargement of the distal right anterior
cerebral artery, suggesting that it supplies collaterals to the
right MCA territory.
2. The left vertebral artery is congenitally small and poorly
seen on MRAs.
.
TEE [**12-9**]: No cardiac source of embolus identified. No
echocardiographic evidence of endocarditis or abscess
identified.
.
Serologies/fever work up as of [**2147-1-23**]:
- HIV - NEGATIVE
- Hepatitis serologies - NEGATIVE
- CMV viral load- NEGATIVE
- dengue- pending
- galactomannan - NEGATIVE
- Beta-glucan - NEGATIVE
- Brucella ab - NEGATIVE
- Bartonella ab - NEGATIVE
- Chlamydia pneumoniae ab - NEGATIVE
- Coccidiodes ab - NEGATIVE
- Histoplasma ab - NEGATIVE
- Legionella ab [**11-26**] - NEGATIVE
- Parvovirus - NEGATIVE
- Q-fever ab - NEGATIVE
- Schistosoma ab - NEGATIVE
- strongyloides ab - NEGATIVE
- urine histoplasma ag - NEGATIVE
- RPR- NEGATIVE
- ACE - elevated to 104
- RF - NEGATIVE
- [**Doctor First Name **] - 1:16, speckled
- ANCA - NEGATIVE
- lupus anticoagulant- NEGATIVE
- Anti-cardiolipin antibody - IgG 7.6, IgM 8.6
- Sputum AFB - negative x 1
- stool O + P - NEGATIVE
- malaria thick/thin smear - negative x 5
.
[**12-10**] bronchial washings: NEGATIVE FOR MALIGNANT CELLS.
.
[**12-12**] carotid USN: IMPRESSION: Right ICA occlusion. No stenosis
of the left carotid.
.
[**12-15**] Chest CT:IMPRESSION: New moderately severe pulmonary edema
and increasing pleural effusions suggest cardiac decompensation.
The multiple pulmonary nodules which previously developed over
several days likely represent disseminated infection, including
septic emboli, not metastases. Bilateral consolidation is a
combination of atelectasis and pneumonia.
.
[**12-15**] head CT:1. Interval evolution of bilateral infarcts.
Hyperdensity sighin a portion of the largest right frontal
infarct is concerning for hemorrhagic transformation, minimal in
degree.
2. New sinus opacification as described above, likely
inflammatory in origin, and possibly related to the intubated
status of the patient.
NOTE: There are secretions in the [**Last Name (un) **]- and oropharynx, also
presumably related to intubation of the patient.
.
[**12-16**] neck soft tissue USN: IMPRESSION: Abnormally enlarged right
supraclavicular lymph nodes.
.
[**12-16**] TTE:Compared with the findings of the prior study (images
reviewed) of [**2146-12-9**], a small pericardial effusion is
now present; otherwise no major change.
If clinically suggested, the absence of a vegetation by 2D
echocardiography does not exclude endocarditis.
.
[**12-31**] TTE: MPRESSION: Trace aortic regurgitation and mild aortic
valve sclerosis. No discrete vegetation identified. Preserved
global and regional biventircular systolic function. Compared
with the prior study of [**2146-12-16**] (images reviewed), the severity
of mitral regurgitation has decreased. Aortic regurgitation and
pulmonary artery systolic pressure are similar (and were
overestimated on the prior study). If clinically suggested, the
absence of a vegetation by 2D echocardiography does not exclude
endocarditis.
.
[**1-2**] CT CAP:1. Overall worse appearance of lungs which may be
due to a combination of cardiac failure and progressive
infection.
2. Improvement in overall size of right pleural effusion, but
evidence of further loculation. Small left pleural effusion also
present.
3. Small amount of ascites is probably related to cardiac
failure.
4. Free abdominal air presumably due to recent gastrostomy tube
placement.
5. Anasarca.
.
[**1-2**] LENI: No femoral or popliteal DVT was demonstrated in
either the right or left legs.
.
[**1-6**] UE USN: No evidence of DVT in the left upper extremity.
.
[**1-10**] CT CAP:1. No significant change in the appearance of the
pleural effusions and diffuse ground glass opacities and _____
parenchymal nodules when compared to the prior study.
2. Unchanged lesions throughout the liver. Please note that this
study was performed without intravenous contrast, limiting full
evaluation for any change in the extent of liver lesions.
3. Overall, no significant change in the quantity of ascitic
fluid, which has redistributed into the lower pelvis.
.
[**1-18**] LE USN:No evidence of DVT.
.
[**1-19**] chest USN for [**Female First Name (un) 576**]: No significant effusion seen at the
right lung base. Therefore, no thoracentesis was performed.
.
[**12-9**] liver needle biopsy: Liver, needle-core biopsy:Liver with
granulomatous inflammation including large necrotizing
granuloma.
Special stains: No microorganisms are seen with GMS, PAS-D,
[**Doctor Last Name 6311**], AFB,or Brown and Brenn stains. No immunoreacivity is
seen for CMV, HSV I and II, or adenovirus.
.
[**12-16**] FNA, Supraclavicular lymph node: Polymorphous lymphoid
population with necrosis and rare granulomas seen.
.
[**12-16**] Pleural fluid, right: NEGATIVE FOR MALIGNANT CELLS. Some
lymphocytes, rare groups of mesothelial cells and blood.
.
[**12-16**] BM aspirate and core biopsy: Markedly hypercellular bone
marrow with trilineage dysplasia and increased blasts (18-20%)
consistent with an evolving acute leukemia. See note.Note: The
findings of marrow hypercellularity and trilineage dysplasia, in
a patient with pancytopenia, are in keeping with involvement by
a myelodysplastic syndrome. Blasts represent approximately
18-20% of aspirate differential suggestive of an evolving acute
leukemia.
.
[**12-16**] liver needle core biopsy: INVOLVEMENT BY NECROTIZING
GRANULOMAS, SEE NOTE.
Note: There are several granulomatous necrotizing lesions in
the core. There is focal fibrosis deposition in relation to the
granulomas. Special stains for microorganisms (AFB, GMS, PAS)
are negative. However, a concurrent wedge biopsy of the lung,
contains similar necrotizing lesions as in this liver, where
there are acid fast organisms present consistent with
mycobacteria (please see report: S07-3791). An iron stain
demonstrates increased stainable iron. By immunohistochemistry,
C-Kit is negative. Myeloperoxidase stains scattered
neutrophils. CD5 stains scattered T-lymphocytes. CD68 stains
Kupffer cells and lesional histiocytes. CD3 stains scattered
T-lymphocytes in the parenchyma and granulomas. CD20 stains
scattered periportal B-cells. No morphologic or
immunophenotypic evidence of leukemia is seen.
.
[**12-16**] RLL wedge:SPECIMEN #1: SUPRACLAVICULAR LYMPH NODE",
EXCISIONAL BIOPSY (A).DIAGNOSIS: UNREMARKABLE ADIPOSE AND NEURAL
TISSUE. NO MORPHOLOGIC EVIDENCE OF LYMPHOMA OR INFECTION SEEN.
SPECIMEN #2: LOWER LOBE WEDGE EXCISION (B-D).
DIAGNOSIS: MULTIPLE NECROTIZING GRANULOMATOUS CONTAINING
NUMEROUS ACID-FAST ORGANISMS, CONSISTENT WITH MYCOBACTERIAL
INFECTION, SEE NOTE. NO EVIDENCE OF LEUKEMIA/GRANULOCYTIC
SARCOMA PRESENT. Note: An acid-fast stain shows numerous
acid-fast positive organisms. The morphologic features of the
bacilli are consistent with mycobacteria. Given the clinical
presentation and the presence of multiple necrotizing granulomas
in the lung and liver the findings are highly suggestive of
miliary tuberculosis. However, additional microbiological
studies are required to speciate the mycobacteria. A GMS stain
is negative for fungal organisms. Immunoperoxidase studies show
the following: CD3, CD5, and CD43 stain many T-cells, while CD20
stains a smaller percentage of B-cells. CD68 highlights numerous
macrophages; myeloperoxidase stains neutrophils and rare
mononuclear cells; c-kit stains scattered mast cells; CD34
highlights vessels and does not show any blast-like cells.
Discharge labs:
[**2147-1-31**]
04:20a
Source: Line-Right Subclavian
Other Blood Chemistry:
Vanco: 23.9
Comments: Vanco: Updated Reference Range As Of [**2146-7-20**] ==
Represents Therapeutic Trough
Source: Line-Right Subclavian
146 117 16 AGap=10
-------------< 79
3.8 23 1.0
Ca: 8.5 Mg: 2.0 P: 2.5
Source: Line-Right Subclavian
89
1.6 \ 8.1 / 170
/ 24.6\
Other Hematology
Gran-Ct: 720
Source: [**Name (NI) 102647**] Subclavian
PT: 14.4 PTT: 25.7 INR: 1.3
[**2147-1-30**]
02:54a
Source: Line-cvl
Source: Line-cvl
144 116 15 AGap=10
-------------< 102
4.1 22 1.1
Ca: 8.4 Mg: 2.1 P: 3.0
Other Blood Chemistry:
Vanco: 13.5
Comments: Vanco: Updated Reference Range As Of [**2146-7-20**] ==
Represents Therapeutic Trough
Source: Line-cvl
86
1.7 \ 8.6 / 147
/ 25.2\
N:55 Band:0 L:37 M:8 E:0 Bas:0 Blast: 0
Comments:
Neuts: DOHLE BODIES
Hypochr: 1+ Anisocy: 1+ Poiklo: OCCASIONAL Microcy: 1+ Schisto:
OCCASIONAL
Plt-Est: Low
Comments: Plt-Smr: Verified By Smear
Plt-Smr: Occ Large Plt Seen
Source: [**Name (NI) **]
PT: 15.2 PTT: 25.6 INR: 1.4
POSITIVE MICRO STUDIES:
[**2147-1-29**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-PRELIMINARY {GRAM NEGATIVE ROD(S)}
[**2147-1-26**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
{ESCHERICHIA COLI}
[**2147-1-23**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
{GRAM NEGATIVE ROD #1, GRAM NEGATIVE ROD #2}
[**2147-1-22**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
{ESCHERICHIA COLI, ESCHERICHIA COLI}
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ESCHERICHIA COLI
| |
AMPICILLIN------------ =>16 R =>32 R
AMPICILLIN/SULBACTAM-- 16 R =>32 R
CEFAZOLIN------------- =>16 R =>64 R
CEFEPIME-------------- 16 R =>64 R
CEFTAZIDIME----------- =>16 R =>64 R
CEFTRIAXONE----------- =>32 R =>64 R
CEFUROXIME------------ =>64 R
CIPROFLOXACIN--------- =>2 R =>4 R
GENTAMICIN------------ =>8 R =>16 R
IMIPENEM-------------- <=1 S <=1 S
LEVOFLOXACIN---------- 4 R
MEROPENEM------------- 2 S <=0.25 S
PIPERACILLIN---------- =>64 R =>128 R
PIPERACILLIN/TAZO----- 16 S 64 I
TOBRAMYCIN------------ =>8 R =>16 R
TRIMETHOPRIM/SULFA---- =>2 R
[**2147-1-17**] 7:59 pm SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2147-1-18**]):
<10 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final [**2147-1-22**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
ESCHERICHIA COLI. MODERATE GROWTH.
gram stain reviewed: 1+ GRAM POSITIVE COCCI IN PAIRS
AND
CLUSTERS. 2+ GRAM NEGATIVE RODS were observed
([**2147-1-20**]).
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.
UNASYN (AMPICILLIN/SULBACTAM) >16/8 MCG/ML.
LEVOFLOXACIN >4 MCG/ML.
BACTRIM (=SEPTRA=SULFA X TRIMETH) >2/38 MCG/ML.
CEFEPIME >16 MCG/ML.
AMIKACIN 16MCG/ML :SENSITIVE.
sensitivity testing performed by Microscan.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>16 R
AMPICILLIN/SULBACTAM-- R
CEFAZOLIN------------- =>32 R
CEFEPIME-------------- R
CEFTAZIDIME----------- =>16 R
CEFTRIAXONE----------- =>32 R
CEFUROXIME------------ R
CIPROFLOXACIN--------- =>2 R
GENTAMICIN------------ =>8 R
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- R
MEROPENEM------------- 4 S
PIPERACILLIN---------- =>64 R
PIPERACILLIN/TAZO----- 64 I
TOBRAMYCIN------------ =>8 R
TRIMETHOPRIM/SULFA---- S
ACID FAST SMEAR (Final [**2147-1-18**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Pending):
[**2147-1-17**] BLOOD CULTURE AEROBIC BOTTLE-PRELIMINARY
{STAPHYLOCOCCUS, COAGULASE NEGATIVE}; ANAEROBIC BOTTLE-FINAL
{STAPHYLOCOCCUS, COAGULASE NEGATIVE}
[**2147-1-12**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
{GRAM NEGATIVE ROD(S)}
[**2147-1-9**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
{GRAM NEGATIVE ROD(S)}
Brief Hospital Course:
72 yo F with h/o DM, prior R CVA p/w dizziness, nausea,
vomiting, found to have an acute right hemispheric watershed
infarct followed by multiple other watershed infarcts now with
progressive neurological decline, as well as multiple lung liver
and spleen nodules with diffuse lymphadenopathy, and recurrent
fevers.
.
1) Fevers: Patient has been intermittently febrile since
admission and overall picture concerning for underlying
infection vs. malignancy given pulmonary, liver, and splenic
lesions, ?BM infiltrative process leading to pancytopenia.
Recent travel history to [**Country 480**] broadens the differential for
possible infectious diseases. Acute CVA could produce fever. For
now, continue coverage with Vancomycin for positive blood
culture on [**1-17**], source probably line infection. Will complete
2 week course of Vancomycin on [**2-1**]. Also, persistently
colonized with E. Coli on sputum cultures, but has received
several courses of antibiotics, including Ciprofloxacin,
azithromycin, ceftriaxone, and piperacillin/tazobactam.
However, sputum cultures still growing E. Coli on [**1-17**].
Meropenem was started empirically for a seven day course (to be
completed on [**2-1**]) but pt continued to spike through this
medication.
For evaluation of the fever infectious/autoimmune serologies and
blood work as listed above in Pertinent Results section. TTE
was negative for endocarditis, and TEE was deferred due to
inability reach family for consent.
.
2) Evolving Watershed Infarcts: Repeat MRI showed evolving
infarcts in watershed distribution with progressive neurological
decline. Patient was transiently hypotensive on admission. DDx
influces embolic from tight R ICA lesions vs. brain mets vs.
infectious such as TB involvement of CNS. Neuro followed closely
during hospital course. She was started on a heparin gtt which
was stopped due to thrombocytopenia and positive HIT assay.
Changed to argatroban. TTE was performed to search for [**Month/Year (2) **]
vegetations as etiology of ? embolic infarcts; however, no
evidence of vegetations or cardiac thrombi. In the setting of
her respiratory failure on [**12-9**], head was reimaged but CT
without any interval change.
.
3) Respiratory failure - Patient with new onset respiratory
distress on the evening of [**12-9**] with ABG 7.4/35/48. She was
tachypneic to the 40's, hypertensive with SBP's >200, and
tachycardic. She was intubated emergently; however, the trigger
for her respiratory distress is undetermined, as CXR is clear
and there is no significant underlying pulmonary process to
which this can be attributed. CT head was performed emergently,
but was negative for evolution of her neurologic picture.
Initial attempt at extubation unsuccessful [**12-23**] agitation. Mental
status moderately improved, with compensated metabolic acidosis
on vent. Continues to have difficulties with weaning on
pressure support ventilation, with RSBI consistently greater
than 200.
.
4) Pulmonary tuberculosis with liver/spleen granulomas: On [**12-16**]
pt had right sided VATS, right supraclavic LN, and liver biopsy
done. Biopsy showed granuloma suspicious for infectious process.
Tissue from lung growing AFB. Sputum cx also + for AFB on
culture but never smear positive. PT also had +PPD in past w/o
treatement. Lymph node biopsy was non-diagnostic. TB was found
to be pan-sensitive. Pt was tx with RIPE starting on [**12-22**] but
continued to spike fevers. ? of drug fever was proposed so RIPE
was held for three days, pt given STM/levaquin instead of
rifampin, but she continued to spike. Pt was then restarted on
Pyrazinamide, ethambutol, INH per ID recommendations. Pt
continued to spike throughout treatment. She grew AFB from BAL
or sputum on [**3-22**], and [**12-12**] but was never smear positive
even on concentrated smear before treatment. She has received
treatment continuously since [**12-22**] (>2 weeks) and has no clinical
symptoms of TB at this time.
.
5) Pancytopenia. DDx primary vs. secondary BM process. Per
hematology, likely myelodysplastic syndrome, based on bone
marrow biopsy results. Patient was transfused as needed for
PRBC and platelets. No evidence of malaria on interpretation of
peripheral smear. EBV IgG +, IgM-. SPEP non specific
abnormality/UPEP multiple bands. HIT positive and all heparin
products discontinued. BM biopsy perfomed on [**12-9**]; MDS vs AML.
.
6) ARF: Creatinine elevated to 1.6 (up from 1.2; baseline 0.9 -
1.0). Likely prerenal although concern for amphotericin effect.
Subsequently resolved back to baseline of 1.0.
.
7) Diabetes. Well controlled on glargine and humalog ISS.
.
8) FEN: Initiated tube feedings. Probalance Full strength;
Starting rate: 10 ml/hr; Advance rate by 10 ml q4h Goal rate: 50
ml/hr
Residual Check: q4h Hold feeding for residual >= : 150 ml
Flush w/ 30 ml water q6h
.
9) Prophylaxis: pneumoboots, bowel regimen, PPI held given low
plts
.
10) Access: PIV x 2, L IJ
.
11) Code Status: Full (discussed with patient prior to
intubation)
.
12) Dispo: MICU level of care
13) Communication:
HCP is [**Name (NI) **] [**Name (NI) **] (son) [**Telephone/Fax (1) 102648**]
Lischen (daughter) [**Telephone/Fax (1) 102649**]
[**Doctor First Name **] (daughter)
Medications on Admission:
MEDICATIONS AT HOME:
Simvastatin 40mg QD
Aspirin 325mg QD
MVI
Ibuprofen 400mg Q6h prn
Tums prn
.
MEDICATIONS UPON TRANSFER TO MICU [**2146-12-9**]:
- 1000 ml LR Continuous at 150 ml/hr Order date: [**12-8**]
- Acetaminophen 650 mg PO Q6H
- CeftriaXONE 1 gm IV Q24H (DAY 5)
- Docusate Sodium 100 mg PO BID
- Heparin IV Sliding Scale Order date: [**12-8**]
- Insulin SC
- Simvastatin 40 mg PO DAILY
.
ALLERGY: Plavix, which caused a rash
Discharge Medications:
1. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q4-6H (every 4 to 6 hours) as needed.
2. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Six
(6) Puff Inhalation Q6H (every 6 hours) as needed.
3. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
4. DiphenhydrAMINE HCl 25 mg IV Q6H:PRN
5. Docusate Sodium 50 mg/5 mL Liquid Sig: Fifty (50) mg PO BID
(2 times a day).
6. Dolasetron 12.5 mg/0.625 mL Solution Sig: 12.5 Intravenous
Q4-6H (every 4 to 6 hours) as needed.
7. Ethambutol 400 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
8. Fentanyl Citrate 25-100 mcg IV Q2H:PRN sedation/ agitation
9. Isoniazid 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q6H (every
6 hours).
11. Vancomycin 1,000 mg Recon Soln Sig: 1000 (1000) mg
Intravenous once a day for 4 days: please dose by level for
trough<15. goal 15-20.
12. Meropenem 1 g Recon Soln Sig: One (1) g Intravenous Q12H
(every 12 hours) for 1 days: [**2-1**] is last day of seven day
course.
13. Midazolam HCl 1 mg IV Q2H:PRN agitation. sedation
14. Morphine Sulfate 0.5-1 mg IV Q6H:PRN
hold for oversedation, RR<10
15. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
16. Pyridoxine HCl 50 mg IV Q 24H
17. Pyrazinamide 500 mg Tablet Sig: 2.5 Tablets PO DAILY
(Daily).
18. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
19. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
20. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
21. insulin
glargine 6u qhs and ISS
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 13753**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary:
disseminated TB- pan sensitive
fever of unknown origin
MDS
secondary:
1)Diabetes mellitus - diet controlled
2)OSA
3)Cataract in the left eye
4)CVA/TIA
5)Asthma
6)Hypercholesterolemia
7)Seizure? - L arm involuntary movements [**2144**]
9)Sickle trait
Discharge Condition:
Improved but stil spiking fevers >101
Discharge Instructions:
You are being transferred to [**Hospital 112**] hospital for further workup per
your family request.
.
The patient's treatment for TB started on [**12-22**] and continues.
Pt had + AFB grown in sputum culture on [**1-2**]. Since then, pt has
had [**1-6**] pleural fluid neg for AFB cx and smear, [**1-17**] no AFB on
smear with cx Pending, [**1-18**] sputum immunoflourescence neg for
PCP. [**Name10 (NameIs) **] further PCP cx or immunoflourescence sent.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2147-5-23**] 2:30
.
Please follow up with [**First Name8 (NamePattern2) 803**] [**Last Name (NamePattern1) **] from infectious
disease([**Telephone/Fax (1) 4170**].
Completed by:[**2147-2-1**]
|
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58,732
| 175,692
|
36521
|
Discharge summary
|
report
|
Admission Date: [**2157-8-19**] Discharge Date: [**2157-10-24**]
Date of Birth: [**2096-1-15**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 8810**]
Chief Complaint:
Disseminated fusarium, VRE bacteremia
Major Surgical or Invasive Procedure:
Bone marrow biopsy [**2157-9-2**]
Bone marrow biopsy [**2157-9-17**]
Bone marrow biopsy [**2157-10-18**]
Skin biopsy [**2157-8-20**]
History of Present Illness:
The patient is a 61yo M with a PMH of biphenotypic leukemia on
outpatient treatment with Ambisome and voriconazole for
disseminated fusarium [**Month/Day/Year 2**] and recent admission to the [**Hospital Unit Name 153**]
on [**7-27**] for fever and abdominal pain, now being admitted for a
new lesion on congenital oral mass concerning for persistent and
worsening fungal [**Month/Day (4) 2**]. Patient had been going to outpatient
clinic daily for IV infusion of Ambisome. Today patient noted a
sore on the congenital mass on the roof of his mouth that has
been persistent for the past 4-5days. Lesion on roof of mouth,
under dentures, [**2156-1-22**] pain improved without dentures in place.
Has not taken pain medication for it, does not believe it is
worsening. Denies fevers/chills, night sweats. Max temperature
in the last 5 days, per patient, has been 99.0F. No CP, SOB,
trouble breathing, wheezing, HA, nausea. BMs unchanged. Patient
was admitted from clinic for work up of this oral lesion.
.
Also, of note patient developed painless nonpruritic
erythematous blanching patches on his shins bilaterally within
the last day.
.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies recent weight loss or gain (currently 155, has ranged
from 145-155, though was 185 in [**Month (only) 116**]). Denies sinus tenderness,
rhinorrhea or congestion. Denied chest pain or tightness,
palpitations. Denied nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denied arthralgias or myalgias.
Past Medical History:
PAST ONCOLOGIC HISTORY:
Biphenotypic Leukemia - Initially prsented with "autoimmune
pancytopenia" treated with steroids and IVIG. In [**3-/2157**] his
cytopenias worsened and he was noted to have about 90% blasts
and he was transferred to [**Hospital1 18**]. Preliminary bone marrow biopsy
was suspicious for a biphenotypic leukemia and therapy was
initiated with hyperCVAD. His day 14 marrow showed persistent
disease and his regimen was changed to 7+3. Day 14 and two
subsequent marrows all continued to show persistent involvement
with leukemia. Further chemotherapy was held as he was found to
have disseminated fusarium [**Hospital1 2**] in the setting of prolonged
neutropenia. He was ultimately discharged on G-CSF and daily
Ambisome infusions. He was admitted to the [**Hospital Unit Name 153**] on [**2157-7-27**] for
neutropenic fever and abdominal pain of unknown etiology. While
hospitalized he was treated with a 10-day course of decitabine
without complications.
.
OTHER PMH:
Disseminated Fusarium ([**5-14**]):treated with Ambisome and
Voriconazole
H/O Hepatitis B (on Lamivudine)
S/P appendectomy
S/P umbilical hernia repair
Social History:
Currently on disability. Wife is a retired physician. [**Name Initial (NameIs) **]
from [**Country 5976**]. Nonsmoker, no EtOH, no IVDU.
Family History:
One brother died of ALL. Denies DM, CAD, Strokes, other CAs
Physical Exam:
Admission Exam:
VS: T 98.5, BP 120/76, HR 69, RR 16, SpO2 100%RA
Gen: pleasant elderly male in NAD. Oriented x3. Mood, affect
appropriate.
[**Country 4459**]: NCAT. Sclera anicteric. PERRL, [**Country 3899**]. MMM, OP with
petechiae on posterior palate and 1X0.5cm submucosal
hardened/firm lesion on anterior roof of mouth with 2mm ulcer
over center. Missing teeth.
Neck: Supple, No cervical lymphadenopathy.
CV: RRR with normal S1, S2. No M/R/G.
Chest: CTAB without crackles, wheezes or rhonchi. No use of
accessory muscles
Abd: Normal bowel sounds. Soft, NT, mildly distended. +
splenomegaly.
Ext: WWP. Digital cap refill <2 sec. No C/C/E. Distal pulses
intact radial 2+, DP 2+, PT 2+.
Skin: Petechiae on lower abdomen around waist line, diffusely on
legs and feet. 1-4cm erythematous, blanching patches on anterior
shins with superficial ulcerations bilaterally.
Neuro: A&O x3.
Discharge Exam:
Pertinent Results:
Admission Labs:
[**2157-8-19**] 10:01AM [**Month/Day/Year 3143**] WBC-0.3* RBC-2.98* Hgb-9.0* Hct-24.8*
MCV-83 MCH-30.0 MCHC-36.2* RDW-14.7 Plt Ct-10*
[**2157-8-19**] 10:01AM [**Month/Day/Year 3143**] Neuts-0* Bands-0 Lymphs-67* Monos-0 Eos-0
Baso-0 Atyps-5* Metas-0 Myelos-0 Blasts-28*
[**2157-8-19**] 10:01AM [**Month/Day/Year 3143**] Hypochr-1+ Anisocy-2+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-2+ Polychr-NORMAL Ovalocy-1+
[**2157-8-19**] 10:01AM [**Month/Day/Year 3143**] Plt Smr-RARE Plt Ct-10*
[**2157-8-20**] 12:10AM [**Month/Day/Year 3143**] PT-15.2* PTT-31.7 INR(PT)-1.3*
[**2157-8-19**] 10:01AM [**Month/Day/Year 3143**] UreaN-25* Creat-1.1 Na-142 K-3.4 Cl-108
HCO3-25 AnGap-12
[**2157-8-19**] 10:01AM [**Month/Day/Year 3143**] ALT-33 AST-24 LD(LDH)-148 AlkPhos-218*
TotBili-0.6
[**2157-8-19**] 10:01AM [**Month/Day/Year 3143**] Calcium-8.5 Phos-3.8 Mg-1.7
Cultures:
[**2157-8-21**] [**Month/Day/Year **] culture: VRE
[**8-26**] [**Month/Day (4) **] culture X2 negative
[**8-30**] [**Month/Year (2) **] culture X2 negative
Imaging:
[**2157-8-21**] MRI soft tissue head: No evidence of enhancing soft
tissues or fluid collection identified in the neck. There is
minimal soft-tissue thickening in the partially visualized
maxillary sinuses. The patient previously had maxillary sinus
disease on prior sinus CT. if further evaluation of sinuses is
clinically indicated, consider a repeat sinus CT.
[**2157-8-30**] Echo: The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
are mildly thickened. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is mild pulmonary artery systolic hypertension.
There is a small to moderate sized pericardial effusion. There
is right ventricular diastolic collapse, consistent with
impaired fillling/tamponade physiology. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 20342**] was
notified by telephone on [**2157-8-30**] at 4:35 pm.
Compared with the prior study (images reviewed) of [**2157-8-1**],
the pericardial effusion is now larger and there is now right
ventricular diastolic collapse. Left ventricular systolic
function appears slightly more vigorous.
[**2157-9-2**] Echo: Overall left ventricular systolic function is
mildly depressed (LVEF= 50 %) with inferior hypokinesis. Right
ventricular chamber size and free wall motion are normal. There
is a small to moderate sized pericardial effusion. The effusion
appears circumferential. No right ventricular diastolic collapse
is seen. There is brief right atrial diastolic collapse
suggestive of elevated intrapericardial pressure without overt
tamponade. Compared with the prior study (images reviewed) of
[**2157-8-30**], no change.
[**2157-9-4**] RUQ US: 1. No biliary obstruction or other explanation
for abnormal LFTs. 2. Trace perihepatic ascites. 3. Right
pleural effusion.
4. Moderate pericardial effusion.
[**2157-9-4**] CXR: AP chest compared to [**6-27**] through [**7-30**]:
Moderate-to-severe enlargement of the cardiac silhouette which
enlarged
between [**6-13**] and [**7-27**] is unchanged subsequently.
Mediastinal and
pulmonary vascular engorgement are essentially unchanged since
[**Month (only) **], and edema is minimal, if any, difficult to
distinguish from relatively symmetric infrahilar opacification
which could also be due to mild-to-moderate atelectasis. There
is no pulmonary edema or consolidation in the upper lungs.
[**2157-9-9**] Echo: Normal LV size with low-normal systolic function.
Normal right ventricular chamber size and systolic function.
Moderate sized circumferential pericardial effusion with
evidence of early hemodynamic effect in inversion of the right
atrium, consistent with increased intrapericardial pressure. No
definitive signs of pericardial tamponade. In the setting of
elevated right sided pressures, echocardiographic evidence of
tamponade may be absent. Mild-moderate mitral regurgitation and
mild-moderate tricuspid regurgitation.
Compared with the findings of the prior study (images reviewed)
of [**2157-9-2**], the effusion is slightly larger and there is
slightly more pronounced diastolic inversion of the right
atrium.
[**2157-9-9**] CXR: In comparison with study of [**9-4**], there is
continued substantial enlargement of the cardiac silhouette with
less prominent vascular congestion that may reflect the PA
rather than supine AP technique. Opacification at the left base
in the retrocardiac region could merely reflect atelectasis,
though in the appropriate clinical setting supervening pneumonia
would have to be seriously considered. There is left and
possibly also right pleural effusion. Scattered streaks of
atelectasis are seen especially at the left base.
Pathology:
[**2157-8-20**] left shin biopsy: The sections shows patchy superficial
and mid-dermal hemorrhage. No primary vasculitis/microthrombotic
vasculitis are seen. There is no evidence of malignancy in this
specimen. Hemosiderin-laden macrophages are present in the
superficial dermis, compatible with relative chronicity of this
hemorrhagic episode. The PAS, GMS, and tissue Gram stains are
negative for microorganisms. Overall, the findings in this
biopsy are non-specific and are suggestive of purpura (e.g.
secondary to trauma, etc.). Culture growing enterococcus
[**2157-9-2**] Bone marrow biopsy: Immunophenotypic findings
consistent with involvement by persistent involvement by
patient's known acute leukemia.
As reported previously, the blasts express myeloid markers
(CD117, CD13) along with B-marker CD19, as well as CD7.
PERSISTENT ACUTE LEUKEMIA WITH MIXED LINEAGE PHENOTYPE (see
note).
Note: Blasts comprise 81% of aspirate differential and a
majority of the core cellularity (overall cellularity 90-100%).
Compared to the previous biopsy (S11-36436R, M11-540 dated
[**2157-7-21**]), the current marrow shows a significant increase in both
overall cellularity and blast count.
Brief Hospital Course:
Mr. [**Known lastname 1005**] is a 61 yo M with refractory biphenotypic leukemia
and history of disseminated fusarium [**Known lastname 2**], on Ambisome and
voriconazole in the setting of prolonged neutropenia from
induction chemotherapy. He was recently transferred to the CCU
for pericardio-centisis on [**2157-9-14**] and pericardial drain
(pulled [**9-16**]).
.
# BIPHENOTYPIC LEUKEMIA: Initial therapy was included hyperCVAD.
His day 14 marrow showed persistent disease and his regimen was
changed to 7+3. Two subsequent marrows all continued to show
persistent involvement with leukemia. Further chemotherapy was
held as he was found to have disseminated fusarium [**Month/Year (2) 2**] in
the setting of prolonged neutropenia. He then received 10 days
of decitabine (C1D41, [**2157-9-10**]). Continued home neupogen to
stimulate WBC in setting of fusarium [**Month/Day/Year 2**]. Patient remained
persistently neutropenic. [**9-2**] BM biopsy showed extensive
disease. The patient then received MEC (C1D1 [**2157-9-24**]). Following
this the patient was noted to have persistence of blasts in
periphery and continued to be pancytopenic. BM on day 21
([**2157-10-18**]) showed >80% blasts. He was discharged with plan to
discuss possible outpatient chemotherapy trials with primary
oncologist Dr. [**Last Name (STitle) **]. Patient was maintained on the following
ppx regimen: bactrim (switched from atovaquone [**10-17**]) and
atovaquone.
.
# FEBRILE NEUTROPENIA, BACTEREMIA: pt with low-grade fevers on
admission. Derm biopsy of left shin showed chronic changes, and
culture grew out enterococcus (likely seeded from [**Last Name (LF) **], [**First Name3 (LF) **]
derm). [**First Name3 (LF) **] culture from [**8-21**] grew VRE. No new murmurs.
[**2157-8-30**] echo showed no signs of endocarditis. Patient was
started on daptomycin for VRE. Repeat [**Month/Day/Year **] culture on [**10-11**] negative. Patient's legs stable without tenderness. Biopsy
site of left shin healing well, still with erythema. Bilateral
changes appear chronic. He spiked a fever in the CCU on [**9-14**]
after placement of pericardial drain ([**Last Name 788**] problem #4), at which
point empiric vancomycin and cefepime were started. Per ID recs,
daptomycin was discontinued. Negative infectious workup,
including UCx, BCx, pericardial fluid cx, and Quantiferon gold.
On [**10-11**], antibiotics were tapered to PO Levofloxacin. He was
discharged on Levoquin for ppx as outpatient, given his chronic
neutropenia.
.
# DISSEMINATED FUSARIUM [**Month/Year (2) **]: occurred in the setting of
neutropenia after induction chemotherapy. Voriconazole held
during chemo on [**11-8**]. Fusarium sensitivities are >4 for
Ambisome, >16 for Vori. On [**10-19**], Ambisome discontinued with
goal of pt returning home shortly not on ambisome infusions.
Patient was discharged on voriconazole. Most recent beta glucan
and galactomannan are negative.
.
# AFIB WITH RVR: On [**9-20**], pt developed new onset Afib with RVR
to the 140s in the setting of low potassium (has chronically low
potassium [**12-22**] ambisome). CXR WNL, electrolytes repleted, trops
neg X2. Managed initially with diltiazem, then switched to
metoprolol and diltiazem per cardiology recs, ultimately
titrated up to metoprolol 37.5mg PO q6 hours and diltiazem 60mg
PO q6 hours. HR in low 100s after that, pt asymptomatic. Pt not
anticoagulated as he is thrombocytopenic.
.
# PERICARDIAL EFFUSION: pt with evidence of cardiac tamponade in
early [**Month (only) **], found on hospitalization to have worsening
pericardial effusion and RV collapse. Repeat echo [**9-2**] showed
persistent effusion without signs of tamponade. Repeat [**9-9**]
echo unchanged, with elevated pulmonary artery pressures
(therefore, RV pressures are likely high, even if no RV
collapse/frank tamponade). On [**9-14**] pt had pericardiocentesis
with placement of pericardial drain, in the setting of starting
anthracycline with potential for cardiotoxicity and worsening
EF. He tolerated the procedure well, with inital output around
500-700 cc and he was transferred to the CCU. While in the CCU
the patient's pericardial drain output eventually started
decreasing and it was pulled. Pulsus remained normal throughout.
Analysis of fluid revealed transudate with reactive inflammatory
cells; cx (including mycobacteria and fungi) and cytology were
negative. However, this was still felt to be most likely
malignant effusion. Repeat TTE on [**2157-9-27**] showed persistence of
small effusion.
.
# PLEURAL EFFUSIONS: pt developed significant BL pleural
effusions of unknown etiology, most likely cardiac given pulm
vascular congestion. While pt had no respiratory compromise and
maintained normal O2 saturations, there was concern for eventual
compromise of lung expansion given severity of effusion. BL
chest tubes placed on [**9-22**], with drainage of about 2L on each
side. Pleural fluid analysis showed transudate with reactive
inflammatory cells; bacterial/mycobacterial/fungal cultures and
cytology negative. Removed R chest tube [**9-22**], unclamped and
removed L chest tube on [**9-23**]. On [**10-7**], left pleural effusion
showed interval worsening. On [**10-18**], CXR showed slightly
improved R atalectasis, stable L pleural effusion. Pt
intermittently clinically volume overloaded during
hospitalization, likely [**12-22**] his cardiopulmonary issues as well
as fluid overload from chemo. He received IV lasix and PO
spironolactone, transitioning to PO lasix and then ultimately
discharged on only spironolactone 20mg PO daily.
.
# RV STRAIN ON TTE: After the pericardial drain was place and
then later pulled, echocardiogram showed new significant RV
strain and volume overload. PE was high on DDx. Negative LENIs
and VQ scan (performed in lieu of CTA [**12-22**] rising creatinine and
thrombocytopenia).
.
# ACUTE RENAL FAILURE: While in the CCU, the patient developed
acute renal failure, with creatinine trending up to 2.1 in the
context of spiking a fever. Found to be prerenal in etiology as
well as from ATN, improved somewhat with IV fluids. Meds renally
dosed, nephrotoxins avoided.
.
# ANEMIA/THROMBOCYTOPENIA: [**12-22**] leukemia, as well as autoimmune
destruction and splenic sequestration (pt with massive
splenomegaly). Patient requiring frequent (q1-2 days) [**Month/Day (2) **] and
platelet transfusions. Goal HCT>25, platelets>20 (or >20 if
having nosebleed).
.
# HEPATITIS B: patient with positive surface and core antibodies
in [**3-30**]. Patient is maintained on Lamivudine. Pt with mildly
elevated LFTs during hospitalization, which improved after
Bactrim was discontinued. Bactrim then restarted without issues.
.
# MECHANICAL FALL: pt had mechanical fall while walking from the
bathroom on the evening of [**2157-9-26**] with minor head trauma and no
other injuries. Given his thrombocytopenia, received immediate
transfusion 2 units platelets. STAT head CT showed no acute
hemorrhage, edema, mass effect or skull fracture but was notable
for left frontal subgaleal hematoma. Serial neurologic exams
WNL. Follow up head CT one week later revealed resolving left
frontal subgaleal hematoma. Pt suffered no consequent
disabilities as a result of this incident.
.
# ORAL LESION: located under patient's dentures. It is unclear
how long it has been present for, but seems to be chronic mass
(possibly congenital) that is newly irritated X4-5days by
dentures. MR showed no evidence of enhancing soft tissues or
fluid collection. Mass does not appear infected and was only
monitored on admission.
.
# MOOD INSTABILITY: Patient has a history of mood instability,
managed on olanzapine. This was continued during
hospitalization.
Medications on Admission:
acyclovir
ambisome
folic acid
lamivudine
levofloxacin
olanzapine
oxycodone
potassium chloride
bactrim
voriconazole
magnesium oxide-Mg AA chelate
Centrum
Omega 3- fish oil
Discharge Medications:
1. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. voriconazole 200 mg Tablet Sig: 1.5 Tablets PO Q12H (every 12
hours).
Disp:*90 Tablet(s)* Refills:*2*
3. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
Disp:*30 Tablet(s)* Refills:*2*
4. lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
Three (3) Tablet Extended Release 24 hr PO once a day.
Disp:*90 Tablet Extended Release 24 hr(s)* Refills:*2*
7. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*90 Tablet(s)* Refills:*2*
8. diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours).
Disp:*120 Tablet(s)* Refills:*2*
9. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
Disp:*12 Tablet(s)* Refills:*2*
11. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for nausea/anxiety/insomnia.
Disp:*120 Tablet(s)* Refills:*0*
13. ipratropium bromide 0.02 % Solution Sig: One (1) neb
treatment Inhalation every four (4) hours as needed for
shortness of breath or wheezing.
Disp:*1 inhaler* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Primary Diagonsis: disseminiated fusarium, VRE bacteremia
Secondary Diagnosis: Biphenotypic Leukemia
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 1005**],
It was a pleasure taking care of you in the hospital. You were
admitted because your doctors suspected your [**Name5 (PTitle) 2**] was
worsening. Your treatment for the fungal [**Name5 (PTitle) 2**] was
continued. You were found to have a bacteria (called
Enterococcus) growing in your [**Name5 (PTitle) **] and on skin biopsy and so
you were treated with an antibiotic called daptomycin. You got
several imaging studies of your heart because we were worried
about the fluid around it. You were given small doses of lasix
to manage the extra fluid in your body and to help you breathe
more easily. You also had irregular and rapid heart beat
(atrial fibrillation) which we treated with diltiazem and
metoprolol. Finally, you had a repeat bone marrow biopsy that
showed persistent leukemia. After discussion with your family
and Dr. [**Last Name (STitle) **], it was decided that you would be discharged home
with outpatient followup to determine how to proceed with your
care.
Please attend the follow-up appointments with Dr. [**Last Name (STitle) **] and
nursing listed below.
We made the following changes to your medications:
1. STARTED diltiazem 60mg by mouth every 6 hours
2. STARTED metoprolol succinate 150mg by mouth once daily
3. STARTED spironolactone 25mg by mouth daily
4. STARTED bactrim DS (double strength) on Mondays, Wednesdays
and Fridays
5. STARTED ipratropium nebulizer 1 treatment every 4 hours as
needed for wheezing/shortness of breath
6. INCREASED voriconazole to 300mg by mouth twice daily (from
300mg by mouth once daily)
Followup Instructions:
Department: BMT CHAIRS & ROOMS
When: TUESDAY [**2157-10-25**] at 12:00 PM
Department: HEMATOLOGY/BMT
When: TUESDAY [**2157-10-25**] at 12:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/BMT
When: TUESDAY [**2157-10-25**] at 2:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7779**], MD [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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icd9cm
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[
[
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icd9pcs
|
[
[
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19958, 20033
|
10622, 18308
|
343, 477
|
20178, 20178
|
4381, 4381
|
21980, 22696
|
3387, 3448
|
18529, 19935
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20054, 20112
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18334, 18506
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20361, 21508
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3463, 4345
|
4362, 4362
|
21537, 21957
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1659, 2047
|
266, 305
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505, 1640
|
20133, 20157
|
4397, 10599
|
20193, 20337
|
2069, 3215
|
3231, 3371
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,573
| 144,106
|
1121
|
Discharge summary
|
report
|
Admission Date: [**2129-9-24**] Discharge Date: [**2129-9-29**]
Date of Birth: [**2070-7-15**] Sex: M
Service: MEDICINE
Allergies:
Cefepime
Attending:[**First Name3 (LF) 7223**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization and stent placement
Temporary pacing wire placed immediately after catheterization,
removed within 24 hours.
History of Present Illness:
This is a 59 yo man with CAD s/p 3V CABG in [**2-27**], PVD, ESRD on
HD, DM who presented for left sided chest pain, [**6-5**], sharp in
nature without radiation, associated w/SOB and N/Vomiting x 1,
+visual changes "blurry" started at 10PM last night, waking him
from sleep and was ongoing. He reported this as different from
his typical anginal pain in that it was very sharp and localized
as opposed to diffuse pressure. He took nitroglycerin x 2 w/o
relief. He noted that he had been chest pain free since his
recent hospital discharge [**2129-9-2**] and noted that he has been
otherwise well. Of note, during that hospitalization he was
found to have patent stents and had a LM/LCx cypher stent
placed. Pt reports vigilantly taking all of his post discharge
medications, including his ASA and plavix. His usual angina he
describes as a "squeeze" brought on by exertion, and he
experiences angina walking up hills and 1 flight of stairs.
.
In the ED, the patient had EKG w/ST changes in V1 and V2 stable
on serial EKGs, Cardiology was consulted and recommended
starting heparin IV. Pt was started on Nitroglycerin gtt and
received Morphine Sulfate 4mg as well as ASA. Pt's pain
decreased to [**2-5**] after morphine.
.
He denied 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 also denied recent fevers, chills or rigors. He did
report exertional calf pain. All of the other review of systems
were negative.
Cardiac review of systems [**Last Name (un) **] notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope. He did report chest pain with exertion as above.
.
Past Medical History:
1. CAD
2. CHF, [**Last Name (un) 7216**], grade II
3. PVD, s/p stenting of the bilateral CIA's, L EIA and PCI of
the left SFA
4. HTN
5. DM II
6. Dyslipidemia
7. ESRD on HD T/R/Sa [**1-28**] DM II, currently undergoing evaluation
for renal transplant
8. Pulmonary fibrosis: PET scan [**5-2**] showed no areas of abl
FDG uptake, cannot r/o broncheoalveolar ca
9. ?COPD
10. Tracheomalacia
12. h/o C. diff
13. h/o UGIB: EGD in [**2-2**] showed non-bleeding [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
tear, gastropathy, and gastritis.
Social History:
Significant for the h/o tobacco use of 15 pack years, quit 14
years ago. There is no history of alcohol abuse. Denies IVDU or
any hx of drug use. From [**Country 7192**], here for past 20 years, and
he returns there annually to visit family. He lives alone in
[**Location (un) 2312**] on disability, with brother close by. No pets.
Family History:
Mother and father with DM II. Father lived to [**Age over 90 **] yo. Pt denied
history of heart disease, sudden deaths.
Physical Exam:
VS: T 97.4 BP 173/66 HR 71 RR 14 O298%4L
Gen: Hispanic middle aged male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP of 5cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. 2+ systolic murmur, 1+ [**Age over 90 7216**] murmur. No
r/g. No thrills, lifts. 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. Abd aorta not enlarged by
palpation. No abdominial bruits.
rectal: guiac (-)
Ext: 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:
[**2129-9-24**] 12:45AM PT-12.7 PTT-28.0 INR(PT)-1.1
[**2129-9-24**] 12:45AM PLT COUNT-177
[**2129-9-24**] 12:45AM NEUTS-72.0* LYMPHS-17.6* MONOS-6.5 EOS-3.4
BASOS-0.3
[**2129-9-24**] 12:45AM WBC-6.9 RBC-3.62* HGB-12.3* HCT-35.3* MCV-98
MCH-33.9* MCHC-34.7 RDW-15.2
[**2129-9-24**] 12:45AM CALCIUM-9.1 PHOSPHATE-3.2# MAGNESIUM-2.7*
[**2129-9-24**] 12:45AM CK-MB-NotDone
[**2129-9-24**] 12:45AM cTropnT-0.23*
[**2129-9-24**] 12:45AM CK(CPK)-66
[**2129-9-24**] 12:45AM estGFR-Using this
[**2129-9-24**] 12:45AM GLUCOSE-340* UREA N-37* CREAT-7.7*#
SODIUM-137 POTASSIUM-4.2 CHLORIDE-97 TOTAL CO2-26 ANION GAP-18
.
MEDICAL DECISION MAKING:
[**2129-9-25**] (admission ECG): "Sinus rhythm. Diffuse non-specific
ST-T wave changes. Compared to the prior tracing there is no
significant change."
.
[**2129-9-26**] (on transfer to CCU post-catheterization): EKG
demonstrated sinus bradycardia with PR prolongation, occasional
dropped beats and intermittent pacing. long QT interval,
inverted T-waves in leads I, aVL, V5-V6, and peaked T-waves in
the precordial leads V1, V2. Incomplete right bundle branch
block.
.
TTE ([**2129-9-26**]):
There is mild symmetric left ventricular hypertrophy with normal
cavity size and systolic function (LVEF>55%). Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Mild to moderate ([**12-28**]+) mitral regurgitation is
seen.
.
CARDIAC CATH performed on [**9-2**] demonstrated:
COMMENTS:
1. Coronary angiography in this right-dominant system revealed
three-vessel disease:
--The LMCA had a distal taper with 60% stenosis and modest
calcification.
--The LAD had proximal calcification with competitive flow
distally.
--The LCx was a non-dominant vessel with a proximal 80% stenosis
and
modest calcification.
--The RCA was a dominant vessel that was occluded proximally.
2. Arterial conduit angiography revealed the LIMA to be widely
patent.
The SVG-OM1 and SVG-RPDA grafts were widely patent.
3. Resting hemodynamics revealed normal left-sided filling
pressures
with LVEDP of 12 mmHg. Systemic arterial systolic and [**Month/Year (2) 7216**]
pressures were normal. Upon pullback of the angled pigtail
catheter
from left ventricle to aorta, no gradient was observed across
the aortic
valve.
4. Successful stenting of the protected LM/LCx lesion with a
2.5x13
mm cypher stent which was postdilated to 2.75mm. Final
angiography
revealed 0% residual stenosis, no angiographically apparent
dissection
and TIMI 3 flow (see PTCA comments).
Summary:Successful stenting of the LM/LCx lesion.
.
Cardiac catheterization [**9-26**], with LAD stenting and D1 POBA. No
right heart catheterization.
.
CT scan [**9-26**]:
IMPRESSION:
1. No evidence of retroperitoneal hematoma.
2. Extensive atherosclerosis of the abdominal aorta and other
abdominal vessels.
3. Aortobi-iliac stent graft.
4. Cholelithiasis.
.
Brief Hospital Course:
Mr [**Known lastname 7203**] is a 59 yo man with CAD s/p 3V CABG in [**2-27**], PVD,
ESRD on HD, DM who presented to [**Hospital1 18**] for chest pain and EKG
changes.
.
#) CAD with unstable angina: EKG showed findings potentially
consistent with inferior wall ischemia. His first set of
troponins was slightly elevated from baseline. His chest pain
improved incompletely on nitroglycerin drip. Given the EKG
changes and persistent CP, heparin drip was started. His
nitroglycerin drip was stopped for hemodialysis. His isosorbide
mononitrate was increased to 120 mg daily with blood pressure
paramaters. We continued atorvastatin, labetalol and full dose
aspirin. We added norvasc. He was taken to the cath lab on [**9-26**],
where he had a LAD stent and D1 rescue as noted above, but after
which he had bradycardia and hypotension, unresponsive to
atropine. He had temporary pacing wires placed and was placed on
dopamine and transferred to the CCU. He soon stabilized there,
and was transferred back to the [**Hospital1 1516**] service the next day, with
pacing wires removed.
.
We narrowed his blood pressure medicine for discharge somewhat
given the possibility that his bradycardia and hypotension may
have been related to a failure to be able to compensate
peripherally for a vagal episode. Accordingly we discontinued
labetalol and after observation in the CCU, started metoprolol
and lisinopril, observed him to ensure there were no problems
with these medications, and seeing good control and no episodes
of hypotension, we discharged him to home.
.
#) Bradycardia with hypotension:
As noted above, he had a brief period of rapid-onset bradycardia
and hypotension immediately after his catheterization procedure.
We judged this to be most likely the result of a vagal effect
combined with labetalol/diltiazem/nifedipine which did not allow
for compensatory BP and PVR rise. We were initially concerned
that an increased dose of labetalol might have been the problem
but the acute timing of onset makes pure medication effects less
likely because overload of medicine effects should occur more
gradually. Additionally, medicines increased in the day prior to
procedure should have reached peak or near-peak levels before
the procedure. After transfer back from the CCU, the patient had
normal blood pressures, though strikingly this was off the
considerable number of BP meds he was on prior without rebound,
which might argue against purely transient vagal effect. There
was no evidence of infection (no prodrome; no other indicators
of sepsis like fever, increased organ failure, etc; a WBC rise
was transient and likely stress-related).
After observing patient after transfer back to the cardiac
medicine floor, we were satisfied that he was stable. On review
of his history, we noted that he had also had at least one
hypotensive episode in the past associated with hemodialysis, so
certainly vigilance for this complication will be helpful for
his care providers in the future.
.
#) Hyperkalemia - In addition to his bradycardia and
hypotension, Mr [**Known lastname 7203**] was found to have a potassium of greater
than 7 in this post-procedure time. He had emergent dialysis at
this point, after which he had a complete dialysis cycle the
next day. Notably, he had an acute rise in K in the post cath
setting, despite a pre-cath dose of kayexelate. This was likely
secondary ESRD combined with transient poor perfusion preventing
kidneys from excreting even the small amount of potassium which
they generally contribute. The renal service advised the CCU
team and the [**Hospital1 1516**] service team, and the patient underwent
dialysis on his usual T Th Sat schedule.
.
#) Congestive heart failure, [**Hospital1 7216**], grade II: Mr [**Known lastname 7203**] was
clinically mildly overloaded by exam on arrival, with crackles
at his lung bases. His fluid status was controlled with
hemodialysis; the inpatient renal dialysis team followed along
with his care and provided [**Known lastname 7219**] to the primary team.
.
#) Hyperlipidemia: We continued his outpatient statin.
.
#) HTN: The plan was initially to continue outpatient labetalol
and Imdur, while increasing Imdur and adding an ACEi. However,
as above, we were concerned that labetalol might have
contributed to his episode of hypotension and bradycardia, and
sent him home with metoprolol after a period of observation, as
above.
.
#) ESRD: The patient had dialysis on his regular schedule of
T/TH/Sat.
.
#) PVD: The patient was s/p stenting of the bilateral CIA's, L
EIA and PCI of
the left SFA. He was continued on his ASA and started on Plavix,
which he will also need to continue as the result of the stent
placed during this admission.
.
#) DM: QID fingersticks and sliding scale insulin provided
generally effective control of his sugar levels.
.
#) FEN: He was placed on a cardiac diet; electrolyte monitoring
and repletion was undertaken in conjunction with dialysis.
.
#) PPx: Heparin IV.
.
#) Access: PIV, L AV fistula for dialysis.
.
#) Dispo: To home.
.
#) Code: Full.
Medications on Admission:
Labetalol 200 mg PO BID
Isosorbide Mononitrate 60 mg PO daily
Aspirin 81 mg PO DAILY
Atorvastatin 80 mg PO DAILY
[**Known lastname 7222**] 800 mg PO TID W/MEALS
nephrocaps
Zantac 150mg daily
Pregabalin 25 mg PO daily
Clopidogrel 75 mg Tablet PO DAILY
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. [**Known lastname 7222**] 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3
TIMES A DAY WITH MEALS).
Disp:*90 Tablet(s)* Refills:*2*
4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
5. Pregabalin 25 mg Capsule Sig: One (1) Capsule PO daily ().
Disp:*30 Capsule(s)* Refills:*2*
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*30 Tablet(s)* Refills:*0*
7. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
Disp:*30 Tablet, Sublingual(s)* Refills:*0*
8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Metoprolol Succinate 50 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. 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*
12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
13. Zantac 150 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Coronary artery disease
Discharge Condition:
Good
Discharge Instructions:
1)You were admitted to the hospital because of chest pain. This
can sometimes be a sign of problems with your heart. You got a
procedure called cardiac catheterization. In this procedure, a
stent was placed into one of the arteries in your heart. The
stent will help make sure that blood flows through this artery.
This may prevent you from having chest pain in the future, and
also may help to prevent future heart problems.
2)Take your medications as shown in your medication sheet. There
were a few changes that were made to your medication list.
Please stop taking the Amlodipine (Norvasc) and Labetolol. You
were started on 3 new medications: Lipitor, Lisinopril, and
Toprol XL. You should continue taking you aspirin and Plavix
everyday. You will be given prescriptions prior to being
discharged home.
3)Please attend all appointments as listed below. Please
schedule an appointment with your cardiologist, Dr. [**First Name (STitle) **]
within the next few weeks.
4)If you have any chest pain, shortness of breath, dizziness, or
any other concerning symptoms please return to the emergency
room.
Followup Instructions:
1)[**Last Name (NamePattern5) 7224**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 62**] Date/Time:[**2129-10-6**] 2:30
2)[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7212**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2129-10-11**] 4:40
3)[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]. GI FACULTY (SB) Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2129-10-14**] 8:00
|
[
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"585.6",
"V49.83",
"443.9",
"515",
"458.29",
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"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.66",
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"00.45",
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icd9pcs
|
[
[
[]
]
] |
14092, 14098
|
7140, 12205
|
281, 416
|
14166, 14173
|
4234, 7117
|
15327, 15781
|
3161, 3282
|
12507, 14069
|
14119, 14145
|
12231, 12484
|
14197, 15304
|
3297, 4215
|
230, 243
|
444, 2208
|
2230, 2796
|
2812, 3145
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,027
| 106,506
|
41039
|
Discharge summary
|
report
|
Admission Date: [**2196-8-9**] Discharge Date: [**2196-8-12**]
Date of Birth: [**2151-11-26**] Sex: M
Service: MEDICINE
Allergies:
Piroxicam / Tramadol / gabapentin
Attending:[**First Name3 (LF) 594**]
Chief Complaint:
Chief Complaint: AMS
Reason for MICU transfer: AMS
Major Surgical or Invasive Procedure:
Interventional radiology guided replacement of urostomy tube
History of Present Illness:
44M from home with end stage bladder cancer with mets. Pt is a
poor historian at baseline. Per wife, increased confusion,
altered from his baseline. Not confused at baseline. No new med
changes. He had a ct scan of the head that was neg. He was found
to be in massive renal failure and a ct scan of his abd showed
that there was a nectoric tumor mass that is compressing the
ileal conduit that is causing hypronephrosis and obstruction to
the kidneys bilaterally. Urology was consulted and they were
able to place a red rubber in stoma with return of urine and
good urine output.
.
In the ED, initial VS were: 23:45 4 98.4 115 127/79 18 98%
.
Patient was given cipro 400mg IV x1, Flagyl 500mg IV x1, 1mg
dilaudid x3, Calcium gluconate 1amp x1, 1 amp dextrose, 10 units
insulin
.
Admission Vitals: 98.4; 115; 127/79; 18; 98%
Past Medical History:
PAST MEDICAL HISTORY
- Bladder cancer
- Radical cystoprostatectomy with ileal conduit urinary
diversion
([**2195-8-28**])
- Lymphedema of lower extremity, left; scrotal/phallus edema
- GERD
- PTX in [**2176**], [**2180**] s/p chest tube
- C3-7 laminectomy with fusion for stenosis
- Bilateral PE dx [**9-3**] after surgery - on Lovenox
.
Onc PMhx:
- Muscle invasive bladder cancer-TURB at [**Hospital1 18**] on
[**2195-2-27**]-poorly differentiated, sarcomatoid. S/p neoadjuvant
Cisplat/Gemzar, followed by cystectomy [**2195-8-28**] at [**Hospital1 **] (above)
- [**2196-2-25**] B12 1000mcg im
- [**2196-3-15**] C1D1 Taxol (25% dose reduction)
- [**2196-3-22**] C1D8 Taxol + Alimta (25% dose reduction)
- [**2196-5-12**] C2D1 Taxol (25% dose reduction)
- [**2196-5-13**] B12
- [**2196-5-19**] C2D8 Taxol + Alimta (25% dose reduction)
- [**2196-6-2**] C3D1 Taxol + Alimta (100%)
- [**2196-6-9**] C3D8 Taxol + Alimta (100%)
Social History:
Lives in [**Location 745**] with his wife and step daugther. Has 2 other
sons. [**Name (NI) 3003**] [**Name2 (NI) 1818**], no current alcohol use.
Family History:
- Mother: COPD, Cervical CA
- Father: CAD/PVD (early, angina @ 55yo, prostate CA, substance
abuse, lung CA), deseased from prostate ca.
- hemochromatosis, paternal cousin
Physical Exam:
Admission Exam:
Vitals: P 113 BP 130/76 Temp 99 RR 21
General: Cachetic appearing
HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI, PERRL
w/ 3->2mm
Neck: supple, JVP not elevated, no LAD
CV: Tachycardia regular rate and rhythm, normal S1 + S2, no
murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: Large RLQ fungating mass that appears to be partial
necrotic mass with red [**Doctor First Name **] foley sutured in place with bag
covering.
GU: edmatous penis
Ext: warm, well perfused, 2+ pulses for UE, 1+ for
RLE,Dolparable for LLE, LLE is edematous
Neuro: CNII-XII intact, follows commands, axox3, tic throughout
no asterixis
.
Discharge Exam:
Vitals: P 106 BP 139/73 Temp 98.8 RR 14
General: Cachetic appearing
HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI, PERRL
w/ 3->2mm
Neck: supple, JVP not elevated, no LAD
CV: Tachycardia regular rate and rhythm, normal S1 + S2, no
murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: Large RLQ fungating mass that appears to be partial
necrotic mass, now with large-bore catheter tube draining from
ileal urinary diversion site.
Ext: warm, well perfused, 2+ pulses for UE, 1+ for
RLE,Dolparable for LLE, LLE is edematous
Neuro: CNII-XII intact, follows commands, a+ox3, no asterixis,
not able to recall all the events of past few days
Pertinent Results:
[**2196-8-9**] 01:37PM LACTATE-0.9
[**2196-8-9**] 01:18PM GLUCOSE-102* UREA N-58* CREAT-6.1*#
SODIUM-134 POTASSIUM-4.7 CHLORIDE-99 TOTAL CO2-22 ANION GAP-18
[**2196-8-9**] 01:18PM ALT(SGPT)-8 AST(SGOT)-10 LD(LDH)-159 ALK
PHOS-131* TOT BILI-0.1
[**2196-8-9**] 01:18PM ALBUMIN-3.0* CALCIUM-8.5 PHOSPHATE-5.5*
MAGNESIUM-1.8
[**2196-8-9**] 01:18PM WBC-18.3* RBC-2.87* HGB-9.5* HCT-28.3*
MCV-99* MCH-33.2* MCHC-33.7 RDW-15.9*
[**2196-8-9**] 01:18PM PLT COUNT-385
[**2196-8-9**] 01:18PM PT-14.7* PTT-30.1 INR(PT)-1.4*
[**2196-8-9**] 09:35AM LACTATE-1.0
[**2196-8-9**] 09:05AM WBC-19.5* RBC-2.98* HGB-9.8* HCT-29.4*
MCV-99* MCH-33.0* MCHC-33.5 RDW-15.9*
[**2196-8-9**] 09:05AM PT-14.3* PTT-29.7 INR(PT)-1.3*
[**2196-8-9**] 04:40AM PT-15.2* PTT-28.4 INR(PT)-1.4*
[**2196-8-9**] 04:15AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2196-8-9**] 04:15AM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-TR
[**2196-8-9**] 04:15AM URINE RBC-<1 WBC-4 BACTERIA-FEW YEAST-NONE
EPI-0
[**2196-8-9**] 02:43AM LACTATE-3.7*
[**2196-8-9**] 12:50AM URINE OSMOLAL-289
[**2196-8-9**] 12:50AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2196-8-9**] 12:50AM URINE COLOR-RED APPEAR-Cloudy SP [**Last Name (un) 155**]-1.013
[**2196-8-9**] 12:50AM URINE BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-LG
[**2196-8-9**] 12:50AM URINE RBC-23* WBC-81* BACTERIA-MOD YEAST-NONE
EPI-8
[**2196-8-9**] 12:15AM GLUCOSE-111* UREA N-71* CREAT-9.9*#
SODIUM-127* POTASSIUM-6.1* CHLORIDE-89* TOTAL CO2-20* ANION
GAP-24*
[**2196-8-9**] 12:15AM estGFR-Using this
[**2196-8-9**] 12:15AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2196-8-9**] 12:15AM NEUTS-90.4* LYMPHS-3.5* MONOS-3.5 EOS-2.6
BASOS-0.1
[**2196-8-9**] 12:15AM PLT COUNT-439
Labs on discharge:
[**2196-8-11**] 03:45AM BLOOD WBC-17.9* RBC-2.85* Hgb-9.3* Hct-28.3*
MCV-99* MCH-32.5* MCHC-32.7 RDW-15.9* Plt Ct-377
[**2196-8-11**] 03:45AM BLOOD PT-15.6* PTT-22.4* INR(PT)-1.5*
[**2196-8-11**] 03:45AM BLOOD Glucose-121* UreaN-29* Creat-2.6* Na-137
K-4.3 Cl-104 HCO3-19* AnGap-18
Radiology
CT A/P: 7.6 x 5.5 cm heterogeneous subcutaneous high density
area is concerning for a complex fluid collection, possibly an
abscess at the ostomy site. This causes compression of the
exiting ileal loop that causes dilatation of the small bowel and
bilateral hydronephrosis. Recommend urgent urology consult.
Additionally the suture material around the side to side bowel
anastamosis more proximally is different in configuration to
the prior CT examination though the area is incompletely
evaluated due to the lack of IV contrast.
.
CT Head: no acute changes
.
CXR: The lungs are low in volume and show three right lung
nodules measuring 14 mm the right upper lobe and 19 and 16 mm in
the right lower lobe. A left lower lobe lesion is better seen on
the concurrently performed abdomen and pelvis CT. The
cardiomediastinal silhouette and hilar contours are normal. No
pleural effusion or pneumothorax is present. An anterior
cervical fusion device is partially imaged.
IMPRESSION:
No acute intrathoracic process. Right pulmonary metastases have
increased in size
.
Repeat CT (after red [**Doctor First Name **] tube placed)
1. Interval partial decompression of the ileal conduit, status
post percutaneous placement of a large-bore conduit catheter.
The degree of moderate hydronephrosis, bilaterally, is not
significantly changed over the short interval.
2. Large parastomal mass, several omental metastases, and
retroperitoneal/pararectal lymphadenopathy, though unchanged
compared to CT from earlier today, are new compared to the [**3-26**], [**2196**] study.
3. Unchanged small-to-moderate volume ascites.
4. Asymmetric subcutaneous edema involving the visualized
portion of the proximal left thigh, increased compared to the
prior study from [**2196-3-26**], with no (non-contrast) CT
evidence of DVT. This finding should be interpreted in the
context of known left lower extremity lymphedema, as discussed
on the prior ultrasound report from [**2196-4-8**].
5. Unchanged small fluid collection anterior to the pubic
symphysis, in continuity with a probable large hydrocele.
Brief Hospital Course:
44 year old man with past medical history of metastatic bladder
cancer s/p neoadjuvant chemo, followed by radical
cystoprostatectomy with ileal conduit urinary diversion,
radiation who was brought in for AMS and found to have [**Last Name (un) **] and
bilateral hydronephrosis secondary to a high density obstruction
temporarily relieved with red [**Doctor First Name **] catheter awaiting further
management.
.
#AMS: Pt was initially somnolent but improved to A&Ox3 on ICU
day 1 after red [**Doctor First Name **] cath placed to relieve the obstructive
uropathy. Likely was secondary to uremia. CT head did not show
evidence of metastases. His mental status improved and remained
stable throughout ICU course.
.
#Acute renal failure, postrenal: Necrotic tumor next to ileal
conduit causing obstruction, obstruction as evidenced by b/l
hydronephrosis, baseline Cr is 0.9. Upon admission, Cr>9. After
red [**Doctor First Name **] cath placed into ileal conduit, repeat CT showed mild
improvement of hydronephrosis. The patient was treated with IV
fluids. Cr improved and trended down to 3.4 on Hospital Day 2
and to 2.6 on [**2196-8-11**]. Pt had IR placement of percutaneous
catheter into ileal conduit on [**2196-8-11**]. The patient was
followed by the Nephrology Consult Service, who signed off on
[**8-10**], when the patient's GFR returned to [**Location 213**].
.
#Leukocytosis: white count elevated >19 and persistent while on
ciprofloxacin. Urine culture eventually grew out Enterococcus,
but only 10k-100k colonies, and the patient did not have
symptoms of sepsis. Sensitivities showed VRE, and Linezolid was
not an option given multiple interactions with patient's other
medications. Therefore, the patient was offered the option of
having a PICC placed for home IV therapy. He declined this
option, and, therefore, will not go home on any antibiotics.
.
#Metabolic Derangments: Patient initially presented with anion
gap metabolic acidosis, hyperkalemia, and hyponatremia. The
acidosis and hyperkalemia were likely due to the acute renal
insufficiency. They resolved when the obstruction was fixed and
when renal function returned to baseline. The hyponatremia was
likely due to volume depletion leading to ADH release. It
resolved after volume resuscitation.
.
#Goals of Care / Pain Management: Goals of care were discussed
between the patient, his family, the MICU team, the [**Location (un) 2274**]
Palliative Care attending, the Hospice nurse, the Urology team,
the patient's primary urologist Dr. [**Last Name (STitle) **], the Hem/Onc Consult
Service, Interventional Radiology, and the patient's primary
oncologist Dr. [**Last Name (STitle) **]. The goal of this hospitalization was
to clear the patient's urinary obstruction in a more permanent
way with the least invasive procedure possible. Therefore,
percutaneous catheter was placed by IR, as discussed above. The
patient and his wife expressed their desire to pursue Hospice
care after discharge from the hospital. The patient's pain was
managed with fentanyl patch, which we increased in dose from
150mcg Q72H to 200mcg Q72H at the recommendation of the Atrius
Palliative Care attending. For break-through pain, the patient
was first treated with IV fentanyl, then with PO oxycodone
(which was discontinued due to myoclonus), and finally PO
Dilaudid 4mg 1-2 tabs q4h PRN. He was discharged with Hospice
care.
.
***Transitional issues:
#The patient and his wife expressed that it is not in their
interest for the patient to be readmitted into the hospital in
the future. Patient is to return home with hospice services.
#The patient has requested home O2, a wheelchair, and a hospital
bed at home.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR His palliative care doctor.
1. Ondansetron 8 mg PO Q8H:PRN nausea
2. butalbital-acetaminophen-caff *NF* 50-325-40 mg Oral q8h PRN
headache
3. BuPROPion (Sustained Release) 150 mg PO BID
4. Prochlorperazine 5 mg PO Q4-6H PRN nausea
5. Quetiapine Fumarate 100 mg PO QHS:PRN insomnia
6. Mineral Oil Dose is Unknown PO BID
7. Lorazepam 0.5 mg PO Q8H:PRN nausea/ anxiety
8. Docusate Sodium 100 mg PO BID
9. Senna 1 TAB PO BID:PRN constipation
10. Enoxaparin Sodium 80 mg SC BID
11. OxycoDONE (Immediate Release) 60 mg PO Q3H:PRN pain
12. Omeprazole 40 mg PO DAILY
13. Citalopram 30 mg PO DAILY
14. FoLIC Acid 1 mg PO DAILY
15. Fentanyl Patch 150 mcg/hr TP Q72H
Discharge Medications:
1. Atropine Sulfate 1% 2 DROP SL Q4H:PRN secretions
RX *atropine sulfate (PF) 1 % 2 drops SL Q4H PRN Disp #*30
Milliliter Refills:*0
2. BuPROPion (Sustained Release) 150 mg PO BID
3. Citalopram 30 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. FoLIC Acid 1 mg PO DAILY
6. Omeprazole 40 mg PO DAILY
7. Ondansetron 8 mg PO Q8H:PRN nausea
8. Prochlorperazine 5 mg PO Q4-6H PRN nausea
9. Quetiapine Fumarate 100 mg PO QHS:PRN insomnia
10. Senna 1 TAB PO BID:PRN constipation
11. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
RX *bisacodyl 5 mg 2 tablet(s) by mouth Daily PRN Disp #*30
Tablet Refills:*0
12. butalbital-acetaminophen-caff *NF* 50 mg ORAL Q8H PRN
headache
13. Mineral Oil 15-30 mL PO BID
14. Lorazepam 0.5 mg PO Q8H:PRN nausea/ anxiety
15. Fentanyl Patch 200 mcg/hr TP Q72H
RX *fentanyl 100 mcg/hour Apply 2 patches Q72H Disp #*20
Transdermal Patch Refills:*0
16. HYDROmorphone (Dilaudid) 4 mg PO Q4H:PRN pain
RX *hydromorphone 4 mg 1 tablet(s) by mouth q4h PRN Disp #*42
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary:
Acute kidney injury
Bladder cancer
Lymphedema of lower extremity
GERD
Pulmonary emboli
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr [**Known lastname 60816**],
It was our pleasure to care for you at [**Hospital1 18**]. You were admitted
for obstruction of your ureters. We were able to place a tube
to drain out the urine and relieve the stress on the kidneys.
We made the following changes to your medications:
STOP taking enoxaparin
STOP oxycodone
START taking atropine sublingually as needed for secretions
use two FENTANYL patches (100mcg each) at an INCREASED DOSE of
200mcg every 72 hours
START Dilaudid 4mg 1-2 tablets by mouth every 4 hours as needed
for pain
Please take all other medications as previously prescribed.
|
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icd9cm
|
[
[
[]
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[
"59.93"
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icd9pcs
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[
[
[]
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344, 407
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14056, 14056
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1282, 2209
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2225, 2375
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,884
| 146,330
|
38203
|
Discharge summary
|
report
|
Admission Date: [**2128-5-30**] Discharge Date: [**2128-6-1**]
Date of Birth: [**2051-7-19**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 76 year old male with a medical history of localized
gastric cancer s/p billroth II and chemo and lung cancer s/p
lobectomy (both 20 years ago) who presented to OSH with nausea
since last evening. He was in his usual state of health unil
about a month ago. At that time he was diagnosed with a TIA
(symptoms of arm and leg parasthesias). One to two weeks later
he had erythema and edema of his left leg and was diagnosed with
a LLE DVT and started on coumadin. He was then doing well until
one day prior to admit. He started complaining of indigestion
that was relieved with belching. HE had decreased PO intake. On
morning of admit his appetite improved and was able to tolerate
some PO intake. Later in the day he started feeling very
lethargic and was a little confused. His wife was concerned he
was having another TIA and brought him to the hospital. At OSH a
CT revealed a small bowel obstruction. At OSH lactate was
elevated to 6.5. Trop-I to 0.9. He was sent to ED at [**Hospital1 **] for
further managment.
.
In the ED, initial vs were: 98.1 120 97/58 20 97% on 4l. OSH CT
with evidence of an SBO without contrast, but mult lesions in
liver consistent with metastatic disease from possible
pancreatic primary. His LLE was also noted to be more purple.
Vascular [**Doctor First Name **] and general surgery consulted. Vascular surgery
recommended transition to argoatrtoban for concern that his INR
was falsely elevated from liver disease. They reported that
there was no indication of limb iscemia at this time and that
all his symptoms were likely from a severe DVT. General surgery
evaluated the patient and reported that he was not a surgical
candidate given his likley metastatic cancer (question related
to pancreas). He received 3L NS. Patient was given
Vanc/Cipro/Flagyl. On transfer vitals were 97.9, 123, 104/44,
30s 96%4L.
.
On the floor, patient was oriented x2. He seemed to understand
why he was in the hospital. He reported he was in no pain.
Past Medical History:
-Gastric cacner "encapsulated" s/p resection and bilroth II
aprox 20 years ago
-Lung nodule ? cancer s/p lobectomy aprox 20 years ago
-Macular degeneration
-Hearing loss
Social History:
Tob: Quit 6 weeks ago prior [**11-22**] cigs per day for years
EtOH: Drinks 1-2 beers and a glass of brandy daily
Family History:
Brother with lymphoma
Physical Exam:
PT expired
Pertinent Results:
[**2128-5-30**] 07:00PM BLOOD WBC-43.8* RBC-2.66* Hgb-7.9* Hct-25.3*
MCV-95 MCH-29.8 MCHC-31.3 RDW-13.2 Plt Ct-60*
[**2128-5-31**] 04:01AM BLOOD WBC-36.2* RBC-2.63* Hgb-7.5* Hct-22.7*
MCV-86 MCH-28.4 MCHC-32.9 RDW-13.5 Plt Ct-61*
[**2128-5-30**] 07:00PM BLOOD PT-32.3* PTT-41.7* INR(PT)-3.3*
[**2128-5-31**] 08:44AM BLOOD PT-52.5* PTT-68.9* INR(PT)-5.8*
[**2128-5-30**] 11:53PM BLOOD Fibrino-271
[**2128-5-31**] 08:44AM BLOOD FDP-80-160*
[**2128-5-30**] 07:00PM BLOOD Glucose-178* UreaN-60* Creat-2.7* Na-132*
K-6.5* Cl-99 HCO3-19* AnGap-21*
[**2128-5-31**] 08:44AM BLOOD Glucose-98 UreaN-67* Creat-2.7* Na-135
K-6.1* Cl-106 HCO3-19* AnGap-16
[**2128-5-30**] 07:00PM BLOOD ALT-103* AST-157* AlkPhos-209*
TotBili-0.7
[**2128-5-30**] 11:53PM BLOOD ALT-105* AST-150* LD(LDH)-803*
CK(CPK)-211 AlkPhos-210* TotBili-0.8
[**2128-5-30**] 11:53PM BLOOD Albumin-2.4* Calcium-8.2* Phos-5.7*
Mg-2.3
[**2128-5-31**] 08:44AM BLOOD Calcium-7.7* Phos-5.7* Mg-2.3
[**2128-5-30**] 11:53PM BLOOD CK-MB-10 MB Indx-4.7 cTropnT-0.25*
[**2128-5-30**] 07:00PM BLOOD Lipase-10
[**2128-5-30**] 11:53PM BLOOD Hapto-161
[**2128-5-30**] 07:02PM BLOOD Glucose-GREATER TH Lactate-2.5* Na-104*
K-4.4 Cl-85* calHCO3-14*
[**2128-5-30**] 07:02PM BLOOD freeCa-0.78*
CXR: Nasogastric tube tip now terminates at the gastroesophageal
junction and continued advancement is recommended as the side
port remains
within the distal esophagus.
Brief Hospital Course:
This is a 76 year old male with a distant history of gastric and
lung cancer who presented to an OSH with N/V and AMS and was
found to have an SBO and liver lesions consistent with
metastatic disease.
.
# Septic shock/MODS: Patient meets criteria for sepsis and is in
shock. He was aggresivly fluid rescussitated. Source felt to be
bowel ischemia/translocation of gut flora. Surgery evaluated pt
but felt that he was not a surgical candidate. Discussions with
family resulted in no escelation of care based on patients poor
prognosis from undiagnosed metastatic cancer likely pancreatic
in source. He was given broad antibiotics initially. Given the
severity of his illness he was made CMO by his family and passed
away about 24 hours after admit to ICU.
.
# SBO: Evaled by surgery who felt that given liver mets and
possible pancreatic head mass that he was not a surgical
candidate. NG tube was placed in the ED. Patient was given IVF
and broad spectrum antibiotics. No transition point seen on CT.
There is an area of small bowel in the right lower quadrant that
is concerning for bowel wall ischemia (less likely hemmorhage).
Medcially managed with NG-tube, fluids and antibiotics until
care withdrawn
.
# Anemia: Patient with anemia and thrombocytopenia in the
setting of elevated INR. [**Month (only) 116**] represent a consumptive
coagulopathy such as DIC. No overt GI bleeding seen. Unclear
chronicity of anemia, may be related to underlying malignancy.
Patient was not given any transfusions.
.
# Thrombocytopenia: As above may be related to DIC. Alt may be
related to liver disease as unclear how much liver damage
patient has. Patient also with recent exposure to heparin
products.
.
# Elevated INR: Patient on coumadin as outpatient. Per family
recent INR has been 1.9. Currently elevated may just be
secondary to coumadin in the setting of decreased PO intake and
infection. Alt may represent liver disease or possible DIC as
above.
.
# DVT: Eval by vascular in ED. Per vascular, pulses on LLE
dopplerable. No current signs of limb ischemia of compartment
syndrome. However given un-reliability of INR in current setting
severe illness and the large size of the clot, vascular
recommended argatroban for treatment acutely. Patient initially
started on Argatroban which was stopped when made CMO.
.
# Elevated creatinine: Unclear baseline. Will give fluids
overnight, trend Cr and renally dose meds. Question given
distention of abdominal compartment syndrome.
.
# Liver lesions/Panc head mass: New diagnosis. Unclear
chronicity. Current thought based on CT is that patient has a
pancretic head mass with mets to liver. No tissue at this point.
.
# Elevated Trop: Likely demand. Trend CE. ECG in am.
Medications on Admission:
Coumadin
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
|
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icd9cm
|
[
[
[]
]
] |
[
"96.07"
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icd9pcs
|
[
[
[]
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|
4141, 6861
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292, 298
|
7009, 7018
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2715, 4118
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,585
| 196,685
|
46053
|
Discharge summary
|
report
|
Admission Date: [**2100-11-7**] Discharge Date: [**2100-11-9**]
Date of Birth: [**2032-5-22**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2090**]
Chief Complaint:
Seizures
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
Mr. [**Known lastname 5903**] is a 68 year old man well known to the neurology
service from multiple admissions in the past for seizures who
has a history of left parieto-occipital and right occipital
hemorrhages and subsequent seizure disorder. He was brought to
the emergency room today by EMS for seizures at home.
Unfortunately the patient is extremely lethargic due to
benzodiazepine administration and unable to provide any history.
I was able to reach his daughter to obtain a history (though
somewhat limited by her lack of knowledge of the [**Hospital 228**]
medical problems). [**Name2 (NI) **] was apparently in his usual state of
health until 2:30PM when he was watching the [**Company **] on
television. His daughter noticed that he was staring to the
left side of the room (not looking at the television). Around
that time, he asked his wife for a dilantin pill. She gave it
to him. He then told them that he thought he was going to have a
seizure. He laid on the floor of the living room and, a few
minutes later, had the onset of facial and left arm shaking.
The movements were "jerking" and rhythmic. He was awake and
conversant through the seizure. The first seizure lasted
approximately 5 minutes. Afterwards, he said that he felt that
it was "over". A few minutes later, however, he had another
seizure (also with facial and left arm jerking). This episode
lasted 5-6minutes. He went on to have a total of 4 seizures in
the next 30 minutes. Per the daughter, the seizures were
becoming longer and becoming more "violent". His family called
EMS. When they arrived, he was noted to have "jaw clenching"
and biting movements. He was not medicated en route to the
hospital. When he arrived here, he was noted to have biting
movements and was moaning, but otherwise non verbal. He was
given a total of 6mg of ativan. ED staff considered intubation
for airway protection and "decreased gag" and called me to
assess the patient prior to intubation. At this point, he is no
longer having clinical seizure activity, but it completely
uresponsive. In lieu of intubation, an oral airway was placed
and he was taken emergently to CT Scan.
His usual seizures consist of an aura of left arm tingling
followed by left sided shaking or generalized tonic clonic
seizure. Afterwards, he remains "groggy" usually for an entire
day. He has also been noted in the past to have a post ictal
Todds paralysis on the left. He has been admitted to the
neurology service several times for such seizures, last in [**8-9**].
He is followed by Dr. [**First Name (STitle) **] as an outpatient.
Per his daughter, he has been feeling well, no complaints of
fever/chills, cough, n/v, cp, palpitaions or dysuria. He has
been taking his medications as prescribed. His family is not
aware of any recent alcohol consumption, though state that he
was drinking rum last weekend. He has apparently had several
"small seizures" since his last admission-most recently 4 weeks
ago. These episodes apparently consisted of a "funny feeling"
about which his daughter does not know the details. He did
speak with his doctor (? neurology vs PCP) about these events.
She does not know if any changes in his medications were made.
As of his last admission, he remained on dilantin monotherapy
with plan to enroll him in the Lamictal trial run by KBK. He
has not yet followed up with epilepsy clinic.
Past Medical History:
1. Coronary artery disease status post myocardial infarction
in [**2089**].
2. Strokes in [**2092**] and [**2093**] with left parietal
occipital and right occipital hemorrhages. Also left pontine
infarct.
3. Hypertension.
4. Hypercholesterolemia.
5. History of deep vein thrombosis treated with coumadin x 6
months.
6. History of small bowel obstruction.
7. Seizure disorder x 4-5 years after strokes.
8. Chronic renal insufficiency.
Social History:
Lives at home with wife. Former restaurant and bakery owner in
[**Location (un) 686**]. History of heavy alcohol use but claims none since
[**2089**]. Denies tobacco and drugs.
Family History:
Father - stroke and MI
Mother - ?cerebral anneurysm
2 children with IDDM, adult onset
1 sister with metastatic breast ca
Physical Exam:
T-[**Last Name (un) 98006**] BP-251/136-->128/64 HR-117-->86 RR-17-21 O2Sat 97-99% (on
NRB)
Gen: Lying in bed, NAD
HEENT: NC/AT, dried blood in mouth
Neck: supple
CV: RRR, Nl S1 and S2
Lung: Course BS bilaterally
Abd: +BS soft, nontender
Ext: no edema
.
Neurologic examination:
Mental status: Unresponsive to verbal or noxious stimulation
(occasionally moans to sternal rub)
.
Cranial Nerves:
Pupils equally round and reactive to light, 3 to 2 mm
bilaterally. No blink to visual threat. Eyes conjugate and
midline. +dolls. Face appears symmetric (limited by
mask/airway). +corneals bilaterally. +gag.
.
Motor:
Increased tone on left, muscle bulk normal. Withdraws right arm
and leg briskly to noxious stimulation. No withdrawal on left.
.
Sensation: Withdraws to noxious on right, grimaces to pain on
right arm and leg. Localizes pain on left.
.
Reflexes:
+3 on left, +2 on right.
Toes mute bilaterally
.
Coordination/Gait: Unable to assess
Pertinent Results:
LAB VALUES:
.
[**2100-11-7**] 04:10PM BLOOD WBC-8.0 RBC-4.59* Hgb-14.5 Hct-41.4
MCV-90 MCH-31.6 MCHC-35.1* RDW-12.8 Plt Ct-263
[**2100-11-7**] 09:50PM BLOOD WBC-7.1 RBC-4.42* Hgb-14.0 Hct-39.4*
MCV-89 MCH-31.8 MCHC-35.6* RDW-12.9 Plt Ct-215
[**2100-11-7**] 04:10PM BLOOD Neuts-42.1* Lymphs-43.0* Monos-4.9
Eos-8.8* Baso-1.1
[**2100-11-7**] 09:50PM BLOOD Neuts-70.6* Lymphs-19.1 Monos-5.0
Eos-4.9* Baso-0.3
[**2100-11-7**] 04:10PM BLOOD PT-17.8* PTT-30.3 INR(PT)-2.2
[**2100-11-7**] 04:10PM BLOOD Plt Ct-263
[**2100-11-7**] 09:50PM BLOOD PT-13.4* PTT-25.4 INR(PT)-1.2
[**2100-11-7**] 09:50PM BLOOD Plt Ct-215
[**2100-11-7**] 09:50PM BLOOD Fibrino-155 D-Dimer-2209*
[**2100-11-7**] 04:10PM BLOOD Glucose-161* UreaN-21* Creat-1.7* Na-138
K-5.0 Cl-100 HCO3-15* AnGap-28*
[**2100-11-7**] 09:50PM BLOOD Glucose-114* UreaN-18 Creat-1.5* Na-138
K-4.1 Cl-103 HCO3-25 AnGap-14
[**2100-11-7**] 04:10PM BLOOD ALT-17 AST-24 AlkPhos-112 TotBili-0.3
[**2100-11-7**] 04:10PM BLOOD CK(CPK)-346*
[**2100-11-7**] 04:10PM BLOOD Albumin-4.5 Calcium-9.4 Phos-4.4 Mg-1.9
[**2100-11-7**] 09:50PM BLOOD Calcium-8.7 Phos-3.5 Mg-1.8
[**2100-11-7**] 04:10PM BLOOD Digoxin-0.4*
.
[**2100-11-8**] 03:56AM BLOOD WBC-6.5 RBC-4.11* Hgb-13.4* Hct-35.5*
MCV-87 MCH-32.6* MCHC-37.6* RDW-12.7 Plt Ct-201
[**2100-11-8**] 03:56AM BLOOD PT-14.3* PTT-29.2 INR(PT)-1.4
[**2100-11-8**] 03:56AM BLOOD Plt Ct-201
[**2100-11-8**] 03:56AM BLOOD Glucose-124* UreaN-18 Creat-1.5* Na-137
K-3.8 Cl-104 HCO3-25 AnGap-12
.
[**2100-11-9**] 08:45AM BLOOD WBC-6.5 RBC-4.61 Hgb-14.7 Hct-40.4 MCV-88
MCH-31.9 MCHC-36.3* RDW-12.9 Plt Ct-209
[**2100-11-9**] 08:45AM BLOOD Plt Ct-209
[**2100-11-9**] 08:45AM BLOOD Glucose-99 UreaN-13 Creat-1.3* Na-139
K-4.3 Cl-104 HCO3-28 AnGap-11
.
CARDIAC ENZYMES:
[**2100-11-7**] 04:10PM BLOOD CK(CPK)-346*
[**2100-11-7**] 04:10PM BLOOD cTropnT-<0.01
[**2100-11-8**] 03:56AM BLOOD CK(CPK)-366*
[**2100-11-8**] 03:56AM BLOOD CK-MB-5 cTropnT-0.03*
[**2100-11-8**] 10:48AM BLOOD CK-MB-5 cTropnT-0.02*
.
DILANTIN LEVELS:
[**2100-11-7**] 04:10PM BLOOD Phenyto-25.6*
[**2100-11-8**] 03:56AM BLOOD Phenyto-22.7*
[**2100-11-9**] 08:45AM BLOOD Phenyto-24.8*
.
TOX SCREEN:
[**2100-11-7**] 04:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
ABG:
[**2100-11-8**] 02:40AM BLOOD Type-ART pO2-527* pCO2-39 pH-7.41
calHCO3-26 Base XS-0
[**2100-11-8**] 02:40AM BLOOD Lactate-0.8
.
CXR, [**11-7**]:
The heart is normal in size. The mediastinal and hilar contours
are normal. The pulmonary vascularity is within normal limits.
There is marked gastric distention. Mild atelectasis is also
demonstrated within the left lung base. No focal consolidation,
pleural effusions, or pneumothorax is present. The osseous
structures are unremarkable.
.
HEAD CT, [**11-7**]:
There is again noted a large old porencephalic CSF collection in
the right parietal occipital region which communicates with the
right lateral ventricle and is secondary to sequela from old
hemorrhage. This is unchanged when compared to the prior study.
There is again noted a small left pons infarct which is also
unchanged. No new intracranial hemorrhage or edema is
identified. The [**Doctor Last Name 352**]-white matter differentiation is otherwise
intact without evidence of acute cerebral infarct. The
visualized portions of the paranasal sinuses are well aerated.
The bone structures are stable. The ventricles are unchanged in
size.
IMPRESSION: Stable appearance of the head. No evidence of new
hemorrhage.
Brief Hospital Course:
The patient is a 68 year old man with a past medical history of
2 strokes, left parietal occiptal and right occiptial and a
secondary seizure disorder, who presents with series of partial
complex seizures, with secondary generalization. The patient
received 6 mg of ativan in the ED for status, was intubated as
his respiratory drive was depressed and admitted to the ICU
where he stayed overnight. Once extubated, he was called out to
the neurology service.
.
Seizures:
The patient was not noted to have any obvious precipitating
factors for his seizures. He admitted to drinking some
alcoholic beverages earlier in the week but not excessively. He
also admits to the occasional missed dose of his dilantin but,
again, not in the past week. His dilantin levels on admission
were 25.6. On exam, he was mildly ataxic on finger-nose-finger
and had some nystagmus on lateral gaze. He notes no other
symptoms of dilantin toxicity.
Dilantin is apparently not sufficient to control his seziures.
He was started on neurontin 100 mg TID. Given his renal failure,
we will not use higher doses for now. No focal motor seizures
were noted during this admission, but the patient described an
episode, lassting minutes, during which he had the feeling of
the TV getting real big, himself becoming very big, and seeing
all as "blood red".
Mr. [**Known lastname 5903**] [**Last Name (Titles) 9304**] that he would like to see an "epilepsy"
doctor for his seizures, especially as they seem not well
controled.
.
CV:
The patient was ruled out for an MI by cardiac enzymes. He was
maintained on telemetry. No events were noted. He was continued
on his outpatient medications of labetalol, ASA, HCTZ, and
lisinopril with reasonable control of his blood pressures
(153/86 on day of discharge). Further monitoring and adjustments
of blood pressure medications to be done as outpatient.
.
Hypercholesterolemia:
The patient was continued on lipitor.
.
Chronic renal failure:
The patient's creatinine was 1.3 on the day of discharge. His
creatinine typically trended in past months between 1.3 to 1.7.
Neurontin was renally dosed.
.
The patient received a cardiac healthy diet once he was on the
neurology floor. He was maintained on seizure precautions. He
received pneumoboots and subcutaneous heparin for DVT/PE
prophylaxis.
Medications on Admission:
Labetalol 100mg [**Hospital1 **]
Digoxin 0.125 mg qd
Lipitor 10mg qd
HCTZ 25mg qd
Lisinopril
Dilantin 100mg QID
ASA 325mg qd
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Labetalol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
7. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule
PO twice a day.
Disp:*120 Capsule(s)* Refills:*2*
9. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*5*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Partial complex seizures with secondary generalization
2. chronic renal failure
3. hypertension
4. s/p strokes
5. hypercholesterolemia
Discharge Condition:
Good
Discharge Instructions:
For your CHF: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight >
3 lbs. Adhere to 2 gm sodium diet.
.
Please continue to take the new medication, Neurontin, 100 mg
three times a day. This is in addition to your old medication
of dilantin.
.
Please return to the emergency room if you have any symptoms of
chest pain, shortness of breath, loss of consciousness, or new
seizure symptoms.
.
Please attend the appointments below that we have arranged for
you.
Followup Instructions:
Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) 3510**], [**11-23**] at 2pm.
If you are unable to attend this appointment, please call
[**Telephone/Fax (1) 3511**]. His office is located at [**Last Name (NamePattern1) 98007**].
.
Please follow up at the epilepsy clinic with Dr. [**Last Name (STitle) 2442**]/Dr.
[**Name (NI) **]. Please call [**Telephone/Fax (1) 3506**] to update your
demographics, make an appointment and receive directions.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43**] MD [**MD Number(1) 2107**]
Completed by:[**2100-11-13**]
|
[
"414.01",
"272.0",
"401.9",
"780.39",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
12265, 12271
|
9029, 11345
|
325, 338
|
12453, 12460
|
5535, 7258
|
12981, 13623
|
4430, 4552
|
11521, 12242
|
12292, 12432
|
11371, 11498
|
12484, 12958
|
4567, 4821
|
7275, 9006
|
277, 287
|
366, 3761
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4960, 5516
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4860, 4944
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4845, 4845
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3783, 4219
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4235, 4414
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
109
| 110,668
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15326
|
Discharge summary
|
report
|
Admission Date: [**2140-8-25**] Discharge Date: [**2140-9-2**]
Date of Birth: [**2117-8-7**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Oxycodone Hcl/Acetaminophen
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Transfer from MICU, initially admitted for hypertensive
emergency
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Ms. [**Known lastname **] is a 23 year old female with h/o SLE, lupus nephritis
and ESRD on HD, and poorly controlled HTN on multiple
medications presenting on [**8-25**] with unresponsiveness, bilateral
lower extremity weakness, and nausea/vomiting. She was in her
USOH until 2 days pta, when she developed n/v, and on the day of
admission, she was found lying on the floor unresponsive to
family members. Upon awakening she found that she could not
move either of her legs. She was taken to the EW, where she had
BP 260s/200s, had a non-contrast head CT showing left frontal
ICH, right parieto-occipital ICH, and edema throughout
bilaterally thought to be c/w PRES (posterior reversible
encephalopathy syndrome) with superimposed ICH, and had a
MRI/MRV to exclude venous thrombosis showing ICH in the
parieto-occipital lobes bilaterally and pons without venous
sinus thrombosis. She had a tonic-clonic seizure in the ED
terminated with 2 mg IV lorazepam. Neurosurgery was consulted
and felt that she should be managed non-surgically, a labetalol
drip was started with a target SBP of 160s-180s, and she was
admitted to the MICU.
.
In the MICU, she was initially maintained on the labetolol gtt.
She was also started on dilantin for seizure prophylaxis. She
was intubated to have an MRI of the head, as there was concern
for sinus venous thrombosis. MRI was negative for thrombosis.
She transiently required phenylepherine for BP maintenence while
she was on a propofol gtt for maintenence of sedation. She was
extubated on [**8-26**]. While in the ICU she was seen by nephrology
who did not think she needed acute HD. Hematology was also
consulted as the patient had thrombocytopenia and hemolytic
anemia. They did not think she had TTP and thought it was more
likely [**Last Name (un) 1724**] from hypertensive emergency. Additionally, she had
[**3-12**] sets of blood cultures from [**8-25**] grow oxacillan resistant
coagulase negative staph and was started on vancomycin. TTE was
done and negative for vegetation. Her PO BP meds were uptitrated
in the ICU and SBPs have been <180s in the past 24 hours. She
was transferred to the Medicine Team.
.
Upon transfer to Medicine team, the patient's SBPs were being
maintained between 150-160's and on po medications. She denied
fever, chills, nausea, vomiting, headache, chest pain, or
shortness of breath.
Past Medical History:
# Lupus - Diagnosed [**2134**] (16 years old)
- Diagnosed when she had swollen fingers, arm rash and
arthralgias
- Previous treatment with cytoxan, cellcept; currently on
prednisone
# CKD/ESRD secondary to SLE - [**2135**]
# HTN - [**2137**]
- baseline BPs 180's/120's
- previous history of hypertensive crisis with seizures
# Uveitis secondary to SLE - [**4-15**]
- s/p left eye enucleation [**2139-4-20**] for fungal infection
# Thrombocytopenia - previous thrombocytopenia and hemolytic
anemia (TTP vs malignant HTN were considered on DDx)
# HOCM - per Echo in [**2137**]
# Anemia
# Vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera
injection requiring transfusion
# History of Coag negative Staph bacteremia and HD line
infection - [**6-15**] and [**5-16**]
# Previous history of SVC and UE clot, previously maintained on
coumadin
- SVC venogram performed [**2139**] s/p coumadin therapy revals patent
SVY and subclavian
- ?APLS but never has had positive anti-phospholipid antibody
Social History:
SH: Lives in [**Location 669**] with mother, who works at [**Hospital1 18**], and her 16
year old brother. She was able to graduated from high school but
unable to work since then secondary to her illness.
Drugs: ??????
Tob: ??????
Alc: ??????
Family History:
No family history of SLE
MGF: HTN, MI, stroke in 70s. No clotting disorders in family. No
history of autoimmune disease.
Physical Exam:
Vitals: T 97.6 HR 102 BP 176/100 RR 16 O2 sat 100% RA
General: Patient is a young African American female, sitting up,
talking on phone, NAD
HEENT: Left eye s/p enucleation. otherwise NCAT.
Neck: Supple
Pulmonary: CTA b/l
Cardio: Regular. +III/VI early systolic murmur throughout
precordium, loudest at LLSB.
Abdomen: SOft, non-tender, non-distended. NABS
Ext: No C/C/E
.
Neuro:
CN 2-12 intact, except EOMI and pupilary light reaction not
tested
Muscle strength intact in upper and lower extremities b/l
.
ON TRANSFER TO MEDICINE:
========================
Vitals: T 97.2 HR 92 BP 154/90 RR 16 O2 sat 100% RA
GEN: NAD, pleasant, sitting in bed.
HEENT: Left eye s/p enucleation. o/w NCAT, OP - no erythema, no
exudate, no LAD
PULM: CTAB, no w/r/r
CV: RRR. +III/VI early systolic murmur throughout precordium,
loudest at LLSB. No rubs/gallops
ABD: NABS, soft, NDNT
EXT: no c/c/e
Pertinent Results:
ADMISSION LABS:
===============
14.4
8.2 >------< 56 MCV 84
41.7
135 109 50
----|----|-----< 103
6.1 14 5.1
free Ca 1.14
.
PERTINENT LABS DURING HOSPITALIZATION:
======================================
Hct Trend: 41.7 - 40.2 - 39 - 30.4 - 26.9 - 25.1 - 23.2 - 21.7 -
25.4 - 25.8 - 27.0 - 28.6 - 25.7 - 27.9
Platelet Trend: 56 - 70 - 59 - 40 - 37 - 44 - 107 - 108 - 148 -
165 - 150 - 139 - 170 - 173
.
[**2140-8-25**] 10:51AM Glucose-94 Lactate-1.2 Na-136 K-6.3* Cl-114*
calHCO3-14*
[**2140-8-25**] 02:23PM Lactate-2.2*
[**2140-8-25**] 04:12PM Lactate-1.0 K-5.1
[**2140-8-25**] 10:51AM Type-[**Last Name (un) **] pH-7.19*
[**2140-8-25**] 01:48PM Type-ART pO2-117* pCO2-24* pH-7.27* calTCO2-12*
Base XS--13
[**2140-8-25**] 04:12PM Type-ART Temp-37.6 Rates-/22 pO2-106* pCO2-25*
pH-7.32* calTCO2-13* Base XS--11 Not Intubated
[**2140-8-25**] 07:47PM Type-ART Temp-36.9 Rates-16/ Tidal V-500 PEEP-5
FiO2-100 pO2-336* pCO2-29* pH-7.26* calTCO2-14* Base XS--12
AADO2-365 REQ O2-64 -ASSIST/CON Intubat-INTUBATED
[**2140-8-25**] 11:02PM Type-ART Temp-36.9 Rates-18/ Tidal V-500 PEEP-5
FiO2-40 pO2-208* pCO2-25* pH-7.30* calTCO2-13* Base XS--11
-ASSIST/CON Intubat-INTUBATED
[**2140-8-26**] 01:27AM Type-ART Temp-36.7 Rates-/20 Tidal V-450 PEEP-5
FiO2-40 pO2-207* pCO2-28* pH-7.30* calTCO2-14* Base XS--10
Intubat-INTUBATED Vent-SPONTANEOU
[**2140-8-26**] 03:59AM Type-ART Temp-36.7 pO2-108* pCO2-31* pH-7.35
calTCO2-18* Base XS--7 Intubat-NOT INTUBA
[**2140-8-26**] 08:25PM Type-[**Last Name (un) **] Temp-37.0 pO2-41* pCO2-36 pH-7.33*
calTCO2-20* Base XS--6 Intubat-NOT INTUBA
.
[**Doctor First Name **]-POSITIVE Titer-1:320
ACA IgG 11.4 ACA IgM 9.0
ESR 15
C3-55* C4-13
Haptoglobin trend: <20 - 69
LDH: 326 - 256 - 246
Retic Count: 1.8 - 2.0
[**Doctor Last Name 17012**] Negative
Urine 24 hr Creat-630
.
MICROBIOLOGY:
=============
[**8-25**] Blood Cultures from venipuncture: Staph, coag negative x 2,
susceptible only to rifampin, tetracycline, and vancomycin.
[**8-25**] Blood Cultures from arterial line: Staph, coag negative x
2, susceptible only to rifampin, tetracycline, and vancomycin.
[**8-27**] Blood Cultures x 2 NGTD
[**8-27**] Blood Cultures x 2 NGTD
[**8-27**] Blood Cultures from catheter tip: Staph, coag negative,
susceptible only to rifampin, tetracycline, and vancomycin.
[**8-28**] Blood Cultures x 2 from femoral NGTD
[**8-28**] Blood Culture from femoral: enterobacter>15
[**8-28**] Blood Cultures x 2 NGTD
[**8-31**] Blood Cultures pending
[**9-1**] Blood Cultures pending
.
STUDIES:
=========
CHEST (PORTABLE AP) [**2140-8-25**]
IMPRESSION: AP chest compared to 11:49 a.m.:
Tip of the new endotracheal tube, with the chin slightly flexed
is no more than 15 mm above the carina, 2 cm below optimal
placement, as reported to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 805**] by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2026**] on
[**8-25**]. An ascending caval catheter ends in the low right atrium.
Nasogastric tube ends in the stomach. There is no pneumothorax
or pleural effusion. Lungs are clear and heart size is normal.
No pneumothorax.
.
MRA BRAIN W/O CONTRAST [**2140-8-25**]
IMPRESSION:
1. Multifocal areas of cortical T2 signal hyperintensity, some
with foci of recent hemorrhage. The most affected areas are the
parietal and occipital lobes, as well as the pons. The
appearance may represent posterior reversible encephalopathy
syndrome. Hemorrhage and pontine involvement in this disorder is
somewhat unusual, but has been described in the literature.
.
2. No definite evidence of major venous sinus thrombosis.
Nevertheless, if further evaluation is felt necessary
clinically, axial and coronal-acquired 2D time-of-flight MR
venography sequences could be performed, allowing each of the
major venous sinuses to be imaged orthogonally, a procedure
which would minimize any in-plane flow artifacts simulating
thrombus. However, this diagnosis, even at present, is
considered highly unlikely.
.
CT HEAD W/O CONTRAST [**2140-8-25**]
IMPRESSION:
1. Acute intraparenchymal hemorrhages peripherally in the right
parietoccipital and left frontal lobes, with surrounding edema
and local mass effect.
.
2. Vasogenic and interstitial edema in a strikingly symmetric
and posterior distribution involving both [**Doctor Last Name 352**] and white matter
of the occipital lobes and frontalparietal regions, bilaterally.
.
COMMENT: These findings are highly suggestive of PRES
(hypertensive encephalopathy), with development of superimposed
hypertensive hemorrhages. However, given the history of SLE,
suspicion of underlying "lupus anticoagulant" and non-arterial
distribution of edema and hemorrhage, cerebral venous (including
dural venous sinus) thrombosis should be excluded, and urgent
MRI with MRV has been recommended, below.
.
The results were discussed with Dr. [**First Name8 (NamePattern2) 698**] [**Last Name (NamePattern1) **], EU
resident, at the time of study.
.
2. Right maxillary sinus mucus retention cyst.
.
CHEST (SINGLE VIEW) [**2140-8-25**]
IMPRESSION: Unremarkable chest radiograph.
.
EKG [**2140-8-25**]
Sinus tachycardia. Voltage criteria for left ventricular
hypertrophy. Diffuse ST-T wave abnormalities, most likely
related to left ventricular hypertrophy. Compared to the
previous tracing of [**2140-7-30**] lateral ST-T wave abnormalities have
improved.
TRACING #1
.
EKG [**2140-8-26**]
Sinus tachycardia. Compared to the previous tracing of [**2140-8-25**]
no significant diagnostic change.
TRACING #2
.
ECHO [**2140-8-26**]
Conclusions:
The left atrium is normal in size. There is severe symmetric
left ventricular hypertrophy. The left ventricular cavity is
unusually small. Regional left ventricular wall motion is
normal. Left ventricular systolic function is hyperdynamic
(EF>75%). There is a mild resting left ventricular outflow tract
obstruction. The gradient increased with the Valsalva manuever.
The findings are consistent with hypertrophic obstructive
cardiomyopathy (HOCM). There is no ventricular septal defect.
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. No masses or vegetations are seen on the
aortic valve. Mild (1+) aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. The estimated pulmonary
artery systolic pressure is normal. There is a
trivial/physiologic pericardial effusion.
.
Compared with the prior study (images reviewed) of [**2140-5-20**], no
change.
.
IMPRESSION: No valvular vegetations seen.
Brief Hospital Course:
Ms. [**Known lastname **] is a 23 yo female with a h/o SLE with secondary lupus
nephritis, uveitis s/p left eye enucleation, question of APLS
and poorly controlled HTN who presented on [**8-25**] with N/V,
lethargy, fatigue and headaches, found to have hypertensive
emergency,who subsequently seized. CT head showed multiple
intraparenchymal hemorrhages.
.
# Hypertensive Emergency with ICH: Patient initially presented
with significantly elevated blood pressures resulting in end
organ damage causing seizure and intracranial hemorrhage. Her
intracranial bleed appears to be most consistent with PRES,
though septic emboli are on the differential. Goal SBP 150-160s.
Continued dilantin 100 mg tid for seizure prophylaxis, and pt
scheduled for follow up at neuro clinic in two weeks after
discharge. Continued po regimen of labetolol 1000 mg TID,
hydralazine 75 mg PO BID (the only change in home meds),
lisinopril 40 mg [**Hospital1 **], valsartan 320 mg PO daily, nicardapine 60
mg PO TID, as well as clonidine patch when transferred to the
floor. Pt achieved goal of SBPs in 150-160s on this regimen and
was discharged home.
.
# Bacteremia: She had high grade bacteremia with 6/6 bottles on
[**8-25**] growing oxacillan resistant coagulase negative staph. HD
cath was d/c'ed. A TTE was negative for vegetation. Blood
cultures from [**8-27**] and [**8-28**] showed NGTD. Pt started on
vancomycin. Levels were followed to achieve therapeutic goals.
Ideally, vancomycin would be continued for 14 days after first
negative blood cultures. Repeatedly, pt was told that
vancomycin was superior to linezolid for bacteremia, but she
still refused PICC. Thus, pt started on po linezolid and
discharged with linezolid. She will need close follow up for
bone marrow suppression secondary to linezolid.
.
# Thrombocytopenia: Patient has had previous episodes of
clinical illness with acute drop in platelets with question of
consumptive coagulopathy from thrombosis vs. secondary to
malignant hypertension. Received one unit platelets with
placement of R femoral line. Platelets slowly improved over
hospitalization. Evaluated by heme who did not think
thrombocytopenia was consistent with TTP, but more likely to be
due to malignant hypertension. Platelets counts improved with
improvement in blood pressures.
.
# SLE: The patient was previously treated with
Cytoxan/Prednisone and on admission was on low dose prednisone.
There had been concern in the past for anti-phospholipid
syndrome but her APA testing has been negative. Rheum consulted.
Pt on 15 mg prednisone during hospitalization and discharged
with this dose and follow up.
.
# CKD stage V - Patient most recently had not been to HD for 3
weeks because she did not like the way it made her feel. Some
residual kidney function and awaiting kidney transplantation
from a relative. HD catheter was pulled during this admission
due to high grade bacteremia. Per renal, not imperative that pt
needs acute HD. Electrolytes monitored. Sevelamer and daily
Kayexalate continued during hospitalization.
.
#. Anemia - Thought to be chronic and likely related to her CKD.
There was concern for hemolytic anemia during this admission,
likely caused by malignant hypertension. Hct trended up during
hospitalization. Continued Epogen 4000 u three times/wk per
renal.
.
# Code - Presumed Full
.
#. Communication: Mother - [**Telephone/Fax (1) 43497**]
.
#. Dispo: Home with services.
Medications on Admission:
Valsartan 320 mg QD
Clonidine patch weekly
Hydralazine 50 mg [**Hospital1 **]
Lisinopril 40 mg [**Hospital1 **]
Nicardipine 60 mg TID
Labetalol 1000 mg TID
Prednisone 20 mg QD
Neurontin 100 mg 3x/week
Sevelemer 800 mg TID
Allergies: PCNs -> rash
Discharge Medications:
1. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO Q8H (every 8 hours).
Disp:*90 Capsule(s)* Refills:*2*
2. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3
TIMES A DAY WITH MEALS).
Disp:*90 Tablet(s)* Refills:*2*
3. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
4. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID (3 times
a day).
Disp:*450 Tablet(s)* Refills:*2*
5. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
6. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Nicardipine 30 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours).
Disp:*180 Capsule(s)* Refills:*2*
8. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QTHUR (every Thursday).
Disp:*4 Patch Weekly(s)* Refills:*2*
9. Hydralazine 25 mg Tablet Sig: Three (3) Tablet PO TID (3
times a day).
Disp:*180 Tablet(s)* Refills:*2*
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
11. Linezolid 600 mg Tablet Sig: One (1) Tablet PO twice a day
for 8 days.
Disp:*16 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Hypertensive emergency
Seizures
Coagulase negative Staph bacteremia
Chronic kidney disease
Discharge Condition:
good
Discharge Instructions:
You were admitted for high blood pressure, seizures and head
bleeding.
.
Your blood pressure was controlled and you were evaluated by the
neurology, [**Location (un) **] and renal doctors. You should follow up
with all of them after you are discharged.
.
Please continue all your medications as prescribed.
.
You should continue taking your antibiotic as prescribed for 8
more days. Linezolid twice a day for 8 days.
.
If any fevers, shortness of breath, chest pain, headaches or any
other symptoms that may concern you please call your PCP or come
to the emergency department.
.
Followup Instructions:
Nephrology
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2140-9-5**] 4:00
.
Primary Care
Provider: [**First Name11 (Name Pattern1) 2671**] [**Last Name (NamePattern4) 44538**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2140-9-6**] 3:00
.
Neurology:
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **] [**9-16**] 1 pm. Phone. [**Telephone/Fax (1) 40554**]
.
[**Telephone/Fax (1) 2225**]:
Provider: [**Name Initial (NameIs) 11595**] (RHEUM LMOB) [**Doctor Last Name 11596**] Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2140-10-5**] 3:30
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
Completed by:[**2140-9-5**]
|
[
"403.91",
"041.19",
"780.39",
"790.7",
"432.9",
"710.0",
"585.5",
"437.2",
"582.81"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
16805, 16862
|
11811, 15247
|
365, 373
|
16997, 17004
|
5098, 5098
|
17633, 18425
|
4064, 4186
|
15543, 16782
|
16883, 16976
|
15273, 15520
|
17028, 17610
|
4201, 5079
|
260, 327
|
401, 2766
|
5114, 11788
|
2788, 3787
|
3803, 4048
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,599
| 179,774
|
52639+59447
|
Discharge summary
|
report+addendum
|
Admission Date: [**2116-10-28**] Discharge Date: [**2116-11-5**]
Service: MEDICINE
Allergies:
Dilaudid / Paxil / Lipitor
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
Endoscopy
Colonoscopy
History of Present Illness:
[**Age over 90 **] yo F w/ h/o s/p st. jude's valve for mitral valve 11 yrs ago
(on coumadin), atrial fib, tachy-brady syndrome s/p pacemaker
placement [**2112-7-29**], DM2, HLD p/w BRBPR.
.
Of note, patient s/p recent admission ([**Date range (1) 108635**]) for
diarrhea, found to have terminal ileitis initially treated w/
cipro that was subsequently d/c'd when stool cx returned
negative and started on immodium. She was then readmitted
([**Date range (1) 108636**]) for coffee ground emesis w/ supratherapeutic INR.
Hct on that admission ranged 26-29; as hcts and pt remained
stable her diet was advanced and she was not scoped. During her
stay in rehab after her last admission, she complained about
loose stools and abdominal pain. She was subtherapeutic on her
coumadin which was increased from 2.0 to 2.5 OD. On the day
before her current admission, she reported abdominal pain and
passage of loose black stools in the PM. She reported chills but
no fever. There was no relief with BM and no relationship with
meals. There was no chest pain reported.
.
ED Course: In the ED, initial VS were: T 97, HR 95, BP 130/70,
RR 20, O2 97% 4l. On exam she had BRBPR and two large bright
bloody bowel movements. She had a small amount of non-bloody
non-biliary emesis and so was not NG lavaged. Labs notable for
lactate 0.7, cr 1.4, k 3.7, na 141, ca 8.9, lfts wnl, h/h
9.7/31.3, plt 237, inr 1.4. Received IV zofran 2mg, IV
metoclopramide 5mg, IV morphine 4mg x2, IV cipro 400mg, flagyl
500mg IV. Non contrast CT a/p - terminal ileits, worse from
prior. During her ED course, HR 70s-90s, BP 100s-120s. EKG
demonstrated afib with an HR of 78. She got 2.5L NS. Chest X ray
showed no free air but some pulmonary edema.
Past Medical History:
s/p st. jude's valve
atrial fib
tachy-brady syndrome s/p pacemaker placement [**2112-7-29**]
DM 2 (not on medications)
hypercholesterolemia - no longer on statin
Social History:
Raised in [**Location (un) **], now lives with son and daughter in-law
[**Name (NI) 4310**]. Close with family including 5 grandkids and 1 new great
grand-daughter. Denies smoking, etOH
Lives with her son and daughter-in-law. She has been living at
rehabilitation for the last ~ 1month.
Family History:
Son died of ALS 5 years ago; otherwise HTN in both sons
Physical Exam:
ADMISSION:
General: Alert, oriented, but in pain
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: basal crackles, but no ronchi or wheezes
Abdomen: soft, tender, non-distended, no guarding, bowel sounds
present, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis.
trace pedal edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
.
DISCHARGE:
Afebrile, normotensive, 96% on RA
GENERAL - NAD, appears comfortable, mildly fatigued
HEENT - NC/AT, EOMI, sclerae anicteric
NECK - supple, no lymphadenopathy
LUNGS - no use of access mm, crackles at bibasilar bases, no
wheezes
HEART - irregularly irregular, no MRG, nl S1-S2
ABDOMEN - +BS, soft/ND, mild periumbilical tenderness, no flank
tenderness, no rebound/guarding
EXTREMITIES - WWP, 2+ peripheral pulses (radials, DPs), mild
lower extremity edema bilaterally, more pronounced around right
ankle.
NEURO - awake, A&Ox3
Pertinent Results:
Admission labs:
[**2116-10-30**] 04:42AM BLOOD WBC-4.0 RBC-3.38* Hgb-8.9* Hct-28.1*
MCV-83 MCH-26.3* MCHC-31.7 RDW-17.4* Plt Ct-163
[**2116-10-29**] 05:30AM BLOOD WBC-6.7 RBC-3.80* Hgb-9.4* Hct-30.8*
MCV-81* MCH-24.6* MCHC-30.4* RDW-16.7* Plt Ct-207
[**2116-10-28**] 08:20PM BLOOD WBC-4.8 RBC-3.88* Hgb-9.7* Hct-31.3*
MCV-81* MCH-25.1* MCHC-31.1 RDW-16.9* Plt Ct-237
[**2116-10-28**] 08:20PM BLOOD Neuts-88.9* Lymphs-6.3* Monos-4.1 Eos-0.3
Baso-0.3
[**2116-10-30**] 04:42AM BLOOD Plt Ct-163
[**2116-10-30**] 04:38AM BLOOD PT-16.9* PTT-39.2* INR(PT)-1.5*
[**2116-10-28**] 08:20PM BLOOD Plt Ct-237
[**2116-10-28**] 08:20PM BLOOD PT-15.5* PTT-24.9 INR(PT)-1.4*
[**2116-10-30**] 04:42AM BLOOD Glucose-140* UreaN-23* Creat-1.2* Na-143
K-3.7 Cl-108 HCO3-26 AnGap-13
[**2116-10-29**] 12:55AM BLOOD CK(CPK)-25*
[**2116-10-28**] 08:20PM BLOOD ALT-18 AST-26 AlkPhos-113* TotBili-0.7
[**2116-10-29**] 12:55AM BLOOD CK-MB-1 cTropnT-<0.01
[**2116-10-28**] 08:20PM BLOOD Lipase-28
[**2116-10-30**] 04:42AM BLOOD Calcium-8.4 Phos-4.1 Mg-2.2
[**2116-10-29**] 05:30AM BLOOD Calcium-8.1* Phos-4.1 Mg-1.8
[**2116-10-28**] 10:41PM BLOOD Lactate-0.7
.
Discharge labs:
[**2116-11-4**] 08:10AM BLOOD WBC-4.9 RBC-3.60* Hgb-9.2* Hct-28.7*
MCV-80* MCH-25.5* MCHC-32.0 RDW-17.1* Plt Ct-212
[**2116-11-5**] 08:04AM BLOOD PT-35.8* PTT-37.4* INR(PT)-3.6*
[**2116-11-5**] 08:04AM BLOOD Glucose-103* UreaN-12 Creat-1.4* Na-135
K-3.5 Cl-94* HCO3-36* AnGap-9
[**2116-11-3**] 07:35AM BLOOD YERSINIA ENTERCOLITICA ANTIBODIES
(IGG,IGA)-PND
.
[**2116-10-29**]
EGD
Impression: Grade 1 esophagitis in the lower third of the
esophagus compatible with Esophagitis
Polyp in the Stomach Body (biopsy)
Normal mucosa in the stomach
Normal mucosa in the duodenum
Otherwise normal EGD to third part of the duodenum
Recommendations: These findings do not account for her possible
bleeding
Follow up biopsy results
Please continue to monitor patient.
Ok to restart heparin for her MVR, but please monitor serial hct
Please prep for colonoscoppy tomorrow with movi-prep
.
[**10-30**]
Colonoscopy
Impression: Erythema in the Terminal ileum compatible with
Terminal ileitis from ischemic, or infectious etiology
Polyp at 65cm in the 65cm (ascending colon)
Normal mucosa in the colon
Internal hemorrhoids
Otherwise normal colonoscopy to cecum
Recommendations: Findings do not explain the patient's reported
hematochezia. She may have had slight bleeding from internal
hemorrhoids, but not current stigmata of bleeding was found.
Follow up biopsy results regarding her terminal ileitis
Consider repeat colonoscopy in one year to evaluate the 6mm
polyp as biopsies/polypectomy was not performed given the need
to restart her heparin infusion for her MVR. Discuss with PCP
regarding risks and benefits of a repeat colonoscopy in one year
.
Biopsy
[**2116-10-30**]:
Terminal ileum, mucosal biopsy (A):
Small intestinal mucosa with minimal superficial acute
inflammation, otherwise within normal limits.
.
Biopsy [**2116-10-29**]:
DIAGNOSIS:
Stomach, polyp, procedure not specified:
Hyperplastic polyp.
PENDING STUDIES:
YERSINIA ENTERCOLITICA ANTIBODIES (IGG,IGA) Results Pending
Brief Hospital Course:
Primary Reason for Hosptialization: Patient is a [**Age over 90 **]yo female
with PMH of tachy/brady syndrome with [**Company 1543**] Sigma
dual-chamber pacemaker, s/p MVR with St. Jude's valve, DM2 and
recent episodes of GI bleed who presented to the ED with report
of BRBPR. In house she never experienced hemodynamic comprimise
and had no significant drop in Hct. EGD and colonoscopy failed
to reveal source of bleed and she was noted to not have bloody
stools while we observed her. She also presented with recent
history of diarrhea and we found terminal ileitis which on
biopsy showed mild, superficial inflammation. She had belly pain
which resolved with treatment for gaseous distension and
antibiotics for UTI.
.
ACUTE CARE:
.
1. GI bleed, loose stools: Patient had an initial complaint of
dark stools at rehab and presented to the ED with two reported
episodes of bright red blood per rectum. For concern of acute
bleed, she was transferred to the MICU where she underwent EGD
and colonoscopy. Colonoscopy showed internal hemmorhoids and
terminal ileitis with a few small polyps and no source of
potential significant bleed. There was no active bleeding and a
biopsy was taken of the terminal ileum which later showed minor
superficial inflammation. GI followed patient on the floor, and
suggested sending Yersinia Ab's which were pending at time of
discharge. Her bloody stools did not recur on the floors, and
she was having formed brown bowel movements at the time of
discharge. The GI team suggested possible MR enterography in the
future if there is concern for Crohn's, but this is very low on
the differential given her age of presentation.
.
3. UTI: Pt had grossly positive UA, and was started on Bactrim
for complicated UTI given catheter-associated. She
symptomatically improved. Preliminary culture data showed E.
coli with sensitivities pending at the time of discharge.
.
4. [**Last Name (un) **]: baseline Cr 0.9-1.1. She had a high of 1.4 on [**10-28**].
She was given maintenance fluids in the MICU. Her Cr has
trended downward to 1.1, but increased back to 1.4 on the day of
discharge likely [**2-5**] additional dose of Torsemide on the day
prior to discharge. She should have Cr rechecked at
rehabilitation to assess for improvemeent.
.
5. Volume Overload: Home torsemide was initially held given
concern for GI bleed as above. On the floors, her torsemide was
restarted. She received an additional dose on the day prior to
discharge. She appeared euvolemic though with mild crackles on
exam. She was discharged on her home dose of torsemide.
.
CHRONIC CARE
1. [**Hospital3 **] for MVR - Last echo done in [**2112**] demonstrated no MR
and good prosthesis function and no MR murmur heard on exam. No
evidence of diastolic (mild LA enlargement) or systolic (EF>55)
dysfunction. Her INR was subtherapeutic at 1.4 in the ED. She
was placed on a heparin gtt which was held during her procedures
and restarted afterwards. She was bridged back to Coumadin on
the floors. Warfarn dose should be rechecked at rehabilitation
given recent antibiotics.
.
2. Tachy-Brady syndrome: Patient was on metoprolol and dilt at
home which were initially held. However, when her HR was 130, we
restarted her home diltiazem at 240 mg daily. She was restarted
on her home Metoprolol on discharge.
.
3. DM- This was managed with diet control, as at home.
.
TRANSITIONS IN CARE:
1. CODE: FULL
2. Follow-up:
-Patient will be transferred to rehab, and the facility will
arrange for PCP f/u appointment within one week. Her urine
cultures should be finalized by then (E. coli with sensitivities
pending at time of discharge) and should be followed-up.
-Patient will follow-up with gastroenterology as an outpatient
for her question GI bleed and terminal ileitis and diarrhea with
incidental finding of cirrhotic-appearing liver.
OF NOTE - CT from [**2116-10-28**] suggested cirrhosis. Discussed this
with GI team, as this was not seen on prior CT scans 2 weeks
prior. She had no stigmata of cirrhosis, and the findings of
this CT were thought to be not of significance. However, could
consider RUQ u/s as an outpatient to assess.
-Patient has a scheduled follow-up appointment in device clinic
for her pacemaker.
3. Medication changes:
As patient completes a 7-day course of Bactrim for UTI, her INR
must be closely monitored with daily labs and coumadin
dose-adjusted.
4. PENDING STUDIES:
Yersinia Ab's pending at the time of discharge
5. CONTACT:
[**Name (NI) **] (cell [**Telephone/Fax (1) 108637**], work [**Telephone/Fax (1) 108638**])
Medications on Admission:
1. diltiazem HCl 240 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO once a day: hold if SBP<100, HR<60.
2. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day: hold if
SBP<100, HR<60.
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. potassium chloride 10 mEq Capsule, Extended Release Sig: One
(1) Capsule, Extended Release PO DAILY (Daily). Capsule,
Extended Release(s)
5. torsemide 20 mg Tablet Sig: One (1) Tablet PO BID(Daily).
6. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: adjust with goal 2.5-3.5.
7. tylenol prn 650 PO.
8. Duo nebs PRN.
9. Neurontin 100mg [**Hospital1 **].
10. Bisacodyl suppository PRN.
Discharge Medications:
1. torsemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 4 days: to be completed on
[**2116-11-9**].
Disp:*8 Tablet(s)* Refills:*0*
3. diltiazem HCl 240 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO once a day.
4. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO once a day.
6. warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day: daily
at 4pm, to be adjusted based on INR goal 2.5-3.5.
7. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**4-8**]
hours as needed for pain.
8. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for abdominal
cramping.
Disp:*60 Tablet, Chewable(s)* Refills:*0*
9. Neurontin 100 mg Capsule Sig: One (1) Capsule PO twice a day.
10. bisacodyl 10 mg Suppository Sig: One (1) Rectal once a day
as needed for constipation.
11. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for
Nebulization Sig: One (1) Inhalation every six (6) hours as
needed for shortness of breath or wheezing.
12. potassium chloride 10 mEq Capsule, Extended Release Sig: One
(1) Capsule, Extended Release PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 4860**] - [**Location (un) 4310**]
Discharge Diagnosis:
Primary:
1. Loose stools, bloody stools
2. Terminal ileitis
3. Urinary tract infection
Secondary:
1. s/p mitral valve replacement
2. 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 **],
You were admitted to the hospital for concern of bleeding into
your gastrointestinal tract. Your blood levels were never
significantly affected by this. We did endoscopes of the upper
and lower GI tract and found no source of bleed. Our CT scan did
show some inflammation of part of your small intestine, and we
biopsied this during your colonoscopy. The biopsy showed only
mild inflammation. You were transitioned back to your coumadin,
which was held for the concern of bleed, and we treated a
urinary tract infection and took off extra fluid with diuretics.
With these interventions we saw no further bleed and your belly
pain and nausea improved.
You were found to have a urinary tract infection. We started you
on antibiotics for this, and these will need to be continued on
discharge.
Please make the following changes to your medications:
1. DECREASE the dose of Warfarin from 2.5mg daily to 1mg daily
for one more day. They should recheck the PT/INR at your
rehabilitation and adjust your dose based on your goal INR of
2.5-3.5.
2. START Bactrim DS 1 tablet twice daily for 4 more days for
total of 7 days (to be completed [**2116-11-9**]).
Please keep all scheduled follow-up appointments.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Please follow-up with the following appointments:
Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2116-11-11**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6953**], 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
Department: CARDIAC SERVICES
When: MONDAY [**2116-11-30**] at 11:00 AM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Since you were going to a facility, we were unable to make an
appointment with your primary care provider. [**Name10 (NameIs) **] you leave
there, please call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 216**] at [**Telephone/Fax (1) 250**] to schedule
a follow-up appointment.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
Name: [**Known lastname **],[**Known firstname 3591**] Unit No: [**Numeric Identifier 17783**]
Admission Date: [**2116-10-28**] Discharge Date: [**2116-11-5**]
Date of Birth: [**2026-4-20**] Sex: F
Service: MEDICINE
Allergies:
Dilaudid / Paxil / Lipitor
Attending:[**First Name3 (LF) 758**]
Addendum:
Final results of inpatient urine culture showed that E. coli
growing is resistant to Bactrim. Patient's doctor at rehab was
contact[**Name (NI) **] and directed to initiate therapy tailored to
sensitivities of the organism, with ertapenem being a viable
choice. Please see culture data below:
[**2116-11-2**] 11:06 pm URINE Source: CVS.
**FINAL REPORT [**2116-11-6**]**
URINE CULTURE (Final [**2116-11-6**]):
Culture workup discontinued. Further incubation showed
contamination
with mixed skin/genital flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
ESCHERICHIA COLI.
>100,000 ORGANISMS/ML. OF TWO COLONIAL MORPHOLOGIES.
PRESUMPTIVE IDENTIFICATION.
Piperacillin/tazobactam sensitivity testing available
on request.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMIKACIN-------------- <=2 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- 32 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 7265**] - [**Location (un) 7266**]
[**First Name11 (Name Pattern1) 27**] [**Last Name (NamePattern1) 28**] MD, [**MD Number(3) 765**]
Completed by:[**2116-11-6**]
|
[
"211.3",
"428.0",
"584.9",
"041.49",
"555.0",
"571.5",
"599.0",
"V58.61",
"V45.01",
"V43.3",
"455.0",
"V49.86",
"250.00",
"530.19",
"285.1",
"428.33",
"427.31",
"272.0",
"211.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.25",
"45.16"
] |
icd9pcs
|
[
[
[]
]
] |
18530, 18761
|
6894, 11113
|
243, 266
|
13958, 13958
|
3746, 3746
|
15489, 18507
|
2517, 2575
|
12283, 13664
|
13782, 13937
|
11465, 12260
|
14141, 14992
|
4893, 6871
|
2590, 3727
|
15021, 15466
|
11133, 11439
|
195, 205
|
294, 2010
|
3762, 4877
|
13973, 14117
|
2032, 2196
|
2212, 2501
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,519
| 189,349
|
2083
|
Discharge summary
|
report
|
Admission Date: [**2113-7-6**] Discharge Date: [**2113-7-11**]
Date of Birth: [**2042-3-17**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
angina
Major Surgical or Invasive Procedure:
[**2113-7-6**]
1. Coronary artery bypass graft x4 left internal mammary
artery to left anterior descending artery and saphenous
vein grafts to posterior descending artery, obtuse
marginal and diagonal arteries.
2. Endoscopic harvesting of the long saphenous vein
History of Present Illness:
71 year old female who developed angina in [**6-8**]. Presented to
OSH and was found to be in Atrial fibrillation. Converted to SR
with beta blocker and started on coumadin. ETT was abnormal and
had cardiac cath on [**6-30**]. Discharged home for plavix washout and
admitted today for surgery
Past Medical History:
CAD s/p cabg x4
A Fib
NIDDM
hypertension
hyperlipidemia
heart murmur
PSH: cholecystectomy
tonsileectomy
Social History:
works as volunteer
lives alone
denies tobacco use
denies ETOH
Family History:
father died of CAD at 88
Physical Exam:
62" 72.6 kg
62 SR 140/63 RR 16 100% RA sat
skin dry and intact
PERRLA, EOMI
neck supple , full ROM, no carotid bruits
CTAB
RRR
soft, NT, ND, + BS
warm, well-perfused; no edema
minimal spider veins anterior BLE
neuro grossly intact
right fem sheath in place; left 2+
R DP + doppler, left + doppler
PT 1+ bil.
PT 2+ bil.
radials 2+ bil.
Pertinent Results:
Conclusions
PRE-BYPASS: There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. There are simple atheroma in
the aortic root. There are simple atheroma in the aortic arch.
There are simple atheroma in the descending thoracic aorta. The
aortic valve leaflets are moderately thickened. There is mild
aortic valve stenosis (valve area 1.2-1.9cm2). No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is severe mitral annular calcification. Mild
(1+) mitral regurgitation, posterior directed is seen. Due to
the eccentric nature of the regurgitant jet, its severity may be
significantly underestimated (Coanda effect).
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including phenylephrine and is in
sinus rhythm
1. Biventricular function is preserved
2. Aortic contours are normal
3. Other findings are unchanged.
Dr. [**First Name (STitle) **] was notified in person of the results.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 928**] [**Name8 (MD) 929**], MD, MD,
Interpreting physician [**Last Name (NamePattern4) **] [**2113-7-6**] 13:30
[**2113-7-10**] 06:57AM BLOOD WBC-7.8 RBC-3.53* Hgb-10.7* Hct-31.4*
MCV-89 MCH-30.3 MCHC-34.1 RDW-14.4 Plt Ct-146*
[**2113-7-6**] 02:40PM BLOOD WBC-13.7* RBC-2.91* Hgb-8.6* Hct-25.2*
MCV-87 MCH-29.5 MCHC-34.1 RDW-14.4 Plt Ct-102*
[**2113-7-10**] 06:57AM BLOOD Plt Ct-146*
[**2113-7-6**] 01:25PM BLOOD PT-19.6* PTT-73.9* INR(PT)-1.8*
[**2113-7-6**] 01:25PM BLOOD Plt Ct-164#
[**2113-7-6**] 11:00PM BLOOD Fibrino-198
[**2113-7-11**] 04:30AM BLOOD UreaN-24* Creat-1.1 K-4.6
[**2113-7-10**] 06:57AM BLOOD Glucose-101 UreaN-28* Creat-1.3* Na-138
K-4.5 Cl-103 HCO3-30 AnGap-10
[**2113-7-6**] 02:40PM BLOOD UreaN-14 Creat-0.8 Cl-112* HCO3-21*
[**2113-7-10**] 06:57AM BLOOD ALT-17 AST-31 LD(LDH)-266* AlkPhos-44
Amylase-42 TotBili-0.6
Brief Hospital Course:
Admitted same day surgery and underwent coronary artery bypass
graft surgery. See operative report for further details.
Perioperative antibiotic was cefazolin. She was transferred to
the intensive care unit for hemodynamic management. In the
first few hours she was coagulopathic requiring FFP, platlets,
cryoprecipitate, and protamine. Bleeding resolved and she
remained intubated overnight on vasoactive medications. She had
a right chest tube placed post operative day one for pleural
effusion. She was started on betablockers for heart rate, ace
inhibititor for blood pressure management and lasix for gentle
diuresis. Physical therapy worked with her on strength and
mobility. She was transitioned to sliding scale insulin with
lantus and resumed home oral hypoglycemics however had episodes
of hypoglycemia. Oral agents discontinued and continued with
sliding scale insulin. [**Last Name (un) **] consulted due to history of
hypoglycemic episodes at home prior to admission on oral
regimen. Plan to continue with insulin sliding scale, recheck
creatinine level in few days at rehab and if remains stable
start metformin. She was ready for discharge post operative day
five to rehab.
Medications on Admission:
gemfibrozil 600mg twice a day
Lisinopril 20 mg daily
Metformin 1,000mg twice a day
Glyburide 5mg 2 tablets twice a day
Diovan 320 mg daily
Lipitor 80 mg daily
Zetia 10 mg daily
Ferrous sulfate 325 mg daily
Aspirin 325mg daily
Os-cal 1 tablet once a day
Multivitamin 1 tablet daily
Ascorbic acid 1 tablet daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day). Capsule(s)
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Sliding Scale insulin
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Humalog Humalog Humalog Humalog
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
0-60 mg/dL 4 oz. Juice 4 oz. Juice 4 oz. Juice 4 oz. Juice
61-150 mg/dL 0 Units 0 Units 0 Units 0 Units
151-200 mg/dL 3 Units 3 Units 3 Units 0 Units
201-250 mg/dL 6 Units 6 Units 6 Units 3 Units
251-300 mg/dL 9 Units 9 Units 9 Units 6 Units
301-320 mg/dL 12 Units 12 Units 12 Units 9 Units
12. Diabetes
please check blood glucose premeals and HS
and if symptoms of hypoglycemia
Continue with sliding scale insulin - check Cr in 3 days, if
remains stable consider resuming metformin
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 620**]
Discharge Diagnosis:
Coronary artery disease s/p CABG
Atrial fibrillation
Diabetes mellitus type 2
Hypertension
Hyperlipidemia
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:
Please call to schedule appointments
Dr. [**Last Name (STitle) 11302**] after discharge from rehab
Dr. [**First Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2113-7-11**]
|
[
"427.31",
"E878.2",
"250.80",
"401.9",
"998.11",
"E849.7",
"458.29",
"414.01",
"V58.61",
"272.4",
"511.89",
"413.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"38.93",
"39.61",
"36.13",
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
6846, 6923
|
3765, 4967
|
326, 603
|
7073, 7080
|
1548, 3742
|
7591, 7882
|
1148, 1174
|
5328, 6823
|
6944, 7052
|
4993, 5305
|
7104, 7568
|
1189, 1529
|
280, 288
|
631, 926
|
948, 1053
|
1069, 1132
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,503
| 174,808
|
14020
|
Discharge summary
|
report
|
Admission Date: [**2136-9-26**] Discharge Date: [**2136-10-10**]
Date of Birth: [**2065-9-26**] Sex: F
Service: MEDICINE
Allergies:
Iodine; Iodine Containing / Codeine / Ticlid / Atorvastatin
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
epigastric and chest pain, radiating to the back.
Major Surgical or Invasive Procedure:
Intubation
Cardioversion
Central line placement
History of Present Illness:
71 yo female with history of CAD, COPD, HTN, who was initially
admitted on [**2136-9-26**] to vascular service with mid upper back pain
that radiated to mid-epigastrium raising concern for an aortic
dissection. CT showed no dissection and no progression compared
with CT at the [**Hospital 4068**] hospital on [**2136-9-25**]. A CT scan revealed a
descending aortic ulcer. Vascular surgery recommended medical
management and she was then transferred to medicine.
Past Medical History:
CAD s/p CABG [**2117**], stents [**2128**] and [**2134**]
HTN
COPD
B/L Renal artery stenosis s/p right stent placed [**11-29**]- Last MRA
[**8-27**]
Anxiety
Possible Barretts seen on last egd [**2134**]- but not on bx
s/p CCY
s/p Appy
s/p Oophrectomy
renal artery stent placed as above
CABG and stent placements as above
Social History:
Patient has no h/o tabacco. She does not use alcohol. She has 7
children.
Family History:
Mother, grandmother died of liver cancer.
Physical Exam:
Exam at the time of transfer to medical floor from the MICU:
VS: 97.0 127/91 84 (70-84) 24 95% on 4L NC
GEN: Elderly female in no distress, eating lunch, alert, awake,
conversant
HEENT: PERRL, EOMI, CN II-XII otherwise intact, no palpable
cervical LAD, OP moist, no lesions
Neck: supple, no LAD, JVP
CV: regular, nl S1/S2, [**1-1**] syst murmur
PULM: soft bibasilar crackles
ABD: soft, nt, nd, NABS.
NEURO: A&O x3, answers questions appropriately, no gross motor
or sensory deficits
EXT: no peripheral edema, warm and well perfused, no clubbing,
DP pulses 2+, PT pulses 1+
Pertinent Results:
Labs on admission:
[**2136-9-26**] 05:45AM BLOOD WBC-16.2* RBC-4.45# Hgb-12.6# Hct-36.8
MCV-83 MCH-28.2 MCHC-34.1 RDW-14.1 Plt Ct-448*
[**2136-9-26**] 05:45AM BLOOD Neuts-79.1* Lymphs-15.7* Monos-3.6
Eos-1.4 Baso-0.3
[**2136-9-26**] 05:45AM BLOOD PT-12.7 PTT-25.0 INR(PT)-1.1
[**2136-9-26**] 05:45AM BLOOD Glucose-95 UreaN-14 Creat-0.9 Na-144
K-4.2 Cl-110* HCO3-25 AnGap-13
[**2136-9-27**] 02:15AM BLOOD Lipase-49
[**2136-9-26**] 01:40PM BLOOD Calcium-9.2 Phos-3.4 Mg-1.9
[**2136-9-26**] 01:46PM BLOOD Lactate-1.1
[**2136-9-27**] 02:15AM BLOOD ALT-156* AST-131* CK(CPK)-96 AlkPhos-126*
Amylase-60 TotBili-0.6 DirBili-0.2 IndBili-0.4
________________
Cardiac Enzymes:
[**2136-9-26**] 10:43AM BLOOD CK-MB-2 cTropnT-<0.01
[**2136-9-27**] 02:15AM BLOOD CK-MB-2 cTropnT-<0.01
[**2136-9-29**] 01:37AM BLOOD CK-MB-24* MB Indx-5.4 cTropnT-0.86*
[**2136-9-29**] 05:41PM BLOOD CK-MB-10 MB Indx-3.9 cTropnT-0.92*
[**2136-10-4**] 01:10PM BLOOD CK-MB-NotDone cTropnT-0.98*
[**2136-10-5**] 03:54AM BLOOD CK-MB-NotDone cTropnT-0.89*
[**2136-10-7**] 05:45AM BLOOD CK-MB-NotDone cTropnT-0.17*
[**2136-10-8**] 06:00AM BLOOD CK-MB-NotDone cTropnT-0.07*
________________
Other pertinent lab results:
[**2136-10-9**] 05:50AM BLOOD calTIBC-273 Ferritn-122 TRF-210
[**2136-9-29**] 01:37AM BLOOD TSH-1.2
[**2136-10-8**] 06:00AM BLOOD TSH-3.9
[**2136-9-30**] 02:02AM BLOOD Cortsol-24.1*
[**2136-9-30**] 09:25AM BLOOD Cortsol-41.2*
________________
Labs at the time of discharge:
[**2136-10-10**] 05:45AM BLOOD WBC-19.6* RBC-3.64* Hgb-10.1* Hct-30.5*
MCV-84 MCH-27.8 MCHC-33.1 RDW-15.8* Plt Ct-553*
[**2136-10-10**] 05:45AM BLOOD Glucose-82 UreaN-24* Creat-1.1 Na-142
K-4.7 Cl-106 HCO3-26 AnGap-15
[**2136-10-10**] 05:45AM BLOOD Calcium-9.2 Phos-3.7 Mg-2.1
[**2136-10-10**] 05:45AM BLOOD PT-18.3* PTT-36.0* INR(PT)-2.3
Microbiology:
RESPIRATORY CULTURE (Final [**2136-10-1**]):
MODERATE GROWTH OROPHARYNGEAL FLORA.
ENTEROBACTER AEROGENES. MODERATE GROWTH.
STAPH AUREUS COAG +. MODERATE GROWTH. (oxacilin
sensitive)
Pertinent Studies:
Echo [**2136-9-27**] Moderately dilated LA, left to right shunt at
rest, moderate ASD (4-6 mm in diameter)secundum, mild LVH, LVEF
60-70%,1+MR
RUQ US [**2136-9-27**]: Dilatation of extrahepatic common bile duct to
1 cm, which is an equivocal finding.
CT [**2136-9-27**] (c/w [**2136-9-25**] CT from [**Hospital 4068**] hospital): 1. No
evidence of pulmonary embolism. 2. Stable appearance of
penetrating descending thoracic aortic ulcer. No evidence of
aortic dissection or intramural hematoma. 3. Interval
development of dependent bilateral air space opacities, diffuse
interlobular septal thickening and small bilateral pleural
effusions. Findings are all consistent with pulmonary edema and
atelectasis.
Renal US [**2136-9-30**]: No hydronephrosis. Fluid is seen within the
bladder in the presence of a Foley catheter suggesting possible
catheter malfunction.
CXR [**2136-10-8**]: Improving right lower lobe consolidation but new
tiny left pleural effusion.
p-MIBI [**2136-10-9**]:
Uninterpretable EKG in the absence of anginal symptoms.
Nuclear report: 1. Mild transient ventricular dilitation. 2.
Moderately partial reversible defects in the distal anterior
wall and apex. 3. Enlarged left ventricular cavity size in
stress. Hypokinesis of distal a
anterior wall and apex.
Brief Hospital Course:
71 yo female admitted from the ED on [**9-26**] with mid upper back
pain that radiated to mid-epigastrium raising concern for an
aortic dissection. A CT scan revealed a descending aortic ulcer.
She was hypertensive to 213/98 on arrival and was found to have
mild epigastric tenderness on exam. She was evaluated by
vascular surgery and because CT scan showed no dissection, no
aneurysmal dilatation, and no changes from [**2136-9-25**] CT from
[**Hospital 4068**] Hospital the patient was transferred to medicine. Strict
blood pressure control was recommended. The patient was treated
aggressively with labetalol, Diltiazem, beta-blocker, Nipride
and essentially periods of sinus arrest with junctional escapes.
She then became hypotensive was given fluids and required ICU
transfer for respiratory distress, chest pain and hypotension in
the setting of afib with RVR. In the MICU, she was initially
treated a NTG gtt that was changed to a nitroprusside gtt,
labetalol gtt and intermittently required pressors after
becoming hypotensive. MICU course was complicated by PNA
requiring intubation on [**2136-9-30**].
1. Hypoxic respiratory failure. On [**9-28**] she was started on
levofloxacin for presumed pneumonia given increasing WBC, cough
and secretions. She has a neutrophilic predominance with 4
bands. The patient required intubation on [**2136-9-30**] in the
setting of aggressive volume resuscitation for hypotension and
progression pneumonia. Her sputum culture later grew
Methicillin-sensitive Staph aureus. The patient was treated
initially with CTX/azithromycin/Vanco then changed to Oxacillin
and then Levofloxacin. She improved with diuresis and
antibiotics and was successfully extubated on [**2136-10-2**]. The
patient was discharged to complete 4 more days of Levofloxacin
(organisms sensitive).
2. Atrial fibrillation. Early in her hospital course, the
patient was noted to have episodes of sinus arrest with
junctional escapes in the setting of all cardiovascular
medications she was receiving. The patient was later noted to be
in AFib with RVR during this admission. She has no prior history
of atrial fibrillation. She also had anginal symptoms during
most of the episodes of rapid ventricular response with chest
pain radiating into her neck and jaw. She was converted with
DCCV to SR at 80 on [**2136-9-30**]. Because of allergy to iodine, she
received was briefly on procainamide, but after more history
about her allergies was obtained, she was started on po
Amiodarone loading on [**2136-10-3**] (TSH normal). She continued to
have recurrent intermittent episodes of a fib with RVR some of
which were poorly tolerated. After she was transferred to the
floor, metoprolol dose was titrated up to 37.5 mg po tid which
appeared to keep her HR in 60's with BP tolerating this dose
well. The patient was started on heparin and then transitioned
to Coumadin during this admission. Her INR was therapeutic at
the time of discharge. Electophysiology consultants followed her
closely throughout this admission, and felt that low dose
digoxin may be an option if the patient continues to have
symptomatic episodes of a fib with RVR on beta-blockers and
metoprolol alone. She will have her INR's followed by her PCP's
office who were notified and follow up was arranged. Her
Amiodarone dose was decreased to 400 mg po daily starting
[**2136-10-11**].
3. Coronary artery disease. Patient has a history of CABG [**2117**],
PCIs in [**2128**] and [**2134**]. During this admission she ruled in for
NSTEMI in the setting of afib/RVR and pneumonia. Troponin has
peaked on [**2136-10-4**] at 0.98. She was continued on aspirin,
beta-blocker, Ace I, niacin and pravachol was added. Because she
had anginal symptoms when in rapid ventricular response,
cardiology consult was obtained and the decision was to further
risk stratify her with a p-MIBI which she had on [**2136-10-9**].
Nuclear images showed moderate size partially reversible defect
in distal ant/apex. Because the defect was relatively small, the
patient had no anginal symptoms with exertion, it was felt that
medical management and a fib management should be tried first.
This was discussed with her outpatient cardiologist, Dr.
[**Last Name (STitle) **], who was in agreement.
4. CHF/volume overload. EF 60-70%, secundum ASD with L to R
shunt, mild LVH, 1+ MR. The patient was diuresed with Lasix as
needed. Her oxygen requirements continued to decrease and she
was slowly weaned off oxygen. The patient is being discharged on
beta-blocker, ACE inhibitor. Her ambulatory oxygen saturations
were 90% at the time of discharge with very quick recovery when
at rest. The patient was seen by PT who cleared her for d/c
home. The patient was instructed to check daily weights. Her
weight at the time of discharge was 58 kg.
5. Aortic ulcer. Patient had evaluation as above. She will need
strict blood pressure control.
6. Transaminitis. The patient had mild transaminitis on
admission (alt 156, ast 131, ap 126) possibly from hepatic
congestion. For her abdominal pain she was evaluated on
admission by the GI service and started on Protonix for possible
gastritis. Her abdominal pain gradually resolved. RUQ US was
done to r/o cholecystitis and was negative. H. pylori serologies
and EGD was recommended and could be considered as part of
outpatient work up. Of note, the patient did report a recent 10
pound weight loss and early satiety.
7. COPD. She was continued on Montelukast and
fluticasone-salmeterol. She was asked to avoid albuterol if
possible given afib to prevent tachycardia. She will use
ipratropium instead of Combivent when possible.
8. Anxiety. Ativan prn was given.
The patient was discharged home with VNA and PT services after
inpatient PT evaluation/clearance. Close outpatient follow up
with PCP and Dr. [**Last Name (STitle) **] was arranged for the patient.
Medications on Admission:
Vasotec 40 mg [**Hospital1 **]
Cardiazem 240 mg daily
Toprol 50 mg daily
Loratadine
Ativan
Advair
ASA 325mg daily
Niacin 500mg daily
Singulair
HCTZ 12.5 mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
2. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for anxiety.
4. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. Niacin 100 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
9. Combivent 103-18 mcg/Actuation Aerosol Sig: One (1)
Inhalation three times a day as needed for shortness of breath
or wheezing.
10. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Amiodarone 400 mg Tablet Sig: One (1) Tablet PO once a day
for 14 days: then your dose should be decreased to 400 mg po
daily.
Disp:*14 Tablet(s)* Refills:*0*
12. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
13. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
Disp:*30 Tablet(s)* Refills:*0*
14. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*0*
15. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual every 5 minutes as needed for chest pain: may take up
to 3 pills under tongue.
Disp:*30 * Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary:
1. Staph aureus pnemonia
2. Atrial fibrillation
3. Coronary artery disease
4. Angina when in rapid ventricular response
5. Aortic ulceration
Secondary:
1. Hypertension
Discharge Condition:
Vital signs stable. Afebrile
Discharge Instructions:
Please take all medications as prescribed. It is very important
that you take your heart medications as scheduled. Please note
that we added several new medications to your list. You are
started on Coumadin, a blood thinner, and your levels (INR) need
to be closely monitored. Please go to Dr.[**Name (NI) 31083**] office for
INR check this Thursday, [**2136-10-11**], at 9:30 am.
Please follow up as listed below.
Please check your weight every morning. Please call your doctor
if you notice > 3lbs weight gain. Please call your doctor if you
have chest pain, more shortness of breath, develop fevers,
chills, increased cough, unable to tolerate po, bleeding that
does not stop after applying pressure for 5 minutes, or if you
have any other concerns.
Followup Instructions:
Please go to Dr.[**Name (NI) 31083**] office for INR check this Thursday,
[**2136-10-11**], at 9:30 am. Please call Dr. [**Last Name (STitle) **] to find out the
results and to adjust Coumadin dose.
Please follow up with Dr. [**Last Name (STitle) **] (covering for Dr. [**Last Name (STitle) **] this
week) on Friday, [**2136-10-12**], at 2:15 pm. Phone number is
[**Telephone/Fax (1) 6163**].
Please follow up with Dr. [**Last Name (STitle) **], on Tuesday, [**2136-10-23**] at
2:30 pm. Please call if you need to reschedule [**Telephone/Fax (1) 6163**].
Please follow up with your cardiologist, Dr. [**Last Name (STitle) **], on
Wednesday, [**2136-10-24**] at 11:00 am. ([**Telephone/Fax (1) 41856**]
Completed by:[**2136-10-10**]
|
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"V45.82",
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"410.71",
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icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.04",
"99.61",
"89.64",
"38.91",
"96.71",
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] |
icd9pcs
|
[
[
[]
]
] |
13273, 13322
|
5372, 11237
|
370, 420
|
13544, 13575
|
2024, 2029
|
14379, 15118
|
1365, 1408
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11449, 13250
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13343, 13523
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11263, 11426
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13599, 14356
|
1423, 2005
|
2692, 5349
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281, 332
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448, 913
|
2043, 2675
|
935, 1258
|
1274, 1349
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,348
| 136,270
|
39944
|
Discharge summary
|
report
|
Admission Date: [**2170-11-26**] Discharge Date: [**2170-12-2**]
Date of Birth: [**2099-12-29**] Sex: M
Service: SURGERY
Allergies:
Penicillins / Codeine
Attending:[**First Name3 (LF) 3200**]
Chief Complaint:
transferred with SAH
Major Surgical or Invasive Procedure:
none
History of Present Illness:
70yo man w/ history of ESRD on TuThSat dialysis, CAD with PCI
x3, s/p AICD and prostate cancer admitted after syncope with a
subarachnoid hemorrhage. He has a history of recurrent syncope,
most recently [**11-4**], when he was apparently admitted to an OSH
and had a negative work-up. This time he was home alone and does
not remember what happened. He does not remember preceding chest
pain, palpitations, ICD firing, dizziness or sick symptoms. He
thinks he fell down the stairs. He then apparently drove himself
to a pre-scheduled CT scan, and the next thing he remembers is
being in the hospital and having rib pain.
Past Medical History:
PMH: hypertension, hyperlipidemia, depression, renal art
stenosis, s/p B stent placement, ESRD on HD Tu/Th/Sat, prostate
ca, AICD pacemaker, CAD s/p stents x 3
Social History:
50 pack year smoking hx, quit 3 years ago. No ETOH or
illicit drug use.
Family History:
No family history of premature cardiac death. His daughter
had recurrent syncope as a child, but not since.
Physical Exam:
T: 96.0 BP: 108/69 HR: 83 R 11 O2Sats 100%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 2.5->2mm bilat 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: [**2-28**] 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, 2.5 to 2mm
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 [**5-2**] 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
Pertinent Results:
On admission:
WBC-6.5 RBC-3.34* HGB-11.1* HCT-31.6* MCV-95 MCH-33.3*
MCHC-35.1* RDW-18.2*
NEUTS-82* BANDS-5 LYMPHS-4* MONOS-9 EOS-0 BASOS-0 ATYPS-0
METAS-0 MYELOS-0
HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-OCCASIONAL
[**Name (NI) 87835**] [**Name (NI) 87836**]
PT-13.5* PTT-23.7 INR(PT)-1.2*
GLUCOSE-139* UREA N-74* CREAT-7.5* SODIUM-138 POTASSIUM-4.3
CHLORIDE-95* TOTAL CO2-26 ANION GAP-21*
On discharge (prior to receiving HD):
WBC 4.5, Hct 23.5, Plts 228
Na 133, K 4.7, Cl 95, HCO3 24, BUN 49, Cr 7.7, Glu 149
Ca 7.9, Mg 2.1, Phos 2.7
[**2170-11-26**] Head CT :
1. Diffuse subarachnoid hemorrhage with a small amount of
intraventricular
blood layering in the occipital horns. The configuration and
extent of the
blood is similar compared to the earlier study. No new
hydrocephalus.
2. No evidence of intracranial aneurysm in the arteries of the
anterior or
posterior circulation. Atherosclerotic narrowing in all the
intracranial
vessels without high-grade stenosis or occlusion.
3. Scalp hematoma along the right frontal convexity with
enhancement on the arterial phase.
[**2170-11-27**] CT Torso :
1. Right renal subcapsular hematoma as above with mass effect on
the atrophic right kidney and delayed excretion of contrast from
the right kidney as compared to the left. Right perinephric
stranding raises concern for perinephric hemorrhage/hematoma.
Small linear high density just medial to the mid pole of the
right kidney may be within a vessel, but on single phase,
difficult to exclude active extravasation, arterial or venous.
Consider patient return for delayed CT scanning for further
evaluation.
The above findings were discussed with Dr. [**Known firstname **] [**Last Name (NamePattern1) **] at 9:15
p.m. on
[**2170-11-26**].
2. Right-sided rib fractures as above.
3. Trace right pleural effusion.
4. Borderline aneurysmal dilatation of the infrarenal abdominal
aorta and the right common iliac artery. Mildly dilated
ascending aorta, as above.
[**2170-11-26**] Right wrist :
1. 2 mm bone fragment dorsal to the proximal carpal row on the
lateral view with overlying dorsal soft swelling, raises concern
for a triquetral fracture.
2. Osteoarthritic changes.
[**2170-11-26**] CT C spine :
1. Non-displaced fracture through the base of an osteophyte from
the right
anterior superior endplate of C6, most likely chronic. Minimal
anterolisthesis at C4-5 and C5-6, more prominent on the [**Hospital 4683**]
Hospital study than on the current study. If there is a concern
for
ligamentous injury, MRI would be helpful.
2. Intracranial hemorrhage, detailed in the same-day head CT and
head CTA
reports.
3. Paraseptal emphysema at the imaged lung apices.
4. Fluid versus polypoid mucosal thickening in the left sphenoid
sinus.
[**2170-11-27**] Cardiac echo :
Suboptimal image quality. 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 probably mildly depressed (LVEF= 40 %) with
mild global hypokinesis and regional infero-lateral severe
hypokinesis. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The ascending
aorta is mildly dilated. The aortic valve leaflets are mildly
thickened (?#). There is no aortic valve stenosis. Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Trivial
mitral regurgitation is seen. The pulmonary artery systolic
pressure could not be determined.
[**2170-11-27**] CTA pelvis :
1. Unchanged right subcapsular renal hematoma without evidence
of active
extravasation. There is no evidence of undelying mass lesion.
2. Right perinephric stranding is stable in size and appearance
from prior
study of [**2170-11-26**].
3. Small pleural effusion on the right and minimal left pleural
effusion.
4. Stable borderline aneurysmal dilatation of the infrarenal
abdominal aorta.
[**2170-11-27**] CTA Head/Neck : no aneurysm, moderate right vertebral
artery stenosis, moderate -severe left vertebral artery
stenosis, mild right ICA stenosis, moderate right subclavian
artery stenosis.
[**2170-11-28**] Head CT :
Diffuse subarachnoid hemorrhage with similar overall appearance
compared to prior.
[**2170-11-28**] EEG :
ABNORMALITY #1: There are frequent bursts of diffuse theta
slowing
throughout the awake portion of the record.
BACKGROUND: An 8.5-9 Hz alpha rhythm with a normal
anterior-posterior
gradient was observed during the awake portion of the recording.
HYPERVENTILATION: Was not performed.
INTERMITTENT PHOTIC STIMULATION: Was not performed.
SLEEP: The patient was observed to be awake and drowsy during
the
recording.
CARDIAC MONITOR: Showed a generally regular rhythm.
IMPRESSION: This is an abnormal routine EEG due the presence of
frequent bursts of diffuse theta slowing during the awake
portions of
the recording. This pattern is consistent with a mild diffuse
encephalopathy. There were no focal abnormalities or
epileptiform
features noted.
Brief Hospital Course:
Mr. [**Known lastname 6955**] was evaluated by the Trauma team in the Emergency
Room and scans were reviewed. He was admitted to the Trauma ICU
for close neurological evaluation, serial hematocrits in light
of his perinephric hematoma and for pain control secondary to
right rib fractures. He was also evaluated by the Hand service
for his right wrist fracture and a splint was applied. He
should not bear weight on the right arm.
Neurosurgery saw the patient and was unsure if the SAH was
traumatic vs. aneurysmal. Patient then underwent an Angio on
[**2170-11-27**] which demonstrated no aneurysm and moderate right and
moderate to severe left vertebral artery stenosis. Also some
mild R ICA (prox cavernous segment) and moderate stenosis of
left
subclavian artery proximal to left vert in origin. Neurology
was then consulted for potential stroke as the cause for LOC and
for the vertebral artery stenosis. His neurologic exam was
unchanged and he had no obvious seizures. An EEG was done which
essentially showed diffuse encephalopathy.
Mr. [**Known lastname 6955**] was transferred to the Trauma floor with a stable
hematocrit in the 23-25 range and was able to continue with his
hemodialysis as scheduled, Tues/Thurs/Sat. His last HD was [**12-1**].
His hemodynamics remained stable and his pain was well
controlled. He was able to use the incentive spirometer
effectively. His AICD was interrogated to assure it was
functioning appropriately and no problems were identified. He
remained in NSR without ectopy and had no further syncope in the
hospital.
From a neurologic standpoint, Mr. [**Known lastname 6955**] was started on
Dilantin for seizure prophylaxis at the time of admission. Due
to their high suspicion of the syncopal events precipitated by
seizures they would like to continue anti seizure medication
indefinitely. Currently for ease of management his Dilantin is
being weaned off and his last dose will be [**2170-12-2**].
Additionally he will start Keppra 500 mg daily on [**2170-12-1**] and on
hemodialysis days he should receive an additional 250 mg post
dialysis. The Neurology and Neurosurgical services will continue
to follow him as an out patient.
The Physical Therapy service evaluated Mr. [**Known lastname 6955**] and he was
well below his baseline functioning; thus acute rehab was
recommended to help him regain strength, balance and hopefully
maintain his independence.
Medications on Admission:
[**Last Name (un) 1724**]: Aspirin, Plavix 75mg daily, Carvedilol 25mg [**Hospital1 **],
Hydralazine 50mg [**Hospital1 **], Nephrocaps 1 cap daily, Omeprazole 40mg
[**Hospital1 **], Paroxetine 20mg daily, Simvastatin 20mg daily, Magnesium
oxide 400mg [**Hospital1 **], Renagel 800mg TID
Discharge Medications:
1. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
4. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
6. sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
8. hydralazine 50 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
9. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
12. phenytoin 125 mg/5 mL Suspension Sig: Four (4) ml PO Q12H
(every 12 hours) for 1 days.
13. phenytoin 125 mg/5 mL Suspension Sig: Four (4) ml PO ONCE
(Once) for 1 doses: on [**2170-12-2**].
14. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): start [**2170-12-1**].
15. levetiracetam 250 mg Tablet Sig: One (1) Tablet PO 3X'S A
WEEK AFTER EACH DIALYSIS RUN ().
16. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital for Continuing Medical Care - [**Location (un) 1121**]
([**Hospital3 1122**] Center)
Discharge Diagnosis:
S/P Fall
1. Diffuse subarachnoid hematoma
2. Right frontal subgaleal hematoma
3. Right 5th & 9th rib fractures
4. Right subcapsular perinephric hematoma
5. Right triquetral fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
* You were admitted to the hospital after falling with multiple
broken bones, a bruise on your brain and a bruise on your
kidney. Despite all of these problems you are recovering well.
* You are being transferred to a rehab facility so that you can
get vigorous Physical and Occupational Therapy so that you can
return home in good shape and maintain your independence.
* Your right arm will stay splinted. Do NOT put any weight on
it.
* You will continue your usual schedule of dialysis at rehab.
* Continue to use your incentive spirometer 10 x's an hour to
prevent pneumonia. Take enough pain medication so that you can
take deep breaths.
* NO DRIVING FOR 6 MONTHS FOLLOWING EVENT OF ALTERED
CONSCIOUSNESS AND/OR SEIZURE
Followup Instructions:
Follow up in the Hand Clinic on Tuesday [**2170-12-4**]. Call
[**Telephone/Fax (1) 3009**] to arrange a time.
Neurology Follow up: Patient should make an appointment with Dr.
[**Last Name (STitle) 87837**], [**First Name3 (LF) 1726**] [**Telephone/Fax (1) 31415**] in [**4-3**] weeks. Appt [**1-22**]
at 1 pm. [**Hospital Ward Name 23**] building [**Location (un) 858**].
Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a follow up
appointment in [**1-31**] weeks.
Call the [**Hospital 4695**] Clinic at [**Telephone/Fax (1) 1669**] for a follow up
appointment in 4 weeks. You will need a CT scan of the Head at
that time. The secretary will arrange that for you.
|
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icd9cm
|
[
[
[]
]
] |
[
"39.95",
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icd9pcs
|
[
[
[]
]
] |
12030, 12166
|
7880, 10304
|
305, 312
|
12393, 12393
|
2735, 2735
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1162, 1236
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,471
| 150,924
|
45768
|
Discharge summary
|
report
|
Admission Date: [**2104-2-6**] Discharge Date: [**2104-2-16**]
Date of Birth: [**2033-11-21**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Jaundice
Major Surgical or Invasive Procedure:
[**2101-2-14**]
1. Exploratory laparotomy.
2. Total abdominal colectomy with end ileostomy.
3. Temporary closure of abdominal wall with [**Location (un) 5701**] bag.
History of Present Illness:
70yo man with history of chronic EOTH abuse (sober X 2yrs) and
remote smoking history, who intially presented to [**Hospital1 59561**] in
[**2104-1-10**] for painless jaundice and generalized pruritus. He also
reported rust colored urine and white colored stool. An
abdomainl US demonstrated intrahepatic and extrahepatic biliary
duct dialtion. An MRCP demonstrated moderate intrahepatic
biliary ductal dialtion with an irregular fillign defect in the
proximal common bile duct. Four attempts at ERCP have failed
secondary to agitation, sheduling difficulties/inability to
tolerate procedure without general anesthesia, bigeminy and
hypotension respectively.
CT-guided placement of a percutaneous biliary stent by IR was
done on [**2104-1-29**] with drainage of bile, symptomatic improvement,
and bili trending down from 16 to 6. Tumor markers were sent
with CEA of 2.4, AFP of 3.5, and CA [**17**]-9 of 49.
He developed leukocytosis from 8 -> 19 -> 21 on [**2-4**]. He was
afebrile, and overall hemodynamically stable, but developed RUQ
pain. Initial CT abdomen - diffuse small bowel thickening -
started on cipro/flagyl. CT abd then read as dilated colon with
fecal matter and air suggestive of ileus vs. SBO. He was
continued on IVF and iv cipro/flagyl. On admission, he reports
that he feels well. No fever/chills/nausea/vomiting. He has been
eating well with no complaints. He has been moving his bowels.
No further abdominal pain. He reports that his pruritus is much
improved since the biliary stent placement.
[**Hospital1 59561**] imaging:
- EGD ([**12-14**]): bile reflux seen in esophagus. BRII anastomosis
site mod erythematous w/small polypoid nodules (Bx sent). O/w
WNL.
- C-scope ([**12-14**]): mild diverticulosis in sigmoid & rectum.
Internal hemorrhoids.
- U/S Abd ([**1-11**]): intra & extrahepatic biliary duct dilatation
likely [**12-19**] stone/obstructing lesion in region of head of
pancreas.
- MRCP ([**1-11**]): mod intrahepatic biliary ductal dilatation with
filling defect in prox CBD that is eccentric & concerning for
tumor. Also on DiffDx is atypical stone.
- ERCP ([**1-14**]): unable to sedate pt so couldn't locate ampulla
Past Medical History:
- HTN
- hyperlipidemia
- CRI
- PVD
- h/o EtOH abuse
- s/p Billroth II for PUD
- seizure disorder
- eczema
:- gout
- remote AF
- diverticulosis
- hemorrhoids
- restless legs syndrome
Social History:
not obtained
Family History:
non-contributory
Physical Exam:
Physical Exam:
97.0, 61, 18, 130/80, 98% RA
.
gen: alert/oriented; no acute distress
heent: + scleral icterus
neck: supple, full range of motion
skin: jaundiced
cv: rrr, no m/r/g
resp: clear with distant breath sounds bilaterally
abd: soft, non-tender, ND, biliary drain in place with
no erythema/induration/pain
extr: no c/c/e; no calf tenderness
Pertinent Results:
SEROLOGIES:
[**2104-2-6**] 09:00PM BLOOD WBC-14.5* RBC-3.08* Hgb-9.5* Hct-27.8*
MCV-90 MCH-31.0 MCHC-34.4 RDW-15.2 Plt Ct-281
[**2104-2-8**] 06:15AM BLOOD WBC-11.7* RBC-3.27* Hgb-10.2* Hct-29.1*
MCV-89 MCH-31.1 MCHC-34.9 RDW-15.2 Plt Ct-431
[**2104-2-10**] 02:28AM BLOOD WBC-27.4*# RBC-3.31* Hgb-10.1* Hct-32.2*
MCV-97# MCH-30.6 MCHC-31.4 RDW-15.0 Plt Ct-503*
[**2104-2-11**] 05:30AM BLOOD WBC-31.6* RBC-3.38* Hgb-10.1* Hct-30.3*
MCV-90 MCH-30.0 MCHC-33.5 RDW-15.3 Plt Ct-540*
[**2104-2-11**] 11:29PM BLOOD WBC-40.6* RBC-3.17* Hgb-9.8* Hct-28.6*
MCV-90 MCH-31.1 MCHC-34.4 RDW-15.2 Plt Ct-541*
[**2104-2-12**] 08:11PM BLOOD WBC-28.4* RBC-2.91* Hgb-8.7* Hct-27.4*
MCV-94 MCH-30.0 MCHC-31.8 RDW-15.6* Plt Ct-456*
[**2104-2-13**] 12:41PM BLOOD WBC-26.1* RBC-3.58* Hgb-11.0* Hct-31.9*
MCV-89 MCH-30.6 MCHC-34.4 RDW-16.4* Plt Ct-362
[**2104-2-16**] 07:52AM BLOOD WBC-42.3* RBC-3.52* Hgb-10.3* Hct-31.6*
MCV-90 MCH-29.3 MCHC-32.7 RDW-16.4* Plt Ct-121*#
[**2104-2-16**] 04:00PM BLOOD WBC-34.3* RBC-3.05* Hgb-9.1* Hct-26.4*
MCV-87 MCH-30.0 MCHC-34.7 RDW-16.8* Plt Ct-92*
[**2104-2-6**] 09:00PM BLOOD PT-13.5 PTT-26.5 INR(PT)-1.2
[**2104-2-12**] 05:05AM BLOOD PT-15.2* PTT-48.4* INR(PT)-1.5
[**2104-2-15**] 09:00AM BLOOD PT-15.9* PTT-49.7* INR(PT)-1.6
[**2104-2-16**] 07:52AM BLOOD PT-18.0* PTT-54.3* INR(PT)-2.0
[**2104-2-16**] 04:00PM BLOOD PT-17.0* PTT-86.5* INR(PT)-1.8
[**2104-2-16**] 04:00PM BLOOD Plt Ct-92*
[**2104-2-6**] 09:00PM BLOOD Glucose-104 UreaN-40* Creat-1.9* Na-131*
K-5.1 Cl-104 HCO3-20* AnGap-12
[**2104-2-9**] 05:05AM BLOOD Glucose-135* UreaN-41* Creat-1.8* Na-131*
K-4.6 Cl-101 HCO3-19* AnGap-16
[**2104-2-11**] 11:29PM BLOOD Glucose-150* UreaN-62* Creat-2.2* Na-139
K-3.5 Cl-103 HCO3-23 AnGap-17
[**2104-2-13**] 12:41AM BLOOD Glucose-193* UreaN-74* Creat-3.2* Na-134
K-4.1 Cl-102 HCO3-20* AnGap-16
[**2104-2-15**] 03:35AM BLOOD Glucose-314* UreaN-77* Creat-3.7* Na-129*
K-3.8 Cl-88* HCO3-26 AnGap-19
[**2104-2-15**] 08:59PM BLOOD Glucose-61* UreaN-59* Creat-3.0* Na-130*
K-4.5 Cl-91* HCO3-21* AnGap-23*
[**2104-2-16**] 11:12AM BLOOD Glucose-367* UreaN-52* Creat-2.6* Na-126*
K-4.1 Cl-82* HCO3-23 AnGap-25*
[**2104-2-16**] 04:00PM BLOOD Glucose-410* UreaN-47* Creat-2.3* Na-128*
K-3.4 Cl-80* HCO3-23 AnGap-28*
[**2104-2-6**] 09:00PM BLOOD ALT-23 AST-19 AlkPhos-143* TotBili-4.3*
[**2104-2-8**] 06:15AM BLOOD ALT-25 AST-23 AlkPhos-156* TotBili-4.4*
[**2104-2-12**] 05:05AM BLOOD ALT-16 AST-24 LD(LDH)-204 AlkPhos-128*
Amylase-21 TotBili-3.7*
[**2104-2-15**] 09:00AM BLOOD ALT-129* AST-219* LD(LDH)-552*
AlkPhos-132* Amylase-26 TotBili-2.3*
[**2104-2-16**] 11:12AM BLOOD ALT-266* AST-1598* LD(LDH)-2530*
AlkPhos-167* Amylase-34 TotBili-3.0*
[**2104-2-7**] 05:20AM BLOOD calTIBC-259* VitB12-941* Folate-6.6
Ferritn-536* TRF-199*
[**2104-2-13**] 09:31AM BLOOD Triglyc-108 HDL-19 CHOL/HD-3.8 LDLcalc-31
[**2104-2-12**] 11:05AM BLOOD Cortsol-58.8*
[**2104-2-12**] 12:04PM BLOOD Cortsol-77.7*
[**2104-2-15**] 03:05PM BLOOD Cortsol-54.1*
[**2104-2-14**] 06:23AM BLOOD Digoxin-1.8
[**2104-2-10**] 01:18AM BLOOD Lactate-2.2*
[**2104-2-11**] 08:03PM BLOOD Lactate-2.8*
[**2104-2-12**] 05:17AM BLOOD Lactate-2.4*
[**2104-2-13**] 03:41AM BLOOD Glucose-148* Lactate-2.2*
[**2104-2-14**] 07:28AM BLOOD Lactate-3.3*
[**2104-2-15**] 03:31AM BLOOD Lactate-8.0*
[**2104-2-15**] 09:11AM BLOOD Lactate-9.7*
[**2104-2-15**] 03:18PM BLOOD Lactate-10.8*
[**2104-2-15**] 06:40PM BLOOD Glucose-94 Lactate-12.2* Na-125* K-4.6
[**2104-2-16**] 09:38AM BLOOD Glucose-248* Lactate-15.3* Na-127* K-3.8
Cl-89*
[**2104-2-16**] 01:36PM BLOOD Lactate-17.8*
[**2104-2-16**] 07:10PM BLOOD Glucose-241* Lactate-18.8*
MICROBIOLOGY:
[**2104-2-15**] Peritoneal Fluid: Coag + Staph Aureus
[**2104-2-14**]: C Diff +
[**2104-2-12**] JP Drain Fluid: MRSA
[**2104-2-10**] Stool: C Diff +
RADIOLOGY:
[**2104-2-8**] CT Abdomen: No fluid collections within the abdomen or
pelvis are present that are amenable to drainage. There are
small amounts of fluid in the abdomen and pelvis as described.
[**2104-2-9**] CT Abdomen:Slightly increased amount of fluid around the
liver and deep within the pelvis. There are bilateral pleural
effusions, right greater than left, that are slightly increased
in the interim.
There is an air-fluid level within the esophagus, not seen on
yesterday's CT. Clinical correllation recommended.
[**2104-2-12**] CT Abdomen: 1) Status post percutaneous biliary drainage
catheter placement. Contrast within the gallbladder, but no
evidence of contrast leakage. Slight increase in volume of
ascites since the prior exam. 2) Atherosclerotic disease. 3)
Nonobstructing bilateral renal stones.
[**2104-2-15**] Abdominal XRay: Portable view of the abdomen again shows
a markedly dilated colon from the cecum to the splenic flexure
of the transverse colon. The maximum diameter is 11.5 cm. A
rectal tube is seen in the rectum. A pig tail catheter
terminates in the mid-abdominal region. There is an opacity at
the right lung base, which could represent atelectasis or
consolidation. No free air is detected.
Brief Hospital Course:
Mr. [**Name13 (STitle) 96013**] is a 70-year-old gentleman who presented to the
care of General Surgery with a month long history of treatment
for biliary duct obstruction at an outside hospital. He had a
prior history of a Billroth II gastric resection for peptic
ulcer disease. Evaluation of his biliary duct disease indicated
a stricture in the mid duct and this was drained percutaneously
at the referring hospital prior to his transfer to [**Hospital1 18**].
Shortly after his arrival here, the percutaneous transhepatic
tube was inadvertently removed from the patient. This was
replaced a few days later. Subsequent to this, he developed
evidence of systemic infection and subsequent multi-system organ
dysfunction. He had an MRSA septicemia. There was evidence of C.
diff. toxin positivity 4 days prior to this procedure, although
his clinical course did not suggest overwhelming infection in
that he did not have major diarrhea, nor was his colon inflamed
on CAT scan. However, he deteriorated rapidly over the next [**12-20**]
days and maintained a persistent elevated white count at 30 to
40 thousand. He had multi-system organ failure involving his
pulmonary, renal and cardiac systems. With this precipitous
decline over a short period and the new evidence of diarrhea, it
was thought that me might have fulminant C. diff. colitis.
Abdominal x- rays showed a massively dilated colon on the
morning of [**2104-2-15**] and a flexible sigmoidoscopy was performed at
the bedside. This revealed pseudomembranes and a necrotic
appearing sigmoid and rectum.
Given all of these findings and the patient's instability
without improvement with maximal support, he was taken to the
operating room on [**2104-2-15**] with the goal of performing a total
abdominal colectomy for fulminant C. diff. colitis. The
patient's family and health care proxy wished to intervene with
this procedure in order to sustain Mr. [**Last Name (Titles) 97518**] life, but
they understood the extreme risks of this operation with his
cardiac and respiratory instability as well as the slim
likelihood that there would be a positive ultimate outcome. The
procedure was performed as planned on [**2104-2-15**] (please see the
operative note of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for full details).
Post-operatively the patient continued to present with a
precipitous SIRS picture with multi-organ dysfunction including
renal failure, cardiovascular failure with pressor dependence,
and ventilatory dependence. After extensive discussion with his
family and health care proxy he was made [**Name (NI) 3225**] 24 hours later and
expired shortly there-after.
Medications on Admission:
percocet
sarna lotion
ASA 325
calcium carbonate 650 QID
cilostazol 100 [**Hospital1 **]
colestiipol 5g [**Hospital1 **]
ciprofloxacin IV
ferrous sulfate 325 TID
HCTZ 12.5 - (held)
hydroxyzine 25mg q6 prn itching
metoprolol 75 TID
odansetron prn
pramipexole 0.125 HS
sennosides
simvastatin 20mg HS
terazosin 10 HS
clonidine 0.1mg/24h patch q FRI
urosdiol 300 TID
zolpidem 10mg HS
triamcinolone ointment
Discharge Medications:
[Patient deceased during this admission]
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary: Multi-system Organ Dysfunction
Secondary: MRSA bacteremia, C. Diff Colitis
Discharge Condition:
Deceased
Discharge Instructions:
None
Followup Instructions:
None
Completed by:[**2104-4-15**]
|
[
"584.9",
"780.39",
"788.20",
"576.8",
"276.1",
"557.0",
"785.52",
"403.91",
"285.9",
"482.41",
"008.45",
"427.31",
"518.82",
"576.1",
"V09.0",
"038.11",
"303.90",
"567.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.21",
"99.15",
"54.63",
"48.23",
"45.8",
"96.04",
"96.72",
"00.11",
"99.12",
"38.93",
"38.91",
"51.98"
] |
icd9pcs
|
[
[
[]
]
] |
11521, 11530
|
8331, 11003
|
279, 446
|
11657, 11667
|
3294, 8308
|
11720, 11755
|
2892, 2910
|
11456, 11498
|
11551, 11636
|
11029, 11433
|
11691, 11697
|
2940, 3275
|
231, 241
|
474, 2640
|
2662, 2846
|
2862, 2876
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,130
| 195,914
|
54275
|
Discharge summary
|
report
|
Admission Date: [**2198-10-10**] Discharge Date: [**2198-10-12**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
S/P fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt is a [**Age over 90 **] yo female with atrial fibrillation on coumadin,
HTN, and CSF who fell at her nursing home and went to an OSH
where head CT showed a L temporal SAH, chronic R SDH. The
patient fell on the tile floor of her bathroom at 8:30 PM last
night. She may have briefly passed out though she is not
completely sure. She fell on the left side of her head. She
complaining of left rib pain as well. CT at the OSH showed the
above findings. Her INR was 2.2 and she was given FFP and
vitamin K. She was then transferred to [**Hospital1 18**].
Past Medical History:
Past Medical History: atrial fibrillation on coumadin, HTN,
CHF,
PVD, CKD, osteoporosis, peripheral neuropathy, MVR.
Social History:
Lives in a nursing home
No tobacco
No ETOH
Family History:
non contributory
Physical Exam:
Vitals: T 97.9; BP 144/76; P 70; RR 18; O2 sat 96%
General: lying in bed NAD
HEENT: ecchymosis with swelling over the left temple, moist
mucous membranes
Neck: supple
Extremities: no c/c/e. ecchymosis of medial R knee.
Neurological Exam:
Mental status: A & O x3. Fluent speech with no paraphasic
errors. Adequate comprehension. Follows simple and multi-step
commands. Able to thumb but not stethoscope.
Cranial Nerves:
I: Not tested
II: PERRL, 3-->2mm with light.
III, IV, VI: EOMI. no nystagmus.
V, VII: facial sensation intact, face symmetric.
VIII: hearing intact b/l to finger rubbing.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: SCM [**6-13**]
XII: Tongue midline without fasciculations.
Motor: Normal bulk. Normal tone. No pronator drift. Full
strength except for limited testing of hamstring due to OA in
both knees causing difficulty with flexion.
Sensation: intact to light touch.
Reflexes: 1+ in UEs, absent in LEs, toes mute.
Coordination: FNF intact.
Pertinent Results:
[**2198-10-10**] 04:43AM WBC-6.7 RBC-4.10* HGB-12.1 HCT-35.7* MCV-87
MCH-29.6 MCHC-34.0 RDW-15.2
[**2198-10-10**] 04:43AM NEUTS-52.1 LYMPHS-39.6 MONOS-5.5 EOS-2.0
BASOS-0.8
[**2198-10-10**] 04:43AM PLT COUNT-138*
[**2198-10-10**] 04:43AM GLUCOSE-142* UREA N-26* CREAT-1.1 SODIUM-139
POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-27 ANION GAP-13
[**2198-10-10**] 12:37PM WBC-7.7 RBC-4.21 HGB-12.0 HCT-37.5 MCV-89
MCH-28.5 MCHC-32.1 RDW-15.0
[**2198-10-10**] 12:37PM PT-17.2* PTT-28.7 INR(PT)-1.5*
[**2198-10-10**] 12:37PM GLUCOSE-128* UREA N-24* CREAT-1.0 SODIUM-138
POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-29 ANION GAP-10
[**2198-10-12**] INR 1.2
[**2198-10-10**] Head CT : Acute subarachnoid hemorrhage overlying the
left temporal lobe and likely acute/subacute small subdural
hematoma over the right frontal lobe.
[**2198-10-10**] Bilat hips : No fracture identified. If there is
continued concern for an occult hip fracture, recommend further
evaluation with MRI.
[**2198-10-10**] Bilat knees : 1. Moderate osteoarthritis of the left knee
and severe osteoarthritis of the
right knee.
2. No definite fractures. If there is continued concern for an
occult
fracture, recommend further evaluation with CT.
[**2198-10-10**] Chest CT :
1. No evidence of intrathoracic injury.
2. Multiple pulmonary nodules measuring up to 1.5 cm, given size
and evidence of asbestos exposure, a three-month followup is
recommended. Alternatively, these could represent focal
contusions in the setting of trauma.
3. RUL ground glass opacity measuring 1.5 cm, could represent a
Bronchoalveolar carcinoma.
4. Mild pulmonary edema and small bilateral effusions.
Brief Hospital Course:
Mrs. [**Known lastname 37557**] was evaluated by the Trauma team in the Emergency
Room and fully scanned. She had a left temporal SAH and a
chronic right SDH but showed no evidence of any neurologic
deficit. She received Vitamin K and FFP to reverse her INR of
2.2 which was successful. She was admitted to the Trauma floor
for further management.
Her neurologic exam remained unchanged but she had generalized
aches and pains from her fall. Luckily she had no broken bones
and her mental status was clear. She was evaluated by the
Neurosurgery service both in the Emergency Room and on the floor
and they recommended keeping her INR < 1.4 and totally
discontinue Coumadin. They also recommended a repeat head CT
but she refused the exam. Again there was no change in her exam.
Her INR on [**2198-10-12**] was 1.2. She was able to tolerate a regular
diet though did not have much of an appetite.
Routine fingerstick blood sugars were followed as in all Trauma
patients and she had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1131**] of 240 on one occasion. Her
serum blood sugars since admission were 120-170 range. Her
elevated sugar may be stress related but nevertheless should be
followed.
On [**2198-10-12**] she discharged back to her nursing home and will
follow up with her PCP as needed.
Medications on Admission:
Digoxin 0.125 [**Last Name (LF) **], [**First Name3 (LF) **] 81 mg q day, Metoprolol 25 mg
[**Hospital1 **], Coumadin 3 mg q day, Lasix 40 mg q day, MVI.
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
6. Oxycodone 5 mg Tablet Sig: [**2-10**] Tablet PO every six (6) hours
as needed for pain: for pain unrelieved by tylenol alone.
7. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day: start
[**2198-10-19**].
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 5176**]
Discharge Diagnosis:
S/P fall
1. Left SAH
2. Chromin right SDH
3. Contusion over left forehead
4. periorbital ecchymosis
5. Bilateral knee contusions
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
* You were admitted to the hospital after falling and hitting
your head.
* You have 2 small areas in your brain that bled when you fell
but physically and mentally you are not showing any deficits.
* You should remain off Coumadin.
* Work with the Physical Therapistfor balance and gait training
so that you will be steady when walking.
Followup Instructions:
Follow up with your primary care doctor to discuss omitting
Coumadin
If you have any questions or concerns call the [**Hospital 4695**]
Clinic at [**Telephone/Fax (1) 1669**]
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2198-10-12**]
|
[
"E888.9",
"428.0",
"424.0",
"427.31",
"432.1",
"443.9",
"920",
"924.11",
"403.90",
"852.01",
"585.9",
"V58.61",
"356.9",
"733.00",
"428.22"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5961, 6039
|
3810, 5135
|
271, 277
|
6212, 6212
|
2138, 3787
|
6749, 7064
|
1086, 1104
|
5340, 5938
|
6060, 6191
|
5161, 5317
|
6388, 6726
|
1119, 1341
|
1360, 1360
|
223, 233
|
305, 868
|
1546, 2119
|
6227, 6364
|
913, 1010
|
1026, 1070
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,573
| 121,955
|
1117
|
Discharge summary
|
report
|
Admission Date: [**2128-9-14**] Discharge Date: [**2128-9-18**]
Date of Birth: [**2070-7-15**] Sex: M
Service: MEDICINE
Allergies:
Cefepime
Attending:[**First Name3 (LF) 4765**]
Chief Complaint:
Chest pain, SOB, nausea
Major Surgical or Invasive Procedure:
Hemodialysis
Cardiac catheterization, no intervention performed
History of Present Illness:
58 yo male with CAD s/p CABG in [**2125**] ([**2-28**] LIMA-> LAD, SVG ->
RCA/PDA, SVG -> OM1) with subsequent cath in [**2126**] showing patent
grafts, ESRD on HD, COPD, who presents with left-sided chest
pain while walking to dialysis. He describes the pain as strong,
non-radiating pain localized slightly to the left of the sternal
border. This pain was associated with SOB and nausea, but no
vomiting. He denies diaphoresis. The pain was constant and not
alleviated by change in position. He endorses recent
palpitations but not on the AM of admission. He also notes PND
but no orthopnea. He has a history of angina for which he is
prescribed SL nitro approximately 2 times/month. He has had no
change in excercise tolerance - can walk 5 blocks without
feeling short of breath or fatigued. Of note, he had a PMIBI in
[**7-/2128**] with moderate reversible inferior defect.
.
Pt. was sent to the ER from HD without being dialyzed. On
arrival, his HR was in the 50s and in a junctional rhythm on EKG
and his BP 158/50. He was given SL NTG x and ASA with which he
reports transient improvement. He was started on a nitro gtt and
his BP dropped to 85/40. He was given a bolus of 250ccs with no
response. Labs revealed a K of 5.8 and he was given
Insulin/dextrose, bicarb and Kayexelate. He was also given
Glucagon for presumed beta blocker toxicity with improvement of
his HR to the 70s. This was later stopped for unclear reasons.
He had a Troponin of .21 and CK of 54. He was started on a
Heparin gtt and taken to the cath lab where he was found to have
patent grafts, but markedly elevated right-sided heart
pressures: RA of 20, RV of 70/25, PA of 70/25 and PCWP mean of
27. Aortic pressure was 115/38, CO - 4.4 and CI - 2.65. He was
given Atropine .5 mg x 1 and Dopamine during the case, the
latter of which was weaned off by the end of the case with a HR
in the 50s and a stable BP.
Past Medical History:
1) CAD: s/p CABG [**2-28**] LIMA-> LAD, SVG -> RCA/PDA, SVG -> OM1
-- [**2127-6-20**] cardiac cath: LMCA
40%, LAD mid 70%, LCx 60%, RCA previously known proximal 99%
occlusion; Patent grafts.
-- Stress [**2127-10-10**]: unchanged from [**2127-6-18**]; moderately
reversible inferolateral to inferior walls perfusion defects
with EF 44%
2) Type II DM (diet controlled) - HgbA1c 6.5 [**12/2126**]
--- retinopathy
--- nephropathy
--- neuropathy
3) HTN
4) Hyperlipidemia- last FLP [**7-/2126**] (TChol 100, LDL 39, HDL 44)
5) CHF: [**2-2**] Echo: unchanged from [**2127-10-14**]; [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 3841**] dilated,
LVEF improved to 55% (from 35% 2 years prior), 1+ MR
6) PVD: s/p stent to bilateral CIAs (Genesis) and steft to [**Female First Name (un) 7195**]
-- s/p POBA and atherectomy of L SFA [**2126-7-17**]
7) ESRD/HD - T/Th/Sat
8) COPD
9) Tracheomalacia
10) C. diff colitis
11) UGI bleed [**2126-5-25**]: EGD showed non-bleeding [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Tear, gastropathy, and gastritis
-- s/p POBA and atherectomy of L SFA [**2126-7-17**]
12) RLL pneumonia
Social History:
patient is originally from [**Country 7192**] (moved here 16 years ago).
His wife and family are still over there. He travelled there
[**11-30**]. He lives alone, but his brother is nearby. He is on
disability. His sister-in law works @ [**Hospital1 18**] in housekeeping. No
tob, EtOH, illicits
Family History:
father d. CAD, mother and brother with [**Name (NI) 7199**].
Physical Exam:
T: 96, P: 50-60, BP: 154/38 (101-164/34-50), R: 20 O2: 94% on 2L
General: Pleasant male, vomiting intermittently
HEENT: JVP seen at angle of jaw
CV: Irregular rate, systolic murmur heard at apex and at LUSB,
radiates to carotids b/l
Lungs: crackles at bases, wheezy at right mid lung field
Abd: soft, nt, nd, +bs
Ext: trace edema, 1+ pedal pulses
Pertinent Results:
Admission Labs:
[**2128-9-13**] 10:00AM PLT COUNT-267
[**2128-9-13**] 10:00AM WBC-9.6# RBC-3.82* HGB-12.0* HCT-36.8* MCV-96
MCH-31.4 MCHC-32.7 RDW-16.2*
[**2128-9-13**] 10:00AM TSH-0.61
[**2128-9-13**] 10:00AM TRIGLYCER-112 HDL CHOL-39 CHOL/HDL-2.6
LDL(CALC)-41
[**2128-9-13**] 10:00AM %HbA1c-5.6 [Hgb]-DONE [A1c]-DONE
[**2128-9-13**] 10:00AM CALCIUM-8.8 PHOSPHATE-3.8 CHOLEST-102
[**2128-9-13**] 10:00AM UREA N-44* CREAT-7.1* SODIUM-138
POTASSIUM-5.0 CHLORIDE-96 TOTAL CO2-30 ANION GAP-17
[**2128-9-13**] 10:00AM GLUCOSE-127*
[**2128-9-14**] 11:30AM PT-11.7 PTT-24.0 INR(PT)-1.0
[**2128-9-14**] 11:30AM PLT COUNT-217
[**2128-9-14**] 11:30AM ANISOCYT-1+ MACROCYT-1+
[**2128-9-14**] 11:30AM NEUTS-85.8* LYMPHS-8.8* MONOS-3.6 EOS-1.6
BASOS-0.3
[**2128-9-14**] 11:30AM WBC-8.4 RBC-3.38* HGB-11.2* HCT-32.4* MCV-96
MCH-33.1* MCHC-34.5 RDW-16.4*
[**2128-9-14**] 11:30AM DIGOXIN-<0.2*
[**2128-9-14**] 11:30AM CALCIUM-8.9 PHOSPHATE-4.2 MAGNESIUM-2.6
[**2128-9-14**] 11:30AM CK-MB-NotDone
[**2128-9-14**] 11:30AM cTropnT-0.21*
[**2128-9-14**] 11:30AM CK(CPK)-54
[**2128-9-14**] 11:30AM GLUCOSE-186* UREA N-64* CREAT-8.6*#
SODIUM-141 POTASSIUM-5.8* CHLORIDE-102 TOTAL CO2-27 ANION GAP-18
[**2128-9-14**] 03:34PM K+-4.9
[**2128-9-14**] 03:34PM COMMENTS-GREEN TOP
[**2128-9-14**] 05:20PM PLT COUNT-110*
[**2128-9-14**] 05:20PM WBC-6.8 RBC-2.01*# HGB-6.7*# HCT-19.5*#
MCV-97 MCH-33.4* MCHC-34.3 RDW-16.3*
[**2128-9-14**] 05:20PM GLUCOSE-94 UREA N-36* CREAT-4.0*# SODIUM-152*
POTASSIUM-2.1* CHLORIDE-132* TOTAL CO2-14* ANION GAP-8
[**2128-9-14**] 06:14PM HGB-11.4* calcHCT-34
[**2128-9-14**] 06:14PM TYPE-[**Last Name (un) **] INTUBATED-NOT INTUBA
[**2128-9-14**] 08:48PM PLT COUNT-187#
[**2128-9-14**] 08:48PM WBC-9.7 RBC-3.40*# HGB-11.3*# HCT-33.4*#
MCV-98 MCH-33.4* MCHC-34.0 RDW-16.4*
[**2128-9-14**] 08:48PM TSH-0.43
[**2128-9-14**] 08:48PM CALCIUM-7.8* PHOSPHATE-4.4 MAGNESIUM-2.4
[**2128-9-14**] 08:48PM CK-MB-NotDone cTropnT-0.17*
[**2128-9-14**] 08:48PM LIPASE-23
[**2128-9-14**] 08:48PM ALT(SGPT)-13 AST(SGOT)-15 LD(LDH)-211
CK(CPK)-60 ALK PHOS-96 AMYLASE-124* TOT BILI-0.3
[**2128-9-14**] 08:48PM GLUCOSE-87 UREA N-65* CREAT-7.9*# SODIUM-141
POTASSIUM-6.0* CHLORIDE-107 TOTAL CO2-22 ANION GAP-18
.
EKG: junctional rhythm, nl axis, nl QTc, narrow QRS, rate 56
with intermittent PVCs or reentrant beats, peaked T waves in
V1-V3.
.
Echo [**2128-9-14**]: The left atrium is elongated. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and systolic function (LVEF>55%). Regional left ventricular wall
motion is normal. [Intrinsic left ventricular systolic function
is likely more depressed given the severity of valvular
regurgitation.] Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Moderate (2+) mitral regurgitation is seen. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.
.
[**2128-8-19**]-Persantine MIBI Tracer was injected 15 minutes prior to
obtaining the resting images. This study was interpreted using
the 17-segment myocardial perfusion model. Left ventricular
cavity size is mildly enlarged with stress and normal at rest.
Resting and stress perfusion images reveal a moderate reversible
inferior wall defect. Gated images reveal septal hypokinesis
consistent with a prior CABG. The calculated left ventricular
ejection fraction is 45%. Compared with the study of [**2127-10-10**]
the inferior wall defect appears more severe and the
inferolateral wall defect less prominent.
.
IMPRESSION: Abnormal myocardial perfusion scan showing a
moderate reversible inferior wall defect, septal hypokinesis
(consistent with a prior CABG) and a LVEF of 45%. There is
transient cavitary dilatation.
.
Cardiac Catheterization - [**2128-9-14**]
.
1. Selective coronary angiography of this right dominant system
reveals
sever native three vessel disease. The LMCA is without
obstructive
disease. The LAD is totally occluded at its mid-section. The
LCx has a
OM that is totally occluded. The proximal RCA is totally
occluded.
2. Arterial conduit angiography revealed patent LIMA to LAD.
The SVG
to OM and SVG to PDA are also patent.
3. Resting hemodynamic measurements revealed markedly elevated
right
and left sided filling pressure with preserved cardiac output as
well as
severe pulmonary hypertension(see table above). Of note, the
tracings
are consistent with constrictive physiology. The RA tracing
showed
prominant y descent. The RV tracing showed dip and plateau
(square root
sign). PA diastolic pressure is [**12-30**] of PA systolic pressure.
4. Left ventriculography was not performed due to concerns about
the
patient's hemodynamic status. Furthermore, non-invasive
assessment of
the patient's left ventricular function is available.
Brief Hospital Course:
58 yo M with h/o CAD, PVD, DMII, who p/w chest pain and SOB,
found to have bradycardia in a junctional rhythm; also found to
have patent grafts on cath, with elevated R sided pressures, was
transferred to the CCU for further treatment persistent
bradycardia.
.
CARDIAC
.
Rhythm: Initially in sinus arrest with junctional escape.
Etiology thought to be from hyperkalemia which can cause such a
rhythm. Additionally, rhythm could have been exacerbated by beta
blocker toxicity, which is likely in a patient with ESRD taking
renally-cleared Atenolol. Ischemia was less likely given patent
grafts on cath. Beta blockers were held initially when patient
arrived to the CCU. He received dialysis the following day after
which he remained in a sinus rhythm, with heart rate range
between high 60s and 80s. The patient's beta blocker was changed
to Metoprolol given his ESRD.
.
Pump: Pt. was found to have a preserved LVEF on echo with
diastolic dysfuntion. He was also thought to be volume
overloaded based on right heart catheterization, likely [**1-29**] to
not receiving HD and perhaps being chronically under-dialyzed.
He was dialyzed while in the CCU with good effect. His blood
pressure and fluid status were both improved after HD. He was
started on Metoprolol for rate control and increased filling
time, given diastolic dysfunction.
.
CAD: Pt had patent grafts on cath, but RCA does not fill
proximally on review of cath. Thus, there is a question of
subendocardial ischemia causing sinus node dysfunction, though
this would likely be a chronic problem. Pt. was continued on his
outpatient medical management with BB, ASA, plavix, ACEI,
statin. He was given Morphine prn for chest pain, as well as
sublingula nitro.
.
ESRD/Hyperkalemia: Pt. was dialyzed while in the hospital and
maintained on his outpatient regimen of Renagel and Nephrocaps.
He tolerated dialysis well. His potassium and other
electrolytes were normalized. He was to continue his normal
outpatient dialysis schedule.
.
DM: Pt. has diet-controlled DM as an outpatient. He was written
for a regular insulin sliding scale as an inpatient, with
infrequent need for insulin. He was also written for a diabetic
diet.
.
Code: The patient was Full Code during admission.
Medications on Admission:
Plavix 75mg daily
Lisinopril 10mg daily
Imdur 30 mg QD
Atenolol 25 mg [**Hospital1 **]
Prilosec 20 mg QD
Lasix 40-80 mg [**Hospital1 **]
Lipitor 80 mg QD
SL NTG .3mg PRN
Renagel 800 mg TID
Rocaltrol .5 mcg QD
Neprocaps 1 QD
Neurontin 400 mg QHS
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
5. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual ONCE (Once) as needed for chest pain.
Disp:*15 Tablet, Sublingual(s)* Refills:*0*
6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
8. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
9. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
Disp:*30 Capsule(s)* Refills:*2*
10. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
Hyperkalemia secondary to End Stage Renal Disease
Bradycardia
Chest Pain
.
Secondary Diagnoses:
Hypertension
Hyperlipidemia
Type II Diabetes Mellitus
Discharge Condition:
Stable, chest pain-free, with appropriate follow-up
Discharge Instructions:
1. Please take all of your medications as directed
2. Please keep all of your follow-up appointments
3. Call your doctor or go to the ER for any of the following:
Chest pain, shortness of breath, fevers/chills or any other
concerning symptoms
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7212**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2128-10-29**] 8:30
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. Phone:[**Telephone/Fax (1) 920**]
Date/Time:[**2128-11-9**] 1:00
.
Provider: [**Name10 (NameIs) 1344**] [**Last Name (NamePattern4) 3125**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2128-11-15**] 8:30
.
You will assume your previous hemodialysis regimen, scheduled
next for Tuesday [**9-21**]
|
[
"414.01",
"V45.81",
"458.9",
"416.0",
"428.0",
"780.6",
"496",
"285.21",
"V15.82",
"250.40",
"403.91",
"276.7",
"427.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.23",
"88.56",
"39.95",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
13150, 13156
|
9210, 11448
|
293, 359
|
13370, 13424
|
4217, 4217
|
13715, 14262
|
3771, 3833
|
11744, 13127
|
13177, 13272
|
11474, 11721
|
13448, 13692
|
3848, 4198
|
13293, 13349
|
230, 255
|
387, 2278
|
4233, 9187
|
2300, 3441
|
3457, 3755
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,923
| 114,625
|
21396
|
Discharge summary
|
report
|
Admission Date: [**2121-10-31**] Discharge Date: [**2121-11-1**]
Date of Birth: [**2040-7-1**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
abdominal pain and fever
Major Surgical or Invasive Procedure:
Endoscopic retrograde cholangiopancreatography
endotracheal intubation and extubation
History of Present Illness:
The patient is an 81 year old male with pmhx significant for
asthma, CBD stones s/p ERCP in [**2119**], anemia,
hypercholesterolemia and GERD initially transferred from [**Location (un) 21541**] hospital for ascending cholangitis and emergent ERCP who
presents s/p ERCP with O2 desaturation to 91% on RA.
.
Per wife, on [**10-28**], patient was sleeping and woke up shivering.
Temp at that time was 102. This has happened in the past when
the patient has PNA and the wife called the paramedics. He was
slightly nauseous before leaving for hospital and had one
episode of blood tinged vomit. Originally the pt went to [**Location (un) 21541**] ED and his presenting vital signs were T 101.1, P 131, BP
175/75, R 24, O2 sat 91% RA. He was noted to be dyspneic and
wheezing, abdomen nontender. He was given IVF,pan cultured and
found to have positive blood cultures w/ gram negative rods [**2-20**]
([**10-29**])-> ID to be pan-sensitive (CTX, quinolones, zosyn) e coli
in 1 out of 3 sets of blood, started on 3 g unasyn, 1 g
ceftriaxone, 500 azithromycin. The patient had abnl LFTs with
increased Tbili (6.4), Dbili (3.5) and AP (301) and left shift
on white count. RUQ US done and showed dilated intra and
extrahepatic bile ducts. GI consulted and thought sepsis [**2-20**]
biliary disease.His alk phos improved to 213 and t bili (4.5)
and d bili (2.7). He was transferred on [**10-31**] to [**Hospital1 18**] for ERCP.
.
During ERCP, patient was given reglan 12.5 mg, versed 4.5 mg,
fentanyl 175 mcg, 2 liters of D5 1/2 NS. Patient noted to be
very lethargic and was desatting. Patient thought to be
over-medicated and given narcan 40 mcg which did not help. He
was intubated for airway protection and transferred to ICU for
monitoring.
Past Medical History:
ascending cholangitis
Asthma
GERD
arthritis
hiatal hernia
anemia ? iron deficiency
high cholesterol
laminectomy [**3-24**]
Social History:
lives in [**Location 23638**] w/ wife; 2 children; smoked while in the navy
and quit 20 years ago; occasional etoh drink ([**1-20**] [**Doctor Last Name 6654**]/nite);
was a microbiologist
Family History:
father had bladder ca; daughter w/ breast cancer, Mother died
70s of CAD, brother died suddenly of MI at age 45
Physical Exam:
Upon arrival to the ICU:
VS: T P 72 BP 115/56 O2 100% on AC TV 450/14/90 % O2/PEEP 5
Gen:intubated, sedated
HEENT: pupil small and round but sluggish to reach, MMM
NEck: Supple, no JVD
CV:RRR, nl S1 and S2, no m/r/g
ABD:Soft, non-tender, non-distended, + bowel sounds
Resp: coarse breath sounds bilaterally
Ext:warm, +2 distal pulses, no edema
Neuro:moves ext, does not open eye or follow command
Pertinent Results:
[**2121-10-31**] 07:30PM WBC-5.0 RBC-4.31* HGB-12.2*# HCT-35.8*#
MCV-83# MCH-28.2# MCHC-34.0 RDW-17.9*
[**2121-10-31**] 07:30PM PLT COUNT-177
[**2121-10-31**] 07:30PM GLUCOSE-238* UREA N-8 CREAT-0.7 SODIUM-137
POTASSIUM-3.0* CHLORIDE-105 TOTAL CO2-24 ANION GAP-11
[**2121-10-31**] 07:30PM ALT(SGPT)-41* AST(SGOT)-48* ALK PHOS-257*
AMYLASE-29 TOT BILI-2.7*
[**2121-10-31**] 07:30PM LIPASE-22
.
[**2121-10-31**]: ERCP
1) Old spincherotomy seen in the major papilla with purulent
drainage. There was a periampullary diverticulum.
2) Cholangiogram showed moderate dilation of the biliary tree
wtih CBD measuring 12mm. There were multiple large CBD stones
largest measuring 10mm.
3) A 5cm by 10F Double pigtail biliary stent was placed in the
bile duct as the patient desaturated and the procedure was
terminated and was completed after endotracheal intubation.
Brief Hospital Course:
In brief, the patient is an 81 year old male w/ ascending
cholangitis [**2-22**] GNR bacteremia tranferred from OSH for ERCP now
s/p ERCP w/ stent and intubated for loss of airway.
.
1.) Respiratory distress - This is likely [**2-20**] to sedation
medication during the ERCP procedure. The patient was intubated
for airway protection. Following weaning of sedation the
patient was successfully extubated. By time of discharge he was
breathing comfortably on room air. He continued to receive his
home dose of inhalers.
.
2.) Ascending cholangitis - The patient underwent ERCP, biliary
stenting and bile stone removal. Blood cultures from the
outside hospital were positive for pan-sensitive e. coli. He
received IV antibiotics while in the hospital and will complete
a 1 week course of oral antibiotics following discharge. His
abdominal pain resolved. He will have a follow-up ERCP and
stent removal in [**4-24**] weeks.
.
3.) Asthma - Following successful extubation, the patient
received his home dose of inhalers.
.
4.) Anemia - This was of unclear etiology. There was no guaiac
positive stools and the patient has been on home iron. Iron
studies were pending at the time of discharge. These will be
follow-up by his primary physician.
.
5.) PPX - PPI, hep sc, replete lytes as needed
.
6.) FEN - initially was NPO while intubated. his diet was
advanced as tolerated by time of discharge.
.
7.) Access- [**Last Name (LF) **], [**First Name3 (LF) **] obtain another [**First Name3 (LF) **]
.
8.) Dispo - monitored in ICU while intubated post-procedure.
discharged to home to follow-up with PCP and GI.
.
9.) Code - FULL
.
10.) Communication - w/ wife [**Telephone/Fax (1) 56515**] and family
Medications on Admission:
prilosec OTC
iron 325 [**Hospital1 **]
advair 250/50 2 puff [**Hospital1 **]
MVI
Calcium
Discharge Medications:
1. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
4. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Ascending Cholangitis
.
Secondary:
Asthma
GERD
Hiatal Hernia
Discharge Condition:
good. tolerating oral intake. afebrile. pain free
Discharge Instructions:
You have been evaluated and treated for an infection in your
bile ducts that was triggered by gall stones. A stent (small
artificial tube) was placed to keep the ducts open. This stent
will need to come out in [**4-24**] weeks.
.
You can resume your regular home medications.
.
You can eat a regular diet as you are able to tolerate.
.
Please take all of the prescribed antibiotic.
.
Please attend your recommended follow-up appointments as below.
.
If you develop any concerning symptoms, particularly fever to
greater than 100.5F, abdominal pain, yellowing of your eyes,
please call your primary physician.
Followup Instructions:
Please call your primary physician to schedule an appointment to
be seen within the next 1-2 weeks.
.
Please call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2743**] office at ([**Telephone/Fax (1) 2306**] to
schedule a follow-up appointment. You should be seen in [**4-24**]
weeks to have an ERCP for stent removal.
|
[
"530.81",
"518.81",
"574.50",
"553.3",
"493.90",
"576.1",
"715.90",
"272.0",
"280.9",
"E937.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.87"
] |
icd9pcs
|
[
[
[]
]
] |
6312, 6318
|
4005, 5715
|
340, 428
|
6432, 6484
|
3111, 3982
|
7144, 7487
|
2565, 2678
|
5855, 6289
|
6339, 6411
|
5741, 5832
|
6508, 7121
|
2693, 3092
|
276, 302
|
456, 2196
|
2218, 2343
|
2359, 2549
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,090
| 150,671
|
41695
|
Discharge summary
|
report
|
Admission Date: [**2151-8-14**] Discharge Date: [**2151-8-24**]
Date of Birth: [**2067-6-10**] Sex: F
Service: MEDICINE
Allergies:
Codeine / aspirin / Sulfa (Sulfonamide Antibiotics) / Heparin
Agents
Attending:[**First Name3 (LF) 9157**]
Chief Complaint:
Fever, altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
84yoF with HTN, migraines, and recent traumatic brain injury [**12-30**]
fall presents from her rehab center with altered mental status,
fever, transferred to the MICU for ?pneumonia.
The patient was recently in-house [**Date range (1) 90619**] for a fall down the
stairs resulting in traumatic brain injury resulting in a left
SDH, SAH, intraparenchymal hemorrhage, and intraventricular
hemorrhage as well as right occipital skull fracture, left
orbital roof fracture, retrobulbar hematoma, and multiple right
rib fractures [**3-6**]. During that hospitalization, she was also
treated with Augmentin for an enterococcal UTI which was
resistant to tetracyclines, and was to complete her course [**8-11**].
She was also found to have elevated cardiac enzymes and an
akinetic distal LV which was diagnosed as likely stress induced
cardiomyopathy (Takotsubo cardiomyopathy) and she was started on
a beta blocker and diuresed per Cardiology consult
recommendations.
The patient was discharged to [**Hospital 38**] rehab, and had been
doing well until the day of admission, when she was noted to be
febrile to 101 with altered mental status. A CT head was
obtained at the rehab facility on [**8-13**] which raised a concern
for an interval increase in the size of her prior L
intraparietal hemorrhage and concern for increased edema. She
was sent to the ED for further evaluation.
In the ED, initial VS were: 97.8 116 128/78 38 97% 4L Nasal
Cannula
The patient was found to have altered mental status and did not
recognize her daughter in the [**Name (NI) **]. She titrated down to 2L NC.
She was febrile to 102 in the ED and CXR showed evidence of
received IV Vancomycin 1 gm, Cefepime 2 gm, Levofloxacin 500 mg.
She was noted to have increased LLE edema and an LENI's showed
(+)LLE DVT. Neurosurgery was notified that the patient was
admitted and reviewed the repeat head CT in the ED, but felt
that the ICH was decreased in size from previous scan on [**7-31**].
They asked to be formally consulted if a neurosurgically related
question arose. EKG per ED report showed non-specific ST-TW
abnormalities compared to prior. The patient received 2L NS,
Zyprexa 2.5 mg po x1, and was admitted to the MICU for pneumonia
and altered mental status.
On arrival to the MICU, the patient was comfortable laying in
bed and was disoriented but denied pain, including headache,
shortness of breath, or cough.
Review of systems:
(+) Per HPI otherwise negative.
Past Medical History:
- HTN
- Migraines
- Pelvic fracture
- Traumatic Brain Injury: ([**Date range (1) 90619**]) Left IPH, left SAH,
intraventricular hemorrhage, left SDH
- Right occipital skull fracture, left orbital roof fracture,
retrobulbar hematoma
- Right rib fractures [**3-6**]
- Enterococcal UTI
- Stress induced cardiomyopathy
Past Surgical History:
- Cholecystectomy
Social History:
- Tobacco: No active tobacco use
- Alcohol: Denies
- Illicits: Denies
Lives alone, admitted from [**Hospital 38**] rehab after recent hospital
stay
Family History:
No CAD or DM.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 97.8 BP: 131/68 P: 106 R: 30 O2: 93% 2L
General: Alert, interactive, oriented x1, no acute distress
HEENT: Right pupil round, reactive to light, L pupil superiorly
displaced and irregular in shape but minimally reactive to
light, sclera anicteric, MMM
Neck: hard cervical collar in place
CV: Tachycardic, regular rhythm, normal S1/S2, GII holosystolic
murmer at LSB and apex, no rubs, gallops
Lungs: Poor inspiratory effort and cooperation but clear to
auscultation bilaterally anteriorly, difficult to assess
laterally and unable to assess posteriorly, no wheezes
Abdomen: Soft, non-tender, non-distended, bowel sounds present
GU: Foley in place
Ext: Warm, well perfused, L>R 1+ LE pitting edema, 2+ DP pulses
b/l, no clubbing, cyanosis
DISCHARGE PHYSICAL EXAM
Vitals: 100.2 118/64 98 18 95%
General: chronically ill appearing, NAD
CV: RRR, II/VI holosystolic murmer
Lungs: Decreased air movement bilaterally, crackles in left
lower lung field.
Abdomen: Soft, NT/ND, BSx4.
Skin: Diffuse erythematous rash
Ext: 2+ edema of LE bilaterally, L>R. LLE with 3 small pustules
and slightly increased erythema.
Pertinent Results:
LABS admission:
[**2151-8-14**] 06:37PM BLOOD WBC-15.1* RBC-3.33* Hgb-10.8* Hct-30.8*
MCV-92 MCH-32.4* MCHC-35.1* RDW-14.5 Plt Ct-57*#
[**2151-8-14**] 06:37PM BLOOD Neuts-85.4* Lymphs-10.4* Monos-3.0
Eos-1.0 Baso-0.2
[**2151-8-14**] 06:37PM BLOOD Glucose-143* UreaN-20 Creat-1.0 Na-137
K-3.9 Cl-101 HCO3-21* AnGap-19
[**2151-8-14**] 06:37PM BLOOD CK(CPK)-48
[**2151-8-14**] 06:37PM BLOOD CK-MB-3 cTropnT-0.03*
[**2151-8-14**] 06:37PM BLOOD Calcium-8.4 Phos-2.4* Mg-2.1
[**2151-8-14**] 06:37PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2151-8-14**] 08:12PM BLOOD Lactate-1.3
IMAGING:
[**8-15**] CT head:
1. Interval evolution of left temporal lobe parenchymal
hemorrhage.
2. Acute on subacute left posterior cerebral SDH (8-mm).
Short-term followup
CT is recommended.
3. Trace residual SAH with small intraventricular hemorrhage.
[**8-15**] CXR:
Consolidations at both lung bases, new on the right concerning
for pneumonia. Left lower lobe consolidation could represent
atelectasis or pneumonia. Interstitial edema also noted.
[**8-15**] LENIs: 1. Occlusive thrombus throughout the interrogated
veins of the left leg.
2. No right leg DVT.
[**8-15**] CTA chest:
1. Extensive pulmonary embolism involving the right main
pulmonary artery,
extending into the lobar and segmental branches of the right
lower lobe, with likely a developing infarction of the right
lower lobe. Pulmonary embolism involving the anterior segmental
artery of the left upper lobe.
2. No evidence of right heart strain.
3. New thrombus within the left ventricle.
4. A small to moderate right pleural effusion, trace left
pleural effusion.
5. Large hiatal hernia containing a major portion of the
stomach.
[**8-16**] TTE: The left atrium and right atrium are normal in cavity
size. Left ventricular wall thicknesses and cavity size are
normal. A 3x2cm mobile mass is seen along the distal
anteroseptal wall c/w thrombus. There is mild regional left
ventricular systolic dysfunction with focal hypokinesis of the
distal half of the anterior septum. The remaining segments
contract normally (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 ascending aorta is mildly dilated. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis. Trace aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. There is mild pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion.
DISCHARGE LABS:
[**2151-8-24**] 05:42AM BLOOD WBC-14.5* RBC-3.09* Hgb-9.5* Hct-28.1*
MCV-91 MCH-30.7 MCHC-33.7 RDW-15.7* Plt Ct-384
[**2151-8-23**] 04:57AM BLOOD Neuts-85* Bands-0 Lymphs-8* Monos-1*
Eos-6* Baso-0 Atyps-0 Metas-0 Myelos-0
[**2151-8-24**] 05:42AM BLOOD PT-26.5* INR(PT)-2.5*
[**2151-8-24**] 05:42AM BLOOD Glucose-106* UreaN-14 Creat-0.8 Na-142
K-3.6 Cl-108 HCO3-24 AnGap-14
[**2151-8-22**] 05:48AM BLOOD ALT-26 AST-38 LD(LDH)-407* AlkPhos-78
TotBili-0.2
[**2151-8-23**] 04:57AM BLOOD Calcium-7.3* Phos-2.8 Mg-2.0
Brief Hospital Course:
84yoF with HTN, migraines, and recent traumatic brain injury [**12-30**]
fall presents from her rehab center with altered mental status,
fever, transferred to the MICU for hypoxia, found to have large
bilateral pulmonary emboli and a left ventricular clot from
heparin-induced thrombocytopenia.
TRANSITIONAL ISSUES
- needs repeat head CT with neurosurgery - appointment scheduled
ACTIVE ISSUES:
# Pulmonary Embolism/DVT: CXR in ED revealed RLL infiltrate
concerning for PNA (HAP vs. aspiration) vs. pulmonary embolism
given the wedge shaped opacity. Bilateral LENIs at ED showed DVT
of left leg, further raising suspicion for PE. CTA chest
confirmed extensive bilateral pulmonary embolism, also
incidentally revealed an LV thrombus (see below). TTE showed
mild pulmonary hypertension with preserved RV function. She
remained hemodynamically stable and given recent head trauma and
intracranial hemorrhage, she was not a candidate for systemic
thrombolyisis. She was started on [**8-15**] on argatroban (given HIT,
see below) after neurosurgery determined her head bleed was
stable and benefit was deemed to outweight risk. Neurosurgery
recommended repeat head CT 48hrs after start of argatroban which
showed no expansion of the bleed. She was continued on
argatroban and warfarin until therapeutic and then continued on
warfarin alone, dosed at 3.5mg daily. INR on discharge was 2.5.
She should be continued on this for a minimum of [**1-31**] months.
# Thrombocytopenia/HIT: Platelets decreased to 57 on admission
from 362 on [**8-5**] prior to her most recent discharge. Her rehab
notes indicate that she reached a nadir of 26 two days prior to
admission. She had been on heparin prophylaxis during her last
admission and at rehab starting on [**8-1**]. HIT was suspected, and
given that she had [**3-1**] clinical criteria, she was started on
argatraban empirically while HIT antibodies were sent. HIT
antibodies returned positive for Heparin PF4 Antibody Test by
[**Doctor First Name **] confirming high clinical suspicion. Continued monitoring
platelets and monitoring for the development of new emboli. A
heparin free PICC line was placed. Over the remainder of her
hospital stay the patient's platelets trended back towards
normal. No new thrombi were identified. Patient was treated
with argatroban and coumadin as above.
#. Fever: The patient presented with fever and WBC count to
15.1, with CXR showing RLL infiltrate concerning for PNA (HAP
vs. aspiration) vs. pulmonary embolism given the wedge shaped
opacity. Pulmonary embolism proven by CT. She was initially
treated for pneumonia but antibiotic were stopped after
discovery of pulmonary emboli.
#. Hypersensitivity Rash: In the MICU, the patient began to
develop a maculopapular rash on her lower back. Over the
subsequent days the rash spread to the patient's chest, upper
extremeties and began to progress distally on her lower
extremeties. Dermatology was consulted and felt that the rash
was most consistent with a drug reaction and was not related to
the patient's thrombocytopenia. Possible offending medications
were minimized and the patient's antibiotic regimen was stopped.
She was started on a low dose steroid cream. Her rash has
slowly improved but was still present on discharge.
#. Leukocytosis: Thought to be secondary to drug rash,
infectious work up negative.
#. Intracranial Hemorrhage: From prior fall. Imaging here
showed stable ICH with no progression. Neurosurgery agreed that
anticoagulation was essential given HIT as above and she was
anticoagulated. She has an appointment for a follow up head CT
with neurosurgery. She was continued on phenytoin per
neurosurgery recommendations who will determine need for
continued use at her next appointment.
#. Delirium: Likely secondary to recent illness and intracranial
process. Patient responded well to prn haldol.
#. LV thrombus: found to have decreased EF on last admission
with Takatsubo physiology. CTA to assess for PE incidentally
showed LV thrombus that had developed since the last
hospitalization, presumably due to stasis from the apical
ballooning. TTE confirmed large LV thrombus, but showed near
resolution of LV systolic function (only mild regional systolic
dysfuntion of anterior septum) LVEF>55%.
# Cellulitis: prior to d/c pt noted to have cellulitis on the
anterio aspect of her L shin with two 1mm pustules. Was started
on vancomycin empirically for a 7 day course. Cellulitis should
be monitored for improvement, can transition to oral antibiotics
if appropriate.
Medications on Admission:
- Diclofenac sodium 0.1 % Drops 1 drop Ophthalmic [**Hospital1 **] to left
eye
- Bacitracin-polymyxin B 500-10,000 unit/g Ointment: 1 Appl
ophthalmic Q2H left eye.
- White petrolatum-mineral oil 56.8-42.5 % Ointment: 1 Appl
Ophthalmic Q2H prn for eye injury: left eye.
- Metoprolol tartrate 6.25 mg po tid
- Pantoprazole 40 mg daily
- Senna 8.6 mg [**Hospital1 **] prn constipation
- Quetiapine 25 mg qhs
- Olanzapine rapid dissolve 2.5 mg [**Hospital1 **] prn agitation
- Docusate 100 mg [**Hospital1 **]
- Acetaminophen 650 mg q5h
- Heparin 5,000 unit/mL SC TID
- Miconazole nitrate 2 % Powder tid prn itching/inflammation.
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
4. quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
7. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for itching.
8. bacitracin-polymyxin B 500-10,000 unit/g Ointment Sig: One
(1) Appl Ophthalmic Q12H (every 12 hours).
9. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gram
Intravenous Q 12H (Every 12 Hours) for 7 days.
Disp:*14 gram* Refills:*0*
10. prednisolone acetate 0.12 % Drops, Suspension Sig: One (1)
Drop Ophthalmic DAILY (Daily).
11. olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet,
Rapid Dissolve PO BID (2 times a day) as needed for agitation.
12. phenytoin 125 mg/5 mL Suspension Sig: One Hundred (100) mg
PO Q8H (every 8 hours).
13. triamcinolone acetonide 0.1 % Ointment Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day).
14. petrolatum Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day) as needed for rash.
15. warfarin 1 mg Tablet Sig: 3.5 Tablets PO Once Daily at 4 PM.
16. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
Primary Pulmonary embolus, Left ventricular thrombus
Secondary: Heparin induced thrombocytopenia, intra-cranial
hemorrhage
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:
It was a pleasure taking care of you at [**Hospital1 18**].
You were re-admitted to the hospital after you developed a fever
and a change in mental status at your rehabilitation facility. A
repeat head ct scan did not show a growing brain bleed. While
in the hospital you were found to have blood clots in your lungs
and a blood clot in your heart. You received anti-coagulation
for these clots. Your symptoms improved.
While you were hopsitalized you developed a drug rash which is
now improving with steroid cream. You should continue the
steroid cream until the rash resolves entirely. You also
developed a cellulitis and were started on an antibiotic called
vancomycin which you should continue for 7 days.
Please see below for changes in your home medication regimen:
1) CONTINUE Warfarin for treatment of blood clots in the lung
and heart. Treatment for 1 year at minimum, course to
ultimately be decided by PCP
2) CONTINUE Vancomycin for cellulitis of the left leg for 7
days.
3) CONTINUE steroid cream until rash resolves.
A new medication list is being provided.
Please see below for instructions regarding follow-up care:
Followup Instructions:
Department: NEUROSURGERY
When: TUESDAY [**2151-9-14**] at 9:30 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 9151**], MD [**Telephone/Fax (1) 1669**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: RADIOLOGY
When: TUESDAY [**2151-9-14**] at 8:45 AM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: CC CLINICAL CENTER [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
|
[
"401.9",
"453.42",
"285.1",
"693.0",
"E947.9",
"415.19",
"289.84",
"349.82",
"429.83",
"429.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
14726, 14800
|
7854, 8237
|
359, 365
|
14966, 14966
|
4623, 5253
|
16308, 16816
|
3419, 3434
|
13089, 14703
|
14821, 14945
|
12439, 13066
|
15143, 16285
|
7318, 7831
|
3215, 3235
|
3474, 4604
|
2820, 2854
|
290, 321
|
8252, 12413
|
393, 2801
|
5262, 7302
|
14981, 15119
|
2876, 3192
|
3251, 3403
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,028
| 195,878
|
37024
|
Discharge summary
|
report
|
Admission Date: [**2193-11-7**] Discharge Date: [**2193-11-29**]
Date of Birth: [**2150-4-21**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Codeine / Biaxin / Toothpaste
Attending:[**First Name3 (LF) 281**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
[**2193-11-12**] 7.0 [**Last Name (un) 295**] trache and foreign body (stent) removal from
the trachea with femoral arterial and venous ECMO
intraoperatively.
History of Present Illness:
This is a 43-year-old female with a
history of relapsing polychondritis and complex airway
involvement. Her initial presentation dates back to [**2186**] where
she initially presented with worsening shortness of breath and
cough. At that time, she was misdiagnosed as asthma and she was
resistant to all inhaled medication. Her symptoms progressed to
the point that further workup was initiated in [**2189**]/[**2190**]
including PFTs and CT scan of the chest. Meanwhile, the patient
was also experiencing classical symptoms of relapsing
polychondritis, including recurrent ear pain and transformation
in the shape of her nose to a saddle nose and hoarseness of her
voice. In [**2190**], based on those symptoms and appearance for CAT
scan, bronchoscopy was performed, which revealed severe
tracheobronchomalacia and follow up airways and two Polyflex
stents were placed in the trachea for central airway
stabilization. Since that time, the patient's breathing
improved; however, she has been having a problem with recurrent
bronchitis and recurrent pseudomonas pulmonary infection
requiring multiple antibiotic courses. Most recently, the
patient was admitted to hospital in [**Location (un) 36413**] for respiratory
distress, stridor. She was given antibiotics and sent home with
PO Cipro for recurrent Pseudomonas infection. In addition, the
patient has been on a very high-dose of systemic steroids,
prednisone 80 mg daily. Currently, her main complaint include
history of recurrent bronchitis, shortness of breath and cough.
She continues to have stridor and reports fatigue while walking
due to tachycardia, and SOB.
Past Medical History:
Relapsing polychondritis
C-section
Knee injury
Gastroesophageal reflux disease
Hypertension after initiation of steroids
NIDDM
Social History:
Denies ETOH, cigarettes. Lives with husband in [**Name (NI) 36413**].
Family History:
Significant for relapsing similar airway problem
in her aunts and a brother with Crohn disease.
Physical Exam:
VS: 97.9 96 115/62 22 100% TM
Gen: alert and oriented x 3, NAD
Cardiac: distant heart sounds, RRR, no MRGC
Pulm: Upper airway transmitted sounds/rhonchi
Abdomen: Soft, non-tender, non-distended
Wounds: Tracheostomy site--purulent discharge on either side of
Bovona. [**Hospital1 **] 2x2 dry dressing change. NOTE: THERE IS ONE 2X2
GAUZE ON EITHER SIDE OF THE TRACH FOR A TOTAL OF 2 2X2
Groin site--serosang discharge. QID 4x4 dry dressing change.
NOTE: THERE IS ONE 4X4 GAUZE PACKED IN THE WOUND
Pertinent Results:
[**2193-11-19**] 06:20AM BLOOD WBC-12.3* RBC-3.28* Hgb-8.1* Hct-27.1*
MCV-83 MCH-24.8* MCHC-30.1* RDW-19.8* Plt Ct-220#
[**2193-11-19**] 06:20AM BLOOD Glucose-121* UreaN-18 Creat-0.5 Na-138
K-4.6 Cl-96 HCO3-34* AnGap-13
[**2193-11-19**] 06:20AM BLOOD WBC-12.3* RBC-3.28* Hgb-8.1* Hct-27.1*
MCV-83 MCH-24.8* MCHC-30.1* RDW-19.8* Plt Ct-220#
[**2193-11-27**] 06:30AM BLOOD Glucose-122* UreaN-17 Creat-0.7 Na-130*
K-4.3 Cl-91* HCO3-29 AnGap-14
Brief Hospital Course:
Mrs. [**Known firstname **] [**Known lastname **] was admitted on [**2193-11-7**] with relapsing
polychondritis,
tracheobronchomalacia and status post two Polyflex stents with
recurrent pseudomonal respiratory infection. She presented with
increasing shortness of breath, tachycardia, and stridor. She
underwent CT of the trachea the following day revealing patent
stents however severe tracheobronchoomalacia with focal stenosis
in the subglottic
region, right mainstem bronchus with obstruction of the origin
of the bronchus
intermedius on the expiratory phase. There was also multifocal
bronchiolitis with peribronchial wall thickening, secretions,
plugging and centrilobular nodules involving all lobes with the
exception of the left upper lobe is most likely due to repeated
aspiration causing infection or inflammation. The patient
underwent flexible bronchoscopy by Dr. [**First Name (STitle) **] [**Name (STitle) **] on [**2193-11-11**]
revealing airway inflammation and granulation tissue. It was
then determined that the patient would need to go to the
Operating Room for rigid bronchoscopy for debridement, however
during this procedure the patient airway edema and difficulties
with oxygen saturations, even becoming pulseless. The patient
was on ECMO and then had open trachestomy due to diffuse airway
edema. The patient also had stent removal during such time. She
stabilized and was taken to the ICU for recovery. She was stable
and transfered to the floor, where she underwent PT/OT
evaluations and swallow evaluation. She had penetration with
nectar thick liquids but was cleared for thin liquids and solids
and pills whole with puree. She was afebrile, and had a modest
WBC elevation to 12.1 on [**2193-11-20**] however the patient had foul
smelling secretions from her trach. It turns out there was a
retained gauze that her skin healed over. The wound was opened
and we started [**Hospital1 **] gauze chages. The wound grew out
pseudomonsas, which she is colonized with in the past.
Infectious disease recommended no further antibiotic treatment.
The patient also complained of decreased motor on the right,
however this is improving and there are no color, temperature or
sensory deficits compared to the left lower extremity. Of note a
doppler US revealed no pseudoaneurysm at the groin site. The
right fem ECMO site was covered by staples and a seroma
developed so the wound was partially opened and packed with a
dry gauze QID. Rheumotology was consulted and they did not want
to change her current high dose prednisone, however to watch the
patient and follow up in one month. They also did not recommend
restarting anti-TNF therapy. She continued to do well, with
stable vital signs, stable respiratory status, ambulating with
the help of PT, and tolerating a regular diet. She was
discharged on [**11-29**] to [**Location (un) 36413**] where she will be admitted back
to her referring physician.
Medications on Admission:
CIPRO 500MG [**Hospital1 **]
ACETYLCYSTEINE - 20 % (200mg/mL) Solution - 2ml for inhalation
prn
ALBUTEROL SULFATE - 2.5 mg/3 mL(0.083 %)Nebulization - 1 neb
q4-6 hours
DIPHENHYDRAMINE HCL - 25 mgCapsule - 1 Capsule(s) by mouth
daily as needed
INSULIN GLARGINE [LANTUS] - (Prescribed by Other Provider) -
100
unit/mL Solution - 15 units subcutaneous qam
MOM[**Name (NI) **] [NASONEX] - 50 mcg Spray, - 2 sprays in each nostril
daily
PREDNISONE - 20 mg Tablet - 2 Tablet(s) by mouth twice a day
TELMISARTAN [MICARDIS] 80 mg Tablet - 1 Tablet(s) by mouth daily
TOLTERODINE [DETROL LA] 4 mg Capsule, Sust. Release 24 hr - 1
Capsule(s) by mouth daily
TRIMETHOPRIM-SULFAMETHOXAZOLE -800 mg-160 mg Tablet - 1
Tablet(s) by mouth q
monday/wenesday/friday
VERAPAMIL - 240 mg Tablet Sustained Release - 1 Tablet(s) by
mouth twice a day
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Tracheobronchomalacia s/p tracheostomy and stent removal.
Discharge Condition:
stable
Discharge Instructions:
Call your local pulmonologist if you experience any worsening
shortness of breath, chest pains, fevers, chills or questions.
Follow up with your local rheumatologist.
Follow up with Dr. [**Last Name (STitle) **] in one month.
Twice daily 2x2 dry dressing change of the tracheostomy site:
put one 2x2 gauze on either side of the tracheostomy for a total
of two gauze sponges.
Four times daily 4x4 dry dressing change of the Right groin
site: put one 4x4 gauze into the groin wound and cover with 4x4
sponges.
Followup Instructions:
Follow up with your local pulmonologist and rheumatologist.
Follow up with Dr. [**Last Name (STitle) **] in one month. Call Dr. [**Last Name (STitle) **] at
[**Telephone/Fax (1) 10084**] for follow up appointment.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**]
Completed by:[**2193-12-3**]
|
[
"278.01",
"478.6",
"998.13",
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"519.19",
"478.71",
"041.7",
"V85.4",
"519.01",
"E878.8"
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icd9cm
|
[
[
[]
]
] |
[
"33.23",
"33.21",
"31.1",
"39.65",
"96.72",
"96.6",
"31.99"
] |
icd9pcs
|
[
[
[]
]
] |
7297, 7316
|
3490, 6419
|
316, 477
|
7418, 7427
|
3025, 3467
|
7985, 8321
|
2396, 2494
|
7337, 7397
|
6445, 7274
|
7451, 7962
|
2509, 3006
|
257, 278
|
505, 2140
|
2162, 2291
|
2307, 2380
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,254
| 115,658
|
1044
|
Discharge summary
|
report
|
Admission Date: [**2108-3-11**] Discharge Date: [**2108-3-12**]
Date of Birth: [**2039-6-15**] Sex: M
Service: MICU
CHIEF COMPLAINT: Dyspnea, acute renal failure.
HISTORY OF PRESENT ILLNESS: A 68-year-old ophthalmologist
with no significant past medical history, who presents today
with diffuse muscle pain and dyspnea on exertion times six
days. Symptoms started when patient awoke six days prior to
admission with lumbar lower back pain. Patient states that
initially the pain was similar to lumbar back pain in the
past, however, he usually notices this type of pain at the
end of the day rather than first thing in the morning.
Throughout the day his lower back pain worsened and patient
began to note diffuse myalgias. Upon getting home from work
that evening, he reports that the pain and myalgias were so
severe that he was unable to walk. The weakness has worsened
throughout the course of the week, and patient has been
nonambulatory.
His dyspnea on exertion began around the same time as the
muscle weakness and prior to being unable to walk, he was
only able to do three steps before he became tachypneic. He
does not report any PND or orthopnea.
The patient has also recently traveled to [**State 108**]
approximately 10 days ago. While he was in [**State 108**], he had
an acute diarrheal illness, which was described as watery and
nonbloody. This resolved spontaneously and was self limited.
He was unclear if this was associated with fevers.
Five days prior to admission, he again had recurrence of
symptoms and his diarrhea in addition to above symptoms of
myalgias and weakness. His original episode of diarrhea was
thought to be secondary to eating out at a restaurant with
Cuban cuisine and possible beef exposure. He does not
believe he had any fresh water exposure and he was not
swimming in any pools.
On presentation to the Emergency Department, he was noted to
be in moderate respiratory distress with respiratory rates in
the 30s and tachycardic with heart rates in the 100s. He was
placed on nonrebreather face mask with initial oxygen
saturation 88 percent, which improved to 95 percent on 3
liters without any intervention. Initial ABG showed
7.33/21/134 on unknown amount of oxygen. He received 2
liters of intravenous normal saline while in the Emergency
Department and had development of bibasilar rales. He did
not have any change in his oxygen saturation while lying
supine.
On review of systems, patient complains of mild oliguria,
which he reports usually going 10 times per day, which
decreased to one time per day over the last six days. He
noted brown urine starting approximately four days ago. He
has not had any dysuria or hematuria as far as he knows. He
also reports a sore throat with a question of dysarthria at
the onset of symptoms five to six days ago. He has had a
headache and some blurry vision. The blurry vision was
approximately two days prior to admission and lasted about 24
hours. One day prior to admission he believes he also had an
episode of diplopia, which lasted approximately six hours.
He has not had any abdominal pain, nausea, vomiting, chest
pain, or palpitations. Of note, he and his wife, who is also
a physician noted that his thighs were mottled.
PAST MEDICAL HISTORY:
1. GERD.
2. Raynaud's phenomenon.
3. Adenomatous polyps x2 resected per colonoscopy in [**2105**].
4. Osteopenia.
5. Status post inguinal hernia repair.
6. Hyperlipidemia.
7. History of lower back pain.
MEDICATIONS AT HOME:
1. Aspirin 81 q.d.
2. Lipitor 20 mg q.d., which has been a stable dose over the
last six to seven years.
3. Prilosec 20 q.d.
4. Aleve two tablets q.d. prn, however, patient has been
taking approximately four tablets per day since the onset
of symptoms six days ago.
5. Feldene 20 mg p.o. q.d.
ALLERGIES:
1. Mice dander causes anaphylactic reaction.
2. Mussels (seafood) causes GI upset, however, other
shellfish are okay.
FAMILY MEDICAL HISTORY: Mother with [**Name (NI) 2481**]. Father
died at age 89 years old of prostate cancer.
SOCIAL HISTORY: Patient is an ophthalmologist/researcher in
the area. He is married. His wife is also a physician. [**Name10 (NameIs) **]
denies any tobacco use. He drinks approximately one glass of
wine per day. He has three children, most of whom live in
the area.
Vital signs in the Emergency Department: Temperature 94.6,
blood pressure 129/90, which increased to 145/75 after 2
liters of intravenous fluid, heart rate went from 105 to 95,
respiratory rate 20s, oxygen saturation 89 percentile on
rebreather face mask, which improved to 95 percent on 3
liters nasal cannula.
In general, patient was in mild respiratory distress,
however, he was able to speak in full sentences. There was
no accessory muscle use. HEENT exam: Pupils are equal,
round, and reactive. Sclerae were anicteric. Extraocular
muscles are intact. Mucous membranes were moist. His
oropharynx was clear. He was normocephalic, atraumatic.
Neck was supple without any jugular venous distention or
thyromegaly. Chest demonstrated bilateral basilar rales
without any wheezes. Cardiovascular: Regular rate, no
murmurs, rubs, or gallops were appreciated. Abdomen was
soft, nontender, nondistended, liver span percussed to
approximately 3-4 cm above costal margin. There was no
splenomegaly. There is a negative [**Doctor Last Name 515**] sign. On back
exam, he had no midline spinal tenderness to palpation. He
had no CVA tenderness bilaterally. Extremities demonstrated
two plus peripheral pulses. There is trace bilateral edema.
Skin exam: He had no rashes, however, there is evidence of
livido reticularis on bilateral thighs. On neurologic exam,
he was alert and oriented times four with cranial nerves II
through XII intact. Deep tendon reflexes were symmetric.
Motor strength was effort dependent, however, he had 3-4/5
weakness in his bilateral hip flexors, knee extensors, knee
flexion with intact strength bilateral plantar flexion,
dorsiflexion. His upper extremities were 4 plus bilaterally.
He had a negative Babinski. His sensation was intact to
light touch bilateral upper and lower extremities.
LABORATORY VALUES ON PRESENTATION: White blood cells 6.5,
hemoglobin 15.5, hematocrit 46.6, MCV 91, 67 percent
neutrophils, 11 percent bands, 8 percent lymphocytes, 9
percent monocytes. PT 14.7, PTT 29.8, INR of 1.4.
Urinalysis showed large blood, nitrite positive, 100 protein,
trace ketones, negative for leukocytes, negative for RBCs,
negative WBCs, few bacteria. Sodium was 140, potassium 3.5,
chloride 97, bicarb 13, BUN 72, creatinine 4.0, which is up
from a baseline of 1.0, glucose 200, anion gap was elevated
at 30. ALT was 96, AST 164, CK 1654, alkaline phosphatase
310, total bilirubin 5.2, direct bilirubin 3.8. Lipase was
20. Troponin was less than 0.01. Calcium 9.8, phosphorus
3.3, magnesium 2.8, albumin 3.3. Serum and urine tox were
both negative.
DIAGNOSTIC IMAGING:
1. Chest x-ray showed linear atelectasis at the left base
with a right lower lobe nodule.
2. CT head was negative for acute pathology.
3. Abdominal ultrasound showed normal liver, portal vein
patent, right kidney 11.7 cm with 1.7 cm simple cyst, left
kidney was 10.8 cm. No hydronephrosis and no ascites were
present.
4. EKG showed a sinus tachycardia, rate 112, P-R of 150,
normal axis, T-wave inversions in III and F, unchanged
when compared with EKG dated [**2104-5-29**].
IMPRESSION: A 68-year-old gentleman with no significant past
medical history, who presents with six days of lower back
pain, myalgias with remote history of diarrheal illness and
possible fevers at home. While in the Emergency Department,
identified to have mild respiratory distress, which improved
without significant intervention as well as acute renal
failure and elevated CK. Also noted to be hypothermic with a
left shift.
HOSPITAL COURSE: Patient was admitted to the Medical
Intensive Care Unit given his acute renal failure and
respiratory distress. He arrived in the Medical Intensive
Care Unit approximately 6 p.m. and he was noted to have cold
and clammy extremities, and was now on 6 liters of oxygen per
nasal cannula. Over the next two hours, the patient
exhibited worsening tachypnea and altered mental status. He
was noted to have worsening slurring of his speech as well.
Neurology evaluated the patient approximately one hour after
being admitted to the Intensive Care Unit, and although was
not able to provide a coherent history at that point,
provided a good exam, which was felt to be nonfocal except
for mild tongue weakness.
Around 8 p.m., patient's condition had deteriorated enough
that he was extremely delirious and his respiratory rate had
increased to approximately 40, and he was taking short and
shallow breaths. He was intubated at that point without any
complications.
After intubation, an arterial blood gas was performed, which
showed a pH of 7.14, pCO2 of 36, and a lactate of 8.0. Given
his worsening clinical condition, he was started on empiric
antibiotics at that point for presumed blood-born infection.
Initial antibiotics were broad spectrum, and included Zosyn,
Levaquin, doxycycline, Vancomycin, Flagyl.
After intubation, a left subclavian line was attempted,
however, was unsuccessful. A left internal jugular central
venous catheter was placed without complications. Followup
chest x-ray after central line placement showed a moderate
sized pneumothorax on the left, which was decompressed with a
chest tube placed by Cardiothoracic Surgery.
Around midnight that evening, approximately six hours after
admission to the Intensive Care Unit, patient's blood
pressure had progressively fallen and now required
intravenous pressors. He was initially started on Levophed
and eventually Vasopressin followed by Neo-Synephrine were
added. Laboratory values returned with values consistent
with DIC.
Likewise, his respiratory status declined throughout the
evening, and cisastracurium was used for paralysis. ARDS Net
ventilation strategy was employed, however, he was very
difficult to oxygenate throughout the evening. Serial blood
gases showed progressive worsening of his acidosis, and by 10
a.m. the next morning, 16 hours after admission, his blood
gas showed a pH of 6.92 and a lactate of 11.8. He had been
previously on a bicarb drip throughout the evening with no
apparent effect.
His potassium continued to rise throughout a few short hours
in the Intensive Care Unit, and reached a level of 9.1 the
following morning at 11 a.m. The Nephrology team, which had
been following him from the night before given his acute
renal failure, were contact[**Name (NI) **] early in the morning and a CVVH
was initiated. Around the time of initiation of CVVH,
patient was noted to have a wide complex tachycardia and was
eventually found to have evidence of complete heart block.
Blood pressures despite maximum dose of three vasopressive
medications remained with the systolics in the 80s to 90s and
heart rate in the 50s to 60s.
A discussion was had with his wife, who felt that
resuscitation would not be consistent with patient's wishes,
and he expired at 2:30 p.m. secondary to cardiac arrest.
Blood cultures drawn from time of admission in the Emergency
Department later grew out methicillin-sensitive Staph aureus
in four blood culture bottles. Further investigation and
discussion with wife revealed that patient had a dental
procedure approximately three weeks prior to admission. It
is unclear this was the source of his bacteremia or whether
there was some infectious process, which was acquired while
he was on [**State 108**] a week and a half prior to admission.
After discussion with his wife, an autopsy was performed
(which report is not available at this time), which was
consistent with septic emboli to multiple organs including
his kidneys. This was the most likely cause of his acute
renal failure. There is also evidence of mitral valve
involvement/endocarditis.
DIAGNOSIS AT TIME OF DEATH:
1. Methicillin-sensitive Staphylococcus aureus high grade
bacteremia.
2. Endocarditis.
3. Septic embolic involvement of bilateral kidneys.
4. DIC.
5. Acute respiratory distress syndrome.
6. Metabolic acidosis.
7. Hyperkalemia secondary to acute renal failure.
8. Myositis.
9. Respiratory failure requiring intubation.
10. Left tension pneumothorax.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-697
Dictated By:[**Last Name (NamePattern1) 6829**]
MEDQUIST36
D: [**2108-5-9**] 15:16:34
T: [**2108-5-10**] 09:00:23
Job#: [**Job Number 6830**]
|
[
"570",
"785.52",
"518.81",
"427.5",
"276.2",
"584.5",
"038.10",
"286.6",
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icd9cm
|
[
[
[]
]
] |
[
"96.71",
"39.95",
"34.04",
"96.04"
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icd9pcs
|
[
[
[]
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7924, 12653
|
3518, 4069
|
155, 186
|
215, 3270
|
3292, 3497
|
4086, 7906
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,421
| 191,326
|
54009
|
Discharge summary
|
report
|
Admission Date: [**2169-8-14**] Discharge Date: [**2169-8-25**]
Date of Birth: [**2091-3-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Univasc
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2169-8-14**] - CABGx4 (LIMA-LAD, SVG-PDA, Y SVG-OM1/OM2)
History of Present Illness:
78 year old gentleman with a known history of coronary artery
disease. Lately he has developed worsening symptoms of dyspnea
on exertion. He underwent an ETT which was positive for
ischemia. A Cardiac catheterization was performed which revealed
left main and three vessel coronary artery disease. He is now
referred for surgical revascularization.
Past Medical History:
Prostate Cancer
Hyperlipidemia
HTN
GOUT
Prostate Cancer s/p prostatectomy
Penile prosthesis
Hyperparathyroid
CAD
Social History:
Lives with wife. Quit smoking in [**2127**]. Works as a part time real
estate [**Doctor Last Name 360**]. Uses ETOH socially.
Family History:
None
Physical Exam:
75 reg 168/85 69" 238
GEN: NAD, lying flat after cath
SKIN: Unremarkable
HEENT: NCAT, PERRL, Anicteric sclera, OP benign
LUNGS: CTA
ABD: Benign
HEART: RRR, nl S1-S2
EXT: Warm, well perfused. Trace LE edema. Pulses 2+.
NEURO: Nonfocal.
Pertinent Results:
[**2169-8-21**] 06:30AM BLOOD WBC-11.3* RBC-3.41* Hgb-10.1* Hct-31.2*
MCV-92 MCH-29.6 MCHC-32.4 RDW-14.4 Plt Ct-271
[**2169-8-21**] 06:30AM BLOOD Plt Ct-271
[**2169-8-21**] 06:30AM BLOOD Glucose-105 UreaN-40* Creat-1.4* Na-139
K-4.6 Cl-97 HCO3-38* AnGap-9
[**2169-8-21**] 06:30AM BLOOD Mg-2.7*
[**2169-8-20**] CXR
Median sternotomy wires are seen. The right-sided IJ catheter
has been removed. There is again seen prominence of the
mediastinum; however, it is smaller when compared to the
previous study. There is a subsegmental atelectasis. There is
also a left-sided pleural effusion. The rest of the lung fields
are clear without signs for overt pulmonary edema.
[**2169-8-14**] ECHO
Conclusions:
Pre bypass: The left atrium is moderately dilated. No atrial
septal defect is seen by 2D or color Doppler. Left ventricular
wall thicknesses and cavity size are normal. The left ventricle
is not well seen. Due to suboptimal technical quality, a focal
wall motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is normal (LVEF>55%). The
ascending aorta is moderately dilated. There are complex
(mobile) atheroma in the [**Month/Day/Year 8813**] arch. There are complex (>4mm)
atheroma in the descending thoracic aorta. The [**Month/Day/Year 8813**] valve
leaflets (3) appear structurally normal with good leaflet
excursion. There is no [**Month/Day/Year 8813**] valve stenosis. Mild to moderate
[**Month/Day/Year 8813**] regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen.
Post Bypass: Preserverd biventricular function, LVEF > 55%. No
change in AI or MR. [**First Name (Titles) **] [**Last Name (Titles) 86554**] preserved and unchanged.
Remaining exam unchanged. All findings discussed with surgeons
at the time of the exam.
Brief Hospital Course:
Mr. [**Known lastname 110722**] admitted to the [**Hospital1 18**] on [**2169-8-14**] for elective
surgical management of his coronary artery disease. He was taken
to the operating room where he underwent coronary artery bypass
grafting to four vessels. Please see operative note for detail.
Postoperatively he was taken to the cardiac surgical intensive
care unit for monitoring. On postoperative day one, Mr.
[**Known lastname **] awoke neurologically intact and was extubated. He
had some episodes of reduced oxygen saturations whcih responded
well to nebulizer treatments, diuretics and Bipap for sleep.
Beta blockade and aspirin were started. He developed atrial
fibrillation which was treated with amiodarone. He initially
converted to normal sinus rhythm however had paroxysmal episodes
over the next few days. Coumadin was started for anticoagulation
with intravenous heparin used as a bridge. On postoperative day
6, Mr. [**Known lastname **] was transferred to the step down unit for
further recovery. The phsycical therapy service was consulted
for assistance with his postoperative strength and mobility.
Gentle diuresis was constinued towards his preoperative weight.
Mr. [**Known lastname **] continued to make steady progress and was
discharged to rehabilitation on postoperative day 11. He will
follow-up with Dr. [**Last Name (STitle) **], Dr. [**Last Name (STitle) 171**] and Dr. [**Last Name (STitle) **]. His
coumadin dosing will be managed by Dr. [**Last Name (STitle) **] for a target INR
of 2.0-2.5 for atrial fibrillation.
Medications on Admission:
Allopurinol
Atenolol
Zocor
Plendil
Aspirin
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. Albuterol Sulfate 0.083 % Solution Sig: One (1) dose
Inhalation Q4-6H (every 4 to 6 hours) as needed.
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 7 days: then 200 mg daily until discontinued by
cardiologist.
7. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
8. Warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day for 3
days: then check INR on Monday, [**2169-8-28**], and dose for INR
2.0-2.5.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Nursing and Rehab
Discharge Diagnosis:
Hyperlipidemia
AF
HTN
Gout
Hyperparathyroid
s/p radical prostatectomy
Penile prosthesis
CAD
Discharge Condition:
Stable
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage or increased pain.
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.
5) You may wash incsision and pat dry. No swimming or bathing
until it has healed.
6) No driving for 1 month.
7) No lifting greater then 10 pounds for 10 weeks.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**]
Follow-up with Dr. [**Last Name (STitle) 171**] (Cardiologist) in [**12-26**] weeks.
[**Telephone/Fax (1) 1989**]
Follow-up with primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in 2 weeks.
([**Telephone/Fax (1) 1300**].
Call all providers for appointments
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 128**]
Date/Time:[**2169-10-13**] 10:00
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) **] & [**Doctor Last Name 1447**] Phone:[**Telephone/Fax (1) 6856**]
Date/Time:[**2169-9-14**] 1:00
Completed by:[**2169-8-25**]
|
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"285.9",
"274.9",
"511.9",
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icd9cm
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[
[
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[
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icd9pcs
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[
[
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5639, 5699
|
3153, 4703
|
293, 355
|
5835, 5844
|
1307, 3130
|
6325, 6995
|
1028, 1034
|
4796, 5616
|
5720, 5814
|
4729, 4773
|
5868, 6302
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1049, 1288
|
234, 255
|
383, 733
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755, 869
|
885, 1012
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,826
| 164,932
|
45904
|
Discharge summary
|
report
|
Admission Date: [**2158-1-3**] Discharge Date: [**2158-1-9**]
Date of Birth: [**2099-5-10**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
altered mental status
Intraparencymal bleed
Major Surgical or Invasive Procedure:
intubation [**2158-1-3**], extubated [**2158-1-5**]
History of Present Illness:
PCP [**Name Initial (PRE) **] [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1728**]
Psych - Dr. [**Last Name (STitle) 6496**]
.
CC:[**CC Contact Info 97767**].
HPI:
58F with h/o meningoencephalitis, adrenal insufficiency, and
labile BPs, who presented to ED with mental status changes. [**Name (NI) 1094**]
mother reported that she went over to pt's apartment the morning
of admission, and found her "acting a little crazy." When mother
tried to help pt out of bed, they both fell. Mother reports that
pt sometimes acts agitated and disoriented when BP is low or
erratic. Expressed concern about pt's recent colonoscopy and
continued flatulance and connection that procedure may have had
to current condition. Mother also reports that pt has been off
all her medications for several days - was fairly sure that this
included psychiatric as well as medical drugs. She had a
colonoscopy and EGD on [**2157-12-29**] for w/[**Location 97768**]
anemia, which demonstrated grade 1 internal hemorrhoids,
diverticulosis, and erosive gastritis with benign path,
respectively.
.
In the ED, she was found to have altered mental status and
extremely agitated. She was also noted to have periorbital
ecchymoses and blood in her oropharynx. She was intubated for
airway protection. She was initially hypertensive to 180/p,
escalating to 223/119, and placed on a labetalol drip. Head CT
demonstrated a 1.2cm x 0.6cm intraparenchymal bleed in her R
frontoparietal region, with no mass effect or midline shift.
Initial FAST scan equivocal. Wet read of chest/abd/pelvis CT
showed no PTX, no solid organ injury. Wet read of CT c-spine
showed cervical spondylosis but no fracture. On placement of
NGT, drew back 200mL maroon fluid which cleared on lavage.
Trauma, [**Location **], and GI were made aware of patient.
Initial labs notable for leukocytosis of 22.3, hct 41.3, and
lactate 6.4, which decreased to 2.9 after administration of IVF.
UA was positive for ketones, but negative for evidence of
infection. Initial ECG demonstrating narrow complex tachycardia
at 120, sinus tach vs atrial flutter. She was empirically
started on vanc/levo/flagyl, and decadron given chronic
prednisone use. Was also given dilantin 1gm. and was
transferred to MICU for further management. Last BP prior to
transfer was 151/83, temp not recorded during entire ED stay.
.
Past Medical History:
1) [**7-7**] admission for sepsis (unclear source)
2) Adrenal insufficiency dx on [**7-7**] admission, on prednisone
3) Meningo-Encephalitis (Neuro ICU at [**Hospital1 2025**], discharged [**2157-5-17**])
4) Anemia
5) Sleep apnea
6) Occult GI bleeding
7) Rheumatoid arthritis
8) Fibromyalgia
9) s/p right elbow replacement surgery [**9-6**]
10) Diverticulitis 25 years ago
11) Migraines
12) HTN
13) Hyperlipidemia
14) s/p lap cholecystectomy
[**66**]) Depression
16) Paraesophageal hernia repair with Nissen fundoplication
([**12-6**])
17) Question [**Month/Year (2) **] dysfunction
.
Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
3. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
4. Trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for sleep.
5. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed.
6. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Lorazepam 1 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime) as needed for insomnia.
8. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for insomnia.
9. Venlafaxine 75 mg Capsule, Sust. Release 24HR Sig: Three (3)
Capsule, Sust. Release 24HR PO DAILY (Daily).
10. Gabapentin 400 mg Capsule Sig: Three (3) Capsule PO TID (3
times a day).
11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed for Pain.
12. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
14. Prednisone 5 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)).
Disp:*90 Tablet(s)* Refills:*2*
15. Prednisone 5 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
16. Cyanocobalamin 1,000 mcg Tablet Sig: One (1) Tablet PO once
a day for 10 days: take daily for 7 days, then once a week.
Disp:*20 Tablet(s)* Refills:*0*
17. Outpatient Lab Work
24 hour urine collection for catecholamines. Please send results
to Dr [**Last Name (STitle) 1728**].
.
Social History:
No tobacco, alcohol or drug use. Divorced. She has three
daughters.
[**Name (NI) 1403**] as P.A. in adult primary care clinic. She is
lebanese/palestinian in background.
.
Labs: See Below
.
Imaging:
-[**2158-1-3**] CXR - Technically limited radiograph as described.
Correlation with CT recommended to evaluate the left supraaortic
mediastinal contour.
.
- CT Torso:
1. No acute intrathoracic or intraabdominal pathology.
Specifically, no pneumothorax, no solid organ injury, no free
air, and no fractures identified.
2. Dilated stomach with coiling of the NG tube back into the
esophagus. This was relayed via page to the ER physician, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 8026**] at 1:30 p.m. on [**2157-1-3**].
3. ET tube tip at the level of clavicles, approximately 5 cm
above the carina.
4. Right femoral line with tip in the proximal common femoral
vein, with soft tissue contusion around the right groin.
5. Unchanged appearance of left [**Date Range **] cyst, diverticulosis, and
anterolisthesis of L4 on L5.
.
- CT C-Spine
1. No acute fracture is noted in the cervical spine.
2. Small, osseous, corticated fragment noted in the right facet
joint, could represent chronic fracture versus osteophyte.
3. Cervical spondylosis with uncovertebral osteophytes at
levels mentioned above, causing mild narrowing of the left
neural foramina.
4. Fibrotic areas in bilateral lung apices, inadequately
evaluated on the present study.
.
- CT Head
1.New, small 1.2 x 0.6 cm intraparenchymal hematoma in the right
frontoparietal region with no mass effect or midline shift.
2.To consider MR of head, for better characterization and to
exclude other associated abnormalities.
.
[**10-7**]
MRA abdomen:
1. No evidence of [**Month/Year (2) **] artery stenosis.
2. Normal appearance of both adrenal glands without evidence of
adrenal mass. No evidence for extra-adrenal paragangliomas
within the retroperitoneum to the aortic bifurcation; further
into the pelvis was not imaged.
3. Otherwise limited study
.
Assessment and Plan: 58F h/o recent meningoencephalitis, adrenal
insufficiency, h/o C. diff infection, RA, and fibromyalgia;
admitted with mental status changes, fever, and intraparenchymal
hemorrhage after fall.
.
# Intraparenchymal hemorrhage: Most likely [**2-3**] witnessed
mechanical fall onto her head, though her hypertension to
220s/110s may have been contributing factor. [**Month/Day (2) 4695**] and
neurology following.
- Appreciate [**Month/Day (2) **] and neurology recs -
- Repeat MRI today to assess for interval change
.
# Fall: Witnessed mechanical fall. Intraparenchymal hemorrhage
as above. CT C-spine without evidence of fracture. Cspine
cleared [**1-4**].
- Intubated for airway protection due to uncertain C-spine,
hemorrhage, and questionnable ability to protect airway. self
extubated [**1-4**]; now on RA.
.
# Fever/MS changes: Unclear etiology. Elevated wbc count and
fever point to likely infectious etiology. No evidence of PNA on
chest CT, no evidence of UTI on UA. No intraabdominal pathology.
With h/o meningoencephalitis, CSF is possible source. LP with 8
wbc, and 2200 rbcs. Has h/o C. diff colitis, with loose stool on
arrival from ED, C. diff possibility. [**1-5**] c.diff neg x 1.
Mental status changes and agitation may be due to
discontinuation of her psychotropic medications over the last
several days.
- LP with no evidence of meningitis; d/c'd all abx [**1-5**]
- f/u blood, urine, sputum cultures
.
# Adrenal insufficiency: Previous w/u demonstrates
hypoaldosterone state. Due to chronic prednisone use, given
decadron in ED. Not currently hypotensive, lytes not suggestive
of Addisonian crisis.
- Decreased stress dose hydrocortisone 100mg IV q8h to po
prednisone [**1-5**]
.
# GIB: Evidence of UGIB on placement of NGT in ED. Initial drop
in hct likely [**2-3**] fluid resuscitation. Will continue to closely
monitor hct. If hct unstable, will consult GI for possible EGD
while in-house. In setting of recent ([**12-29**]) EGD demonstrating
gastritis, unlikely that there is a significant new bleed.
- IV PPI [**Hospital1 **]
- q8h hct
- serum H. pylori Ab pending
- restarted iron
.
FEN: NPO, replete lytes as needed
PPx: PPI, pneumoboots
Code: Full
Access: R fem TLC. Likely d/c tomorrow. D/c once IR picc in.
Communication - pt's mother, [**Name (NI) 2429**] [**Name (NI) **] ([**Telephone/Fax (1) 97769**])
.
Past Medical History:
1) [**7-7**] admission for sepsis (unclear source)
2) Adrenal insufficiency dx on [**7-7**] admission, on prednisone
3) Meningo-Encephalitis (Neuro ICU at [**Hospital1 2025**], discharged [**2157-5-17**])
4) Anemia
5) Sleep apnea
6) Occult GI bleeding
7) Rheumatoid arthritis
8) Fibromyalgia
9) s/p right elbow replacement surgery [**9-6**]
10) Diverticulitis 25 years ago
11) Migraines
12) HTN
13) Hyperlipidemia
14) s/p lap cholecystectomy
[**66**]) Depression
16) Pparaesophageal hernia repair with Nissen fundoplication
([**12-6**])
17) Question [**Month/Year (2) **] dysfunction
Social History:
No tobacco, alcohol or drug use.
Divorced. She has three daughters.
[**Name (NI) 1403**] as P.A. in adult primary care clinic.
She is lebanese/palestinian in background.
Family History:
Father died of MI at 85.
Mother had MI at 75.
There is family history of CAD and diabetes.
Physical Exam:
VS: T36.8 BP: 109/79 HR 87 RR: 12 95%RA
GEN: NAD, A&O X 3, easily conversing. c/o some word-finding
difficulty
HEENT: PERRL, EOMI, MM sl. dry, ecchymoses around eyes
(superior>inferir)
Neck: no [**Doctor First Name **]
CV: RRR, no MRGs
Lungs: CTAB
Abd: Soft, NDNT, with ecchymoses at injection sites L>R abodmen
Ext: Tr edema bilaterally, no CC, 2+ DPs
Neuro: CN II-XII grossly intact. FS, nl sensation all 4 ext.
Pertinent Results:
[**2158-1-3**] 06:08PM CEREBROSPINAL FLUID (CSF) PROTEIN-39
GLUCOSE-71
[**2158-1-3**] 06:08PM CEREBROSPINAL FLUID (CSF) WBC-8 RBC-2200*
POLYS-48 LYMPHS-38 MONOS-2 MACROPHAG-12
[**2158-1-3**] 05:50PM TYPE-ART RATES-[**12-11**] TIDAL VOL-500 PEEP-5
O2-60 PO2-118* PCO2-34* PH-7.47* TOTAL CO2-25 BASE XS-2
-ASSIST/CON
[**2158-1-3**] 05:50PM LACTATE-2.4*
[**2158-1-3**] 05:50PM freeCa-1.16
[**2158-1-3**] 04:02PM GLUCOSE-201* UREA N-11 CREAT-0.9 SODIUM-137
POTASSIUM-3.3 CHLORIDE-103 TOTAL CO2-24 ANION GAP-13
[**2158-1-3**] 04:02PM CALCIUM-9.0 PHOSPHATE-1.8*# MAGNESIUM-1.9
[**2158-1-3**] 04:02PM CRP-23.6*
[**2158-1-3**] 04:02PM WBC-14.7* HCT-34.7*
[**2158-1-3**] 04:02PM PLT COUNT-455*
[**2158-1-3**] 04:02PM SED RATE-31*
[**2158-1-3**] 12:08PM LACTATE-2.9*
[**2158-1-3**] 10:42AM URINE HOURS-RANDOM
[**2158-1-3**] 10:42AM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2158-1-3**] 10:42AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.018
[**2158-1-3**] 10:42AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
[**2158-1-3**] 10:42AM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0-2
[**2158-1-3**] 10:30AM GLUCOSE-183* LACTATE-6.4* NA+-142 K+-3.2*
CL--106 TCO2-18*
[**2158-1-3**] 10:20AM UREA N-13 CREAT-0.9
[**2158-1-3**] 10:20AM estGFR-Using this
[**2158-1-3**] 10:20AM ALT(SGPT)-13 AST(SGOT)-18 LD(LDH)-328* ALK
PHOS-141* AMYLASE-41 TOT BILI-1.2
[**2158-1-3**] 10:20AM ALBUMIN-4.5
[**2158-1-3**] 10:20AM HOMOCYSTN-9.1
[**2158-1-3**] 10:20AM TSH-0.98
[**2158-1-3**] 10:20AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2158-1-3**] 10:20AM WBC-22.6*# RBC-5.23# HGB-14.0# HCT-41.3#
MCV-79* MCH-26.7* MCHC-33.8 RDW-16.7*
[**2158-1-3**] 10:20AM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-OCCASIONAL
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-OCCASIONAL
OVALOCYT-OCCASIONAL
[**2158-1-3**] 10:20AM PLT SMR-VERY HIGH PLT COUNT-705*#
[**2158-1-3**] 10:20AM PT-14.4* PTT-21.6* INR(PT)-1.3*
Imaging:
-[**2158-1-3**] CXR - Technically limited radiograph as described.
Correlation with CT recommended to evaluate the left supraaortic
mediastinal contour.
.
- CT Torso ([**2158-1-3**]):
1. No acute intrathoracic or intraabdominal pathology.
Specifically, no pneumothorax, no solid organ injury, no free
air, and no fractures identified.
2. Dilated stomach with coiling of the NG tube back into the
esophagus. This was relayed via page to the ER physician, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 8026**] at 1:30 p.m. on [**2157-1-3**].
3. ET tube tip at the level of clavicles, approximately 5 cm
above the carina.
4. Right femoral line with tip in the proximal common femoral
vein, with soft tissue contusion around the right groin.
5. Unchanged appearance of left [**Date Range **] cyst, diverticulosis, and
anterolisthesis of L4 on L5.
.
- CT C-Spine ([**2158-1-3**]):
1. No acute fracture is noted in the cervical spine.
2. Small, osseous, corticated fragment noted in the right facet
joint, could represent chronic fracture versus osteophyte.
3. Cervical spondylosis with uncovertebral osteophytes at levels
mentioned above, causing mild narrowing of the left neural
foramina.
4. Fibrotic areas in bilateral lung apices, inadequately
evaluated on the present study.
.
CT Head ([**2158-1-3**]):
1.New, small 1.2 x 0.6 cm intraparenchymal hematoma in the right
frontoparietal region with no mass effect or midline shift.
2.To consider MR of head, for better characterization and to
exclude other associated abnormalities.
.
MRI head ([**2158-1-5**])
IMPRESSION:
1. Posterior subcortical swelling likely consistent with
reversible
leukoencephalopathy. .
2. Unchanged right frontoparietal intraparenchymal hematoma.
3. Normal circle of [**Location (un) 431**] MRA.
CT head ([**2158-1-6**])
IMPRESSION: No new intracranial hemorrhage. Unchanged right
parietal intraparenchymal hemorrhage.
Posterior reversible leukoencephalopathy syndrome.
MR/MRA head ([**2158-1-6**])
IMPRESSION: Since [**2158-1-5**], new T2 hyperintense lesion involving
the right pons. Stable posterior subcortical white matter
changes which may represent posterior reversible
leukoencephalopathy.
Stable small right parietal hemorrhage.
MRA HEAD:
IMPRESSION: Normal MRA of the head.
MRI/MRA neck:
IMPRESSION: No evidence of acute dissection of the vertebral,
basilar or internal carotid arteries. No evidence of thrombosis.
Brief Hospital Course:
58F h/o recent meningoencephalitis, adrenal insufficiency, RA,
and fibromyalgia; admitted with mental status changes, fever,
and intraparenchymal hemorrhage after fall.
.
# Intraparenchymal hemorrhage: witnessed mechanical fall onto
her head vs. [**2-3**] hypertension to 220s/110s at admit. Some of
patient's severe altered mental status thought to be secondary
to this hemmorhage. She was intubated for airway protection and
admitted to the MICU. She was intubated for 3 days, after which
she self extubated, without any respiratory difficulties.
During hospitalization, she received followup MRI and CT which
did not show any expansion of bleed. [**Month/Day (2) 4695**] followed as
inpatient, and will follow up with Dr. [**Last Name (STitle) 548**] 4 weeks after
discharge with follow up head CT. Pt. was started on phenytoin
for sz. prophylaxis, with goal phenytoin trough of [**11-21**]. That
was achieved here in the hospital with a dose of 150mg po tid
after initial load. MRI/MRA was done to assess for interval
change which showed a pontine lesion, likely related to initial
event. MRA neck to look for vertebral dissection as source for
embolic strokes is negative. She will folow up with
[**Date Range **] in 4 weeks and neurology in 4 weeks.
.
# Fall: Witnessed mechanical fall. Intraparenchymal hemorrhage
likely a result of fall. CT C-spine without evidence of
fracture. Cspine cleared [**1-4**].
.
# Labile blood pressures: On presentation was hypertensive and
needed to be placed on labetalol drip, though may have been [**2-3**]
GI bleed. [**Month/Day (2) 2793**] and Endocrine teams consulted at previous
admissions for further work-up of secondary HTN and has been
seen in outpatient eval with [**Month/Day (2) **] (Dr. [**Last Name (STitle) 118**] and endocrine
(Dr. [**Last Name (STitle) 97766**], no note in OMR). history of cortisol deficiency
[**2-3**] chronic steroid use, had been placed on stress dose steroids
intially, then tapered quickly to outpt prednisone dose. Has had
serum and urine metanephrines which were elevated but did not
meet pheo criteria as less than 3x normal. Urine catechols. wnl.
Of note, pt. on lots of psychoactive medications at the time. On
previous hospitilzation, MRA of the abdomen revealed no [**Month/Day (2) **]
artery stenosis, adrenal masses, or paraganglions that could
represent sites of ectopic catechols. MR head without e/o mass.
24 hour 5HIAA was also very slightly elevated, so unlikely
carcinoid. PEr outpt. nephrologist and endocrinologist, blood
pressures had been quite well controlled at home without any
anti-hypertensive regimen. After initial labetalol drip, pt.
was largely normotensive. During her hospitalization, her BPs
trended up slightly, so in conjunction with [**Month/Day (2) **] input, metop
was started initially in ICU and then increased on floor to 25mg
[**Hospital1 **]. She will be scheduled for outpatient appointment with
neurology [**Hospital1 **] dysfunction clinic and will continue to
follow up with [**Hospital1 **]/endocrine doctors. She will be instructed
to continue to take her blood pressures regularly at home.
.
# Fever: Unclear etiology, and on admit had persistent high
grade feversX 3-4 days prior to defervescing. Initially with
elevated wbc count, but resolved. No evidence of PNA on chest
CT, no evidence of UTI on UA. No intraabdominal pathology. LP
with 8 wbc, and 2200 rbcs, viral studies pending, but unlikely
meningitis. Initially, broad spectrum antibiotics were started
at meningitic doses (amp,cef, vanco, acyclovir) but were stopped
when LP could be performed and results were not c/w infection.
She continued to have increased diarrhea during her stay which
may have resulted from antibiotics vs. dilantin. Had h/o C.
diff colitis from stay at [**Hospital1 2025**], with loose stool s c.diff neg x
2. Fever may also have resulted from bleed and resulting
inflammation itself vs. drug fever from any of the antibiotics
she was on.
# Altered mental status: Initial mental status changes and
agitation may be due to discontinuation of her psychotropic
medications over the last several days vs. hypertension end
organ MS [**First Name (Titles) 4245**] [**Last Name (Titles) **]. bleed. She had extensive neurologic workup
including scans, bleed, LP which was negative for infectious w/u
showed RPML, which is consistent with h/o hypertension. Her AMS
improved steadily over her stay in the hospital and she achieved
baseline within 3-4 days of admit. Most of her remaining
neurologic symptoms (difficult with wordfinding, visual changes)
most likely explained by her bleed. Of note, pt. had similar
admission (without intraparenchymal hemmorhage) with AMS, labile
HTN requiring neuro ICU admission to [**Hospital1 2025**] in past.
.
# GIB: had blood in throat and + blood. Initial drop in hct
likely [**2-3**] fluid resuscitation. Hcts were stable since initial
drop.
.
# Psych: psych meds initially held while intubated but were
restarted with POs
# Hyperlipidemia/CAD: restart atorvastatin, aspirin held given
head bleed
# Back pain: scheduled to have surgery on 11th. Currently has
not been requiring pain meds despite large narcotic doses at
home. Continue gabapentin. started percocets, and low dose ms
contin as well if pain increasing [**2-3**] more movement (these are
home meds).
Medications on Admission:
. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
3. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
4. Trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for sleep.
5. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed.
6. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Lorazepam 1 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime) as needed for insomnia.
8. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for insomnia.
9. Venlafaxine 75 mg Capsule, Sust. Release 24HR Sig: Three (3)
Capsule, Sust. Release 24HR PO DAILY (Daily).
10. Gabapentin 400 mg Capsule Sig: Three (3) Capsule PO TID (3
times a day).
11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed for Pain.
12. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
14. Prednisone 5 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)).
Disp:*90 Tablet(s)* Refills:*2*
15. Prednisone 5 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
16. Cyanocobalamin 1,000 mcg Tablet Sig: One (1) Tablet PO once
a day for 10 days: take daily for 7 days,
.
Discharge Medications:
1. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Lorazepam 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime):
take 2mg at bedtime and 1mg in AM.
Disp:*90 Tablet(s)* Refills:*0*
5. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
6. Venlafaxine 75 mg Capsule, Sust. Release 24HR Sig: Three (3)
Capsule, Sust. Release 24HR PO DAILY (Daily).
Disp:*90 Capsule, Sust. Release 24HR(s)* Refills:*2*
7. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release(s)* Refills:*0*
8. Phenytoin 50 mg Tablet, Chewable Sig: Three (3) Tablet,
Chewable PO TID (3 times a day).
Disp:*270 Tablet, Chewable(s)* Refills:*2*
9. Gabapentin 400 mg Capsule Sig: Three (3) Capsule PO TID (3
times a day).
Disp:*270 Capsule(s)* Refills:*2*
10. Quetiapine 200 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
Disp:*15 Tablet(s)* Refills:*2*
11. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
13. 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*
14. Prednisone 5 mg Tablet Sig: One (1) Tablet PO qpm.
Disp:*30 Tablet(s)* Refills:*2*
15. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea.
Disp:*60 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Intraparenchymal hemorrhage
Altered mental status
Labile hypertension
Reversible posterior leukoencephalopathy syndrome
_____________________
rheumatoid arthritis
Discharge Condition:
good, tolerating POs, a& O X 3, ambulating without assistance,
satting well on RA
Discharge Instructions:
Please take all medications as prescribed.
.
Please record your blood pressures at least twice per day.
.
Call your doctor or return to the ED if you should experience
chest pain, shortness of breath, nausea, vomiting, sweating,
fevers, chills, bleeding, or other concerning symptoms. Please
call your PCP if you blood pressure is greater than 170 mmhg or
if you have chest pain, chest pressure, nausea, vomiting,
headache, confusion or any other concerning symptoms.
Follow up at the appointments which we have scheduled below
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 1728**] on Thursday [**1-19**] at 1PM
Follow up with Neurology for [**Month (only) **] testing at the following
appt.
Provider: [**Name10 (NameIs) **] TESTING [**Name10 (NameIs) **] LAB Date/Time:[**2158-2-7**]
9:00
([**Telephone/Fax (1) 19252**]
They will mail you a packet with instructions and directions.
Follow up with Dr. [**Last Name (STitle) 548**] [**Last Name (STitle) **] ([**Telephone/Fax (1) 11314**]:
[**2-1**] at 10:45AM. [**Last Name (NamePattern1) **]. [**Location (un) 470**] [**Hospital Unit Name **].
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] WEST Date/Time:[**2158-2-1**]
10:45
Prior to your appintment you should get a head CT on the [**Location (un) **] of [**Hospital Ward Name 23**]. Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**]
Date/Time:[**2158-2-1**] 9:15
Follow up with Dr. [**Last Name (STitle) 118**] as below
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2158-2-14**] 8:00
Follow up with Drs. [**Last Name (STitle) 4638**] and [**Name5 (PTitle) **] of neurology at [**2-15**]
4:30PM ([**Telephone/Fax (1) 5088**]. Prior to your appt., you will get a head
MRI at the [**Hospital Ward Name **] bldg. [**Location (un) **] Phone:[**Telephone/Fax (1) 327**]
Date/Time:[**2158-2-15**] 9:45
|
[
"578.9",
"V58.65",
"E884.4",
"780.6",
"851.80",
"272.4",
"255.4",
"714.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"03.31",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
24189, 24195
|
15430, 19413
|
336, 390
|
24403, 24487
|
10913, 15407
|
25064, 26544
|
10370, 10462
|
22361, 24166
|
24216, 24382
|
20793, 22338
|
24511, 25041
|
10477, 10894
|
253, 298
|
418, 2804
|
19428, 20767
|
9581, 10166
|
10182, 10354
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,071
| 155,783
|
24350
|
Discharge summary
|
report
|
Admission Date: [**2174-10-21**] Discharge Date: [**2174-11-12**]
Date of Birth: [**2118-4-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Vancomycin
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Back pain and shortness of breath
Major Surgical or Invasive Procedure:
[**2174-10-21**] Ascending Aortic Replacement(26mm Gelweave Graft) with
Resuspension on Aortic Valve
History of Present Illness:
Mr. [**Known lastname **] presented to outside hospital with severe, radiating
back pain associated with shortness of breath. The pain did not
resolve with lying down. Mr. [**Known lastname **] prior to presentation, had
been experiencing intermittent mid back discomfort for several
weeks. CT scan at outside hospital revealed Type A aortic
dissection. He was emergently brought to the [**Hospital1 18**] for emergent
surgical intervention.
Past Medical History:
Hypertension, Coronary Artery Disease - 3VD, Congestive Heart
Failure, Renal Insufficiency - baseline Cr 1.5, Obesity, Non
Insulin Dependent Diabetes Mellitus, Cerebrovascular Disease -
History of Stroke at age 35, Proteinuria, History of Lower Leg
Cellulitis, Prior Knee Arthoroscopy
Social History:
Irish, drinks socially but drinks 10-12 beers/occasion. Denies
tobacco or illicit drugs. Smokes one cigar per month.
Family History:
Mother had CABG at age 42, died at age 49. Brother had coronary
stent at age 46.
Physical Exam:
Vitals: BP 137/78, HR 59, RR 14, SAT 96 on nasal cannula
General: obese male in no acute distress
Neck: supple, no JVD,
Heart: regular rate, normal s1s2, distant heart sounds
Lungs: clear bilaterally
Abdomen: obese, soft, nontender, normoactive bowel sounds
Ext: warm, 1+ edema
Pulses: 2+ distally
Neuro: alert and oriented, nonfocal
Pertinent Results:
[**2174-11-11**] 06:10AM BLOOD WBC-4.9 RBC-3.22* Hgb-9.5* Hct-28.0*
MCV-87 MCH-29.4 MCHC-33.9 RDW-15.7* Plt Ct-392
[**2174-11-10**] 04:25PM BLOOD WBC-5.9 RBC-3.21* Hgb-9.3* Hct-27.7*
MCV-87 MCH-29.1 MCHC-33.7 RDW-15.7* Plt Ct-418
[**2174-11-11**] 06:10AM BLOOD Plt Ct-392
[**2174-11-12**] 05:55AM BLOOD Glucose-95 UreaN-20 K-3.9
[**2174-11-11**] 06:10AM BLOOD Glucose-94 UreaN-19 Creat-1.3* Na-138
K-3.9 Cl-103 HCO3-26 AnGap-13
Brief Hospital Course:
Mr. [**Known lastname **] was initially maintained on intravenous Esmolol and
Nipride for tight blood pressure and heart rate control. He was
urgently taken to the operating room where Dr. [**Last Name (STitle) 914**] performed
a replacement of his ascending aorta. For surgical details,
please see seperate dictated operative note. Following the
operation, he was brought to the CSRU for invasive monitoring.
CARDIAC: He was initially started on Amiodarone for bouts of
perioperative atrial fibrillation. He also required multiple
intravenous anti-hypertensives for persistent hypertension. In
the postop period, he remained mostly in a normal sinus rhythm.
No further episodes of atrial fibrillation was noted. Amiodarone
was discontinued in the early postop period secondary to ARDS.
Anti-hypertensives were titrated to maintain MAP less than 100
mmHg. The cardiology service was eventually consulted to assist
in the management of his hypertension. At discharge, his blood
pressure was still labile but improving. Patient should follow
up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] as an outpatient.
NEURO: He initially failed to recover after withdrawal of
sedation and paralysis. He initially remained comatose and
unresponsive which suggested severe brain stem injury. However
brain MRI revealed no evidence of brainstem infarction. Over
several days, his neurological exam gradually started to
improve. EEG was suggestive of severe encephalopathy, no
epileptiform discharges or seizures were seen. All sedative were
withheld and by postoperative day eight, he showed remarkable
improvements. He intermittently required Haldol for
hallucinations. Throughout the remainder of his hospital stay,
his neurological status continued to improve.
PULMONARY: Initially hypoxic, most likely secondary to ARDS, he
underwent multiple diagnostic and therapuetic bronchoscopies.
Amiodarone was discontinued in the early postop period as it may
have contributed to ARDS. Eventually started on empiric
antibiotics for concern for ventilator associated pneumonia.
Given his respiratory failure, the thoracic service was
consulted for tracheostomy and gastrostomy. This was originally
delayed due to his increasing requirements for ventilatory
support. As his neurological status improved, so did his
oxygenation. He was slowly weaned from mechanical ventilation
and was extubated on postoperative day 10. No tracheostomy was
required. At discharge, he was tolerating room air with 94%
oxygen saturations.
RENAL: Had acute decline in renal function with oliguria. His
creatinine peaked to 3.1 on postoperative day two. Nephrology
service was consulted and attributed his ARF to acute tubular
necrosis/prerenal azotemia. There was no indication for
hemodialysis. Diuretics were initially held to allow auto
diuresis. Over the remainder of his hospital stay, his renal
function gradually improved. ACE inhibitor was eventually
resumed for hypertension without any further renal insult. At
discharge, he continued to have 3+ bilateral pedal edema. He was
diuresing well with Lasix.
INFECTIOUS DISEASE: Started to experience fevers around
postoperative day three. His fevers persisted despite no obvious
source on infection. Postop white count peaked at 16K. All
invasive lines were changed and pan cultures were obtained, all
remaining negative. Ceftriaxone and Linezolid were empirically
started for coverage with major concern for ventilator
associated pneumonia. Chest x-ryas showed persistent right lower
lobe collapse. Around postoperative day seven, was noted to have
a widespread rash. ID recommended to discontinue Ceftriaxone(PCN
allergy) and start Aztreonam. Drug fever at this point could not
be ruled out. By postoperative day 10, his fevers resolved.
Intravenous antibiotics were transitioned to PO.
NUTRITION: Given prolonged sedation period, was started on
trophic tube feeds. He was maintained on an Insulin drip for
strict glycemic control. He tolerated goal tube feeds but
required free water for hypernatremia. Eventually transitioned
to oral diet without difficulty.
OTHER: Given immobility, maintained on subcutaneous Heparin.
Initially very deconditioned, he worked with physical therapy to
improve strength and mobility. In the postop period, required
treatment with Colchicine for acute gouty attack. Will continue
to wear compression stockings for lower extremity edema.
Medications on Admission:
Nifedical 60 [**Hospital1 **], Lasix 40 [**Hospital1 **], Aspirin 325 qd, Toprol Xl 50 qd,
Cozaar 100 [**Hospital1 **], Enalapril 20 [**Hospital1 **], Lipitor 40 qd, Glucophage 500
qd
Discharge Medications:
1. Outpatient Physical Therapy
Medically Necessary
2. Skilled Nursing
Medically necessary
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. Hydralazine 25 mg Tablet Sig: Three (3) Tablet PO Q6H (every
6 hours).
Disp:*360 Tablet(s)* Refills:*2*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Enalapril Maleate 10 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
Disp:*120 Tablet(s)* Refills:*2*
9. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
10. Labetalol 200 mg Tablet Sig: 4.5 Tablets PO BID (2 times a
day).
Disp:*270 Tablet(s)* Refills:*2*
11. Furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
12. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home with Service
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Type A Aortic Dissection - s/p Replacement of Ascending Aorta,
Postoperative Acute Renal Insufficiency, Postoperative Altered
Mental Status, Postoperative Fevers, Postop Respiratory
Failure/ARDS, Drug Rash
PMH: Hypertension, Coronary Artery Disease, Congestive Heart
Failure, Renal Insufficiency, Obesity, Non Insulin Dependent
Diabetes Mellitus, Cerebrovascular Disease - History of Stroke
at age 35, Proteinuria, History of Left Leg Cellulitis, Prior
Knee Arthoroscopy
Discharge Condition:
Good
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for at least one month. No lifting more
than 10 lbs for at least 10 weeks from the date of surgery.
Monitor wounds for signs of infection. Please call with any
concerns or questions.
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in [**4-6**] weeks, call for appt
Dr. [**Last Name (STitle) 8430**] in [**2-4**] weeks, call for appt
Dr. [**Last Name (STitle) **] in [**2-4**] weeks, call for appt at [**Location (un) 620**] Cardiology
Completed by:[**2174-11-14**]
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78,076
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10766
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Discharge summary
|
report
|
Admission Date: [**2113-7-1**] Discharge Date: [**2113-10-11**]
Date of Birth: [**2043-3-24**] Sex: M
Service: SURGERY
Allergies:
Aspirin / Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
At admission: The patient is a 70M with gallstone pancreatitis
who then underwent a failed ERCP which led to abdominal
compartment syndrome after insufflation. This was further
complicated by vasodilatory SIRS shock with subsequent
decompressive exploratory laparotomy ([**2113-7-3**]) w/ persistent
open abdomen, expansion of wound ([**2113-7-3**]), a bleeding
Dieulafoy's ulcer s/p clipping ([**2113-7-17**]), acute renal failure,
ARDS and c.diff, abdominal closure and repeat decompressive ex
lap ([**2113-7-19**]), tracheostomy ([**2113-7-24**]), partial closure of
abdomen with mesh ([**2113-7-29**]) and wound Vac ([**2113-8-1**]). Repeatedly
febrile, repeat abd CT shows air in pancreas. now s/p drainage
of pancreatic collection by IR ([**2113-8-13**]) upsizing of drain
([**2113-8-18**]), laparoscopic minimally invasive pancreatic
necrosectomy ([**2113-8-22**], [**2113-8-28**], [**2113-9-4**]) for necrotizing
pancreatitis.
Major Surgical or Invasive Procedure:
[**2113-7-13**] closure, GJ tube
[**2113-7-8**] partial abd closure, drsg [**Name5 (PTitle) **]
[**2113-7-4**] Open abdomen dressing revision
[**2113-7-3**] Decompressive laparotomy, open abd
[**2113-7-8**] partial closure abdominal wound
[**2113-7-13**] formal closure GJ tube
[**2113-7-19**] Decompressive laparotomy, open abd
[**2113-8-13**] and [**2113-8-18**] -I&D of pancreatic fluid collection and
subsequent upsizing of drain by IR
[**2113-8-22**], [**2113-8-28**], [**2113-9-4**] -Laparoscopic pancreatic
necrosectomy
History of Present Illness:
Mr [**Known lastname 35199**] is a 70M who presents complaining of severe RUQ pain
since last evening. He states that he had similar pain 4 nights
ago that only lasted for a few hours and then resolved, was not
associated with nausea or vomiting. Then last evening a few
hours after dinner he felt the pain return, severe and diffuse
upper abdomen, progressing to more diffuse abdomen and raditaing
across his back. He says he had mild nausea without emesis, no
chest pain or shortness or breath. Last bowel movement was last
evening after the pain had started, normal, no blood, no
diarrhea. Can not say if he has passed gas. Otherwise has not
had this before, no history of gallstones.
Past Medical History:
Asthma, HTN, Basal cell carcinoma
Social History:
No smoking, one glass of wine per night, no drugs, retired
upholsterer
Family History:
Non-contributory
Physical Exam:
Physical Exam on admission:
98.2 84 160/97 16 97%6L facemask
Gen: NAD. uncomfortanble. A&Ox3.
HEENT: Anicteric. dry mucosal membranes.
CV: RRR
Pulm: course BS, decreased on right
Abd: distended and tympanic, tender diffusely with focal
tenderness in epigastrum, +guarding, no rebound.
DRE: Normal tone. No masses. No gross or occult blood.
Ext: Warm and well perfused. No peripheral edema.
Neuro: Motor and sensation grossly intact.
Physical Exam upon Discharge:
97.1 105 110/72 80 30 100% trachmask
Gen: NAD. awake, alert
HEENT: PERRL. EOMI
CV: RRR
Pulm: BL breath sounds, CTA
Abd: Soft, nondistended, nontender, midabdominal wound vac in
place, right side G-tube in place, no guarding, no rebound.
Ext: Warm and well perfused. 1+ edema BL.
Neuro: Motor and sensation grossly intact.
Pertinent Results:
[**2113-7-1**] CT abd - acute pancreatitis
[**2113-7-2**] - ERCP - Failed CBD cannulation due to duodenal edema
and distortion of the ampullary area
Multiple CT abdomen/pelvis consistent with pancreatitis
Multiple CT head for mental status changes demonstrating no
evidence of acute hemorrhage, Chronic small vessel infarction,
Mucosal sinus disease
[**2113-9-19**] - Fistulagram - Spontaneous passage of contrast from
the peripancreatic collection into the descending colon near the
splenic flexure, consistent with fistula.
Speech and swallow evalutation [**2113-10-9**] - Continue PMV use as
tolerated throughout the day. PO sips of nectar thick liquid
with alternative means for primary hydration/nutrition. Meds via
alternative means. Q4 oral care
1:1 supervision with sips to carefully monitor 02 sats, suction
when needed, and maintain aspiration precautions
MICRO Data:
[**2113-7-11**] BAL: yeast, aspergillus
Cdiff: +
[**2113-7-25**] sputum: E.coli+yeast
[**2113-7-28**] BAL- Pan-S pseudomonas, cipro-R e.coli
[**2113-8-13**] pancreatic fluid culture: Pseudomanas and [**Female First Name (un) **]
albicans
[**2113-9-4**]:[**Female First Name (un) 564**]. Variable rods and gram positive cocci in chains
and clusters.
[**2113-9-7**] BCx=coag neg staph and UCx Neg, L flank drainage -
pseudomonas, cipro and pip [**Last Name (un) 36**].
[**2113-9-7**] Wound Cx pseudomonas/ cipro-sensitive
[**2113-9-7**] Sputum +Pseudomonas and rare GNR
[**2113-9-9**] SputumCx: 4+(>10 per 1000X FIELD): GNR; 1+ Budding Yeast
[**2113-9-11**] SputumCx: 4+ GNR, 2+ yeast - pseudomonas, rare e. coli.
[**2113-9-24**] Sputum Cx 4+ GNR - 2 colonies of pseudomonas, a:
susceptible to everything but [**Last Name (un) 2830**], b: resistant to cipro, [**Last Name (un) 2830**],
zosyn, only susceptible to tobra
[**2113-10-9**] 03:37AM BLOOD WBC-8.3 RBC-2.82* Hgb-8.1* Hct-24.3*
MCV-86 MCH-28.6 MCHC-33.2 RDW-16.5* Plt Ct-353
[**2113-10-10**] 03:57AM BLOOD Glucose-113* UreaN-83* Creat-1.8* Na-137
K-4.5 Cl-107 HCO3-22 AnGap-13
[**2113-10-8**] 03:43AM BLOOD ALT-18 AST-24 AlkPhos-79 TotBili-0.5
[**2113-7-1**] 06:00PM BLOOD Lipase-2881*
[**2113-10-4**] 02:02AM BLOOD Lipase-27
[**2113-10-8**] 03:43AM BLOOD Albumin-1.9* Calcium-9.6 Phos-3.9 Mg-2.1
Iron-27*
[**2113-10-8**] 03:43AM BLOOD calTIBC-107* Ferritn-1568* TRF-82*
Brief Hospital Course:
[**7-2**]: [**Hospital Ward Name **] for ERCP, aspiration mid-procedure so
intubated. Unsuccessful ERCP, difficulty passing NG tube.
Excessive air causing compartment syndrome of abdomen. Taken to
OR for Abd compartment syndrome from air insufflation. Target
bladder pressure <26 (43 on admission to SICU).
[**7-3**]: Ex-lap, enterotomy for abd decompression. Due to worsening
abd distension, hemodynamic instability the abd wound was
extended at the bedside in the ICU by the surgical team and
packed open with bogata bag and sponges. CO improved and pressor
requirements decreased post op. Worsening renal failure.
[**7-4**] - UOP steady at 10cc/hr but massively retaining fluids,
BUN/cr rising. CVVH started, transient tachycardia limited vol
off. PEEP decreased to 18. LFTs, panc enzymes improving.
[**7-5**]: fixed OG tube. Line rewired and CVVH initiated. Plan OR in
weekend for closure. Off pressors. Panc enzymes cont improve.
Improving static compliance to vent. Fibrinogen 1028
[**7-6**]: Vanco D/c'd, bladder balloon D/C'd. TPN initiated.
[**7-7**]: goal net 4 L negative w/ HD. Continues on CVVH. PEEP
decreased 10->8. TPN day 2 (hole in bag, got premix instead).
WBC 9.5->12.8, afebrile, cultures sent. NGT replaced.
[**7-8**]: TPN day 3, to OR for washout + dressing change + partial
closure, ABD still open, continue HD goal 4L negative
[**7-9**]: DC cis atracurium. TPN day 4. Plan OR [**7-11**]. started Fluc.
Slowed rate due to hypotension. Primary did not want start
pressors. ? desat to 88% whle on 40%/[**8-18**]. Responed Fio2 100%.
Wean down to FiO2 60%. [**7-8**] Sputcx: yeast w/ aspergillus
[**7-10**]: fem aline and RIJ CVL removed. Vanc/Zosyn restarted d/t
fevers, rigors, increasing WBC. restarted neo gtt for
hypotension.
[**7-11**]: Bronch, mucus plugs suctioned from RML, RLL. KOH prep of
BAL - no aspergillus, BAL for viral neg.
[**7-12**]: cdiff+, started po vanco, flagyl, dc vanco, zosyn. OR [**Doctor First Name **].
Plan to resite line if wbc still elevated in am. Peep 10>8
[**7-13**]: closed in OR
[**7-14**]: Hemodialysis catheter sent, Bronch and BAL washing sent,
febrile to 102.7. Non-obstructive clot in the left lower
internal jugular vein
[**7-15**]: BAL w/ aspergillus. Off sedation, added fentanyl for pain
control. PEEP 12>10. Weaning neo. Hct 25.3>22.2. TTE: increased
RA size, TR gradient. TF at 10. INR 1.3>1.4.
[**7-17**]: Upper GI bleed, 3units PRBC, switched to
Levo+phenylephrine, back on versed for sedation, S/P Upper GI
scope by GI and clipping of bleeding vessel, protonix IV
started. Likely Dieulafoy's lesion. stopped fluconazole
[**7-18**]: Dialysis catheter changed over wire. Xfused 1 unit for hct
24.4. Back on levo and and neo. Bladder pressure increased to
24. TF stopped. 2L drained from GT. Zosyn started for possible
aspiration pna.
[**7-19**]: Will c/s transplant [**Doctor First Name **] re: tunneled catheter and future
need for HD/transplant. Head to pelvis CT - pancreatic necrosis,
no evidence of large hematoma or abscess. Increased Gtube output
-> GI scoped - lots of debris in stomach, no evidence acute
bleeding. Placed OG with red blood suctioned. Brought to OR for
decompressive laparotomy for bladder pressures >28.
[**7-24**]: OR for tracheostomy.
[**7-29**]: OR for vicryl mesh closure of abdomen and placement of
negative pressure dressing.
[**8-1**]: Levofloxacin d/c'd.
[**8-2**]: Micafungin d/c'd. Transfused 2 units for hct 24.
[**8-3**]: PO vanc/flagyl d/c'd. Abdominal VAC dressing changed.
[**8-4**] - [**8-5**] : continued supportive care
[**8-6**]: CVVH d/c'd, blood pressure stable to begin HD. Started
haldol 1mg PO BID for agitation. Abdominal VAC dressing
changed.
[**8-7**]: HD catheter placed, hemodialysis run x 1
[**8-8**] - [**8-11**]: continued supportive care, ventilatory managment,
tube feeds, wound vac in place changed every 3 days
[**8-12**]: temperature spikes, meropenem, zosyn and fluconazole
started.
[**8-13**]: 4 units FFP given for CT guided pancreatic drain placement,
continued sedation as needed, antibiotics, intermittent
vasopressors needed.
[**8-14**]: 2 units of RBCs given for low hematocrit, continued CVVH,
continued meropenem, fluconazole, discontinued zosyn, started
vancomycin, ciprofloxacin, micafungin
[**8-15**]: transfused 1 unit RBCs, continued CVVH, ventilatory
support, TPN started
[**8-16**]: discontinued vancomycin, ciprofloxacin, micafungin, tube
feedings resumed, continued CVVH, ventilatory support
[**8-18**]: the patient was taken to the operating room for
laparoscopic pancreatic necrosectomy, returned to the ICU,
continued tube feeds, meropenem, fluconazole, CVVH, vac dressing
in place on abdominal wound
[**8-19**]: vancomycin added to antibiotics for fever, HIT positive -
heparin stopped, continued tube feeds, ventilatory support
[**8-22**] returned to the operating room for laparoscopic pancreatic
necrosectomy, returned to the ICU on vancomycin, meropenem,
fluconazole, continued CVVH, tube feeds, foley catheter in
place, pancreatic drain with continued flushing, ventilatory
managment
[**8-23**]: PICC line placed, vancomycin held for high levels,
continued fluconazole / vancomycin
[**8-24**]: argatroban drip started, central line removed and sent for
cultures, continued antibiotics, tube feeds, ventilatory support
[**Date range (1) 35200**] continued supportive care in the ICU, ventilatory
management, tube feeds, antibiotics, argatroban continued
[**8-28**] returned to the operating room for laparoscopic pancreatic
necrosectomy, returned to the ICU for ventilatory management,
tube feeds, antibiotics, argatroban
[**2113-9-4**]: to OR for repeat necrosectomy, started levophed gtt, on
CMV. Left flank drain O/P bloody.
[**2113-9-5**]: 2 units PRBC, G/J changed in IR (tube was leaking),
trach collar trial
[**2113-9-6**]: Out of bed to chair, tube feeds re-started at 10 but
bilious vomiting several hours later, KUB ruled out obstruction,
TF re-started again
[**2113-9-7**]: TM trialx7h, CT A/P with PO unchanged per surgery,
methadone 10 [**Hospital1 **], started lopressor. T spike 101.6 ON--panCx and
CXR.
[**2113-9-8**]: Bowel contents draining from wound around pancreatic
drain. Pt made NPO, TPN started. V/C/F started empirically.
[**2113-9-9**]: SputumCx 4+ GNR, 1+ yeast. Pancreatic drain dressing?
[**2113-9-10**]: Zosyn for ?pseudomonas, resent ET aspirate per ID as
they did not trust initial sputum/contam. KUB=+contrast still.
Surgery wants wet-dry [**Hospital1 **] dressings, res and att aware of local
breakdown [**2-6**] fistula. IJ thrombi largely resolved on U/S.
heparin gtt d/c'd.
[**2113-9-11**]: VAC change, Cr increasing to 3.3, Renal Reconsulted.
[**2113-9-12**]: New CVL, PICC pulled and sent for culture, A line
placed. Abg with 7.08 PCo2 81 HCO3 26 Lactate 1.2. Methadone
held and placed on rate - repeat gas 2 hrs later 7.26/50/153/23.
[**2113-9-13**]: Decrease IVF, per renal. KVO. Albumin 25% TID. Oliguric
ARF (u/o 20-30mL/hr).
[**2113-9-14**]: Methylene blue drained from G port but not chest
tube/collection. Started TFs at 10. pCO2 rose on PS 8/5, incr to
PS 15/5 with improved TVs and reassuring ABG.
[**2113-9-15**] Vanc d/c'd ([**Date range (1) 21873**]), Cr Continues to rise now 4.5,
Start Trickle Tube feeds at 10cc/hr
[**2113-9-16**] Tf to 20 cc/hr. Cr 4.7. Colace started. 101.6 fever
pancultured.? stool via wound (not saved)
[**2113-9-17**] fluc started, TF increased to 30, pancreatic fluid pH
7.24
[**2113-9-18**] HD cath L femoral placed, hemodialysis started. Readress
vent weaning after dialysis with metab acidosis improvement. TFs
30cc/h, ducolax/colace for constipation.
[**2113-9-19**] Cont HD, Fistulogram demonstrating connection between
pancreatic drain and descending colon. Tube feeds d/c'd.
[**2113-9-20**] Decreased sbp to 60s while on dialysis, peritoneal
irrigation dc'd, rec'd third round of HD
[**2113-9-21**] Trach collar trial, olanzapine for agitation when off
vent, improved neuro exam
[**2113-9-22**] Lopressor to Q4 from Q6. Surgery flushed drain, unsure
if drain will adequately drain fistula. Bowel rest, stop
dialysate flushes of GJ, ok to flush chest tube. Team discussing
trach w/Dr [**First Name (STitle) **]. Anemic ON to 21-->2 units with 9/19 dialysis.
[**2113-9-23**]: HD, 2 units PRBC, dc abx.
[**2113-9-24**]: TM trial. IJ u/s. Gnr on sputum.
[**2113-9-26**]: Trach upsized, HD cath rewired and heplocked.
Novosource 20cc tube feeds started. Team wants to keep chest
tube in. No dialysis done.
[**2113-9-27**]: Unable to get HD due to low flow, Left Fem HD cath &
subclavian CVL d/c. Renal team says no need for dialysis now.
[**2113-9-28**]: Wound vac change. Contact precautions [**2-6**] resistant
pseudomonas. Fistula output not increasing with TF, so will
increase gradually back up to goal.
[**9-29**] temp spike, started empirically on meropenem for a 14 day
course (until [**10-12**]), continued TPN, help tube feeds, PICC line
removed, transfused 1 unit RBC
[**9-30**]: continued TPN, meropenem, added vancomycin, transfused one
unit RBC
[**10-1**]: continued TPN, meropenem, vancomycin, OOB to chair,
attempt to wean to trach collar as much as possible
[**10-3**]: PICC line placed, continued TPN, meropenem, vancomycin
[**10-4**]: resumed tube feeds at 10, stopped vancomycin, continued
TPN, meropenem
[**10-6**]: Speech and swallow evaluation with diet advanced to sips
of nectar thick liquids, Abdominal vac dressing changed.
[**10-8**] Tube feeds advanced to 20 cc/hr, pt able to speak using
device
[**10-9**]: tube feeds advanced to 30 cc/hr - increasing 10 cc/day as
tolerated, continued meropenem until [**10-12**], OOB to chair,
tolerating trach collar more each day, only going on vent
CPAP/PSV overnight, able to pivot from bed to chair, Abdominal
vac dressing changed.
[**10-10**]
Neurologic: Patient with stable MS. [**Name14 (STitle) 35201**] and tylenol PRN.
with Zyprexa and Ativan PRN agitation.
Cardiovascular: Patient stable on Lopressor 10mgQ4H
PULM: Tolerating trach mask during day with CPAP overnight.
Gently advancing time on trach mask. Atrovent PRN.
GI: Pancreaticocolonic fistula. G-tube balloon 10ml
insufflation. + BM's. Follow panc/stool drainage. Panc drain
replaced [**10-3**]. Wound vac changed [**10-9**].
FEN: TPN daily, diet advanced to clears - nectar thick. Patient
with a small bout of emesis and TF decreased to 20cc/hr.
Patient will continue to advance TF at 10cc/day.
RENAL: Cr stable, no longer requiring HD, UOP
appropriate/stable.
HEME: Requires 8hrs blood bank notice for blood products. Hct
stable.
ENDO: Endo pancreas functioning 28U regular in TPN. Minimal
RISS.
ID: [**Last Name (un) **] until [**10-12**] (MDR pseudomonas lung colonization).
Wounds: Abdomen wound vac (changed q3d, last [**10-9**]). L flank
wound around panc tube, wet>dry [**Hospital1 **].
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a clear
nectar thick diet, and pain was well controlled. The patient
received discharge teaching and follow-up instructions with
understanding verbalized and agreement with the discharge plan.
Medications on Admission:
Diovan 160 mg QD
Simvastatin 40 mg QD
Albuterol IH prn
Discharge Medications:
1. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
2. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q6H (every 6 hours) as needed for fever >101.
3. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation Q4H (every 4 hours) as needed for wheeze.
4. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed) as needed for dry eyes.
5. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed for rash.
6. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO BID (2 times a day) as needed for agitation.
7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
8. Acetaminophen 160 mg/5 mL Solution Sig: One (1) 20ML PO Q6H
(every 6 hours) as needed for fever / pain.
9. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4H (every 4 hours).
10. Ondansetron 4 mg IV Q4H:PRN nausea
11. HYDROmorphone (Dilaudid) 0.4-1 mg IV Q4H:PRN pain
12. 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.
13. Lorazepam 0.5 mg IV Q4H:PRN anxiety
14. 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.
15. Metoprolol Tartrate 10 mg IV Q4H
Hold for SBP<110, HR<55
16. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: per
sliding scale Subcutaneous four times a day: sliding scale
Glucose Insulin
0-60 [**1-6**] amp D50
61-160 0 Units
161-180 2 Units
181-200 5 Units
201-220 8 Units
221-240 11 Units
241-260 14 Units
261-280 17 Units
281-300 20 Units
> 300 Notify M.D. .
17. Meropenem 500 mg Recon Soln Sig: Five Hundred (500) ml
Intravenous twice a day for 2 days.
Disp:*2 day* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 1110**]
Discharge Diagnosis:
gallstone pancreatitis s/p failed ERCP and abdominal compartment
syndrome([**2113-7-2**]) c/b vasodilatory SIRS shock w/subsequent
decompressive exploratory laparotomy ([**2113-7-3**]) w/ persistent
open abdomen, expansion of wound ([**2113-7-3**]) bleeding Dieulafoy's
s/p clipping ([**2113-7-17**]) ARF, s/p episode ARDS and c.diff, s/p abd
closure and repeat decompressive ex lap ([**2113-7-19**]), trached
([**2113-7-24**]), partial closure with mesh ([**2113-7-29**]) and wound vac
([**2113-8-1**]). Repeatedly febrile, repeat abd CT shows air in
pancreas. now s/p drainage of pancreatic collection by IR
([**2113-8-13**]) upsizing of drain ([**2113-8-18**]), laparoscopic minimally
invasive pancreatic necrosectomy ([**2113-8-22**], [**2113-8-28**], [**2113-9-4**]) for
necrotizing pancreatitis.
Discharge Condition:
Stable, requires vent capable facility
Discharge Instructions:
NEURO: Stable MS. Dilaudid/tylenol PRN. Improved agitation.
Zyprexa SL [**Hospital1 **]. Ativan prn.
CVS: Stable. Lopressor 10mg Q4h.
PULM: Tolerating trach mask during day, CPAP overnight. Will
continue to wean vent time by 1 hour daily. Atrovent PRN.
GI: Pancreaticocolonic fistula. G-tube balloon 10ml
insufflation. + BM's. Follow panc/stool drainage. Panc drain
replaced [**10-3**]. Wound vac changed [**10-9**].
FEN: TPN daily, TF at 20cc/hr. Will continue to increase 10cc
daily. (as TF go up, will plan to decrease TPN).Follow daily
chemistry.
RENAL: Cr stable, no longer requiring HD, UOP
appropriate/stable.
HEME: Requires 8hrs blood bank notice for blood products. Hct
stable.
ENDO: Endo pancreas functioning 28U regular in TPN. Minimal
RISS.
ID: [**Last Name (un) **] until [**10-12**] (MDR pseudomonas lung colonization).
Wounds: Abdomen wound vac (changed q3d, last [**10-9**]). L flank
wound around panc tube, aquacell AG, change qday.
PPx: SCDs, H2B in TPN, Heparin in TPN.
Diet: nectar thick
diabetic clear liquids
Tube feed: replete with fiber @ 20ml/hr
TPN: 1650ml 320g dextrose/ 66g Amino Acid/ 50g lipid
Dietary Plan: Ht: 163 cm
Admit wt: 108.3kg
Wt ([**10-3**]): 82 kg*
138% IBW, BMI = 30.8*
Adjusted body wt: 65kg
Estimated nutrition needs (based on adjusted body wt):
1625-[**2054**] calories (25-30cal/kg) and 59-78g protein
(0.9-1.2g/kg)
Patient with long ICU stay. TPN started [**7-6**], on most of stay
for primary source of nutrition. Current TPN provides 1854
calories and 66g protein. 35 units of insulin in TPN, lytes
stable. Tube feed on/off during ICU stay. Currently tube feed
running via J tube to provide 720 calories and 45g protein. Also
with G tube to drainage. Seen by SLP [**10-9**], recommend Clear
nectar thick liquids with PMV.
Recommendations:
1. Fibersource HN or similiar product - with goal of 65ml/hr
= 1872 calories and 83g protein
2. Increase tube feed as able
3. Wean TPN once patient tolerating tube feed
4. Monitor lytes, adjust in TPN PRN
5. BS management
6. Monitor BUN/creatinine, change to lower protein formula if
labs increase
7. SLP follow-up for diet advancement
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] in clinic in two to three weeks.
Please call the office ([**Telephone/Fax (1) 6347**] to make an appointment.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
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16,786
| 122,244
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16927
|
Discharge summary
|
report
|
Admission Date: [**2121-10-20**] Discharge Date: [**2121-10-31**]
Date of Birth: [**2082-7-26**] Sex: F
Service: MEDICINE
Allergies:
Amoxicillin / Sulfa (Sulfonamides) / Bactrim / Iodine; Iodine
Containing
Attending:[**Last Name (NamePattern1) 4377**]
Chief Complaint:
hypotension, abdominal pain transfere from OSH
Major Surgical or Invasive Procedure:
midline venous catheter
History of Present Illness:
39 yo woman with h/o AML s/p related allo-PSCT [**2118**], chronic
GVHD, on prednisone, cellcept, h/o CAD s/p MI and stents, h/o R
brachiocephalic DVT who was in her USOH until about 1300 today
when she developed acute onset of mid abdominal pain after
eating a few bites of her meal. She described her abdominal pain
as sharp and crampy at the same time, non-radiating. Immediately
following the onset of abdominal pain, she became diaphoretic,
felt weak, and complained of tingling in bilateral lower
extremities. She then developed shortness of breath with
associated chest pain. Her husband [**Name (NI) 47658**] her down and called the
ambulance which brought her to the [**Hospital 8**] hospital. On
presentation to the OSH VS 97.0; HR 57; BP 60/palp; RR 24; O2
sat 86% on RA (96% on NRB). ABG 7.23/46/22. Labs notable for
Lactate of 11. BUN 17. Creat 0.8. Glucose was 558. AG 15. Urine
ketones and urine gucose negative. Right femoral central venous
catheter was placed. At the OSH, she received IVF,
Hydrocortisone 100 mg IV once, Ertapenem 1 gm IV, had a KUB, CT
chest and abdomen. She was also started on Insulin gtt. Bedside
echo EF 55%, limited study, but no effusion noted or flow
abnormalites detected. CT chest showed PE. Surgery was consulted
and recommended conservative management with serial exams. The
patient was started on heparin gtt with a bolus and transfered
to [**Hospital1 18**].
.
Upon arrival to [**Hospital1 18**] ED initial VS HR 87; BP 108/70; O2 SAT 99%
on 100 % NRB. Lactate down to 3.9. K low 2.5. Glucose 280. The
patient was given Morpine 2 gm IV, D51/2 NS c 40 mEq KCL. Blood
cultures were drawn. Insulin and heparin gtt were stopped (PTT
>150). General surgery was consulted given findings of GB wall
thickening on CT from the OSH. They did not feel that she had an
acute abdomen.
.
Currently, the patient c/o mid abdominal pain about [**5-21**],
non-radiating. She denies any chest pain, shortness of breath,
dizziness, lightheadedness, diaphoses, nausea or vomiting. She
had loose BM today after CT scan contrast at the OSH, but
otherwise denies diarrhea, melena, or hematochezia.
.
Past Medical History:
1. AML: diagnosed [**4-14**] s/p allo-HSCT in [**10-14**] (sister was donor)
Cytoxan/MTX/TBI
2. CAD s/p STEMI [**11-16**] with 2VD s/p DES in LAD, POBA D1 with BMS
to mid D1.
3. GVHD: skin, gut (now controlled), mouth,liver- left hand
digit amps x4, chronic immune suppression cellcept, entocort,
prednisone, rituxan (last [**2121-8-22**])
. Chronic left upper extremity brachiocephalic DVT
. ankle fracture in left ankle ~2.5 months ago.
. asthma
. eczema
. migraine headaches
. history of oral HSV
Social History:
lives with husband and two sons (12yo, 14yo) mother-in-law on
[**Location (un) 1773**]. no drink. smoking down to 2-3 cig per day. no
illicit
Family History:
no cad, mother died of cancer
Physical Exam:
Upon presentation to the ICU:
afebrile, 120 100/60 24 100% on NRB
Gen: pleasant woman, + Cushingoid, lying in bed, NAD, breathing
comfortably, speaking in full sentences
HEENT: PERRL, no scleral icterus, mm dry, no lesions
Neck: supple, no LAD, unable to assess JVD due to body habitus
CV: regualar, nl S1S2, no murmur/rub/gallop
Pulm: CTA bilaterally, ? pleural rub RLL
Abd: + BS, soft, diffusely tender to palpation (L >R), ND
Ext: bilateral 2+ LE edema, LE's warm, LEU with digits
amputated.
Neuro: alert and oriented x3, appropriate, moving all 4
extremities
Skin: changes c/w GVH, hyperpigmentation of face,
thick/tightened arm skin
Rectal (per surgery note): trace guaiac +
Pertinent Results:
[**2121-10-19**] 09:00PM URINE RBC-[**12-1**]* WBC-0-2 BACTERIA-RARE
YEAST-NONE EPI-0-2
[**2121-10-19**] 09:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2121-10-19**] 09:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.041*
[**2121-10-19**] 09:00PM PT-15.8* PTT-150* INR(PT)-1.4*
[**2121-10-19**] 09:00PM PLT COUNT-316
[**2121-10-19**] 09:00PM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-2+
MACROCYT-2+ MICROCYT-2+ POLYCHROM-1+ SPHEROCYT-1+
SCHISTOCY-OCCASIONAL BURR-2+ STIPPLED-2+ TEARDROP-2+
PAPPENHEI-2+ ACANTHOCY-1+
[**2121-10-19**] 09:00PM NEUTS-85* BANDS-1 LYMPHS-4* MONOS-8 EOS-0
BASOS-0 ATYPS-1* METAS-0 MYELOS-0 YOUNG-1*
[**2121-10-19**] 09:00PM WBC-11.2* RBC-3.20* HGB-10.8* HCT-31.7*
MCV-99* MCH-33.8* MCHC-34.1 RDW-16.8*
[**2121-10-19**] 09:00PM CALCIUM-7.7* PHOSPHATE-3.7 MAGNESIUM-2.2
[**2121-10-19**] 09:00PM CK-MB-4
[**2121-10-19**] 09:00PM cTropnT-<0.01
[**2121-10-19**] 09:00PM GLUCOSE-280* UREA N-19 CREAT-0.5 SODIUM-135
POTASSIUM-2.5* CHLORIDE-94* TOTAL CO2-27 ANION GAP-17
[**2121-10-19**] 09:34PM LACTATE-3.9*
[**2121-10-20**] 12:22AM PT-14.9* PTT-150* INR(PT)-1.3*
[**2121-10-20**] 12:23AM LACTATE-2.0 K+-3.5
[**2121-10-20**] 12:23AM COMMENTS-GREEN TOP
[**2121-10-20**] 04:28AM PT-13.6* PTT-53.6* INR(PT)-1.2*
[**2121-10-20**] 04:28AM PLT COUNT-303
[**2121-10-20**] 04:28AM WBC-10.6 RBC-2.89* HGB-9.4* HCT-28.6* MCV-99*
MCH-32.6* MCHC-32.9 RDW-16.7*
[**2121-10-20**] 04:28AM CALCIUM-7.9* PHOSPHATE-3.0 MAGNESIUM-2.2
[**2121-10-20**] 04:28AM CK-MB-3 cTropnT-<0.01 proBNP-2673*
[**2121-10-20**] 11:36PM PT-14.2* PTT-150* INR(PT)-1.3*
[**2121-10-20**] 04:29PM PTT-150.0*
[**2121-10-20**] 02:23PM CK(CPK)-21*
[**2121-10-20**] 02:23PM CK-MB-3 cTropnT-<0.01
[**2121-10-20**] 02:17PM PTT-150*
[**2121-10-20**] 04:28AM GLUCOSE-246* UREA N-13 CREAT-0.3* SODIUM-135
POTASSIUM-3.5 CHLORIDE-99 TOTAL CO2-29 ANION GAP-11
Brief Hospital Course:
In brief the patient is a 39 year old woman with AML s/p related
allo-PSCT, chronic GVHD, CAD s/p MI, DM who is admitted to ICU
for close monitoring given bilateral PEs and hypotension on
presentation.
.
# PE. The patient with bilateral PEs and R common femoral
thrombus documented on the OSH CTA. Trop <0.01. Currently HD
stable.
- She was initially put on supplemental oxygen and started on a
continuous IV heparin infusion for anticoagulation. Per her
primary oncologist, her clopidogrel was stopped since she was
>11 months out from stenting given the bleeding risk with
additional anticoagulation. Upon transfer out of the [**Hospital Unit Name 153**], her
heparin was transitioned to enoxaparin 1mg/kg [**Hospital1 **] for long-term
anticoagulation. Her supplemental oxygen was very slowly weaned
off. She was seen by physical therapy who initially recommended
rehab; the patient adamantly and consistently refused rehab
placement. The patient's strength gradually improved to the
point where she was cleared by PT for discharge home with
continued home PT. Upon discharge, she wsa completely off of
supplemental oxygen and able to ambulate with a walker.
.
# Hypotension/tachycardia.
- Her CCB and beta blocker were initially held while in the [**Hospital Unit Name 153**]
due to hypotension. Upon transfer out, her BP was stable and
she was resumed on her home dose of beta blocker for rate
control of her chronic sinus tachycardia. She was kept on
telemetry on the floor for several days until her sinus
tachycardia was adequately controlled.
.
# CAD: hx of STEMI s/p PCI with stents. EKG with ST depressions.
- She was continued on her beta blocker as above. She was
continued on aspirin and her statin. Her clopidogrel was held
as above since she was 11 months out from stenting and since her
new enoxaparin therapy would be further increasing her risk of
bleeding.
.
# DM2
- Her Lantus dose was increased to 40u QAM (from a home dose of
20u) upon admission to the ICU. The was continued while on the
floor due to her elevated steroid dose. As her steroids were
tapered back to her home dose, her Lantus was gradually tapered.
She was discharged on 25u QAM.
.
# Chronic GVHD.
- Due to her chronic prednisone therapy, she was put on
stress-dose steroids at the outside hospital. This was switched
to prednisone upon admission to the floor and gradually tapered
back to her home regimen of 5mg daily. She was continued on
chronic CellCept and Entocort per her home regimen.
.
# PPX. Continued on atovaquone, acyclovir, and fluconazole.
.
# Access.
- Had a PICC placed in the [**Hospital Unit Name 153**] (due to poor peripheral access)
which was taken out prior to discharge.
- A R femoral line placed at the outside hospital was d/c'ed
while in the [**Hospital Unit Name 153**]
.
# Communication: HCP husband [**Name (NI) 3065**] [**Name (NI) 37032**] [**0-0-**]
.
# Code: FULL
Medications on Admission:
1. Prednisone 20 mg po qd
2. Mycophenolate Mofetil 500 mg po qid
3. Acyclovir 400 mg po q 8hrs
4. Fluconazole 200 mg po bid
5. Lipitor 80 mg po qd
6. Folic Acid 1 mg po qd
7. Nexium 40 mg po qd
8. Clopidogrel 75 mg po qd
9. Aspirin 325 mg po qd
10. Atovaquone 750 mg/5 mL po bid
11. Lasix 20 mg po bid
12. Verapamil 180 mg Tablet po bid
13. Metoprolol Tartrate 100 mg po bid
14. Budesonide 3 mg po tid
15. Insulin Glargine 36 units qam
16. Humalog per sliding scale.
17. Nexium 40 mg po qd
18. MagOx 400 mg po bid
19. Potassium Chloride 20 mEq po qd
.
Allergy: Amoxicillin, Sulfa, Bactrim, Iodine
Discharge Medications:
1. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8
hours).
Disp:*180 Capsule(s)* Refills:*2*
2. Budesonide 3 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO tid ().
Disp:*90 Capsule, Sust. Release 24HR(s)* Refills:*2*
3. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q 12H (Every
12 Hours).
Disp:*60 Tablet(s)* Refills:*2*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
Disp:*90 Tablet, Chewable(s)* Refills:*2*
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
8. Atovaquone 750 mg/5 mL Suspension Sig: Five (5) mL PO BID (2
times a day).
Disp:*300 mL* Refills:*2*
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*0*
11. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) pre-filled
syringe Subcutaneous Q12H (every 12 hours).
Disp:*60 pre-filled syringe* Refills:*2*
12. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
13. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day): Do not take if your systolic blood pressure is
less than 100, or your heart rate is less than 60 per minute.
Disp:*120 Tablet(s)* Refills:*2*
14. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
15. Prednisone 5 mg Tablet Sig: 1-2 Tablets PO once a day:
Please take 2 tablets (10mg) per day for the next two days;
after that, resume taking 1 tablet per day.
Disp:*33 Tablet(s)* Refills:*2*
16. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release(s)* Refills:*2*
17. Lantus 100 unit/mL Solution Sig: Twenty Five (25) units
Subcutaneous qam.
Disp:*qs units* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Primary diagnosis: bilateral pulmonary emboli
Secondary diagnoses: history of AML status-post bone marrow
transplant; chronic cutaneous and GI GVHD; coronary artery
disease; type 2 diabetes mellitus
Discharge Condition:
stable
Discharge Instructions:
You were admitted to the hospital with blood clots in both of
your lungs. For this, you were placed on Lovenox injections
twice daily; you need to continue these for at least 6 months to
help prevent new clots. Because you were put on Lovenox, and
because your coronary stent was more than 9 months ago, we have
stopped your [**Location (un) **].
While you were sick in the hospital, your prednisone dose was
increased; this is being tapered down back to your chronic dose
of 5mg daily. Please take 10mg for the next two days and then
resume taking 5mg daily.
Your Lantus dose was increased while you were in the hospital
and has been controlling your blood sugars well. We are
discharging you on 25 units every morning.
Over the past few days, your blood pressure has been
normal/borderline low. Because of this, you have not received
your blood pressure medication (metoprolol) for the past couple
of days. Please do not take this again until your blood
pressure can be checked by one of your outpatient physicians or
nurses.
If you experience shortness of breath, chest pain, high fevers,
or other concerning symptoms, you need to seek medical
attention. Please take all medications as prescribed and please
attend all follow-up appointments.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 6175**], MD Phone:[**Telephone/Fax (1) 3237**]
Date/Time:[**2121-11-6**] 12:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11755**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3237**]
Date/Time:[**2121-11-6**] 12:30
|
[
"250.00",
"996.85",
"427.89",
"V45.82",
"205.01",
"905.4",
"453.8",
"458.9",
"285.29",
"412",
"415.19"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11949, 12024
|
6008, 8914
|
390, 415
|
12268, 12277
|
4020, 5985
|
13582, 13909
|
3270, 3301
|
9563, 11926
|
12045, 12045
|
8941, 9540
|
12301, 13559
|
3316, 4001
|
12113, 12247
|
304, 352
|
443, 2570
|
12064, 12092
|
2592, 3094
|
3110, 3254
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,184
| 192,999
|
2400
|
Discharge summary
|
report
|
Admission Date: [**2143-2-22**] Discharge Date: [**2143-2-26**]
Service: MEDICINE
Allergies:
Lisinopril / Atenolol / Hydrochlorothiazide / Nsaids /
Nifedipine Er
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Syncope
.
Major Surgical or Invasive Procedure:
Pacemaker placement
EEG
History of Present Illness:
Patient is an 89 y/o F w/ PMH of hypothyroidism, RLS who
presents with 2 episodes of syncope in the last 24 hrs.
Yesterday at ~5 pm the patient's son witnessed an episode while
pt was sitting having cofee. Per the son, the patient suddenly
appeared glassy-eyed, stared, then her eyes rolled back to the
left and she dropeed her coffee from her right hand. She quickly
became alert after he slapped her face and then she was back to
baseline. There was no witnessed seizure activity, no
incontinence, no acute focal neuro sx, and no headache. The
patient reports that at 2 am she got up to go to the bathroom
and suddenly found herself on floor. She hit the back of her
head but otherwise felt normal afterwards. She dressed herself
and called her son. She denies any history of syncope, however
she reports that over the last year she has felt intermittantly
"unsteady" on her feet, however she denies recent falls,
vertigo, pre-syncope, palpitations or lightheadedness. On
arrival to the floor the patient was being interviewed and
stated "it's happening again" and was noted by the housestaff to
become unresponsive for a brief moment. Telemetry revealed
bradycardia with HR in 20s for a few seconds. She was then
transferred to CCU for closer monitoring. The patient currently
feels tired but otherwise feels well.
.
Per PCP, [**Name10 (NameIs) **] had previous [**Hospital1 18**] admission w/ neuro eval neg for
seizure, CVA. However, has never had Holter monitor or
echocardiogram. Has been on increasing Mirapex x years for RLS,
recently added magnesium. Rarely has taken an extra mirapex, not
recently.
.
In the ED, initial vitals: 96, 163/80, 72, 16, 98% on RA. She
was asymptomatic at that point. CT head and CXR w/o acute
change.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations.
Past Medical History:
1. CARDIAC RISK FACTORS:: (-) Diabetes, (+) Dyslipidemia,
(+)Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: None
-PACING/ICD: None
.
OTHER PAST MEDICAL HISTORY:
-Seen by Dr. [**Last Name (STitle) **] intermittently since [**2133**] for restless legs
syndrome. On Mirapex. On last recorded visit in [**2141-6-23**],
reportedly had "dizziness" thought to be secondary to
orthostatic
hypotension.
-Hypertension
-Dyslipidemia
-Hypothyroidism
-Spinal stenosis s/p surgical repair ~10 years ago
-Polymyalgia rheumatica (in remission)
-Osteoporosis
-Degenerative joint disease
-Left cataract extraction
-ERCP w/ sphincterotomy ([**2139**])
.
PSurgH:
-Hernia repair [**2142-8-2**]
-s/p surgical repair for spinal stenosis ~10 years ago
-Laparascopic cholecystectomy ([**2139**])
-Carpal tunnel repair
Social History:
Has never smoked, occasional alcohol (at most 1 glass of
wine/week), denies IVDU, other drugs. Lives by herself in [**Location (un) 3146**]
near her son and his wife and kids.
Family History:
Mother- question of cancer, Living [**Name (NI) 12408**] DM, brother and
sister- died of "cardiac problems"
Physical Exam:
Vitals: T: 98.4 P: 71 BP: 133/64 RR: 13 SaO2: 96% RA
General: Elderly woman, appears younger than stated age, awake,
alert, NAD.
HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus
noted, MMM, no lesions noted in OP
Neck: supple, no JVD or carotid bruits appreciated
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses
b/l.
Lymphatics: No cervical, supraclavicular, axillary or inguinal
lymphadenopathy noted.
Skin: no rashes or lesions noted.
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
without difficulty.
-cranial nerves: II-XII intact
-motor: normal bulk, strength and tone throughout. No abnormal
movements noted.
-sensory: No deficits to light touch throughout.
-cerebellar: No nystagmus, dysarthria, intention or action
tremor
-DTRs: 2+ biceps, triceps, brachioradialis, patellar and 1+
ankle jerks bilaterally. Plantar response was flexor
bilaterally.
Pertinent Results:
LABS ON ADMISSION:
.
[**2143-2-22**] 01:00PM BLOOD WBC-7.0 RBC-3.91* Hgb-13.4 Hct-35.3*
MCV-90 MCH-34.2* MCHC-37.8*# RDW-13.5 Plt Ct-264
[**2143-2-22**] 01:00PM BLOOD Neuts-79.8* Lymphs-16.1* Monos-3.5
Eos-0.5 Baso-0.2
[**2143-2-23**] 02:30AM BLOOD PT-13.9* PTT-31.8 INR(PT)-1.2*
[**2143-2-22**] 02:10PM BLOOD Glucose-109* UreaN-13 Creat-0.8 Na-133
K-5.4* Cl-97 HCO3-32 AnGap-9
[**2143-2-22**] 02:10PM BLOOD Calcium-10.2 Phos-3.6 Mg-2.3
.
OTHERS:
[**2143-2-22**] 02:10PM BLOOD TSH-1.5
[**2143-2-22**] 01:00PM BLOOD cTropnT-<0.01
[**2143-2-23**] 02:30AM BLOOD CK-MB-6 cTropnT-<0.01
[**2143-2-23**] 02:30AM BLOOD CK(CPK)-250*
.
.
RADIOLOGY:
CT Head ([**2-22**]): IMPRESSION: No acute intracranial process. No
fractures.
.
Chest x-ray [**2143-2-26**] - Satisfactory position of the pacemaker and
its leads. Hyperinflation. Prior granulomatous exposure.
Extensive coronary artery calcifications.
.
EEG [**2143-2-25**]- IMPRESSION: This telemetry showed a normal
background in wakefulness and in sleep there were no clearly
epiltiform discharges. Some sharp paroxysmal activity in the
left central region appeared best correlated with the patient
moving by video, thus most likely representing movement artifact
with motion of left central and parietal EEG leads against the
pillow. Several different types of movement were associated with
these EEG changes, they did not show definite spike and slow
wave discharges.
Brief Hospital Course:
Ms [**Known lastname 12409**] is an 89 F w/ PMHx of hypothyroid, prior syncopal
episodes of unknown etiology presents w/ syncope and high degree
AV block, now s/p temporary pacer placement.
.
#) Syncope: Initially concern for cardiac arrythmia vs.
neurologic. Patient's telemetry demonstrates increased vagal
tone during asystolic episode where P-P intervals also increased
during the high degree block. This may suggest seizures with
increased vagal outflow as an etiology, which fits clinically
with the episodes of ??????blank stares?????? that patient??????s son
describes. With bradycardia and AV block, initially patient had
temporary pacemaker placed which was then replaced by permanent
pacemaker. There were no additional events on telemetry.
Neurology was consulted. Patient had EEG placed which was read
as normal. Neurology impression was that episode of syncope was
all completely replated to cardiac arrythmia and apparently
patient has had previous EEG which was also normal. Patient to
follow up with cardiology and neurology on discharge.
.
# CORONARIES: No history of coronary disease. Denies any
history of chest pain. ECG without ischemic changes and no
change from prior. Troponins negative x2 and they were taken 12
hours apart. Patient has previously had lipids checked in [**2-/2142**]
which demonstrated LDL < 100 and currently no indication for
antilipid [**Doctor Last Name 360**].
.
# PUMP: Patient appears euvolemic on exam. No h/o CHF and no
prior TTE. On admission patient got echo which demonstrated
mild-moderate mitral regurgitation. Mild pulmonary artery
systolic hypertension. Increased PCWP. Normal biventricular
cavity sizes with preserved global and regional biventricular
systolic function. No structural cardiac cause of syncope
identified.
.
# RHYTHM: Patient has history AV delay and now with documented
high degree AV block on tele and multiple syncopal events.
Patient initially got temporary pacemaker and now is now s/p
permanent pacemaker placement. Patient was not previously on
any nodal agents. After temporary pacer placed, no addition
events on telemetry.
.
# Hyponatremia - patient with Na of 130 this morning which
improved prior to discharge to 134 with 500 cc normal saline
bolus so likely hypovolemic hyponatremia. Ordered urine lytes,
serum osms which were not drawn prior to discharge.
.
#) Hypothyroidism: Last TSH in [**10-31**] normal. TSH on admission
was 1.5. Patient was continued levothyroxine at outpatient dose.
.
#) Hypertension: Patient denies, however listed in problem list.
Was on atenolol and ACE in past, not currently on
antihypertensives. Of note, patient was noted to be hypertensive
during pacemaker procedure to the 200s requiring hydral however
subsequently was normotensive. Did not discharge patient on any
additional medications. Would monitor clinically as outpatient
and consider addition of low dose ACEi if patient requires
anti-htn [**Doctor Last Name 360**] in the future
.
#) RLS: continue outpatient mirapex
.
#) Osteoporosis: continue fosamax, calcium, vitamin d
.
#) Prophylaxis: taking PO, sc heparin, bowel regimen
.
#) FEN: p.o. diet as tolerated, replete lytes prn
.
#) Code: full
Medications on Admission:
FOSAMAX PLUS D- 70 mg-2,800 unit Tablet weekly
LEVOTHYROXINE [LEVOXYL] - 75 mcg Tablet - 1 Tablet(s) by mouth
every day except Wednesdays
PRAMIPEXOLE [MIRAPEX] - 1 mg Tablet qhs.
CALCIUM 600 + D(3) 600mg-400 unit Tablet daily
VITAMIN B-12 2,000 mcg Tablet daily
FIBER 625 mg Tablet - 1 Tablet(s) by mouth once a day
MAGNESIUM - (OTC) - 250 mg Tablet qhs - 1 Tablet(s) by mouth at
bedtime for restless legs
MULTIVITAMIN WITH IRON-MINERAL - (OTC) - Dosage uncertain
Discharge Medications:
1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Pramipexole 1 mg Tablet Sig: One (1) Tablet PO qhs ().
3. Calcium 600 + D(3) 600-400 mg-unit Tablet Sig: One (1) Tablet
PO once a day.
4. Cyanocobalamin 500 mcg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
5. Fiber Tablet Sig: One (1) Tablet PO once a day.
6. Magnesium Oxide 250 mg Tablet Sig: One (1) Tablet PO at
bedtime.
7. Multivitamin with Iron-Mineral Oral
8. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 3 days.
Disp:*12 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary: syncope, first degree AV block s/p pacemaker placement
.
Secondary:
Hypertension
Dyslipidemia
Hypothyroidism
Spinal stenosis s/p surgical repair ~10 years ago
Polymyalgia rheumatica (in remission)
Osteoporosis
Degenerative joint disease
Left cataract extraction
ERCP w/ sphincterotomy ([**2139**])
Discharge Condition:
afebrile, vital signs stable
Discharge Instructions:
You were admitted to the hospital with syncope and found to have
complete AV block. You underwent pace maker placement. In
addition, you were evaluated by neurology and underwent a EEG.
.
There were no changes made to your medications while you were in
the hospital.
.
We have made you follow up appointments with cardiology for
device clinic as well as routine follow-up in addition to
neurology follow-up. It is very important you continue to follow
up with us here at the [**Hospital1 **].
.
You should return to the Ed if you experience any worsening
shortness of breath, chest pain, or abdominal discomfort. It has
been a pleasure taking of you at [**Hospital1 **].
Followup Instructions:
You need to follow up with device clinic in 1 week. In addition,
you need to follow up with EP in 3 months which we have also
made for you below. You device clinic appointment is for Tuesday
[**3-5**] at 11:30 am [**Hospital Ward Name 23**] 7. We have made you an appointment
for Tuesday [**5-28**] -1 pm with Dr. [**Last Name (STitle) **].
.
IN addition, you have an appointment with your primary care
provider already scheduled below. Provider: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) 2352**]
[**Last Name (NamePattern1) 2352**] - ADULT MEDICINE (SB) Phone:[**Telephone/Fax (1) 1144**]
Date/Time:[**2143-5-22**] 3:00
.
You should follow up with neurology as an outpatient. You
missed your appointment with Dr. [**Last Name (STitle) **] while you were in the
hospital. We have made you a new appointment with neurology.
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43**], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 541**]
Date/Time:[**2143-4-18**] 1:00. Please call if you are unable to make
any of these appointments.
Completed by:[**2143-2-26**]
|
[
"272.0",
"276.1",
"780.2",
"733.00",
"426.0",
"E888.9",
"725",
"333.94",
"401.9",
"427.89",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.78",
"37.72",
"37.83"
] |
icd9pcs
|
[
[
[]
]
] |
10601, 10658
|
6303, 9500
|
286, 312
|
11008, 11038
|
4865, 4870
|
11758, 12869
|
3655, 3765
|
10016, 10578
|
10679, 10987
|
9526, 9993
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11062, 11735
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4509, 4846
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3780, 4413
|
2707, 2788
|
236, 248
|
340, 2591
|
4884, 6280
|
4428, 4492
|
2810, 3445
|
3461, 3639
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,789
| 120,636
|
49085
|
Discharge summary
|
report
|
Admission Date: [**2123-12-4**] Discharge Date: [**2123-12-26**]
Service: [**Doctor First Name 147**]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
86M presenting to the ED with history of CAD, DMII, PVD,
presents with sudden onset left chest & abdominal pain.
Major Surgical or Invasive Procedure:
Swan Ganz catheter placement
bronchoscopy
History of Present Illness:
The patient had been in usual state of health, the evening prior
to admission. Following dinner, he developed a severe stabbing
pain. The pain is described as intense and throbbing, not made
worse by any position or activity. The patient denies any prior
similair episodes, or prescipitating foods. Denies any sick
contacts. Denies any fever or chills, nausea/vomiting, or
diarrhea.
Past Medical History:
1. CAD
2. HTN
3. PVD s/p fem-[**Doctor Last Name **] by-pass
4. Depression
5. DM Type II
6. S/p R. nephrectomy for RCC in [**2114**]
7. Diabetic nephropathy
8. BPH s/p TURP
9. Spinal stenosis
10. Cataract surgery
Social History:
Retired postal worker. Six children. [**Doctor Last Name **] alone. 90 PPY
smoking history, quit smoking 25 years ago.
Family History:
non contributory
Physical Exam:
99.5 50 185/60 22 95%RA
Caucasian male, A&Ox3, in no acute distress
Patient is clearly dysarthric, with considerblae difficulty
speaking. Comprehension and language skills remain intact.
Repeat and [**Location (un) 1131**] skills are intact. There is no evidence of
any neglect syndromes.
PERRL (surgical pupils noted), CN II-XII intact, scalarae
non-icteric.
HEENT is N/AT, no evidence of JVD or tracheal shifts
Lungs are clear to ausculation bilaterally.
Cardiac examination shows RRR no evidence of M/R/G
Abdomen shows no incisions. It is soft, diffusely tender. No
peritoneal signs, no [**Doctor Last Name 515**] sign, no localization of pain, no
organomegaly on deep palpation. There are normal bowel sounds.
Lower extremities are warm, well perfused without any evidence
of edema.
Neuro examination is consistent with a pontine stroke. There is
noticeable R. hemi-paresis, with R>L grip strength assymetry.
Rectal examination is guiac negative.
Pertinent Results:
[**2123-12-4**] 02:05AM BLOOD WBC-10.2 RBC-4.31* Hgb-12.9*# Hct-38.6*
MCV-90# MCH-29.8# MCHC-33.3 RDW-13.5 Plt Ct-223
[**2123-12-5**] 10:15PM BLOOD Neuts-80.0* Bands-0 Lymphs-10.7*
Monos-4.0 Eos-5.1* Baso-0.3
[**2123-12-8**] 07:20AM BLOOD Plt Ct-203
[**2123-12-8**] 07:20AM BLOOD Glucose-108* UreaN-31* Creat-1.6* Na-136
K-4.1 Cl-104 HCO3-24 AnGap-12
[**2123-12-8**] 07:20AM BLOOD ALT-104* AST-47* AlkPhos-526*
Amylase-107* TotBili-1.2
[**2123-12-4**] 10:00AM BLOOD CK-MB-2 cTropnT-0.01
[**2123-12-4**] 02:05AM BLOOD Calcium-9.2 Phos-3.3 Mg-2.1
[**2123-12-6**] 10:00AM BLOOD %HbA1c-10.2*
[**2123-12-6**] 09:20AM BLOOD Triglyc-179* HDL-13 CHOL/HD-8.6
LDLcalc-63
[**2123-12-11**] 04:20PM BLOOD WBC-19.4* RBC-2.80* Hgb-8.2* Hct-25.8*
MCV-92 MCH-29.2 MCHC-31.7 RDW-14.6 Plt Ct-223
[**2123-12-12**] 04:12AM BLOOD WBC-21.1* RBC-3.27* Hgb-9.7* Hct-29.7*
MCV-91 MCH-29.9 MCHC-32.8 RDW-14.5 Plt Ct-247
[**2123-12-13**] 03:30AM BLOOD WBC-21.6* RBC-3.12* Hgb-9.4* Hct-28.8*
MCV-92 MCH-30.1 MCHC-32.6 RDW-14.6 Plt Ct-232
[**2123-12-18**] 03:13AM BLOOD WBC-16.6* RBC-3.04* Hgb-8.7* Hct-27.2*
MCV-90 MCH-28.5 MCHC-31.9 RDW-16.1* Plt Ct-156
[**2123-12-22**] 02:55AM BLOOD WBC-13.6* RBC-3.51* Hgb-10.4* Hct-31.4*
MCV-89 MCH-29.6 MCHC-33.1 RDW-16.4* Plt Ct-236
[**2123-12-25**] 01:52AM BLOOD WBC-13.1* RBC-3.44* Hgb-10.1* Hct-30.9*
MCV-90 MCH-29.2 MCHC-32.5 RDW-16.9* Plt Ct-282
Brief Hospital Course:
While in the ED, patient underwent R. UQ U/S. This showed a
moderately inflamed GB, with a suspicious appearing 3.5cm mass
within the fundus of the GB. It was equivocal whether this was
a solid mass or a collection of sloughed material. While being
worked up for this, the patient's BP increased to a SBP >190.
He was given a single dose of IV labteolol and his pressure
dramatically dropped to <80s. While in the ED, patient also
spiked a temperature to 101.6. Blood, urine, and sputum
cultures were sent. Patient was started empirically on levo,
flagyl, and ampicillin, later changed to just unasyn.
Shortly after arriving on the floor, it was noted that the
patient was slurring his speech. By his descripton, he "knew
what he wanted to say, but couldn't say it". A CT scan was done
which showed no evidence of acute infarct or bleeding. MR of
the brain demonstrated diffusion signal abnormality in the left
superior ventral pons, consistent with acute infarction.
Limited MR of the carotids showed no evidence of flow
abnormalities. Following neurology consultation, patient
underwent a TTE to r/o possible embolic sources, but this was
normal. Per neurology recommendations, the patient's SBP was
carefully maintained between 140 & 160, but no other
interventions were recommended at that time.
Attention then turned to the patients abdominal pain and fevers.
Blood cultures ultimately came back [**3-15**] positive for GNR, these
later speciated to bacteroides. Subsequent surveillance
cultures have all been negative in consultation with ID, it was
felt that the patient needed to receive a full 2 weeks of IV
antibiotics. Therefore a PICC line was placed, and arrangements
were made for IV antibiotics at
rehab. On the night of HD 7, patient had his first repeat
fever. Although U/A was negative, chest X-ray showed evidence
of R. lower lobe pneumonia.
On HD 2, patient underwent an MRCP. This confirmed that there
was no evidence of any extension of mass into the liver bed, but
could not definitively demonstrate whether the area in question
is a collection of sloughed tissue within the gall bladder, or
is a solid tumor mass. The following day, the patient underwent
ERCP. While sludge was seen coming out of the major papilla,
there were no obstructions noted, nor were any filling defects
seen within the gall bladder. The duct was stented, but no
further action was taken.
Irrespective, it was felt that the next step in the patient's
management would be cholecystectomy. This would provide
definitive diagnosis for the questionable gall bladder mass,
while providing symptomatic relief for possible acalculus
cholecystitis. In discussion with the neurology team, it was
felt that the surgery would be best delayed 3-4 weeks such that
the patient could be started on ASA and plavix and given enough
time to recover.
On [**12-10**], th pt acutely decompensated, thought to be due to
aspiration event. The pt went into respiratory failure
requiring intubation. The pt was transferred to the ICU where
he required volume resusitation and pressor support. An
arterial line swan ganz catheter was placed. The rest of his
hospital course was remarkable for the following.
Neuro: Neurology team followed the pt throughout his hospital
stay. He remain weaker on the R with slight improvement. The
pt's plavix/aspirain were held per recommendations of Neurology.
CVS: The pt went into atrial fibrillation on [**11-30**] and converted
to SR with B-Blockers and amiodarone. The pt was switched from
an amio ggt to PO after 3 days. The pt occasionally had brief
runs of AFib but remained in SR for the most part.
Pulm: The pt remained on AC ventilatory support throughout his
hospital stay and did not tolerate any attempts to wean. He
required more PEEP toward the end of his stay and serial CXR
showed minimal improvement of his B lower lobe infiltrates.
GI: the pt was started on trophic TF's and tolerated it well
with low residuals. He was also on H2 blockers for GI
prophylaxis.
Renal: The pt's renal function steadily deteriorated with a
rising Cr/BUN. The pt continued to make adequate urine despite
his renal failure. The pt was severely volume overloaded with
exam remarkable for 3+ edema and weights that steadily
increased. Reanl was consulted. It was decided between the
primary team, SICU team and family that CVVH was not going to be
an option given his poor prognosis. The pt's TF's were switched
to nepro and volume given was limited. The pt also had
hypernatremia which was corrected with free water boluses in IV
form and through his feeding tube.
Heme: SC heparin TID was administered. It was thought that the
pt's RUE appeared more edematous than the Left. An US was
obtained on [**12-20**] which showed no DVT.
ID:
Derm: the pt's B UE were remarkable for a diffusely erythematous
rash. Dermatology was consulted and thought it may have been a
drug rash from previous antibiotics. They recommended various
topical agents which were admistered per their recommendations
which minimal improvement.
Endo: the remained on an insulin ggt throughout his ICU stay
with varying requirements.
ID: The pt was septic with spiking temperatures, positive blood
cultures, and hemodynamic evidence of sepsis throughout most of
his ICU stay. He was placed on broad spectrum antibiotics,
antifungals, and pressors. The infectious disease team followed
his care and made recommendations on antibiotic coverage.
Notably, Bl Cx from [**2123-12-10**] were pos for Cornebacteria and Bl
cx from [**12-4**] for Bacteriodes fragiles. Other pertinent cx
included sputum cx positive for yeast [**12-10**]. Serial CXR's
revealed Bilateral pleural effusions/infiltrates which showed
little improvement throughout his stay.
Multiple family meetings were coordinated and on [**2123-12-26**], the
attending surgery, the SICU attending and family decided to make
the ptaient comfort measures only.
Medications on Admission:
1. Toprol XL
2. Plavix
3. Insulin 75/25 AM &PM
4. ASA
5. Lasix
6. Neurontin
7. Isosorbide
8. Celexa
9. Zocor
Discharge Medications:
NA
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
overwhelming sepsis
pneumonia
atrial fibrillation
Possible acalculous cholecystitis
Possible gall bladder mass
Pontine stroke
Refractory hypertension
Brittle diabetes
Discharge Condition:
deceased
Discharge Instructions:
NA
Followup Instructions:
NA
Completed by:[**2124-1-3**]
|
[
"995.92",
"434.91",
"576.2",
"724.00",
"576.1",
"575.0",
"584.5",
"038.3",
"575.8",
"250.50",
"276.0",
"693.0",
"E930.9",
"427.31",
"401.9",
"507.0",
"362.01",
"250.40",
"440.20",
"518.81",
"V10.52",
"V45.82",
"583.81",
"600.00",
"V45.73",
"785.52",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"88.72",
"89.64",
"00.17",
"96.72",
"51.87",
"96.6",
"38.93",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
9793, 9878
|
3652, 9598
|
394, 438
|
10088, 10098
|
2266, 3629
|
10149, 10181
|
1256, 1274
|
9766, 9770
|
9899, 10067
|
9624, 9743
|
10122, 10126
|
1289, 2247
|
242, 356
|
466, 855
|
877, 1100
|
1116, 1240
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,558
| 164,149
|
22404
|
Discharge summary
|
report
|
Admission Date: [**2123-5-19**] Discharge Date: [**2123-5-26**]
Date of Birth: [**2045-4-29**] Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 38982**]
Chief Complaint:
marked visual loss
Major Surgical or Invasive Procedure:
Left frontal craniotomy, resection of meningioma.
Stereotactic volumetric computer-assisted procedure.
Microscope microdissection.
History of Present Illness:
78 year old female who has h/o HTN, DM, multiple sugeries for
cataracts and retinal disease and progressive vision loss.She
evaluated by ENT for decrease hearing on [**6-19**], which ENT
requested a [**Month/Year (2) 4338**]. [**Month/Year (2) 4338**] revealed 4 cm homogeneuosly changing mass
in left anterior cranila fossa with mass effect on the frontal
lobe and some effect on optic chiazm. Pateint seen by Dr` [**Doctor Last Name **] in
[**7-19**], and family decided to follow up with serial scans.In
[**2123-5-17**] patient came for follow up with Dr [**First Name (STitle) **] and decided to
persue with surgery. Pateint has complicated cardiac history had
an anterior STEMI on [**2122-12-31**] with drug-eluting stent to LAD
then disharged prescried plavix for stent . Echo showed left
ventricular aneurysm therefore patient placed on a
coumadin.Cardilogy(Dr [**Last Name (STitle) **] following her closely. patient
surgery was scheduled [**2123-5-19**].
Past Medical History:
HTN
Hyperlipidemia
DM - 18 years
Meningioma
Social History:
Pt lives in an [**Hospital3 **] facility with her husband. She
was a waitress now retired. She smoked a [**1-17**] pack/day for 20
years. She quit smoking 20 years ago. She presently does not
drink alcohol.
Family History:
non-contributory
Physical Exam:
VS:Blood pressure 122/56, pulse 60, temperature 97.8,
respiration 16.
GEN: alert, pleasant elderly woman, NAD, mildly overweigt.
CVS: RRR, S1 S2, no M/G/R.
CHEST: slight wheezing, cleared after cough.
ADB: soft, nontender, bowel sounds present.
EXT: no clubbing, cyanosis or edema.
[**Last Name (un) **]:normocephalic, PERRLA, EOMI, tongue midline, no drift, CN
II-XII, grossly intact.
Motor;
D B T GRIP IP Q H GASTR AT [**Last Name (un) 938**]
Left 5 5 5 5 5 5 5 5 5 5
right 5 5 5 5 5 5 5 5 5 5
sensation intact to light touch T/O.
DTR: 2+ upper extremities and patella, absent on achilles.
Pertinent Results:
[**2123-5-19**] 03:52PM GLUCOSE-205* UREA N-19 CREAT-0.6 SODIUM-141
POTASSIUM-4.0 CHLORIDE-109* TOTAL CO2-21* ANION GAP-15
[**2123-5-19**] 03:52PM CK(CPK)-87
[**2123-5-19**] 03:52PM CALCIUM-8.7 PHOSPHATE-2.0* MAGNESIUM-1.3*
[**2123-5-19**] 03:52PM PHENYTOIN-10.3
Brief Hospital Course:
78 year-old female underwent left frontal craniotomy and
resection of meningioma on [**2123-5-19**]. Patient followed by
cardiology for extensive cardiac history and recent MI [**12-19**]
with stent/left ventricular aneurysm. patient Troponin was
slightly up;0.28, with no ECG changes, R/O for MI postop. [**Hospital **]
clinic followed her for Diabetes Mellitus. Patient is slowly but
progressively improving from surgery.Initially after surgery
unable to assess her pronator drift, at present no pronator
drift noted. evaluated by physical therapy need for rehab and
mobilization. Patient finished her course of steroid and is more
awake and alert and oriented x 3. she will follow up in the
brain tumor clinic on [**6-7**] at 2pm
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
2. Pravastatin Sodium 20 mg Tablet Sig: Four (4) Tablet PO HS
(at bedtime).
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
4. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
5. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
Two (2) Tablet Sustained Release 24HR PO DAILY (Daily).
6. Escitalopram Oxalate 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Amlodipine Besylate 2.5 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
8. Losartan Potassium 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
5000 Injection TID (3 times a day).
10. Dolasetron Mesylate 12.5 mg IV Q8H:PRN
11. Famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day:
D/C when off of steroids.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
left subfrontal planum meningioma
Discharge Condition:
neurologically stable.
Discharge Instructions:
report any mental status changes, headache, seizures or any
other concerns.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:
Followup Instructions:
Follow up with [**Hospital 341**] Clinic..........
[**Hospital 341**] Clinic phone number is [**Telephone/Fax (1) 1844**].
Staple removal in [**2123-5-29**].
Completed by:[**2123-5-26**]
|
[
"225.2",
"997.1",
"V58.61",
"412",
"E878.8",
"414.01",
"V45.82",
"410.71",
"401.9",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.51"
] |
icd9pcs
|
[
[
[]
]
] |
4477, 4549
|
2757, 3492
|
296, 429
|
4627, 4651
|
2462, 2734
|
4894, 5083
|
1734, 1752
|
3515, 4454
|
4570, 4606
|
4675, 4871
|
1767, 2443
|
238, 258
|
457, 1422
|
1444, 1489
|
1505, 1718
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,637
| 189,200
|
31402
|
Discharge summary
|
report
|
Admission Date: [**2160-8-26**] Discharge Date: [**2160-8-27**]
Date of Birth: [**2127-1-30**] Sex: F
Service: NEUROSURGERY
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
Basal Ganglia bleed
Major Surgical or Invasive Procedure:
None
History of Present Illness:
34 yo F s/p epigastric hernia repair; post-operatively, the
patient went to the floor, and at 1340, was noted to have
difficulty talking, and garbled speech. She followed commands x
4, but had left sided flaccid hemiparesis. Her pupils were
equal and reactive, but a disconjugate gaze was noted. She
nodded to questions. The patient was intubated and sent by
Medivac to [**Hospital1 18**] for further treatment. She received Mannitol
and panvecuronium (10 mg) in flight. On arrival at [**Hospital1 18**], she
was immediately evaluated and noted to have b/l 6 mm dilated and
nonreactive pupils. She was immediately taken to CT for CT
head/CTA for evaluation. A large right sided bleed was noted
with b/l IVH, herniation and mass effect. No aneurysms or AVMs
were noted.
Past Medical History:
migraine, PUD, hypothyroidism, Cholecystectomy
Social History:
lives with husband, no etoh, drug, cig abuse
Family History:
Non contributory
Physical Exam:
O: T: afebrile BP: 121/38 HR:109 O2Sats 97 on vent
Gen: intubated
HEENT: Pupils: 6 mm b/l unreactive.
Neuro:
Mental status: Intubated, and does not react to voices, noxious
stimuli
Cranial Nerves:
I: Not tested
II: Pupils equally round, 6mm unreactive bilaterally.
no gag, no cough, no corneals
4 weak twitches on the train of 4
Motor: Normal bulk bilaterally. weak withdrawal of bilateral LE,
L>R
Pertinent Results:
[**2160-8-27**] 12:47PM BLOOD Neuts-82.7* Bands-0 Lymphs-13.8*
Monos-2.7 Eos-0.2 Baso-0.6
[**2160-8-27**] 12:47PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL
[**2160-8-27**] 10:14PM BLOOD Plt Ct-299
[**2160-8-27**] 10:14PM BLOOD Fibrino-474*#
[**2160-8-27**] 10:14PM BLOOD Glucose-171* UreaN-5* Creat-0.5 Na-136
K-3.5 Cl-99 HCO3-25 AnGap-16
[**2160-8-27**] 10:14PM BLOOD ALT-15 AST-24 CK(CPK)-190* AlkPhos-69
Amylase-268* TotBili-0.7
[**2160-8-27**] 10:14PM BLOOD Lipase-15
[**2160-8-27**] 10:14PM BLOOD CK-MB-30* MB Indx-15.8* cTropnT-0.27*
[**2160-8-27**] 11:41PM BLOOD Type-ART pO2-393* pCO2-37 pH-7.42
calTCO2-25 Base XS-0
[**2160-8-27**] 11:41PM BLOOD O2 Sat-99
Brief Hospital Course:
A unfortunate 33 yo female with a large right sided bleed,
herniation, mass effect, and b/l IVH, morbid exam however she
hypothermic on exam she was admitted to the ICU for close
monitoring. Dr [**Last Name (STitle) 739**] spoke with the family regarding the
poor prognosis. Neurology was consulted and saw the patient on
the second hospital day the patient was had a full brain death
by Neurology and Dr [**Last Name (STitle) **] and the exam
exam confirms lack of brainstem reflexes, in keeping with the
diagnosis of brain death. Family was notified notified of brain
death and social work is worked with family to help through this
difficult time. She passed away on [**8-27**].
Medications on Admission:
Vicodin
- potassium
- Celexa
- Inderal
- Protonix
- effervescent granule
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
IPH
Discharge Condition:
Deceased
Discharge Instructions:
None
Followup Instructions:
None
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2161-6-4**]
|
[
"997.02",
"431",
"346.90",
"244.9",
"E878.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
3314, 3323
|
2476, 3161
|
320, 326
|
3370, 3380
|
1730, 2453
|
3433, 3562
|
1274, 1292
|
3285, 3291
|
3344, 3349
|
3187, 3262
|
3404, 3410
|
1307, 1416
|
261, 282
|
354, 1126
|
1505, 1711
|
1431, 1489
|
1148, 1196
|
1212, 1258
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,616
| 133,084
|
11951
|
Discharge summary
|
report
|
Admission Date: [**2144-9-7**] Discharge Date: [**2144-9-23**]
Service: CARDIOTHORACIC SURGERY
HISTORY OF PRESENT ILLNESS: This is an 81-year-old gentleman
with known history of aortic stenosis admitted to [**Hospital1 346**] for cardiac catheterization prior to
aortic valve replacement. He had been followed by his
cardiologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7047**] for the last several years,
but recently had increasing symptoms of shortness of breath
and dyspnea on exertion. An echocardiogram from [**Month (only) 205**] of this
year showed aortic stenosis with an aortic valve area of 0.4
cm squared with a peak gradient of 96. Left ventricular
ejection fraction was estimated at 60%. They also had mild
mitral regurgitation. Cardiac catheterization revealed left
ventricular ejection fraction of 65%, no coronary artery
disease, severe aortic stenosis with an aortic valve area of
0.66.
PAST MEDICAL HISTORY:
1. Bladder cancer.
2. Prostate cancer status post x-ray treatment.
3. COPD.
4. Perforated ulcer status post ulcer surgery.
5. Status post bowel resection in [**2136**].
6. Atrial fibrillation.
7. Aortic stenosis.
8. Hypertension.
MEDICATIONS:
1. Digitek 125 mcg p.o. q.d.
2. Hydrochlorothiazide 12.5 mg p.o. q.d.
3. Verapamil 40 mg p.o. t.i.d.
4. Albuterol two puffs q.i.d.
5. Atrovent two puffs q.i.d.
6. Flovent two puffs b.i.d.
7. Axid 150 mg b.i.d.
ALLERGIES: The patient states no known drug allergies.
REVIEW OF SYSTEMS: Review of symptoms upon admission was
unremarkable.
SOCIAL HISTORY: The patient was a heavy smoker for many
years, but quit 14 years prior to admission. The patient
does admit to drinking four alcoholic beverages per day, and
he lives with his wife.
LABORATORY VALUES UPON ADMISSION: Unremarkable.
The patient was taken to the operating room on [**2144-9-8**], where he underwent an aortic valve replacement by Dr.
[**First Name (STitle) **] [**Last Name (Prefixes) **]. He received a 23 mm [**Last Name (un) 3843**]-[**Doctor Last Name **]
pericardial valve. Please see operative note for full
details of operative procedures and events in the operating
room.
Patient was transported from the operating room to the
Cardiac Surgery Recovery Unit in good condition intubated on
mechanical ventilator and on IV Neo-Synephrine drip.
Postoperative day one, he was atrially paced for some
bradycardia. He was on Neo-Synephrine and propofol for
sedation and dopamine was started on postoperative day two,
[**9-10**]. Later on that day on [**9-11**], the
patient was weaned from mechanical ventilator, and was
successfully extubated. He required a fair amount of
pulmonary toilet, and did have a lot of respiratory
secretions and remained rhonchorous by examination. He was
begun with gentle diuresis and was started on Lopressor. His
Neo-Synephrine had been weaned off.
The following day, [**9-13**], the patient did have an
episode of atrial flutter and again had another episode of
atrial flutter/atrial fibrillation the following day on
[**9-14**]. This was treated with IV amiodarone as well
as IV diltiazem drip for rate control, and he ultimately
converted back to normal sinus rhythm. His IV amiodarone was
converted to p.o. over the next couple of days. On [**9-14**], the patient also underwent bronchoscopy for copious
secretions and large amounts of thick tan sputum was
suctioned bilaterally.
Patient continued to have large amounts of secretions and
difficulty clearing them. He had been started on
levofloxacin empirically for respiratory secretions. Sputum
specimen was sent on [**9-15**], which ultimately grew
out Klebsiella pneumonia for which he was ultimately placed
on Zosyn at the recommendation of the Infectious Disease
Service. Subsequent blood and urine cultures have been
negative to date.
Patient was ultimately reintubated on postoperative day nine,
[**9-17**] due to increased work of breathing. He also
had another episode of atrial fibrillation and flutter at
that time for which he received another bolus IV dose of
amiodarone and ultimately converted back to normal sinus
rhythm.
On [**2144-9-18**], it was evident that the patient would
not wean easily from mechanical ventilator. He remained with
copious secretions and with difficulty clearing those on his
own. He underwent placement of a percutaneous tracheostomy
as well as bronchoscopy on [**2144-9-18**]. This was
performed by Dr. [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) **]. Patient tolerated the
procedure well. It was felt that the patient should not have
surgically placed gastrostomy tube for continued feeding
since he has had previous surgery on his stomach as well as
intermittent elevated white blood cell counts. Therefore,
Dobbhoff feeding tube was placed into his stomach and he was
begun on tube feeds at that time, which he has been
tolerating well.
Infectious Disease consult was also obtained on [**2144-9-18**] for continued elevated white blood cell count as well as
Klebsiella in his sputum. Repeat cultures were sent. Repeat
sputum cultures ultimately were negative with the exception
with oral flora. Blood cultures and urine have also remained
negative. It was the Infectious Disease Service
recommendation to continue Zosyn for a two week course to
treat this Klebsiella in his sputum. The patient was
ultimately weaned off vasoactive drips and has remained
hemodynamically stable. Has also remained in normal sinus
rhythm on oral amiodarone.
Patient has tolerated decreasing levels of ventilatory
support, being placed on CPAP with decreasing levels of
pressure support. Patient has tolerated intermittent periods
of being off the ventilator with oxygen being delivered via
tracheostomy collar. He occasionally becomes tachypneic
after a couple of hours and gets placed back on ventilator
support to rest.
It was felt that the patient has been hemodynamically stable
on decreasing amounts of ventilatory support and ready to be
transferred to a rehabilitation facility to assist with
ultimate ventilator weaning and increased activity and
physical therapy.
Condition today on [**2144-9-22**] is as follows: Patient
is afebrile with a temperature of 98.0. He is in normal
sinus rhythm with a rate of 80. His blood pressure is
127/53. His oxygen saturation is 99% on CPAP with 8 of
pressure support and 40% FIO2. Neurologically, the patient
appears to be intact and following commands albeit
intermittently. He does move all extremities with equal
strength bilaterally. Respiratory status: He remains with
coarse bilateral breath sounds and fair amount of secretions.
His cardiac examination is regular, rate, and rhythm. His
abdomen is slightly distended, soft, and nontender. His
extremities are warm with trace to 1+ peripheral edema.
On the evening of [**9-22**], the patient was noted to
have an episode of hemoptysis. Blood was suctioned from his
endotracheal tube. Laboratories were sent at that time to
evaluate abnormal coagulation factors and these were all
normal. Most recent laboratory values on this patient are
from [**9-22**]. He has white blood cell count of 20.2,
hematocrit of 31.6, and platelet count of 186,000. He has a
sodium of 137, potassium 4.3, chloride 106, CO2 27, BUN 21,
creatinine 0.5. His hematocrit at 8 p.m. which was rechecked
after the episode of hemoptysis is 32.3. His prothrombin
time also at 8 p.m. is 12.0 with an INR of 1.0 and a PTT of
27.8. He also has a platelet count of 192,000. Most recent
blood gas is also from 8 p.m. on [**9-22**], which is
7.35, pCO2 52, with a pAO2 of 101.
Most recent chest x-ray reveals bibasilar atelectasis with a
small bilateral pleural effusions and no congestive heart
failure.
DISCHARGE MEDICATIONS:
1. Tylenol 650 mg per nasogastric tube q.4h. prn temperature
greater than 38 degrees.
2. Aspirin 325 mg via nasogastric tube q.d.
3. Colace 15 mL via nasogastric tube b.i.d.
4. Flovent 110 mcg two puffs b.i.d.
5. Multivitamins 5 mL via nasogastric tube q.d.
6. Combivent metered-dose inhaler 1-2 puffs q.4h.
7. Diltiazem 30 mg via G tube q.i.d.
8. Amiodarone 400 mg via nasogastric tube b.i.d.
9. Lisinopril 5 mg one via G tube q.d.
10. Lansoprazole 30 mg via nasogastric tube q.d.
11. Zosyn 4.5 grams IV q.6h. for 10 more days after discharge
from the hospital.
FOLLOW-UP INSTRUCTIONS: The patient is to followup with Dr.
[**First Name (STitle) **] [**Last Name (Prefixes) **], Cardiac Surgery Service upon discharge
from rehabilitation facility. He can be contact[**Name (NI) **] at
[**Telephone/Fax (1) 170**]. His office should be contact[**Name (NI) **] for any
surgical related questions. The patient should also follow
up with his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Name (STitle) 17996**]
upon discharge from rehabilitation, and he should follow up
with his cardiologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7047**] also upon discharge
from rehabilitation.
DISCHARGE DIAGNOSES:
1. Aortic stenosis status post aortic valve replacement.
2. Atrial fibrillation.
3. Respiratory failure.
CONDITION ON DISCHARGE: Fair.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Name8 (MD) 964**]
MEDQUIST36
D: [**2144-9-22**] 21:37
T: [**2144-9-23**] 04:27
JOB#: [**Job Number 37611**]
|
[
"428.0",
"482.0",
"V10.51",
"424.1",
"427.31",
"V46.1",
"496",
"286.6",
"786.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.05",
"33.21",
"33.23",
"88.56",
"37.23",
"96.72",
"31.1",
"33.22",
"99.15",
"39.61",
"38.93",
"96.04",
"88.53",
"35.22"
] |
icd9pcs
|
[
[
[]
]
] |
9055, 9161
|
7783, 8347
|
1505, 1558
|
136, 951
|
1794, 7760
|
8372, 9034
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973, 1485
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1575, 1779
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9186, 9441
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23,390
| 180,429
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23301+57344
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Discharge summary
|
report+addendum
|
Admission Date: [**2143-10-30**] Discharge Date: [**2143-12-5**]
Date of Birth: [**2076-7-5**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamides) / Acetaminophen / Percocet
Attending:[**First Name3 (LF) 10223**]
Chief Complaint:
Cold right lower extremity
Major Surgical or Invasive Procedure:
1. Right AKA ([**11-1**])
2. IVC filter ([**11-12**])
2. Vent drain/Suboccipital Craniotomy/Duroplasty ([**11-22**])
History of Present Illness:
Mrs. [**Known lastname 59838**] is a 67 year old woman with a past medical
history significant for htn, cad, copd and severe peripheral
vascular disease who initially presents for RLE Above Knee
Amputation. She will undergo the procedure on [**2143-11-1**]. She
presents for pre-operative assessment.
Past Medical History:
1.htn
2.cad
3.copd
4.gout
5.anemia
6.anxiety
7.nausea
8.s/p aorto-bifem
9.s/p fem-[**Doctor Last Name **]
10.s/p several digit amputations
11. stroke
Physical Exam:
BP 185/84 ; HR 91 ; RR 16
gen - NAD
heent - mmm. o/p clear. no scleral icterus or injection.
neck - supple. no lad or carotid bruits appreciated.
lungs - CTAB
heart - rrr, nl s1/s2
abd - soft, nt/nd, nabs
ext - warm LLE, no edema
Pertinent Results:
[**2143-10-30**] 02:00AM WBC-11.6* RBC-4.19* HGB-12.3 HCT-35.4* MCV-85
MCH-29.4 MCHC-34.8 RDW-14.3
[**2143-10-30**] 02:00AM NEUTS-73.2* LYMPHS-19.7 MONOS-6.3 EOS-0.4
BASOS-0.4
[**2143-10-30**] 02:00AM PLT COUNT-369
[**2143-10-30**] 02:00AM PT-15.4* PTT-42.8* INR(PT)-1.5
[**2143-10-30**] 02:00AM GLUCOSE-99 UREA N-54* CREAT-1.1 SODIUM-133
POTASSIUM-5.1 CHLORIDE-102 TOTAL CO2-19* ANION GAP-17
Brief Hospital Course:
Ms [**Known lastname 59838**] [**Last Name (Titles) 1834**] R AKA on [**11-1**], and had done well post-op
until POD4, [**11-5**] 5am when was she found by nurse to be
"unresponsive." She was not responding to questions, and not
moving unless given painful stimuli. Patient was intubated.
Neurology was consulted. Head CT was suggested with DDx of
infarct vs bleed. IVC filter placed on [**11-12**]. She was extubated
on [**11-13**]. Later Head CT shown to have noncommunicating
hydrocephalus secondary in the posterior fossa. MRI showed
diffuse edema of pons, occipital lobe, and cerebellum; etiology
of edema thought to be hypertensive encephalopathy. Patient was
transferred to Neurosurgery.
On [**11-19**], patient was intubated secondary to apnea; she was also
bradycardic in the 40s. Ventricular drain was placed on [**11-22**];
she was taken to OR for craniotomy and duroplasty by [**Doctor Last Name 1132**]. She
tolerated procedure and was transferred back to MICU-A. She was
extubated on [**11-26**].
On [**11-27**], she developed flash pulmonary edema for second time
this admission; was tachy in 130s, hypertensive in the 210s, and
tachypneic in the 30s. She was re-intubated for 3rd time this
admission.
Today, [**11-28**], CVPs remain low; Echo on [**11-21**] negative. No
etiology found for pulmonary edema. Running dry by CXR. Will
attempt to transfer to MICU team for better treatment of medical
issues. No further neurosurgical issues at this time.
[NOTE: THIS DISCHARGE SUMMARY WILL REQUIRE ADDENDUM AFTER
OFFICIAL DISCHARGE FROM HOSPITAL]
Medications on Admission:
metoprolol, levaquin, vancomycin, dulcolax, nebs, vicodin
prn, heparin sc, ntg patch, nicotine, colchicine, lisinopril,
protonix, colace, xanax, dolasetron mesylate
Discharge Medications:
Not known at this time
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Flash pulmonary edema
PVD
HTN
Discharge Condition:
Intubated
Discharge Instructions:
F/U with [**Doctor Last Name 1327**] in 2 weeks.
F/U with Vascular per their dispo.
[NOTE: THIS DISCHARGE SUMMARY WILL REQUIRE ADDENDUM AFTER
OFFICIAL DISCHARGE FROM HOSPITAL]
Followup Instructions:
[NOTE: THIS DISCHARGE SUMMARY WILL REQUIRE ADDENDUM AFTER
OFFICIAL DISCHARGE FROM HOSPITAL]
Completed by:[**2143-11-28**] Name: [**Known lastname 10959**],[**Known firstname 1940**] Unit No: [**Numeric Identifier 10960**]
Admission Date: [**2143-10-30**] Discharge Date: [**2143-12-5**]
Date of Birth: [**2076-7-5**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamides) / Acetaminophen / Percocet
Attending:[**First Name3 (LF) 9224**]
Addendum:
This is a summary and continuation of [**Hospital 277**] hospital course after
she was transferred from the neurosurgical service to the MICU
then to the medical floor.
Chief Complaint:
CC:[**CC Contact Info 10961**]
Major Surgical or Invasive Procedure:
PEG tube placement
History of Present Illness:
HPI: 67 F with severe PVD s/p recent R AKA, labile HTN,
noncommunicating hydrocephalus/ hypertensive encephalopathy, s/p
ventricular drainage and craniotomy/ [**Hospital 10962**] transferred to
MICU from NSICU for resp failure from aspiration vs mucous
plugging.
.
Hospital course: 67 F w/ h/o HTN, CAD, COPD, severe PVD, who
initially presented to [**Hospital1 8**] ED [**10-30**] with abdominal pain. Pt
noted to have ischemic R foot (no pain) & admitted to vasc [**Doctor First Name **]
for RLE AKA performed on [**11-1**]. Pt did well until [**11-5**] when
found unresponsive by RN and was intubated. MRI showed a
non-communicating hydrocephalus. There was diffuse edema of the
pons, occipital lobe, and cerebellum c/w hypertensive
encephalopathy and pt was transferred to NSICU service. A
venticular drain was placed on [**11-5**]. Pt underwent craniotomy
and duroplasty. Pt was extubated on [**11-13**] and developed apnea on
[**11-19**] requiring reintubation. She was extubated on [**11-26**] then
developed flash pulmonary edema on [**11-27**] requiring third
intubated. Her HR was in 130s, SBP 210s, tachypnea in 30s. She
developed a troponin leak with peak troponin of 0.23 on [**11-29**]
which cardiology felt was secondary to rate-related ischemia.
The cardiology team has also been following the pt for labile
blood pressure. ICU course was complicated by LLL Klebsiella
pneumonia with fluctuating mental status with a question of
re-emergence of her leukoencephalopathy.
Past Medical History:
1.htn
2.cad
3.copd
4.gout
5.anemia
6.anxiety
7.nausea
8.s/p aorto-bifem
9.s/p fem-[**Doctor Last Name **]
10.s/p several digit amputations
11. stroke
Physical Exam:
Physical Exam:
VS: Tm 96.6, Tc 95.1, p91 (73-91), 170/58 (128-170/30-50), rr24,
96%RA
Gen: cachectic, NAD
HEENT: PERRL, clear OP, dry MM
Neck: supple, no cervical lymphadenopathy
CVS: RRR, nl s1 s2, no m/g/r
Lungs: fair breath sounds anteriorly, no c/w anteriorly
Abd: large vertical incision, small reducible ventral hernia,
2inch incision in LUQ with staples in place with does not appear
infected, soft, ND, NT, +BS
Ext: R stump with steri strips in place without drainage or
signs of infection. no edema bilaterally. left leg warm and
well-perfused.
Neuro: alert and oriented x 3 (name, hospital but doesn't know
name, [**Month (only) 768**], year "24"). thinks she is in the hospital
because she got "shot in the head"
Pertinent Results:
[**2143-11-29**] CXR: FINDINGS: ETT, NG tube, subclavian central venous
catheter, and VP shunt are again noted, in stable position.
There has been interval placement of a right sided PICC catheter
which terminates within the mid SVC. In the interval, there has
been marked improvement in the appearance of the previously
evident left upper lobe parenchymal opacity. Small left pleural
effusion has decreased in size. There is a left retrocardiac
density likely representing atelectasis, but pneumonia cannot be
excluded.
IMPRESSION: Overall improved appearance of the chest, with
resolving left upper lobe parenchymal opacity and decrease in
size with small left pleural effusion. Residual left lower lobe
atelectasis or consolidation.
.
[**2143-11-28**]: head CT
FINDINGS: There is again demonstrated a ventricular drainage
catheter which enters in the left frontal region and terminates
in the region of the third ventricle. There has been interval
development of subcortical white matter hypodensity along the
tract of the ventricular catheter in the left frontal lobe. The
ventricles have decreased in size compared to the prior study
with a stable amount of blood seen layering within the occipital
[**Doctor Last Name **] of the left lateral ventricle. The sulci are not effaced.
There are no new areas of hemorrhage identified. Hypodensities
again appreciated in the left cerebellar hemisphere. There are
stable postoperative changes in the sub occipital craniotomy
site. There is no shift of normally midline structures or mass
effect. There has been decreased soft tissue swelling along the
left temporal scalp. The osseous structures and paranasal
sinuses are unchanged.
IMPRESSION: Decreased size of ventricles with preserved sulci.
This may reflect decompression by the ventricular drainage
catheter. 2) Post surgical changes along the tract of the
catheter in the left frontal lobe. 3) No new areas of hemorrhage
identified.
.
[**2143-11-28**] CTA
CTA OF THE CHEST WITHOUT & WITH IV CONTRAST:
The pulmonary arteries are well opacified and demonstrate no
intraluminal filling defects to suggest pulmonary embolism. The
heart, pericardium and great vessels are stable in appearance.
Note is made of coronary artery calcifications. There is a left
subclavian line, endotracheal tube and NG tube present in
satisfactory position. There has been significant interval
improvement in the previously identified left-sided pleural
effusion, which is now small in size. There has been reexpansion
of the left lower lobe with a persistent area of consolidation
seen superior and laterally. There has been resolution of the
previously seen right-sided pleural effusion. Diffuse emphysema
is again demonstrated. Improved aeration is also demonstrated in
the left upper lobe with two residual adjacent, somewhat nodular
1-cm opacities. The imaged portions of the upper abdomen are
unchanged in appearance with note of extensive vascular
calcifications and an IVC filter present.
BONE WINDOWS: There are no suspicious lytic or sclerotic
lesions.
IMPRESSION:
1) No evidence of pulmonary embolism.
2) Resolution of right-sided pleural effusion and significant
improvement in left-sided pleural effusion.
3) Residual areas of consolidation in both the left upper and
lower lobes. As underlying lesions cannot be excluded, continued
follow up is recommended.
.
[**2143-11-21**] Echo
Conclusions:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or
color Doppler. Left ventricular wall thicknesses are normal. The
left
ventricular cavity size is normal. Overall left ventricular
systolic function
is normal (LVEF 60-70%). No masses or thrombi are seen in the
left ventricle.
There is no ventricular septal defect. Right ventricular chamber
size and free
wall motion are normal. The aortic valve leaflets (3) are mildly
thickened but
aortic stenosis is not present. Mild to moderate ([**12-14**]+) aortic
regurgitation
is seen. The mitral valve leaflets are mildly thickened. There
is no mitral
valve prolapse. Trivial mitral regurgitation is seen. The
estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
.
[**2143-11-19**]: MRI head
FINDINGS: The ventricular shunt catheter is unchanged in
appearance compared to the previous examination. Ventricular
size is unchanged. Postsurgical changes in the left inferior
cerebellar hemisphere are again demonstrated. There is a focus
of abnormal signal on the diffusion-weighted sequence in the
left parieto-occipital region which was present on the previous
examination. There is no ADC map at this time to indicate
whether this represents a diffusion abnormality or T2
shine-through and it is unchanged from the prior study. In
addition, there is a T2 abnormality in this region consistent
with remote infarct. Since there has been no particular change
in its appearance in these three days, it is suggested that this
represents T2 shine- through rather than a diffusion
abnormality.
IMPRESSION: No change from previous examination. Remote
infarcts. No change in ventricular dimension. Postoperative
changes. No definite evidence of acute infarction.
.
[**2143-11-5**] head CT
FINDINGS: The lateral and third ventricles are markedly dilated.
The cerebral acqueduct is also dilated. The fourth ventricle is
occluded. There is swelling in the cerebellum and in the
occipital lobes, of uncertain etiology. Urgent neurosurgical
consultation is recommended. This was discussed with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 10963**] and Dr. [**First Name4 (NamePattern1) 10964**] [**Last Name (NamePattern1) **] at 10 a.m. on [**2143-11-5**].
There is no acute hemorrhage. The visualized osseous structures
appear unremarkable. The visualized paranasal sinuses and
mastoid air cells are normally aerated.
IMPRESSION: Occlusion of the fourth ventricle with marked
dilatation of the lateral ventricle, third ventricle and the
cerebral acqueduct. Urgent neurosurgical consultation is
recommended.
.
[**2143-11-5**] Head MRI
FINDINGS: A shunt has been placed into the frontal [**Doctor Last Name **] of the
right lateral ventricle. The temporal horns of the lateral
ventricles are less dilated compared to the head CT of three
hours prior. Overall, the lateral ventricles, third ventricle
and cerebral aqueduct remain prominent, and there is
transependymal edema. The fourth ventricle remains compressed.
There is marked diffuse cerebellar edema, and there area areas
of increased T2 signal in the pons. There are no foci of slow
diffusion in the cerebellum or brainstem. However, there is a
small focus of slow diffusion in the left parietal subcortical
white matter. There is a corresponding hyperintense lesion on
T2W images, suggesting an evolving acute infarction. There is
diffuse high T2 signal in the white matter of the occipital
lobes. This appearance is concerning for hypertensive
encephalopathy.
There is elevated T2 signal in the right frontal sulci, adjacent
to the intraventricular drain and likely blood secondary to
drain placement.
MRA of the Circle of [**Location (un) **] was performed with a 3D time of
flight method. MIP and source images are reviewed.
FINDINGS: No flow signal is observed int he left vertebral
artery. Flow is present in the right vertebral artery, basilar
artery, both posterior communicating arteries and the proximal
posterior cerebral arteries, as welll as in both anterior and
middle cerebral arteries and the intracranial internal carotid
arteries.
The findings and recommendations were discussed with Dr. [**Last Name (STitle) 10965**]
at 14:30 on [**2143-11-5**]. The findings and recommendations
were also discussed with Drs. [**Last Name (STitle) **], [**Name5 (PTitle) 10963**], and [**Doctor Last Name **]
between 14:30 and 15:30 on [**2143-11-5**].
IMPRESSION:
1. Diffuse edema in the cerebellar and occipital white matter,
concerning for hypertensive encephalopathy. Clinical correlation
recommended.
2. Small acute infarction in the left parietal subcortical white
matter. No evidence of acute infarction in the cerebellum.
3. Slight decrease in dilatation of the lateral ventricles.
Persistent occlusion of the fourth ventricle.
4. Follow-up MRI with diffusion-weighted images in a few days
would be helpful for further evaluation of the above
abnormalities.
5. MRA of the Circle of [**Location (un) **] demonstrates flow in the major
proximal branches of the intracranial circulation, except for
the left vertebral artery.
.
[**2143-10-30**]: aorto-iliac-a gram
IMPRESSION:
1) Occlusion of the right limb of the aortobifemoral graft. This
was most likely caused by outflow obstruction. There was no
filling of the arteries below the pronfuda branches in the right
leg. It is suggested that on may be able to outline a suitable
artery by cut down on the popliteal artery in the or since one
cannot demonstrate one by injecting in the aorta above the
aortobifemoral by pass. There are no collaterals.
2) Short areas of segmental occlusion of the distal SFA and
popliteal arteries with a 2 vessel runoff in the left leg. The
left aortobifemoral limb of the graft is widely patent.
Brief Hospital Course:
1. Respiratory failure: MICU course was notable for 3
intubations (last extubated on [**11-29**]). Respiratory status
complicated by mucous plugging, flash pulmonary edema, and
Klebsiella pneumonia in pt with underlying COPD. Has remained
stable from respiratory standpoint since last extubation on
[**11-29**]. Pt was treated for Klebsiella pneumonia with levofloxacin
for a total of 12 days and should complete a 14 day course. Pt
was kept on aspiration precautions and pulmonary toilet. Pt was
continued on her COPD nebulizers and inhalers. Pt remained
euvolemic. Pt remained stable from a respiratory standpoint
until discharge.
.
2. HTN: Pt had hyperternsive leukoencephalopathy complicated by
non-communicating hydrocephalus and mental status changes. Pt's
goal SBP is 120-150. Pt was getting po metoprolol and lasix.
Prior to transfer to the floor, pt's dobhof fell out. Pt was
then given IV hydralazine and IV metoprolol. On [**12-4**], pt was
restarted on po metoprolol, lisinopril, and hydralazine through
a PEG tube with adequate blood pressure control.
.
3. CAD: In the MICU, pt had a troponin leak thought to be
secondary to rate-related ischemia. Pt was continued on a
beta-blocker and ACEi for HR and BP control. Pt was continued on
low-dose aspirin. Pt was started on a statin for elevated
lipids. Please follow up on LFTs
.
4. Neuro/MS change: Pt is s/p craniotomy, duroplasty ([**11-22**]), VP
shunt. Pt was noted to be more alert than a few days prior to
transfer to the floor. Pt was noted to have a fluctuating mental
status, secondary to delirium superimposed on her hypertensive
leukoencephalopathy. Pt was continued to be treated for PNA
without other signs of infection. Electrolytes were carefully
monitored and repleted. BP was controlled. Pt should follow up
in neurosurgery and neurology clinic.
.
5. FEN: Pt was evaluated by speech and swallow who felt that she
was a high aspiration risk and was not able to take po's. Pt had
a PEG tube placed by GI. She recieved peri and post-procedure
prophylactic antibiotics, since her VP shunt puts her at
increased risk of infection.
.
6. ID: Low grade fever noted on [**11-28**], central venous line was
discontinued. All cultures were negative to date. Vascular
surgery felt that stump is okay. Pt was continued on
Levofloxacin for Klebiella pneumonia. Pt was put on MRSA
precautions for a positive nasal swab.
.
7. s/p AKA: Vascular surgery felt that pt's right stump looks
well without signs of infection. Pt has an eschar in the area,
which may need to be revised at a later date. Pt should follow
up in vascular surgery clinic.
.
8. Anemia: Iron studies consistent with anemia of chronic
disease.
.
9. Endocrine: Pt was continued on regular insulin sliding scale
with adequate blood sugar control. TSH on [**11-20**] was 3.6
.
10. PPX: Pt was continued on sc heparin and PPI
.
11. Access: PICC
.
12. Code:full
Medications on Admission:
Meds on transfer from MICU to the floor:
1. combivent IH q4h prn
2. Albuterol IH [**12-14**] puff q4h prn
3. Albuterol neb q6h prn
4. ASA 81 qd
5. Bisacodyl 10mg po/pr qd prn
7. Dolasetron Mesylate 12.5 mg IV Q8H:PRN
8. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
9. Furosemide 20 mg IV BID
10. Heparin 5000 UNIT SC TID
11. Hydralazine HCl 10 mg PO Q6H
12. Hydralazine HCl 10 mg IV Q4H:PRN
13. Ipratropium Bromide Neb 1 NEB IH Q6H
14. Lansoprazole 30 mg PO DAILY
15. Levofloxacin 500 mg IV ONCE
16. Lisinopril 30 mg PO DAILY
17. Metoprolol 50 mg PO BID
18. Morphine Sulfate 2-4 mg IV Q2H:PRN
19. Nitro sl prn
20. insulin sliding scale
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
2. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
3. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-14**]
Puffs Inhalation Q4H (every 4 hours) as needed.
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
5. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
6. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
9. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
12. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
13. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
14. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
15. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 2 days.
16. Hydralazine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).
17. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
18. Morphine Sulfate 8 mg/mL Syringe Sig: One (1) Injection Q2H
(every 2 hours) as needed.
19. Dolasetron Mesylate 12.5 mg/0.625 mL Solution Sig: One (1)
Intravenous Q8H (every 8 hours) as needed.
20. Vancomycin HCl 500 mg Recon Soln Sig: One (1) Intravenous
at bedtime for 1 doses: Pt has one dose remaining of post-PEG
placement prophylaxis.
21. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 7
days: Please recheck K level on [**12-9**]. Please adjust K dose as
needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 3465**] - [**Location (un) 824**]
Discharge Diagnosis:
Primary diagnoses:
Hypertensive leukoencephalopathy
Non-communicating hydrocephalus
Right AKA
Secondary diagnoses
1.htn
2.cad
3.copd- no PFTs in OMR
4.gout
5.anemia
6.anxiety
7.severe PVD (s/p aorto-bifem ([**2-14**]), s/p fem-[**Doctor Last Name **] ([**2-14**]), s/p
several digit amputations, s/p R AKA ([**11-1**]))
8. stroke
9. Echo [**11-21**]: EF 60-70%, [**12-14**]+AR
Discharge Condition:
Stable with normal blood pressures and improving mental status
Discharge Instructions:
If you develop chest pain, difficulty breathing, nausea,
vomiting, abdominal pain, fevers, chills please call your PCP or
return to the emergency room.
Followup Instructions:
Follow-up with your primary care doctor Dr. [**Last Name (STitle) 10966**]
([**Telephone/Fax (1) 10967**]when you are discharged from rehab.
Follow up in [**Hospital **] clinic on [**12-16**]. Please get
non-contrast head CT on [**12-16**], 1pm (Rhabb building, [**Location (un) 10539**]). Then, see Dr. [**Last Name (STitle) **] in clinic on [**12-16**], 1:40pm
(located in [**Doctor First Name **], [**Hospital Unit Name **]) ([**Telephone/Fax (3) 10968**])
Follow up with Neurology [**Doctor First Name 9371**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD Where: [**Hospital 3950**] NEUROLOGY Phone:[**Telephone/Fax (1) 190**] Date/Time:[**2144-1-2**]
1:00
Follow up in vascular surgery clinic with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on
[**12-17**], 1:45pm, located at [**Doctor First Name **] suite 9C. ([**Telephone/Fax (1) 10969**])
[**First Name11 (Name Pattern1) 1811**] [**Last Name (NamePattern4) 9226**] MD [**MD Number(2) 9227**]
Completed by:[**2144-1-1**]
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|
6209, 6360
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,869
| 110,540
|
465
|
Discharge summary
|
report
|
Admission Date: [**2104-2-28**] Discharge Date: [**2104-3-7**]
Service: MEDICINE
Allergies:
Xanax / Ativan
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
Tachycardia, feeling unwell
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] M with pacemaker admitted for rapid afib. In [**2102**], he had a
dual chamber St. [**Male First Name (un) 1525**] pacemaker placed for symptomatic
bradycardia and chronitropic incompetence and has been doing
fairly well. He walks his dog 1.5 miles daily. This morning, he
woke up feeling lousy and tried to walk the dog but could only
make it down the block and had to turn back. Did not have enough
energy and felt some lightheadedness. No chest pain or shortness
of breath. He called [**Hospital **] clinic who interogatted the pacer over
the phone and found him tachycardic. He was told to go to the
ED.
Otherwise he feels well. On review of systems, denies fevers,
chills, nausea, vomit, abd pain, diarrhea. On cardiac review of
systems, denies orthopnea, PND or increase in peripheral edema.
In the ED, vitals were: 98.6, 128, 144/85, 24, 100%RA. Because
of his fast heart rates, he was given dilt 10 IV x 3 and dilt 30
mg PO followed by 60 mg PO.
Past Medical History:
# Chronic renal failure
- Followed by Dr. [**Last Name (STitle) **]. On Epogen.
- Baseline creatinine is 2.0 - 2.4.
# Claudication
- Walks 1.5 miles daily but has to stop and rest.
# Aortic stenosis
- Mean gradient 60 on last ECHO [**9-6**]
- Declined AVR or valvuloplasty
# B12 deficiency
# HTN
# GERD
# PVD
# H/O stomach cancer
- s/p total gastrectomy and Roux-en-Y in late [**2085**]
# Left renal artery stenosis
- s/p stenting [**2102-3-8**]
# Type 2 DM
# Hyperkalemia in the past attributed to dietary supplements
# Paroxysmal atrial fib
- reported after gastrectomy but no h/o recurrence
# COPD
# TIA
# Abdominal aortic aneurysm repair
# Right ICA 50% occluded, [**Doctor First Name 3098**] 90% occluded
Social History:
Lives at home with his wife. [**Name (NI) **] [**Name (NI) **] [**Known lastname 3937**] is a ED physician
in [**Name9 (PRE) 1727**]. Phone numbers are [**Telephone/Fax (1) 3938**] and [**Telephone/Fax (1) 3939**].
Patient is a retired jazz musician--- played the clarinet and
sax. No ETOH or drugs. Smoked [**3-4**] PPD for 30 years but quit
approximately 20 years ago.
Family History:
No fam hx or early CAD.
Physical Exam:
VITALS: 97.1, 143/62, 76, 20, 100%2LNC
GEN: A+Ox3, NAD, pleasant
HEENT: PERRL, EOMI, OP clear, MMM
NECK: No JVD
CV: Soft heart sounds, irregular and tachy, iii/vi SEM, no rubs
or gallops
PULM: Distant breath sounds, no wheezes, rhonchi rales.
ABD: Soft, ND, NT, +BS, murmur radiates to abdomen
EXT: Trace ankle edema
Pertinent Results:
CXR ([**2104-2-28**]): Left-sided pacer is again seen with leads
overlying the right atrium and ventricle. Cardiac and
mediastinal contours appear stable. Pulmonary vascularity
appears within normal limits. There is persistent eventration of
the right hemidiaphragm and mild hyperexpansion, not
significantly changed in appearance from prior. There are no
focal consolidations or large pleural effusions.
CT Head ([**2104-2-29**]):
FINDINGS: There is no intracranial hemorrhage, mass effect, or
shift of normally midline structures. The ventricles, cisterns,
and sulci are enlarged secondary to involutional change,
unchanged from [**2097**]. Periventricular white matter hypodensities
are the sequelae of chronic small vessel infarction. [**Doctor Last Name **]-white
matter differentiation, however, is preserved. The osseous
structures are unremarkable. The visualized paranasal sinuses
and mastoid air cells are clear.
CXR ([**2104-2-29**]): A new interstitial edema has developed in both
lungs more predominantly at the bases. The heart is enlarged.
Small subtle left pleural effusion might be present. A
left-sided pacer is again noted with leads overlying the right
atrium and right ventricle. Persistent eventration the right
hemidiaphragm.
ECHO:
The left atrium is mildly dilated. There is moderate symmetric
left ventricular hypertrophy. The left ventricular cavity is
unusually small. There is mild global left ventricular
hypokinesis (LVEF = 40-50 %). Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg).
Transmitral Doppler and tissue velocity imaging are consistent
with Grade III/IV (severe) LV diastolic dysfunction. Right
ventricular chamber size and free wall motion are normal. The
number of aortic valve leaflets cannot be determined. The aortic
valve leaflets are severely thickened/deformed. There is severe
aortic valve stenosis (area <0.8cm2). Mild to moderate ([**1-2**]+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. [Due to acoustic shadowing, the
severity of mitral regurgitation may be significantly
UNDERestimated.] The left ventricular inflow pattern suggests a
restrictive filling abnormality, with elevated left atrial
pressure. The tricuspid valve leaflets are mildly thickened.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2102-9-25**], there is now moderate concentric left
ventricular hypertrophy with a small cavity, reduced ejection
fraction, and evidence of severe diastolic dysfunction. The
cardiac rhythm is now atrial fibrillation.
Renal US:
IMPRESSION:
1. Cortical atrophy of the right kidney and absence of diastolic
flow in the segmental arteries indicative of an intrinsic
vascular abnormality. The limited Doppler study on the right
does not allow for evaluation of renal artery stenosis.
2. Multiple simple bilateral renal cysts, unchanged from [**3-7**], [**2102**].
Brief Hospital Course:
[**Age over 90 **] year old male with a St. [**Male First Name (un) 923**] pacemaker placed for
symptomatic bradycardia in [**2102**] who presented with new onset
afib with RVR. The patient was initially anticoagulated with
heparin for new onset atrial fibrillation with RVR with
initiation of coumadin. Two of his home antihypertensives were
held (Amlodipine and Losartan) to leave room to uptitrate
beta-blockade for improved rate control. He was seen by EP who
decided to attempt chemical cardioversion which was successful.
On the day of cardioversion the patient became acutely
hypertensive to 270 systolic. He also had difficulty breathing
in this setting. He was treated with 30 of IV hydralazine, 25
mg of IV Lopressor, 25 mg po captopril and 20 IV lasix. His
blood pressure was fairly refractory to these interventions and
the patient was transferred to the cardiac intensive care unit
for closer monitoring. He also received 2 mg IV Ativan for
agitation. Upon arrival in the unit, the patient became
somewhat unresponsive with minimally reactive pupils. Given his
hypertensive emergency, there was suspicion for stroke. The
patient had a negative head CT scan. He was unable to have MRI
given his pacer. His mental status improved to baseline
overnight. According to his wife, he has had similar episodes
in the past with benzodiazapines and it was thought his mental
status change was most likely secondary to a medication effect.
The patient returned to the floor with difficult to control
blood pressure. He was treated aggressively with
anti-hypertensives. The patient experienced dizziness with both
blood pressure highs and when his blood pressure was too low.
Per his PCP, [**Name10 (NameIs) **] patient generally has a blood pressure between
140-160. Per his wife, the patient has had transient elevations
in his blood pressure over 200 in the past. From prior notes,
it appears the patient has some element of autonomic dysfunction
in addition to known left renal artery stenosis s/p stent and
critical aortic stenosis. As he became relatively hypotensive
(sbp of 90) on labetolol as well as hydralazine, both of these
agents were discontinued. The patient experienced acute on
chronic renal failure, most likely secondary to kidney
hypoperfusion while hypotensive. His creatinine had leveled off
at discharge. He was discharged with services and scheduled to
have electrolytes checked the Wednesday after discharge with
results to be faxed to both his PCP and nephrologist. The
patient was eventually discharged on his original home
medication regimen with uptitration of his amlodipine while his
losartan was being held.
The patient had a troponin leak consistent with NSTEMI in the
setting of his hypertensive emergency. He was medically managed
with beta-blockade and low dose aspirin as well as high dose
statin. He was already anticoagulated on heparin at the time.
He had an ECHO while in the hospital which showed moderate
concentric left ventricular hypertrophy with a small cavity,
reduced ejection fraction, and evidence of severe diastolic
dysfunction.
The patient was continued on his home Plavix regimen for his
left renal artery stenosis s/p stent by Dr. [**First Name (STitle) **]. He also has
known carotid disease.
The patient was noted to have a urinary tract infection during
this admission. Cultures grew out Klebsiella sensitive to
cipro. The patient was treated with cipro and discharged to
complete a course of antibiotics.
He also had a left hand thrombophlebitis from an IV. The IV was
removed and the thrombophlebitis resolved with no further
intervention.
He was discharged with home VNA for assessment of his
cardiopulmonary status, INR draws for his anticoagulation, which
should be maintained between two and three until decided
otherwise by his PCP and cardiologist as well as home CHF
monitoring, which the patient has had in the past. He should be
restarted on his losartan as an outpatient once his renal
function starts to return to his baseline ~2-2.5.
Medications on Admission:
NORVASC 5 mg--1.5 (one and a half) tablet(s) by mouth once a day
METOPROLOL TARTRATE 25 mg--0.5 tablet(s) by mouth twice a day
PLAVIX 75 mg--1 tablet(s) by mouth once a day
URSODIOL 300 mg--1 capsule(s) by mouth twice a day
ZANTAC 300 mg--1 tablet(s) by mouth daily
PROTONIX 40 mg--1 (one) tablet(s) by mouth daily
HYDROCHLOROTHIAZIDE 25 mg--1 tablet(s) by mouth daily
LIPITOR 10 mg--1 tablet(s) by mouth once a day
COZAAR 25 mg--1 tablet(s) by mouth twice a day
SENOKOT 8.6 mg--1 (one) tablet(s) by mouth twice a day as needed
for constipation
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
3. Ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
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).
7. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
8. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
10. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
11. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
12. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO once a day
as needed for headache.
Disp:*10 Tablet(s)* Refills:*0*
13. Warfarin 2 mg Tablet Sig: One (1) Tablet PO at bedtime:
Please start this medication on Saturday, [**2104-3-8**].
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
#Atrial fibrillation with rapid ventricular response
#Hypertensive emergency
Secondary:
#Chronic renal insufficiency on epogen
#Claudication
#Aortic stenosis
#GERD
#COPD
#Peripheral vascular disease
#Left renal artery stenosis
#Type II diabetes mellitus
#TIA
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital because your heart rate was
very fast. While in the hospital you underwent chemical
conversion with medication to change your heart rate to sinus.
Your heart rate has been controlled since the conversion. We
started you on a blood thinner which you will need to take until
you are instructed otherwise. If you have any bleeding from
your nose or blood in your stool, please notify your doctor
immediately.
Please do not take your warfarin tonight (the blood thinner).
Please take the warfarin tomorrow night (Saturday) and Sunday
night. The VNA will check your INR levels on Sunday.
You also had an episode of extremely high blood pressure. We
treated your blood pressure with medications. We are sending you
home on a slightly different medication regimen. We increased
your dose of amlodipine to 10 mg daily. We would like you to
hold your Losartan (Cozaar) until instructed otherwise by your
primary care physician.
We will check your kidney function on Wednesday, [**2104-3-12**].
Your outpatient doctors [**Name5 (PTitle) **] [**Name5 (PTitle) **] [**Name5 (PTitle) **] when you may restart your
losartan.
We did not change your dose of beta-blocker or
hydrochlorothiazide. We increased your cholesterol medication.
Please take all your other medications as prescribed.
Please call your doctor or come to the emergency room with any
chest pain, shortness of breath, increasing headaches or other
symptoms you find concerning.
Followup Instructions:
You have the following appointments scheduled:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3940**], MD Phone:[**Telephone/Fax (1) 719**]
Date/Time:[**2104-3-13**] 3:00 pm.
Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2104-3-20**] 11:00 AM.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. Phone:[**Telephone/Fax (1) 920**]
Date/Time:[**2104-3-25**] 3:00 pm.
Provider: [**Name10 (NameIs) 3941**] CALL TRANSMISSIONS Phone:[**Telephone/Fax (1) 59**]
Date/Time:[**2104-4-7**] 9:00 AM.
You have an appointment with Dr. [**Last Name (STitle) 2232**] on [**2104-4-9**] at 11 AM
to follow up for your cardioversion. Please call ([**Telephone/Fax (1) 3942**].
|
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283, 1261
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1283, 1995
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2011, 2384
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,617
| 145,699
|
45948
|
Discharge summary
|
report
|
Admission Date: [**2102-5-27**] Discharge Date: [**2102-6-9**]
Date of Birth: [**2036-11-14**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
Hypotension, worsening oxygen requirement
Major Surgical or Invasive Procedure:
Dialysis
History of Present Illness:
Mr [**Known lastname 41841**] is a 65 year old male with a history of diastolic CHF
(EF > 60%), CAD s/p CABG in [**2079**] and STEMI [**2102-5-19**] with three
stents placed, ESRD on hemodialysis s/p failed transplant and
known chronic bilateral pleural effusions with associated
trapped lung who presented on [**2102-5-27**] with worsening dyspnea on
exertion.
.
The patient has had worsening dyspnea on exertion for
approximately one month. He presented to [**Hospital6 **]
center on [**2102-5-19**] at which times he was diagnosed with a
posterior STEMI and underwent thrombectomy to the PDA, and three
Vision stents to the PDA. His procedure was complicated by
ventricular fibrillatoni arrest which requierd 2 shocks. Peak
Troponin I was 21 and CK 657. He was subsequently transferred to
[**Hospital1 18**] for persistent dyspnea on exertion. He was admitted to
this hospital from [**2102-5-23**] to [**2102-5-25**]. During that admission he
was noted to have persistent large pleural effusions but was not
considered a candidate for pleurex catheter placement given his
need for aspirin and plavix. Rheumatology evaluation was
negative. His effusions were felt to be secondary to his
diastolic heart failure and volume overload from chronic
hemodialysis. He was started on digoxin and underwent scheduled
dialysis and was discharged home.
.
He returned on [**2102-5-27**] with persistent shortness of breath
without recurrent chest pain. He underwent his regularly
scheduled dialysis on Friday but on returning home could not
climb the steps to his home. His dyspnea resolved within about
5 minutes but then returned. He initially presented to [**Hospital1 **] where he received plavix, cefepime and vancomycin and
was transferred to [**Hospital1 18**] for further evaluation. Reportedly he
had a low grade fever at [**Hospital3 7362**].
.
In the ED, initial vitals were T: 97.9, BP: 100/64, HR 68, RR
18, O2 96% 2L. Exam was notable for decreased breath sounds at
the bases. Troponin was elevated at 6.23. BNP was elevated at
[**Numeric Identifier 97839**]. There was initially concern for pulmonary embolism but
the patient refused heparin gtt and CTA. He was admitted to
[**Hospital Unit Name 196**] as an NSTEMI and for DOE.
.
On arrival to the floor, patient was comfortable. He denied
lower extremity edema, orthopnea or paroxysmal nocturnal
dyspnea. He was not experiencing palpitations. His
nephrologists have been aggressively dialyzing him for his
pleural effusions and he was at his dry weight. Although he
endorsed a low grade fever in the [**Hospital1 3597**] emergency room he
otherwise denied fevers, chills, nausea, vomiting, diarrhea,
constipation, abdominal pain or dysuria since discharge.
.
Since admission he has had a persistent oxygen requirement
ranging from 2 to 4 L nasal canula. Antibiotics were
discontinued on admission. He underwent echocardiogram on
[**2102-5-29**] which showed improvement of his ejection fraction to
60%, diastolic dysfunction and moderate pulmonary hypertension.
He underwent right sided thoracentesis on [**2102-5-29**] complicated by
the development of a small basilar pneumothorax. 600 cc
serosangionous fluid was removed and fluid studies were
consistent with transudate. He underwent hemodialysis on
[**2102-5-29**] and [**2102-5-30**] with blood pressures ranging from 90s to
100s systolic. He was evaluated by thoracic surgery for
potential VATS decortication and pleurodesis and was felt not to
be a surgical candidate.
.
He first triggered at [**2026**] on [**2102-5-30**] for hypotension and
hypoxia with blood pressure of 88/64 and O2 sats of 86% on 3L.
T max was 99.9. CXR showed reaccumulation of right sided
pleural effusion. Blood cultures were drawn. He triggered
again on [**2102-5-31**] for hypotension to the 60s systolic and
somnolence. ABG at that time was 7.31/58/79 on 4L nasal canula.
EKG showed normal sinus rhythm, normal axis, QTc 485, TWF II,
III, avF, TWI V1-V3, compared to prior dated [**2102-5-30**] TWI were
more prominent. He had a right EJ 18 g placed and received 2 L
normal saline bolus and was transferred to the MICU. He did not
receive antibiotics prior to MICU transfer.
.
On arrival to the MICU he was persistently hypotensive to the
70s. Peripheral dopamine is currently running at 20 mcg/kg/min
with blood pressures in the 70s systolic. He has received a
total of 4L normal saline. He had a left sided subclavian line
placed. He had a stat echocardiogram which was unchanged from
prior study dated [**2102-5-29**].
Past Medical History:
Past Medical History:
Diastolic Congestive Heart Failure: EF 60%
Coronary Artery Disease s/p 7-vessel CABG in [**2079**]
STEMI s/p Vision stent x 3 on [**2102-5-19**] complicated by vfib arrest
requiring 2 shocks
Atrial fib/[**Last Name (un) **] s/p ablation [**2099**], recurrence in [**2100**] on
Coumadin
Upper GI bleed [**2101**], pill esophagitis and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **] tear
Recurrent candidal esophagitis.
ESRD on HD, failed renal transplant in [**2069**].
Recurrent squamous cell skin cancer, ? related to
immunosuppression Basal cell carcinoma
Diverticulitis.
Home O2 2L NC
Chronic Bilateral Pleural Effusions
.
Past Surgical History:
Renal biopsy
Appendectomy
Left AV fistula placement 30 years ago.
Skin resections for CA
Social History:
Social history is notable for his being married. He has 2
grownchildren. He lives with his wife. [**Name (NI) **] is a retired
automation engineer. He does not drink alcohol. He smoked cigars
for about a year [**13**] years prior. He had tried marijuana 45 years
ago. No other illicit drug use. He was exposed to second hand
smoke as a child. Although he states that he is still working in
a pharmaceutical plant. He does have a dog at home. He lives in
[**Location 86**].
Family History:
Family history is notable for a brother with a deep venous
thrombosis (DVT) at age of 67
Physical Exam:
Physical Exam:
Vitals: T: 96.6 HR: 63 BP: 86/44 RR: 15 O2: 100% on 4L
General: Somnolent, responds to questions appropriately,
oriented x 3, cachectic
HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus
noted, MM dry, no lesions noted in OP
Neck: supple, JVP 12 CM
Pulmonary: Diminished breath sounds bilaterally with dullness to
percussion and trace crackes bilaterally
Cardiac: Regular rate and rhythm, normal s1 and s2, no murmurs,
rubs or gallops, well healed mid line CABG scar
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses
b/l. Left groin at site of catheter access is w/o hematoma or
bruit but with minor bruising. Fistua on left arm with + thrill
and bruit, no LE edema, dry scabs on LE.
Lymphatics: No cervical, supraclavicular, or lymphadenopathy
noted.
Skin: 1 cm hard bumps across legs, multiple areas of brusing,
multiple areas of skin grafts
Pertinent Results:
[**2102-5-27**] 09:30AM CK(CPK)-23*
[**2102-5-27**] 09:30AM CK-MB-NotDone cTropnT-5.07*
[**2102-5-27**] 01:28AM COMMENTS-GREEN TOP
[**2102-5-27**] 01:28AM LACTATE-1.0
[**2102-5-27**] 01:15AM GLUCOSE-84 UREA N-24* CREAT-4.4* SODIUM-140
POTASSIUM-4.7 CHLORIDE-97 TOTAL CO2-32 ANION GAP-16
[**2102-5-27**] 01:15AM CK(CPK)-24*
[**2102-5-27**] 01:15AM cTropnT-6.23*
[**2102-5-27**] 01:15AM CK-MB-4 proBNP-[**Numeric Identifier 97839**]*
[**2102-5-27**] 01:15AM DIGOXIN-1.2
[**2102-5-27**] 01:15AM WBC-6.4 RBC-3.44* HGB-9.8* HCT-31.7* MCV-92
MCH-28.6 MCHC-31.0 RDW-17.4*
[**2102-5-27**] 01:15AM NEUTS-77.8* LYMPHS-11.3* MONOS-9.7 EOS-0.7
BASOS-0.5
[**2102-5-27**] 01:15AM PLT COUNT-239
[**2102-5-27**] 01:15AM PT-17.6* PTT-30.9 INR(PT)-1.6*
Imaging:
CXR [**5-27**]:
UPRIGHT RADIOGRAPH OF THE CHEST: There has been no significant
interval
change with persistent bilateral pleural effusions and bibasilar
opacities. Cardiomediastinal silhouette is largely obscured by
the pleural effusions and the basilar opacities; however,
grossly unchanged. Median sternotomy wires and mediastinal clips
are unchanged.
IMPRESSION: No significant changes since [**2102-5-24**], with
persistent
bilateral pleural effusions.
Echo [**5-29**]:
Conclusions
The left atrium is dilated. EF>60%. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity is
mildly dilated. Tissue Doppler imaging suggests an increased
left ventricular filling pressure (PCWP>18mmHg). Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. The aortic arch 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. 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.
IMPRESSION: Mildly dilated LV with mild symmetric LVH and
preserved systolic function. Diastolic dysfunction. Mild mitral
regurgitation. Moderate pulmonary artery systolic hypertension.
Echo [**5-31**]:
Conclusions
The left atrium is dilated. The right atrium is moderately
dilated. There is mild symmetric left ventricular hypertrophy
with normal cavity size and regional/global systolic function
(LVEF>55%). There is no ventricular septal defect. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. There is no
pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
No significant valvular abnormality seen.
Compared with the prior study (images reviewed) of [**2102-5-29**], no
change.
CXR [**5-31**]:
FINDINGS: New left subclavian vascular catheter terminates in
the proximal to mid superior vena cava, directed towards the
lateral wall of this vessel. There is no evidence of
pneumothorax. Otherwise, no relevant changes since the recent
radiograph performed a few hours earlier.
CXR [**6-7**]:
Large bilateral pleural effusions, greater on the left side are
unchanged. There is mild worsening in moderate pulmonary edema.
Bibasilar
consolidations, greater on the left side, are unchanged.
Cardiomediastinal
silhouette is obscured by parenchymal opacities. Sternal wires
are aligned.
Brief Hospital Course:
BRIEF HOSPITAL COURSE, BY PROBLEM:
65 year old male with a history of diastolic CHF (EF > 60%), CAD
s/p CABG in [**2079**] and STEMI [**2102-5-19**] with three stents placed,
ESRD on hemodialysis s/p failed transplant and known chronic
bilateral pleural effusions with associated trapped lung who was
admitted to the hospital with NSTEMI in the setting of a recent
STEMI with stent placement. His hospital course was complicated
by admission to the MICU for refractory hypotension and
worsening oxygen requirement. He was subsequently transferred to
the medicine service for further evaluation.
# Shock:
Most likely etiology was thought to be septic shock during
refractory hypotension. He required initially dopamine and
levophed. Most likely etiology would be pneumonia although
blood stream infection was considered. Patient was ablee to be
liberated from dopamine fairly rapidly after MICU admission. He
had a repeat cardiac echo on [**5-31**] which was compared to his
admission cardiac echo on [**5-29**] which did not appear to be
cardiogenic shock. Patient on low dose prednisone and random
cortisol yesterday was 11.5. His blood pressures improved on
vanco and zosyn and he was weaned off levo without
complications. He was continued on a course of vanco and zosyn
for HAP. His cultures both at [**Hospital3 **] as well as [**Hospital1 18**]
continued to be negative. He was initially started on stress
dose steroids and then tapered appropriately. On [**6-2**] he was
completely off pressors with stable blood pressure.
Hemodialysis was reinitiated and he tolerated it well. He was
called out to the floor. Blood pressures were stable after
transfer.
# Pleural Effusions/Hypoxia:
From admission, patient with increasing dyspnea and hypoxia
thought most likely related to restrictive disase in setting of
chronic pleural effusions and trapped lung. With abx treatment,
his oxygen requirement was weaned down to 3L by nasal cannula
and dyspnea is resolved. Stable resp status off pressors.
Serial arterial blood gases were followed. Given his need for
aspirin and Plavix, in addition to the loculations of the left
pleural effusion, interventional pulmonary and thoracics did not
think he was a surgical candidate. He was scheduled close follow
up with both IP and pulmonary.
#Coronary Artery Disease:
s/p recent posterior MI with PCI and three vision stents
complicated by vfib arrest requiring shocks. Currently chest
pain free. New echocardiogram without evidence of post-MI
complications. EKG with new TWI but no ST segment changes.
Repeat cardiac enzymes with flat CKs. He was continued on ASA,
plavix and his statin through his hospital course but his
antihypertensives were held after he became hypotensive, and
restarted (carvedilol and isosorbide).
# Chronic diastolic congestive heart failure: He was continued
on carvedilol (at lower dose, prescription provided) once his
blood pressures could tolerate them. Digoxin was discontinued
during this hospitalization, with the thought that it might be
worsening his heart failure. Aggressive fluid removal via HD was
attempted but was not particularly successful. He was discharged
on home oxygen.
# Atrial Fibrillation: Patient was put on heparin gtt as well
as ASA/plavix through his hospital course. His anticoagulation
was initially discontinued, and warfarin was restarted on [**6-4**].
He was then restarted on coumadin on [**6-2**] (2mg daily). Digoxin
was discontinued as above. He should have his INR checked at his
appointment with his primary care physician on Tuesday.
# ESRD on HD s/p failed transplant: HD started back on [**6-2**]
once he was liberated from pressor requirement. His prednisone
was continued. He was continued on sevelamer and fluconazole.
Approximately 3-3.5L were taken off with each dialysis session
on [**5-23**], and [**6-9**].
# Gout: Stable. Patient continued on home allopruinol 100mg PO.
# Recurrent [**Female First Name (un) **] esophagitis. He was treated with
fluconazole without complications.
# Depression: Continued on citalopram, increased to 30mg daily.
Medications on Admission:
Allopurinol 100 mg PO daily
Coreg 37.5 mg PO daily
Citalopram 30 mg PO daily
Epogen with dialysis
Fluconazole 100 mg PO daily
Hydralazine 50 mg TID
Isosorbide Dinitrate 40 mg PO TID
Omeprazole 20 mg [**Hospital1 **]
Home oxygen 2L
Pravastatin 80 mg daily
Prednisone 2.5 mg daily
Sevelamer 800 mg PO TID
Prometazine 12.5 mg PO daily
Temezepam 15 mg PO QHS:PRN
Coumadin 2 mg Po daily
Plavix 75 mg PO daily
Digoxin 125 mcg q Tuesday and Saturday
Aspirin 325 mg daily
Discharge Medications:
1. Home Oxygen
Home oxygen @ 2-4 liters per minute via nasal cannula conserving
device for portability
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): Do NOT take the morning of hemodialysis.
Disp:*30 Tablet(s)* Refills:*2*
5. Pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
6. Isosorbide Dinitrate 10 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*2*
7. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
10. Fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
11. Citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Disp:*45 Tablet(s)* Refills:*2*
12. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
13. Promethazine 25 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8
hours) as needed for nausea.
14. Temazepam 15 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime) as needed.
15. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
acute on chronic diastolic congestive heart failure LVEF 55%
ESRD on HD s/p failed renal transplant
HTN
bilateral pleural effusions
Discharge Condition:
Stable, Sat low 90's on 2L nasal cannula
Discharge Instructions:
You were admitted with chest pain and difficulty breathing. You
were found to have suggestion of another heart attack. You also
had large amounts of fluid around and in your lungs. Your blood
pressure became very low and you required a stay in the medical
intensive care unit. Since then, we have been able to remove
fluid from your body through dialysis, and you are going home
with home oxygen.
Your medications have been changed:
- Your carvedilol has been cut in half (to 12.5mg twice daily)
- Your citalopram has been increased (to 30mg daily)
- Your hydralazine has been discontinued
- Your prednisone has been increased to 5mg daily
- Your isosorbide dinitrate has been decreased to 20mg three
times a day
- You should continue taking 2mg warfarin daily and have Dr.
[**Last Name (STitle) **] recheck an INR
- Your digoxin was discontinued.
.
You must continue your aspirin and Plavix until instructed to
stop by your cardiologist. You should continue dialysis three
times weekly, and keep all of your follow up appointments as
scheduled. If you develop worsening shortness of breath, chest
pain, palpitations, abdominal pain, nausea, vomiting, or other
concerning symptoms, please seek medical attention immediately.
.
Followup Instructions:
Primary Care:
Dr. [**First Name4 (NamePattern1) 1575**] [**Last Name (NamePattern1) 1576**] Phone: [**Telephone/Fax (1) 1579**] Date/Time: [**2102-6-13**]
12:00
Cardiology:
DR. [**Known firstname **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2102-6-19**] 2:30
Interventional Pulmonology:
[**Doctor Last Name 17853**] CLINIC INTERVENTIONAL PULMONARY (SB)
Phone:[**Telephone/Fax (1) 3020**] Date/Time:[**2102-6-26**] 10:00
Pulmonology:
DR. [**First Name (STitle) **] & DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2102-7-24**]
4:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,388
| 180,667
|
28399
|
Discharge summary
|
report
|
Admission Date: [**2190-1-6**] Discharge Date: [**2190-1-13**]
Date of Birth: [**2118-11-10**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2167**]
Chief Complaint:
Cough, hemoptysis
Major Surgical or Invasive Procedure:
Pericardial Drain
Angioseal to Right Ventricle s/p pericardial drain insertion
into right ventricle
Embolisation of right bronchial artery
Bronchoscopy
History of Present Illness:
This is a 71 year old woman with a 10 year history of non-small
cell carcinoma of the lung who is transferred from [**Hospital 4199**]
Hospital for care for a pericardial effusion as well as for
potential treatment of hemoptysis. She is status post a number
of courses of chemotherapy and radiation.
She initially presented to the [**Last Name (un) 4199**] ED with increasing
hemoptysis. Per the ED note she reported having coughed up a
large amount of blood 1.5 months prior to presentation, and then
4 days prior the bleeding increased again. She also was having
chest pain with coughing (and only with coughing), described by
the [**Last Name (un) 4199**] ED report as intermittent and sharp and associated
with shortness of breath.
She had a chest x-ray there and per report had a dense opacity
in the right upper lobe with moderate airspace opacity in the
right lower lobe with loss of lung volume; as well as mild
mediastinal shift to the right and decreased aeration of the
right lung. She had a Hct of 32.1 with 88% neutrophils; and a K
of 3.4. She was reportedly tachycardic in the 110s-120s and
afebrile through her stay there and per the discharge summary
these heart rates have been typical of her for the past "several
weeks".
She has been seen here at the [**Hospital1 18**] earlier in [**2189**] for an
attempt to stent her bronchus; this did not improve symptoms.
In discussion with the patient and her family (including son
[**Name (NI) 54826**] and daughters [**Name (NI) 504**], [**Name (NI) 21212**], and [**Month (only) 116**]), with a [**Hospital1 18**] Chinese
interpreter, history was made somewhat difficult by the fact
that Ms [**Known lastname **] is hard-of-hearing and evidently speaks a rural
mainland Chinese Cantonese dialect distinct from the [**Location (un) 6847**]
dialect spoken by her children and the [**Hospital1 18**] interpreter.
Nonetheless, a review of systems suggested that hemoptysis and
pain with coughing have been the most troubling symptoms; there
has been no fever, chills, or sweats; she has had some white
sputum when it is not bloody, but no other color of sputum; she
denies troubling palpations although she says her heart beats
much faster with exertion; she occasionally has chest tightness
but distinct chest tightness or pain is not a prominent symptom;
she does not have pain elsewhere.
On arrival in MICU 7, her vitals were HR 122 BP 96/69 (map 67)
RR 24 88% RA. She came up to high 90s for O2 sat with nasal
cannula.
Past Medical History:
Lung CA, first diagnosed in [**2178**], s/p radiation, s/p
gemcitapbine and carboplatin, Alimta, Tarceva, taxotere,
erbitux.
Hypertension
Anxiety
Reflux
Colonic polyps, partially removed
Social History:
The patient grew up in mainland [**Country 651**] and then raised her
children in [**Location (un) 6847**]. No tobacco or asbestos exposure. Has
lived in [**Location (un) 6847**], [**Location (un) **], and the United States; worked as a
kitchen worker; now lives with son and daughter-in-law. [**Name (NI) **] is
[**Name (NI) 54826**], daughters are [**Name (NI) 21212**], [**First Name3 (LF) 116**], and [**Name (NI) **]. [**Male First Name (un) 54826**] is informal
family decisionmaker while [**Doctor First Name 21212**] is the spokesperson as she is
the best English speaker. Relevant to this admission, husband
died after apparent pericardiocentesis.
Family History:
NC
Physical Exam:
Vitals: HR 122 BP 96/69 (map 67) RR 24 88% RA. Pulsus [**1-10**]
GEN: Elderly woman in no acute distress, occasional paroxysms of
coughing
HEENT: Dry mucus membranes; clear OP; PERRL.
NECK: Several lymph nodes felt along the anterior cervical chain
on the right side, ?one node on the left.
HEART: RRR, no murmur, rub, or gallop; distant heart sounds
LUNGS: both sides, diffuse crackles. Left side: bronchial and
rhonchorous low-pitched breathing sounds. Right: poor air
movement; absent air movement at right base
ABDOMEN: BS active, NT, ND
EXT: No edema, WWP, pulses 1+ on all 4 ext; clubbing on fingers
Pertinent Results:
ON ADMISSION:
[**2190-1-6**] 11:23PM BLOOD WBC-7.0 RBC-3.62* Hgb-10.1* Hct-31.5*
MCV-87 MCH-27.9 MCHC-32.0 RDW-16.6* Plt Ct-317
[**2190-1-6**] 11:23PM BLOOD Neuts-82.9* Lymphs-12.0* Monos-4.7
Eos-0.2 Baso-0.2
[**2190-1-6**] 11:23PM BLOOD PT-14.8* PTT-24.5 INR(PT)-1.3*
[**2190-1-6**] 11:23PM BLOOD Glucose-125* UreaN-11 Creat-0.5 Na-142
K-3.3 Cl-102 HCO3-31 AnGap-12
[**2190-1-6**] 11:23PM BLOOD ALT-41* AST-23 LD(LDH)-291* AlkPhos-60
TotBili-0.4
[**2190-1-6**] 11:23PM BLOOD Albumin-3.2* Calcium-8.4 Phos-2.9 Mg-2.1
IRON STUDIES:
[**2190-1-6**] 11:23PM BLOOD Iron-24* calTIBC-261 Ferritn-197* TRF-201
ON TRANSFER FROM MICU TO FLOOR:
[**2190-1-10**] 02:46AM BLOOD WBC-10.7 RBC-4.31 Hgb-13.0 Hct-37.5
MCV-87 MCH-30.1 MCHC-34.5 RDW-16.7* Plt Ct-317
[**2190-1-9**] 05:27AM BLOOD PT-14.9* PTT-23.9 INR(PT)-1.3*
[**2190-1-10**] 02:46AM BLOOD Glucose-82 UreaN-10 Creat-0.5 Na-138
K-3.7 Cl-102 HCO3-31 AnGap-9
[**2190-1-10**] 02:46AM BLOOD Calcium-8.2* Phos-2.1*# Mg-1.9
CULTURE DATA:
[**2190-1-7**] Coag negative staph and clostridium species
[**1-8**], [**1-9**] blood cultures with no growth to date
[**1-10**] pericardial catheter IV tip no growth to date
.
[**2190-1-7**] 5:00 pm FLUID, PERICARDIAL. no growth to date.
.
STUDIES:
[**1-7**] ECHO
Moderate circumferential pericardial effusion with evidence of
pericardial tamponade. Left ventricular function is
hyperdynamic. The right ventricle appears small and compressed
during systole and diastole. The heart is moving around within
the effusion with the result that the minimal amount of fluid
anteriorly can be as little as 0.7cm. The majority of the fluid
is at the apex (more than 2cm wide).
.
[**1-9**] ECHO
Small organized pericardial effusion, without echocardiographic
signs of tamponade physiology
.
[**1-11**] ECHO: There is a very small, primarily inferolateral
echogenic pericardial effusion without evidence for hemodynamic
compromise.
.
[**1-7**] CARDIAC CATH: PLACEMENT OF PERICARDIAL DRAIN
1. Pericardiocentesis was performed with removal of 350 ml of
bloody
fluid. 2. Resting hemodynamics revealed elevated right and left
sided filling pressures with RVEDP of 20 mm Hg and mean PCWP of
22 mm Hg. The
pericardial pressure was 11 mm Hg as was the initial RA mean.
This is
consistent with tamponade physiology. Following the drainage of
350 ml
of sanguinous fluid, Pericardial pressure became neagtive with
respiration. The systemic arterial blood pressure was normal at
119/65
mm Hg. The cardiac index was preserved at 3.4 l/min/m2. 3.
Prior to successful pericardiocentesis, initial attempts to
acess the pericardial space led to early removal of bloody
fluid, with a transduced pressue similar to RA mean pressure.
This was believed to be pericardial pressure. However, after
draining 60-100 ml of fluid, the patient became hypotensive, and
contrast injection through the catheter revealed opacification
of the pulmonary artery, suggesting entry into the RA. FINAL
DIAGNOSIS: 1. Successful pericardiocentesis 2. Pericardial
effusion with tamponade physiology. 3. Procedure complicated by
placement of pericardial drainage catheter into the right
atrium.
.
[**1-8**] IR REPORT (PRELIM)
Successful embolization of the right bronchial artery.
Intercostal artery
inferior to the right bronchus and artery was identified, which
was also
supplying the tumor activity. If the patient's hemoptysis does
not stop,
selective embolization of this intercostal artery can be
offered.
.
[**1-10**] CXR: The right-sided PICC line has been readjusted, and
the distal tip is now in the right subclavian/axillary vein
junction. There is again noted deformity of the right chest wall
with complete lung opacification. The catheter seen projecting
over the left base has been removed, likely related to the
patient's pericardiocentesis. The left lung is clear. No
pneumothoraces are identified.
Brief Hospital Course:
71 year old woman with non-small cell lung CA who presents with
complaints of hemoptysis, ongoing cough, transferred from OSH
with diagnosis of pericardial tamponade.
PERICARDIAL TAMPONADE
Repeat ECHO revealed RV collapse and signs of pericardial
tamponade. Patient underwent pericardial drain placement
complicated by cannulization of the right ventricle. The right
ventricle drain was removed and an angioseal was placed. During
procedure patient went into SVT/Atrial fibrillation and was
placed on an amiodarone drip. Given subsequent hemodynamic
compromise with atrial fibrillation in MICU, patient was
maintained on amiodarone drip for 24 hours and converted to oral
amiodarone. Patient did not have significant bleeding post
procedure into her pericardial drain. The patient's pericardial
drain was pulled on post op day 2. Repeat ECHO on 12.13 and then
12.15 revealed evidence of small clot in pericardium without
significant reaccumulation of fluid. She had persistent atrial
fibrillation to 120, rarely as high as 160 for brief periods of
time. Metoprolol was added to amiodarone for improved rate
control. Home diltiazem was discontinued. The patient tolerated
the addition of metoprolol for several days prior to discharge.
HEMOPTYSIS
Patient's submassive hemoptysis was treated with IR embolization
of right bronchial artery for palliation of symptoms. Patient
was followed by interventional pulmonary. Flexible bronchoscopy
on [**2190-1-11**] revealed tumor erosion of bronchi with near complete
compression of the right bronchus intermedius. At the
recommendation of the IP team and in accordance with the patient
and her family's wishes, the patient underwent repeat palliative
bronchial artery embolization on [**2190-1-11**].
LUNG CANCER
Patient with metastatic non-small cell lung cancer. Patient and
family appreciated palliative care consult and plans to go home
with hospice. Patient was maintained on her home prednisone
dose. Patient was also given levofloxacin for empiric treatment
of pneumonia given patient has new oxygen requirement and lung
opacification with known bronchus compression. Her oxygen
requirement is also likely in part due to tumor progression and
compression of right bronchus intermedius. The patient will
complete a 10 day course of levofloxacin and was set up with
home oxygen for continuous supplementation by nasal cannula. She
will have home hospice services who will help with obtaining a
nebulizer machine for ipratropium nebs and a home hospital bed.
POSITIVE BLOOD CULTURES: Patient grew 3 different colonies of
coag neg staph and a clostridium species on initial blood
cultures. She was started on Vancomycin. Repeat surveillance
blood cultures remained negative. The patient had a midline
placed which was subsequently removed. Ultimately the patient's
positive blood cultures were felt most likely consistent with
contamination. She was discharged on levofloxacin monotherapy
for treatment of likely pneumonia as above.
HYPERTENSION. She continues on metoprolol. Her home diltiazem
was discontinued. She did have relative hypotension during the
beginning of her hospitalization, requiring no antihypertensives
to maintain good blood pressure control.
Contact: Daughter, [**Name (NI) 21212**]: cell, [**Telephone/Fax (1) 68905**], home, [**Telephone/Fax (1) 68906**];
[**Name (NI) 54826**], [**First Name3 (LF) **], [**Telephone/Fax (3) 68907**]
Primary care doctor: Dr. [**Last Name (STitle) 65851**] at [**Hospital1 5991**].
Oncology: Dr. [**First Name (STitle) **] at [**Hospital6 12736**].
PATIENT AND FAMILY AGREE WITH DNR/DNI STATUS.
Medications on Admission:
MEDICATIONS ON TRANSFER FROM OSH:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Megestrol Acetate 40 mg PO DAILY
3. Benzonatate 100 mg PO TID:PRN cough
4. Multivitamins 1 TAB PO DAILY
5. Clonazepam 0.5 mg PO BID:PRN anxiety
6. Omeprazole 20 mg PO DAILY
7. Guaifenesin-Dextromethorphan 5 mL PO Q4H:PRN
8. PredniSONE 5 mg PO DAILY
9. Levofloxacin 500 mg PO Q24H
10. Sertraline 100 mg PO DAILY
HOME MEDS:
anitidine
Cheratussin
prednisone 5 mg daily
diltiazem CR 120 daily
clonazepam 0.5 mg as needed
megestrol 40 mg daily
multivitamin
naproxen 500 mg twice daily
sertraline 100 mg daily,
prilosec OTC
tylenol no. 3
Discharge Medications:
1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*5*
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
3. Megestrol 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*5*
4. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*5*
5. Clonazepam 0.5 mg Tablet Sig: 1-2 Tablets PO BID (2 times a
day) as needed for anxiety.
Disp:*45 Tablet(s)* Refills:*5*
6. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO Q4H (every 4 hours) as needed.
Disp:*100 ml* Refills:*5*
7. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
Disp:*90 Capsule(s)* Refills:*5*
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheeze.
Disp:*1 inhaler* Refills:*5*
9. Amiodarone 200 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Disp:*45 Tablet(s)* Refills:*5*
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*5*
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*60 Tablet(s)* Refills:*5*
12. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*5*
13. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
14. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*5*
15. Home Oxygen
Home Oxygen: 3.5L nasal cannula continuous. Pulse dose for
portability.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Hemoptysis
Pericardial tamponade
Metastatic lung cancer
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with blood in the sputum. This is due to
complications from lung cancer. You underwent several procedures
to try to prevent further bleeding. A home nurse will come to
your house and be available by phone to help with any new
medical problems.
You should continue to receive oxygen by nasal cannula at home.
A home oxygen unit will be provided for you. In addition, your
hospice nurse can help you obtain a nebulizer machine for
further breathing treatments. The hospice nurse will also help
you obtain a hospital bed.
Complete a course of the antibiotic levofloxacin for 10 total
days to treat a possible infection in your lungs. You also must
take prednisone as prescribed.
Take all medications as prescribed.
Call your home hospice nurse for any new or concerning symptoms
that you would like [**Location (un) **] with.
Followup Instructions:
A home hospice nurse [**First Name (Titles) **] [**Last Name (Titles) **] with ongoing needs. You may
call Dr.[**Name (NI) 68908**] or Dr.[**Name (NI) 39123**] office for further
follow-up if you would like.
|
[
"786.3",
"427.31",
"998.2",
"530.81",
"427.1",
"E878.8",
"162.8",
"401.9",
"423.3",
"486",
"997.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.17",
"32.01",
"37.0",
"37.21",
"38.93",
"88.55",
"39.79"
] |
icd9pcs
|
[
[
[]
]
] |
14428, 14485
|
8425, 12034
|
333, 486
|
14586, 14595
|
4546, 4546
|
15488, 15699
|
3898, 3902
|
12699, 14405
|
14506, 14565
|
12060, 12676
|
14619, 15465
|
3917, 4527
|
276, 295
|
514, 2997
|
4560, 8402
|
3019, 3208
|
3224, 3882
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,914
| 168,353
|
26119
|
Discharge summary
|
report
|
Admission Date: [**2111-12-31**] Discharge Date: [**2112-1-20**]
Date of Birth: [**2065-10-11**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Amoxicillin / Ampicillin / Penicillins
Attending:[**First Name3 (LF) 297**]
Chief Complaint:
Transfer from [**Hospital3 5173**] for diffuse alveolar damage
requiring intubation
Major Surgical or Invasive Procedure:
Intubation x 2
Bronchoscopy with BAL
Percutaneous tracheostomy
History of Present Illness:
46 yo F with h/o asthma and tob use presents from OSH intubated
for progressive hypoxic respiratory failure. Pt is currently
paralyzed and sedated.
.
Pt initially presented to [**Hospital3 5173**] on [**2111-12-21**] with 5-6
days of fevers to 101, cough productive of bloody sputum,
wheezing, and progressive SOB refractory to her inhalers. She
initially received Rocephin, Azithromax, SoluMedrol, and Nebs.
An HIV test was obtained.
.
Per OSH pulmonologist, Dr. [**Name (NI) 8260**], pt has had progressive dsypnea
x5-6 months requiring multiple admissions. SOB has been
partially responsive to steroids. CXR's over the last several
months revealed progressive b/l infiltrates, initially mostly at
the bases. CT scan from [**11-8**] revealed enlarged medistinal LN's;
CT scan from 1 yr prior with minimal mediastinal LAD. PFT's
revealed normal spirometry with minimally decreased lung volumes
c/w obesity. Bronchoscopy 1 yr ago was unremarkable.
.
Pt underwent an open pulmonary bx ([**2111-12-25**]). Path revealed
diffuse alveolar damage. Cx from lung biopsy (AFB, Mycoplasma,
PCP, [**Name Initial (NameIs) **]) were all negative. She was extubated 2 days
post-op. Chest tube removed [**12-28**].
.
Her respiratory status further deteriorated BiPAP and
reintubation. Since [**12-21**] she has had a leukocytosis (WBC ~20)
thought to be secondary to high dose steroids. She has been
afebrile. She became hypotensive prior to transfer requiring
dopamine. Her initial gas revealed an acidosis that improved
with increasing tidal volume.
Past Medical History:
Past Medical History:
- bipolar disorder with panic attacks
- asthma since childhood never requiring intubation
- interstitial lung disease
- steroid induced diabetes
- s/p C-section
Social History:
SH: Smokes 2 packs per day, +EtOH abuse (unclear amount),
possible illicit drug abuse. She is in an abusive relationship.
.
FH: Mother with [**Name (NI) 64807**], Father with COPD.
Family History:
NC
Physical Exam:
Discharge Physical
Tc 99.2 BP 114/54 HR 80s RR 28 Sat 100%
CPAP: PS of 10, PEEP 5; TV 430 x 20. ABG ([**2111-1-19**]) 7.45/37/81
Gen: alert and communicative
HEENT: anicteric, pupils 5 mm; reactive, OGT and trach in place
CV: RRR, nl S1S2, No M/R/G
Lungs: rhoncherous breath sounds throughout, crackles at lung
bases and decreased breath sounds
Abd: obese, soft, NT/ND
Ext: strong DP/PT pulses bilaterally
Pertinent Results:
Labs On Admission:
[**2111-12-31**] 10:05PM BLOOD WBC-22.1* RBC-3.55* Hgb-10.1* Hct-30.6*
MCV-86 MCH-28.5 MCHC-33.0 RDW-15.7* Plt Ct-505*
[**2111-12-31**] 10:05PM BLOOD Neuts-92.0* Lymphs-6.0* Monos-1.8* Eos-0
Baso-0.2
[**2111-12-31**] 10:05PM BLOOD Glucose-163* UreaN-22* Creat-0.5 Na-136
K-3.7 Cl-101 HCO3-25 AnGap-14
[**2111-12-31**] 10:05PM BLOOD Calcium-8.6 Phos-3.4 Mg-2.1
[**2112-1-1**] 11:45AM BLOOD Albumin-2.6*
[**2112-1-1**] 11:45AM BLOOD ALT-32 AST-28 LD(LDH)-360* AlkPhos-81
TotBili-0.3
[**2112-1-1**] 11:45AM BLOOD RheuFac-17* CRP-221.5*
[**2111-12-31**] 10:18PM BLOOD Type-ART pO2-168* pCO2-48* pH-7.34*
calHCO3-27 Base XS-0
[**2112-1-1**] 11:45AM BLOOD ESR-11
[**2111-12-31**] 10:18PM BLOOD Lactate-1.0
.
Further Labs:
[**Doctor First Name **] (-)
IgE slightly elevated
ACE (-)
.
OSH Labs:
BAL with cultures, fungals, afb NGTD
Path with cultures, fungals, afb NGTD
.
Path appears consistent with organizing pneumonitis.
.
CT Chest [**1-1**]:
IMPRESSION:
1. Nonspecific widespread predominantly ground-glass opacities
in both lungs could be consistent with the history of diffuse
alveolar damage. Acute interstitial pneumonia, hypersensitivity,
drug toxicity, pulmonary edema and infection are within the wide
differential for the above findings.
2. Mediastinal adenopathy.
3. Small right pleural effusion.
ECHO [**1-1**]:
Conclusions:
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. 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. There is borderline pulmonary
artery systolic hypertension. There is no pericardial effusion.
.
ECHO [**1-11**]:
Conclusions:
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. Left ventricular wall thickness, cavity
size, and systolic function are normal (LVEF>55%). Regional left
ventricular wall motion is normal. Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) are mildly thickened. There is no valvular aortic stenosis.
The increased transaortic gradient is likely related to high
cardiac output. The mitral valve appears structurally normal
with trivial mitral regurgitation. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
Compared with the prior study (images reviewed) of [**2112-1-1**],
the degree of TR and pulmonary hypertension detected has
decreased. The LVEF and RVEF remain normal to hyperdynamic.
There is no pericardial effusion.
.
CXR: [**2112-1-11**]:
An endotracheal tube and central venous catheter remain in
satisfactory position. A nasogastric tube is coiled within the
stomach. Cardiac contours are obscured by adjacent alveolar
process, limiting assessment of heart size. There has been
interval worsening of a diffuse bilateral alveolar process,
which relatively spares the extreme lung apices. The worsening
is more pronounced on the left than the right. Underlying
bilateral pleural effusions are likely but difficult to quantify
in the setting of diffuse lung disease.
.
CXR: [**1-15**]:
FINDINGS: AP single view of the chest has been obtained with
patient in supine position and comparison is made with a similar
previous examination of [**2112-1-11**]. Position of ETT, NG
tube and right subclavian approach central venous line is
unchanged. Same holds for the previously described extensive
left-sided and right-sided basal parenchymal densities. New is
now the presence of a pneumothorax along the lower right-sided
lateral chest wall with a maximal width of about 2 cm.
Thickening of the parietal pleura is noted. The pneumothorax
does not extend into the apical area. It is suspected that a
thoracocentesis has been performed during the interval unless
the pneumothorax is spontaneous. Clinical correlation is
essential.
.
CXR [**2112-1-19**]:
Moderate-to-severe pulmonary edema has worsened.
Small-to-moderate right hydropneumothorax, largely fluid is
stable since [**1-17**], collecting more fluid compared to
[**1-16**]. Heart is mildly enlarged. Mediastinal widening
reflects vascular engorgement. Tip of the right central venous
line projects over the right atrium. Tracheostomy tube has a
standard appearance.
.
MICROBIOLOGY:
[**1-1**]:
Coag Negative Staph 1/4 bottles
.
[**1-4**]: Urine Culture:
VRE: 10-100 x 10^3 colonies
.
Urine Culture: [**1-7**]:
No growth
.
[**1-10**]: BAL
- PCP [**Name Initial (PRE) 5963**]
.
[**1-18**]: Blood cultures:
(+) from central line in [**1-7**] bottles
(-) peripheral cultures in [**1-7**] bottles
.
LABS:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW
Plt
[**2112-1-20**] 05:24AM 12.7* 3.04* 8.8* 26.6* 88 29.0 33.0
18.3* 412
[**2112-1-19**] 03:41AM 13.8* 3.12* 9.1* 27.3* 88 29.0 33.2
18.1* 404
[**2112-1-18**] 04:50AM 14.0* 3.76* 10.9* 32.6* 87 29.0 33.4
17.7* 566*
[**2112-1-17**] 04:34AM 12.3* 3.63* 10.8* 31.4* 86 29.6 34.3
17.5* 595*
[**2112-1-16**] 05:06AM 11.1* 3.77* 10.8* 32.4* 86 28.5 33.3
17.7* 667*
.
COAGS:
[**2112-1-20**]:
PT: 12.8 PTT: 24.3 INR: 1.1
.
SMA 7:
RENAL & GLUCOSE Glu BUN Cr Na K Cl HCO3 AG
[**2112-1-20**] 05:24AM 77 12 0.5 140 4.2 107 261 11
[**2112-1-19**] 03:41AM 108 15 0.5 142 3.7 108 241 14
[**2112-1-18**] 04:50AM 98 27 0.7 135 3.9 102 261 11
[**2112-1-17**] 04:34AM 66 30 0.6 135 4.4 102 251 12
[**1-20**]: Ca: 8.8 Mg: 1.9 Phos: 3.3
.
ABG:
[**2111-1-19**]: 7.45/37/81
.
Brief Hospital Course:
46 yo F with h/o asthma and tob use presents from OSH intubated
for progressive hypoxic respiratory failure.
.
Initial MICU stay:
.
While in the MICU (initially), the patient was intubated and
started on dopamine for hypotension. She was treated
empirically with Vanc, Azithromycin and Ceftriaxone, and IV
steroids were continued. A repeat chest CT showed ground glass
opacities and increased mediastinal LAD. The patient underwent
an extensive w/u for BOOP w/ diff dx including ideopathic,
allergic/reactive, cryptococcus, RA, atypical pna, typical pna,
AIP, DIP, PAP, and ABPA. Sarcoid labs were WNL, RF slightly
elevated, CRP high, but normal ESR. IgE elevated at 407, [**Doctor First Name **]
negative, [**Doctor First Name 14616**] ag & cryptococcal ag both negative.
Cultures from bronchoscopy have been negative. The patient was
successfully extubated, but continued to have an increased
oxygen requirement. She was also weaned off dopamine and
transitioned to oral steroids (from 125 IV solumedrol q 8 hours
to 60 of oral prednisone daily). An echo was done which showed
borderline pulm HTN with normal LV size and EF >55%. She was
found to have urine cx positive for VRE, foley was changed and
repeat culture was negative.
.
On transfer to the floor, she has been maintained on Face mask
(50%)and 6 lpm via nc with sats in the mid-nineties. With any
activity (bowel movements, eating, transfering to the bedside
commode), she has consistently become tachypneic to the 30's to
40's, desaturated to the 70's and then had superimposed anxiety
requiring use of NRB and ativan. This morning she was found to
be relatively [**Name2 (NI) 24420**] at a systolic of 90, with a question of
electrical alternans on her ECG per the team on the floor. From
a respiratory standpoint, she was stable on her facemask and nc,
with sats of 95, breathing at approx 28. She endorsed
lightheadedness, but no other specific complaints. Given the
multiple desaturations overnight requiring relatively constant
nursing care, the MICU was called to evaluate for transfer back
to the unit. On evaluation, her pressure was systolic of 104,
pulsus was 8.
.
On transfer back to the ICU:
- she was reintubated for decreased oxygenation. She was
maintained on AC/CPAP and oxygenated and ventilated well.
However, she did not tolerate breathing trials very well. Hence,
it was felt that a tracheostomy would be a better long term
solution to her respiratory needs. On [**1-15**], she was trached
without difficulty. 2 days later, a small pneumothorax in her R
Lung base was discovered. She was placed on 100% O2 overnight,
with interval resolution of the pneumothorax. By [**1-19**], the
pneumothorax has mostly resolved.
- she was bronched on [**2112-1-10**] and all cultures were negative.
.
With the tracheostomy, she was able to breath on her own,
intermittently requiring CPAP with pressure support. In AM of
[**1-19**], her ABg was 7.45/37/81
.
- she also completed a 10 day course of Azithromycin/Ceftriaxone
- prednisone was changed to 125mg IV q8 of methylprednisolone on
readmission to MICU; this was reconverted to 60mg prednisone
daily on [**1-17**]. Our plan regarding the steroids is to taper her
slowly, being treated at 1mg/kg (60mg prednisone) for 3 months,
with a slow taper thereafter.
.
Her course in the hospital was also complicated by:
- VRE UTI (10-100 x 10^3 colonies) on [**1-4**]. Repeat cultrues were
negative.
- finished 7 day course of Abx.
- increased prolactin levels: stopped risperdal and weaned off
fentanyl; prolactin dropped from 41.0 to 4.0.
- GPC in pairs and chains from central line (but negative in
periphery) on [**2111-1-18**]: started on linezolid - would finish 7 day
course; would recommend surveillance cultures and D/C linezolid
if negative. She has been afebrile for ~48 hours prior to
discharge. We have sent repeat cultures and these are pending as
of AM of [**2112-1-20**].
.
- nebs: ipratropium and albuterol
.
# Bipolar disorders-> Continue wellbutrin. On Prozac, appears
stable. Patient often has anxiety with unclear precipitant;
ativan has some effect. Olanzapine has been working well to
assist with sleep. Changed to seroquel on [**2111-1-19**] - with good
effect.
.
# Galactorrhea: Pt with elevated prolactin. ? Unknown etiology.
held risperdal. fentanyl stopped. Rechecked prolactin 4.0
.
# PPX-> SC heparin, PPI, bowel regimen, chlorhex oral care.
.
# Diet: Regular
.
# Communication:
Dr. [**First Name (STitle) 8260**] (pulmonologist [**Hospital3 5173**]) - [**Telephone/Fax (1) 64808**]
[**Name (NI) 717**] [**Name (NI) **], HCP, [**Telephone/Fax (1) 64809**].
Medications on Admission:
Home Meds:
Mucinex 600 [**Hospital1 **]
[**Doctor First Name **] 180 daily
Accolate 20 [**Hospital1 **]
Topamax 100 qam, 400 qPM
Avandia 4 qam
Prozac 60 qam
Risperdal 1 mg tid
Combivent inhaler 2 puffs q4 hrs
Advair diskus 500/50 1 puff [**Hospital1 **]
?Prozac
?Wellbutrin
Steroids xseveral months (when tapered clinical status
deteriorates)
Zyflo 600 qid
.
Transfer Meds:
Propofol gtt
Salumedrol 125 q 6hrs
Morphine 2 mg q 4 hrs
Vecuronium gtt
Tylenol
Albuterol q4 hrs
Atrovent q 4 hrs
Humalog SS
Pepcid
Prozac 60 daily
Risperdal 1 mg q8 hrs
Topamax 400 qhs, 100 qam
Discharge Medications:
1. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q4-6H
(every 4 to 6 hours) as needed.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. Fluoxetine 20 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily).
5. Bupropion 75 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
9. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
11. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
12. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every
4 to 6 hours) as needed.
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO once a day:
15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
16. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
17. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours): Started for GPC from line. Continue until
surveillance Cx negative.
18. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q8:PRN as needed
for anxiety.
19. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation Q4H (every 4 hours).
20. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours).
21. Fluticasone 110 mcg/Actuation Aerosol Sig: Six (6) Puff
Inhalation [**Hospital1 **] (2 times a day).
22. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours) as needed.
23. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff
Inhalation Q4H (every 4 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital2 **] [**Hospital3 4094**]
Discharge Diagnosis:
Cryptogenic organizing pneumonitis
Discharge Condition:
AAO x 3
Intermittently requiring CPAP
Afebrile
OOB to chair
Tachypneic - ~mid 30s RR
Discharge Instructions:
Patient can breathe on her own at times; at other times, needs
some CPAP with pressure support.
Her secretions need intermittent suctioning.
Her tachypnea worsens with anxiety - we have been giving her
ativan, zyprexa for sedation. On [**1-19**], seroquel was added on
nightly, which has helped her to sleep (and olanzapine was
D/Cd).
We have also written her for PRN valium for the anxiety.
.
She is on prednisone - with plans to continue at 60mg/d for 3
months and a slow subsequent taper.
Started on linezolid on [**1-19**] for GPC in pairs and chains from
central line - but negative in peripheral. Would send
surveillance cultures and D/C when cultures negative or finish 7
day course.
Followup Instructions:
Please call Dr. [**First Name (STitle) 8260**] (pulmonologist) for a follow up
appointment.
Completed by:[**2112-1-20**]
|
[
"305.1",
"296.80",
"512.1",
"611.6",
"785.50",
"515",
"E932.0",
"276.2",
"516.8",
"V09.80",
"251.8",
"599.0",
"300.01",
"518.81",
"V58.65",
"493.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.6",
"96.04",
"33.24",
"31.1"
] |
icd9pcs
|
[
[
[]
]
] |
16029, 16093
|
8641, 13260
|
394, 458
|
16172, 16259
|
2898, 2903
|
16999, 17122
|
2451, 2455
|
13880, 16006
|
16114, 16151
|
13286, 13857
|
16283, 16976
|
2470, 2879
|
271, 356
|
486, 2028
|
2917, 8618
|
2072, 2235
|
2251, 2435
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,811
| 146,729
|
30667
|
Discharge summary
|
report
|
Admission Date: [**2154-6-27**] Discharge Date: [**2154-7-8**]
Date of Birth: [**2091-6-16**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
Microcytic anemia/lower Gastrointestinal Bleeding (transfusion
dependent) secondary to an ulcerating mass in the small bowel or
cecum
Major Surgical or Invasive Procedure:
1- S/p Right Hemicolectomy/terminal ileal resection w/ a primary
ileo-transverse colostomy with a side-to-side, functional
end-to-end stapled anastamosis ([**2154-6-27**])
2- S/p Segmental Sigmoid Colectomy and takedown of a colovesical
fistula with primary bladder repair and an end-to-end handsewn,
single layer anastamosis ([**Last Name (un) **]-colostomy) ([**2154-6-27**])
History of Present Illness:
Mr. [**Known lastname 19219**] is a pleasant, 63yo M w/ a PMHx significant for
Obesity, HTN, DM2, GERD, PUD, Afib on coumadin, prior LBBB on
ECG who now presents with chronic anemia and guaiac positive
stools. Work-up with the GI service including upper and lower
endoscopy, as well as a capsule endoscopy w/ Dr. [**Last Name (STitle) **]
revealed the possibility of a small bowel or cecal mass/ulcer.
This prompted a general surgery consult w/ Dr. [**Last Name (STitle) **] and
accordingly, the patient was consented for exploration, right
hemicolectomy and exploration of the small bowel.
Past Medical History:
1- DM2
2- HTN
3- GERD
4- Obesity
5- ^lipids
6- Afib/LBBB
7- OSA
Social History:
married, lives in [**Last Name (LF) **], [**First Name3 (LF) **] lives locally, rare EtOH, no
tobacco
Family History:
N/C
Physical Exam:
VS: 99.0 HR 90 BP 128/90 RR 24 SpO2 96%RA
HEENT- no JVD, OP clear, no thyromegaly, no LAD
Cor- SIS2 ?S3, no m/r/g
Pulm- decreased breath sounds at the bases, no crackles
Abd- appropirately tender, protuberant/obese, +BS, wound C/D/I
Ext- 1+ edema, warm, normal ROM, pulse NP, +good cap refill
Pertinent Results:
[**2154-6-27**] 11:13AM PT-14.2* PTT-27.3 INR(PT)-1.3*
[**2154-6-27**] 11:25AM freeCa-1.21
[**2154-6-27**] 11:25AM HGB-9.0* calcHCT-27
[**2154-6-27**] 11:25AM GLUCOSE-107* LACTATE-0.9 NA+-135 K+-4.1
CL--103
[**2154-6-27**] 11:25AM TYPE-ART PO2-73* PCO2-43 PH-7.44 TOTAL CO2-30
BASE XS-4 INTUBATED-NOT INTUBA
[**2154-6-27**] 05:06PM BLOOD WBC-6.7 RBC-3.28* Hgb-9.3* Hct-27.7*
MCV-84 MCH-28.4 MCHC-33.6 RDW-15.5 Plt Ct-249
[**2154-7-3**] 08:50AM BLOOD WBC-10.9 RBC-3.42* Hgb-9.6* Hct-28.1*
MCV-82 MCH-28.0 MCHC-34.1 RDW-15.4 Plt Ct-326
[**2154-7-7**] 09:21PM BLOOD WBC-7.1# RBC-2.72* Hgb-7.4* Hct-23.9*
MCV-88 MCH-27.3 MCHC-31.0 RDW-15.8* Plt Ct-324
[**2154-6-27**] 05:06PM BLOOD Glucose-159* UreaN-33* Creat-0.9 Na-136
K-4.2 Cl-104 HCO3-25 AnGap-11
[**2154-7-3**] 08:50AM BLOOD Glucose-143* UreaN-38* Creat-1.7* Na-129*
K-4.1 Cl-90* HCO3-30 AnGap-13
[**2154-7-7**] 09:21PM BLOOD Glucose-180* UreaN-23* Creat-0.9 Na-138
K-4.0 Cl-105 HCO3-27 AnGap-10
Pathology Examination
Procedure date Tissue received Report Date Diagnosed
by
[**2154-6-27**] [**2154-6-27**] [**2154-7-2**] DR. [**Last Name (STitle) **]. BROWN
Ileocolectomy (A-R):
1.Colonic adenocarcinoma (see synoptic report).
-low grade adenocarcinoma, T3N2 (4 out of 23 lymph nodes)
2. Colectomy, sigmoid colon (S-Z, AA):
-Diverticular disease with focal diverticulitis and
peridiverticulitis with scarring, acute and chronic
inflammation, stricture formation and clinical history of
bladder fistula.
CYSTOGRAM ([**Numeric Identifier 34386**], [**Numeric Identifier 34387**]) [**2154-7-2**]
No evidence of contrast extravasation or fistula
CTA CHEST/ABD/PELVIS W&W/O C&RECONS, NON-CORONARY [**2154-7-3**]
11:48 AM
1. No evidence of pulmonary embolism. Enlarged main pulmonary
artery.
2. Small bowel obstruction with a transition zone in the region
of the mid ileum.
3. Small amount of pneumoperitoneum which may be a normal
finding six days after surgery.
CHEST (PORTABLE AP) [**2154-7-3**] 9:00 AM
1. Mild cardiomegaly without overt pulmonary edema.
2. Bibasilar atelectasis.
PORTABLE ABDOMEN [**2154-7-5**] 9:16 AM
No evidence of obstruction. No evidence of perforation
Brief Hospital Course:
Patient underwent right colectomy on [**6-27**], At the time of
operation, the patient was noted to have advanced sigmoid
diverticulitis with a phlegmon and clinical [**Last Name (un) **]-vesical
fistula. He did well initially after surgery and even recorded
having [**12-18**] bowel movements/day. He was being prepared for
discharge but on the evening of POD#6, he developed rapid atrial
fibrillation, hypotension and the need for transfer to ICU. CTA
chest was negative and the CT w/ IV (no oral) contrast showed no
collection/leak in the abdomen. He did have evidence of
postoperative ileus so a nasogastric tube was inserted with
copious output. It was felt that some of his hemodynamic issues
related to dehydration from poor absorbtion of his liquid diet.
Moreover, his cardiac medications may have 'pooled' in the
gastroduodenal chyme. He was placed in the ICU for further
management. The AFib was rate controlled and the patient was
ruled out for MI. He returned to the [**Hospital1 **] within 48hrs. He
received GI/DVT prophylaxis throughout his hospital stay. A
course by systems follows:
NEURO: Pt was A/O throughout hospital stay, pain was controlled
with PCA pump and pt. properly transitioned to PO medication
upon d/c. No other issues
PULM: The patient uses BiPap at night at baseline for sleep
apnea. BiPap held intially secondary to ileus and
gastric/intestinal distention from the BiPap. The pt. c/o not
being able to sleep secondary to not using this, but this
resolved once BiPap resumed 2 days prior to d/c. At noght, w/o
BiPap developed mild respiratory acidosis 2nd to CO2 retention,
but again this resolved. CXR showed atelectasis expected 2nd
post op, but no other acute cardiopulmonary issues throughout
hospital stay.
CV: Pt. remained in a-fib rate controlled w/ BB throughout stay.
Post-oper, as described above, pt. developed ileus and
subsequent hypotention, tachycardia. This responded to fluid and
increase in BB. His a-fib is stable and on home cardiac Rx upon
d/c.
GI/FEN: As described above. Pt had [**Doctor First Name **] for LGIB and obstruction
w/ T3N2 adenocarcinoma of cecum. Pt. developed post op ileus w/
nausea, distention, anorexia. CT on [**7-3**] was remarkable only for
transition point of ileus, no leak or other abnl. This resolved
w/ NG and supportive care. KUB prior to d/c showed no evidence
of obstruction or perf. Pt. is taking good PO and without sx
upon d/c.
Heme/Id: Pt remained afebrile and only had minor bump in WBC to
11.2 during ileus, never required Abx therapy.
GU/FEN: Mild bump in BUN/Cr during episode of ileus, likely
secondary to hypotn and hypovol, responded well to fluid and has
returned to baseline of Cr 0.9 upon D/C.
Medications on Admission:
metformin 1000", lisinopril 10', amaryl 2', atenolol 50',
aldactone 50', B12, crestor 5', prilosec 10', poly-Fe 325",
warfarin as dir., avandia 8', lasix 40"
Discharge Medications:
1. Rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime) for 7 days.
Disp:*7 Capsule, Sust. Release 24 hr(s)* Refills:*0*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for 5 days.
Disp:*30 Tablet(s)* Refills:*0*
7. Prilosec 10 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
8. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
9. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. Amaryl 2 mg Tablet Sig: One (1) Tablet PO Qam ().
11. Rosiglitazone 8 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
12. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
1- Right Hemicolectomy and segmental sigmoid colectomy for T3N2
2- Stage IIIc Colon Cancer
3- Atrial fibrillation (with rapid ventricular response)
4- Post-operative Ileus
5- Compensated Congestive Heart Failure
6- Diabete mellitus (controlled)
7- Hypertension (controlled)
8- Benign Prostatic Hypertrophy (BPH)
9- GERD
10- Hyperlipidemia
Discharge Condition:
Stable, afebrile, adequate pain control with oral analgesics,
cleared by PT for stairs and home disposition. Wound intact, no
evidence of erythema or suppuration. He was tolerating an
1800kcal [**Doctor First Name **], heart-healthy diet with adequate glycemic control.
Discharge Instructions:
[**Month (only) 116**] resume your home medications as previously instructed. No
heavy lifting greater than 15-20lbs for 3-4 weeks. You may
shower and pat the wound dry. Please do not submerge the wound
under water for 2 additional weeks (ie no swimming, whirlpool,
jaccuzzi, etc). Allow steri-strips on wound to fall off on own.
I fyou experience further bleeding in your stools, severe
abdominal pain, fever, chills, or any other symptom that is
worrisome, please seek medical attention.
Followup Instructions:
[**Month (only) 116**] call Dr. [**First Name8 (NamePattern2) 916**] [**Last Name (NamePattern1) **] (Heme-Onc) if you wish to have
adjuvant chemotherapy here in [**Location (un) 86**] ([**Telephone/Fax (1) 72688**]). You should
call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] office for a follow-up post-operative
visit/appointment upon leaving the hospital ([**Telephone/Fax (1) 6429**]).
Completed by:[**2154-7-8**]
|
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"276.2",
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"997.4",
"V58.61",
"153.4",
"E878.6",
"250.00",
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] |
icd9cm
|
[
[
[]
]
] |
[
"45.73",
"45.76",
"57.83",
"99.04"
] |
icd9pcs
|
[
[
[]
]
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8215, 8273
|
4148, 6849
|
404, 784
|
8656, 8930
|
1963, 4125
|
9472, 9921
|
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|
7058, 8192
|
8294, 8635
|
6875, 7035
|
8954, 9449
|
1648, 1944
|
231, 366
|
812, 1405
|
1427, 1493
|
1509, 1612
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,373
| 145,693
|
32914
|
Discharge summary
|
report
|
Admission Date: [**2194-3-16**] Discharge Date: [**2194-3-19**]
Service: MEDICINE
Allergies:
Diltiazem / Codeine
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Elective catheterization
Major Surgical or Invasive Procedure:
coronary catheterization
History of Present Illness:
Mr. [**Known firstname 449**] [**Known lastname 13304**] is an 88 year old male with a history of CAD
s/p CABG (LIMA-LAD, SVG-OM, SVG-PDA), porcine AVR '[**85**], DM2, HTN,
and MS who was admitted to the [**Hospital1 1516**] service on [**3-16**] for
prehydration prior to planned intervention to LIMA-LAD. On
[**2194-2-9**], the patient presented to [**Hospital3 417**] with chest
pain, dyspnea on exertion and was found to have NSTEMI. He was
transferred to [**Hospital1 18**] for cath on [**2-11**] and found to have LMCA
30%, LAD 80% into the diag, occluded distally, LCx/RCA occluded,
LIMA-LAD patent with 90% at touchdown into D2, SVG-PDA patent
with 70% PDA lesion. The SVG-OM had a 90% stenosis; this was
intervened upon on [**2-14**]. Following the intervention on [**2-14**] he
developed creatinine elevation to 1.8. He was discharged on [**2-19**]
with plans to return today for LIMA-LAD intervention.
.
During PTCA with atherectomy, patient sustained a small
dissection of his native LAD. LAD angiography showed severe
calcified disease into a large diag which was not able to be
crossed with balloon. A rotablator was used and resulted in a
small perforation. PTCA was performed which resulted in 20%
residual with normal flow and sealing of dissection. He had an
echocardiogram during catheterization which showed no signs of
effusion or tamponade. He is transferred to the CCU for closer
monitoring.
.
On admission to the CCU, the patient is chest pain free. He
denies shortness of breath, nausea, vomiting, palpitations,
orthopnea. He is lying comfortably in bed.
Past Medical History:
- Multiple sclerosis, [**Month/Day (4) 75629**] in [**2126**]'s
- CAD s/p CABG in [**2178**] at CMC in [**Location (un) 5450**]
- AVR (Bioprosthetic--porcine) in [**2185**] ([**2179**] also noted, but
[**2185**] felt to be correct) at CMC
- Carotid endarterectomy [**2176**]
- Diabetes type II
- HTN
- NSTEMI [**1-21**]
.
Cardiac Risk Factors: Diabetes, Possible Dyslipidemia,
Hypertension
.
Cardiac History: CABG, in [**2178**] anatomy as follows: LIMA to LAD,
saphenous vein graft to obtuse marginal and PDA.
.
Percutaneous coronary intervention, in [**2185**] at CMC anatomy as
follows:
Left main with 40% distal.
LAD completely occluded in prox and mid portion w/severe disease
of diagonal branches.
.
Patent grafts to OM and RCA. LIMA was not assessed as known open
during pt's prior cath. Severe 3 vessel disease. Critical AS at
that time, resulting in valve replacement. EF noted to be 51% at
that time.
.
Pacemaker/ICD: N/A.
.
Other Past History: N/A.
.
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse. He lives in [**Location **] and
was in [**Hospital1 1474**] visiting family. He is married and lives with
his wife of 60 years in NH, they have grown children. He was
formerly an accountant. He quit smoking in [**2139**], and drinks only
occasionally at social events.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
VS - T 96.1 P 66 127/59 R 18 98% 3L NC
Gen: WDWN elderly male in NAD. Lying flat. 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 flat neck veins. JVP 6cm
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, loud S2. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB anteriorly, no
crackles, wheezes or rhonchi. Good air movement.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: Groin is clean, dry intact. No hematoma. No femoral
bruits. Dopplerable distal pulses.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: Carotid 2+ Femoral 2+ DP dop PT dop
Left: Carotid 2+ Femoral 2+ DP dop PT dop
Pertinent Results:
[**2194-3-16**] 05:42PM BLOOD WBC-6.5 RBC-4.72# Hgb-14.3# Hct-43.3#
MCV-92 MCH-30.3 MCHC-33.0 RDW-13.9 Plt Ct-265
[**2194-3-18**] 06:00AM BLOOD WBC-7.8 RBC-3.85* Hgb-11.7* Hct-35.5*
MCV-92 MCH-30.3 MCHC-32.9 RDW-13.8 Plt Ct-208
[**2194-3-16**] 05:42PM BLOOD PT-13.9* PTT-32.5 INR(PT)-1.2*
[**2194-3-17**] 07:20AM BLOOD PT-14.0* PTT-34.9 INR(PT)-1.2*
[**2194-3-16**] 05:42PM BLOOD Glucose-152* UreaN-29* Creat-1.3* Na-139
K-4.7 Cl-100
[**2194-3-18**] 06:00AM BLOOD Glucose-57* UreaN-21* Creat-1.1 Na-140
K-4.1 Cl-105 HCO3-25 AnGap-14
[**2194-3-17**] 08:30PM BLOOD CK(CPK)-48
[**2194-3-18**] 06:00AM BLOOD CK(CPK)-46
[**2194-3-17**] 08:30PM BLOOD CK-MB-NotDone cTropnT-0.07*
[**2194-3-18**] 06:00AM BLOOD CK-MB-NotDone cTropnT-0.09*
[**2194-3-18**] 06:00AM BLOOD Calcium-8.4 Phos-3.4 Mg-2.4
.
Cardiac Cath ([**2194-3-17**]):
1. SVG-OM angiography showed patent Cypher stent.
2. Successful rotational atherectomy and balloon angioplasty of
the D1
with 20% residual stenosis.
3. Dissection and perforation due to rotablation malfunction
(jump in
speed) treated successfully with prolonged balloon inflation and
reversal of anticoagulation.
FINAL DIAGNOSIS:
1. Successful rotablation and balloon angioplasty of D1.
.
Echo ([**2194-3-18**])
The left atrium is markedly dilated. The estimated right atrial
pressure is 0-10mmHg. There is moderate symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is moderate to severe global left ventricular
hypokinesis with anteroseptal and anterior walls best preserved
(LVEF = 30 %). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). Right ventricular
chamber size and free wall motion are normal. A bioprosthetic
aortic valve prosthesis is present. The transaortic gradient is
normal for this prosthesis. No aortic regurgitation is seen.
There is severe mitral annular calcification. There is mild
functional mitral stenosis (mean gradient 3 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.] There is no pericardial
effusion.
Brief Hospital Course:
Mr. [**Known lastname 13304**] is a 88 yo male with CAD s/p CABG, AVR '[**85**], DM2,
HTN who presented for PTCA of LIMA-LAD and D1. His procedure was
successful but complicated by small perforation in the diag
coronary artery with the rotablator.
.
#. CAD: s/p CABG '[**78**] and NSTEMI in [**2194-2-9**] admitted for staged
PTCA of LIMA-LAD/D1. He was prehydrated with bicarb and NAC
prior to catheterization. During procedure a small perforation
occurred in the diagonal with rota wire which was balloon
tamponaded with no signs of bleeding or dissection after. An
echocardiogram performed during catheterization showed no
pericardial effusion. He was monitored overnight in the CCU and
showed no signs of hemodynamic instability or tamponade. A
repeat TTE done the next day again showed no pericardial
effeusion. He was continued on his ASA, Plavix, metoprolol, and
Imdur with good control of his HR and BP. He will follow up with
his primary cardiologist.
.
#. Pump: He appeared to clinically euvolemic on exam and
remained without any signs of volume overload during his
admission. He was continued on his Toprol. An ACE inhibitor may
be appropriate for him in the future but this should be
considered by his PCP
.
#. DM2: Held Glyburide while in house and well covered with a
RISS. His glyburide was restarted on discharge.
.
#. MS: Per patient, has remained fairly stable for many years.
He was not on any medications for this condition at the time of
admission. He was followed clinically, monitoring for possible
bed sores, and was given DVT prophylaxis. He was evaluated by
physical therapy to help in his mobilization post intervention
with good effect.
.
#. Code: Full code. Discussed with patient extensively. Had
pink DNR sheet in chart at the time of admission, but indicated
that he actually wishes full code.
.
# Communication: [**Name (NI) **] [**Name (NI) 13304**] HCP
.
#. Dispo: Returned to rehab.
Medications on Admission:
ASA 325 mg daily
Atorvastatin 80 mg daily
Plavix 75 mg daily
Docusate 100 mg [**Hospital1 **]
Nexium 20 mg daily
Folic acid 1 mg daily
Glyburide 5 mg daily
MVI
Toprol XL 25 mg daily
Isosorbide mononitrate 30 mg daily
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 11252**] Center
Discharge Diagnosis:
Coronary artery disease
Hypertension
Diabetes Mellitus Type 2
Bioprosthetic Aortic Valve replacemnt
Multiple sclerosis
Discharge Condition:
All vitals signs stable, ambulatory, chest pain free.
Discharge Instructions:
You were admitted for an elective cardiac catheterization. You
had a narrowing in one of the vessels that supplies your heart.
This was opened but there was some small amount of damage to
that vessel. However, this was repaired during the
catheterization. You were monitored overnight in the cardiac
intensive care unit and showed no signs of further damage.
Please take all your medications as prescribed and attend all of
your follow up appointments.
Please call your doctor or return to the emergency room if you
experience chest pain, shortness of breath, fevers, chills,
nausea, vomitting or any other symptoms that concern you.
Followup Instructions:
Please call Dr. [**Last Name (STitle) **] office at [**Telephone/Fax (1) 11254**] to schedule a
follow up appointment in the next 1-3 weeks. We suggest you ask
her if you would benefit from being on a medication called an
ACE inhibitor.
|
[
"414.01",
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"250.00",
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icd9cm
|
[
[
[]
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] |
[
"88.57",
"00.66",
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icd9pcs
|
[
[
[]
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] |
8741, 8800
|
6548, 8474
|
251, 277
|
8963, 9019
|
4345, 5482
|
9703, 9943
|
3297, 3379
|
8821, 8942
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5499, 6525
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3394, 4326
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187, 213
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1921, 2886
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2902, 3281
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,703
| 105,187
|
18153
|
Discharge summary
|
report
|
Admission Date: [**2175-8-23**] Discharge Date: [**2175-8-29**]
Date of Birth: [**2100-9-8**] Sex: M
Service: NEUROLOGY
Patient is a 74 year old male with a past medical history of
hypertension, coronary artery disease status post coronary
artery bypass graft, congestive heart failure with known
ejection fraction of 35%, hypercholesterolemia, and atrial
fibrillation status post cardioversion one year ago, not on
Coumadin therapy at the present moment, who presented on
[**2175-8-23**] as a transfer from [**Hospital **] Hospital with weakness,
slurred speech. The patient was transferred to [**Hospital1 346**] for TPA thrombolytic therapy. Here
magnetic resonance scan demonstrated evidence of a right
sided MCA stroke. After obtaining a signed informed consent from
the family, the patient was given 0.9 mg/kg of TPA according to
the DIFFUSE protocol and at 3:30 a.m.
During the initial presentation, he never complained of chest
pain, shortness of breath. After TPA did have improvement of
his left sided facial weakness but was noted to have left
sided hemineglect and hemiparesis which remained severe
status post TPA. He was transferred to the Intensive Care
Unit for further monitoring. On [**2175-8-24**], the patient began
to complain of an episode of chest pain which began that
morning. The pain was described as centered over the left
chest "raking" [**7-9**] in severity, lasting about 30 minutes not
associated with any nausea, vomiting, diaphoresis,
palpitations or shortness of breath. For this pain, the
patient received 2 mg of intravenous morphine and was started
on intravenous nitroglycerin drip. He was also given aspirin
and Plavix. He had his cardiac enzymes including CK and
troponin cycled times three and was ruled out for myocardial
infarction.
At that time he was not heparinized, but he was started on
Coumadin. He was receiving intravenous Metoprolol 10-15 mg
intravenous for heart rate greater than 70 in the
Neurosurgical Intensive Care Unit for rate control of his
atrial fibrillation. He was pain-free on the intravenous
nitroglycerin drip until approximately 9:00 p.m. on [**2175-8-25**].
At that time, he had a recurrent episode of chest pain, same
description lasting minutes, which resolved on its own.
Per the patient's cardiologist, Dr. [**Last Name (STitle) 8421**], the patient has a
history of coronary artery bypass graft performed [**3-/2168**] with
left internal mammary artery to left anterior descending,
saphenous vein graft to right posterior descending artery,
saphenous vein graft to OM-1/diagonal.
Follow-up catheterization on [**2173-3-30**] showed severe three
vessel disease, ejection fraction of 50%, saphenous vein
graft to right posterior descending artery graft occluded,
saphenous vein graft OM-1 graft occluded with diagonal open.
Left internal mammary artery to the left anterior descending
graft was patent at that time.
PAST MEDICAL HISTORY:
1. Status post right middle cerebral artery stroke status
post thrombolytic therapy with TPA in [**8-2**].
2. Coronary artery disease status post coronary artery
bypass graft 7 years ago with left internal mammary artery to
left anterior descending, saphenous vein graft to right
posterior descending artery, saphenous vein graft to
OM-1/diagonal. Follow-up catheterization [**3-30**] with severe
three vessel disease, ejection fraction 50%, saphenous vein
graft to right posterior descending artery occluded,
saphenous vein graft to OM-1 occluded but diagonal open.
Left internal mammary artery to left anterior descending
patent at that time.
3. History of chronic atrial fibrillation status post
cardioversion approximately two years ago. The patient noted
to be in normal sinus rhythm on Cardiology office visit in
[**2175-2-28**]. However, on presentation with his acute stroke
was found to be in atrial fibrillation, not on Coumadin.
4. Hypercholesterolemia.
5. Status post cholecystectomy.
ALLERGIES:
The patient reports allergies to penicillin resulting in
rash.
MEDICATIONS:
1. Sotalol 80 mg p.o. q.d.
2. Atenolol 25 mg p.o. q.d.
3. Lipitor 10 mg p.o. q.d.
4. Norvasc 5 mg p.o. q.d.
5. Isosorbide.
6. Enteric coated aspirin 81 mg p.o. q.d.
SOCIAL HISTORY: The patient denies any smoking. He is
retired from work in advertising.
FAMILY HISTORY: The patient reports positive family history
of coronary artery disease and cancer.
PHYSICAL EXAMINATION: Upon admission, temperature 98.8,
blood pressure 133/70, heart rate 64, oxygen saturation 98%
on room air. General appearance, well developed, well
nourished white male noticeable left sided facial droop, no
acute distress. HEENT examination: Normocephalic atraumatic
with exception of left sided facial droop, mucous membranes
moist. Neck supple, no masses or lymphadenopathy. Carotid
pulses 1+, no carotid bruits. Lungs: Clear to auscultation
bilaterally, no rhonchi, rales, wheezes. Cardiovascular
examination: Irregularly irregular, S1, S2 auscultated, no
murmurs, rubs or gallops. Abdomen: Soft, nontender,
nondistended, positive bowel sounds. Neurological
examination: Mental status alert, oriented to person, place,
month, year, President. Cranial nerves: Left sided facial
droop, left hemianopsia versus visual neglect. Sensory
examination: Positive left sided neglect, his hand was the
examiner's. Coordination: Finger-nose-finger and
heel-to-shin intact on the right. Examination of gait was
deferred. Reflexes: Brachioradialis 1+ bilaterally, biceps
bilaterally, patellar 3+ bilaterally, no ankle jerk reflex is
noted, left sided flexor response equivocal, right sided
withdrew.
LABORATORY: Upon admission showed white blood count 8.1,
hemoglobin 13.7, hematocrit 39, platelets 175. Serum
chemistry showed sodium 139, potassium 3.7, chloride 107,
bicarbonate 26, BUN 17, creatinine 0.9, glucose 126, calcium
9.0. Coagulation profile showed PT 12.6, PTT 30.4, INR 1.12.
Cardiac enzymes showed CK 53, troponin less than 0.10.
Electrocardiogram showed atrial fibrillation with ventricular
response of 65 beats/min.
Magnetic resonance scan showed area of diffusion, swelling
and right MCA in one branch. The vessels were poor flow over
the right MCA and ICA.
BRIEF SUMMARY OF HOSPITAL COURSE:
1. Cerebrovascular accident, the patient was felt to have a
right middle cerebral artery ischemic stroke in the setting
of atrial fibrillation with significant left sided
hemiparesis. While he was outside the FDA approvement of her
TPA he qualified for the DIFUFE study and was consented to a
trial of TPA thrombolysis. He was given TPA without any
complications. Immediately post TPA infusion, he was noted
to have slight resolution of his left sided facial weakness
and asymmetry. However, his dense left sided hemiparesis
remained. He was monitored TPA in the Neurosurgical
Intensive Care Unit for several days. On [**2175-8-25**] follow-up
CT scan showed hemorrhagic transformation of his infarct.
Therefore, aspirin and Coumadin therapy were withdrawn.
Initially he found a swallow evaluation and so nasogastric
tube was placed and he was fed through nasogastric tube per
Nutrition recommendations.
Over the course of the next several days his neurological
status improved somewhat with increased sensation and tone in
his left side. He had follow-up speech swallow evaluation on
[**2175-8-28**] and was able to tolerate soft puree foods, thin
liquids, able to tolerate having his meds crushed in puree
food with the understanding that he would be fed in the bolt
upright position. On [**2175-8-28**], the patient's outpatient dose
of Lipitor was reinstated. On [**2175-8-29**] after discussion with
Neurology staff, he was able to tolerate initiation of
aspirin 81 mg p.o. q.d. In terms of restarting the patient
for anticoagulation on Coumadin in light of his history of
stroke and atrial fibrillation, it was felt that the bleeding
risk and evidence of hemorrhagic transformation on CT was too
great to tolerate the benefit of anticoagulation therapy.
The patient is to have a follow-up head CT performed around
[**2175-9-7**]. Pending results of that CT Neurology to
decide whether initiation of heparin and Warfarin therapy is
appropriate. If after initiation of aspirin therapy, if the
patient has any changes of alertness or left sided weakness a
STAT head CT should be checked.
[**First Name8 (NamePattern2) 1785**] [**Last Name (NamePattern1) 10220**] with coordinate 30 day follow-up magnetic
resonance scan. She can be contact[**Name (NI) **] at [**Telephone/Fax (1) **], as the
patient will need transportation for that magnetic resonance
scan from his rehabilitation facility or other if he goes
home.
At the time of discharge, the patient's neurological status
was that he was alert with fluent speech, mild dysarthria.
He is noted to have left sided facial droop but left facial
sensation was intact. He had some improvement in his left
lower extremity strength, rated [**1-4**]. However, left upper
extremity strength remained 0/5.
2. Coronary artery disease, the patient has a known history
of coronary artery disease status post coronary artery bypass
graft several years ago. In light of his stroke and overall
medical picture it is felt that his chest pain to be managed
medically although there may be an ischemic component to his
chest pain, it was felt that the patient would likely be a
candidate for cardiac catheterization or possible Persantine
MIBI as an outpatient, notably 6-8 weeks status post
cerebrovascular accident and status post his rehabilitation.
Therefore, he is managed medically with beta blocker therapy
which was titrated up by his blood pressure. He is also
started on Ace inhibitor. He was continued on Lopressor and
Imdur. In the interim, symptomatic chest pain should be
managed with sublingual nitroglycerin +/- morphine sulfate as
needed for pain control.
3. History of atrial fibrillation, although the patient had
history of atrial fibrillation status post cardioversion to
normal sinus rhythm several years ago, and was known to be in
normal sinus rhythm on recent outpatient office visit [**2-/2175**]
on presentation to hospital with this event he was noted to
be back in atrial fibrillation. He was not taking Coumadin
for unknown reasons.
4. In light of his cerebrovascular accident possibly
secondary to embolic disease, it was felt important to follow
the patient's atrial fibrillation and perhaps cardiovert him
back to normal sinus rhythm. However, he was unable to be
anticoagulated secondary to the hemorrhagic transformation of
his infarct. Therefore, the patient is to have follow-up CT
scan on [**9-7**] for check of interval change of his infarct
and in regard to its hemorrhagic changes. If it is stable,
Neurology will decide whether the patient is able to tolerate
anticoagulation with Coumadin and heparin. Once his INR is
greater than 2.0, likely would proceed with transesophageal
echocardiogram to rule out embolus or clot and then be loaded
on Amiodarone for chemical cardioversion back into normal
sinus rhythm. Pending this process, the patient will be rate
controlled with beta blocker therapy.
5. Urinary tract infection. The patient complained of
abdominal pain on the morning of [**2175-8-22**]. Urinalysis at
that time was suggestive of urinary tract infection.
Therefore, he was started on Levofloxacin 250 mg p.o. q.d.
At the time of discharge he will have one remaining day of
therapy to complete a 3 day course.
6. Hyperglycemia. Although the patient has no history of
diabetes per se it was noted during his hospitalization that
he had elevated blood glucose levels. In order to provide
the tightest glucose control, he was monitored on q.i.d.
finger sticks and Regular insulin sliding scale.
7. Activity level. The patient was evaluated by both
Physical Therapy and Occupational Therapy status. He is felt
to be a good candidate for outpatient rehabilitation.
8. Code status: The patient is DNR/DNI.
CONDITION ON DISCHARGE: The patient still with dense left
sided hemiparesis although somewhat improved upon
admission and improved status post thrombolysis. Discharge
pain is being managed medically with aspirin, beta blocker,
Lipitor, Ace inhibitor therapy. Recurrent chest pain should
be managed with nitroglycerin and morphine. The patient is
felt to be a good candidate for Physical Therapy and
rehabilitation and was discharged to an acute rehabilitation
facility.
DISCHARGE STATUS: The patient was discharged to home.
DISCHARGE DIAGNOSIS:
1. Atrial fibrillation.
2. CVA/cerebral artery occlusion, unspecified.
3. Congestive heart failure, systolic, chronic.
4. Coronary artery disease, unspecified vessel.
5. Urinary tract infection.
6. Hypercholesterolemia
DISCHARGE MEDICATIONS:
1. Regular insulin sliding scale.
2. Nitroglycerin 0.3 mg tablets sublingual one tablet
sublingual q.5 minutes p.r.n. as needed for chest pain for a
total of 3 doses.
3. Protonix 40 mg p.o. q. day.
4. Lipitor 10 mg p.o. q.d.
5. Milk of Magnesia 30 cc oral q.6h. as needed for GI upset.
6. Captopril 25 mg p.o. t.i.d.
7. Imdur 30 mg p.o. q.d.
8. Senna one tablet p.o. b.i.d.
9. Dulcolax 10 mg rectal suppository h.s. p.r.n.
constipation.
10. Colace 100 mg p.o. b.i.d.
11. Levofloxacin 250 mg p.o. q.24h. times one day, a total of
3 day course for urinary tract infection.
12. Metoprolol Tartrate 100 mg p.o. t.i.d.
13. Aspirin 81 mg p.o. q.d.
FOLLOW-UP PLANS: The patient instructed to call his primary
care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], for follow-up appointment within
7-10 days after discharge to rehabilitation. He is also
instructed to call Neurology to schedule follow-up with
either Dr. [**First Name (STitle) **] or Dr. [**Last Name (STitle) **], the phone number for
Neurology is [**Telephone/Fax (1) 44**]. Finally, he should schedule a
follow-up with his primary cardiologist, Dr. [**Last Name (STitle) 8421**]. Dr.
[**Last Name (STitle) 8421**] then can initiate therapy for cardioversion of the
patient's atrial fibrillation pending Neurology
recommendations on anticoagulation. Finally, the patient
already has an appointment scheduled for follow-up magnetic
resonance scan at the [**Hospital Ward Name 517**] Clinical Center in the
basement, phone number [**Telephone/Fax (1) 50198**]. Appointment is
scheduled for [**2175-9-20**], at 11:00 a.m.
[**Name6 (MD) 725**] [**Name8 (MD) 726**], M.D. [**MD Number(1) 727**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) **]
Dictated By:[**MD Number(4) 50199**]
MEDQUIST36
D: [**2175-8-29**] 14:41
T: [**2175-8-29**] 15:59
JOB#: [**Job Number 50200**]
cc:[**Hospital1 50201**]
|
[
"401.9",
"434.91",
"272.0",
"428.22",
"427.31",
"414.01",
"V45.81",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"99.10"
] |
icd9pcs
|
[
[
[]
]
] |
4323, 4407
|
12803, 13455
|
12554, 12780
|
6259, 12002
|
4430, 5191
|
13473, 14770
|
5208, 6231
|
2949, 4215
|
4232, 4306
|
12027, 12533
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,769
| 133,364
|
54611
|
Discharge summary
|
report
|
Admission Date: [**2203-12-25**] Discharge Date: [**2204-1-16**]
Service: MEDICINE
Allergies:
Percocet / Tylenol
Attending:[**First Name3 (LF) 2763**]
Chief Complaint:
progressive DOE x 3 days
Major Surgical or Invasive Procedure:
PICC line placement
CPAP
History of Present Illness:
87 yoM with h/o AFib not on coumadin and SCC on the face s/p
resection, who presents with three days of progressive DOE. He
reports pink-tinged frothy sputum as well as chills, anorexia
and rhinorrhea, though he denies fever, Ha,
arhtralgias/myalgias, chest pain, emesis and diarrhea. He says
he "may have gained weight recently," though was at the doctor
on [**2203-12-22**] and seemed to be doing well. He denies weight loss
over the last several months. He also told the ED he had
increased urinary output.
.
In the ED, VS were T 100.3, BP 139/70, HR 124 in AFib, RR 16,
96% on NRB (85% RA, 95% 4LNC) on presentation. He was given ASA
325 mg, ibuprofen 400 mg Po, and levofloxacin 740 mg IV,
ceftriaxone 1 g IV, and vanco 1g IV for CAP. In the ED, BP was
initially in the 120's on admission but then dropped to 84/43;
it improved to the 110-120's with a IVF bolus. He got a total of
~2L betwen IVF and antibiotics. Blood cultures were sent. ABG
was not done. There was concern for an element of CHF with a BNP
> [**Numeric Identifier 3652**], though he was not diuresed in the ED because of the
concern for infection.
.
On arrival to the ICU, T 96.0, HR 92, BP 122/49, 92-96% NRB.
Initially there was concern for volume overload and he was given
lasix 20 mg IV. He also had some hemoptysis.
Past Medical History:
DM2
Paroxysmal Atrial Fibrillation on anticoagulation
CRI- baseline Cr 1.5 - 2.0
HTN
Gout
COPD
OA
h/o GIB ([**2198**]; found to have gastritis, ulcerations, no active
bleeding, and angioectasia in colon)
h/o hip fx s/p ORIF/IM nail R hip, L hip [**2201**]
[**Name (NI) 3674**] unclear etiology, previously treated with regular
transfusions, now on procrit, baseline 30
h/o pericardial effusion in setting of AF with RVR, CHF, pleural
effusions ([**2198**])
s/p TURP for prostate enlargement and urinary retention
h/o sigmoid colon ca s/p sigmoid colectomy [**2192**]
right cheek SCC s/p skin graft
Diastolic CHF
Social History:
Patient denies tobacco or illicit drugs. He reports occasional
alcohol consumption. [**Name (NI) **] (HCP) report recent falls. House
with stairs between kitchen and bedroom. Speaks multiple
languages.
Family History:
NC
Physical Exam:
VS on arrival to the ICU: T 96.0, HR 92, BP 122/49, 92-96% NRB
General: elderly, comfortable but appears somewhat SOB, NAD,
speaking in full sentences
HEENT: poor dentition, OP clear, tacky MM
Lungs: end exp wheezes on right throughout; high pitched sounds,
rhonchi, crackles throughout on left; some use of SCM for
breathing
Cardio: heart sounds difficult to hear over O2 and breath
sounds; difficult to assess JVD with surgical scars and SCM use
Abd: somewhat distended and obese, but soft, no fluid wave
appreciated, NT
Ext: chronic woody changes of b/l LE to mid-shin, [**1-21**]+ [**Location (un) **] b/l
symmetric
Skin: multiple SK's and AK's; large area of skin
graft/post-surgery on left fronto-parietal foreheaad/head
MS: left leg slightly shorter and externally rotated
Neuro: AA, Ox3, speaking in full sentences, conversant,
appropriate, resting tremor in L>R
Pertinent Results:
Admission CXR (12/6/9):
SINGLE UPRIGHT FRONTAL CHEST RADIOGRAPH: There is near-complete
opacification
of the left hemithorax, with some residual aeration noted in the
upper lung.
Air-bronchogram is the mid lung suggests a component of
air-space
consolidation with probable increased effusion. The right
hemithorax is
normally aerated. There is no pneumothorax. No large pleural
effusion is
noted on the right. The cardiomediastinal silhouette is
incompletely assessed
secondary to the left hemithorax opacification. There is
unchanged
calcification in the aortic knob.
IMPRESSION: Interval near-complete opacification of the left
hemithorax,
compatible with a large left-sided pleural effusion and likely
consolidation.
.
12/7/9 echo:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is
moderate global left ventricular hypokinesis (LVEF = 35 %). The
right ventricular cavity is moderately dilated with mild global
free wall hypokinesis. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. The pulmonary
artery systolic pressure could not be determined. There is a
trivial/physiologic pericardial effusion.
Compared with the report of the prior study (images unavailable
for review) of [**2199-10-11**], biventricular systolic function is now
seen.
CLINICAL IMPLICATIONS:
The left ventricular ejection fraction is <40%, a threshold for
which the patient may benefit from an ACEI or [**Last Name (un) **]
.
12/7/9 CT chest:
1)Diffuse dense left lung consolidation and collapse with
extensive airway
occlusion, likely due to infectious pneumonia and coexisting
atelectasis from retained secretions. Correlation with
bronchoscopy may be helpful to clear secretions and to exclude a
fixed endoluminal lesion. No definite hilar mass but assessment
limited by absence of IV contrast.
2)Focal consolidation in the right upper lobe also likely due to
infection but attention to this area on follow up imaging
recommended to ensure resolution.
3)Coronary artery, aortic valve and mitral annulus
calcification.
4)Gallstones
.
[**1-1**] CXR:
There is slight improvement of the left lung consolidation
although
significant amount of consolidation is still involving most of
the left lung with some minimal sparing of the lateral portion
of the left lower lobe. The right upper lobe is entirely
consolidated but the right lower lung appears to be relatively
clear. There is potentially present left pleural effusion.
There is no pneumothorax. Multiple abnormalities might be
further evaluated by chest CT if clinically warranted.
.
[**1-5**] CXR:
Cardiomediastinal contours are unchanged with cardiac size top
normal.
Multifocal consolidations have continuously improved. Still they
are greater on the right upper lobe and left lower lobe. If any,
there is a small left pleural effusion. There is no
pneumothorax.
.
[**1-11**] CXR:
Left PICC tip is in the proximal SVC. Cardiomediastinal contours
are obscured by the lung abnormalities. Multifocal
consolidations are unchanged as does a left pleural effusion.
There are lower lung volumes . There is no evident
pneumothorax.
.
[**1-16**] CXR:
HISTORY: Pneumonia, to evaluate for change.
FINDINGS: In comparison with the study of [**1-14**], the patient has
taken a
somewhat better inspiration. The degree of left perihilar
opacification,
retrocardiac opacification, and perihilar opacification on the
right is
similar. There may be some increase in the right upper lobe
opacification
when compared to the prior study.
PICC line position is unchanged.
[**12-25**] negative blood cultures
12/7 negative urine legionella
.
[**1-1**]:
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
.
Labs on day of discharge;
WBC RBC Hgb Hct MCV Plt Ct
7.5 2.6 6.6 24.5 99 140*
.
Glucose UreaN Creat Na K Cl HCO3 AnGap
172* 60* 1.1 143 4.6 109* 32 7*
Brief Hospital Course:
Mr. [**Known lastname 1968**] is an 87yoM, with a PMH significant for AFib not on
coumadin and SCC on the face s/p resection, who presented to the
MICU with complete white out of left lung.
.
#. UNILATERAL PLEURAL EFFUSION: This was thought to be due to a
pneumonia given the unilateral nature of the effusion;
parapneumonic effusion as most likely diagnosis. Given smoking
history and degree to which whole lung is affected,
post-obstructive PNA (due to malignancy) was considered as a
possibility too. Less likely CHF b/c of left-sided unilateral
nature, although the pt appeared to have element of volume
overload with peripheral edema and response to lasix. It seems
of relatively short onset, given that the patient had a normal
PEat PCP's office four days prior to admission, per the pt.
Blood and sputum cultures and urine legionella were negative. CT
and CXR's showed the significant effusion. The patient refused
VATS/surgery/thoracentesis, so no clear etiology was discovered.
He was treated broadly with antibiotics (empirically), and there
was progressive (albeit slow) improvement in patient's
oxygenation (>90% on 2L NC at discharge), his physical exam, and
his chest x-rays. He was treated empirically with
vancomycin/cefepime/azithromycin for hospital-acquired pneumonia
broad coverage.
.
On multiple occasions, patient had SOB, increased RR and work of
breathing, SpO2 decreased - on those occasions, lasix was tried,
in case CHF was a component, in addition to morphine, haldol
(sparingly, for anxiety/confusion), and nebs. We found that
talking/anxiety was big contibutor to [**Last Name (LF) **], [**First Name3 (LF) **] tried to control
that with reassurance. Patient was placed on CPAP on a few of
these separate occasions, and tolerated it well, and was able to
come back off of the CPAP without repercussion. Goal SpO2 in low
90s which is finally acheived with 2L NC and off CPAP for
several days prior to dishcarge.
.
Chemical pneumonitis is likely a component of the dypnea, as the
pt's neighbor later reported that he had found no less than 2
dozen RAID bombs on the patient's bedroom floor, which the
patient had been setting off due to "bugs on the floor" (likely
visual hallucinations). The pt completed 5 days of
methylprednisolone course.
.
#. COPD/ASTHMA: As patient will now be long-term NPO any
non-inhaled meds had to be d/c'd and he was sent out on
fluticasone INH and PRN nebs.
.
#. AFIB: The pt went into Afib went into RVR after his PO meds
(including metoprolol) were held. Ultimately, scheduled IV
metoprolol was begun with good rate control. He required
diltiazem drip at two different time points during his
hospitalization. One of those times, his heart rate went into
the bradycardic range. On other occasions, he would just become
bradycardic without an obvious trigger, but tolerated it without
symptoms. He was in sinus rhythm at discharge.
.
Given fall risk/history and questionable history of GI bleed,
patient was not anticoagulated. He was originally on aspirin
325mg daily, but in the setting of melena (see below), that was
stopped. This should be restarted [**1-17**].
.
#Melena - Patient had one large melanotic stool without CHT drop
or decompensation during his hospitaliation, thoguht to be due
to c. diff infection. We held aspirin which should be restarted
as below. His PPI was also increased to [**Hospital1 **], and should be
restarted at QD on the [**1-17**].
.
# Agitation/Disorientaion: Patient quite classically sundowns,
but responds well to redirection and zydis tab if necessary. He
had apparently been having nightly visual hallucinations at home
prior to this admission.
.
#. DIABETES: Held home PO meds, used SSI. Not an active issue.
.
# C.DIFFICILE INFECTION: C. diff positive, started on Flagyl
morning of [**2204-1-2**], should continue until [**2204-1-23**].
.
#.CONTACT: with the patient, has friends/[**Name2 (NI) 9259**] who are [**Name (NI) 18133**]
([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 111706**]). They were updated
frequently.
.
#. CODE: DNR, DNI. Palliative care was consulted, suggested
morphine for discomfort/anxiety, and consider zydis as needed
also (used very rarely during admission).
.
# Access: PICC (double-lumen).
.
# Nutrition: Started TPN through PICC. We watched electrolytes
closely, due to concern for refeeding syndrome given patient was
not eating for many days prior. Difficulty swallowing, concern
for aspiration. PO pills converted to IV form and non-essentials
d/c'd.
Medications on Admission:
Buproprion 75 mg [**Hospital1 **]
Combivent 2 puffs [**Hospital1 **]
Diltiazem 240 mg QD
Epo 10,000 SC QWeek
Ferroud sulfate 325 mg QD
Fluticasone [**Hospital1 **]
Lasix 40 mg QD
Lisinopril 10 mg QD
Montelukast 10 mg QD
MVI
Pantoprazole 40 mg QD
Rosiglitazone 2 mg Qd
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation. Tablet, Delayed Release (E.C.)(s)
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
4. Insulin Lispro 100 unit/mL Solution Sig: see attached sliding
scale unit Subcutaneous ASDIR (AS DIRECTED): See attached
sliding scale.
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
6. Albuterol Sulfate 2.5 mg/0.5 mL Solution for Nebulization
Sig: One (1) Inhalation every six (6) hours.
7. Morphine 2 mg/mL Syringe Sig: One (1) Injection Q6H (every 6
hours) as needed for pain,.
8. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
One (1) Intravenous Q8H (every 8 hours): D 1 = [**1-2**], DC on
[**2204-1-23**] for 14 day course after planned completion of cefepime.
Changed to IV as pt could not swallow pill [**1-4**].
9. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours).
10. Metoprolol Tartrate 5 mg/5 mL Solution Sig: 7.5 mg
Intravenous Q6H (every 6 hours).
11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) treatment Inhalation Q6H (every 6
hours) as needed for wheezing/sob.
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) treatment
Inhalation Q6H (every 6 hours) as needed for wheezing/sob.
13. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet,
Rapid Dissolve PO BID (2 times a day) as needed for Agitation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **]
Discharge Diagnosis:
Primary: 1) pneumonia, 2) respiratory distress, 3) C. dificile
colitis, 4) atrial fibrillation
Secondary: 1) congestive heart failure, 2) Type 2 diabetes, 3)
chronic renal insuffiency, 4) squamous cell cancer, 5) iron
deficiency anemia
Discharge Condition:
Mental status: Confused - majority of time, especially when
hypoxic. Difficult to understand speech [**2-21**] hoarseness, face
mask.
Generally Alert and interactive.
Out of Bed with assistance to chair or wheelchair
Discharge Instructions:
You were seen in the ED for difficulty breathing. You had a very
large pneumonia and required a large amount of respiratory
support in the MICU at [**Hospital3 **] Medical Center for several
weeks in the ICU to maintain your oxygenation levels. Overtime,
you improved with IV antbiotics and IV steroids. While you were
hospitalized, you developed an antibiotic-associated infection
of the colon called Clostridium Dificile, which you will need to
take antibiotics for 2 weeks after the treatment for your
pneumonia is completed.
During your stay in the ICU, you became quite confused. We
think this is due to your pneumonia, decreased oxygen levels in
your blood, and being in an unfamiliar location. You can take a
medication called zydis which disolves on your tongue when you
get very confused or agiatated.
Your heart was evaluated while you were hospitalized and you do
have congestive heart failure; because of your CHF, pleae weigh
yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3
lbs. You were diuresed with IV lasix periodically during your
hospitalization.
Additionally, your infection triggerred your heart to go into a
rapid, abnormal rhythm, atrial fibrillation, during your
hospitalization--this was treated with Metoprolol IV.
New Medications:
Antibiotics:
MetRONIDAZOLE (FLagyl) 500 mg IV Q8H (discontinue on [**2204-1-23**] for
14 day course, can be changed to PO when patient is eating)
Vancomycin 500 mg IV Q 24H Start: [**2204-1-1**], discontinue on
[**2204-1-15**] for 14 day course.
Heart medications:
Metoprolol Tartrate 7.5 mg IV Q6H (Hold for HR<60 SBP<90,
patient can be started on Metop 25mg PO TID when taking PO
again)
Zydis 2.5mg fast melt can be uptitrated to a max of 5mg [**Hospital1 **] for
agitation
Heparin 5000 Units subcutaneous TID for anticoagulation
Combivent nebulizer treatments
Changed Pantoprazole 40 mg PO Qday to Pantoprazole IV 40mg [**Hospital1 **]
(can be changed to PO when pt taking POs).
Holding these medications in acute setting:
Rosiglitazone 2 mg Qday
Buproprion 75 mg [**Hospital1 **]
Lasix 40mg PO Qday
Ferrous sulfate 325 mg PO QDay
Discontinued:
Diltiazem 240 mg PO QDay
Followup Instructions:
Please follow up with your Primary Care Physician [**Name Initial (PRE) **] [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 7476**] in [**1-21**] weeks. You will need to call for an appointment.
Phone: [**Telephone/Fax (1) 7477**]
.
Please see your cardiologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
Date & Time: Tuesday, [**1-31**] at 12:40pm
Location: [**Location (un) **], [**Hospital Ward Name 23**] Bldg [**Location (un) **], [**Location (un) 86**], MA
Phone: [**Telephone/Fax (1) 62**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**]
|
[
"578.1",
"276.0",
"274.9",
"786.3",
"736.89",
"486",
"V64.2",
"518.81",
"008.45",
"510.9",
"V10.83",
"564.00",
"293.0",
"428.0",
"V15.88",
"250.00",
"403.90",
"585.9",
"428.43",
"427.31",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.15",
"34.91",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
13988, 14031
|
7420, 12025
|
252, 278
|
14312, 14312
|
3384, 4862
|
16753, 17423
|
2472, 2476
|
12344, 13965
|
14052, 14291
|
12051, 12321
|
14555, 16730
|
2491, 3365
|
4885, 7397
|
188, 214
|
306, 1602
|
14327, 14531
|
1624, 2237
|
2253, 2456
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,128
| 124,474
|
28606
|
Discharge summary
|
report
|
Admission Date: [**2187-11-7**] Discharge Date: [**2187-11-15**]
Date of Birth: [**2119-10-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 11495**]
Chief Complaint:
Increasing shortness of breath, dyspnea on exertion
Major Surgical or Invasive Procedure:
1)Swan-Ganz catheter
2)Cardiac catheterization
3)Biventricular ICD placement
History of Present Illness:
The patient is a 68M w/ with h/o CHF (EF 15%), CAD,
hypercholesterolemia, HTN, who presents with increasing SOB,
DOE, orthopnea. Has EF15% and Class IV CHF, has been
decompensating from a CHF standpoint over the past few days
(weight gain, orthopnea, cough). Despite weighing himself daily
and noting some weight loss, he is still above his reported dry
weight of 169.5 lbs by about 5 lbs and his symptoms have been
slowly progressing. Because his dosage of medications, most
notably Lasix, have been increased several times in the last
couple of weeks, he was referred in for admission for more
tailored diuresis.
.
On review of symptoms, 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,
palpitations, syncope, or presyncope. He reports dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema.
Past Medical History:
1)CHF, NYHA Class IV (EF 15%)
2)CAD: Inferior MI in [**2166**] s/p PTCA, repeat PTCA in [**2167**]
3)Hyperlipidemia
4)Hypertension
5)Gout (diuresis induced)
Social History:
Denies current tobacco use although he is a former smoker and
quit in [**2148**]. No history of alcohol abuse; consumes [**2-16**]
drinks/night. He is retired and lives in [**State 32926**]
with his wife.
Family History:
There is no family history of sudden death. A sister had CAD at
age 35. His mother and father died of heart disease in their
70s.
Physical Exam:
vitals BP 108-118/65-70 HR (reg) 76-84 RR 18 Temp 98.6 O2Sat
94-98% on RA
Weight 80kg I/O 840/450 since admission
Gen: well developed, well nourished and well groomed. The
patient was oriented to person, place and time. The patient's
mood and affect were not inappropriate.
HEENT: no xanthalesma, conjunctiva were pink, no pallor or
cyanosis of the oral mucosa. OP clear, MMM, PERRL, EOMI.
Neck: supple, JVP of [**8-22**] cm H2O. The carotid waveform was
normal. No bruits. There was no thyromegaly.
Pulm: mildly labored respirations while speaking, no use of
accessory muscles. Crackles at the left base without dullness to
percussion or altered tactile fremitis.
Heart: PMI located in the 5th intercostal space, mid clavicular
line. no thrills, lifts or palpable S4. normal S1S2, +S3 no
rubs, murmurs, clicks or gallops.
Abdomen: abdominal aorta was not enlarged by palpation, no
hepatosplenomegaly, NT, soft, ND
Extremities: no pallor, cyanosis, clubbing, trace non-pitting
lower extremity edema bilaterally, 2+ DP/PT pulses bilaterally
Skin: no stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
Laboratory Results:
[**2187-11-6**] 11:00PM WBC-8.8 RBC-3.96* HGB-11.9* HCT-34.2* MCV-86
MCH-30.1 MCHC-34.9 RDW-16.0*
[**2187-11-6**] 11:00PM NEUTS-69.0 LYMPHS-18.2 MONOS-5.7 EOS-6.8*
BASOS-0.3
[**2187-11-6**] 11:00PM PLT COUNT-265
[**2187-11-6**] 11:00PM PT-17.3* PTT-30.2 INR(PT)-1.6*
[**2187-11-6**] 11:00PM GLUCOSE-140* UREA N-23* CREAT-1.0 SODIUM-138
POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-26 ANION GAP-16
[**2187-11-6**] 11:00PM CK(CPK)-80
[**2187-11-6**] 11:00PM cTropnT-0.01
[**2187-11-6**] 11:00PM CK-MB-NotDone proBNP-6296*
[**2187-11-7**] 09:50AM TSH-1.3
[**2187-11-7**] 09:50AM DIGOXIN-1.1
[**2187-11-15**] 06:00AM BLOOD WBC-11.5* RBC-4.60 Hgb-12.7* Hct-41.2
MCV-90 MCH-27.7 MCHC-30.9* RDW-15.5 Plt Ct-396
[**2187-11-15**] 06:00AM BLOOD Plt Ct-396
[**2187-11-15**] 06:00AM BLOOD Glucose-109* UreaN-30* Creat-0.9 Na-138
K-5.0 Cl-102 HCO3-29 AnGap-12
[**2187-11-14**] 06:50AM BLOOD CK(CPK)-33*
[**2187-11-15**] 06:00AM BLOOD Mg-2.4
.
EKG ([**11-6**]): Sinus rhythm, left atrial abnormality, Left bundle
branch block with left axis deviation ,no previous tracing
available for comparison
.
EKG ([**11-14**]): Since previous tracing, ventricular pacing, probably
biventricular
.
Relevant Imaging:
1)[**Last Name (un) **] ([**11-6**]):Indistinct opacity in right lower lobe. Given
unilaterality and focality, atypical for edema though confluent
edema can peresent this way. An early developing pneumonia
cannot be excluded.
.
2)ECHO ([**11-6**]): 1. The left atrium is normal in size. 2. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is severely dilated. There is severe global left
ventricular hypokinesis. No masses or thrombi are seen in the
left ventricle. Overall left ventricular systolic function is
severely depressed. [Intrinsic left ventricular systolic
function is likely more depressed given the severity of valvular
regurgitation.] The left ventricle appears dyssnchronous with 12
segment SD>33ms but the images were difficult. These findings
are c/w significant LV dysnchrony for which the patient may
benefit from CRT therapy. 3. Right ventricular chamber size is
normal. Right ventricular systolic function is normal. 4.The
aortic valve leaflets (3) are mildly thickened. No aortic
regurgitation is seen. 5. Mild thickness of the mitral valve.
Moderate (2+) mitral regurgitation is seen. 6.The left
ventricular inflow pattern suggests a restrictive filling
abnormality, with elevated left atrial pressure. 7.There is
borderline pulmonary artery systolic hypertension.
8.There is no pericardial effusion.
.
3)Foot xray ([**11-12**]):No fracture. Mild talonavicular degenerative
change.
.
4)Cardiac cath ([**11-13**]):1. Selective coronary angiography of this
right dominant system revealed multi vessel coronary disease.
The LMCA had mild diffuse disease. The LAD had a 70% lesion
after a large D1 branch. The LCX had a 50% lesion before a
large, branching OM1. The RCA contained serial
lesions of 80% and 70% in the mid and distal vessel. 2. Left
ventriculography was not performed. 3. Central aortic pressure
was low at 86/55 prior to and throughout the procedure. 4.
Successful PTCA and stenting of the RCA with a 2.5 Bare metal
stent with no residual stenosis and TIMI III flow in the distal
vessel. (See PTCA comments)
5. Successful balloon angiplasty of the distal RCA lesion with a
30%
residual stenosis and stable grade B dissection at the
conclusion of the
procedure. (See PTCA comments)
.
5)ECHO ([**11-15**]):Compared with the findings of the prior study
(images reviewed) of [**2187-11-7**], the left ventricular end
diasolic dimension is unchanged; the left ventricular ejection
fraction is slightly increased.
Brief Hospital Course:
Patient is a 68 yo male with h/o CHF (EF=15%), HTN, dyslipidemia
presents in decompensated CHF admitted for tailored therapy
prior to cath +/- ICD/BiV. Symptomatically improved with
diuresis.
.
1) CHF: Patient was initially symptomatic with significant SOB,
PND, and orthopnea. Initial dry weight on admission was 176 lbs.
He was given multiple doses of Lasix IV and responded well. A
Swan Ganz catheter was placed upon transfer to the CCU to
monitor his CVP and PCWP closely. His inital CVP and PCWP was 27
& 16 and decreased to 13 & 10 after several days of diuresis. He
was also started on a Nitroprusside drip for a short period of
time to reduce his afterload. Patient was continued on his home
regimen of Coreg, Digoxin, and Diovan. His Diovan was initally
increased to 160mg [**Hospital1 **] but was decreased to 80 [**Hospital1 **] because of
hyperkalemia. Spironolactone was also stopped for this reason.
He was also restarted on his home dose of Lasix 80mg daily. He
was evaluated by EP for ICD placement. He underwent cardiac MRI
which suggested an EF out of proportion to degree of LV
dysfunction suggesting non-ischemic cardiomyopathy. Mr. [**Known lastname 68224**] [**Last Name (Titles) 8783**]t left heart cardiac catheterization which showed 3VD
and his RCA was stented. A biventricular pacer was placed and pt
tolerated procedure well. He is scheduled to follow-up in the
device clinic in the next week. Also asked him to schedule
follow-up with Dr. [**Last Name (STitle) 3302**] and Dr. [**Last Name (STitle) **] in 4 weeks. Weight
on discharge was 157 lbs.
.
2) CAD: On admission patient was started on his home regimen of
Aspirin, Lipitor, and Zetia. He underwent cardiac
catheterization which showed 3VD but only his RCA was stented.
.
4) Gout: Patient complained of pinpoint tenderness at the
Achilles Tendon. Patient
takes Indocin as needed at home. Xray of left foot did not
suggest an acute process. He was started on a 7 day Prednisone
taper, which per patient was helpful.
.
5) FEN: Patient was placed on a 2gm sodium diet, daily I/O's &
weight's were recorded.
Medications on Admission:
Aspirin 325mg daily
Bupropion 150mg [**Hospital1 **]
Coreg 6.25mg [**Hospital1 **]
Potassium 20mg [**Hospital1 **]
Furosemide 40mg [**Hospital1 **], increased to 80mg [**Hospital1 **] a few weeks ago and
120mg [**Hospital1 **] yesterday
Indocin 50mg TID prn (last took 3 day course 2-3 weeks ago)
Digoxin 0.125 mg daily
Imdur 30 mg daily
Imipramine 25 mg QHS
Lipitor 20 mg QHS
Zetia 10 mg QHS
Nitroglycerin SL PRN
MVI
Vitamin C 500mg qam
spironolactone 25mg [**Hospital1 **]
Diovan 80mg qam
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1)CHF
Secondary Diagnosis:
1)CAD
2)Hypertension
3)Hyperlipidemia
4)Gout
Discharge Condition:
Stable
Discharge Instructions:
1)Please take all medications, as listed on discharge
instructions.
2)You are being discharged on a Prednisone taper. Please take 6
tablets on [**11-16**] tablets on [**11-17**] tablets on [**11-18**] tablets
on [**11-19**] tablets on [**11-20**], and 1 tablet on [**11-21**]. You will then
stop taking the medication.
3)Please schedule follow-up with your primary care physician,
[**Name10 (NameIs) 2085**], and the device clinic. Some of your appointments
have already been scheduled, they are listed in the discharge
instructions.
4)Please weigh yourself daily; if you notice a weight gain>3
lbs, please contact your cardiologist.
5)If you have any symptoms of chest pain, difficulty breathing,
dizziness, or any other concerning symptoms please return to the
ED.
Followup Instructions:
1)Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2187-11-21**]
11:30
2)Please schedule follow-up with your primary care physician.
[**Last Name (NamePattern4) **]. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **].
|
[
"V15.82",
"412",
"428.0",
"V45.82",
"425.4",
"401.9",
"274.9",
"414.01",
"272.0",
"998.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.20",
"00.66",
"37.22",
"00.45",
"88.56",
"00.51",
"36.06",
"00.40",
"89.64"
] |
icd9pcs
|
[
[
[]
]
] |
9665, 9671
|
7032, 9124
|
370, 448
|
9806, 9815
|
3316, 4521
|
10634, 10906
|
2052, 2183
|
9692, 9692
|
9150, 9642
|
9839, 10611
|
2198, 3297
|
279, 332
|
4539, 7009
|
476, 1634
|
9738, 9785
|
9711, 9717
|
1656, 1814
|
1830, 2036
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,185
| 191,707
|
10229
|
Discharge summary
|
report
|
Admission Date: [**2144-5-14**] Discharge Date: [**2144-5-21**]
Date of Birth: [**2096-6-8**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
infected av graft
Major Surgical or Invasive Procedure:
removal of infected left arm graft [**2144-5-16**]
TEE [**2144-5-20**]
History of Present Illness:
The patient is a 47 year old
male, well known to us, who presented with a small fluctuant
area overlying the graft. This was in the vicinity of a
known seroma and we were uncertain if this was infected being
as he was having no fevers, no pain, and no erythema. Blood
cultures were obtained as an outpatient and when these came
back positive, we admitted him for a graft excision
Past Medical History:
ESRD on HD (MWF), HCV, HIV, malignant HTN
Physical Exam:
99.8 76 140/87 16 97%RA
NAD AOx3
CTA b/l
RRR
soft NT ND no masses
LUE graft +thrill/bruit, tender inferiorly. no discharge no
erythema
Pertinent Results:
[**2144-5-14**] 08:00PM BLOOD WBC-5.4 RBC-3.50* Hgb-12.3* Hct-38.1*
MCV-109* MCH-35.1* MCHC-32.2 RDW-19.2* Plt Ct-178
[**2144-5-16**] 02:02PM BLOOD WBC-4.0 RBC-3.16* Hgb-11.3* Hct-33.7*
MCV-107* MCH-35.6* MCHC-33.4 RDW-19.2* Plt Ct-153
[**2144-5-18**] 04:51AM BLOOD WBC-6.5 RBC-3.06* Hgb-11.1* Hct-32.4*
MCV-106* MCH-36.4* MCHC-34.3 RDW-18.9* Plt Ct-171
[**2144-5-21**] 05:43AM BLOOD WBC-4.7 RBC-2.74* Hgb-9.9* Hct-29.5*
MCV-108* MCH-36.2* MCHC-33.6 RDW-18.7* Plt Ct-265
[**2144-5-14**] 08:00PM BLOOD PT-15.3* PTT-34.9 INR(PT)-1.4*
[**2144-5-17**] 06:41PM BLOOD PT-14.9* PTT-45.7* INR(PT)-1.3*
[**2144-5-14**] 08:00PM BLOOD Glucose-101 UreaN-46* Creat-11.5*# Na-138
K-5.6* Cl-96 HCO3-26 AnGap-22
[**2144-5-17**] 03:00AM BLOOD Glucose-106* UreaN-62* Creat-14.1*
Na-132* K-7.7* Cl-93* HCO3-24 AnGap-23*
[**2144-5-18**] 04:51AM BLOOD Glucose-109* UreaN-42* Creat-11.1*#
Na-131* K-4.9 Cl-88* HCO3-28 AnGap-20
[**2144-5-21**] 05:43AM BLOOD Glucose-88 UreaN-45* Creat-11.4*# Na-136
K-4.8 Cl-95* HCO3-25 AnGap-21
[**2144-5-18**] 04:51AM BLOOD Lipase-21
[**2144-5-14**] 08:00PM BLOOD Calcium-8.3* Phos-5.5*# Mg-2.1
[**2144-5-17**] 06:41AM BLOOD Calcium-14.3* Phos-5.9* Mg-2.2
[**2144-5-19**] 05:25AM BLOOD Calcium-8.3* Phos-8.8*# Mg-1.9
[**2144-5-16**] 06:10AM BLOOD Vanco-14.8*
[**2144-5-21**] 05:43AM BLOOD Vanco-9.8*
[**2144-5-13**] 8:20 am BLOOD CULTURE #1.
**FINAL REPORT [**2144-5-17**]**
AEROBIC BOTTLE (Final [**2144-5-17**]):
VIRIDANS STREPTOCOCCI.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
208-5586J
[**2144-5-13**].
ANAEROBIC BOTTLE (Final [**2144-5-17**]):
VIRIDANS STREPTOCOCCI.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
208-5586J
[**2144-5-13**].
[**2144-5-13**] 8:20 am BLOOD CULTURE #2.
**FINAL REPORT [**2144-5-17**]**
AEROBIC BOTTLE (Final [**2144-5-17**]):
VIRIDANS STREPTOCOCCI.
IDENTIFICATION AND SENSITIVITIES PERFORMED FROM
ANAEROBIC BOTTLE.
ANAEROBIC BOTTLE (Final [**2144-5-17**]):
REPORTED BY PHONE TO DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] AT 15:00PM ON
[**2144-5-14**] - OUTPT.
VIRIDANS STREPTOCOCCI. FINAL SENSITIVITIES.
Sensitivity testing performed by Sensititre.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
VIRIDANS STREPTOCOCCI
|
CLINDAMYCIN----------- S
ERYTHROMYCIN---------- 0.25 S
PENICILLIN------------ 0.06 S
VANCOMYCIN------------ 1 S
[**2144-5-16**] 12:15 pm FOREIGN BODY AV FISTULA GRAFT.
**FINAL REPORT [**2144-5-20**]**
WOUND CULTURE (Final [**2144-5-20**]): NO GROWTH.
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2144-5-16**] 1:57 PM
CHEST (PORTABLE AP)
Reason: eval for pulm edema
[**Hospital 93**] MEDICAL CONDITION:
47 year old man with ESRD, extubated in OR, required
re-intubation in OR for shallow breaths
REASON FOR THIS EXAMINATION:
eval for pulm edema
CLINICAL HISTORY: End-stage renal disease, intubated.
CHEST: The tip of the endotracheal tube lies 3 cm from the
carinal angle. The heart is enlarged. Costophrenic angles appear
sharp. There is a diffuse increase in overall opacification of
both the lung fields. I am unsure whether this is technical or
represents some pathology. Followup films suggested.
IMPRESSION: Mild increase in overall opacity of the lungs of
uncertain significance. Continued followup recommended.
Conclusions:
The left atrium is elongated. The right atrium is moderately
dilated. There is
mild symmetric left ventricular hypertrophy with normal cavity
size and
systolic function (LVEF>55%). Regional left ventricular wall
motion is normal.
Right ventricular chamber size and free wall motion are normal.
The aortic
valve leaflets (3) are mildly thickened. There is a minimally
increased
gradient consistent with minimal aortic valve stenosis. No
aortic
regurgitation is seen. The mitral valve appears structurally
normal with
trivial mitral regurgitation. A 1.6cm mobile linear echodensity
is noted in
the left atrium attached to the mitral annulus. There is no
mitral valve
prolapse. Mild mitral regurgitation is seen. 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
[**2143-9-5**], the mobile linear echodensity is new and c/w a
vegetation.
If clinically indicated, a TEE is suggested to better define the
mitral
annulus abnormality.
Reason: Dialysis line temporary infected with strep viridens
[**Hospital 93**] MEDICAL CONDITION:
47 year old man with ESRD. AV graft infected sp graft removal
REASON FOR THIS EXAMINATION:
Dialysis line temporary infected with strep viridens
TEMPORARY DIALYSIS CATHETER PLACEMENT
INDICATION: Renal failure.
Details of the procedure and possible complications were
explained to the patient and informed consent was obtained.
RADIOLOGIST: Dr. [**Last Name (STitle) 380**] was performing the procedure.
TECHNIQUE: Using sterile technique, local anesthesia and
conscious sedation, the right internal jugular vein was
localized with ultrasound and accessed with a micropuncture set
under direct ultrasound guidance. Hard copies of ultrasound
images before and after access of the internal jugular vein were
obtained. The tract was dilated with sequential dilators and
12.5 French temporary dialysis catheter placed over the wire
with its tip positioned in the right atrium under fluoroscopic
guidance. Position of the catheter was confirmed by chest x-ray
in one view.
The catheter was secured to the skin.
The patient tolerated the procedure well. There were no
immediate complications.
IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided
placement of the temporary dialysis catheter via the right
internal jugular venous approach.
Conclusions:
No spontaneous echo contrast is seen in the body of the left
atrium. 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 systolic function is normal. There
are simple
atheroma in the aortic arch. The aortic valve leaflets (3) are
mildly
thickened with focal calcifications of the aortic root. No
masses or
vegetations are seen on the aortic valve. No aortic valve
abscess is seen. No
aortic regurgitation is seen. The mitral valve leaflets are
structurally
normal. There is irregular mitral annular calcification with
calcified, fairly
immobile, "frond- like" projections from the posterior mitral
annulus (on the
[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]). No definite mobile vegetation is seen on the mitral
valve or on the
mitral valve annulus. Trivial mitral regurgitation is seen.
There is no
abscess of the tricuspid valve. No vegetation/mass is seen on
the pulmonic
valve. There is a trivial/physiologic pericardial effusion.
Impression: No definite, mobile vegetation or abscess seen. No
signifcant
valvular regurgitation. Due to the irregular pattern of mitral
annular
calcification, endocarditis cannot be fully excluded.
Brief Hospital Course:
Patient was admitted from the ED, NPO for graft debridement the
next day, started on pre-op vancomycin. cultures started growing
GPC on HD 2 in both aerobic and anaerobis bottles so HD was
held. Patient went to the OR on HD3 with an uncomplicated graft
excision and a tem-porary femoral catheter was placed for
hemodialysis. Was extubated in the OR but needed to be
reintubated for hypoventilation and was transferred to the SICU
for monitoring. Was extubated wsuccessfully the enxt morning on
POD1. Renal followed along for continuing need for HD - patient
was having high potassium levels. Had a surface echo on POD2
which showed possible vegetations on the mitral valve. Was
transferred to the floor on POD2 in stable condition. Had a TEE
on POD4 which did not show vegetations and got a temporary line
for HD. Surveillence blood cultures were obtained daily which
have not grown out anything. ID was consulted for further
recommendations. Though they recommended 4 weeks of IV PCN, the
patient could not get a PICC line placed in order to preserve
arm/veins for fistula. It was ultimately agreed upon by all the
services involved to send the patient on 4 weeks of vancomycin
to be given at dialysis 3 times a week and dosesd accordingly.
Patient was discharged in good condition tolerating po and
ambulating.
Medications on Admission:
Androgel 0.75%, Diovan 160qd, Epivir 150TIW, Labatalol
200qam/100qhs, Nelfinavir 1250bid, Nifedipine SR 90qd, Protonix,
Renagel 4000qid, Spectazole 1%, Zidovudine
Discharge Medications:
1. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous Q48H (every 48 hours) for 4 weeks: to be given 3x
/week x 4 week if vanco level <15 for infected left graft. .
2. Resume Pre-hospital medications
Discharge Disposition:
Home
Discharge Diagnosis:
infected left av graft
esrd
hiv
hcv
strep veridans, blood culture [**2144-5-13**]
Discharge Condition:
stable
Discharge Instructions:
Call [**Telephone/Fax (1) 673**] if fevers, chills, nausea,vomiting, inability
to take medications, redness, drainage or bleeding from left arm
or if left arm is swollen/cold
resume pre-hospital medication
resume regularly scheduled hemodialysis. To receive vancomycin
at hemodialysis x4 weeks
Dry gauze to left arm-change once a day. observe for
redness/pus/bleeding. [**Month (only) 116**] shower
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2144-6-1**] 3:10
Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 6197**]
Date/Time:[**2144-6-4**] 9:30
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2144-6-4**] 11:40
Completed by:[**2144-5-22**]
|
[
"V08",
"E879.1",
"996.62",
"070.70",
"E870.2",
"304.03",
"995.91",
"038.0",
"998.2",
"585.6",
"E878.2",
"E849.8",
"403.01",
"416.8",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.95",
"88.72",
"39.42",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
10162, 10168
|
8391, 9705
|
330, 403
|
10294, 10303
|
1049, 4005
|
10750, 11231
|
9918, 10139
|
5818, 5880
|
10189, 10273
|
9731, 9895
|
10327, 10727
|
894, 1030
|
273, 292
|
5909, 8368
|
431, 814
|
836, 879
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,942
| 172,673
|
53253
|
Discharge summary
|
report
|
Admission Date: [**2204-2-13**] Discharge Date: [**2204-3-1**]
Service: SURGERY
Allergies:
Sulfonamides / Iodine; Iodine Containing / Ivp Dye, Iodine
Containing
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
RLE cellulitis, ulcer
Major Surgical or Invasive Procedure:
[**2204-2-15**] Angioplasty of Right peroneal vessel
History of Present Illness:
[**Age over 90 **] y/o woman with hx. of CAD who was admitted [**2-13**] with rt. foot
ulcer and pain to Dr.[**Name (NI) 10879**] service (vascular surgery). A
plain film was consistent with Rt. 1st MT head osteomyelitis.
She was started on Vanc, cipro, flagyl, and underwent Rt.
peroneal angioplasty on [**2-15**]. 2 d after this, she experienced
rapid atrial fibrillation with sbp in the 70's a/w troponin
elevation. This was rate controlled with lopressor. She then
experienced flash pulmonary edema on [**2-20**] and was diuresed with
lasix. On the am of [**2-21**] she was reportedly 4 kg lighter, and had
sbp 76 with HR 50's. She was given two 250 cc boluses with sbp
up to 80's, started on dopamine gtt, and transfered to the CCU
at Dr.[**Name (NI) 5452**] request, for further management. Patient improved
and she was transfered back to Vascular on [**2204-2-27**]. Medications
adjusted. Physical therapy and nutrition following patient.
Stable for discharge on [**2204-3-1**]. See Hospital course for full
report.
Past Medical History:
s/p PTCA w/ RCA '[**91**]
IDDM
osteo
diverticulitis
CVA and TIAs
Htn
Breast CA
DVT
anemia
mastectomy
R fem-[**Doctor Last Name **] BPG w/ arm vein
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
Blood pressure was 113/48 mm Hg while seated. Pulse was 67
beats/min and irregular, respiratory rate was 14 breaths/min.
Generally the patient was well developed, well nourished and
well groomed. The patient was oriented to person, place and
time. The patient's mood and affect were not inappropriate.
.
There was no xanthalesma and conjunctiva were pink with no
pallor or cyanosis of the oral mucosa. The neck was supple with
JVP of 6 cm. The carotid waveform was normal. There was no
thyromegaly. The were no chest wall deformities, scoliosis or
kyphosis. The respirations were not labored and there were no
use of accessory muscles. The lungs had basilar crackles
bilaterally with normal breath sounds and no adventitial sounds
or rubs.
.
Palpation of the heart revealed the PMI to be located in the 5th
intercostal space, mid clavicular line. There were no thrills,
lifts or palpable S3 or S4. The heart sounds revealed a normal
S1 and the S2 was normal. There were no rubs, murmurs, clicks or
gallops.
.
The abdominal aorta was not enlarged by palpation. There was no
hepatosplenomegaly or tenderness. The abdomen was soft nontender
and nondistended. The extremities had no pallor, cyanosis,
clubbing or edema. There were no abdominal, femoral or carotid
bruits. Inspection and/or palpation of skin and subcutaneous
tissue showed no stasis dermatitis, ulcers, scars, or xanthomas.
RT foot w/chronic ulceration medial aspect of R 1st MPJ minimal
surrounding redness, no drainage.
B/L DP/PT pulses doppler
Pertinent Results:
[**2204-2-28**] 04:31PM BLOOD WBC-13.2* RBC-2.97* Hgb-9.6* Hct-27.9*
MCV-94 MCH-32.4* MCHC-34.5 RDW-16.3* Plt Ct-317
[**2204-2-29**] 03:40AM BLOOD PT-24.3* PTT-32.0 INR(PT)-2.4*
[**2204-2-28**] 04:31PM BLOOD Glucose-166* UreaN-35* Creat-1.7* Na-137
K-4.0 Cl-102 HCO3-27 AnGap-12
[**2204-2-28**] 04:31PM BLOOD Calcium-8.1* Phos-3.9 Mg-2.4
Brief Hospital Course:
# HYPOTENSION: Patient initially admitted to CCU for this, but
subsequently resolved. Could be multifactorial. Possible
etiologies include hypoglycemia, excessive diuresis, infection,
cardiogenic, symptomatic a-fib. Required dopamine initially, now
weaned. Received 1 unit PRBCs, but otherwise hematocrit was
stable. Sepsis unlikely as patient has no increase in WBC and
afebrile, but still must be considered and was continued on
Vancomycin. Cardiogenic etiology unlikely given CK and trop
flat. ECG demonstrated global TWI, but essentially unchanged.
Echocardiogram showed ejection fraction > 55%. Patient
transferred from CCU to VICU [**2204-2-27**]. Continued to improve. Had
2nd event of bradycardia/hypotension on [**2204-2-28**].
Lethargic/confused. ECG negative. Enzymes cycled. Patient
improved after fluid bolus. Beta blocker discontinued.
Amiodarone tapered and discontinued.
# Pump function: Diuresed during CCU admission.
.
# Atrial fibrillation: Continued amiodarone. Heparin gtt
started initially for anticoagulation, then transitioned to
warfarin. At time of discharge, amiodarone discontinued.
Discharged on Coumadin 0.5mg daily with INR checks to be sent to
Dr. [**Last Name (STitle) **] and patient's primary Dr. [**Last Name (STitle) 4390**].
.
# OSTEOMYELITIS: Likely secondary to poor perfusion, healing in
the setting of diabetes. Continued vancomycin
.
# DELIRIUM: Likely sundowning as occured in the evening, but
otherwise stable and responded to Haldol 1mg, with monitoring of
QTc, since patient is also on amiodarone.
At time of discharge patient returned to her baseline (oriented
to self, family)
.
# Coronary artery disease: Question of recent ischemia during
CCU admission but as above, enzymes flat. At home on metoprolol
and nifedipine, but held in the setting of hypotension.
Restarted beta-blocker and uptitrated as blood pressure
tolerated. Monitored ECG and cardiac enzymes. Continued
aspirin, atorvastatin, and ezetimibe.
.
# Diabetes mellitus: Stable. Did have labile blood sugars
initially. Continued sliding scale insulin but held home regimen
until adequate PO intake.
.
# S/p peroneal angioplasty: Vascular following. Appreciate recs.
Will monitor neurovascular exam closely. Pain management as
needed.
.
# ACCESS: Right arm PICC line was placed. All lines discontinued
at discharge.
.
# PPX: on coumadin, PPI, bowel regimen
.
# DNR, but would want intubation for respiratory failure as
needed for short period (days). Health care proxy [**First Name8 (NamePattern2) **]
[**Name (NI) 19755**] [**0-0-**], Daughter [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 19755**] [**Telephone/Fax (1) 109611**].
# Vascular: previous superficial femoral artery to above knee
popliteal bypass graft on the right side who presented with
right lower extremity ulcers. Underwent right lower extremity
unilateral runoff with PTA of the peroneal artery. B/L PT/DP
pulses dopplerable.
Medications on Admission:
Allopurinol, Amiodarone, ASA, Atorvastatin, Cipro, vanco,
flagyl, dopamine gtt, ezetemibe, tramodol, SC heparin, Insulin,
metoprolol, nifedipine, ppi, tramodol prn.
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
6. Warfarin 1 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
Disp:*60 Tablet(s)* Refills:*2*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for constipation.
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Other
Humalog sliding scale
0-60 mg/dL juice/crackers
61-120 mg/dL 0 Units
Breakfast-Lunch-Dinner-Bedtime
121-160 mg/dL 2 Units 2 Units 0 Units 0 Units
161-200 mg/dL 4 Units 4 Units 2 Units 0 Units
201-240 mg/dL 6 Units 6 Units 4 Units 2 Units
241-280 mg/dL 8 Units 8 Units 6 Units 3 Units
> 280 mg/dL 10 Units 10 Units 8 Units 4 Units
10. Insulin NPH-Regular Human Rec 100 unit/mL (70-30) Cartridge
Sig: 46 units with breakast, 10 units with dinner Subcutaneous
twice a day.
11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain only.
12. Outpatient Lab Work
INR/pt draw weekly and prn.
fax results to Dr. [**Last Name (STitle) **] phone [**Telephone/Fax (1) 1241**] and FAX
[**Telephone/Fax (1) 17352**]
and Dr. [**Last Name (STitle) **],[**First Name3 (LF) 278**] phone [**Telephone/Fax (1) 3070**] FAX: ([**Telephone/Fax (1) 109612**]
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
1) Peripheral vascular disease [**2204-2-15**]: PTA of R peroneal
2) non-ST elevation myocardial infarct
3) ulceration secondary to gout
Discharge Condition:
Stable. BP 120/62. 70 98%RA
B/L PT/DP pulses dopplerable
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Lower Extremity Angioplasty/Stent Discharge Instructions
Medications:
?????? Take Aspirin 81mg once daily
??????
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
What to expect when you go home:
It is normal to have slight swelling of the legs:
?????? Elevate your leg above the level of your heart (use [**12-24**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
?????? It is normal to feel tired and have a decreased appetite, your
appetite will return with time
?????? Drink plenty of fluids and eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
?????? After 1 week, gradually increase your activities and
distance walked as you can tolerate
?????? No driving until you are no longer taking pain medications
?????? Call and schedule an appointment to be seen in [**1-22**] weeks for
post procedure check and ultrasound
What to report to office:
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site)
?????? Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office [**Telephone/Fax (1) 1237**]. If bleeding does not stop, call
911 for transfer to closest Emergency Room.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 3749**], MD Phone:[**Telephone/Fax (1) 3241**]
Date/Time:[**2204-3-23**] 11:30
You have a visit scheduled with Dr. [**Last Name (STitle) **] on [**2204-3-27**] at 215pm.
You will have an ultrasound and then see Dr. [**Last Name (STitle) **]. Call
[**Telephone/Fax (1) 1241**] with any questions.
Call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] office at ([**Telephone/Fax (1) 5455**] to schedule
follow up to be seen in [**12-24**] weeks.
Completed by:[**2204-3-1**]
|
[
"707.14",
"731.8",
"730.27",
"401.9",
"V10.3",
"250.80",
"682.7",
"996.74",
"427.31",
"440.23",
"410.71",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.40",
"39.50",
"88.48",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8515, 8572
|
3706, 6642
|
298, 353
|
8753, 8812
|
3344, 3683
|
11405, 11977
|
1717, 1799
|
6857, 8492
|
8593, 8732
|
6668, 6834
|
8836, 10707
|
10733, 11382
|
1814, 3325
|
236, 260
|
381, 1405
|
1427, 1576
|
1592, 1701
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,594
| 112,636
|
48205
|
Discharge summary
|
report
|
Admission Date: [**2149-5-5**] Discharge Date: [**2149-5-9**]
Service: .
HISTORY OF PRESENT ILLNESS: This is a [**Age over 90 **] year old woman who
presented to [**Company 191**] on [**5-5**], after two episodes of bright red
blood per rectum. She denied nausea, vomiting,
lightheadedness, abdominal pain, fevers and chills. She was
also orthostatic in the Emergency Department. She had a
negative NG lavage and an initial hematocrit of 33. She had
an anoscopy without clear evidence of obvious bleeding
source. She was admitted to the Medical Intensive Care Unit.
PAST MEDICAL HISTORY:
1. Asthma.
2. Diverticulitis with lower gastrointestinal bleed.
3. Coronary artery disease status post coronary artery
bypass graft times two in [**2140**].
4. Leiomyoma sarcoma with total abdominal hysterectomy,
bilateral salpingo-oophorectomy.
5. Hypertension.
6. Glaucoma.
ALLERGIES: She has no allergies to drugs.
MEDICATIONS ON ADMISSION:
1. Verapamil SR.
2. Lasix.
3. Albuterol.
4. Xalatan drops.
5. Beclomethasone.
6. Aspirin.
7. Zantac.
8. Colace.
9. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**].
SOCIAL HISTORY: She denied tobacco and alcohol use.
PHYSICAL EXAMINATION: Temperature 97.2 F.; pulse 66 to 92;
blood pressure was 106 to 170 over 40 to 76; respirations 13
to 26; and O2 saturation is 95% on room air. In general, she
is alert and oriented times three in no acute distress,
comfortably resting. HEENT: Pupils equally round and
reactive to light. Extraocular movements are intact. Mucous
membranes were moist. Oropharynx was clear. Heart is
regular rate and rhythm; no murmurs, rubs or gallops. Lungs
bibasilar crackles two-thirds of the way up. No rhonchi.
Abdomen soft, nontender, nondistended, active bowel sounds.
Extremities with no cyanosis, clubbing or edema. Neurologic
examination is grossly nonfocal.
LABORATORY: On admission are notable for a creatinine of
1.6, hematocrit of 33.3, and white blood cell count of 5.1.
HOSPITAL COURSE: The patient was admitted to the Medical
Intensive Care Unit and started on intravenous Pantoprazole.
The aspirin and verapamil were held. Bleeding scan was
positive in the distal descending colon. The patient's
clinical bleeding resolved, but the hematocrit continued to
decrease, therefore, was transfused two units of packed red
blood cells on [**5-6**] and another two units of packed red
blood cells on [**5-7**]. GI was consulted and performed a
colonoscopy on [**5-7**], showing non-bleeding Grade II internal
hemorrhoids, multiple diverticula in the colon without active
bleeding; otherwise normal colonoscopy.
Further hospital course was complicated by supraventricular
tachycardia which responded well to Lopressor. She was also
ruled out for myocardial infarction now. Currently
hemodynamically.
She presented to the floor hemodynamically stable and did not
require any further transfusions as of the 9th when her blood
count was 36.
DISPOSITION: The patient transferred to Rehabilitation on
the following medications.
DISCHARGE MEDICATIONS:
1. Verapamil SR 240 p.o. q. day.
2. Minoxidil 7.5 p.o. q. day.
3. Pantoprazole 40 p.o. q. day.
4. Furosemide 40 p.o. q. day.
5. Docusate 100 p.o. twice a day.
6. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 p.o. q. day.
FINAL DIAGNOSES:
1. Gastrointestinal bleeding secondary to diverticulosis.
2. Hypertension.
3. Acute mental status change consistent with sundowning.
4. Hypokalemia.
5. Hypomagnesemia.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 16-403
Dictated By:[**Name8 (MD) 6069**]
MEDQUIST36
D: [**2149-9-11**] 16:42
T: [**2149-9-18**] 12:46
JOB#: [**Job Number 101607**]
|
[
"293.0",
"562.12",
"493.90",
"V45.81",
"285.1",
"455.0",
"V10.42",
"276.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
3097, 3355
|
959, 1158
|
2034, 3074
|
3372, 3763
|
1235, 2016
|
112, 583
|
605, 933
|
1175, 1212
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,442
| 165,224
|
33845
|
Discharge summary
|
report
|
Admission Date: [**2130-5-25**] Discharge Date: [**2130-5-28**]
Date of Birth: [**2049-5-14**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 458**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Cardiac catherization.
Intubation and extubation
History of Present Illness:
History is limited as the patient is intubated and sedated but
was obtained through thorough chart review. Ms. [**Known lastname 51681**] is an
81 year old woman with no past medical history who presented to
the emergency room after 2 hours of chest pain, with radiation
to the back. She received aspirin 325mg en route to the ED. In
the ED, she was found to be in atrial fibrillation with rapid
ventricular response at 122 and hypotensive with ST elevations
inferolaterally and in lead I. She was hypotensive to 78/44 on
initial vital signs. Code STEMI was called, and she was given
aspirin and clopidogrel, 1L of IVF (given inferior ST elevations
and possible RV infarct), and a heparin bolus; given ongoing
chest pain, eptifibatide was also started. She was then taken
immediately to the cath lab.
.
In the cath lab, her blood pressure improved to 110 systolic
with IV fluid. Coronary angiography initially showed no CAD.
Given the location of her chest pain and its radiation, an
aortogram was performed; it showed no evidence of dissection. A
right heart cath showed near-equalization of right and left
heart filling pressures at 25mm, and cardiac echo showed more
than moderate circxumferential pericardial effusion with a
dilated RV and no evidence of tamponade. Repeat RH pressures
showed RA 15, PCW 22, [**MD Number(3) 78228**] 70's. She was intubated given
ongoing agitation. She initially required dopamine after
intubation, which was subsequently changed to levophed with a
hypertensive response, and her rhythm had converted to NSR with
frequent APB's.
.
Review of systems could not be obtained, but per discussions
with the cardiology fellow, she noted only chest pain, cough,
and pain with deep inspirations.
Past Medical History:
Bilateral hip replacements (seen on cath)
Family History:
Noncontributory
Physical Exam:
VS: T97.7F, BP 124/60, HR 77, RR 14, O2 100% on vent settings
AC, rate 14, volume 500, FiO2 100%, PEEP 5.0
Gen: WDWN elderly female in NAD, intubated and sedated.
HEENT: Sclera anicteric. PERRL (but sluggish), EOMI. Conjunctiva
were pink, no pallor or cyanosis of the oral mucosa.
Neck: Unable to assess JVP as patient supine.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3. No murmurs or rubs appreciated.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use anteriorly. No crackles,
wheeze, rhonchi.
Abd: Soft, nontender, mildly distended, No HSM or tenderness. No
abdominal bruits.
Ext: No clubbing, cyanosis, or edema. Arterial and venous
sheaths in place without bleeding. 1+ DP pulses bilaterally.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
EKG demonstrated atrial fibrillation at 120bpm with diffuse ST
elevations most notable inferolaterally.
.
CXR: Low lung volumes with left retrocardiac opacity, likely a
combination of atelectasis and effusion, although evolving
infectious process is not excluded.
.
TELEMETRY demonstrated: Normal sinus rhythm with notable ST
elevations in lead II, frequent PVC's.
.
2D-ECHOCARDIOGRAM performed on [**2130-5-25**] demonstrated: Read
pending.
.
ETT: None
.
CARDIAC CATH performed on [**2130-5-25**] demonstrated: Referred from ED
with mid chest to back pain with slight diffuse ST elevations
most prominent inferolaterally. Rhythm was AF with RVR. SBP was
in 70's. Coronary angiography initially showed no CAD.
Aortography then showed no evidence of dissection. SBP improved
to 110 with IVF. RHC then done showing near equalization of
right and left heart filling pressures at 25mm. Intubated due to
continued hypotension, hypoxemia and failure to cooperate.
Cardiac echo then done showing no more than moderate
circumferential pericarfdial effusion with dilated RV and no
evidence of tamponade. REpeat RH pressures showed RA 15, PCW 22,
[**MD Number(3) 78228**] 70's. Initially required dopamine, changed at end of
procedure to levophed with hypertensive response. Rhythm had
reverted to NSR with frequent APB's. Plan to continue monitoring
in CCU for any evidence of tamponade. Amio started for
maintenance of NSR with BP appearing related to conversion from
AF. Following pressor requirement. Consider carefuil diuresis.
Most likely seems pericarditis with AF and effusion presently
without tamponade.
.
HEMODYNAMICS in CCU: ABP 135/65, PAP 26/15
.
LABORATORY DATA:
ABG: 7.38/32/99/20
.
Hct 29.1
Trop-T: <0.01
CK 46 MB: Notdone
.
Na 139 K 3.6 Cl 107 HCO3 24 BUN 13 Creat 0.8 Gluc 156
Ca: 8.5 Mg: 1.9 P: 3.1
.
WBC 7.6
N:81.1 L:13.6 M:4.7 E:0.4 Bas:0.2
Hgb 10.9
Hct 32.6
Plt 270
MCV 87
.
PT: 12.5 PTT: 24.1 INR: 1.1
.
Brief Hospital Course:
# Pericarditis:
The patient was admitted with ST elevations due to pericarditis.
A cardiac catheterization showed no coronary flow-limiting
lesions. Given her hypotension was responsive to volume, with an
underfilled LV and slightly larger RV on cardiac
catheterization, patient was evaluated for pulmonary embolus
with CT angiogram, which did not show evidence of PE. She was
treated with an intravenous heparin drip until both pulmonary
embolism and myocardial infarction were ruled out. Initially the
patient was started on aspirin but this was discontinued after
goals of care discussion took place and pt did not want active
intervention.
.
# Pump:
Echocardiogram showed normal function. She had mild symmetric
left ventricular hypertrophy. The patient was volume
resusciated as she was tachycardic. She was volume resuscitated
and remained euvolemic.
.
# Rhythm:
The patient was noted to be in sinus rhythm on admission. The
patient was noted to be in paroxysmal atrial fibrillation on
[**2130-5-25**], thought to be new onset. She was loaded with amiodarone
and continued on amiodarone therapy for rhythm control.
However, this medication was discontinued due the patient's and
her family's wished. She was initially placed on a heparin gtt
but this was discontinued after goals of care were addressed and
pt did not want any active interventions of medications. It was
explained that discontinuation of these medications would lead
to stroke, heart attack or death. The patient and her son/HCP
expressed understanding of this and requested the medications be
discontinued.
.
# Respiratory failure:
The patient was intubated in setting of procedure and
significant agitation. She was extubated on [**2130-5-26**] without
complication.
.
# Pulmonary nodules: The patient had pulmonary nodules, the
largest measuring 3 mm, noted on CT of her chest completed to
rule out a pulmonary embolus. She will need follow up of these
nodules at 3 months with a repeat CT scan for further evaluation
if she should choose so as an outpatient. However, based on her
wishes, she did not want this at the time of discharge.
.
#Mental status: At baseline the patient is alert and oriented to
person and place, has very poor short term memory, and is
intermittently agitated at home. This is per the patient's son.
During this admission she demonstrated significant agitation.
She was initially treated with haldol and zyprexa. A CT head
was done which showed no evidence of intracranial bleed. An MRI
was initially ordered but discontinued after goals of care were
addressed. Given the patient and her family's desire to hold all
medications, the patient was given no further medications.
# Level of care - Th eteam had a long disucssion with the pt and
pt's son on several occasions over more than one day. Due to
the patient's religious beliefs, she decided - and the son
agreed - that she shoul dnot receive any medications or any
further interventions. Her medications were discontinued and
the patient was discharged - as per her and her son's wishes.
They understood that the pt remained at risk for potnetially
life-threatening complications.
Medications on Admission:
None
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 55**] Benevolent Association
Discharge Diagnosis:
Primary diagnosis:
- Pericarditis
Secondary diagnoses:
- Hypotension
- Arrhythmia
Discharge Condition:
Stable. The patient is asymptomatic and her vital signs are
stable.
Discharge Instructions:
You were admitted for chest pain and low blood pressure. You
underwent cardiac catherization to evaluate your chest pain, and
briefly required intubation (breathing tube) to help with your
breathing. Your blood pressure and breathing stabalized.
Treatment options and goals of care were discussed, and you and
your family decided to no pursue any further testing or medical
treatment. No medications were prescribed in accordance with
your wishes.
.
Please contact your doctor or go to the emergency room if you
desire any treatment for pain, shortness of breath, bleeding,
chest pain, or other concerning symptoms you wish to address.
.
It has been a pleasure caring for you.
Followup Instructions:
Please follow up as desired with your primary provider.
.
If desired, please complete a repeat CT of your chest in 3
months.
|
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icd9cm
|
[
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,387
| 193,791
|
24462
|
Discharge summary
|
report
|
Admission Date: [**2111-6-12**] Discharge Date: [**2111-6-22**]
Date of Birth: [**2039-9-24**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
GI bleed and type 2 aortic dissection
Major Surgical or Invasive Procedure:
None
History of Present Illness:
71 y/o female with PMH significant for CAD, HTN, and dementia
admitted on [**6-12**] from [**Hospital6 2910**] with a
decreased Hct and type 2 aortic dissection. Pt was in her normal
state of health until around late [**5-/2111**] when she developed
fevers, cough, and was found to have new acute renal failure
that was attributed to dehydration. Her creatinine increased to
2.1 but subsequently decreased to 1.2 following hydration. Then,
on [**6-11**], the pt developed new nausea and vomiting associated
with coffee ground emesis. At that time, she denied abdomnal
pain. Her Hct decreased from 36 to 24 and the pt was transferred
2 units PRBC. A CT of the abdomen and pelvis was obtained to
evaluate for expansion/dissection of the pt's known AAA. Images
were compared to a previous scan from [**4-28**]. There were
bilateral pleural effusions L>R. The thoracic aorta was enlarged
and tortuous which was similar in appearance to the previous
study. There was air within the abdominal aortic aneurysm
measuring approximately 5 cm in diameter which is unchanged. The
aorta tapers ot approximately 2.5 cm at the renal arterial level
and dilates again to nearly 3.5 cm. This more distal dilation
was new since [**4-28**] and the margins of the aorta were ill
defined which suggests aortic aneurysm leakage. The dissection
appears to end at the thoraco abdominal junction. Pt was then
transferred to [**Hospital1 18**] for further care regarding her Hct drop and
type B aortic dissection.
On arrival at [**Hospital1 18**], the pt was initially admitted to the VICU
but was then transferred to the SICU on the day of arrival as
her SBP was extremely elevated at 200. On arrival to the SICU,
her VS were 97.6 187/79 94 24 96% RA. Pt was guiac positive
and her abdomen was diffusely tender on exam. A repeat CT scan
was done. It showed a thracic aortic aneurysm in which the
thoracic aorta measured 4.4 cm in diameter at the level of the
arch and 4.1 cm at the aortic root. There is prominent mural
thrombus within the thoracic aorta and areas of contrast
extending into the aortic wall consistent with ulcerating plaque
within the inferior aspect of the descending aorta. There is
excessive tortuosity of the aorta just at the level of the
diaphragmatic hiatus with numerous saccular aneurysms. This has
the appearance of a complex aneurysm rather than a focal type B
dissection. There is also a complex abdominal aortic aneurysm
extending from the level of the diaphragmatic hiatus to the
infrarenal aorta. At its largest diameter, within the inrarenal
aorta, the aneurysm measures approximately 4.7 cm. There is
extensive mural thrombus and irregular atheromatous plaque
within the aorta. The aneurysm extends to the level of the
aortic bifurcation and involves the left common iliac artery.
There is mild stranding surrounding the aneurysm just inferior
to the level of the renal arteries and just above the
bifurcation without evidence of periaortic fluid collections or
free fluid in the abdomen to suggest rupture. Given the pt's
multiple medical issues and clinic picture, she was not a
surgical candidate and medical management with tight blood
pressure control was persued. On [**6-13**], a GI consult was
obtained to further evaluate the pt's Hct decrease. At that
time, the pt had guiac + [**Known lastname **] stool and a negative NG lavage.
It was felt that the Hct decrease was not due to bleeding from
her aneurysms but likely a GI source, most likely gastritis. On
[**6-14**], a surgery consult was obtained for increasing abdominal
pain. There was a concern for mesenteric angina given the pt's
low flow state from her severe BP conrol. Her BP was libralized
and she was started on IV levo, vanco, and flagyl. At this time,
the pt will be transferred to the MICU service for further care.
Past Medical History:
1. Alzheimer's dementia
2. [**Last Name (un) 865**] esophagus
3. Past GI bleeds
4. Gastritis- Seen on EGD from 03/[**2111**].
5. Right upper lobe PNA
6. Ischemic cholitis of the right colon- [**1-/2111**]
7. Known AAA- Last known to be 4.6 cm.
8. S/P lap cholecystectomy
9. HTN
10. COPD
11. S/P CVA
[**18**]. Recurrent UTIs
Social History:
Lives in a [**Hospital1 1501**]. Has two sons.
Family History:
Noncontributory.
Physical Exam:
96.4 84 150/70 CVP- 7 16 98% 5L NC
I/O: 5370/1088 (+4282) LOS +9292
Gen- Alert. Oriented only to self. Often saying "ouch" but when
asked where she is having pain is unsure.
HEENT- NC AT. Anicteric sclera. MMM. NG tube in place.
Cardiac- RRR. No m,r,g.
Pulm- Poor air movement but CTA anteriorly and laterally.
Abdomen- Soft. G tube in place. ND. Pt denies tenderness to
palpation. No rebound or gaurding. +BS.
Extremities- Anasarca. Dopplable DP pulses.
Pertinent Results:
[**2111-6-12**] 07:15PM BLOOD WBC-16.1* RBC-4.78 Hgb-12.6 Hct-37.4
MCV-78* MCH-26.3* MCHC-33.6 RDW-15.0 Plt Ct-442*
[**2111-6-12**] 07:15PM BLOOD Neuts-89.5* Lymphs-6.4* Monos-3.0 Eos-1.0
Baso-0.1
[**2111-6-12**] 07:15PM BLOOD Poiklo-1+ Microcy-1+
[**2111-6-12**] 07:15PM BLOOD Plt Ct-442*
[**2111-6-12**] 07:15PM BLOOD PT-12.5 PTT-25.0 INR(PT)-1.0
[**2111-6-12**] 07:15PM BLOOD Glucose-106* UreaN-22* Creat-1.2* Na-138
K-3.2* Cl-101 HCO3-24 AnGap-16
[**2111-6-12**] 07:15PM BLOOD ALT-31 AST-22 LD(LDH)-191 CK(CPK)-23*
AlkPhos-104 Amylase-52 TotBili-0.7
[**2111-6-12**] 07:15PM BLOOD Lipase-21
[**2111-6-12**] 07:15PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2111-6-12**] 07:15PM BLOOD Albumin-3.5 Calcium-9.4 Phos-2.7 Mg-1.7
[**2111-6-12**] 07:35PM BLOOD Type-ART pO2-89 pCO2-33* pH-7.46*
calHCO3-24 Base XS-0
CT 150CC NONIONIC CONTRAST [**2111-6-12**]:
CT OF THE CHEST WITHOUT AND WITH INTRAVENOUS CONTRAST: There is
a thoracic aortic aneurysm. The thoracic aorta measures 4.4 cm
in diameter at the level of the arch and measures 4.1 cm at the
aortic root. There is prominent mural thrombus within the
thoracic aorta, and areas of contrast extending into the aortic
wall consistent with ulcerating plaque within the inferior
aspect of the descending aorta. There is excessive tortuosity of
the aorta just at the level of the diaphragmatic hiatus, with
numerous saccular aneurysms. This has the appearance of multiple
saccular components of a complex aneurysm rather than a focal
type B dissection. There is no evidence of periaortic hematoma.
Bilateral pleural effusions are low density and not suggestive
of hemothorax. The pulmonary arteries appear unremarkable,
without filling defects to suggest pulmonary embolus. A
nasogastric tube is in place. There is no pathologic appearing
mediastinal, hilar, or axillary lymphadenopathy. There is
atelectasis within the lower lobes adjacent to the pleural
effusions. No focal nodules or masses are identified within the
pulmonary parenchyma. The airways are patent to the level of the
segmental bronchi bilaterally.
CT OF THE ABDOMEN WITHOUT AND WITH INTRAVENOUS CONTRAST: There
is a complex abdominal aortic aneurysm extending from the level
of the diaphragmatic hiatus to the infrarenal aorta. At its
largest diameter, within the infrarenal aorta, the aneurysm
measures approximately 4.7 cm (series 3, image 55). There is
extensive mural thrombus and irregular atheromatous plaque
within the aorta. The aneurysm extends to the level of the
aortic bifurcation and involves the left common iliac artery.
There is mild stranding surrounding the aneurysm just inferior
to the level of the renal arteries and just above the
bifurcation, without evidence of periaortic fluid collections or
free fluid within the abdomen to suggest rupture. The liver,
spleen, pancreas, and adrenal glands appear unremarkable. The
left kidney is atrophic and does not enhance. There are several
small, rounded, hypodense lesions within the right kidney, too
small to accurately characterize but possibly representing
cysts. The visualized large and small bowel loops are normal in
caliber. No abnormal bowel wall thickening is identified.
There is a branching linear low atenuation in the region of the
left renal vein (series 3, image 57). This could represent air
within a vein, within an adjacent loop of bowel, or artifact.
The superior mesenteric artery is patent. The celiac axis
opacifies; however, there is marked stenosis or short segment
occlusion at the base of the celiac, and retrograde
opacification of the celiac through collaterals cannot be
excluded. The inferior mesenteric artery is not well seen at its
origin. There is no free fluid within the abdomen. The
visualized portions of the uterus and adnexae appear
unremarkable. Note is also made of a small hiatal hernia. A
gastrostomy tube is in place.
BONE WINDOWS: Bone windows demonstrate no evidence of suspicious
lytic or sclerotic osseous lesions.
MULTIPLANAR REFORMATS: Coronal and sagittal reformatted images
demonstrate a complex aortic aneurysm extending from the level
of the aortic arch to the aortic bifurcation, with multiple
saccular components, most prominent at the level of the
diaphragmatic hiatus, but without evidence of aortic dissection
or rupture. The value of multiplanar reformats is 3.
IMPRESSION:
1) Complex abdominal aortic aneurysm extending from the thoracic
aorta to the level of the aortic bifurcation, with multiple
saccular components and with mural thrombus. No evidence of
hemoperitoneum or aortic rupture.
2) Bilateral pleural effusions.
3) Possible short segment occlusion of the celiac trunk with
possible retrograde opacification, versus severe stenosis at the
base of the celiac.
4) Tiny, rounded, hypodense lesions within the right kidney, too
small to accurately characterize but likely representing cysts.
5) Branching linear lucency within the area of the left renal
vein, a finding of uncertain significance.
6) Atrophic left kidney with nonenhancement and nonvisualization
of the left renal artery.
Brief Hospital Course:
71 y/o female with PMH signfiicant for Alzheimer's dementa, past
GI bleeds, HTN, and [**Hospital 2182**] transferred to the MICU from the SICU
for managment of GI bleed, type 2 aortic dissection, and ARF.
.
1. Type 2 aortic dissection- Pt with thoracic and abdominal
aortic aneurysms. However, from imaging, these appear stable and
are not thought to be the cause of the pt's Hct drop. At this
time, she is not a surgical candidate and medical management is
being persued.
- Appreciate vascular surgery input.
- Due to concern for mesenteric ischemia and ARF, have
libralized BP control from initial goal of SBP of 90 to 100. At
this time, will increase to goal SBP of 120. Will maintain pt on
nipride drip at this time as she has not been tolerating PO
medications secondary to vomiting.
- Will transition to PO antihypertensives when pt tolerating PO
medications.
.
2. GI bleed- Pt with Hct drop at OSH. However, her Hct has been
stable within range over the last three days. Although her
stools remain guiac positive, she has had no melena or
hematoemesis. Felt that Hct decrease was most likely secondary
to gastritis.
- Appreciate GI input.
- Plan for EGD if pt has Hct drop or other signs of active
bleeding.
- Continue [**Hospital1 **] IV PPI.
- Follow TID Hct and transfuse for Hct of 28 or less.
- Maintain active type and cross.
.
3. Abdominal pain- Pt with worsening abdominal pain on [**6-14**].
Surgery was consulted and concern for mesenteric angina from
pt's low BP and probable low flow state.
- Appreciate surgery input.
- Pt's BP goal has been libralized and abdominal pain seems to
have decreased since that time. Pt currently denies pain and is
nontender on exam.
- Continue to follow serial abdominal exams.
- Will follow serial lactates to continue evaluation for
possible mesenteric ischemia.
- Continue vanco, levo, and flagyl.
- Will send stool studies to evaluate for possible infectious
source of pt's abdominal pain.
.
4. Acute renal failure- Pt with new acute renal failure since
transfer. Her creatinine has increased from 1.2. to 2.2 and her
BUN today is 29. Possible causes include low flow state to the
kidneys (prerenal) and contrast nephropathy from the two CT
scans.
- Await renal US.
- Will obtain urine electrolyltes.
- Hopefully, with moderate libralization of SBP, pt's urine out
put will improve and her creatinine will decrease.
- Follow [**Hospital1 **] electrolytes and creatinine at this time.
.
5. [**Name (NI) 3672**] Pt carries the diagnosis of COPD. Do not have any
available PFTs. Clear on exam today. PRN nebs.
.
6. Alzheimer's dementia- Pt unable to make medical decisions.
Will contact her two sons to update them on situation.
.
7. FEN- NPO. Agressive electrolyte replacement.
.
8. Proph- Pneumoboots; IV PPI
.
9. Access- Right subclavian placed [**6-12**]. Left A line placed
[**6-12**].
.
10. Code- Listed in OSH records as DNR/DNI but as full code in
our system. Will contact sons to confirm her code status.
.
11. [**Name (NI) 2638**] Pt has two sons. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 61869**] at
[**Telephone/Fax (1) 61870**]. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 61869**] at [**Telephone/Fax (1) 61871**].
After prolonged hospital course, pt became hypotensive,
tachycardic, tachypenic on the morning og [**2111-6-22**]. LENIs showed
bilateral DVTs. Heparin was started for presumptive pulmonary
embolus. In the late afternoon of [**6-22**], pt developed
cardiopulmonary failure. She expired at 17:49. Her son [**Name (NI) **] was
contact[**Name (NI) **] immediately after the patient's death and did not wish
for an autopsy.
Medications on Admission:
1. Esmolol drip
2. Levofloxacin 250 mg IV daily
3. Flagyl 500 mg IV Q8H
4. Metoprol 25 mg TID
5. Nitroprusside drip
6. Pantoprazole 40 mg IV Q12H
7. Vancomycin 1000 mg daily
PRNs-
Tylenol
Hydralazine
Morphine sulfate
Discharge Disposition:
Expired
Discharge Diagnosis:
Thoractic Aortic Aneurysm
Abdominal aortic aneurysm
Pulmonary Embolism
DVT
1. Alzheimer's dementia
2. [**Last Name (un) 865**] esophagus
3. Past GI bleeds
4. Gastritis- Seen on EGD from 03/[**2111**].
5. Right upper lobe PNA
6. Ischemic cholitis of the right colon- [**1-/2111**]
7. Known AAA- Last known to be 4.6 cm.
8. S/P lap cholecystectomy
9. HTN
10. COPD
11. S/P CVA
[**18**]. Recurrent UTIs
Discharge Condition:
Dead
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
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[
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,806
| 158,260
|
39337
|
Discharge summary
|
report
|
Admission Date: [**2178-8-29**] Discharge Date: [**2178-9-1**]
Date of Birth: [**2128-1-1**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 20146**]
Chief Complaint:
Headache x 2 days
Major Surgical or Invasive Procedure:
Bronschoscopy and biopsy
History of Present Illness:
Patient is a 50 yo F with PMHx significant for current tobacco
use, hypothyroidism, hyperlipidemia, hx CVA [**2175**] who presented
to OSH this morning complaining of severe headache. The patient
reports that the headache woke her from sleep at 1 am on the day
prior to presentation. She describes it as bitemporal,
radiating to the back of her head, throbbing and associated with
nausea, sensitivity to light and sound. No aura, blurry vision
or other neurologic symptoms. She does have a history of
migraine headaches, for which she takes excedrine migraine once
every few months - describes this headache as significantly
different, and the "worst headache of her life." She remained
at home for one day without any relief. She also experienced
fever to 101 and shaking chills at home last night prior to
presentation at [**Hospital3 **], as well as right-sided
pleuritic chest pain. She denies any SOB, cough, or sick
contacts. On arrival to OSH, initial vitals were T 98.1, BP
113/71, HR 111, 96% on RA. She had CT head, which was
unremarkable, and LP which was normal. CXR showed a RUL PNA and
she became progressively more hypotensive, with a nadir at 62/35
around 1300. She received 3 L IVF, CTX 2 grams IV, azithromycin
500 mg PO, Morphine 4 mg IV x 2 , Dilaudid IV (total of 4 mg
IV), reglan 10 IV, and zofran 4 IV x2 and and BP improved to
90s/30s. She was transferred to [**Hospital1 18**] as there were no ICU beds
available at the OSH - en route she reportedly received another
1L NS (although not documented).
.
In the ED, initial vs were: T 97.7 P 93 BP 78/p R 18 O2 sat 98%
on 4L NC, pain 4/10 intensity. CXR showed a RUL pneumonia, labs
were significant for WBC 24 with a left shift (88% pmns, 5%
bands), Hct 34, lactate of 1.6. She was given levofloxacin 750
mg IV, acetaminophin 1gm PO, toradol 30 mg IV and 500cc NS.
Blood and urine cultures were sent, and she was admitted to the
MICU service for further management.
.
On arrival to the MICU, patient reported improvement in her
headache, with intensity down to 5/10. She denied SOB, chest
pain, cough, abd pain or other new complaints. Did report
feeling thirsty and hungry.
.
Review of systems:
(+) Per HPI. Also reports recent 50 lb intentional weight loss,
accomplished through weight watchers.
(-) Denies cough, shortness of breath, or wheezing. Denies
palpitations, or weakness. Denies 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
-Hyperlipidemia
-Hx of CVA in [**2175**] - affect L optic nerve, has some residual
left peripheral vision loss
-OSA - was on CPAP at home, but discontinued use after
significant recent weight loss
-Migraines, typically monthly
- s/p hysterectomy
- s/p L kidney removal 5-6 years ago (reports it was removed b/c
of a benign tumor)
- remote hx of left knee surgery (in high school)
Social History:
Lives at home with husband of 30 years. Had been unemployed for
14 months, and then recently started a new job. Has smoked
since the age of 18 - at least 30 pack years. Currently smokes
[**2-12**] ppd. EtOH [**1-14**] drinks most friday and saturday nights. No
increase in EtOH use lately. Denies illicit drug use.
Family History:
Father with lung and bone cancer, died age 57. Mother with
breast Ca diagnosed in her 40s. No family history of MI or CVA.
Physical Exam:
VS: 97.8, BP: 132/74, P: 86, RR: 20, 97% on RA
Gen: well-nourished, well-appearing female
HEENT: MMM, clear oropharynx, no LAD
CV: RRR, no m/r/g
PULM: decreased breath sounds over right upper lobe, clear at
bases and over left side
ABD: soft, non-tender, non-distended, BS+,
EXT: warm, well-perfused, radial, DP, PT pulses 2+ bilaterally
Pertinent Results:
[**2178-9-1**] 06:00AM BLOOD WBC-11.4* RBC-3.69* Hgb-12.1 Hct-34.4*
MCV-93 MCH-32.9* MCHC-35.2* RDW-14.0 Plt Ct-284
[**2178-8-31**] 06:28AM BLOOD WBC-15.7* RBC-3.41* Hgb-11.3* Hct-33.3*
MCV-98 MCH-33.1* MCHC-33.9 RDW-13.9 Plt Ct-294
[**2178-8-30**] 05:00AM BLOOD WBC-19.7* RBC-3.05* Hgb-10.0* Hct-29.7*
MCV-97 MCH-32.8* MCHC-33.7 RDW-13.9 Plt Ct-259
[**2178-8-29**] 06:00PM BLOOD WBC-24.3* RBC-3.45* Hgb-11.4* Hct-34.2*
MCV-99* MCH-33.2* MCHC-33.5 RDW-13.8 Plt Ct-277
[**2178-8-29**] 06:00PM BLOOD Neuts-88* Bands-5 Lymphs-3* Monos-4 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2178-8-29**] 06:00PM BLOOD PT-14.5* PTT-29.3 INR(PT)-1.3*
[**2178-8-31**] 06:28AM BLOOD PT-11.8 PTT-24.2 INR(PT)-1.0
[**2178-9-1**] 06:00AM BLOOD Glucose-114* UreaN-3* Creat-0.7 Na-139
K-3.6 Cl-106 HCO3-25 AnGap-12
[**2178-8-31**] 06:28AM BLOOD Glucose-83 UreaN-11 Creat-0.9 Na-142
K-4.2 Cl-111* HCO3-23 AnGap-12
[**2178-8-30**] 05:00AM BLOOD Glucose-90 UreaN-16 Creat-0.9 Na-138
K-3.7 Cl-111* HCO3-20* AnGap-11
[**2178-8-29**] 06:00PM BLOOD Glucose-90 UreaN-18 Creat-1.0 Na-137
K-4.7 Cl-108 HCO3-19* AnGap-15
[**2178-8-29**] 06:00PM BLOOD ALT-15 AST-17 AlkPhos-87 TotBili-0.2
[**2178-8-29**] 06:00PM BLOOD Lipase-13
[**2178-8-30**] 05:00AM BLOOD cTropnT-<0.01
[**2178-8-29**] 06:00PM BLOOD cTropnT-<0.01
[**2178-9-1**] 06:00AM BLOOD Calcium-8.4 Phos-4.4 Mg-1.6
[**2178-8-31**] 06:28AM BLOOD Calcium-8.6 Phos-3.0 Mg-2.0
[**2178-8-30**] 05:00AM BLOOD Calcium-7.8* Phos-2.8 Mg-1.8
[**2178-8-29**] 06:00PM BLOOD Calcium-7.3* Phos-3.8 Mg-1.7
[**2178-8-29**] 06:13PM BLOOD Lactate-1.6
CXR: [**2178-8-31**]:
FINDINGS: Portable AP upright view of the chest is obtained.
There is dense consolidation in the right upper lobe with air
bronchograms again noted, which could represent right upper lobe
pneumonia. Although, followup to resolution is advised as an
underlying malignancy cannot be excluded at this time. The left
lung remains clear. No pleural effusion is seen. Clips in the
upper abdomen are noted. Heart size remains normal.
IMPRESSION: Right upper lobe consolidation with air
bronchograms, most likely representing pneumonia, although
followup to resolution is advised to exclude underlying
malignancy.
CT Abdomen [**2178-8-31**]:
IMPRESSION:
1. Probable right upper lobe/right suprahilar mass with
postobstructive
pneumonia. Right sided mediastinal and right hilar
lymphadenopathy and
contralateral mediastinal nodal enlargement. If this is a mass
such as from malignancy, this is probable T3 N3 M0. However this
may represent dense right upper lobe consolidation from
infection, but less likely.
2. Homogenous enlargement of the left adrenal gland may relate
to a
nephrectomy as no focal adrenal lesion is shown.
3. Possible right first rib invasion, this can be confirmed with
a PET-CT or limited MRI of the chest wall, if clinically
appropriate.
Result communicated by telephone to Dr [**Last Name (STitle) 86984**] medical
resident, at 3.44 PM [**2178-8-30**].
Cytology: [**2178-8-31**]
-Transbronchial FNA of 3 lymph nodes: negative for malignant
cells.
-Bronchial Washings: negative for malignant cells
-unable to biopsy dominant mass via bronchoscopy
Brief Hospital Course:
50 yo F tobacco user with hx of stroke, hyperlipidemia and
hypotension who presents with RUL pneumonia and hypotension
concerning for septic shock.
# Hypotension/sepsis: Differential included sepsis, medication
effect, hypovolemia. The patient was stablizied with fluid
boluses. A CXR showed a consolidation in the RUL more
consistent with a mass than infiltrate. She was initially
started on ceftriaxone and levofloxacin to cover for community
acquired pneumonia. She was continued on levofloxacin alone for
a 14 day total course.
# RUL opacity - A CT Chest was obtained which was consistent
with a pancoast tumor of the right lung with mediastinal nodes
on the opposite mediastinum. The pulmonary team performed a
bronchoscopy with endoscopic ultrasound. They were unable to
biopsy the dominant mass. FNAs were obtained from 3 lymph nodes
and bronchial alveolar lavage was also performed. The cytology
results were negative for malignant cells. Patient will
follow-up with her primary care physician regarding further
[**Name9 (PRE) 8019**] of this mass, including possible IR-guided transthoracic
biopsy. Patient wanted to follow-up at [**Hospital 5871**] Hospital which is
a [**Hospital3 328**] Cancer Institute affliate.
# Headache - Unclear etiology, possibly initially a migraine HA
that may have been complicated by post-LP, positional component.
Resolved with pain medication.
#Anxiety: Patient appropriately anxious regarding her diagnosis
of a lung mass. Patient received lorazepam 1 mg po qHS while
hospitalized. She was given a prescription for ambien. She will
follow up with outpatient social work.
# Tobacco Use: patient with current history of tobacco use, ~30
pack year history. She was given nicotine patch 14 mg daily and
nicotine gum 2 mg po q4h prn nicotine craving and was given
nicotine replacement prescriptions.
#Hx of CVA: residual left side peripheral vision loss. Continued
on asa 325 mg po qDay.
#Hypothyroidism: continued on levothyroxine.
#Hyperlipidemia: continued on simvastatin and eztimibe.
Medications on Admission:
-Levothyroxane 137 mcg daily
-Zetia 10 mg daily
-Simvastatin 5 mg daily
-ASA 325 mg daily
-Excedrine migraine prn
-Claritin prn allergies
-zofarax prn cold sores
Discharge Medications:
1. Levothyroxine 137 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
2. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Simvastatin 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*14 Patch 24 hr(s)* Refills:*0*
6. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
7. Claritin Oral
8. Zovirax Topical
9. Fioricet 50-325-40 mg Tablet Sig: One (1) Tablet PO every
four (4) hours as needed for headache.
Disp:*10 Tablet(s)* Refills:*0*
10. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO three times a day
as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
11. Cepacol Sore Throat 15-2 mg Lozenge Sig: One (1) lozenge
Mucous membrane four times a day as needed for sore throat.
Disp:*30 lozenges* Refills:*0*
12. Ambien 10 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Pneumonia
Lung Mass
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
1. Pneumonia: you were admitted to the hospital with high
fevers, headache and chest pain. You were found to have a
pneumonia. Your infection caused your blood pressure to become
low. You were given intravenous fluids to bring up your blood
pressure. You were given antibiotics to treat your infection.
You will continue to take antibiotics. The instructions for this
are:
-Levofloxacin 750 mg once a day until [**2178-9-12**]
2. Lung Mass: We found a mass in your lung on your chest x-ray.
We got a CT scan to further evaluate the mass. We also performed
a brochoscopy to obtain a biopsy of the mass. The results of the
biopsy are not available yet. You will review these results with
your primary care physician. [**Name10 (NameIs) **] were given a CD with the images
from your CT scan. Your PCP will set up follow-up care with
oncology at [**Hospital 5871**] Hospital which is an affiliate of [**Hospital 10596**] Cancer Institute
3. The following changes were made to your medications:
-Added Levofloxacin 750 mg once a day until [**9-12**]
-Added nicotine patch- apply daily
-Added nicotine gum as needed for nicotine cravings
-Added fioricet as needed for headache
-Added ambien as needed for sleep
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] L.
Location: TRI-RIVER FAMILY HEALTH CENTER
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 63010**]
Phone: [**Telephone/Fax (1) 47884**]
**Dr. [**Last Name (STitle) 86985**] office will contact you to schedule an
appointment. If you dont hear by Wednesday, [**9-2**], please call
the number above.
Dr.[**Name (NI) 86986**] office will assist you in setting up a follow-up
appointment at [**Hospital 5871**] Hospital.
|
[
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icd9cm
|
[
[
[]
]
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[
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icd9pcs
|
[
[
[]
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] |
10725, 10731
|
7388, 9428
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332, 359
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10795, 10795
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4219, 7365
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12177, 12678
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3720, 3846
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9640, 10702
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10752, 10774
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9454, 9617
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10946, 12154
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3861, 4200
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2570, 2948
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275, 294
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387, 2551
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10810, 10922
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2970, 3367
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3383, 3704
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,218
| 123,387
|
3259
|
Discharge summary
|
report
|
Admission Date: [**2172-5-11**] Discharge Date: [**2172-5-20**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
nausea and lightheadedness
Major Surgical or Invasive Procedure:
endoscopy with ulcer injection
History of Present Illness:
HPI: Ms. [**Known lastname **] is an 81 yo F s/p THR [**2172-5-5**], COPD, HTN who
presented with nausea and lightheadedness in the setting of
blood-loss anemia.
Ms. [**Known lastname **] [**Last Name (Titles) 1834**] uncomplicated scheduled THR at NEBH, with an
EBL of 300cc. However, whereas her HCT was 40 pre-operatively,
she had progressive decline in HCT over her hospitalization, and
was discharged to rehabilitation with an HCT of 28 [**5-8**]. She was
started on coumadin for post-op DVT/PE prophylaxis. She did not
apparently receive any transfusion while hospitalized. Bloodwork
the morning of admission demonstrated a HCT of 20, and she was
referred to the ED for further workup.
In ED, patient noted to be OB negative and probability of
post-surgical bleeding from hip was raised. She [**Month/Day (4) 1834**] a CT
pelvis which showed right adductor muscle hematoma. She was
transfused 4 uniutes over a 3 day period with an appropriate
rise in hematocrit from 19 to 30. NG lavage was attempted x 2
without success due to patient discomfort. On hospital day #2,
the patient had a large OB + stool but non-melanotic. Vitamin K
was given with INR decreasing from 2.0 to 1.0. Patient without
abdominal complaints. On [**5-14**] patient had another large melanotic
bowel movement with hematocrit drop 30 to 24 therefore patient
transferred to unit for urgent EGD. EGD showed a large duodenal
bulb ulcer which was injected with epinephrine. The patient was
started on Protonix [**Hospital1 **]. Her hematocrit remained stable and on
[**5-15**] the patient is stable for call out to floor.
Of note, hospital course also c/b afib/flutter with RVR,
difficulty swallowing pills, CT chest with RUL lesion suspicious
for cancer
Past Medical History:
1. COPD
2. HTN
3. Glaucoma
4. Arthritis
5. IgM anticardiolipin
6. Asthma
7. s/p cataract surgery to L eye
8. Osteopenia
9. h/o hematuria
10. s/p repair at NEBH [**2172-5-5**] as part of a scheduled, staged
bilateral hip repair.
11. ECHO [**3-9**] EF 55%, 1+TR/MR/AR. Mild Pulm HTN.
Had reportedly normal dobutamine echo [**3-9**] (pre-op) NEBH
12. colonoscopy [**Hospital1 18**] 2 years ago, reportedly nl other than
polyps
Brief Hospital Course:
A/P: 81 yo F with COPD, s/p total hip replacement at the [**Hospital1 15204**] hopsital on [**5-5**] admitted with blood-loss
anemia, initially presumed to be from operative site and
hematoma in adductor muscle, but after melanotic stool found to
have large duodenal bulb ulcer. Her hospital course was
complicated by supraventricular tachycardia requiring
initiation of diltiazem and a chest CT scan with suspicious Righ
apical lung lesion, and leukocytosis.
1) Hematocrit drop: This was felt to be multifactorial from
both adductor muscle hematoma and bleeding duodenal bulb ulcer.
GI was consulted during the hospital stay and found the duodenal
bulb ulcer as above. She was transfused a total of 4 units PRBCs
(last transfusion on [**5-12**]). Hemtocrit remained stable after
epinephrine injection of ulcer. GI recommended continuing her
Protonix [**Hospital1 **] x 2 months and then decreasing to daily. Her
gastrin level was 104. Her coumadin was held given the bleeding
and she will be started on lovenox SC 40 daily until procedure.
2) SVT - exact rhythm unclear. Rate was well-controlled with
Diltiazem. She was monitored on telemetry which showed only
premature atrial beats. Her heart rate was well-controlled in
80s on diltiazem. The day of discharge her HR increased to 100s
after being NPO for the bronchoscopy. She was given IVF with
improvement in her heart rate.
3) Lung mass: CT scan revealed worsening RUL scarring with
spiculations suspicious for malignancy. Given her extensive
smoking history and recent weight loss, there was significant
concern for malignancy. The patient was made aware of concerns
and need to biopsy. the case was reviewed with radiology who
felt the patient was too high risk for CT guided biopsy.
Pulmonary was consulted and recommended bronchoscopy with BAL
for cytology. After much discussion, the patient decided against
bronchoscopy in favor of electromagentic field directed
transbronchial biopsy by interventional pulmonary to be
scheduled within a week of discharge. This was discussed by
pulmonary at length with patient and daughters.
4)Leukocytosis: Her WBC improved during the hospital course and
remained stable in 12's prior to discharge. Her urinalysis was
negative, but the urine culture grew >100,000 Ecoli. She was
started on Ciprofloxacin for a 10 day course on [**2172-5-13**]. She had
a Foley catheter in place that was removed on [**5-19**]. She should
have a repeat urine culture on completion of therapy to document
clearance.
5) s/p THR: Given the need for further lung biopsies for
diagnsotic purposes of right apical lesion, the patient was not
discharged on lovenox SC or coumadin. Per pulmonary
recommendations, coumadin was not restarted. However, after
hearing patient's concerns about DVT, she was started on lovenox
40mg SQ daily which will be held 1 day prior to biopsy. She
should begin ambulating as much as possible to prevent
development of DVT. While in bed, she was continued on
pneumoboots and this should be continued at rehab as well.
6) COPD: Her COPD remained stable throughout the hospital
course. She was continued on advair and tiotropium.
7) Glaucoma: No active issues. She remained on diazolamide
throughout the hospital stay.
8) Thrush, resolved: Likely [**1-8**] inhaled steroids. She was
initially treated with nystatin swish and swallow. We
recommended rinsing her mouth after advair usage.
9) Sacral Decub: She had an early sacral decubitus. This was
covered with duoderm and her family applied bag balm (niece
hospice RN). This should be monitored on discharge.
11) Code - reversed for EGD and 48 hours post procedure.
DNR/DNI.
Medications on Admission:
Verapamil 240 mg [**Hospital1 **]
Atrovent 80 mcg 4 times daily
Albuterol 90 mcg PRN
Spiriva
Advair 500/50
Percocet PRN
Spironolactone/HCTZ 25/25 daily. Should restart if BP permits
Discharge Medications:
1. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) puff Inhalation [**Hospital1 **] (2 times a day).
2. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) inhalation Inhalation DAILY (Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
6. Dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic TID (3
times a day).
7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 2 days.
9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for neck pain: hold for mental status changes.
10. Lovenox 40 mg/0.4mL Syringe Sig: One (1) injection
Subcutaneous once a day for 13 days: last dose 6/28. Do not give
on the am of [**2172-6-3**].
11. Cardizem CD 180 mg Capsule, Sust. Release 24HR Sig: Two (2)
Capsule, Sust. Release 24HR PO once a day. Capsule, Sust.
Release 24HR(s)
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Duodenal ulcer
Gasrointestinal bleed
Supraventricular Tachycardia
Total hip replacement
Discharge Condition:
Stable
Discharge Instructions:
Please continue all medications as directed.
Please note that you will take your protonix twice daily for 2
months, then you can decrease your protonix to daily.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) 1395**] within 1 week of discharge from
rehab.
CAll [**Telephone/Fax (1) 15205**] for an appointment.
You will also need to return [**6-3**] for further diagnostic testing
of right upper lobe lung scarring. This was scheduled by Dr.
[**Name (NI) **] as follows. You should not get any Lovenox on
[**2172-6-3**].
Provider: [**Name10 (NameIs) 454**],NINE DAY CARE [**Hospital Ward Name **] 8 Where: DAY CARE [**Hospital Ward Name **] 8
Date/Time:[**2172-6-3**] 11:00
Please see Dr. [**Last Name (STitle) 15206**] to help with further treatment decisions
once the lung biopsy has been performed. You have the
appointment below.
Provider: [**Name10 (NameIs) **] [**Last Name (STitle) **]/NP [**Doctor Last Name 15207**] Where: [**Hospital6 29**] REHAB
SERVICES (DYSPNEA) Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2172-6-10**] 8:00
You should also follow up with the gastroenterologist, Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 437**], on discharge. Please call [**Telephone/Fax (1) 8892**] to set up
an appointment.
You need to follow up with your orthopedic surgeon within 1 week
of discharge from the hospital.
Provider: [**Name10 (NameIs) 1571**] BREATHING TEST Where: [**Hospital6 29**]
PULMONARY FUNCTION LAB Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2172-6-10**]
7:45
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
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icd9cm
|
[
[
[]
]
] |
[
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icd9pcs
|
[
[
[]
]
] |
7746, 7831
|
2553, 6207
|
288, 320
|
7963, 7971
|
8181, 9638
|
6439, 7723
|
7852, 7942
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6233, 6416
|
7995, 8158
|
222, 250
|
348, 2083
|
2105, 2530
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,732
| 159,594
|
36524
|
Discharge summary
|
report
|
Admission Date: [**2158-6-5**] Discharge Date: [**2158-6-30**]
Date of Birth: [**2096-1-15**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
fever, rinorrhea
Major Surgical or Invasive Procedure:
Bipap
History of Present Illness:
62M w/ refractory biphenotypic leukemia, hx disseminated
fusarium and multiple prior treatments (hyperCVAD, 7+3 [**4-30**],
decitabine, MEC [**9-25**], several more cycles decitabine last [**3-16**])
who presents with neutropenic fever. He also has a history of
enterococcal empyema, admitted [**Date range (1) 82695**] w/ sepsis from E coli
bacteremia which was complicated by AF w/ RVR and empyema. He
received a chest tube for drainaige and was discharged on
voriconazole, linezolid, and ertapenem as outpatienton. He was
then readmitted from [**Date range (1) 24818**] with fever and concern for soft
tissue [**Date range (1) 2**]. His Ertapenam was switched to Cefepime, and
his empyema and effusions improved. He was discharged on 4
additional days of cefepime for a total of 5 days.
.
The patient reports that he developed clear rinorrhea 4 days
prior to admission that resulted in subsequent sore throat and
voice change 1-2 days later. He then developed a non-productive
[**Date range (1) **] and low-grade temperatures to 99.5. He denies any sick
contacts, headaches, nausea, or vomiting. He had a standing
appointment in oncology clinic the day of admission wheere his
temperature was 100.4. He received CXR, [**Date range (1) **] cultures, and 1
unit of platelets for a count og 10K (patient has been receiving
transfusion support 2-3x/week recently). On arrival to the
floor, he feels feverish but otherwise has no change in his
symptoms.
.
Review of Systems:
(+) Per HPI + intermittant palpitations with no associated
dyspnea or chest pain
(-) Denies chills, night sweats. Denies blurry vision, diplopia,
loss of vision, photophobia. Denies headache, sinus tenderness.
Denies chest pain or tightness, lower extremity edema. Denies
shortness of [**Date range (1) 1440**], or wheezes. Denies nausea, vomiting,
diarrhea, constipation, abdominal pain, melena, hematemesis,
hematochezia. Denies dysuria, stool or urine incontinence.
Denies arthralgias or myalgias. Denies rashes or skin breakdown.
All other systems negative.
.
Past Medical History:
.
Hematologic History:
1) followed since [**2154**] for an autoimmune pancytopenia treated
with steroids and IVIG.
2) In [**3-/2157**] his cytopenias worsened and he was noted to have
about 90% blasts and he was transferred to [**Hospital1 18**]. Preliminary
bone marrow biopsy was suspicious for a biphenotypic leukemia
3) therapy was initiated with hyperCVAD. His day 14 marrow
showed persistent disease
4) Regimen was changed to 7+3. Day 14 and 2 subsequent marrows
all continued to show persistent involvement with leukemia.
5) Further chemotherapy was held as MR. [**Known lastname 1005**] was found to
have disseminated fusarium [**Known lastname 2**] in the setting of prolonged
neutropenia and was treated with a prolonged course of AmBisome
with voricoanzole before transitioning to voriconazole alone.
6) He has subsequently been treated with Dacogen with
refractory disease;
7) He has had several admissions for pericardial effusions
with tamponade physiology, treated medically;
8) He has had periodic pleural effusions requiring thoracentesis
with transudative to exudative chemistries; cell blocks and flow
cytometry have not been suggestive of leukemic infiltration, and
work up for infectious causes including viral, fungal and AFB
have remained unrevealing.
9) admission for VRE bacteremia presumed to be of line
origin though line tip cultures were unrevealing and completed a
prolonged course of linezolid.
9) admission in late [**Month (only) 956**] 2012for acute shortness of
[**Month (only) 1440**], fevers and found to have an enterococcal empyema.
10) Prior HBV [**Month (only) 2**], on lamivudine prophylaxis.
11) admitted [**Date range (1) 82695**] w/ sepsis from E coli bacteremia, AF w/
RVR, pleural effusions, and discharged on voriconazole,
linezolid, and ertapenem.
12) He was then readmitted from [**Date range (1) 24818**] with fever and concern
for soft tissue [**Date range (1) 2**]. His Ertapenam was switched to
Cefepime, and his empyema and effusions improved. He was
discharged on 4 additional days of cefepime for a total of 5
days
.
Other Medical History:
1. Biphenotypic leukemia CLL/AML (s/p hyper [**Last Name (LF) **], [**First Name3 (LF) **]/Ara, MEC,
two cycles of Decitabine)
2. Autoimmune pancytopenia
3. Disseminated fusarium [**First Name3 (LF) 2**], treated with Ambisome and
Voriconazole for four and half months. Ambisome was stopped on
[**10-20**]. Last voriconazole level was 1.0 on [**10-8**]
4. HBV, on Lamivudine
5. VRE bacteremia/cellulitis
6. Pericardial effusion of unknown etiology
7. s/p appendectomy
8. s/p umbilical hernia repair
9. a-fib, MVR
.
Social History:
Lives in [**Hospital1 487**] with his wife. Currently on disability. Wife
is a retired physician. [**Name10 (NameIs) **] from [**Country 5976**]. Nonsmoker, no
EtOH, no IVDU.
Family History:
One brother died of ALL. Denies DM, CAD, strokes, other CAs.
Physical Exam:
Admission Exam:
VS T 101.2 bp 100/60 HR 120 RR 20 SaO2 95 RA
GEN: AAOx3, NAD, chronically ill appearing
[**Country 4459**]: [**Country 3899**], MMM, no thrush, no OP erythema or lesions
NECK: supple, no JVD
CVS: irregular tachycardia, no m/r/g
LUNGS: reg resp rate, breathing unlabored, no accessory muscle
use, no wheezes, decreased [**Country 1440**] sounds on half of the right
lung field at from the base.
ABD: soft, NT, slightly distended without rebound or guarding,
NABS
EXT: normal perfusion, no edema
Skin: no rashes
neuro: no focal deficits
PSYCH: cooperative
Discharge Exam:
Gen: awake, alert, NAD
CV: irreg irreg, no m/r/g
Lungs: coarse BS bilaterally
Abdomen: +BS, soft, NT/ND
Ext: WWP, no c/c/e
Line: R PICC - no erythema, non-tender
Pertinent Results:
ADMISSION LABS:
[**2158-6-5**] 04:40PM PLT COUNT-32*#
[**2158-6-5**] 01:45PM UREA N-20 CREAT-0.6 SODIUM-138 POTASSIUM-4.9
CHLORIDE-103 TOTAL CO2-26 ANION GAP-14
[**2158-6-5**] 01:45PM ALT(SGPT)-65* AST(SGOT)-41* LD(LDH)-256* ALK
PHOS-162* TOT BILI-0.3
[**2158-6-5**] 01:45PM CALCIUM-8.6 PHOSPHATE-4.3 MAGNESIUM-1.9
[**2158-6-5**] 01:45PM IgG-911 IgA-147 IgM-26*
[**2158-6-5**] 01:45PM WBC-6.2 RBC-2.82* HGB-8.3* HCT-23.5* MCV-83
MCH-29.4 MCHC-35.3* RDW-14.0
[**2158-6-5**] 01:45PM NEUTS-0 BANDS-0 LYMPHS-3* MONOS-0 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0 BLASTS-97*
[**2158-6-5**] 01:45PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
[**2158-6-5**] 01:45PM PLT SMR-RARE PLT COUNT-10*#
[**Hospital3 984**]:
[**2158-6-17**] 11:04AM [**Month/Day/Year 3143**] Type-ART pO2-43* pCO2-48* pH-7.38
calTCO2-29 Base XS-1
[**2158-6-17**] 11:04AM [**Month/Day/Year 3143**] Lactate-1.0
[**2158-6-11**] 11:30PM [**Month/Day/Year 3143**] ASPERGILLUS GALACTOMANNAN ANTIGEN-
NEGATIVE
[**2158-6-11**] 11:30PM [**Month/Day/Year 3143**] B-GLUCAN-NEGATIVE
[**2158-6-11**] 12:34PM [**Month/Day/Year 3143**] M.PNEUMONIAE AB IGG, EIA 1.20 H
(POSITIVE)
[**2158-6-11**] 12:34PM [**Month/Day/Year 3143**] MYCOPLASMA PNEUMONIAE ANTIBODY
IGM-M.PNEUMONIAE AB IGM, EIA 36 (NEGATIVE)
MICRO:
[**2158-6-11**] CRYPTOCOCCAL ANTIGEN (Final [**2158-6-12**]): CRYPTOCOCCAL
ANTIGEN NOT DETECTED.
[**2158-6-11**] URINE Legionella Urinary Antigen (Final [**2158-6-12**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
[**2158-6-10**] [**Month/Day/Year **] Culture, Routine (Final [**2158-6-16**]): NO GROWTH
[**2158-6-10**] [**Month/Day/Year **] Culture, Routine (Final [**2158-6-16**]): NO GROWTH.
[**2158-6-6**] URINE CULTURE (Final [**2158-6-8**]):NO GROWTH.
[**2158-6-6**] 6:11 pm Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal aspirate.
Respiratory Virus Identification (Final [**2158-6-7**]):
POSITIVE FOR PARAINFLUENZA TYPE 3.
IMAGING:
CHEST (PA & LAT) Study Date of [**2158-6-5**] FINDINGS: The position
of the right-sided PICC line is unchanged. Heart appears
enlarged. Trachea is midline. There is some widening of
mediastinum, mainly on the right side of the carina suggestive
of a loculated pleural effusion. This does not appear to be
significantly changed from the prior study. A small left
pleural effusion is stable. There is some improvement of the
right-sided atelectatic changes. No pneumothorax.
IMPRESSION: Marginal improvement of the right lung atelectatic
changes
compared to the previous study, otherwise unchanged.
LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of [**2158-6-7**]
IMPRESSION:
1. No evidence of cholecystitis or cholelithiasis.
2. Hepatosplenomegaly.
3. Minimal ascites and small right pleural effusion.
CHEST (PORTABLE AP) Study Date of [**2158-6-10**]
There is interval progression of right lower lobe pleural
effusion and right lung consolidation highly concerning for
interval development of infectious process. There is also
additional involvement of left mid lung opacity, concerning for
infectious process as well. Small bilateral pleural effusions
cannot be excluded. Right PICC line tip is at the level of mid
SVC. The
heart size and mediastinum are stable.
CT CHEST W/O CONTRAST Study Date of [**2158-6-10**]
IMPRESSION:
1. New peribronchiolar nodular opacities are visualized in the
posterior
segment of the right upper lobe as well as in the non-collapsed
portions of the superior segment of the right lower lobe and are
suggestive of an
infectious process.
2. Mild interval decrease in dominant loculated right lower
hemithorax
pleural effusion/empyema as well as the second large
paramediastinal right pleural effusion.
3. Small-to-moderate left pleural effusion is stable.
Cardiovascular Report ECG Study Date of [**2158-6-11**] 4:12:26 PM
Atrial fibrillation with rapid ventricular response. Lateral
ST-T wave
flattening. No major change from the previous tracing.
CXR [**6-17**]: IMPRESSION: 1. Right subclavian PICC line remains
unchanged in position. There has been interval worsening of
consolidation which now involves the right upper lobe and left
upper and mid lung. There has also been progression at the left
lung base. The right mid and lower lung continues to be stably
consolidated. These findings are concerning for worsening
pneumonia with the differential also including hemorrhage or
leukemic infiltrates given the patient's history of leukemia.
Clinical correlation is advised. The heart remains stably
enlarged. There is fullness to the mediastinal contours, some
of which correlates with a loculated right pleural effusion seen
on the CT study dated [**2158-6-10**]. No pneumothorax. No evidence
of pulmonary edema.
EKG [**6-23**]: Atrial fibrillation with rapid ventricular response.
Poor R wave progression, probable normal variant. Low amplitude
QRS complexes in the limb leads. Non-specific lateral ST-T wave
changes. Compared to the previous tracing of [**2158-6-11**] QRS
voltage in the limb leads has decreased further. One aberrantly
conducted beat versus a ventricular premature beat is seen.
DISCHARGE LABS:
[**2158-6-30**] 06:00AM [**Month/Day/Year 3143**] WBC-2.3* RBC-2.51* Hgb-7.4* Hct-21.2*
MCV-85 MCH-29.4 MCHC-34.6 RDW-15.2 Plt Ct-17*
[**2158-6-30**] 06:00AM [**Month/Day/Year 3143**] Neuts-0 Bands-0 Lymphs-6* Monos-0 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0 Blasts-94*
[**2158-6-30**] 04:26PM [**Month/Day/Year 3143**] Plt Ct-27*#
[**2158-6-30**] 06:00AM [**Month/Day/Year 3143**] Glucose-100 UreaN-19 Creat-0.5 Na-136
K-4.9 Cl-101 HCO3-32 AnGap-8
[**2158-6-30**] 06:00AM [**Month/Day/Year 3143**] ALT-31 AST-31 LD(LDH)-255* AlkPhos-110
TotBili-0.4
[**2158-6-30**] 06:00AM [**Month/Day/Year 3143**] Calcium-8.2* Phos-3.7 Mg-1.7
Brief Hospital Course:
62M w/ refractory biphenotypic leukemia, off therapeutic chemo,
admitted for neutropenic fever and pneumonia, and transferred to
[**Hospital Unit Name 153**] for respiratory distress requiring BiPAP treatment; pt
stabilized, transferred back to the floor.
Active issues:
#Refractory biphenotypic leukemia: Pt is s/p hyperCVAD, 7+3
[**4-30**], decitabine, MEC [**9-25**], several more cycles decitabine last
[**3-16**], followed by Dr. [**Last Name (STitle) **], now on hydroxurea. Patient is
neutropenic, thrombocytopenic and anemic. He will not be
receiving further chemotherapy. Patient received supportive
care with transfusions of red cells and platelets as needed.
#Neutropenic fever: Patient presented with rhinorrhea developing
into sorethroat, [**Last Name (STitle) **] and fever. A chest x-ray was unchanged
from previous admission. The patient was placed on oxygen and
[**Last Name (STitle) **] cultures were drawn. He was continued on voriconazole for
history of disseminated fusarium and linezolid for history of
VRE empyema. Ertapenam was changed to Cefepime given history of
E. coli bacteremia in order to broaden for possible Pseudomonas.
The infectious disease team was consulted, who recommended
switching cefepime to meropenem. A respiratory culture was done
and the patient was found to be positive for parainfluenza. The
patient's respiratory status declined over the course of the
next week. A CT was done on [**2158-6-10**] which showed new
peribronchiolar opacity in right upper and right lower lobe
compatible with [**Date Range 2**]. On [**6-13**] antibiotics were changed to
voriconazole, cefepime, metronidazole, linezolid and levaquin.
The patient was supported with albuterol nebulizers and
ipratropium for obstructive lung disease along with [**Month/Year (2) **]
suppressants. Respiratory status declined acutely on [**2158-6-17**];
the patient desaturated to 84% and was placed on a
non-rebreather briefly and then transitioned to a mask on 6
liters. An arterial [**Date Range **] gas revealed a PO2 of 43 and PCO2 of
48. The patient and family wished to persue BiPap and the
patient was transferred to the ICU for continued care. While in
the ICU, pt was briefly on BiPaP overnight but was soon able to
be on shovel mask. He was gently diuresed and his respiratory
status remained stable on shovel mask O2. Pt was transferred out
of the ICU and onto the BMT floor. While on the floor he
received a prednisone taper (40mg x2days, 30x2days, 20x2days,
10x2days). He also received 10g IVIG. Pt was switched to
xopenex from albuterol nebs due to tachycardia. Pt's respiratory
status slowly improved and he remained stable on 2-4L NC. His IV
antibiotics were taken off and he remained afebrile for several
days prior to discharge.
Chronic issues:
# Atrial fibrillation: History of paroxysmal atrial
fibrillation. Rate control has previously been difficult with
hypotension on beta blockade. Patient was continued on
metoprolol 50 mg [**Hospital1 **], digoxin 12mcg daily and diltiazem in
fractionated doses. His rates were in the low 100's to 110's
and systolic [**Hospital1 **] pressures were mostly in the 90's, consistent
with prior admissions. In the ICU, his rates were increased to
the 130's, and his metoprolol was increased to 50 mg PO TID. He
tolerated this well. He was continued on this regimen upon
transfer to the floor.
# Hepatitis B: Patient has known hepatitis B and was continued
on Lamivudine 100mg po daily.
# Anxiety: The patient was continued on home lorazepam 0.5mg
tabs q4hrs as needed.
Transitional issues:
# Goals of care: Per most recent clinic note, Pt has a
[**State 350**] Comfort Care form at home. He is DNR/DNI but does
want antibiotics, [**State **] products, and admission if he becomes
ill. Pt does not want additional ICU admissions or Bipap.
# Pt will need close follow up and continued platelet and [**State **]
transfusions
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver[**Name (NI) 581**].
1. Acyclovir 400 mg PO TID
2. Digoxin 0.125 mg PO DAILY
3. Diltiazem Extended-Release 120 mg PO DAILY
4. ertapenem *NF* 1 gram Injection daily
5. Hydroxyurea 1500 mg PO DAILY
6. Ipratropium Bromide Neb 1 NEB IH Q4H:PRN SOB or wheeze
7. LaMIVudine 100 mg PO DAILY
8. Linezolid 600 mg PO Q12H
9. Lorazepam 0.5 mg PO Q4H:PRN nausea/anxiety/insomnia
10. Metoprolol Tartrate 50 mg PO BID
11. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
12. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
13. Voriconazole 300 mg PO Q12H
14. Furosemide 20 mg PO DAILY
15. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Linezolid 600 mg PO Q12H
RX *Zyvox 600 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
2. Levalbuterol Neb *NF* 0.63 mg/3 mL INHALATION Q4H:PRN SOB or
wheeze Reason for Ordering: tachycardic with albuterol
RX *Xopenex 0.63 mg/3 mL 1 Solution(s) inhaled every 4 hours as
needed Disp #*1 Box Refills:*0
3. Acyclovir 400 mg PO TID
4. Digoxin 0.125 mg PO DAILY
5. Furosemide 20 mg PO DAILY
6. Ipratropium Bromide Neb 1 NEB IH Q4H:PRN SOB or wheeze
7. LaMIVudine 100 mg PO DAILY
8. Lorazepam 0.5 mg PO Q4H:PRN nausea/anxiety/insomnia
9. Metoprolol Tartrate 50 mg PO TID
hold SBP < 90
10. Multivitamins 1 TAB PO DAILY
11. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
12. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
13. Voriconazole 200 mg PO Q12H
14. Fluticasone Propionate NASAL 2 SPRY NU [**Hospital1 **]
RX *fluticasone 50 mcg 2 sprays intranasal twice a day Disp #*1
Bottle Refills:*0
15. Levofloxacin 750 mg PO DAILY
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
16. Hydroxyurea 500 mg PO BID
17. Diltiazem Extended-Release 120 mg PO DAILY
18. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
Discharge Disposition:
Home With Service
Facility:
all care vna
Discharge Diagnosis:
Parainfluenza pneumonia
Biphenotypic leukemia, refractory
Atrial fibrillation
Hepatitis B
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr. [**Known lastname 1005**],
You were admitted to the hospital for fever and [**Known lastname **]. You were
found to have a parainfluenza viral [**Known lastname 2**]. You were treated
with antibiotics, nebulizers and [**Known lastname **] supressants. During your
admission you required a brief stay in the ICU for Bipap and
diuresis (getting extra fluid out of your body with water
pills). Your respiratory status improved and you were
transferred back to the floor. You remained afebrile and your
IV antibiotics were stopped and you continued to be afebrile.
Please weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up
more than 3 lbs.
Followup Instructions:
Department: HEMATOLOGY/BMT
Where: 7 [**Hospital Ward Name 1826**] Outpatient Clinic
When: Sunday [**7-2**] at 10:30AM
Phone: [**Telephone/Fax (1) 447**]
Department: BMT CHAIRS & ROOMS
When: TUESDAY [**2158-7-4**] at 1:30 PM
Department: HEMATOLOGY/BMT
When: TUESDAY [**2158-7-4**] at 1:30 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/BMT
When: TUESDAY [**2158-7-4**] at 3:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7779**], MD [**Telephone/Fax (1) 3237**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"205.00",
"V02.59",
"V09.80",
"518.81",
"070.32",
"487.0",
"780.61",
"482.83",
"427.31",
"511.9",
"288.04",
"784.7",
"284.19",
"496",
"510.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
17940, 17983
|
11995, 12252
|
320, 327
|
18117, 18117
|
6107, 6107
|
18990, 19852
|
5256, 5318
|
16676, 17917
|
18004, 18096
|
15937, 16653
|
18300, 18967
|
11345, 11972
|
5333, 5908
|
5924, 6088
|
15576, 15911
|
1838, 2405
|
264, 282
|
12267, 14770
|
355, 1819
|
6123, 11329
|
18132, 18276
|
14786, 15555
|
2427, 5047
|
5063, 5240
|
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