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5,791
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3539
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Discharge summary
|
report
|
Admission Date: [**2152-10-28**] Discharge Date: [**2152-11-6**]
Date of Birth: [**2106-6-1**] Sex: M
HISTORY OF PRESENT ILLNESS: This is a 46-year-old male with
known metastatic renal cancer and known portal vein
thrombosis and biliary obstruction with esophageal varices,
diagnosed in [**2152-4-2**], who was transferred from an
gastrointestinal bleed. The patient was admitted to [**Hospital **]
Hospital on [**2152-10-27**]. At that time, he complained of
nausea and vomiting times three days, hematemesis, and melena
times two days. He was noted to have hematemesis in the
Emergency Department and his admission hematocrit was 20.1.
He was started on Sandostatin drip.
[**3-5**]+ esophageal varices without acute bleed and without
stigmata of bleed. A red clot was seen on the greater curve
of the fundus without an active bleed. There was an adherent
clot with normal underlying mucosa. No [**Doctor First Name **]-[**Doctor Last Name **] tears
and patient had received nine units of packed red blood cells
with an increase in hematocrit to 23.5. Patient also
received eight units of FFP for INR of 1.5. He also received
10 mg of subcutaneous Vitamin K and was then transferred to
[**Hospital6 256**] for further management.
Patient was witnessed to have around 500 cc of bright red
blood with clots in route. Also, had bright red blood per
rectum at that time. Patient had not been hemodynamically
stable at any time prior to admission.
PAST MEDICAL HISTORY:
1. Metastatic renal cell carcinoma, status post right
nephrectomy in [**2139**], status post high dose IL-2 therapy in
[**2141**], status post right pulmonary nodule resection in [**2143**]
and status post high dose IL-2 therapy in [**2149**], then status
post IL-12 with IL-2 in [**Month (only) **] to [**2151-11-3**]. Went
through one and a half cycles and stopped secondary to
personal reasons, status post thalidomide from [**2152-5-2**] to
present.
2. Biliary obstruction, status post biliary stent in [**2152-4-2**] which was replaced by a new biliary stent in [**2152-4-2**].
3. Portal vein thrombosis, diagnosed [**2152-12-16**].
4. Peripheral neuropathy secondary to thalidomide.
MEDICATIONS ON ADMISSION: Thalidomide 300 mg po q.d.,
propranolol 60 mg po b.i.d., Xanax 0.5 mg po b.i.d.,
OxyContin 20 mg po q.d.
ALLERGIES: No known drug allergies.
MEDICATIONS ON TRANSFER: Octreotide 100 mg intravenous,
Protonix 40 mg intravenous b.i.d. and Ativan prn.
SOCIAL HISTORY: This is a machinist, married with two
children. No tobacco and no alcohol.
PHYSICAL EXAMINATION: Vital signs: Temperature 100.1.
Pulse 130. Blood pressure 154/66. General: Pale jaundiced
man. Pulmonary: Clear to auscultation bilaterally, except
rales at the bases. Cardiovascular: Tachycardic with
regular rhythm, no murmurs. Abdomen: Soft, nontender,
nondistended, positive bowel sounds. Extremities: No
cyanosis, clubbing or edema, warm, 2+ distal pulses and pale
(that was the physical examination from the first progress
note on [**10-29**], no physical examination from the [**10-28**] night float admission note).
LABORATORIES ON [**9-13**]: White blood cell count of 4.3,
hematocrit 33.6 and platelets 139,000. Electrolytes were all
within normal limits. Uric acid 4.6, ALT 17, AST 16, LDH
130, alkaline phosphatase 101 and T bilirubin 0.5.
Abdominal CT on [**2152-8-14**] masses at pancreatic and
peripancreatic region, masses of adrenals bilaterally,
splenomegaly with a splenic mass, splenic vein obliterated by
tumor with collateral varices, status post right nephrectomy,
lesion of left kidney, inguinal and pelvic lymph nodes, no
free fluid and persistent extrinsic occlusion of the portal
vein.
Endoscopic retrograde cholangiopancreatography from [**2152-7-11**]: Limited exam of the esophagus, stomach, duodenum all
normal. Malignant looking common bile duct stricture with
multiple filling defects and a 7 cm stent was placed.
Esophagogastroduodenoscopy from [**2152-4-2**]: Grade 2
varices at 30 cm from the incisor.
LABORATORIES FROM THE OUTSIDE HOSPITAL ON [**10-28**]: All
electrolytes were within normal limits. Hematocrit 21.3.
Coags: PT was 14.9, PTT 22.2, INR of 1.5. D dimer was
positive, fibrinogen 424 and the FDP was less than 10.
Alkaline phosphatase was 257 but otherwise normal liver
function tests.
Electrocardiogram on [**10-27**] at outside hospital with
sinus tachycardia at 122, axis 61, intervals 125.84.419
corrected. No ST elevation or depression. T wave inversion
in III.
ASSESSMENT AND PLAN: This was a 46-year-old man with
metastatic renal cancer with known esophageal varices and
portal hypertension, secondary to extrinsic compression of
the portal system by the mass and portal vein thrombosis who
presented to an outside hospital with an upper
gastrointestinal bleed thought to be secondary to gastric
varices.
1. Upper gastrointestinal bleed: The patient with endoscopy
at outside hospital, negative for stigma of variceal bleed,
most likely secondary to gastric varices. The patient was
put on octreotide and Protonix. Despite this, patient
continues to have active bleeding. Patient was planned to
have abdominal ultrasound and then Gastrointestinal and
Interventional Radiology to evaluate. Hematocrit will be
followed and transfusion prn.
HOSPITAL COURSE: Gastrointestinal was consulted and an
emergent abdominal ultrasound was done which showed limited
portal vein flow distally. A multiphasic CT showed unchanged
metastases with portal vein flow distally but minimal flow
proximally. Interventional Radiology was contact[**Name (NI) **] and a
portal vein stent was placed along with an external-internal
biliary drain which drained percutaneously in one direction
and also into the duodenum. Patient received a total of 28
units of packed red blood cells and 23 units of FFP. During
the procedure, which the patient was stented by
Interventional Radiology, he went under general anesthesia.
There was some difficulty extubating the patient and he was
ultimately extubated two days later. He developed a left
lower lobe pneumonia, believed to be due to an aspiration
pneumonia during patient's intubation. He was put on a ten
day course of Levaquin and clindamycin. Enterococcus also
grew out from patient's bile which was sensitive to Levaquin
and thus treated with a ten day course of Levaquin, also used
for the pneumonia.
Difficult with extubation, secondary to low oxygen
saturation. Patient was later found to have an abnormally
high AA gradient and also a VQ mismatch. This was believed
to possibly be secondary to small pulmonary emboli being sent
from patient's existent left popliteal deep vein thrombosis.
Interventional Radiology was again consulted and an IVC
filter was attempted to be placed secondary to patient's
inability to be anticoagulated. During the procedure, it was
discovered that patient's inferior vena cava was abruptly
tapered secondary to extrinsic compression by tumor.
Therefore, a filter was not placed at that time. Patient
remained on a 100% nonrebreather for two to three days and
ultimately his oxygen was weaned as his pneumonia resolved.
On [**11-6**], on the day of discharge, patient was
saturating between 92 and 99% on room air and was not
experiencing any dyspnea on exertion with ambulation and
denied any cough.
During patient's intubation, he was agitated on his vent,
and, therefore, started on propofol at which time he became
hypotensive and required Neo-Synephrine in order to maintain
blood pressure. Patient also experienced acute renal failure
likely secondary to the dye load given during a CT and angio
procedure during the admission. Patient maintained good
urine output and creatinine rose to 1.8, then resolved on its
own.
The patient's diet was slowly advanced from NPO to a full
regular diet. Patient at time of discharge was able to
tolerate all foods. His hematocrit remained stable for five
to six days around 30. Patient's total bilirubin also rose
to a peak of 20. Once the total bilirubin had peaked, it
began to drop status post drainage procedure a few points a
day. In the days prior to discharge it had dropped from
16.6, 12.7 to 10.6, 10.0, 9.5 and on the day of discharge to
8.4. Interventional Radiology was again consulted and it was
decided that patient could have the drain capped and be
discharged home with visiting nursing assistant and follow-up
one week later with Dr. [**Last Name (STitle) **] and the Interventional [**Hospital **]
Clinic.
Also, during the admission, patient with a liquid diet for
which stool studies were sent. All cultures and fecal
leukocytes were negative. Ova and parasites was never sent.
Patient was finally discharged on [**2152-11-15**].
DISCHARGE DIAGNOSES:
1. Upper gastrointestinal bleed secondary to gastric
varices.
2. Portal vein thrombosis.
3. Renal cell cancer with metastases.
4. Deep vein thrombosis, status post internal and external
biliary stent, status post portal vein stent and peripheral
neuropathy.
DISCHARGE MEDICATIONS:
1. Clindamycin 300 mg po q.i.d. until [**11-11**].
2. Protonix 40 mg po q.d.
3. Ativan 1-2 mg po q. 8 hours prn.
4. Propranolol 60 mg po b.i.d.
5. Levofloxacin 500 mg po q.d. until [**11-10**].
6. Patient was sent home with an extra biliary drainage bag
so that patient may attach the bag if it becomes obstructed
and call his Oncologist or Interventional [**Hospital **] Clinic.
FOLLOW-UP: Patient to follow-up with Dr. [**Last Name (STitle) **] and also with
Interventional [**Hospital **] Clinic on [**11-15**]. A VNA was
set up to flush the catheterization with 10 cc of saline and
dressing changes q.d. The patient was sent home on a regular
diet.
Addendum: Patient developed moderate abdominal discomfort
shortly after arrival home and was told by Dr. [**Last Name (STitle) **] to uncap the
biliary drain and resume external drainage. This relieved the
patient's symptoms.
JWM
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9402**], M.D. [**MD Number(1) 16215**]
Dictated By:[**Name8 (MD) 15885**]
MEDQUIST36
D: [**2152-11-8**] 16:59
T: [**2152-11-8**] 16:59
JOB#: [**Job Number 16216**]
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3,100
| 146,062
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53795
|
Discharge summary
|
report
|
Admission Date: [**2120-10-11**] Discharge Date: [**2120-10-16**]
Date of Birth: [**2066-10-13**] Sex: F
Service: MEDICINE
Allergies:
Ace Inhibitors / Lisinopril
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Facial swelling/Hypercarbic respiratory failure
Major Surgical or Invasive Procedure:
Endotracheal Intubation [**2120-10-11**], extubation [**2120-10-13**]
History of Present Illness:
53 yo primarily Spanish speaking female with obesity
hypoventilation on home CPAP with multiple hospital admissions
for hypercarbic respiratory failure, OSA, panhypopit, pulmonary
HTN, diastolic CHF, brought in by EMS to ED with facial swelling
since this morning per daughter. [**Name (NI) **] noted tongue swelling or
difficulty speaking or swallowing. Old notes mention hx of
angioedema [**3-2**] ACEI. No new meds, not currently on an ACEI - but
has been on [**First Name8 (NamePattern2) **] [**Last Name (un) **].
In the ED, on triage, T99.2, HR 98, BP 115/56, 92% on home 2L.
For the facial swelling, she received IV benadryl, IV
solumedrol, and pepcid and facial edema improved. ABG on 4L was
7.32/77/65. Patient's baseline PCO2 is in the 60s. Patient
initially was alert, but within 45 minutes, patient was opening
eyes, following commands but nonverbal. Patient was wheezing on
exam, received nebs. Repeat vitals were HR70, BP107/59, RR 16-18
on BIPAP. Repeat ABG was 7.3/82/55 and noted to have wheezing on
exam. Patient intubated in ED. Tube was too far down on xray and
was pulled back. Both legs looked red, tense to knees, so
received vanc/unasyn for cellulitis coverage. In ED, received 2L
fluid, was stopped when repeat CXR showed pulmonary edema.
Past Medical History:
1)Obstructive Sleep Apnea on home CPAP, 16cm H20
2)Obesity Hypoventilation
- Multiple admissions for hypercarbic respiratory failure; PFT's
consistent with a restrictive defect
- PFTs: FVC 39%, FEV1 37%, FEV1/FVC 96%, TLC 59%, DLCO reduced
3)ASD with right-left shunt (12% shunt fraction documented in
nuclear study from [**2116-3-30**])
4)Pulmonary artery hypertension: Echo in [**10/2118**] demonstrated a
TR gradient of 33mmHg ?????? followed by [**Location (un) 4507**]
5)Hypertension
6)Pan-hypopituitarism with partially empty sella on
desmopressin, levothyroxine, prednisone ?????? followed by Dr.
[**Last Name (STitle) **]
7)Diastolic CHF with dilated RA/LA on previous echo
8)Angioedema (unclear history, possibly related to ACE-I)
Social History:
Lives with daughter and 3 grandchildren [**Location (un) 6409**].
Originally from [**Male First Name (un) 1056**]. Goes to [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Program
History of tobacco use, no h/o ETOH or IVDU
Family History:
Non-contributory
Physical Exam:
PHYSICAL EXAMINATION:
VS - BP 130/60 , HR 66, R 12 BMI 50.3
GENERAL - short, obese woman, sitting in the chair.
HEENT - PERRL, EOMI. Strabismus.
LUNGS - Posterior- slight decreased BS on R.
HEART - RRR, 3/6 SEM heard across the precordium
ABDOMEN - soft, NT, obese, BS+
EXTREMITIES - slightly warm with trace erythema but no evidence
of open lesions
NEURO: AOx3, Cn2-12 grossly intact.
Pertinent Results:
[**2120-10-11**] 11:30AM BLOOD WBC-10.1 RBC-3.68* Hgb-9.8* Hct-33.9*
MCV-92 MCH-26.6* MCHC-28.9* RDW-15.0 Plt Ct-168
[**2120-10-12**] 03:17AM BLOOD WBC-15.5*# RBC-3.70* Hgb-9.9* Hct-32.3*
MCV-88 MCH-26.9* MCHC-30.7* RDW-16.0* Plt Ct-179
[**2120-10-13**] 04:45AM BLOOD WBC-19.4* RBC-3.68* Hgb-9.8* Hct-33.4*
MCV-91 MCH-26.6* MCHC-29.3* RDW-15.2 Plt Ct-179
[**2120-10-15**] 05:45AM BLOOD WBC-9.3 RBC-3.58* Hgb-9.6* Hct-30.8*
MCV-86 MCH-26.8* MCHC-31.1 RDW-15.7* Plt Ct-118*
[**2120-10-16**] 06:20AM BLOOD WBC-9.4 RBC-3.97* Hgb-10.4* Hct-34.4*
MCV-87 MCH-26.2* MCHC-30.2* RDW-16.0* Plt Ct-168
[**2120-10-12**] 03:17AM BLOOD PT-14.9* PTT-26.7 INR(PT)-1.3*
[**2120-10-11**] 11:30AM BLOOD Glucose-90 UreaN-12 Creat-0.9 Na-147*
K-4.0 Cl-102 HCO3-41* AnGap-8
[**2120-10-16**] 06:20AM BLOOD Glucose-77 UreaN-20 Creat-0.9 Na-147*
K-3.5 Cl-98 HCO3-42* AnGap-11
[**2120-10-15**] 05:45AM BLOOD ALT-18 AST-21 LD(LDH)-216 AlkPhos-70
TotBili-0.9
[**2120-10-12**] 03:17AM BLOOD CK(CPK)-31
[**2120-10-12**] 03:17AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2120-10-11**] 11:30AM BLOOD cTropnT-<0.01
[**2120-10-11**] 11:11AM BLOOD Type-ART pO2-65* pCO2-77* pH-7.32*
calTCO2-42* Base XS-9
[**2120-10-11**] 12:29PM BLOOD Type-ART pO2-55* pCO2-82* pH-7.30*
calTCO2-42* Base XS-10
[**2120-10-11**] 09:44PM BLOOD Type-ART pO2-138* pCO2-51* pH-7.47*
calTCO2-38* Base XS-12
.
[**10-11**] CXR: Final Report
SINGLE PORTABLE VIEW OF THE CHEST.
HISTORY: 53-year-old woman with facial swelling and hypercarbia.
Evaluate
for acute cardiopulmonary process.
COMPARISON: Multiple prior chest x-rays, most recently
[**2120-8-23**], dating back
to [**2116-1-21**].
FINDINGS: A single portable AP semi-upright view of the chest
was obtained.
Given differences in technique, findings are not significantly
changed in
comparison to [**2120-8-23**]. The cardiac silhouette remains
massively enlarged.
Interstitial prominence and indistinctness of the pulmonary
vessels suggests a
degree of interstitial edema. No new airspace consolidation or
large effusion
is identified on this single portable view.
IMPRESSION: Stable findings of interstitial edema and
cardiomegaly.
.
[**10-15**] CXR: Final Report
HISTORY: COPD and fever.
FINDINGS: In comparison with the study of [**10-14**], there is again
substantial
enlargement of the cardiac silhouette with bibasilar opacities
consistent with
atelectasis. Blunting of both costophrenic angles suggests
pleural fluid.
Mild vascular engorgement persists.
IMPRESSION: Little overall change.
.
Brief Hospital Course:
# Facial Edema:
Initial concern for angioedema in ED given h/o similar reaction
to Ace-I, and currently taking [**Last Name (un) **]. She received IV benadryl, IV
solumedrol, and facial edema improved. However, patient also on
chronic steroids and thought maybe to have cushingoid facie with
volume overload from CHF. [**Last Name (un) **] was restarted in ICU without
evidence of anaphlactic reaction throughout the rest of her
hospital course.
#Hypercarbic respiratory failure:
Patient is chronically hypercarbic in the 60s due to chronic
obstructive sleep apnea/obesity hypoventilation syndome. In the
ED, patient noted to be wheezing. ABG on 4L was 7.32/77/65,
repeat ABG was 7.3/82/55, patient was then intubated for airway
protection for possibly impending obstruction [**3-2**] edema. Pt was
difficult intubation because of inflammation; got 3 doses of
steroids. On arrival to the ICU, the patient was weaned on a
PEEP of 8, FiO2 of 100. Was extubated on ICU day 2 and
stabilized on CPAP at night and 3L 02 via NC during the day.
She was seen by physical therapy and abulatory stats were >90%
on 3L02
#Bacterial Pneumonia:
Patient had low grade fevers and leukocytosis in the ICU, CXR
was concerning for PNA. MSSA was cultured from sputum. She
received 3 days of IV Nafcillin and was transitioned to PO
Dicloxacillin (total 7 day course, last day [**10-19**]). We considered
levofloxacin but her QTc was slightly prolonged so we avoided
it. She remained afebrile and leukocytosis resolved.
#Obesity Hypoventilation/Obstructive Sleep Apnea:
Chronic, causing hypercarbia. Once extubated was placed on CPAP
nightly and 3L 02 via NC . Did not keep last appointment with
outpatient sleep lab. We set up patient with close follow up for
sleep and weight management
#Chronic Diastolic Heart Failure:
Grade 2, EF >55%. Was diuresed with 20IV lasix daily in the ICU.
Not diuresed on the floor given concern that hypernatremia was
due to diuresis and poor po intake/no IVF.
#Acute blood loss Anemia from gastritis:
Guaiac positive emesis in the ICU likely Likely [**3-2**] high dose
steroids given in ED. Was given PO PPI, HCT increasing, not
tachycardic or hypotensive.
#Hypernatremia:
Patient without IVF or PO for several days, receiving diuretics,
BUN:Cr ratio indicative of pre-renal azotemia. Likely
hypovolemic hypernatremia. Should resolve now that patient is
taking in good PO.
#Metabolic Alkalosis:
Likely compensatory for respiratory acidosis. Gave potassium to
maintain K>4.0 and treated underlying respiratory acidosis w/
CPAP.
#Benign Hypertension:
Chronic. Patient continued on home regimen of metoprolol,
valsartan and clonidine.
#Panhypopituitarism:
Thought to be secondary to "empty sella". No evidence of shock,
hypotension. Was continued on home dose of Prednisone 5mg,
Levoxyl, and Desmopressin.
#Dispo: Patient seen by physical therapy and cleared to go home.
O2 sats ambulatory remained >90% on 3L. Will continue to have
VNA services as previous.
Medications on Admission:
Valsartan 40 mg QAM
Valsartan 80 mg QPM
Clonidine 0.1 mg daily
Metoprolol Tartrate 25 mg PO BID
Omeprazole 20 mg daily
Aspirin 81 mg daily
Synthroid 150 mcg daily
Desmopressin 0.2 mg daily
Prednisone 5 mg daily
Cholecalciferol (Vitamin D3) 400 unit daily
Calcium Carbonate 500 mg TID
Albuterol Sulfate 1 nebulizer treatment Inhalation Q6H prn
Discharge Medications:
1. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Levothyroxine 50 mcg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
4. Desmopressin 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
9. Valsartan 80 mg Tablet Sig: One (1) Tablet PO QPM (once a day
(in the evening)).
10. Valsartan 40 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Dicloxacillin 250 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours).
Disp:*120 Capsule(s)* Refills:*2*
14. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) ih Inhalation every six (6) hours as
needed for shortness of breath or wheezing.
Discharge Disposition:
Home With Service
Facility:
Americare at Home Inc
Discharge Diagnosis:
Primary Diagnosis:
Community Acquired Pneumonia
Hypercarbic Respiratory Failure
Obstructive sleep apnea
Obesity hypoventilation
Hypernatremia
.
Secondary Diagnosis:
Acute Blood Loss Anemia from GI source
Chronic Diastolic Heart Failure
Benign Hypertension
Panhypopituitarism
Discharge Condition:
Stable on home 3L 02 and CPAP at night.
Discharge Instructions:
You came to the hospital with facial swelling and respiratory
distress. You were treated with IV steroids and IV benadryl for
the swelling and you were intubated for airway protection and
transferred to the ICU. We then found that you had a pneumonia
and treated you with antibiotics, continued your home CPAP at
night and supplemental oxygen during the day. You were
successfully extubated and transferred to the floor. We found
you had a high sodium level and think this was due to diuresis
and to poor po intake and we treated you by encouaraging good
water intake and healthy diet.
You were seen by physical therapy who...
.
We made the following changes to your medication:
ADDED Dicloxacillin 250 QID for 4 days (last day [**10-19**])
.
When you leave the hospital please weigh yourself every morning,
[**Name8 (MD) 138**] MD if weight > 3 lbs. Please also adhere to 2 gm sodium
diet. Fluid Restriction: none. Please wear your CPAP as
directed every single night.
.
If you have increasing shortness of breath, swelling in your
feet or legs, chest pain, palpitations, nausea, diarrhea, fever,
chills or any general worsening of your condition, please call
your PCP or come to the emergency room immediately.
.
Please take your medications as directed and follow up with your
PCP as below.
Followup Instructions:
Please follow up with your PCP in the next two weeks, Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 6680**]. She has recently moved from [**Hospital3 4262**] Group to
[**Hospital 882**] Hospital. You need to call 1-[**Telephone/Fax (1) 110403**] to register
and then they will set you up with an appointment. If you have
any problems, Dr.[**Name (NI) 104690**] office number is [**Telephone/Fax (1) 6803**].
Please follow up with Dr. [**First Name (STitle) **] the [**Hospital1 18**] sleep
center:Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 7746**], M.D. Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2120-11-15**] 9:30
|
[
"459.81",
"285.1",
"276.4",
"278.01",
"416.8",
"E932.0",
"276.0",
"276.8",
"428.0",
"518.81",
"535.51",
"482.41",
"253.2",
"287.4",
"327.23",
"745.5",
"428.32",
"V46.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"93.90",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
10401, 10453
|
5738, 8718
|
339, 411
|
10772, 10814
|
3219, 5715
|
12162, 12842
|
2779, 2797
|
9112, 10378
|
10474, 10474
|
8744, 9089
|
10838, 12139
|
2812, 2812
|
2834, 3200
|
252, 301
|
439, 1705
|
10639, 10751
|
10493, 10618
|
1727, 2470
|
2486, 2763
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,643
| 117,838
|
4428
|
Discharge summary
|
report
|
Admission Date: [**2107-6-18**] Discharge Date: [**2107-6-22**]
Date of Birth: [**2039-3-10**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 19017**] is a 68yo gentleman with h/o HTN and severe COPD on
4L of oxygen presenting with chest pain.
.
The patient describes substernal chest pain "like pins and
needles" over the last two days with minimal exertion, such as
getting up out of bed. Last night, he began having chest pain at
rest. Pain was associated with diaphoresis and shortness of
[**Known lastname 1440**] (above his baseline). It was not radiating. He took a
sublingual NTG with temporary relief of the pain. Although he
reports having heart attacks in the past, he is not sure if his
current symptoms are similar to his prior events. He felt warm
two days ago but did not check his temperature. No cough,
myalgias, or congestion.
.
In the ED, initial VS were: 98.4 90 77/46 16 90%. By the time he
arrived in the ED, chest pain had resolved. Guaiac was negative.
EKG showed RBBB without significant change from prior; cardiac
enzymes were negative. A CTA of the chest was negative for
dissection. IV fluids were given with improvement in his blood
pressure, although his pressures continued to be somewhat
labile. He received a dose of ASA as well as vanc and zosyn for
possible pneumonia. Just prior to leaving the ED, he was given
stress dose steroids because of hypotension in the setting of
chronic prednisone use. He was incidentally found to have a
laceration of his hand and a tetanus shot was given.
Past Medical History:
s/p NSTEMI in [**2101**] with Troponin of 12; however [**2103**] cath showed
normal coronaries. TTE [**8-10**] showed mild RV enlargement and
preserved BiV function
Possible pulmonary HTN per chart but not documented on TTE or
cath
COPD on baseline 4L NC, nightly BiPAP 12/5
HTN
Hyperlipidemia per records, but last cholesterol in [**2105**] showed
HDL 62 and LDL 58
Iron-deficiency anemia with baseline Hct 29-31
GERD
Diverticulosis
UTIs with VRE and Pseudomonas
Chronic low back pain s/p L1-L2 laminectomy
s/p b/l cataract surgery
BPH s/p TURP
h/o pseudomonas and MRSA
Social History:
Originally from [**Country 7936**]. Lives with his wife in [**Location (un) 686**]; her
health is good. Has children who live in the area. Retired
mechanic. 20 pack year history, quit at age 37. Prior marijuana
use. Drinks alcohol occasionally.
Family History:
Father with [**Name2 (NI) 499**] cancer diagnosed in his 70s. Mother with
[**Name (NI) 2481**].
Physical Exam:
97.3 111/65 86 25 97% 4L 79.6kg
Very pleasant, thin man with labored breathing at rest.
Pupils small and equal. EOMI. No scleral icterus.
Mucous membranes moist, dentures in place, OP clear.
Neck supple. No thyroid enlargement. JVP not elevated.
S1, S2, RRR, but very distant heart sounds.
Purse-lipped breathing. +barrel-chested with paradoxical
movement of abdomen. Lungs with poor air movement and very
increased expiratory phase. No crackles or wheeze.
Abd soft and not tender. No hepatosplenomegaly.
Femoral pulses +2 b/l without bruits. DPs are weakly dopplerable
and very high towards ankles.
Alert and oriented, fluent speech, moving all extremities
equally.
No LE edema b/l. ++clubbing. +Skin tear covering most of dorsum
of right hand. No fluid collection or fluctuance. Not actively
bleeding. Steri strips in place.
Pertinent Results:
Admission labs:
[**2107-6-18**] 08:02AM WBC-11.0 RBC-4.03* HGB-10.5* HCT-34.0* MCV-84
MCH-26.1* MCHC-31.0 RDW-14.2
[**2107-6-18**] 08:02AM NEUTS-66.9 LYMPHS-14.7* MONOS-6.9 EOS-11.0*
BASOS-0.4
[**2107-6-18**] 08:02AM PLT COUNT-282
[**2107-6-18**] 08:02AM GLUCOSE-136* UREA N-12 CREAT-0.7 SODIUM-135
POTASSIUM-5.8* CHLORIDE-89* TOTAL CO2-40* ANION GAP-12
[**2107-6-18**] 08:02AM ALT(SGPT)-15 AST(SGOT)-41* LD(LDH)-494*
CK(CPK)-81 ALK PHOS-66 TOT BILI-0.4
[**2107-6-18**] 08:02AM LIPASE-25
[**2107-6-18**] 08:02AM CK-MB-NotDone cTropnT-<0.01 proBNP-99
[**2107-6-18**] 02:16PM CK(CPK)-31*
[**2107-6-18**] 02:16PM CK-MB-4 cTropnT-0.01
[**2107-6-18**] 08:46PM CK(CPK)-33*
[**2107-6-18**] 08:46PM CK-MB-4 cTropnT-<0.01
.
Imaging:
CXR:
PORTABLE SEMI-UPRIGHT RADIOGRAPH OF THE CHEST: The hilar and
cardiomediastinal contours are stable although prominent main
pulmonary
arteries bilaterally suggest pulmonary arterial hypertension.
Aorta is
tortuous. The lungs are clear with no focal consolidation,
pleural effusion or pneumothorax. Atelectatic changes of the
right lung base has improved. There is hyperinflation of both
lungs with flattening of the diaphragm suggesting obstructive
pulmonary disease.
.
CTA:
1. Interval progression in degree of lower lobe bronchiectasis
with increased bronchial wall thickening, right lower lobe
ground-glass opacity, and fibrotic-type changes involving the
right lower lobe which all likely represent sequelae of acute on
chronic recurrent aspiration and/or infectious bronchiolitis. No
evidence of aortic dissection.
2. Unchanged diffuse emphysema with probable underlying
pulmonary arterial
hypertension.
Brief Hospital Course:
A/P: 68yo gentleman with severe COPD on home oxygen and history
of MI with clean cath in [**2103**] presenting with chest pain.
.
# COPD exacerbation: Ruled out for MI given reported chest pain
and CTPA without dissection or PE. Responded to doubling of his
steroid and azithromycin for 5 day course.
.
# Hand laceration: Confirmed with ED staff, there was no
indication for stitches. Pt has steri strips in place. These
were replaced once during admission for partial dislodgement.
There was no erythema or inflammation or pain to suggest hand
infection. He was instructed to return to the ED if
pain/redness/fever develop. He received tetanus vaccine in ED.
.
# Chronic low back pain:
- continued home percocet, MS contin low dose added with good
effect.
Medications on Admission:
ASA 81mg daily
Prednisone 20mg daily
Lisinopril 5mg daily--not taking
Pravastatin 40mg daily--not taking
NTG 0.4mg SL prn
Montelukast 10mg daily, taking prn
Omeprazole 20mg daily to [**Hospital1 **] (recently stopped b/c not having
heartburn lately)
Percocet 7.5mg/325mg 2 tablets up to five times a day prn pain
Lorazepam 0.5mg QHS
Bactrim 800/160mg three times a week
Alendronate 70mg weekly
Calcium/Vitamin D [**Hospital1 **]
Lactulose 30ml prn constipation
Senna prn
Albuterol nebs and inhaler
Spiriva 18mcg daily
Home oxygen at 4L with BIPAP at 12/5 at night
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*90 Tablet(s)* Refills:*0*
2. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*0*
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*90 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
4. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
Disp:*90 Tablet(s)* Refills:*0*
5. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
Disp:*40 Tablet(s)* Refills:*0*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: Two (2) Tablet
PO Q6H (every 6 hours) as needed for pain: do not drink alcohol
or drive while using.
Disp:*240 Tablet(s)* Refills:*0*
7. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QMON (every
Monday).
Disp:*12 Tablet(s)* Refills:*0*
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
Disp:*90 Tablet(s)* Refills:*0*
9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q2H (every 2 hours) as
needed for shortness of [**Hospital1 1440**], patient request.
Disp:*60 nebs* Refills:*0*
10. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*90 Cap(s)* Refills:*0*
11. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day
for 5 days: Then resume usual dosing of one tablet daily,
ongoing.
Disp:*95 Tablet(s)* Refills:*0*
12. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*180 Tablet(s)* Refills:*0*
13. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
14. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours): do not drink alcohol
or drive while using.
Disp:*180 Tablet Sustained Release(s)* Refills:*0*
15. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*270 Tablet, Chewable(s)* Refills:*0*
16. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for Constipation.
Disp:*1000 ML(s)* Refills:*0*
17. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
Disp:*180 Capsule(s)* Refills:*0*
18. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
Disp:*180 Tablet(s)* Refills:*0*
19. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for puritis.
Disp:*1 tube* Refills:*0*
20. commode Sig: One (1) bedside commode once a day.
Disp:*1 bedside commode* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Severe copd with exacerbation
chronic lower back pain
Discharge Condition:
Stable, VSS, AF, at baseline O2 use of 4 litres via nasal
cannula.
Discharge Instructions:
Return to the [**Hospital1 18**] for shortness of [**Hospital1 1440**], chest pain, fevers
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10134**], MD Phone:[**Telephone/Fax (1) 7976**]
Date/Time:[**2107-7-7**] 2:15
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2107-8-11**] 10:10
Provider: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2107-8-11**] 10:30
|
[
"280.9",
"V09.80",
"562.10",
"482.9",
"530.81",
"272.0",
"V46.2",
"V12.04",
"401.9",
"327.23",
"491.21",
"E928.9",
"412",
"338.29",
"724.2",
"V58.65",
"416.0",
"V13.02",
"882.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9415, 9473
|
5282, 6047
|
326, 332
|
9570, 9638
|
3597, 3597
|
9777, 10233
|
2637, 2734
|
6662, 9392
|
9494, 9549
|
6073, 6639
|
9662, 9754
|
2749, 3578
|
276, 288
|
360, 1764
|
3613, 5259
|
1786, 2359
|
2375, 2621
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,714
| 142,710
|
17502
|
Discharge summary
|
report
|
Admission Date: [**2150-3-7**] Discharge Date: [**2150-3-14**]
Date of Birth: [**2123-10-28**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
Light headedness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Had hemodialysis day of admission and was unable to eat
secondary to lightheadedness. Had chills with HD last Thursday.
Currently no f/n/v abd pain, cp, sob, d, const, having BMs.
Past Medical History:
LURT ([**2-17**]) - rejection - txp nephrectomy
ESRD [**1-1**] VUR
HTN
UTIs
PD Cath
T&A
Physical Exam:
AAOx3
NAD
Tachycardic to 115
CTAB
Soft NT/ND
PD Cath in place, cuff out
No cellulitis
no rebound no guarding
Pertinent Results:
[**2150-3-14**] 05:55AM BLOOD WBC-5.8 RBC-3.18* Hgb-10.3* Hct-30.1*
MCV-95 MCH-32.5* MCHC-34.3 RDW-16.3* Plt Ct-477*
[**2150-3-12**] 04:47AM BLOOD WBC-8.0 Hct-24.4* Plt Ct-398
[**2150-3-11**] 02:32PM BLOOD WBC-10.1 RBC-2.83* Hgb-8.9* Hct-25.9*
MCV-92 MCH-31.3 MCHC-34.2 RDW-17.5* Plt Ct-487*
[**2150-3-11**] 02:00AM BLOOD WBC-9.3 RBC-2.79* Hgb-8.7* Hct-25.7*
MCV-92 MCH-31.3 MCHC-34.0 RDW-17.5* Plt Ct-378
[**2150-3-10**] 07:45PM BLOOD Hct-27.8*#
[**2150-3-10**] 11:23AM BLOOD WBC-11.9* RBC-2.25* Hgb-7.3* Hct-21.9*
MCV-97 MCH-32.2* MCHC-33.1 RDW-16.6* Plt Ct-446*
[**2150-3-10**] 05:45AM BLOOD WBC-11.1* RBC-2.29* Hgb-7.7* Hct-22.3*
MCV-97 MCH-33.6* MCHC-34.5 RDW-16.6* Plt Ct-411
[**2150-3-9**] 05:30AM BLOOD WBC-8.8 RBC-2.52* Hgb-8.3* Hct-24.6*
MCV-98 MCH-33.1* MCHC-33.9 RDW-16.8* Plt Ct-403
[**2150-3-8**] 06:30AM BLOOD WBC-6.0 RBC-2.38* Hgb-7.8* Hct-23.3*
MCV-98 MCH-32.9* MCHC-33.6 RDW-16.9* Plt Ct-315
[**2150-3-7**] 07:20PM BLOOD WBC-6.5 RBC-2.74* Hgb-9.0* Hct-26.2*
MCV-96 MCH-33.0* MCHC-34.5 RDW-16.9* Plt Ct-358#
[**2150-3-7**] 07:20PM BLOOD Neuts-81.6* Bands-0 Lymphs-12.0*
Monos-4.4 Eos-1.4 Baso-0.6
[**2150-3-11**] 02:32PM BLOOD Hypochr-NORMAL Anisocy-1+
Poiklo-OCCASIONAL Macrocy-1+ Microcy-NORMAL Polychr-OCCASIONAL
Ovalocy-OCCASIONAL Burr-OCCASIONAL
[**2150-3-7**] 07:20PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-NORMAL
Macrocy-1+ Microcy-NORMAL Polychr-1+ Tear Dr[**Last Name (STitle) 833**]
[**2150-3-14**] 05:55AM BLOOD Plt Ct-477*
[**2150-3-13**] 05:05AM BLOOD Plt Ct-402
[**2150-3-12**] 04:47AM BLOOD Plt Ct-398
[**2150-3-11**] 02:32PM BLOOD Plt Ct-487*
[**2150-3-11**] 02:32PM BLOOD PT-15.3* PTT-28.6 INR(PT)-1.4*
[**2150-3-11**] 02:00AM BLOOD Plt Ct-378
[**2150-3-11**] 02:00AM BLOOD PT-16.8* PTT-30.2 INR(PT)-1.5*
[**2150-3-10**] 11:23AM BLOOD Plt Ct-446*
[**2150-3-10**] 11:23AM BLOOD PT-18.8* PTT-37.4* INR(PT)-1.8*
[**2150-3-10**] 08:35AM BLOOD PT-19.9* PTT-30.3 INR(PT)-1.9*
[**2150-3-10**] 05:45AM BLOOD Plt Ct-411
[**2150-3-9**] 05:30AM BLOOD Plt Ct-403
[**2150-3-8**] 06:30AM BLOOD Plt Ct-315
[**2150-3-8**] 06:30AM BLOOD PT-15.0* PTT-25.1 INR(PT)-1.3*
[**2150-3-7**] 07:20PM BLOOD Plt Smr-NORMAL Plt Ct-358#
[**2150-3-7**] 07:20PM BLOOD PT-14.1* PTT-21.8* INR(PT)-1.3*
[**2150-3-11**] 02:00AM BLOOD Fibrino-508*#
[**2150-3-11**] 02:32PM BLOOD ESR-135*
[**2150-3-11**] 02:00AM BLOOD ESR-41*
[**2150-3-9**] 08:35AM BLOOD ESR-110*
[**2150-3-12**] 04:47AM BLOOD Ret Aut-3.4*
[**2150-3-10**] 08:35AM BLOOD ACA IgG-PND ACA IgM-PND
[**2150-3-10**] 08:35AM BLOOD Lupus-NEG ProtCFn-81 ProtSFn-41*
ProtSAg-PND
[**2150-3-14**] 05:55AM BLOOD Glucose-91 UreaN-57* Creat-9.3*# Na-139
K-4.1 Cl-97 HCO3-21* AnGap-25*
[**2150-3-13**] 05:05AM BLOOD Glucose-94 UreaN-45* Creat-7.4*# Na-139
K-4.3 Cl-100 HCO3-24 AnGap-19
[**2150-3-12**] 04:47AM BLOOD Glucose-148* UreaN-72* Creat-11.2*#
Na-136 K-5.1 Cl-95* HCO3-21* AnGap-25*
[**2150-3-11**] 02:00AM BLOOD Glucose-139* UreaN-52* Creat-10.4*#
Na-133 K-5.8* Cl-95* HCO3-21* AnGap-23*
[**2150-3-10**] 07:45PM BLOOD Glucose-126* UreaN-55* Creat-12.0*#
Na-135 K-5.7* Cl-97 HCO3-19* AnGap-25*
[**2150-3-10**] 11:23AM BLOOD Glucose-107* UreaN-65* Creat-15.8*#
Na-136 K-5.6* Cl-95* HCO3-23 AnGap-24*
[**2150-3-10**] 08:35AM BLOOD Glucose-103 UreaN-60* Creat-14.7* Na-133
K-6.5* Cl-97 HCO3-21* AnGap-22*
[**2150-3-10**] 05:45AM BLOOD Glucose-107* UreaN-60* Creat-15.5*#
Na-130* K-7.0* Cl-91* HCO3-21* AnGap-25*
[**2150-3-9**] 05:30AM BLOOD Glucose-117* UreaN-46* Creat-12.3*#
Na-135 K-4.1 Cl-94* HCO3-21* AnGap-24*
[**2150-3-8**] 06:30AM BLOOD Glucose-95 UreaN-36* Creat-10.9*# Na-139
K-4.6 Cl-98 HCO3-25 AnGap-21*
[**2150-3-7**] 07:20PM BLOOD Glucose-100 UreaN-30* Creat-9.5* Na-141
K-4.0 Cl-97 HCO3-27 AnGap-21
[**2150-3-11**] 02:32PM BLOOD LD(LDH)-133
[**2150-3-11**] 02:00AM BLOOD LD(LDH)-218
[**2150-3-10**] 07:45PM BLOOD CK(CPK)-38
[**2150-3-10**] 11:23AM BLOOD CK(CPK)-32*
[**2150-3-10**] 08:35AM BLOOD ALT-5 AST-6 LD(LDH)-135 CK(CPK)-21*
AlkPhos-66 Amylase-96 TotBili-0.9
[**2150-3-10**] 08:35AM BLOOD Lipase-23
[**2150-3-10**] 08:35AM BLOOD CK-MB-NotDone cTropnT-0.09*
[**2150-3-12**] 04:47AM BLOOD Iron-72
[**2150-3-11**] 02:32PM BLOOD Phos-6.3* Mg-1.9
[**2150-3-11**] 02:00AM BLOOD Calcium-9.4 Phos-5.5* Mg-1.7
[**2150-3-10**] 07:45PM BLOOD Calcium-8.9 Phos-5.2* Mg-1.5*
[**2150-3-10**] 11:23AM BLOOD Calcium-8.6 Phos-6.6* Mg-1.6
[**2150-3-10**] 08:35AM BLOOD Albumin-3.1* Calcium-7.5* Phos-5.3*
Mg-1.4*
[**2150-3-10**] 05:45AM BLOOD Calcium-8.6 Phos-5.3* Mg-1.5*
[**2150-3-9**] 08:35AM BLOOD UricAcd-7.4*
[**2150-3-9**] 05:30AM BLOOD Calcium-8.8 Phos-3.9# Mg-1.6
[**2150-3-8**] 06:30AM BLOOD Calcium-9.2 Phos-5.9*# Mg-1.6
[**2150-3-7**] 07:20PM BLOOD Calcium-9.0 Phos-3.7# Mg-1.5*
[**2150-3-12**] 04:47AM BLOOD calTIBC-195* Ferritn-562* TRF-150*
[**2150-3-11**] 02:32PM BLOOD VitB12-241 Folate-5.1
[**2150-3-11**] 02:32PM BLOOD Hapto-458*
[**2150-3-11**] 02:00AM BLOOD Hapto-417*
[**2150-3-12**] 10:40AM BLOOD PTH-134*
[**2150-3-10**] 01:48PM BLOOD Cortsol-42.1*
[**2150-3-10**] 01:13PM BLOOD Cortsol-40.1*
[**2150-3-10**] 12:45PM BLOOD Cortsol-25.1*
[**2150-3-10**] 08:35AM BLOOD Cortsol-36.1*
[**2150-3-11**] 02:32PM BLOOD CRP-GREATER TH
[**2150-3-11**] 02:00AM BLOOD CRP-GREATER TH
[**2150-3-9**] 08:35AM BLOOD CRP-60.5*
[**2150-3-12**] 04:47AM BLOOD Vanco-16.5*
[**2150-3-11**] 02:00AM BLOOD Vanco-22.8*
[**2150-3-10**] 08:35AM BLOOD Vanco-13.9*
[**2150-3-9**] 05:30AM BLOOD Vanco-18.6*
[**2150-3-8**] 06:30AM BLOOD Vanco-23.4*
[**2150-3-11**] 02:32PM BLOOD RedHold-HOLD
[**2150-3-7**] 07:20PM BLOOD RedHold-HOLD
[**2150-3-11**] 02:45PM BLOOD Type-ART pH-7.47*
[**2150-3-11**] 12:05PM BLOOD Type-ART pO2-65* pCO2-40 pH-7.42
calHCO3-27 Base XS-0
[**2150-3-11**] 08:07AM BLOOD Type-ART pO2-92 pCO2-36 pH-7.41
calHCO3-24 Base XS-0
[**2150-3-11**] 02:15AM BLOOD Type-ART pO2-93 pCO2-43 pH-7.38
calHCO3-26 Base XS-0
[**2150-3-10**] 07:58PM BLOOD Type-ART pO2-95 pCO2-38 pH-7.42
calHCO3-25 Base XS-0
[**2150-3-10**] 05:43PM BLOOD Type-ART pO2-86 pCO2-35 pH-7.40
calHCO3-22 Base XS--1
[**2150-3-10**] 03:39PM BLOOD Type-ART pO2-101 pCO2-39 pH-7.39
calHCO3-24 Base XS-0
[**2150-3-10**] 01:36PM BLOOD Type-ART pO2-102 pCO2-41 pH-7.39
calHCO3-26 Base XS-0
[**2150-3-10**] 11:37AM BLOOD Type-ART pO2-112* pCO2-40 pH-7.39
calHCO3-25 Base XS-0
[**2150-3-11**] 02:45PM BLOOD Glucose-144* K-5.3
[**2150-3-11**] 12:05PM BLOOD Na-136 K-5.0 Cl-97*
[**2150-3-11**] 08:07AM BLOOD Glucose-168* K-4.9
[**2150-3-11**] 02:15AM BLOOD K-5.6*
[**2150-3-10**] 07:58PM BLOOD K-5.8*
[**2150-3-10**] 05:43PM BLOOD K-5.0
[**2150-3-10**] 03:39PM BLOOD K-5.8*
[**2150-3-10**] 01:36PM BLOOD K-5.5*
[**2150-3-10**] 11:37AM BLOOD K-5.4*
[**2150-3-10**] 08:55AM BLOOD K-6.6*
[**2150-3-7**] 07:27PM BLOOD Glucose-102 Lactate-1.9 K-4.0
[**2150-3-11**] 02:45PM BLOOD freeCa-1.09*
[**2150-3-11**] 12:05PM BLOOD freeCa-1.13
[**2150-3-11**] 08:07AM BLOOD freeCa-1.13
[**2150-3-11**] 02:15AM BLOOD freeCa-1.12
[**2150-3-10**] 07:58PM BLOOD freeCa-1.10*
[**2150-3-10**] 05:43PM BLOOD freeCa-1.01*
[**2150-3-10**] 03:39PM BLOOD freeCa-1.07*
[**2150-3-10**] 01:36PM BLOOD freeCa-1.06*
[**2150-3-10**] 11:37AM BLOOD freeCa-1.09*
[**2150-3-10**] 08:35AM BLOOD FACTOR V LEIDEN-PND
[**2150-3-9**] 12:50PM BLOOD CH 50-Test
Brief Hospital Course:
Pt was admitted and c/o joint pain. Had extreme pain in B/L
wrists and ankles. He was seen by Rheum and they Pt was given
toradol and then prednisone and pain improved. Rheum trued to
asp the joint but were not able to draw back fluid. They
thought it was most likely serum sickness due to ATG vs crystal
disease. On HD 4 he became hypotensive at dialysis. he was
treated for a low HCT and High K and tx'd to the SICU for closer
monitoring. Here he was on CVVHD, he did well, and was
tranferred back to the floor. he was treated with Vanc and
Zosyn for poss sepsis, these were d/c'd when pt stablized and
there were no obvious causes of infx. It was determined by
renal that he would tol PD and he was in good condition for d/c
home on [**2150-3-14**] to foolow-up with outpt PD.
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO QD ().
3. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
4. Cinacalcet 30 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
5. Doxercalciferol 2.5 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q3H (every 3 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
7. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
follow up with transplant office.
Disp:*30 Tablet(s)* Refills:*0*
8. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
esrd secondary to VUR on hemodialysis
serum sickness
Discharge Condition:
stable
Discharge Instructions:
Call Transplant Office [**Telephone/Fax (1) 673**] if fevers, chills, increased
joint pain, increased abdominal pain or if hemodialysis access
not working.
Resume hemodialsyis
Followup Instructions:
call transplant office [**Telephone/Fax (1) 673**] to schedule follow up
appointment
|
[
"585.6",
"276.7",
"583.9",
"999.5",
"403.91",
"276.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
9525, 9531
|
7965, 8755
|
331, 338
|
9628, 9637
|
805, 7942
|
9861, 9949
|
8778, 9502
|
9552, 9607
|
9661, 9838
|
676, 786
|
275, 293
|
366, 549
|
571, 661
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,403
| 182,948
|
46074
|
Discharge summary
|
report
|
Admission Date: [**2118-5-11**] Discharge Date: [**2118-5-23**]
Service: MEDICINE
Allergies:
Allopurinol Sodium
Attending:[**First Name3 (LF) 56857**]
Chief Complaint:
mental status change
Major Surgical or Invasive Procedure:
Right burr hole drainage
History of Present Illness:
[**Age over 90 **]yo F with chronic subdural hematoma, dementia, atrial
fibrillation (not on anticoagulation) presents from [**Hospital 100**] Rehab
with mental status change. Pt had subdural hematoma noted in
[**3-22**] (multiple recent falls), with extension on repeat 2 weeks
ago. Was recently treated for UTI with cipro, completed course
[**5-6**]. Pt was noted to be more confused, agitated, and paranoid
today. She was hostile towards staff members, accusatory,
throwing items, incontinence of stool, calling others "the
devil", expressing that someone was trying to hurt her.
.
In [**Name (NI) **], pt was oriented x 2. She received Haldol 2.5mg x 3 for
agitation, yelling at staff members. UA consistent with UTI,
given one dose ceftriaxone.
.
Upon arrival to floor, pt is sedated, appears comfortable, with
1:1 sitter at bedside. She has no complaints other than "stop
bothering me, leave me alone". Denies abdominal pain, dysuria,
headache. Refusing most of physical exam.
.
Discussed hx with son, who states current state is significantly
different than baseline. Change first noted on [**5-8**], when pt
stated she "didn't feel well", but was unable to elaborate.
Aggression/hostility today very far from baseline.
Past Medical History:
MedHx: (Obtained through prior records, pt unable to provide hx)
-Chronic subdural hematoma
-Dementia (likely Alzheimers)
-Depression
-CVA
-A fib
-HTN
-Gout
-GERD
-Anemia
-?vision impairment
SurgHx: Bilateral TKA
Social History:
Living in [**Hospital 100**] Rehab since [**3-22**] after fall complicated by SDH.
Prior to that, she had been living independently with
assistance of Meals on Wheels and a homemaker.
Family History:
n/c
Physical Exam:
VS 96.2 140/82 84 18 97%RA
Gen: Thin elderly woman sleeping comfortably on approach. Easily
arousable. Answers most questions appropriately, but
perseverating about moving to chair. Oriented to month, but not
date "the 5th", year (no response), or location ("I'm right
here").
CV: Regular pulse, not tachycardic. Distant heart sounds. Unable
to assess entirely secondary to lack of pt cooperation (moving,
talking, pushing away)
Lungs: CTAB
Abd: Soft, nontender, nondistended
Ext: No C/C/E
Neuro: CNII-XII grossly intact. Follows commands. Strength 5/5
bilat U&LE. Sensation grossly intact. Patellar reflexes 2+
bilat.
Pertinent Results:
[**2118-5-11**] 02:00PM BLOOD WBC-7.2 RBC-3.88* Hgb-10.2* Hct-32.3*
MCV-83 MCH-26.4* MCHC-31.7 RDW-13.5 Plt Ct-282
[**2118-5-18**] 01:42AM BLOOD WBC-8.8 RBC-3.73* Hgb-10.5* Hct-30.3*
MCV-81* MCH-28.2 MCHC-34.6 RDW-13.3 Plt Ct-263
[**2118-5-20**] 07:00AM BLOOD WBC-9.0 RBC-3.95* Hgb-10.5* Hct-32.5*
MCV-82 MCH-26.7* MCHC-32.4 RDW-13.2 Plt Ct-263
[**2118-5-22**] 07:40AM BLOOD WBC-9.7 RBC-4.49 Hgb-12.1 Hct-37.1 MCV-83
MCH-27.0 MCHC-32.6 RDW-13.3 Plt Ct-300
[**2118-5-23**] 07:15AM BLOOD WBC-10.7 RBC-4.28 Hgb-11.5* Hct-34.6*
MCV-81* MCH-26.9* MCHC-33.4 RDW-13.2 Plt Ct-308
.
[**2118-5-11**] 02:00PM BLOOD PT-13.5* PTT-30.1 INR(PT)-1.2*
[**2118-5-15**] 06:30AM BLOOD PT-13.2 PTT-32.1 INR(PT)-1.1
[**2118-5-19**] 07:07AM BLOOD PT-13.6* PTT-34.9 INR(PT)-1.2*
.
[**2118-5-11**] 02:00PM BLOOD Glucose-103 UreaN-19 Creat-1.0 Na-139
K-4.0 Cl-102 HCO3-30 AnGap-11
[**2118-5-15**] 06:30AM BLOOD Glucose-82 UreaN-16 Creat-0.9 Na-139
K-3.8 Cl-102 HCO3-26 AnGap-15
[**2118-5-20**] 07:00AM BLOOD Glucose-92 UreaN-13 Creat-0.5 Na-142
K-3.4 Cl-106 HCO3-25 AnGap-14
[**2118-5-23**] 07:15AM BLOOD Glucose-108* UreaN-11 Creat-0.6 Na-135
K-3.8 Cl-100 HCO3-25 AnGap-14
[**2118-5-19**] 07:07AM BLOOD ALT-11 AST-23 CK(CPK)-107 AlkPhos-75
TotBili-0.6
[**2118-5-11**] 02:00PM BLOOD cTropnT-<0.01
[**2118-5-19**] 07:07AM BLOOD CK-MB-2 cTropnT-<0.01
[**2118-5-11**] 02:00PM BLOOD Calcium-9.1 Phos-3.2 Mg-1.8
[**2118-5-20**] 07:00AM BLOOD Albumin-3.3* Calcium-8.6 Phos-2.9 Mg-1.9
[**2118-5-23**] 07:15AM BLOOD Calcium-8.9 Phos-2.8 Mg-1.5*
.
[**2118-5-20**] 07:00AM BLOOD Ammonia-20
.
[**2118-5-11**] 02:00PM BLOOD TSH-2.8
[**2118-5-19**] 07:07AM BLOOD TSH-2.1
.
[**2118-5-18**] 01:42AM BLOOD Phenyto-19.0
[**2118-5-18**] 02:15PM BLOOD Phenyto-17.5
[**2118-5-20**] 07:00AM BLOOD Phenyto-12.2
.
[**2118-5-19**] 10:00AM BLOOD Type-ART pO2-183* pCO2-35 pH-7.52*
calTCO2-30 Base XS-6
.
CXR [**5-11**]
FINDINGS: The lungs are clear. The cardiomediastinal silhouette
and pulmonary vessels are within normal limits. There is no
evidence of pleural effusion. Incidental note is made of severe
rotatory thoracolumbar S-shaped scoliosis and "pencilling"
deformity of the right distal clavicle, unchanged.
Calcifications of the arch of the aorta are also noted.
IMPRESSION:
1. No acute cardiopulmonary process.
2. Highly asymmetric severe degenerative change of the right
glenohumeral joint and "pencilling" deformity of the right
distal clavicle, of uncertain significance.
.
[**5-11**]
HEAD CT WITHOUT IV CONTRAST: The subdural collection along the
right cerebral convexity demonstrates interval blood resorption
(2:20). There is a small residual hemorrhagic component,
posteriorly. A slight increase in thickness to 18 mm (previously
measuring 14 mm) may be related to slice selection/angulation
differences. There is no apparent increase of mass effect on the
subjacent gyri. There is no change in minimal (2 mm) midline
shift. There is no new hemorrhage.
There is no change in appearance of prominence of the ventricles
and sulci related to age-appropriate parenchymal atrophy.
Periventricular white matter hypodensity representing chronic
small vessel ischemic disease, is also unchanged. There has been
prior left lens replacement. The visualized paranasal sinuses
remain clear.
IMPRESSION:
1. Interval organization of the subdural collection along the
right cerebral convexity, with apparent slight increase in
thickness and interval resorption of blood products with a small
residual hemorrhagic component, posteriorly.
2. No new hemorrhage.
.
[**5-17**] HEAD CT
FINDINGS: Right frontal burr hole placement with overlying
surgical skin clips in place. There are expected post-operative
changes including a small focus of air adjacent to the surgical
site and moderate subgaleal soft tissue swelling. The known
right cerebral convexity subdural collection has decreased in
size measuring 9.5 mm in maximal thickness compared to 1.8 mm
previously. Some hyperdensity consistent with more acute blood
products is seen layering along the right intraparietal
convexity. No new foci of hemorrhage are seen. No change in
minimal 2 mm leftward midline shift is noted. There is no
increased mass effect along the sub-adjacent gyri. The
ventricles are stable in size. Periventricular white matter
hypodensity representing chronic microvascular ischemic disease
is stable. No fractures are seen. The imaged paranasal sinuses
and mastoid air cells are well aerated.
IMPRESSION:
1. Status post right burr hole placement with expected
post-operative change and decrease in size of the underlying
subdural collection along the right cerebral convexity.
2. No new hemorrhage.
.
[**5-19**] HEAD CT
FINDINGS: There is mild increase in the transverse dimension of
the right subdural hematoma, (1.2CM NOW COMPARED TO THE PRIOR OF
0.9CM) with a few hyperdense foci and predominantly less dense
fluid collection. Small foci of free air are again noted.
There is no significant change in the minimal shift of the
midline structures No new hemorrhage is noted.
IMPRESSION: Minimal increase in the transverse dimension of the
right subdural fluid collection, (COMPARED TO THE MOST RECENT
STUDY) with some hyperdense foci, related to hemorrhage. No new
hemorrhage or shift of midline structures. Findings were
discussed with Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 51681**] by Dr. [**Last Name (STitle) **] on [**2118-5-19**].
.
[**5-19**] EEG
FINDINGS:
ABNORMALITY #1: Throughout the recording the background rhythm
was
disorganized and usually mildly slow, reaching a 7-7.5 Hz
maximum most
of the time.
ABNORMALITY #2: There were frequent bursts of slowing, most
generalized. These included sharp and triphasic features. Some
bursts
of slowing were more prominent over one hemisphere or the other,
but
most were generalized.
HYPERVENTILATION: Could not be performed.
INTERMITTENT PHOTIC STIMULATION: Could not be performed.
SLEEP: No normal waking or sleeping morphologies are seen.
CARDIAC MONITOR: Showed a very irregular rhythm although with
some
periods of regularity. There were pauses of over two seconds
though
these were infrequent.
IMPRESSION: Abnormal portable EEG due to the slow and
disorganized
background rhythm and frequent bursts of generalized slowing.
These
findings indicate a widespread encephalopathy affecting both
cortical
and subcortical structures. Medications, metabolic disturbances,
and
infection are among the most common causes. There were no areas
of
prominent and persistent focal slowing. There were no clearly
epileptiform features. A markedly abnormal cardiac rhythm was
noted.
.
Brief Hospital Course:
[**Age over 90 **]yo F with chronic subdural hematoma, dementia, HTN, a fib
admitted with acute mental status change.
.
*) Mental status change: Pt has hx of chronic subdural hematoma,
first diagnosed [**3-22**], with expansion on subsequent imaging
(approx 2 weeks later) and "slight increase in thickness" of
hemorrhage on imaging this PM. Today, became agitated, hostile,
confused, and paranoid. Was recently treated for UTI, but UA in
ED consistent with UTI. Mental status change likely [**1-15**]
worsening chronic subdural hematoma in combination with UTI and
known Alzheimer's dementia. Neurosurgery followed throughout
admission and family and pt did consent for burr hole drainage
of hematoma, which occurred on HD#7. Procedure was
uncomplicated. Please see full operative note for details. She
was transferred to the TSICU for a short period of recovery and
was called out to the floor on POD#1. She was started on
dilantin for seizure prophylaxis, but was extremely sedated on
POD#2. Given concern for continued bleeding versus infection, an
extensive workup was initiated. Her head CT was unchanged, CXR
WNL, UA not c/w UTI, and EEG without seizure activity. Neurology
was consulted and neurosurgery also assessed pt. Given lack of
abnormal results, most likely culprit was determined to be
dilantin, as level was corrected with albumin to 21
(supratherapeutic). By POD#3, her mental status began to return
to baseline and neurosurgery recommended d/c'ing dilantin as
risk of sedation outweighs risk of seizure activity. Throughout
the rest of her hospitalization, her mental status was at
baseline--alert, responsive to verbal stimuli, follows commands,
generally sensical speech with evidence of dementia, lack of
orientation to time/place.
.
*) UTI: Initially thought to be contributing to mental status
change. Culture of previous UTI showed urogenital contamination,
though pt tx with cipro. Pt did not have additional systemic sx
like fever, chills, back pain. Pt was started on ceftriaxone,
transitioned to cefpodoxime, but antibiotics were d/c'd when
urine culture returned as contaminated. Pt had a second UTI on
POD#3, which was negative.
.
*) Poor PO intake: Pt was seen by nutrition, who suggested
Ensure supplementation with meals. Despite return to baseline
mental status, pt did not take in significant POs. IV fluids
were continued to ensure adequate hydration and should be
continued upon discharge (D5 1/2NS @ 60cc/hr) until tolerating
adequate POs.
.
*) Atrial fibrillation: Pt was mostly in NSR during the
hospitalization, with occassional episodes of coarse a fib with
return to NSR. Not on anticoagulation [**1-15**] fall risk and SDH.
TEDs and pneumoboots were placed for prophylaxis. No indication
for tele. Per neurosurgery, safe to restart ASA on POD#7. Will
defer to provider following pt upon discharge.
.
*) HTN: BPs stable without meds.
.
*) Gout: Continued colchicine.
.
*) Anemia: Continued iron. Hct 31.5
.
*) Communication: Son [**Name (NI) **] [**Name (NI) **] (HCP) kept abreast of clinical
status throughout hospitalization ([**Telephone/Fax (1) 98056**]). Son [**Name (NI) **]
[**Name (NI) **] (neurologist) [**Telephone/Fax (1) 98057**].
Medications on Admission:
Tums 650mg daily
Vitamin D 1000u daily
Colchicine 0.6mg daily
Colace 250mg daily
Iron 325mg daily
Prilosec 20mg daily
Ativan 0.125mg q6h prn
Discharge Medications:
1. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO DAILY (Daily).
2. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day
for 1 doses.
3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: 2.5 Tablets
PO DAILY (Daily).
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
6. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day:
Please start [**5-24**].
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed. Tablet(s)
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Tablet, Delayed Release (E.C.)(s)
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours).
10. Colace 50 mg/5 mL Liquid Sig: Five (5) ml PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary:
-Mental Status changes
-Chronic subdural hematoma
-Dementia (likely Alzheimers)
-Urinary tract infection
Secondary:
-Depression
-CVA
-A fib
-HTN
-Gout
-GERD
-Anemia
Discharge Condition:
Discharge Instructions:
You were admitted with a change in mental status and found to
have a slight enlargement of the subdural hematoma in your
brain. Neurosurgery performed burr hole drainage of the
hematoma.
.
Your caregivers should call a physician or have you return to
the hospital if you have further changes in mental status,
headache, weakness, numbness, pain with urination, fevers,
chills, nausea/vomiting/diarrhea, or any other questions or
concerns.
MRS. [**Known lastname **] IS A FALL RISK AND SHOULD BE PLACED UNDER STRICT FALL
PRECAUTIONS UPON RETURN TO [**Hospital **] REHAB.
Followup Instructions:
-PLEASE CALL DR[**Doctor Last Name **] OFFICE (NEUROSURGERY) AT [**Telephone/Fax (1) **]
TO SCHEDULE THE FOLLOWING:
1. 10 DAY POST-OP APPOINTMENT TO HAVE YOUR SUTURES REMOVED
(~[**2118-5-29**])
2. A 1 MONTH POST-OP FOLLOW-UP APPOINTMENT FOR TO EVALUATE
YOUR
CONDITION (~[**2118-6-19**])
-Follow up with physicians at [**Hospital 100**] Rehab.
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 1239**] DO 12-ASV
|
[
"331.0",
"285.9",
"274.9",
"E888.9",
"599.0",
"294.11",
"852.20",
"530.81",
"427.31",
"293.0",
"434.91",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.39"
] |
icd9pcs
|
[
[
[]
]
] |
13545, 13611
|
9268, 12458
|
248, 275
|
13832, 13832
|
2656, 9245
|
14451, 14967
|
1987, 1992
|
12650, 13522
|
13632, 13808
|
12484, 12627
|
13856, 14428
|
2007, 2637
|
188, 210
|
303, 1532
|
1554, 1769
|
1785, 1971
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,717
| 198,296
|
38383
|
Discharge summary
|
report
|
Admission Date: [**2136-5-27**] Discharge Date: [**2136-6-12**]
Date of Birth: [**2112-7-18**] Sex: M
Service: SURGERY
Allergies:
Erythromycin Base / Amoxicillin / Penicillins
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
small small SAH, Gr IV liver lac, tib/'fib fx, bilateral femur
fxs, L talus fx.
Major Surgical or Invasive Procedure:
PRINCIPAL PROCEDURE:
1. Intramedullary rod fixation of right mid shaft femur
fracture.
2. IM rod fixation of right basocervical femoral neck
fracture.
3. IM rod fixation of left distal third femur fracture.
4. Irrigation and debridement of grade [**1-7**] open mid shaft
femur fracture to bone.
5. Incision and drainage of right medial knee laceration.
6. Incision and drainage of left medial knee laceration.
History of Present Illness:
Pt is a 23yo Cauc M transf'd from [**Hospital **] Hospital s/p high
speed MVC car vs. tree in which pt was the unrestrained driver
of a single occupant vehicle. Per chart, + airbags, unknown
LOC. Per chart, pt arrived to [**Hospital1 18**] awake but confused w/
repetitive questioning- GCS 15 and not intubated until in the OR
for his femur fx ORIFs. ETOH (BAL) upon arrival at [**Hospital1 18**] was
249. Tox was otherwise neg. Pt suffered a small small SAH, Gr
IV liver lac, tib/'fib fx, bilateral femur fxs, L talus fx.
Past Medical History:
none
Social History:
ETOH
Family History:
non contributory
Pertinent Results:
MICRO:
[**5-27**]: MRSA screen negative
[**5-28**]: Urine cx. negative
[**5-30**]: MRSA screen pending, sputum contamination w/upper flora
[**5-31**]: Mini BAL No micro
[**6-1**] Bl cx: no growth
[**6-1**] Ucx: No growth
[**6-2**]: BAL: No growth
[**6-5**]: bld x neg x2
[**6-6**]: Bl cx: no growth
[**6-8**] Bl cx: no growth / urine cult no grown
[**6-9**]: stool cult neg c d-ff neg
[**6-10**]: stool cult neg c diff neg
[**6-11**] : stool culg pend c diff neg
.
IMAGING:
[**5-27**] CT head:LIMITED BY MOTION. POSSIBLE SUBARACHNOID HEMORRHAGE
IN THE LEFT SILVIAN FISSURE. THIS CAN BE ARTIFACTUAL. REPEAT
SCAN IS RECOMMENDED.
[**5-27**] CT c-spine: no fx
[**5-27**] CT torso: RUL PULM CONTUSION. SEVERE LIVER INJURY (LAC AND
HEMATOMA INVOLING BOTH LOBES.NO DEFENITE ACTICE EXTRAV. R ADRNAL
HEMATOMA. MESENTERIC HEMATOMA-INJURY ?DISTAL ILEUM MILD DIL CAN
REPRESENT EARLY ISCHEMIA (PLS CLINICALLY CORRELATE).SMALL ABD,
PERIHEPATIC AND PELVIC HEMORRHAGE. SMALL MEDIASTINAL
HEMATOMALIKELY VENOUS ORIGIN. RIGHT FEM NECK (LIKELY OPEN) FX
WITH ADJ AIR.
[**5-27**] LE x-rays: ? L TALUS AND R TIBIAL PLATEAU FX (DEDICATED
IMAGING CAN BE OBTAINED.) BILAT FEMUR FX.
[**5-27**] Repeat L ankle Xray=
[**5-27**] Repeat head CT: No intracranial hemorrhage identified.
Previously noted possible subarachnoid hemorrhage in the left
sylvian fissure was likely artifactual
[**5-27**] Repeat A/P CT: 1. Liver laceration as detailed above, now
showing improved perfusion without interval progression.
Hemoperitoneum with increase seen in the right paracolic gutter.
Stable right adrenal hemorrhage. Stable small mesenteric
hematoma. Interval development of small bilateral pleural
effusions with bibasilar atelectasis.
[**5-30**] CTA= 1. No pulmonary embolism. 2. Widespread severe
bronchocentric pulmonary abnormality could be pneumonia
or atypical fat embolism syndrome, alternatively drug reaction,
but unlikely pulmonary hemorrhage. 3. Mild pulmonary edema
[**5-31**] CXR: severe diffuse airspace opacification, worse at the
right base and improved at left base, enlarged rt small
effusion.
[**6-1**] CXR: Diffuse airspace opacities throghout worsened with pm
cxr.
[**6-2**] CT torso: Decreased hepati, mesenteric heamtoma, difuse
airspace disease. Slight increase in pelvic heamtoma.
[**6-3**] CXR: Interval worsening c/ diffuse opacification of both
lungs
[**6-4**] CXR: The consolidation in the left base inc
[**6-5**] CXR:bilateral parenchymal opacities have decreased
[**6-7**] CXR: unchanged
Lab results:
[**2136-6-12**] 07:20AM BLOOD WBC-11.9* RBC-3.88* Hgb-11.5* Hct-34.3*
MCV-88 MCH-29.6 MCHC-33.5 RDW-15.5 Plt Ct-726*
[**2136-6-11**] 06:00AM BLOOD WBC-15.6* RBC-3.96* Hgb-11.3* Hct-33.9*
MCV-86 MCH-28.4 MCHC-33.2 RDW-15.4 Plt Ct-842*
[**2136-6-10**] 09:15AM BLOOD WBC-19.9* RBC-3.74* Hgb-10.9* Hct-32.7*
MCV-87 MCH-29.2 MCHC-33.5 RDW-15.7* Plt Ct-780*
[**2136-6-9**] 07:10AM BLOOD WBC-24.2* RBC-3.63* Hgb-10.5* Hct-31.0*
MCV-85 MCH-29.0 MCHC-33.9 RDW-15.6* Plt Ct-883*
[**2136-6-8**] 07:05AM BLOOD WBC-19.1* RBC-3.45* Hgb-10.1* Hct-29.7*
MCV-86 MCH-29.3 MCHC-33.9 RDW-15.4 Plt Ct-794*
[**2136-6-7**] 02:00AM BLOOD WBC-14.1* RBC-3.48* Hgb-9.8* Hct-29.6*
MCV-85 MCH-28.2 MCHC-33.2 RDW-14.7 Plt Ct-768*
[**2136-6-6**] 01:50AM BLOOD WBC-14.2* RBC-3.06* Hgb-8.9* Hct-26.2*
MCV-86 MCH-29.1 MCHC-33.9 RDW-14.4 Plt Ct-514*
[**2136-6-5**] 02:09AM BLOOD WBC-12.0* RBC-3.19* Hgb-9.3* Hct-27.6*
MCV-87 MCH-29.2 MCHC-33.7 RDW-14.4 Plt Ct-473*
[**2136-6-4**] 02:19AM BLOOD WBC-8.4 RBC-2.92* Hgb-8.6* Hct-25.6*
MCV-88 MCH-29.4 MCHC-33.5 RDW-14.8 Plt Ct-327
[**2136-6-3**] 02:13AM BLOOD WBC-9.3 RBC-2.55* Hgb-7.5* Hct-22.5*
MCV-88 MCH-29.5 MCHC-33.4 RDW-15.1 Plt Ct-220
[**2136-5-27**] 04:30AM BLOOD WBC-26.8* RBC-4.21* Hgb-12.6* Hct-37.4*
MCV-89 MCH-30.0 MCHC-33.8 RDW-13.9 Plt Ct-263
[**2136-6-12**] 07:20AM BLOOD Plt Ct-726*
[**2136-6-11**] 06:00AM BLOOD Plt Ct-842*
[**2136-6-10**] 09:15AM BLOOD Plt Ct-780*
[**2136-6-9**] 07:10AM BLOOD Plt Ct-883*
[**2136-6-8**] 07:05AM BLOOD Plt Ct-794*
[**2136-6-7**] 02:00AM BLOOD Plt Ct-768*
[**2136-6-6**] 01:50AM BLOOD Plt Ct-514*
[**2136-6-5**] 02:09AM BLOOD Plt Ct-473*
[**2136-6-4**] 02:19AM BLOOD Plt Ct-327
[**2136-6-12**] 07:20AM BLOOD Glucose-116* UreaN-18 Creat-0.8 Na-131*
K-4.9 Cl-100 HCO3-23 AnGap-13
[**2136-6-11**] 06:00AM BLOOD Glucose-134* UreaN-20 Creat-0.8 Na-130*
K-4.9 Cl-97 HCO3-22 AnGap-16
[**2136-6-10**] 09:15AM BLOOD Glucose-127* UreaN-23* Creat-0.7 Na-128*
K-5.0 Cl-95* HCO3-20* AnGap-18
[**2136-6-9**] 07:10AM BLOOD Glucose-128* UreaN-21* Creat-0.8 Na-128*
K-5.2* Cl-92* HCO3-22 AnGap-19
[**2136-6-8**] 07:05AM BLOOD Glucose-143* UreaN-16 Creat-0.7 Na-129*
K-5.3* Cl-94* HCO3-24 AnGap-16
[**2136-5-27**] 12:12PM BLOOD Glucose-128* UreaN-13 Creat-1.2 Na-147*
K-4.3 Cl-115* HCO3-22 AnGap-14
[**2136-5-27**] 04:24PM BLOOD Glucose-121* UreaN-12 Creat-1.1 Na-145
K-4.2 Cl-113* HCO3-23 AnGap-13
[**2136-5-27**] 08:10PM BLOOD Glucose-123* UreaN-13 Creat-1.1 Na-146*
K-4.0 Cl-113* HCO3-24 AnGap-13
[**2136-5-30**] 09:30PM BLOOD Glucose-114* UreaN-12 Creat-0.8 Na-138
K-3.4 Cl-104 HCO3-26 AnGap-11
[**2136-5-30**] 06:20AM BLOOD Glucose-82 UreaN-12 Creat-0.8 Na-138
K-3.6 Cl-104 HCO3-25 AnGap-13
[**2136-5-27**] 04:24PM BLOOD ALT-358* AST-753* AlkPhos-58 TotBili-1.0
[**2136-5-31**] 03:31AM BLOOD ALT-73* AST-120* AlkPhos-56 TotBili-1.0
[**2136-6-9**] 07:10AM BLOOD ALT-37 AST-31 AlkPhos-194* TotBili-1.2
[**2136-6-11**] 06:00AM BLOOD ALT-30 AST-20 AlkPhos-254* TotBili-0.9
[**2136-5-27**] 01:03PM BLOOD Calcium-8.0* Phos-4.7* Mg-1.7
[**2136-6-12**] 07:20AM BLOOD Calcium-9.1 Phos-5.0* Mg-2.4
[**2136-6-5**] 02:09AM BLOOD calTIBC-181* Ferritn-1312* TRF-139*
[**2136-6-5**] 02:09AM BLOOD Triglyc-471* HDL-13
[**2136-5-27**] 04:30AM BLOOD ASA-NEG Ethanol-249* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2136-5-31**] 10:35AM BLOOD Type-ART Temp-38.6 FiO2-100 pO2-85
pCO2-55* pH-7.35 calTCO2-32* Base XS-2 AADO2-589 REQ O2-95
Vent-SPONTANEOU Comment-NON-REBREA
[**2136-5-31**] 11:55AM BLOOD Type-ART pO2-66* pCO2-45 pH-7.39
calTCO2-28 Base XS-1 Intubat-NOT INTUBA Comment-NON-REBREA
[**2136-5-31**] 02:32PM BLOOD Type-ART pO2-63* pCO2-40 pH-7.46*
calTCO2-29 Base XS-4
[**2136-6-1**] 02:56AM BLOOD Type-ART pO2-173* pCO2-42 pH-7.47*
calTCO2-31* Base XS-7
[**2136-6-5**] 06:02AM BLOOD Type-ART pO2-136* pCO2-45 pH-7.44
calTCO2-32* Base XS-6
[**2136-6-5**] 08:39AM BLOOD Type-ART pO2-119* pCO2-36 pH-7.49*
calTCO2-28 Base XS-5
[**2136-6-6**] 04:24PM BLOOD Type-ART pO2-87 pCO2-31* pH-7.47*
calTCO2-23 Base XS-0
Brief Hospital Course:
Pt arrived in ED glascow of 15, with grade IV liver laceration,
small SAH, bilateral femor fractures, Laceration right medial
knee. Laceration left medial knee, both 7 cm. Open grade 1 right
mid shaft femur fracture. Right basocervical neck fracture. Left
mid shaft femur fracture. After initial survey pt was taken
directly to OR with Dr [**First Name (STitle) **] from orthopedics for bilateral
femor fracture repair. Between OR and [**Name (NI) **] pt was transfused 8U
PRBC/2 FFP/Cryo/Plt. In or pt had intramedullary rod fixation of
right mid shaft femur fracture. IM rod fixation of right
basocervical femoral neck fracture. IM rod fixation of left
distal third femur fracture. Irrigation and debridement of grade
[**1-7**] open mid shaft femur fracture to bone. Incision and drainage
of right medial knee laceration. Incision and drainage of left
medial knee laceration. Pt was kept intubated initially from OR
transfered to PACU. On [**5-28**] pt extubated and on [**5-29**] was
transfered to the floor.
On [**5-30**] Pt returned to [**Location **] hypoxemia and tachypnea, found to be
in ARDS [**2-7**] to fat emboli. On [**5-30**] pt had a CTA which showed 1.
No pulmonary embolism. 2. Widespread severe bronchocentric
pulmonary abnormality could be pneumonia or atypical fat
embolism syndrome, alternatively drug reaction, but unlikely
pulmonary hemorrhage. 3. Mild pulmonary edema After several days
of supportive care and antibiotcs for possible pneumonia, pt
improved. On [**6-5**] was extubated improving resp status off abx. On
[**6-7**] pt CXR showed improvment, respiratory status was stable, pt
was transfered to the floor. On [**6-9**] had low grade fever, WBC
rose to 25 pt started to have frequent loose stools. Pt was
placed on flaggyl for presumed C-diff (despite negative c-diff
x3). Pt fever deffervesed, wbc came down to 11.9, pt was
afebrile for >24 prior to discharge, diarrhea had also supsided.
Pt recieved some ns and free water restriction for mild
hyponatremia thought to be [**2-7**] to secretory dirrhea.
EVENTS:
[**5-27**]: ORIF bilat femur fx with EBL 500cc, arrives intubated to
TICU. Repeat head CT WNL and L ankle xray=?talar fx, CT +.
Trauma to decide thromboprophylaxis. Abd more tense->repeat Abd
CT stable. O/N pt specific, writing requests.
[**5-28**]: extuabted will monitor, pca for pain, ciwa scale, banana
bag tense abdomen, drop in hct will monitor.
[**5-30**]: Readmitted, Aline, Meropenem due to PCN allergy (no
Zosyn), Albuterol nebs, needs [**Country 4825**] Red stain in urine for
marrow. Hypoxemic.
[**5-31**]: Intubated for resp failure
[**6-1**]: Transfused 1 unit for hct 22 with repeat hct 24. Worsening
oxygenation with increased peep to 10, with concominant cxr
worsening. Febrile 103.3. TFs held (found in mouth by RN).
[**6-2**]: Repeat thorax scan for fever workup->larger effusions.
Vanc trough low (4.5), increased dosing to 1250. Bronch/BAL
w/[**Doctor Last Name **], then TFs restarted (but off ON due to TF suctioned from
mouth).
[**6-3**]: OGT replaced. Propofol -> Versed for sedation. Added
clonidine. Switched to pressure control. Weaned FiO2. Abx d/c'd
[**6-4**]: PS with maintanence of MAPs, RSBI 48, precedex started.
Still hyperdynamic w fever.
[**6-5**]: d/c fent gtt. dilaudid PCA. Extubated. S/S eval. Ortho recs
lovenox/OOB ok, trauma recs cont heparin sc.
[**6-6**]: Lasix 10. Cont PCA. Ortho recs cont short leg. PT therapy.
[**6-7**]: Percocet. d/c foley. Transferred to floor.
[**6-8**]: CXR Aside from minimal atelectasis in the left lower lobe,
the lungs are clear with resolution of previously seen
extensive bilateral parenchymal opacities. There is no
pneumothorax or pleural effusion.
[**6-9**]: CXR: Cardiomediastinal contours are normal. The lungs are
clear. There is no
pneumothorax or pleural effusion.
[**6-12**]: discharged to rehab
In summary by systems:
NEURO: No neurologic events, neuro exam wnl.
.
CVS: Hyperdynamic with episodes of hypertension then hypotension
around [**Date range (1) 16805**] TICU course currently wnl.
-
PULM: ARDS, reintubated [**5-30**] then extubated [**6-5**]. Using nebs, but
CXR improved currently No respiratory issues on floor.
.
GI: Grade IV liver lac. No active issues
- Regular diet
.
RENAL: Hyponatremia [**2-7**] to dirrhea, otherwise Adequate UOP. free
water restricted and ns was given, pt responded appropriately.
no active issues.
.
HEME: Grade IV liver lac/hematoma, Transfusions 1u [**6-1**], 1u
[**6-3**]. Started SCH [**5-30**].
.
ENDO: No acute issues
.
ID: Febrile intermittantly to 101 with ARDS on TICU admit
treated with vanc/[**Last Name (un) 2830**] ([**Date range (1) 16805**]). Then started on flaggyl for
?c-diff on [**6-11**] WBC trending down now at 11.9.
.
MSK: Bilat femur fx s/p ORIF [**5-27**], left talar/tibial fx. -
Ortho recs LLE NWB, RLE PWB. Short leg cast neutral LLE with
splinting for L talar fx.
.
dispo: At the time of discharge the patient was doing well,
afebrile with stable vital signs. The patient was tolerating a
regular diet, working with physical therapy, voiding without
assistance, 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:
none
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Six (6) Puff Inhalation Q4H (every 4 hours) as needed for
wheezing.
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for SOB/wheezing.
5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q 8H PRN
() as needed for Pain.
7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours): Continue until 6/ 12.
Discharge Disposition:
Extended Care
Facility:
Five Star, [**Location (un) 4047**]
Discharge Diagnosis:
small small SAH, Gr IV liver lac, tib/'fib fx, bilateral femur
fxs, L talus fx. ARDS s/p fat emboli to lungs.
Discharge Condition:
alert and oriented x3 NAD, regular diet, working with PT but non
weight bearing.
Discharge Instructions:
You are recovering from major trauma with bilateral leg
fractures and severe damage to your lungs. You will need time to
recover. Do not drink alcohol or smoke cigaretts as these will
seriously impair recovery. You are not to bear weight on your
left lower extemity, and only partial on your right. You will
need physical therapy to recover, please stay as active as you
can.
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 in not improving. 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.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to work with physical
therapy and be active several times per day, and drink adequate
amounts of fluids. Avoid driving or operating heavy machinery
while taking pain medications.
Followup Instructions:
please follow up with Dr. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],in orthopedics
within 1 week of discharge. Call for an appointment at
[**Telephone/Fax (1) 1228**]
Please follow up with Dr. [**Last Name (STitle) 519**] in [**1-7**] weeks call for an
appointment at [**Telephone/Fax (1) 6554**]
Please follow up with your primary care physician [**Last Name (NamePattern4) **] [**1-7**] weeks.
Call [**Last Name (LF) **],[**First Name3 (LF) **] R. [**Telephone/Fax (1) **] for an appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
|
[
"820.03",
"518.5",
"821.11",
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"276.1",
"821.01",
"825.21",
"285.1",
"864.05",
"891.0",
"823.82",
"958.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"83.39",
"79.35",
"96.72",
"33.24",
"79.65",
"96.6",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
13930, 13992
|
7950, 13199
|
388, 812
|
14145, 14228
|
1473, 1958
|
16003, 16689
|
1436, 1454
|
13254, 13907
|
14013, 14124
|
13225, 13231
|
14252, 15980
|
266, 350
|
840, 1370
|
1966, 2679
|
2688, 7927
|
1392, 1398
|
1414, 1420
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
423
| 170,890
|
3133
|
Discharge summary
|
report
|
Admission Date: [**2169-3-30**] Discharge Date: [**2169-4-25**]
Date of Birth: [**2091-5-22**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Tylenol
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
n/v/dizziness
Major Surgical or Invasive Procedure:
1. Hemiarch replacement (28mm gelweave)
2. Aorta to innominate artery conduit (6mm graft)
3. Aortic valve resuspension
History of Present Illness:
HPI: 77yo with hx HTN, AF with RVR who p/w nausea and dizziness.
States that she was walking around in her house and as she went
to pull up the shade she fellt sudden onset dizziness, "room
spinning around me". Went to the couch and sat down, no LOC, no
trauma. Approximately 2h later felt nauseous and had dry
heaves. Also states she had a "knot" in her chest that felt
better with burping. Pressure non-radiating, no shortness of
breath, no fevers, chills. +productive cough but chronic,
+weakness and malaise, +nausea, no vomiting.
Past Medical History:
hypertension, atrial fibrillation with rapid ventricular
response, s/p ventral hernia repair, s/p ccy, arthritis
Social History:
Former smoker, 15pk/yr history, quit 30y ago. No EtOH, IVDA.
Family History:
CAD--> father age 62
Physical Exam:
PE: T98.9 BP123/57 HR 45-->66 RR 18 100%@RA
Gen: AOx3, NAD
HEENT: PERRL, EOMI. Dry MM
Lungs CTA bilaterally
CV RRR no m/r/g
Abd Soft, BS present, NT/ND
Ext no edema
Back ecchymoses L back, no oozing
Pertinent Results:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2169-4-25**] 05:35AM 15.9* 3.87* 11.2* 34.6* 89 29.0 32.5 14.7
398
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2169-4-25**] 05:35AM 398
[**2169-4-25**] 05:35AM 18.9*1 2.4
1 NOTE NEW NORMAL RANGE AS OF 12 AM [**2169-4-8**]
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2169-4-25**] 05:35AM 90 15 1.2* 137 4.6 99 26 17
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2169-4-25**] 05:35AM 2.0
Brief Hospital Course:
77yo with hx HTN, AF with RVR who p/w nausea and dizziness.
States that she was walking around in her house and as she went
to pull up the shade she fellt sudden onset dizziness, "room
spinning around me". Went to the couch and sat down, no LOC, no
trauma. Approximately 2h later felt nauseous and had dry
heaves. Also states she had a "knot" in her chest that felt
better with burping. Pressure non-radiating, no shortness of
breath, no fevers, chills. +productive cough but chronic,
+weakness and malaise, +nausea, no vomiting.
Patient was evaluated by cardiac surgery on [**2169-4-4**]. After
appropriate pre-operative work-up, she was taken to the OR on
[**2169-4-7**] for hemiarch replacement (28mm gelweave), aorta to
innominate conduit, AV resuspension. Post-operatively, she was
transferred to the CSRU where she had peri-operative atrial fib
with hypotension. She was electrically cardioverted POD 3,
however did not stay in a sinus rhythym. Her hemodynamics did
improve, though, and she was eventually extubated on POD 5,
chest tubes and wires were removed per protocol. She had some
serous drainage from her sternum which resolved without
intervention. Patient was also anti-coagulated with heparin and
coumadin for atrial fib. She was transferred to the floor on
POD 8, where she did well. She was evaluated by PT and they
recommended short term rehab. On POD#12 she was noted to have
an elevated WBC. Her central line was d/c and her WBC began to
decrease. She was started on bactrim for a positive UA. She
thrn developed a rash and had a negative urine culture, so the
bactrim was discontinued. She continued to improve and was
discharged to rehab on POD#17 in stable condition.
Medications on Admission:
1. Coumadin 2.5 mg PO QD
2. Atenolol 25 mg PO QD
3. Lisinopril 10 mg PO QD
Discharge Medications:
1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
2. Ferrous Sulfate 325 (65) 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).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
6. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Potassium Chloride 20 mEq Packet Sig: Two (2) packets PO Q12H
(every 12 hours) for 1 weeks.
Disp:*28 packets* Refills:*0*
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
10. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
11. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
12. Coumadin 1 mg PO qhs for INR goal of [**1-11**].5
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Senior Healthcare - [**Location (un) 55**]
Discharge Diagnosis:
1. Atrial fibrillation
2. Ascending aortic dissection
3. UTI
4. Hypertension
Discharge Condition:
Good
Discharge Instructions:
1. Medications as directed.
2. Please follow INR, goal of [**1-11**].5.
3. Call office or go to ER if fever/chills, drainage from
sternal incision, chest pain, or shortness of breath.
[**Last Name (NamePattern4) 2138**]p Instructions:
Call for an appointment with Dr. [**Last Name (STitle) 1968**] in [**12-11**] weeks.
Dr. [**Last Name (Prefixes) **], 4 weeks, please call for appointment.
Make an appointment with Dr. [**Last Name (STitle) 911**] for 2-3 weeks.
Completed by:[**2169-4-25**]
|
[
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"401.9",
"787.91",
"599.0",
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"424.1",
"473.9",
"E931.0",
"511.9",
"458.29",
"486",
"423.0",
"286.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.17",
"39.61",
"99.62",
"35.39",
"96.72",
"96.6",
"38.93",
"33.24",
"39.59",
"38.45"
] |
icd9pcs
|
[
[
[]
]
] |
5300, 5386
|
2057, 3768
|
288, 409
|
5507, 5513
|
1464, 2034
|
1208, 1230
|
3893, 5277
|
5407, 5486
|
3794, 3870
|
5537, 5722
|
5773, 6033
|
1245, 1445
|
235, 250
|
437, 978
|
1000, 1114
|
1130, 1192
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,978
| 120,032
|
28682
|
Discharge summary
|
report
|
Admission Date: [**2133-9-28**] Discharge Date: [**2133-11-18**]
Date of Birth: [**2091-2-15**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Diphenhydramine
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
Hemoptysis
Major Surgical or Invasive Procedure:
Multiple bronchoscopies
Embolization of the right bronchial artery by interventional
radiology
prolonged MICU stay
Thoracentesis
History of Present Illness:
42 year old female with a history of chronic alcohol abuse,
Hepatitis B, Hepatitis C, GI bleed from gastric/duodenal ulcers,
and a RUL cavitation felt to be secondary to post-obstructive
[**Hospital 16486**] transferred from [**Hospital 1474**] hospital to the [**Hospital1 18**] MICU on
[**2133-9-28**] for hemoptysis. She initially presented to the [**Hospital1 1474**]
ED with a chief complaint of "coughing up blood" from 5:00 am
the morning of [**2133-9-27**]. She reported shortness of breath, sore
throat, dizziness and sinus congestion. VS were: T 100.3 P: 128
BP: 112/83 O2 sat: 100%. Her hematocrit in the ED was 31.0. An
NG lavage was negative and rectal exam was guaiac negative. She
then began to "vomit" bright red blood and was intubated for
airway protection. Bright red blood was noted in the ETT tube
which persisted despite repeated suctioning. She was then
transported to the OR for urgent bronchoscopy which was not
completed. She was transfused 1 unit PRBC and 2 units FFP. Her
pressures dropped as low as the 80's and she was transferred to
[**Hospital1 18**] MICU for futher care.
.
Past Medical History:
1. GI bleed from gastric and duodenal ulcers
2. Grade II esophageal varices
3. RUL cavitary lesion seen in [**2130**]
4. Chronic anemia
5. Alcoholic fatty infiltration of the liver
6. History of Hepatitis B
7. History of Hepatitis C
8. History of delirium tremens
9. History of drug overdose
10. Cholelithiasis
Social History:
Chronic alcohol (1/2L vodka/day) and tobacco use x 1.5 yrs;
lives with her mother, 2 children. Denies any history of IVDA;
endorses occasional cocaine. Has been in alcohol rehab before,
states "the only thing I got out of that was a smoking habit"
Family History:
Grandfather died of alcoholic cirrhosis
Uncle with alcoholic cirrhosis
Physical Exam:
Upon transfer to Medicine floor from MICU
119/70, HR 87, 92-96% on RA
Gen: jaundiced, mental status waxing and [**Doctor Last Name 688**]
HEENT: icteric sclera, OP clear
CV: RRR II/VI SM apex
Resp: Diffuse ronchi
Abd: marked distention, diffusely tender to palapation
specifically in RUQ and LUQ. No rebound, no guarding.
Ext: 1+ pitting edema bilaterally
Neuro: No asterixis
Pertinent Results:
OSH chart review:
Pt had RUL cavity and bronchoscopy with washings [**6-/2130**] (likely
cavitary lesion): result "neutrophilic debris, histiocytes,
epithelial cells"
.
[**4-/2132**] ("2cm mass") pt had RUL FN bx showing: fragmts pulm
tissue w/ marked fibrosis + focal moderate chronic inflamm with
scattered foarmy macrophages.
.
Studies
.
PFTs: FEV1 67%, FEF 25-75 80% pred, TLC 58%, VC 60%, DLCO 98%
.
[**9-28**] BAL: 1+ PMN; cx negative for AFB and cx.
.
respiratory cultures 8/26 was + for aspergillus (not fumigatus)
"rare," negative on [**10-6**].
.
[**10-26**] sputum: + budding yeast + gpc's
.
Resp cx negative for AFB x2
- sputum [**9-28**];
- [**9-28**] sputum + aspergillus fumigatus
- BAL [**9-28**] negative
- PPD neg
- AFB negative @ [**Hospital1 1474**] on [**9-27**]
- UCx neg
- HIV neg this admit
- HCV viral load -
- HBV core ab +, SAg-, SAb +
- legionella ag -
- galactomannin -
- beta-glucan +
.
[**9-30**] RUQ US: Fatty infiltration of the liver. Cannot exclude
more advanced liver disease such as cirrhosis and/or fibrosis.
Cholelithiasis without evidence of acute cholecystitis. Ascites.
Splenomegaly.
.
[**10-14**] swallow study: no aspiration
.
[**10-26**] CXR: Stable radiographic appearance of right cavitary
lesion. No superimposed focal consolidation or edema-like
process noted. Interval placement of PICC line with no
pneumothorax
.
[**2133-11-3**] CXR: Again seen is a 2.5 mm cavitary lesion in the right
upper lobe. There is a small left-sided pleural effusion. There
is left lower lobe atelectasis. Multiple left sided healing rib
fractures are again seen.
.
repeat RUQ US: with no ductal dilitation, CBD on 3mm
.
[**10-16**] chest CT: 1. Cavitary lesion at the right upper lung with
soft tissue density seen within it. While this may represent a
mycetoma within an old benign cavity, a cancerous lesion cannot
be excluded and correlation with direct tissue sampling is
recommended. No additional cavities seen.
2. Diffuse hazy opacities throughout the lungs may represent
infection or hemorrhage.
3. Splenic infarct. Recommend echo to assess for cardiac origin
of emboli
.
[**10-29**] CT chest: stable RUL cavity although appears to be
extending toward chest wall; + inflammation surrounding cavity.
Resolution of some of the haziness in the lung parenchyma
(especially the LUL), mild pulmonary edema.
.
[**10-17**] CT abdomen: 1. Small-to-moderate left pleural effusion,
mild-to-moderate ascites, and moderate mesenteric fluid. All of
these areas of fluid are of intermediate density, of 24
Hounsfield units, which can be consistent with an exudative
process, such as chylous effusion of infected fluid.
2. Coarse appearance of liver consistent with cirrhosis.
3. Chronic splenic infarct.
.
TTE: no vegetations
.
LENI ([**2133-11-10**]): No evidence of DVT.
Brief Hospital Course:
1. RUL cavitary lesion: The patient was transferred to the MICU
with bright red blood per the ET tube, and underwent
bronchoscopy and embolization of the right bronchial artery.
She ruled out for TB, and underwent several bronchoscopys which
did not uncover the cause of her lesion. One sputum grew
Aspergillus sp. not fumigatus, and one grew Aspergillus
fumigatus. CT scan performed to characterize lesion, and the
etiology and appropriate management was widely debated by the
pulmonary, thoracic surgery and infectious disease services.
The scan had evidence of disseminated/semi-invasive disease of
the lungs that would require systemic antifungals. She began
empiric treatment with Ambisome for likely aspergillus
infection, which she did not tolerate secondary to acute renal
failure. At this point, the option of surgical removal came up
again, however, the patient was considered high operative risk
with as high as a 25% chance of perioperative mortality from the
procedure. Moreover, there remained a concern about invasive
disease, which could not be completely resected. The other
option was Voriconazole, which was not ideal given her
underlying liver cirrhosis. Hepatology was consulted regarding
the risk of fulminant liver failure on voriconazole, which was
deemed to be around 13%. The decision was made to treat the
patient with voriconazole with close monitoring of her liver
function, in an effort to contain the infection, such that it
could be removed at a later date. The patient began
voriconazole therapy with close monitoring which she tolerated
well. She was discharged on voriconazole, and will have a
repeat CT scan performed within a week of discharge to evaluate
the extent of her disease after several weeks of systemic
therapy. She was hesistant to undergo surgery at the time of
discharge, given the potential recovery time. She will follow up
with Infectious Disease and Thoracic Surgery as an outpatient.
Further treatment decisions will be made after her repeat CT
scan.
.
2. Hepatitis/Pancreatitis: During her ICU stay, the patient
developed transaminitis and elevated total bilirubin to a max of
10, most likely secondary to alcoholic hepatitis. She also
developed diffuse abdominal pain and was found to have
pancreatitis. MRCP was negative for stone/ductal dilation. Her
lab abnormalities corrected without intervention. She was
started on Ursodiol for cholestasis.
.
3. Pleural effusion: She was found to have a left pleural
effusion. She underwent thoracentesis in which 1.2 liters of
bloody fluid was removed. All cultures were negative. Etiology
unclear, although likely related to her fungal infection.
.
4. Acute renal failure: developed secondary to empiric Ambisome
therapy for suspected aspergillus infection. Baseline
creatinine at admission was 0.3, which maxed at 1.8. Her
creatinine stabilized at 1.2-1.4 after discontinuation of
Ambisome therapy.
.
5. Cirrhosis: secondary to long-standing alcoholism. By report
she had a history of Hepatitis B and Hepatitis C. Her mental
status waxed and waned through the hospitalization, requiring
numerous medications, however, finally stabilized on Lactulose
15 mg po bid. After her episode of hepatitis, her liver
function tests stabilized and were monitored closely while on
voriconazole. She has a history of esophageal varices, however,
there was no evidence of GI bleed in the hospital. She had a
distended abdomen initially, however, several ultrasounds failed
to reveal a pocket of ascites amenable to paracentesis, and the
final ultrasound did not reveal significant ascites. She
tolerated Lasix and Spironolactone well.
.
6. Lower extremity edema: Secondary to cellulitis, poor
nutritional status, and cirrhosis. Lower extremity ultrasound
did not reveal DVT. She was treated with
vancomycin/ciprofloxacin for cellutitis, and she responded
immediately. Secondary to nausea, she was changed to
levofloxacin. Diuretics were re-instated when her renal
function stabilized which likely added to her improvement.
.
7. Tachycardia: The patient's heart rate was often in the
100s-110s, always in sinus tachycardia. Her baseline blood
pressures ranged in the 90s/50s.
.
8. Anemia: Known history of anemia of chronic disease. After
treatment of and stabilization from her massive hemoptysis, she
required several blood transfusions during the hospitalization.
.
9. Prurigo nodularis: likely from her liver disease, however, at
the time of exacerbation, there was also a concern for cutaneous
dissemination of her aspergillus. Dermatology was consulted who
felt the lesions represented prurigo nodularis and she was
treated topically. She used Hydroxyzine as needed for itching,
as she had a Benadryl allergy.
.
10. Chronic low back pain: She was stable on a regimen of MSSR
[**Hospital1 **] and MSIR as needed.
.
11. Anxiety: Effectively controlled with prn Ativan. She
ultimately became very anxious about the upcoming surgery and
the prospect of rehabilitation after an already long hospital
stay.
.
12. Insomnia: Effectively controlled with Trazodone.
.
13. Tobacco and Alcohol Abuse: The patient was seen by numerous
social workers and the Addictions specialist. At discharge, she
was committed to not smoking or drinking and reported that she
had not wanted any alcohol while inpatient. Her desire to quit
both substances was encouraged and reinforced, especially given
her underlying cirrhosis and the potentially hepatotoxic nature
of voriconazole.
.
14. Disposition: The patient was discharged home after a
prolonged hospitalization. She was originally scheduled for
resection of her aspergilloma during the hospital stay, however,
decided that she was not ready for the surgery at this point.
She was willing to continue taking the antifungal medication and
to have a repeat CT scan done as an outpatient. She will follow
up in the [**Hospital **] clinic once the scan is completed. She will also
make an appointment with Dr. [**Last Name (STitle) 952**] in Thoracic Surgery to
discuss her surgical option once her repeat studies are done.
Medications on Admission:
Unknown
Discharge Medications:
1. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
Disp:*qs * Refills:*0*
3. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours as needed for itching.
Disp:*20 Tablet(s)* Refills:*0*
4. Voriconazole 50 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours).
Disp:*120 Tablet(s)* Refills:*2*
5. Lactulose 10 g/15 mL Syrup Sig: Fifteen (15) ML PO BID (2
times a day).
Disp:*900 ML(s)* Refills:*2*
6. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
9. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
Disp:*20 Tablet(s)* Refills:*0*
10. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
Disp:*20 Tablet Sustained Release(s)* Refills:*2*
11. Clindamycin Phosphate 1 % Solution Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day).
Disp:*qs * Refills:*0*
12. Outpatient Lab Work
AST/ALT/Alkaline phosphatase/total bilirubin/PT/INR weekly.
Please fax results to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD in the Infectious
Disease Clinic at [**Telephone/Fax (1) 1419**].
13. CT Chest with IV Contrast
CT chest with IV Contrast. Eval for size of right upper lobe
cavitary lesion/aspergilloma and evidence of invasive disease.
14. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Primary:
Aspergilloma
Hemoptysis
Cellulitis
Alcoholic cirrhosis
Alcoholic hepatitis
Pancreatitis
Cholestasis
Hepatic encephalopathy
Anemia requiring blood transfusions
Left exudative pleural effusion
Acute renal failure
Prurigo nodularis
Insomnia
Secondary:
Chronic low back pain
Anxiety
Alcohol abuse
Tobacco abuse
Discharge Condition:
Afebrile, hemodynamically stable. Patient is leaving of own
volition and understands and is able to verbalize the risks
associated with not undergoing surgery at this point in time.
She will take all antifungal medications, have her blood work
checked and will follow up with the [**Hospital **] clinic and Thoracic
surgery clinic.
Discharge Instructions:
Please return immediately to the emergency department if you
begin coughing or throwing up blood or develop blood per rectum.
Please return for fevers, chills, chest pain or shortness of
breath.
.
Please come to the emergency department or call your primary
doctor if the redness, pain and swelling in your legs returns.
.
Please be sure to take your antibiotics and antifungals as
prescribed. You are strongly advised to avoid ALL alcohol.
.
Please obtain a CT scan of your chest with IV contrast 1 week
from your hospital discharge.
.
Please make and keep follow up appointments with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] in Infectious Disease Clinic and Dr. [**Last Name (STitle) 952**] in the
Thoracic Surgery Clinic. Numbers below.
Followup Instructions:
-Please call [**Telephone/Fax (1) 457**] for the Infectious Disease clinic with
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] after you obtain the CT scan of your chest.
If you get the scan done at an outside facility, please be sure
to bring a copy of the [**Location (un) 1131**] and scan if possible to your
appointment with Dr. [**First Name (STitle) **].
-Please call [**Telephone/Fax (1) 170**] for the Thoracic surgery clinic with
Dr. [**Last Name (STitle) 952**] to discuss your surgical options after you obtain the
CT scan of your chest. If you get the scan done at an outside
facility, please be sure to bring a copy of the [**Location (un) 1131**] and scan
if possible to your appointment with Dr. [**Last Name (STitle) 952**].
-Please make an appointment with your primary doctor within 2
weeks of hospital discharge.
|
[
"584.9",
"507.0",
"305.1",
"285.1",
"698.3",
"E884.6",
"117.4",
"513.0",
"117.3",
"786.3",
"723.1",
"E930.1",
"511.9",
"571.0",
"571.1",
"303.90",
"780.52",
"577.0",
"070.20",
"571.2",
"447.8",
"724.2",
"518.89",
"574.20",
"682.6",
"518.81",
"456.21",
"286.7",
"070.71",
"300.00",
"484.6",
"531.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"88.44",
"00.17",
"96.56",
"99.04",
"96.6",
"34.91",
"33.24",
"99.07",
"96.72",
"39.79"
] |
icd9pcs
|
[
[
[]
]
] |
13437, 13492
|
5491, 11570
|
302, 433
|
13853, 14188
|
2671, 5468
|
15006, 15866
|
2187, 2260
|
11628, 13414
|
13513, 13832
|
11596, 11605
|
14212, 14983
|
2275, 2652
|
252, 264
|
461, 1570
|
1592, 1904
|
1920, 2171
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,901
| 127,243
|
5139
|
Discharge summary
|
report
|
Admission Date: [**2134-7-9**] Discharge Date: [**2134-7-10**]
Date of Birth: [**2072-11-25**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 297**]
Chief Complaint:
melena and BRBPR
Major Surgical or Invasive Procedure:
colonoscopy
History of Present Illness:
61 yo previously healthy man had colonoscopy 12 d again during
which sessil 8 mm polyp removed from the mid rectum (pathology
c/w fragmnents of hyperplastic polyp and adenoma) and a 18 mm
sessile multinodular polyp (pathology c/w adenoma w/ focal high
grade dysplasia) removed from the cecum. 5d later patient had
BRBPR on toilet paper only. DOA pt had large dark stool with
some BRB in toilet and CP. no other complaints, specifically no
n/v/d/f/c. In the ED, his sbp was 110, HR 110. Lavage was (-).
He was evaluated by GI, who plan a colonoscopy in the morning
and he was admitted to the ICU for evaluation. Currently, he
denies chest pain, nausea, vomiting, abdominal pain, fevers, or
chills, recent diarrhea . At baseline, he exercises in a gym
(treadmill, weight-lifting) for 30 minutes daily without chest
pain.
Past Medical History:
1) seizure d/o: last seizure 30 yrs ago
2) Basal cell carcinoma s/p removal
3) [**Doctor Last Name 21078**] transient acantholytic dermatitis.
Social History:
lives at home with wife. - tobacco, social etoh.
Family History:
non contributory
Physical Exam:
Gen: pleasant, conversant, well-kemt man in nad
HEENT: PERRL, MMM, EOMI
Cor: S1S2, no R.G.M, RRR
Pulm: CTAB
Abd: ntnd, +bs, soft, no hsm
neuro: grossly nl, a&o x 3
ext: no edema bUE and bLE, WWP, 2+ DP and radial pulses bilat
Pertinent Results:
CK 175--127--124
MB 6--4--4
trop <0.01 x 3
Hct: 42.5--38.5--38.9--37.1
Brief Hospital Course:
Pt was admitted evening of [**2134-7-9**]. Admitted through the
emergency room to MICU. vital signs stabilized. after initial
drop in Hct, stabilized x 4 over 24 hours. Began golytely prep
for colonoscopy and passed BRB and clots in toilet. asymptomatic
after admitted to micu (not tachy, not hypotensive).
colonoscopy performed the morning of [**2134-7-10**] and found small
active bleeding near polypectomy site. cauterization was
performed. pt was seen after procedure and was stable. pt was
discharged to home with his wife and was instructed not to drive
for 12 hours as well as instructed signs/symptoms to watch out
for to call his pcp.
Medications on Admission:
dilantin 100mg qd PO
Discharge Medications:
dilantin 100mg qd PO
Discharge Disposition:
Home
Discharge Diagnosis:
Bleeding at polypectomy site
Discharge Condition:
good
Discharge Instructions:
Do not drive a car for 12 hours. IF you have dark or bright red
stool, or if you feel lightheaded please call your doctor.
Followup Instructions:
follow up with Dr. [**First Name (STitle) 679**] for colonoscopy in one year to evaluate
polyps.
Completed by:[**2134-7-10**]
|
[
"786.50",
"780.39",
"V58.69",
"998.11",
"V10.83"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.43"
] |
icd9pcs
|
[
[
[]
]
] |
2583, 2589
|
1819, 2467
|
331, 344
|
2662, 2668
|
1723, 1796
|
2839, 2967
|
1443, 1461
|
2538, 2560
|
2610, 2641
|
2493, 2515
|
2692, 2816
|
1476, 1704
|
275, 293
|
372, 1195
|
1217, 1361
|
1377, 1427
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,386
| 116,522
|
10148
|
Discharge summary
|
report
|
Admission Date: [**2136-10-6**] Discharge Date: [**2136-12-4**]
Date of Birth: [**2072-5-17**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Back pain with fevers
Major Surgical or Invasive Procedure:
T3-L3 posterior spinal fusion
Iliac crest bone graft
T6-7 corpectomy with T5-8 fusion and strut graft
History of Present Illness:
64F h/o mental retardation, ESRD on HD, DM2, epidural abscess,
p/w GI bleed and resp distress. The pt recently had a
complicated hospital course at [**Hospital1 18**] from [**2136-7-16**] to [**2136-9-1**]
during which she had sepsis and resp failure requiring
mechanical ventilation for roughly 2 weeks. She was found to
have epidural spinal abscesses with spinal cord impingement
treated operativelyt by Orthopedics [**2136-7-26**] and then with abx.
Course was also c/b ATN/ARF requiring HD which the pt required
at discharge. She returned on [**9-16**] to [**9-26**] with fevers from rehab
and was found to have radiographic worsening of the vertberal
osteomyletis which was treated by tailoring abx, without
surgery. The plan was for her to continue a course of linezold
followed by nafcillin at discharge to [**Hospital **] Rehab.
On [**10-5**], the pt was admitted to [**Hospital **] Hospital for tachycardia
and respiratory distress. At [**Hospital1 **], she was tachy to 130, was
diuresed and put on nitro gtt for suspected CHF. WBC 8.1 though
pt was febrile to 101.8. CXR showed CHF and possible infiltrate
so pt was treated broadly for PNA, UA was positive as well. Hct
was noted to be 23 on admission and had h/o coffee grounds
emesis at rehab, though green stool found at [**Hospital1 **]. Pt was
transferred to [**Hospital1 18**] for further evaluation.
Past Medical History:
COPD
Mental retardation
DVT [**1-/2130**]
NIDDM
Obesity
Sciatica
Hypertension
Hypercholesterolemia
Anxiety
Psoriasis
Paroxysmal A. fib
Osteomyelitis T6-7
Social History:
Lives in apartment with 24 hour caregiver; has a long term
boyfriend. [**Name (NI) 1403**] part time. Guardian is [**Name (NI) 402**] [**Name (NI) 33801**]
[**Telephone/Fax (1) 33802**].
Family History:
Pt unable to provide
Physical Exam:
VS: Temp: 99.9 BP: 131/69 HR: 114 RR: 44 O2sat: 99% 2L NC
GEN: moderate tachypnea and resp distress, awake, alert,
interactive
RESP: crackles [**1-23**] way up, no wheezes
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice
NEURO: moving all extremities, no ankle clonus
Pertinent Results:
[**2136-12-3**] 01:41AM BLOOD WBC-7.2 RBC-2.88* Hgb-9.3* Hct-27.0*
MCV-94 MCH-32.3* MCHC-34.5 RDW-19.8* Plt Ct-278
[**2136-12-2**] 02:03AM BLOOD WBC-5.6 RBC-2.98* Hgb-9.5* Hct-28.1*
MCV-95 MCH-31.8 MCHC-33.6 RDW-19.7* Plt Ct-291
[**2136-12-1**] 02:08AM BLOOD WBC-5.6 RBC-2.95* Hgb-9.2* Hct-27.7*
MCV-94 MCH-31.2 MCHC-33.2 RDW-19.6* Plt Ct-289
[**2136-11-30**] 03:52AM BLOOD WBC-5.4 RBC-3.13* Hgb-9.6* Hct-29.4*
MCV-94 MCH-30.6 MCHC-32.7 RDW-19.4* Plt Ct-328
[**2136-11-28**] 03:05AM BLOOD WBC-6.2 RBC-2.28* Hgb-7.2* Hct-21.1*
MCV-92 MCH-31.7 MCHC-34.4 RDW-20.8* Plt Ct-301
[**2136-11-26**] 03:38AM BLOOD WBC-6.5 RBC-2.36* Hgb-7.5* Hct-22.0*
MCV-93 MCH-31.6 MCHC-34.1 RDW-20.7* Plt Ct-287
[**2136-11-24**] 03:33AM BLOOD WBC-7.3 RBC-2.48* Hgb-7.9* Hct-23.1*
MCV-93 MCH-31.8 MCHC-34.1 RDW-20.4* Plt Ct-233
[**2136-11-22**] 04:00AM BLOOD WBC-15.4* RBC-3.22* Hgb-10.0* Hct-28.9*
MCV-90 MCH-30.9 MCHC-34.5 RDW-20.8* Plt Ct-281
[**2136-11-20**] 02:22AM BLOOD WBC-10.0 RBC-2.39* Hgb-7.4* Hct-21.3*
MCV-89 MCH-31.0 MCHC-34.7 RDW-23.4* Plt Ct-212
[**2136-11-17**] 03:09AM BLOOD WBC-7.9 RBC-2.88* Hgb-8.8* Hct-25.8*
MCV-90 MCH-30.4 MCHC-34.0 RDW-22.1* Plt Ct-282
[**2136-11-15**] 03:26AM BLOOD WBC-8.1 RBC-3.18* Hgb-9.7* Hct-28.2*
MCV-89 MCH-30.5 MCHC-34.4 RDW-20.9* Plt Ct-430
[**2136-11-14**] 06:01PM BLOOD WBC-8.6 RBC-3.23*# Hgb-9.7*# Hct-28.8*#
MCV-89 MCH-29.9 MCHC-33.6 RDW-20.7* Plt Ct-438
[**2136-11-13**] 03:14AM BLOOD WBC-10.9 RBC-2.81* Hgb-8.6* Hct-25.2*
MCV-90 MCH-30.7 MCHC-34.2 RDW-20.3* Plt Ct-560*
[**2136-11-11**] 04:29AM BLOOD WBC-12.1* RBC-3.06* Hgb-9.6* Hct-27.5*
MCV-90 MCH-31.4 MCHC-35.0 RDW-18.9* Plt Ct-609*
[**2136-11-9**] 02:45AM BLOOD WBC-7.8 RBC-3.10* Hgb-9.4* Hct-27.4*
MCV-88 MCH-30.4 MCHC-34.5 RDW-17.6* Plt Ct-541*
[**2136-11-7**] 05:16AM BLOOD WBC-9.2 RBC-2.87* Hgb-8.7* Hct-24.8*
MCV-86 MCH-30.4 MCHC-35.2* RDW-18.1* Plt Ct-446*
[**2136-11-3**] 03:55PM BLOOD WBC-11.9* RBC-3.29* Hgb-10.1* Hct-27.9*
MCV-85 MCH-30.7 MCHC-36.2* RDW-16.2* Plt Ct-206
[**2136-11-2**] 03:15PM BLOOD WBC-7.9 RBC-3.37* Hgb-10.4* Hct-28.5*
MCV-85 MCH-30.8 MCHC-36.3* RDW-16.1* Plt Ct-87*
[**2136-11-1**] 03:05AM BLOOD WBC-8.2 RBC-2.54* Hgb-8.0* Hct-21.9*
MCV-86 MCH-31.6 MCHC-36.6* RDW-21.3* Plt Ct-81*
[**2136-10-29**] 03:10AM BLOOD WBC-7.8 RBC-3.10* Hgb-9.7* Hct-26.8*
MCV-87 MCH-31.4 MCHC-36.3* RDW-21.5* Plt Ct-135*
[**2136-10-26**] 03:00AM BLOOD WBC-7.0 RBC-2.87* Hgb-8.8* Hct-24.7*
MCV-86 MCH-30.8 MCHC-35.8* RDW-23.7* Plt Ct-238
[**2136-10-23**] 02:16AM BLOOD WBC-8.5 RBC-3.21* Hgb-9.5* Hct-28.3*
MCV-88 MCH-29.6 MCHC-33.6 RDW-23.7* Plt Ct-298
[**2136-10-20**] 03:10PM BLOOD Hct-30.0*
[**2136-10-19**] 05:29PM BLOOD WBC-8.8# RBC-4.20# Hgb-12.4 Hct-36.9
MCV-88 MCH-29.6 MCHC-33.6 RDW-24.0* Plt Ct-284
[**2136-10-19**] 12:06AM BLOOD Hct-28.5*
[**2136-10-16**] 06:00AM BLOOD WBC-6.2 RBC-2.53* Hgb-8.3* Hct-25.2*
MCV-100* MCH-32.6* MCHC-32.8 RDW-19.9* Plt Ct-305
[**2136-10-13**] 05:39AM BLOOD WBC-5.9 RBC-2.55* Hgb-8.4* Hct-25.3*
MCV-99* MCH-32.7* MCHC-33.0 RDW-19.5* Plt Ct-303
[**2136-10-11**] 05:46PM BLOOD WBC-6.2 RBC-2.78* Hgb-8.9* Hct-26.5*
MCV-95 MCH-31.8 MCHC-33.4 RDW-19.8* Plt Ct-318
[**2136-11-29**] 03:11AM BLOOD Neuts-70.4* Lymphs-13.3* Monos-6.0
Eos-10.0* Baso-0.2
[**2136-10-16**] 06:00AM BLOOD Neuts-71.0* Lymphs-15.4* Monos-7.1
Eos-6.2* Baso-0.4
[**2136-10-10**] 05:40AM BLOOD Neuts-72.3* Lymphs-14.1* Monos-5.9
Eos-6.9* Baso-0.8
[**2136-10-6**] 08:27PM BLOOD Neuts-71.4* Lymphs-15.8* Monos-5.4
Eos-7.0* Baso-0.3
[**2136-11-30**] 03:52AM BLOOD PT-14.9* PTT-32.5 INR(PT)-1.3*
[**2136-11-23**] 03:31AM BLOOD PT-17.1* PTT-34.0 INR(PT)-1.6*
[**2136-11-17**] 03:09AM BLOOD PT-18.1* PTT-35.5* INR(PT)-1.7*
[**2136-11-13**] 03:14AM BLOOD Plt Ct-560*
[**2136-11-13**] 03:14AM BLOOD PT-19.6* PTT-38.5* INR(PT)-1.9*
[**2136-11-11**] 04:29AM BLOOD PT-17.1* PTT-34.7 INR(PT)-1.6*
[**2136-11-10**] 03:29AM BLOOD Plt Ct-606*
[**2136-11-7**] 05:16AM BLOOD PT-14.8* PTT-34.6 INR(PT)-1.3*
[**2136-11-6**] 03:34AM BLOOD PT-14.1* PTT-35.6* INR(PT)-1.3*
[**2136-11-5**] 02:09AM BLOOD PT-15.1* PTT-39.2* INR(PT)-1.4*
[**2136-11-4**] 03:40AM BLOOD Plt Ct-247
[**2136-11-3**] 03:55PM BLOOD PT-15.2* PTT-31.8 INR(PT)-1.4*
[**2136-11-2**] 12:22PM BLOOD PT-14.9* PTT-34.2 INR(PT)-1.3*
[**2136-10-30**] 02:44AM BLOOD PT-13.1 PTT-31.5 INR(PT)-1.1
[**2136-10-21**] 02:44AM BLOOD PT-17.0* PTT-35.2* INR(PT)-1.6*
[**2136-10-20**] 01:24AM BLOOD Plt Ct-283
[**2136-10-19**] 05:29PM BLOOD Plt Ct-284
[**2136-10-18**] 05:00AM BLOOD PT-15.2* PTT-31.4 INR(PT)-1.4*
[**2136-10-13**] 05:39AM BLOOD PT-14.5* PTT-34.8 INR(PT)-1.3*
[**2136-10-9**] 12:16PM BLOOD PT-15.0* PTT-29.5 INR(PT)-1.3*
[**2136-12-3**] 01:41AM BLOOD Glucose-103 UreaN-47* Creat-1.4* Na-141
K-4.2 Cl-114* HCO3-20* AnGap-11
[**2136-11-30**] 03:52AM BLOOD Glucose-104 UreaN-54* Creat-1.3* Na-144
K-4.7 Cl-116* HCO3-19* AnGap-14
[**2136-11-28**] 03:05AM BLOOD Glucose-117* UreaN-56* Creat-1.5* Na-147*
K-5.1 Cl-119* HCO3-17* AnGap-16
[**2136-11-24**] 03:33AM BLOOD Glucose-116* UreaN-43* Creat-1.2* Na-147*
K-4.2 Cl-117* HCO3-16* AnGap-18
[**2136-11-21**] 05:11AM BLOOD Glucose-118* UreaN-38* Creat-1.4* Na-141
K-4.8 Cl-108 HCO3-19* AnGap-19
[**2136-11-18**] 02:06AM BLOOD Glucose-127* UreaN-27* Creat-1.6* Na-144
K-3.8 Cl-110* HCO3-18* AnGap-20
[**2136-11-16**] 04:23AM BLOOD Glucose-187* UreaN-27* Creat-1.7* Na-146*
K-3.8 Cl-115* HCO3-16* AnGap-19
[**2136-11-14**] 06:01PM BLOOD Glucose-104 UreaN-27* Creat-2.0* Na-147*
K-4.5 Cl-118* HCO3-14* AnGap-20
[**2136-11-12**] 02:40AM BLOOD Glucose-153* UreaN-31* Creat-2.1* Na-144
K-3.1* Cl-112* HCO3-19* AnGap-16
[**2136-11-9**] 02:15PM BLOOD Glucose-76 UreaN-35* Creat-2.3* Na-144
K-3.5 Cl-109* HCO3-22 AnGap-17
[**2136-11-8**] 04:28PM BLOOD Glucose-69* UreaN-39* Creat-2.2* Na-145
K-3.6 Cl-109* HCO3-21* AnGap-19
[**2136-11-5**] 02:09AM BLOOD Glucose-122* UreaN-46* Creat-2.1* Na-141
K-4.0 Cl-107 HCO3-20* AnGap-18
[**2136-10-31**] 02:15AM BLOOD Glucose-134* UreaN-61* Creat-2.5* Na-141
K-3.5 Cl-106 HCO3-18* AnGap-21*
[**2136-10-27**] 03:00AM BLOOD Glucose-109* UreaN-50* Creat-2.8* Na-136
K-3.5 Cl-105 HCO3-17* AnGap-18
[**2136-10-23**] 04:27PM BLOOD Glucose-119* UreaN-40* Creat-2.4* Na-135
K-3.5 Cl-104 HCO3-19* AnGap-16
[**2136-10-20**] 01:24AM BLOOD Glucose-88 UreaN-41* Creat-1.8* Na-143
K-4.0 Cl-116* HCO3-18* AnGap-13
[**2136-10-19**] 04:47AM BLOOD Glucose-144* UreaN-51* Creat-1.9* Na-141
K-4.6 Cl-110* HCO3-23 AnGap-13
[**2136-10-12**] 05:04AM BLOOD Glucose-101 UreaN-16 Creat-1.9* Na-144
K-3.3 Cl-110* HCO3-28 AnGap-9
[**2136-10-9**] 03:16AM BLOOD Glucose-63* UreaN-20 Creat-2.1* Na-154*
K-3.4 Cl-113* HCO3-26 AnGap-18
[**2136-10-10**] 05:40AM BLOOD ALT-5 AST-12 AlkPhos-106 Amylase-17
TotBili-0.4
[**2136-11-24**] 10:28PM BLOOD CK-MB-NotDone cTropnT-0.46*
[**2136-11-24**] 03:07PM BLOOD CK-MB-NotDone cTropnT-0.44*
[**2136-10-16**] 10:50AM BLOOD CK-MB-4 cTropnT-0.30*
[**2136-12-3**] 01:41AM BLOOD Calcium-8.3* Phos-3.1 Mg-2.2
[**2136-12-1**] 02:08AM BLOOD Calcium-8.2* Phos-3.0 Mg-2.0
[**2136-11-29**] 03:11AM BLOOD Calcium-8.4 Phos-2.9 Mg-2.0
[**2136-11-14**] 06:01PM BLOOD Calcium-8.1* Phos-3.1 Mg-2.0
[**2136-11-13**] 09:12PM BLOOD Calcium-8.1* Phos-0.9* Mg-2.2
[**2136-11-11**] 04:29AM BLOOD Calcium-8.1* Phos-2.8 Mg-1.9
[**2136-11-7**] 05:16AM BLOOD Calcium-7.9* Phos-4.5 Mg-1.9
[**2136-11-4**] 12:19PM BLOOD Calcium-7.2* Phos-4.5 Mg-1.9
[**2136-11-1**] 03:05AM BLOOD Calcium-7.4* Phos-4.3 Mg-1.7
[**2136-10-28**] 07:54PM BLOOD Calcium-6.8* Phos-5.1* Mg-2.0
[**2136-10-24**] 03:15AM BLOOD Calcium-5.9* Phos-5.0* Mg-1.9
[**2136-10-19**] 05:29PM BLOOD Albumin-1.9* Calcium-7.9* Phos-4.3 Mg-1.6
Iron-50
[**2136-10-9**] 03:16AM BLOOD Albumin-1.9* Calcium-7.1* Phos-2.4*
Mg-1.8
[**2136-11-5**] 04:22PM BLOOD calTIBC-48* Ferritn-GREATER TH TRF-37*
[**2136-10-28**] 02:07AM BLOOD Free T4-0.40*
[**2136-10-18**] 04:10PM BLOOD PTH-42
[**2136-10-27**] 05:02PM BLOOD Cortsol-27.7*
[**2136-10-20**] 01:17PM BLOOD Cortsol-42.7*
[**10-6**] CHEST, SINGLE AP VIEW.
There are low inspiratory volumes. Allowing for this, there is
probably underlying cardiomegaly. Marked prominence of pulmonary
vascular markings and vascular blurring most likely reflects the
presence of CHF, but is probably also accentuated by low lung
volumes. There is increased retrocardiac opacity with
obscuration of the left hemidiaphragm and blunting of left
greater than right costophrenic angles. Compared with [**2136-9-24**],
the degree of left lower lobe consolidation is worse. The
inspiratory volumes are lower. A dual lumen right-sided central
line is present with tips over distal SVC and SVC/RA junction.
[**10-9**] CT Pelvis IMPRESSION:
1) Left lower lobe pneumonia with moderate parapneumonic
effusion. Small focus of consolidation/atelectasis in the right
posterior medial lung. Without IV contrast we cannot assess for
empyema.
2) Destructive process involving the T7 and T8 vertebral bodies.
This has progressed markedly compared to the CT of [**2136-8-16**].
Limited assessment on these non-contrast axial images, however
there appears to be associated soft tissue. These findings are
highly concerning for osteomyelitis and potentially epidural
abscess. If the patient is able to cooperate, MRI could better
assess for cord involvement and/or epidural abscess.
[**10-10**] MR [**Name13 (STitle) 2854**] IMPRESSION:
1. Increased retropulsion of T7 vertebral body with increased
kyphotic deformity, destruction of the T8 vertebral body and
continued enhancing anterior epidural tissue. This is associated
with increasingly severe canal narrowing and development of cord
edema at this level.
2. No significant interval change in lumbar spine.
[**10-19**] SINGLE AP PORTABLE VIEW OF THE CHEST: ET tube tip is
located 34 mm above the carina. Right internal jugular vein dual
catheter is in unchanged position. There is no pneumothorax.
There is small left pleural effusion. The lungs are better
expanded. There is a new left chest tube. Patient is post
anterior T5/T8 spinal fusion.
There is a small subcutaneous emphysema in the left chest wall.
[**11-14**] Chest IMPRESSION: No significant change showing moderate
congestive heart failure and stable cardiomegaly.
[**11-27**] FINDINGS: Compared to the prior study, there has been no
significant interval change. There continues to be left lower
lobe volume loss and effusion. There is some mild pulmonary
vascular redistribution. There is no overt failure. Tracheostomy
tube, spinal fixation devices are unchanged. The right lateral
chest is off the film.
[**2136-11-24**] 3:30 am SPUTUM Site: ENDOTRACHEAL
**FINAL REPORT [**2136-12-2**]**
GRAM STAIN (Final [**2136-11-24**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
RESPIRATORY CULTURE (Final [**2136-12-2**]):
RARE GROWTH OROPHARYNGEAL FLORA.
ACINETOBACTER BAUMANNII. MODERATE GROWTH.
"Note, for Amp/sulbactam, higher-than-standard dosing
needs to be
used, since therapeutic efficacy relies on intrinsic
activity of
the sulbactam component". AMIKACIN SENSITIVE AT 8
MCG/ML.
ACINETOBACTER BAUMANNII. MODERATE GROWTH. 2ND COLONY
TYPE.
"Note, for Amp/sulbactam, higher-than-standard dosing
needs to be
used, since therapeutic efficacy relies on intrinsic
activity of
the sulbactam component". AMIKACIN SENSITIVE AT 16
MCG/ML.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ACINETOBACTER BAUMANNII
| ACINETOBACTER BAUMANNII
| |
AMPICILLIN/SULBACTAM-- =>32 R =>32 R
CEFEPIME-------------- =>64 R =>64 R
CEFTAZIDIME----------- =>64 R =>64 R
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ =>16 R =>16 R
IMIPENEM-------------- =>16 R =>16 R
LEVOFLOXACIN---------- =>8 R =>8 R
TOBRAMYCIN------------ 2 S 8 I
TRIMETHOPRIM/SULFA---- I I
[**2136-11-16**] 4:22 am STOOL CONSISTENCY: WATERY Source:
Stool.
**FINAL REPORT [**2136-11-16**]**
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2136-11-16**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
[**2136-11-13**] 12:32 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2136-11-18**]**
GRAM STAIN (Final [**2136-11-13**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS.
RESPIRATORY CULTURE (Final [**2136-11-18**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup will be performed appropriate to the isolates
recovered from
this site.
ACINETOBACTER BAUMANNII. MODERATE GROWTH.
"Note, for Amp/sulbactam, higher-than-standard dosing
needs to be
used, since therapeutic efficacy relies on intrinsic
activity of
the sulbactam component".
Trimethoprim/Sulfa sensitivity testing available on
request.
AZTREONAM RESISTANT AT >= 64 MCG/ML.
TIGECYCLINE RESISTANT AT >12 MCG/ML BY E-TEST.
EXTRA SENSIS REQUESTED BY DR.[**Last Name (STitle) **]([**Numeric Identifier 21494**]) ON [**2136-11-15**].
ENTEROBACTER CLOACAE. SPARSE GROWTH.
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.
Trimethoprim/Sulfa sensitivity testing available on
request.
TIGECYCLINE SENSITIVE AT 1.5 MCG/ML BY E-TEST.
AZTREONAM RESISTANT AT >64 MCG/ML.
GRAM NEGATIVE ROD #3. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ACINETOBACTER BAUMANNII
| ENTEROBACTER CLOACAE
| |
AMPICILLIN/SULBACTAM-- =>32 R
CEFEPIME-------------- =>64 R 2 S
CEFTAZIDIME----------- =>64 R =>64 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ =>16 R =>16 R
IMIPENEM-------------- =>16 R <=1 S
LEVOFLOXACIN---------- =>8 R =>8 R
MEROPENEM------------- <=0.25 S
PIPERACILLIN---------- =>128 R
TOBRAMYCIN------------ 4 S 8 I
[**2136-11-6**] 4:54 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2136-11-11**]**
GRAM STAIN (Final [**2136-11-6**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2136-11-11**]):
ACINETOBACTER BAUMANNII. HEAVY GROWTH.
"Note, for Amp/sulbactam, higher-than-standard dosing
needs to be
used, since therapeutic efficacy relies on intrinsic
activity of
the sulbactam component".
ACINETOBACTER BAUMANNII. SPARSE GROWTH STRAIN 2.
"Note, for Amp/sulbactam, higher-than-standard dosing
needs to be
used, since therapeutic efficacy relies on intrinsic
activity of
the sulbactam component".
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ACINETOBACTER BAUMANNII
| ACINETOBACTER BAUMANNII
| |
AMPICILLIN/SULBACTAM-- =>32 R =>32 R
CEFEPIME-------------- 16 I 8 S
CEFTAZIDIME----------- =>64 R =>64 R
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ 8 I 4 S
IMIPENEM-------------- 8 I 8 I
LEVOFLOXACIN---------- =>8 R 4 I
TOBRAMYCIN------------ 2 S <=1 S
OPERATIVE REPORT
[**Last Name (LF) 2194**],[**First Name3 (LF) 900**] J.
Signed Electronically by [**Last Name (LF) 2194**],[**First Name3 (LF) 900**] on SAT [**2136-11-24**] 2:51 PM
Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 33886**]
Service: MED Date: [**2136-11-9**]
Date of Birth: [**2072-5-17**] Sex: F
Surgeon: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 33887**]
PREOPERATIVE DIAGNOSES:
1. Sepsis.
2. Respiratory failure with prolonged intubation.
POSTOPERATIVE DIAGNOSES:
1. Sepsis.
2. Respiratory failure with prolonged intubation.
ASSISTANT: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 33888**], RES
PROCEDURE PERFORMED:
1. Tracheostomy.
2. Percutaneous endoscopic gastrostomy.
INDICATIONS FOR PROCEDURE: The patient is an unfortunate
woman who has had a spinal epidural abscess from which she
has manifested prolonged sepsis. She is bedridden and
ventilator dependent. She has been intubated for a
considerable length of time. The patient is quite obese
despite a small body frame, and has been quite difficult to
manage from a respiratory standpoint. Also, she has been
nasogastric tube feed dependent.
DETAILS OF THE PROCEDURE: The patient was brought to the
operating theater and placed on the operating table supine. A
roll was fashioned behind the shoulders and the head was
extended on a jelly roll to the extent possible. This was
somewhat limited. The patient had a very short neck and was
very stout. The patient's breasts were taped, protecting the
nipples, and pulled towards the feet. The neck, face, chest
and abdomen were now prepared sterilely with Betadine and
draped. At this time, a 2-1/2-cm vertical incision was
fashioned between the estimated location of the cricoid and
the sternal notch. This was deepened carefully using [**Last Name (un) 4161**]
cautery through the midline raphe of the neck. The trachea
was encountered with a difficult segment of thyroid over it.
This was elevated from the trachea with right-angle clamps
and suture ligated bilaterally with 2-0 silk suture. At this
point, a right-angle clamp was placed under the thyroid and
it was further elevated, dividing it with cautery. At this
time, there was still residual isthmus which was divided with
cautery, and eventually isolated and suture ligated. Now, the
2 lobes of the thyroid were grasped with right-angle clamps
and elevated off the trachea and dissected from it with
cautery. There was troublesome bleeding behind the right lobe
of the thyroid. This was controlled with Surgicel.
At this time, the trachea was marked for an inferior-based
flap with the incision between the 1st and 2nd tracheal
rings. The anesthesiologist was asked to suction the pharynx
and deflate the balloon, at which point the stay sutures were
placed into the trachea above and the flap below. The balloon
was reinflated and the trachea was elevated using stay
sutures. At this time, once more the balloon was deflated and
a transverse tracheotomy was fashioned. At this point, we
noted that we were well above the balloon and the vertical
arms of the flap were cut. At this time, the endotracheal
tube was withdrawn under direct vision by the
anesthesiologist to a point where the tip was just above the
tracheotomy. A #8 cuffed Portex tracheostomy tube was now
passed into the trachea and connected to the ventilator
circuit. Ventilation through this system was unsatisfactory,
although the patient was able to be oxygenated. Close
inspection revealed that the balloon was herniating outward.
My feeling was that this was too large a balloon for her
trachea. We therefore withdrew it and re-passed the
endotracheal tube from above. The patient was now fully
oxygenated. A 7 Portex tube was brought on the field, and the
tube was once more withdrawn, and the 7 Portex tube passed
without problem into the trachea. The balloon was inflated.
It was attached to the circuit and excellent CO2 and gas
exchange were observed. At this point, the tracheotomy was
slightly closed at the inferior end with a single cutaneous
suture. The tracheostomy was sutured in place with 0 silk
sutures and secured with umbilical tapes. The tracheostomy
part of the procedure was now terminated.
At this point, the previously prepared abdomen, which had
been covered sterilely, was uncovered from its secondary
draping. The gastroscope was passed into the mouth and
carefully passed through the esophagus into the stomach. The
stomach was inflated. Despite the patient's obesity, it was
remarkably easy to isolate the location in the mid stomach
where we saw excellent transillumination and easy dimpling
visible from the scope. A puncture was fashioned at this
point, and the wire was passed into the stomach. At this
point, a snare was passed through the gastroscope, grasping
the wire, and the wire was pulled along with the gastroscope
out through the mouth. Now, an 11 blade was used to incise a
generous skin incision for egress of the gastrostomy. The
gastrostomy tube was attached to the wire and pulled down
until the mushroom was just at the mouth.
At this time, the scope was reattached using the snare to the
gastrostomy tube and the entire assembly was pulled through
the pharynx and into the stomach. The PEG tube came to rest
easily at 4 cm. At this point, the snare was loosened and
disengaged from the PEG tube. The cross piece was placed, the
stomach was suctioned free of air, and the cross piece was
secured to the PEG tube. Dry sterile dressings were placed.
The PEG was placed to gravity suction. The procedure was
terminated. Photo documentation was obtained of the PEG and
tracheostomy position.
COMPLICATIONS: Both procedures went without apparent
complication.
ESTIMATED BLOOD LOSS: Minimal.
The patient was returned to the ICU in unchanged condition.
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**MD Number(2) 33889**]
OPERATIVE REPORT
[**Last Name (LF) **],[**First Name3 (LF) **] A.
Signed Electronically by [**Last Name (LF) **],[**First Name3 (LF) **] on SAT [**2136-11-10**] 10:12 AM
Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 33886**]
Service:ORTHO Date: [**2136-11-2**]
Date of Birth: [**2072-5-17**] Sex: F
Surgeon: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3191**], [**MD Number(1) 3192**]
First Assistant: [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) 33890**], MD
PREOPERATIVE DIAGNOSES: Kyphosis and status post
osteomyelitis and epidural abscess.
POSTOPERATIVE DIAGNOSES: Kyphosis and status post
osteomyelitis and epidural abscess.
OPERATIONS:
1. Fusion T3-L3.
2. Multiple thoracic laminotomies.
3. Instrumentation T3-L3.
4. Right iliac crest bone graft.
PROCEDURE: The patient was brought to the operating room and
placed on the table int he supine position. After adequate
general endotracheal anesthesia has been obtained, a Foley
catheter was inserted under sterile conditions. [**Male First Name (un) **] hose and
intermittent compression stockings were applied. The patient
was gently transferred to the [**Location (un) 1661**] table. The arms were
kept at less than 90 degrees to prevent injury to the
brachial plexus. The legs were extended to maintain their normal
natural lumbar lordosis. The back was prepped and draped in
the usual sterile fashion.
The midline incision was made over
the spinous processes from T3 down to L3. Dissection was
carried down through the skin and subcutaneous tissue.
Meticulous hemostasis was obtained using [**Last Name (un) 4161**]
electrocautery. Self-retaining Weitlaner and Gelpi retractors
were applied. Exposure was taken down to the level of the
midline muscle and fascia. This was divided in the midline
and then carried out to the lateral margins of the transverse
processes extending from T3 down to L3. There was significant
scarring from the previous decompression and fibrosis of the
musculature at the T12-L2 levels.
The fascia was divided and a revision laminectomy was
performed at the level of T12, L1, and L2. The
medial border of the pedicle was identified at L1, L2 and L3
and the junction of the superior articular facet and
transverse process was decorticated with [**First Name8 (NamePattern2) **] [**Last Name (un) 30565**] bur and
then using a reamer probe, pedicle screw holes were made.
These were palpated with a ball-tipped probe ensure that
no breach of the pedicle had been performed. Then, a 5.5 x 40
mm screw was inserted at each of these levels. On the
left at L3, a 6.5 mm screw was placed to obtain purchase.
There was moderate osteoporosis encountered. Multiple thoracic
laminotomies were performed after removing the spinous processes
and interspinous ligament from T3-T12 distally.
The inferior articular facets were removed with
[**First Name8 (NamePattern2) **] [**Last Name (un) 30565**] burr and the remaining articular cartilage was
removed as well by the decortication. The multiple laminotomies
were performed by first dividing the midline ligamentum flavum
with an angled curette. The ligamentum was then resected with
Kerrison rongeurs. A claw construct of hooks was placed with a
downward-going hook on the superior lamina at T3 and
an upward going at T4. Simlarly hooks were placed at T6 and T8
on
the left. A downgoing hook was placed on the superior margin of
T4 on the right and upward going hooks were placed at T5 and T7
as well. Sublaminar Atlas cables were applied also at T9 and T10
to enhance the rigidity of the construct. A rod was contoured
into ther appropriate thoracic kyphosis and lumbar lordosis and
attached to the previously placed segmental instrumentation. All
the set caps were applied to the hooks and screws distally and
these were tightened down with gentle distraction of the claw
constructs superiorly with a torque wrench.
Intraoperative x-rays showed accurate location of
the implants. Two transverse connectors were applied after
decorticating all the transverse processes and remaining
lamina with the [**Last Name (un) 30565**] bur.
The patient had a separate skin
incision made over the right iliac crest. Dissection was
carried down through the skin and subcutaneous tissue.
Meticulous hemostasis was obtained using [**Last Name (un) 4161**]
electrocautery. Self-retaining and Gelpi retractors were
applied. Exposure was taken down to the level of the crest
where a subperiosteal dissection was performed. An osteotome and
mallet was used to obtain cortical and cancellous bone graft.
Once adequate bone graft had been obtained, Gelfoam and bone wax
were applied for hemostasis.
The fascia overlying the crest was then closed with #1 Vicryl
suture in a running continuous fashion, after allograft bone
was used to restore the crest. The subcutaneous tissue was
closed with 2-0 Vicryl and the skin was closed with staples.
This bone graft was morselized, mixed with allograft and
packed in the posterior gutters from T3-L3. The
midline muscle and fascia were reapproximated with #1 Vicryl
suture in a running continuous fashion. The subcutaneous
tissue was closed with 2-0 Vicryl and the skin was closed
with interrupted staples. A sterile dressing including 4x4s,
ABDs and Elastoplast tape were applied without tension.
Sponge and instrument counts were correct at the end of the
case x3.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3191**], [**MD Number(1) 3192**]
Brief Hospital Course:
64 y/o female with DM, MR, ESRD on HD through tunneled catheter
presented to [**Hospital Unit Name 153**] on [**2136-10-6**] with fevers and resp distress. CXR
revealed pneumonia and sputum grew out enterobacter. On
meropenem with improvement in pna. Was also started on vanco for
nosocomial pna and hx MSSA spinal osteo. Sputum has also grown
out acenitobacter (likely colonizer) and 1 blood cx out of many
coag neg staph (likely a contaminant.) PT was spiking temps on
vanco and [**Last Name (un) 2830**]. CT chest/abd/pelvis with pleural effusions and
worsening of osteo at T7-T8. Pleural effusion was tapped and
consistent with transudate. Pt also with diarrhea- though cdiff
negative. Was placed on flagyl. MRI spine with worsening
destruction of T7- T8 with cord compression. Ortho-spine
consulted surgery for T7-T8 destruction and cord compression.
Went to OR [**10-19**] for T6-7 corpectomy with T5-8 strut graft/fusion
for osteomyelitis. In SICU, intubated, on neo. Multiple
hemodialysis treatments with renal function was improving but
now may be having some post-op ATN. Renal following and deciding
whether or not to dialyze.
She had been stable for over a week - pending repeat surgery of
her spine. She was supposed to go to OR- but was nutritionally
depleted -so surgical procedure postponed. She remains
intubated. The only new culture that has grown out is
acinetobacter from the sputum on [**10-20**]. Subsequent sputum
cultures did not grow it out - but we decided since she had
thick yellow sputum - to treat her for a [**7-30**] day course with
Tobra.
[**10-25**] Ms. [**Known lastname **] continued to spike through Tobramycin,
Nafcillin and Fluconazole without an obvious source.
Antibiotics were at appropriate therapeutic levels. At this
time Ms. [**Known lastname **] has been continually ventilated since her
spinal fusion [**10-19**]. Renal recommendation were followed and
dialysis initiated as needed. ID recommendations were followed
and antibiotics were titrated to cover source of fevers.
[**10-28**] 2 units PRBC were tranfused for Hct of 22 in preparation
for posterior spinal fusion with instrumentation. Ms. [**Known lastname **]
was thought to have chronic aspirations and was considered for a
trach and PEG potentially concurrently with the spinal fusion.
Between her thoracolumbar spinal fusion and her posterior spinal
fusion she failed extubation due to respiratory distress.
[**11-2**] Ms. [**Known lastname **] returned to the Operating Room and was fused
posteriorly T3-L3. Her guardian, as with her anterior spinal
fusion, gave her consent. Please see Operative Note for
procedure in detail.
[**11-3**] 2 units PRBC were transfused for post-operative anemia.
She remained intubated; however, began making copious urine and
the hemodyalisis catheter was discontinued.
[**11-9**] Ms. [**Known lastname **] remained intubated and a Trach and PEG was
placed. An attempt to wean off the ventilator failed due to
respiratory distress.
[**11-15**] transfused 2 units PRBC for dropping hematocrit.
Responded accordingly. Fevers persisted with a rare
acinctobacter which is highly resistant persisting. At this
time Linezolid, vancomycin, cefepime and tobramycin.
[**11-20**] posterior midline staples removed and incision clean, dry
and intact without evidence of source of infection.
[**11-21**] Thoracic service was consulted for an air leak around
tracheostomy which was determined to be due to tracheostomy
being too large. Bronchoscopy at bedside performed and they
found the airway without collapse, the cuff was reinflated and
the leak obliterated. Thoracentesis performed for large left
pleural effusion. Antibiotics adjusted to accommodate the
results.
[**11-26**] PICC line changed. Source of fevers still inclear. Fever
curve improving on Nafcillin.
[**12-3**] Rehab screening started and bed found. Planning long term
Nafcillin via PICC.
Fluconazole X 1 week, began [**12-3**].
Medications on Admission:
Paroxetine
Albuterol
Ipratropium
Metoprolol
Pantoprazole
Discharge Medications:
1. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q6H (every 6 hours).
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for wheezing.
3. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
syringe Injection ASDIR (AS DIRECTED).
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for fever.
5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for rash.
6. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed.
7. Epoetin Alfa 4,000 unit/mL Solution Sig: Three (3) syringes
Injection QMOWEFR (Monday -Wednesday-Friday).
8. Lamotrigine 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
9. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO DAILY (Daily).
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
syringe Injection TID (3 times a day).
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
12. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
13. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
14. Nafcillin 2 gm IV Q4H tx of osteomyelitis
15. Fluconazole 100 mg IV Q24H
16. Hydromorphone 2 mg/mL Syringe Sig: 0.5 mg Injection Q4H
(every 4 hours) as needed.
17. Lorazepam 2 mg/mL Syringe Sig: 0.5-2 mg Injection Q2-3H
(every 2-3 hours) as needed.
18. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours).
19. Levothyroxine 200 mcg Recon Soln Sig: Fifty (50) mcg
Injection DAILY (Daily).
20. Metoclopramide 5 mg/mL Solution Sig: Ten (10) mg Injection
Q6H (every 6 hours).
21. Metoprolol 7.5 mg IV Q4H:PRN HR>100
hold for SBP <100, HR <60
22. Morphine Sulfate 2 mg IV Q2H:PRN pain
23. Outpatient Lab Work
Please draw weekly CBC, BUN/Cr, LFT's and fax to [**Hospital **] clinic [**Telephone/Fax (1) 10739**].
24. Fluconazole
Fluconazole 100 mg IV Q24H QAM X 1 week. Began [**2136-12-3**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Hospital1 **]
Discharge Diagnosis:
Pneumonia
Epidural abscess/Osteomyelitis
GI bleed
Post-operative fever
Post-operative anemia
Discharge Condition:
Stable
Discharge Instructions:
Please continue current treatment plan. Inspect the surgical
incisions daily for signs of infection.
Please draw weekly CBC, BUN/Cr, LFT's and fax to [**Hospital **] clinic [**Telephone/Fax (1) 10739**].
Followup Instructions:
Please follow up with the Orthopedic Spine Clinic in two months.
Call [**Telephone/Fax (1) 11061**] for an appointment.
Provider: [**First Name8 (NamePattern2) 7618**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2137-1-1**]
10:30.
Please draw weekly CBC, BUN/Cr, LFT's and fax to [**Hospital **] clinic [**Telephone/Fax (1) 10739**].
Please follow up with your nephrologist at [**Hospital1 **].
Completed by:[**2136-12-4**]
|
[
"707.14",
"585.6",
"787.91",
"427.31",
"737.10",
"336.3",
"599.0",
"730.18",
"428.30",
"324.1",
"403.91",
"995.92",
"319",
"518.84",
"496",
"285.1",
"482.83",
"707.05",
"250.00",
"278.00",
"511.9",
"038.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.08",
"34.91",
"81.64",
"99.15",
"99.04",
"81.62",
"43.11",
"77.79",
"97.23",
"44.32",
"39.95",
"38.93",
"31.1",
"00.14",
"80.99",
"33.24",
"96.6",
"86.05",
"81.04",
"96.72",
"93.90",
"33.21",
"84.51"
] |
icd9pcs
|
[
[
[]
]
] |
36874, 36949
|
30646, 34590
|
298, 402
|
37086, 37095
|
2607, 30623
|
37349, 37808
|
2198, 2221
|
34697, 36851
|
36970, 37065
|
34616, 34674
|
37119, 37326
|
2236, 2588
|
237, 260
|
430, 1800
|
1822, 1977
|
1993, 2182
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,667
| 114,682
|
12622
|
Discharge summary
|
report
|
Admission Date: [**2125-3-30**] Discharge Date: [**2125-4-26**]
Date of Birth: Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: This is a 55 year old male with
a history of hypertension, unspecified heart problems, who
recently immigrated from [**Country 4812**] six weeks ago, who
presented to the Emergency Room with chest pain in the
setting of cough. The patient, again, immigrated from
[**Country 4812**] six months ago. Over the past six months, he has
been experiencing a dry cough; at baseline he does have some
chest discomfort as well and it seems that this pain is
exertional; however, over the last several weeks, he has
begun to have a pleuritic sharp chest pain with radiation to
the back, worse again when he coughs.
On a trip to [**Location (un) **] two weeks prior to admission, he did
complain of a similar pain and presented to a local hospital.
All the details of that hospitalization are unclear. [**Name2 (NI) **] did
leave the hospital pain free. The patient again came back to
the US several days ago and on the date of admission he was
in a car with his daughter when he experienced retrosternal
discomfort once again with radiation to the back. Per the
daughter, he looked pale and diaphoretic and for this reason,
he was brought to the Emergency Room.
He denies any history of syphilis, heart murmur, scarlet
fever, Strep-throat or rheumatic fever. He does take some
medicines for his cough but does not know what they are.
In the Emergency Room, he was noted to have a significant
diastolic murmur. His blood pressure was elevated in the 200
to 100 range similar bilaterally. Chest x-ray noted a large
widened mediastinum and the patient was initially placed on
labetalol and then a Nipride drip for blood pressure control.
Chest CT scan was performed which showed a large thoracic
aneurysm but no evidence of dissection, and the patient was
admitted to Coronary Care Unit for aggressive blood pressure
control.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Question of angina.
3. History of negative PPD six months ago.
MEDICATIONS:
1. Labetalol 200 twice a day.
2. Zestril over the last week.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is of Ethiopian origin,
recently immigrated to the US six years ago. No tobacco or
alcohol.
PHYSICAL EXAMINATION: On examination, temperature 97.3 F.;
heart rate 70; respiratory rate 18; blood pressure was
180/60; saturation of 95% on room air. In general, this is an
middle aged male in no acute distress. HEENT: Pupils
reactive. Oropharynx clear. Mucous membranes were moist.
Neck was supple. Jugular venous pressure was not visualized.
No carotid bruits. Chest was clear to auscultation
bilaterally. Cardiac: S1, S2 normal. There was a III/VI
diastolic murmur at the right upper sternal border. Abdomen
was benign, soft, good bowel sounds, no palpable masses.
Extremities with no edema. Neurologically intact. Good
motor and sensory in all extremities. Cranial nerves intact.
Toes downgoing bilaterally. Deep tendon reflexes symmetric.
LABORATORY: Initial laboratory data was notable for a white
blood cell count of 7.5, hematocrit of 39.3, platelets of 259
with 13% eosinophilia. SMA7 was notable for a creatinine of
1.3. CK was 110; initial coagulation studies within normal
limits. Initial EKG showed normal sinus rhythm, left
ventricular hypertrophy, left atrial abnormality.
Chest x-ray revealed a large aneurysmal mass abutting the
left hilar area. CT scan of the chest showed a 6.6 by 6.7
centimeter large oblong descending thoracic aneurysm
compressing the left upper lobe bronchus with no evidence of
dissection, no lung masses or infiltrates.
HOSPITAL COURSE:
1. LARGE THORACIC ANEURYSM: The patient was admitted with a
new diagnosis of a large thoracic aortic aneurysm without any
evidence of dissection on initial chest CT scan. The
patient's blood pressure was aggressively managed with
Nipride drip and labetalol and eventually was transitioned
over to a PR regimen.
CT Surgery was consulted initially, however, initially they
wanted a cardiac catheterization and an echocardiogram prior
to surgery, however, they did feel that the surgery was
needed urgently. However, due to an episode of hemoptysis
that the patient had in-house, they deferred surgery until
the patient had a bronchoscopy and was further stabilized.
Due to multiple other complications during the hospital
course, the patient's surgery was deferred and to be done
when the patient stabilized. The patient was eventually
discharged to return for an elective surgical resection.
During the hospitalization, the patient had no evidence of
dissection or any catastrophic effects of aneurysm.
2. HEMOPTYSIS: The patient was initially presenting with an
aneurysm that had abutted the left upper lobe bronchus.
During the hospitalization, the patient had episodes of
hemoptysis. Bronchoscopy which was performed showed blood
trickling from the left upper lobe bronchus, but did not
reveal any discrete masses or lesions. The question of
fistula was entertained. The patient, however, was intubated
electively due to recurrent hemoptysis for airway protection,
however was able to be extubated eventually and discharged.
No further hemoptysis was noted after extubation.
3. AORTIC INSUFFICIENCY: The patient with a loud diastolic
murmur. A 2D echocardiogram revealed a three plus aortic
insufficiency. Cardiac catheterization revealed no coronary
disease. The plan was to replace the aortic valve at the
time of aneurysm repair.
4. PNEUMONIA: The patient developed a Hemophilus influenzae
pneumonia while on the ventilator. The patient was treated
with a prolonged course of Levaquin for his pneumonia with
improvement.
5. STAPHYLOCOCCUS COAGULASE NEGATIVE LINE SEPSIS: The
patient developed Staphylococcus coagulase negative
bacteremia in the setting of peripheral line. The patient's
line was removed and the patient was treated with a prolonged
course of intravenous Vancomycin with clearance of subsequent
blood cultures.
6. MYOCLONIC JERKS: The patient with myoclonic jerks
interrupted he setting of infection and medication. He was
seen by Neurology who recommended an EEG which did not show
any evidence of epileptiform features. The myoclonus
resolved with treatment of the infection.
DISCHARGE DIAGNOSES:
1. Large thoracic aortic aneurysm with communication to left
upper lobe bronchus.
2. Hemoptysis secondary to a question of aortobronchus
fistula.
3. Aortic insufficiency.
4. Hemophilus influenzae pneumonia.
5. Staphylococcus line sepsis.
6. Hypertension.
DISCHARGE MEDICATIONS:
1. Protonix 40 q. day.
2. Hydralazine 100 p.o. four times a day.
3. Zestril 40 p.o. q. day.
4. Procardia XL 90 p.o. q. day.
5. Lopressor 100 p.o. three times a day.
DISPOSITION: The patient was discharged on [**2125-4-26**].
DISCHARGE INSTRUCTIONS:
1. The patient will follow-up with Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] in CT
Surgery for an elective admission for thoracic aortic
aneurysm repair and possible aortic valve repair.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-463
Dictated By:[**Name8 (MD) 2439**]
MEDQUIST36
D: [**2126-8-1**] 09:32
T: [**2126-8-4**] 20:52
JOB#: [**Job Number 39010**]
|
[
"424.1",
"038.11",
"441.2",
"428.0",
"682.3",
"401.9",
"996.64",
"786.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"33.22",
"96.6",
"96.72",
"96.04",
"88.55",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
6390, 6652
|
6675, 6909
|
3736, 6369
|
6933, 7349
|
2355, 3719
|
158, 1982
|
2004, 2207
|
2225, 2331
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,563
| 199,725
|
40949
|
Discharge summary
|
report
|
Admission Date: [**2153-6-3**] Discharge Date: [**2153-6-22**]
Date of Birth: [**2076-7-11**] Sex: F
Service: NEUROLOGY
Allergies:
Ace Inhibitors
Attending:[**First Name3 (LF) 7575**]
Chief Complaint:
Chief Complaint: Abd pain and fever
Reason for MICU transfer: A. fib with
Major Surgical or Invasive Procedure:
PEG tube placement [**2153-6-19**]
History of Present Illness:
Ms. [**Known lastname 10680**] is a 76 y/o F with a h/o frontal dementia,
hypothyroidism, and hypertension who was admitted from [**Location (un) 8220**] (lives there as long term care) on [**2153-6-3**] with abdominal
pain and fever. CT of her abdomen/pelvis in the ER were notable
for an SBO and a LLL PNA, she was admitted to ACS for
conservative management of a SBO. Her abdominal pain improved,
she had a BM and ACS said her SBO resolved, they then
transferred her to CC6 on [**2153-6-5**] for management of her pna and
and delirium. She is currently on vanc/cefepime/flagyl for abx
coverage. She is afebrile, only oriented to herself, she is
pulling out her IV's, etc. Her O2 requirement and CXR was
worseing during her [**Hospital1 **] course. On [**2153-6-6**] she triggered at
8:55 for difficulty breathing and HR to 140s in a fib with BPs
of 170s to 90s. Pt noted at that time to be positive 4Ls with
UOP of about 20/Hr of fluid and requiring 2L NC for 88%. 20mg of
IV lasix was given and 5mg of metoprolol iv which she diuressed.
Throughout the day she had occasional a fib with SBPs in the
160-170s and triggered an additional two times. She was given
20+20+40 IV lasix, 5+5 of metoprolol and 25 of PO metoprolol
Q8Hr. Then she continued to be in A. fib with RVR to the
150-160s and was transferred to the MICU.
Past Medical History:
- Dementia, Hypertension, Hypothryroid, Latent syphilis,
depression, Osteoarthritis
- Bilateral knee replacement in [**2140**]
Social History:
The patient quit smoking 30 years ago, does not drink alcohol.
No recreational drugs, no transfusions. Stopped working more
than ten years ago.
Family History:
Two brothers and two sisters, one of which died of old age. The
living siblings have dementia, hypertension, diabetes mellitus
and a stroke. Five children, one with asthma, three with
hypertension.
Physical Exam:
ADMISSION EXAM PER ACS:
Vitals: 98.6 99 137/69 16 96%RA
GEN: sleeping but intermittently responsive, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear on right, mildly coarse BS on left
ABD: Soft, +distension, mildly tender L abd, no rebound or
guarding, normoactive bowel sounds, no palpable masses
Ext: No LE edema, LE warm and well perfused
TRANSFER EXAM:
GEN: eyes closed, NG tube in place, arms restrained, NAD
HEENT: sclera anicteric, no nuchal rigidity
CV: RRR, no m/r/g
PULM: CTA anteriorly
EXT: no edema
NEURO:
MSE: Eyes open with light sternal rub, grimaces, and makes sound
but not discernable words. Does not follow commands or answer
what her name is. Fixes on examiner intermittently when eyes
open and awake, but then closes eyes and has roving eye
movements apparent under closed lids. When eyes are forced open
she does resist, with positive Bells phenomenon. No clear
neglect, as she
attends to her daughter on either side.
CN: PERRL 4 to 2mm, no hippus. EOMI. R lower facial droop.
MOTOR: paratonia more on the left side. Bilateral hand tremor
while at rest, R>L that is not suppressible.
LUE spontaneous antigravity and purposeful (tries to grab my
hand while pinching her).
RUE not moving as much as left and not as purposeful, withdraws
very briskly and antigravity to pinch.
LLE is externally rotated and paratonic. Both LEs withdraw
briskly to Babinski testing.
Sensation intact to pinch throughout.
DTR: 2+ UEs, 0 patellars (s/p TKR), no clonus, L toe upgoing at
baseline with positive Babinski response, R toe equivocal.
DISCHARGE EXAM:
GENERAL EXAM: mildly tenderness to palpation on abdominal exam,
otherwise comfortable, NAD.
NEURO:
MSE: opens eyes briefly to voice, and the keeps it closed for
the rest of the exam. does not follow commands.
CN: PERRL 4->2mm bilaterally, right nasolabial flattening
MOTOR: paratonia on L side, also increased tone on right side.
LUE spontaneous antigravity and purposeful movements. RUE
withdraws with antigravity strength in elbow, some spontaneous
movements but less than left side. Both [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 43829**] to noxious
stimuli.
Reflexes: hyperreflexic in RUE, positive babinski bilaterally.
Pertinent Results:
Admission Lab:
[**2153-6-2**] 11:45PM GLUCOSE-180* UREA N-26* CREAT-1.7* SODIUM-137
POTASSIUM-4.2 CHLORIDE-99 TOTAL CO2-23 ANION GAP-19
[**2153-6-2**] 11:45PM WBC-20.4*# RBC-3.88* HGB-10.3* HCT-32.6*
MCV-84 MCH-26.7* MCHC-31.7 RDW-14.8
[**2153-6-2**] 11:45PM NEUTS-95.7* LYMPHS-2.4* MONOS-1.4* EOS-0.5
BASOS-0
[**2153-6-2**] 11:45PM PLT COUNT-236
[**2153-6-2**] 11:45PM ALT(SGPT)-17 AST(SGOT)-37 ALK PHOS-66 TOT
BILI-0.7
[**2153-6-2**] 11:45PM LIPASE-11
[**2153-6-2**] 11:45PM ALBUMIN-3.8
EKG: A fib, rate 94, rr [**Age over 90 **]m pr 130, qrs 106, qtc 459, nl axis
DISCHARGE LABS:
[**2153-6-22**] 04:30AM BLOOD WBC-7.7 RBC-3.18* Hgb-8.3* Hct-27.6*
MCV-87 MCH-26.2* MCHC-30.2* RDW-17.6* Plt Ct-421
[**2153-6-22**] 04:30AM BLOOD Glucose-129* UreaN-11 Creat-0.6 Na-137
K-3.7 Cl-100 HCO3-31 AnGap-10
[**2153-6-22**] 04:30AM BLOOD Calcium-8.9 Phos-4.1 Mg-1.7
COAGS:
[**2153-6-22**] 04:30AM BLOOD PT-14.7* PTT-31.2 INR(PT)-1.4*
[**2153-6-21**] 07:10PM BLOOD PT-15.9* PTT-30.6 INR(PT)-1.5*
[**2153-6-21**] 01:35PM BLOOD PT-15.3* PTT-66.4* INR(PT)-1.4*
[**2153-6-21**] 04:35AM BLOOD PT-14.0* PTT-49.6* INR(PT)-1.3*
[**2153-6-20**] 07:35PM BLOOD PT-13.5* PTT-71.9* INR(PT)-1.3*
MICROBIOLOGY:
[**2153-6-13**] STOOL C. difficile DNA amplification assay NEGATIVE
[**2153-6-12**] BLOOD CULTURE NEGATIVE
[**2153-6-12**] BLOOD CULTURE NEGATIVE
[**2153-6-11**] URINE CULTURE- YEAST 10-100K
[**2153-6-7**] MRSA SCREEN NEGATIVE
[**2153-6-4**] URINE CULTURE- YEAST 10-100K
[**2153-6-3**] BLOOD CULTURE NEGATIVE
[**2153-6-3**] BLOOD CULTURE NEGATIVE
[**2153-6-3**] BLOOD CULTURE NEGATIVE
[**2153-6-2**] BLOOD CULTURE NEGATIVE
IMAGING:
[**2153-6-3**] CT ABD/PELVIS:
IMPRESSION:
1. Findings consistent with small-bowel obstruction with a
transition point in the left lower quadrant of the abdomen.
2. Left lower lobe pneumonia.
3. Extensive lumbar spine degenerative changes with compression
of L1
vertebral body, acuity unknown.
4. Healing right-sided rib fractures.
[**2153-6-8**] ECHO:
The left atrium is moderately dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Overall
left ventricular systolic function is normal (LVEF 65%). 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. Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
[**2153-6-8**] HEAD CT:
1. No evidence of acute vascular territorial infarction. In
the setting of high clinical suspicion for acute ischemia, MRI
with diffusion sequences can be considered for further
assessment.
[**2153-6-15**] HEAD CT:
1. Low-attenuating region within the left corona radiata
extending into the left caudate head and possibly the left
putamen appears better evolved than [**2153-6-8**] and is concerning
for subacute infarction.
2. Lacunes in the left striatocapsular region are unchanged
since the prior examination.
3. Left maxillary sinus disease.
[**2153-6-8**] MRI HEAD:
IMPRESSION:
1. Extensive relatively acute infarction involving the left
deep [**Doctor Last Name 352**] matter structures, including the caudate and lentiform
nuclei, likely accounting for the acute presentation.
2. Numerous additional more punctate infarcts scattered
throughout both cerebral hemispheres, including in the posterior
circulation territory. The overall appearance is suggestive of
"embolic shower" from a central source, with which should be
correlated with clinical information.
3. No evidence of hemorrhage.
4. No space-occupying lesion or pathologic enhancement.
5. Disproportionate medial temporal atrophy, compared to the
degree of global volume loss, raising the possibility of
underlying Alzheimer disease, which should also be correlated
with clinical information.
[**2153-6-12**] EEG:
This is an abnormal continuous video EEG monitoring study
because of abundant generalized and multifocal epileptiform
discharges, seen in the
left central temporal region, right frontal temporal region, or
isolated to either the left central or right central regions. At
times, these discharges occurred in a periodic fashion at 1-1.5
Hz, but there was no clinical change noted on video during these
bursts. These findings indicate generalized and multifocal
epileptogenic cortex but the discharges did not evolve into
electrographic seizures. There was a single pushbutton
activation for limb shaking, but the EEG demonstrated no
evidence of electrographic seizures and this could not be
visualized on video. Otherwise, the background was slow and
disorganized indicative of a diffuse encephalopathy with further
slowing noted at times over the left hemisphere indicative of
focal hemispheric dysfunction. Compared to the previous day's
recording, there was no significant change.
[**2153-6-18**] CXR:
The NG tube is in good position in the distal stomach.
Stability of the surelevation of the right hemidiaphragm with
small pleural effusion. Stable left lower lobe atelectasis.
Stability of the proeminence of the
vessels that could be compatible with light volume overload.
Mediastinal and cardiac contours normal.
[**2153-6-22**] abdominal XRAY:
Nonspecific bowel gas pattern with no evidence of bowel
obstruction.
Brief Hospital Course:
TRANSITIONAL ISSUE:
[ ] Monitor INR and adjust coumadin dosing as needed
[ ] Post stroke rehab
====================
Mrs. [**Known lastname 10680**] is a 76 y/o F with PMH of dementia, hypothyroidism,
and hypertension who was admitted from [**Location (un) 169**] (lives
there as long term care) with abdominal pain and fever. She was
found to have an SBO and LLL infiltrate concerning for pneumonia
on CT of her abdomen/pelvis in the ER so she was initially
admitted to ACS. She was conservatively managed with improvement
in her abdominal pain. As her SBO resolved, she was transferred
to medicine service for management of her pneumonia and
delirium. She developed afib with RVR and hypertension and was
transferred to MICU for diltiazem gtt for her rate control and
was converted back to sinus rhythm. In MICU, she was noted to
have persistent left gaze and somnolence, so neurology was
consulted. Her CT did not show an acute process but her MRI did
show L sided acute infarcts, which was thought to be from
thromboembolic source associated with her paroxysmal afib and
conversion to sinus. Her TTE did not show an atrial thrombus.
She was started on anticoagulation with heparin gtt and bridged
to coumadin. She was called out to the neurology floor and was
monitored. Keppra was initially started given concern for
seizures, but as her long term EEG monitoring only epileptiform
discharges and no electrographic seizures, it was discontinued.
Unfortunately, her neurologic status did not improve much after
her stroke and as she was unable to pass speech/swallow
evaluation, PEG tube was placed. Coumadin was restarted after
PEG tube placement.
# NEURO: Patient with baseline dementia and living at dementia
unit, but during this hospitalization developed small embolic
infarcts L>R, likely from paroxysmal atrial fibrillation.
Embolic infarcts were found when patient developed persistent
left gaze and R sided weakness, CT head did not show an acute
stroke but her MRI did show multiple small embolic infarcts,
L>R. She was started on heparin gtt and bridged to coumadin.
Patient had residual right sided spastic hemiparesis, no speech
output and could not follow commands. Given these neurologic
deficits, she failed speech and swallow evaluation multiple
times. Given the poor mental status and leukocytosis during this
hospitalization, lumbar puncture was considered and her
anticoagulation was reversed and patient started on heparin gtt
for LP. Both the attempt on the floor and IR guided LP were
unsuccessful, and as leukocytosis resolved without any
antibiotics, no further attempt at LP were made. While she was
on heparin gtt, PEG tube was placed and patient was restarted on
coumadin. As she had been in sinus rhythm since transfer from
the ICU with heparin gtt on board, heparin was discontinued and
only coumadin was continued. Patient will require INR follow up
and [**Hospital 89367**] rehabilitation in hopes of improving her
functional status.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes - () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
() Yes - (x) No
-> patient developed stroke more than 2 days into the
hospitalization, but heparin started within 2 days of diagnosis
of new stroke.
4. LDL documented? (x) Yes (LDL = 75) - () No
5. Intensive statin therapy administered? Not applicable, LDL =
75 (for LDL > 100) () Yes - (x) No (if LDL >100, Reason Not
Given: )
6. Smoking cessation counseling given? () Yes - (x) No (Reason
(x) non-smoker - (x) unable to participate)
7. Stroke education given? () Yes (to family) - () No
8. Assessment for rehabilitation? (x) Yes - () No
9. Discharged on statin therapy? () Yes - (x) No (LDL <100)
10. Discharged on antithrombotic therapy? (x) Yes (Type: ()
Antiplatelet - (x) Anticoagulation) - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (x) Yes - () No - () N/A
# CV: Patient developed atrial fibrillation with RVR on the
medicine service and was transferred to MICU for diltiazem gtt.
Her heart rhythm converted to sinus after diltiazem gtt was
started and remained in sinus. Her blood pressure initially
remained elevated but came down. Patient appeared volume
overloaded so she was diuresed with IV and then PO furosemide.
Her anticoagulation was managed as above.
# Pulm: Prior to transfer to the ICU, patient became hypoxic,
requiring supplemental O2. Thought to be due to acute pulmonary
congestion from volume overload. Respiratory status improved
with diuresis and she remained 93-96% on RA.
# ID: Patient with ? of LLL pneumonia on abdomen/pelvis CT on
admission. However, patient did not have leukocytosis or fevers
at that time. She was empirically treated with vanc/cefepime and
flagyl for healthcare associated pneumonia with possible
component of aspiration pneumonia. However, the antibiotics were
stopped as her respiratory status improved with diuresis. Later
during the hospitalization, patient did develop leukocytosis to
22, and another infectious work up was done with UA/UCx (yeast),
CXR (largely unchanged, still with bilateral pleural fluids and
atelectasis), c diff toxin and blood cultures, which were
otherwise negative. Patient's zoster was treated with 5 day
course of PO acyclovir. LP was also attempted without success
both by the floor team and also by IR. As patient's leukocytosis
resolved on its own without antibiotics and remained normal, no
further infectious work up was undertaken.
# GI: After her PEG placement, patient would wince with
abdominal exam, but otherwise comfortable. No peritoneal signs
and soft abdomen. This was thought to be due to recent procedure
and patient was given tylenol with improvement.
# Endo: Continued on levothyroxine for hypothyroidism.
# FEN: Patient unable to pass speech and swallow test after her
stroke, and underwent PEG placement on [**2153-6-19**]. Tube feed
started through PEG with residuals ranging from 30-100 cc, but
now tube feed at goal without issues.
# Contact: daughter [**Name (NI) 89368**] is HCP, cell [**Telephone/Fax (1) 89369**]
# [**Name2 (NI) 7092**] status: DNR/DNI, confirmed with daughter
Medications on Admission:
1. Alendronate Sodium 70 mg PO Frequency is Unknown
2. Amlodipine 5 mg PO DAILY
3. Citalopram 20 mg PO DAILY
4. Clobetasol Propionate 0.05% Ointment 1 Appl TP PRN [**Hospital1 **] rash
stop when rash resolves
5. Mupirocin Nasal Ointment 2% 1 Appl NU [**Hospital1 **] PRN open wounsd
Duration: 5 Days
6. Nystatin Powder *NF* 1 application topical daily prn rash
7. Omeprazole 20 mg PO DAILY
8. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours
9. traZODONE 50 mg PO DAILY
10. Triamcinolone Acetonide 0.1% Cream 1 Appl TP [**Hospital1 **]:PRN itch
11. Aspirin 81 mg PO DAILY
12. Calcium Carbonate 1500 mg PO BID
13. Guaifenesin [**4-19**] mL PO QID
1 table spoon of 100mg/5mL 4times a day
14. Multivitamins 1 TAB PO DAILY
15. Senna 2 TAB PO HS
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
Hold if SBP < 100 and HR <60
2. Citalopram 20 mg PO DAILY
3. Senna 1 TAB PO BID:PRN constipation
4. Bisacodyl 10 mg PO DAILY:PRN constipation
5. Docusate Sodium (Liquid) 100 mg PO BID:PRN constipation
6. Levothyroxine Sodium 12.5 mcg PO DAILY
7. Metoprolol Tartrate 25 mg PO BID
hold for SBP <100, HR<50
8. Alendronate Sodium 70 mg PO QMON
9. Calcium Carbonate 1500 mg PO BID
10. Acetaminophen 650 mg PO Q6H:PRN pain/fever
11. Ipratropium Bromide Neb 1 NEB IH Q6H
12. Aspirin 81 mg PO DAILY
13. Multivitamins 1 TAB PO DAILY
14. Omeprazole 20 mg PO DAILY
15. Miconazole Powder 2% 1 Appl TP [**Hospital1 **]:PRN groin
16. Furosemide 40 mg PO DAILY
hold if SBP <100
17. Warfarin 5 mg PO DAILY16
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] LivingCenter - [**Location (un) 1411**]
Discharge Diagnosis:
Primary Diagnosis: embolic stroke, paroxysmal atrial
fibrillation, dementia, hypertension, hypothyroidism
Secondary Diagnosis: latent syphilis, osteoarthritis
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mrs. [**Known lastname 10680**],
It was a pleasure to take care of you at [**Hospital1 827**]. You were admitted to the hospital because of
abdominal pain and fevers and were found to have a small bowel
obstruction. Your obstruction was managed medically and
improved. However, you developed a rapid irregular heart rhythm
(atrial fibrillation with rapid ventricular rhythm) and had to
be transferred to the intensive care unit. Your heart rate
returned to [**Location 213**] with medications. While in the ICU, you were
noted to have deviated eyes and brain imaging showed new
strokes. Because we thought your stroke was from the irregular
heart rhythm, you were started on blood thinner called heparin
and transitioned to coumadin.
Because of your strokes, you could not swallow without risk of
getting food or liquid into your lungs. Given this finding,
discussion was had with your daughter and feeding tube was
placed in your stomach.
Followup Instructions:
Please call your primary care physician's office at [**Telephone/Fax (1) 14405**]
after discharge from rehabilitation facility to make a follow up
appointment.
NEUROLOGY
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) **] & [**Doctor Last Name **]
Phone:[**Telephone/Fax (1) 3506**]
Date/Time:[**2153-9-26**] 4:00
[**Hospital Ward Name 23**] [**Location (un) **]
|
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"348.39",
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"244.9",
"486",
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"276.0",
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"507.0",
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] |
icd9cm
|
[
[
[]
]
] |
[
"89.19",
"96.6",
"43.11"
] |
icd9pcs
|
[
[
[]
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] |
17884, 17966
|
10074, 16342
|
350, 387
|
18169, 18169
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4555, 5138
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3897, 4536
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415, 1740
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|
1907, 2053
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,669
| 168,291
|
6173
|
Discharge summary
|
report
|
Admission Date: [**2119-11-6**] Discharge Date: [**2119-11-28**]
Date of Birth: [**2043-7-9**] Sex: M
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
shortness of breath, red-tinged sputum production
Major Surgical or Invasive Procedure:
Bedside bronchoscopy with bronchoalveolar lavage
Ebdotracheal intubation and ventilation
Nasogastric tube placement
History of Present Illness:
This is a 76 year-old [**First Name3 (LF) 24075**]-speaking male with h/o DM,
infarct-related cardiomyopathy, CHF (most recent EF of 50% in
[**Month (only) 359**], nadir of 20%), CAD s/p CABG x 2 ([**2091**], [**2099**]) &
biventricular ICD ([**2110**]), and chronic atrial fibrillation (on
Warfarin, INR 10.1 on presentation), severe MR s/p MVR in [**2115**],
s/p AVN ablation in [**2114**], history of CRI with intolerance to ACE
inhibitors and ARBs, history of carotid artery disease not
amenable to operation, and a recent history cellulitis and
erysipelas (finished a course of doxycycline at end of [**Month (only) **])
presents with increasing dyspnea for 1 day of worsening of SOB
consistent with prior chf exacerbations. Denies fever, chills,
nausea, vomiting, cp or back pain.
.
Of note the patient has had three recent admissions for similar
symptoms of dyspnea on exertion which improved with diuresis.
(d/c [**6-8**], [**7-18**], [**9-7**]). During his most recent admission, a CT
scan was done and demonstrated generalized additional
abnormality involving both lungs with associated areas of
ground-glass opacity, which had slightly progressed since the
prior study. Overall, radiographically likely represented
worsening pulmonary edema, interstitial lung disease could not
be ruled out. There were a few pulmonary nodules, have been
stable since [**2115-4-25**]. There is cardiomegaly involving the
left atrium and ventricle, pulmonary arterial hypertension as
well as cholelithiasis. Echocardiogram from that admission
demonstrated an EF of 50% with a moderately dilated LV cavity
mildly depressed LVEF and the normal RV and normal right
ventricle aorta, minimal AS, MR, 2+ MR [**First Name (Titles) 151**] [**Last Name (Titles) **] that was
estimated as moderate. Of note, eccentric jet of at least 2+
mitral regurgitation was seen and due to acoustic shadowing, the
severity of MR could have been underestimated per report.
Spirometry and DLCO at that time also demonstrated moderate
restrictive ventilator deficit with a severe gas exchange and no
significant response with bronchodilator testing. Most recent
spirometry testing is stable. FVC of 1.29, 42% predicted, FEV1
is 0.94, 47% predicted; and FEV1/FVC ratio is 73, 111%
predicted. Overall, he has a stable restrictive ventilatory
deficit, no DLCO was done. He saw pulmonary on [**2119-10-5**], who
felt that he does not have PFTs supporting COPD and stopped his
Advair and Spiriva. They noted thrush that is likely secondary
to the Advair and gave him a 7 day course of nystatin. He saw
his PCP [**Last Name (NamePattern4) **] [**2119-10-16**], who started him on Clindamycin 300 mg QID
for 14 days for recurrent cellulitis, however, he was not
tolerating the abx. He was placed on Bactrim for 10 days (last
day - [**2119-11-9**]). He was also started on Miralax for 17 g daily
for constipation. Today, he was seen by visiting nurse today
for INR check but was found to be in CHF exacerbation (SOB,
edematous, 02 sat 87% on 3L, crackles 1/2 up. BP 110-120. Wife
reports that he has been coughing up dark sputum, not sleeping
at baseline 2 pillows at night due to PND. No fevers). He was
referred to the ED by Dr. [**Last Name (STitle) 1911**].
.
In the ED: intial vitals were: 97.1 70 126/79 40 74% 3L NC. Labs
were significant for BNP 6843 and trop 0.02 (baseline), Cr 3.0
(baseline of 1.8), INR 10.1 and Hct 28.7. Physical exam was
significant were crackles at the bilateral lower lung fields and
erythema of the b/l lower extremity. A chest xray demonstrated
moderate congestive heart failure. Guaiac was negative. DRE
was notable for mixture of bright red blood and brown stool -> ?
anal lesions. His saturation improved with BiPAP, however, his
sats fell to the 90 and he developed retractions on trial off
BiPAP. He was given aspirin, lasix 40 x1, sl NG x2. Vitals on
transfer: 70 107/74 33 100% on non-rebreather.
.
On arrival to the floor, initial vitals are 70 99/42 25 100%
sat. He is accompanied by wife and son and is dyspneic on exam.
His wife and son translated.
.
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:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
- CABG: s/p CABG in [**2091**] and [**2099**] (SVG-LAD, SVG-OM1)
- PERCUTANEOUS CORONARY INTERVENTIONS: Successful Cypher
stenting of the mid-LCX [**2110**]
- PACING/ICD: biventricular ICD implantation in [**2110**]
.
3. OTHER PAST MEDICAL HISTORY:
- Chronic atrial fibrillation status post AV nodal ablation in
[**2114**]
- Chronic renal insufficiency with intolerance to ACE inhibitors
and ARBs (baseline creatinine prior to admit 1.8)
- mitral valve annuloplasty in in [**2115**] (size 28 [**Doctor Last Name **] Physio
ring)
- Diabetes type 2, on insulin
- infarcted cardiomyopathy
- CVA in [**2115**]
Social History:
- Married with two sons. [**Name (NI) **] is retired from construction work.
- He came from [**Country 5881**] >30 yrs ago and only speaks [**Country 24075**] but wife
can communicate well in both [**Name (NI) 24075**] and English.
- Former smoker (smoked 4ppd, quit 12 years ago) for ~120pack-yr
history
- Occasional EtOH.
- Denies other drugs.
- employment: exposure to asbestos in [**Name (NI) 24075**] navy, 41 years in
construction.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
PHYSICAL EXAMINATION (on admission):
.
VS: T=98 BP=99/42 HR=70 RR=20 O2 sat= 100% on nrb
GENERAL: Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple, JVP to 10cm.
CARDIAC: RR, normal S1, S2. [**1-30**] harsh blowing murmur heard best
at the apex but radiating to the carotids.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were labored, accessory muscle use. Stable lung exam, trace
crackles just on the left side, good air movement despite lower
saturations.
ABDOMEN: Soft, NTND. No HSM or tenderness, BS present
EXTR: 3+ edema to the ankle, erythematous, + peteche. No joint
tenderness.
SKIN: LE erythema c/w venous stasis changes.
PULSES:
Right: Carotid 2+ 1+ DP 1+ PT 2+ radial 2+
Left: Carotid 2+ DP 1+ PT 1+ radial 2+
Pertinent Results:
ADMISSION LABS:
.
[**2119-11-6**] 01:35PM BLOOD WBC-7.2 RBC-2.87* Hgb-8.8* Hct-28.7*
MCV-100* MCH-30.7 MCHC-30.7* RDW-19.3* Plt Ct-112*
[**2119-11-6**] 01:35PM BLOOD PT-98.7* PTT-64.3* INR(PT)-10.11*
[**2119-11-6**] 01:35PM BLOOD Glucose-176* UreaN-57* Creat-3.0*#
Na-132* K-5.8* Cl-96 HCO3-24 AnGap-18
[**2119-11-7**] 04:37AM BLOOD ALT-26 AST-63* LD(LDH)-615* CK(CPK)-66
AlkPhos-121 TotBili-1.1
[**2119-11-7**] 04:37AM BLOOD CK-MB-3 cTropnT-0.02*
[**2119-11-6**] 01:35PM BLOOD cTropnT-0.02*
[**2119-11-6**] 01:35PM BLOOD proBNP-6843*
[**2119-11-7**] 04:37AM BLOOD Albumin-3.9 Calcium-8.8 Phos-5.7*#
Mg-3.1* Iron-35*
[**2119-11-7**] 04:37AM BLOOD calTIBC-337 Ferritn-164 TRF-259
[**2119-11-7**] 03:14PM BLOOD C3-116 C4-27
[**2119-11-7**] 05:11AM BLOOD Type-ART pO2-45* pCO2-49* pH-7.39
calTCO2-31* Base XS-3
[**2119-11-6**] 01:41PM BLOOD Lactate-2.3* K-5.1
[**2119-11-7**] 05:11AM BLOOD O2 Sat-73
.
ON DISCHARGE:
[**2119-11-28**] 05:32AM BLOOD WBC-6.0 RBC-2.56* Hgb-7.9* Hct-25.6*
MCV-100* MCH-30.8 MCHC-30.8* RDW-20.9* Plt Ct-164
[**2119-11-28**] 05:32AM BLOOD PT-16.2* PTT-68.6* INR(PT)-1.5*
[**2119-11-28**] 05:32AM BLOOD Glucose-92 UreaN-63* Creat-1.7* Na-142
K-4.3 Cl-103 HCO3-34* AnGap-9
MICROBIOLOGIC STUDIES:
[**2119-11-6**] Blood culture - negative
[**2119-11-6**] Urine culture - negative
[**2119-11-6**] MRSA screen - negative
[**2119-11-7**] Bronchoalveolar lavage - no organisms, no PMNs -
negative
[**2119-11-7**] Broncheal washings - negative for malignancy
[**2119-11-7**] Rapid Respiratory Viral Screen & Culture - negative
[**2119-11-7**] Blood culture - negative
[**2119-11-8**] Blood culture - negative
[**2119-11-8**] Blood culture - negative
[**2119-11-8**] Urine culture - negative
[**2119-11-9**] Blood culutre - negative
[**2119-11-9**] Urine culture - negative
[**2119-11-9**] Sputum culture - no organisms seen; negative
[**2119-11-9**] Blood culture - negative
.
IMAGING STUDIES:
[**2119-11-6**] CHEST (PORTABLE AP) - Patient is status post median
sternotomy, CABG, and mitral valve replacement. A left-sided
AICD device is noted with leads terminating in the right atrium,
right ventricle, and coronary sinus. Mild enlargement of the
cardiac silhouette is redemonstrated, with unchanged tortuosity
of the thoracic aorta. There is perihilar haziness with vascular
indistinctness and diffuse alveolar opacities compatible with
moderate pulmonary edema. No large pleural effusion or
pneumothorax is seen. There are no acute osseous abnormalities.
.
[**2119-11-7**] CT CHEST W/O CONTRAST - Since [**2119-9-12**],
bilateral interstitial thickening and ground-glass opacities
have progressed, new multifocal peribronchial consolidations and
small bilateral pleural effusions, right side more than left,
are concerning for concurrent multifocal lung infection and
pulmonary edema in the background
of pre-existing interstitial abnormalities. Moderate
cardiomegaly, predominantly involving the left [**Doctor Last Name 1754**]. Mild
pulmonary arterial hypertension. Multiple enlarged mediastinal
lymph nodes are stable.
.
[**2119-11-8**] 2D-ECHO - No atrial septal defect is seen by 2D or
color Doppler. There is mild regional left ventricular systolic
dysfunction with hypokinesis of the mid to distal septum.
Overall left ventricular systolic function is low normal (LVEF
50-55%). Right ventricular chamber size and free wall motion are
normal. There are simple atheroma in the aortic arch and the
descending thoracic aorta. The aortic valve leaflets (3) are
mildly thickened. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. A mitral valve annuloplasty
ring is present. Mild to moderate ([**11-27**]+) mitral regurgitation is
seen. Moderate [2+] tricuspid regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion. Mild to moderate mitral regurgitation in
spite of a well seated mitral annuloplasty ring. Moderate
tricuspid regurgitation. Moderate pulmonary arterial systolic
hypertension.
.
[**2119-11-8**] RENAL U.S. PORT - The right kidney measures 10.2 cm and
the left kidney measures 10.2 cm. There is no hydronephrosis. No
perinephric fluid collection is identified. No stone or
suspicious solid mass is seen in either kidney. A cyst is seen
at the upper pole of the right kidney on the posterior margin
measuring 2.4 x 2.2 x 2.4 cm. A cyst is also seen at the lower
pole of the right kidney measuring 1.4 x 1.2 x 0.9 cm. The
urinary bladder could not be assessed as a Foley catheter is in
place.
.
[**2119-11-8**] CT HEAD W/O CONTRAST - There is an unchanged region of
cystic
encephalomalacia in the posterior left parietal lobe resulting
from an old
infarct. This lesion is expectedly associated with volume loss
and ex vacuo dilation of the occipital [**Doctor Last Name 534**] of the left lateral
ventricle. There is a hypoattenuating focus of within the right
corona radiata (2:19), from an old lacunar infarct, also stable
from [**2115**]. There is no evidence of hemorrhage, edema, mass, mass
effect, new infarction, or hydrocephalus. Mild sulcal prominence
is consistent with age-related cerebral cortical atrophy. The
visualized paranasal sinuses, mastoid air cells, and middle ear
cavities are clear. No acute intracranial process. Cystic
encephalomalacia due to an old left posterior parietal infarct.
Old lacunar infarct in the right corona radiata.
.
[**2119-11-9**] EEG - This continuous monitoring continues to show a
diffuse
encephalopathy that does not have any clear focal or
lateralizing
features. There were a few interictal epileptic discharges
identified
by computer algorithm but no sustained seizures.
.
[**2119-11-12**] CXR - Since the prior radiograph there was interval
insertion of right internal jugular line with its tip
terminating in the level of cavoatrial junction. There is no
evidence of pneumothorax or apical hematoma. The ET tube tip is
4.3 cm above the carina. The replaced mitral valve and the
pacemaker leads are in unchanged position. Overall there is no
change in widespread parenchymal opacities, bibasal atelectasis
and pleural effusion.
[**2119-11-24**] Radiology CT HEAD W/O CONTRAST
1. No acute intracranial process.
2. Stable cystic encephalomalacia secondary to old left
posterior parietal
infarct.
3. Stable right corona radiata lacune.
CHEST (PORTABLE AP) Study Date of [**2119-11-25**] 11:54 AM
Bedside frontal radiograph centered at the diaphragm shows
nasogastric tube ending in the proximal duodenum, and the distal
portions of a transvenous right ventricular pacer defibrillator
and left ventricular pacer leads, as well as a right PICC lead
that ends in the upper right atrium and retained epicardial
leads. Previous mild pulmonary edema has improved, but there is
still substantial consolidation at the right lung base probably
largely atelectasis. There is no appreciable pleural effusion in
the imaged portion of the chest. The apices of the lungs are not
included in this image. Mild-to-moderate cardiomegaly is
unchanged.
EEG Study Date of [**2119-11-11**]
IMPRESSION: This continuous monitoring continues to show a
diffuse
encephalopathy that does not have any clear focal or
lateralizing
features. There were a few interictal epileptic discharges
identified
by computer algorithm but no sustained seizures.
BRONCHIAL WASHINGS Procedure Date of [**2119-11-7**]
NEGATIVE FOR MALIGNANT CELLS
Abundant hemosiderin-laden macrophages and squamous cells.
Brief Hospital Course:
76 M w Hx of systolic congestive heart failure (EF 50% in
[**2119-8-26**]), CAD s/p CABG (SVG-LAD, SVG-OM1), PCI with LCx,
mitral valve repair in [**2115**] (28 [**Doctor Last Name **] physio ring),
biventricular ICD implantantation, and atrial fibrillation s/p
AV-nodal ablation in [**2114**] (on Coumadin, INR 10.1 on
presentation), who presented with worsening shortness of breath
x 1-days duration found to have diffuse alveolar hemorrhage
resulting in acute hypoxic respiratory failure, acute on chronic
renal insufficiency, coagulopathy and anemia with
thrombocytopenia, which all fortunately resolved.
.
# ACUTE HYPOXIC RESPIRATORY FAILURE, DIFFUSE ALVEOLAR HEMORRHAGE
?????? The patient presented with a known restrictive lung disease
pattern based on previous PFTs; history of remote COPD and
extensive prior smoking history with asbestos exposures. He also
is on 2-3L home oxygen via nasal cannula at baseline. On
admission, he was acutely hypoxic with labored breathing and
tachypnea, thus he was switched from his home nasal cannula to
BiPAP with partial response initially. Overnight on [**11-6**] he
continued to have worsening oxygen desaturations in the setting
of positive pressure ventilation and he began expectorating
red-blood tinged sputum with worsening ABG values (acute
respiratory acidosis in the setting of compensatory metabolic
alkalosis). He was also aggressively diuresed (with good
diuretic response) on admission with a Lasix gtt and his CXR
appeared worsened with worsening pulmonary status. Etiologies
considered: diffuse pulmonary hemorrhage (DAH) given
coagulopathy and worsening CXR findings and acute hypoxia in the
setting of adequate diuresis vs. lobar consolidation and
pneumonia with superimposed pulmonary congestion vs. worsening
diastolic heart failure with pulmonary congestion. Given his
worsening oxygenation and poor clinical response, he was
non-urgently intubated on [**2119-11-7**]. Pulmonary Medicine was
consulted and a bronchoalveolar lavage with bronchoscopy was
requested. The bronchoscopy demonstrated evidence of blood,
although the hematocrit from the sample was < 2.0%. A chest CT
was obtained that demonstrated bilateral diffuse interstitial
thickening and multifocal peribronchial opacities and moderate
right and small left new pleural effusions suggest a combination
of multifocal lung infection and edema. These CT features did
not favor pulmonary hemorrhage nonetheless. He was also noted to
spike fevers to 101F with negative culture data, but he was
covered with IV Vancomycin, Azithromycin and Ceftriaxone since
admission -- and was broadened given concern for on-going fevers
to Cefepime on [**11-9**]. This was discontinued on [**11-12**]. Overall,
his WBC remained reassuring despite fevers. We sent a number of
vasculitides laboratory studies given the concern for a primary
lung, renal and dermatologic process (see below), which
included: a negative ANCA, negative [**Doctor First Name **], negative HIV antibody,
anti-GBM, anti-histone, cyroglobulins, anti-lupus antibody, C3
and C4 levels were normal. He was conservatively supported to
reverse his coagulopathy in the setting of his presumed diffuse
alveolar hemorrhage. He received 5 mg PO Vitamin K, 4 units of
fresh frozen plasma (for an INR of 10.1 on admission, which
improved) and 2 units of packed red cells total given an HCT of
21%. He was extubated [**11-18**]. His respiratory status returned
near his baseline of 2LNC at rest and 4LNC with exertion.
.
# DIASTOLIC CONGESTIVE HEART FAILURE ?????? The patient presented
with a known CHF history; 2D-Echo from [**8-/2119**] showing a
moderately dilated left ventricular cavity with mildly depressed
LV systolic function and mid- and apical septal hypokinesis with
inferior akinesis/hypokinesis (LVEF 34-50%, discrepancy with
perfusion imaging and 2D-Echo). Per his VNA, he has been more
edematous with increasing dyspnea, oxygen saturations in the 87%
range on 3L NC, and his wife notes that he had been coughing up
dark-red sputum, but he has remained afebrile. Although his
clinical picture became more concerning for a primary pulmonary
process, etiologies to consider for acute diastolic CHF
exacerbation: infectious (WBC 7.2, afebrile. U/A negative, urine
and blood cultures drawn and CXR showing pulmonary congestion
without focal consolidation on admission (but CT imaging later
showing multifocal consolidation and edema), lower extremity
venous stasis changed noted) vs. dietary indiscretion vs.
medication non-compliance vs. uncontrolled hypertension
(unlikely) vs. worsening valvular disease (s/p MVR repair with
2+ MR noted on 2D-Echo from [**2119-8-26**]) vs. ACS/MI (EKG
stable, Troponin 0.02) vs. Bactrim interacting with his heart
failure medications vs. progression of restrictive lung disease
(PFTs showing restrictive ventilatory defect). On exam, he
appeared volume overloaded with pedal edema and inspiratory
crackle to the mid-lung fields with elevated JVP. He was placed
on a Lasix gtt and has had adequate diuretic response with
minimal oxygenation improvement on his ABGs. Therefore he
required intubation (see above). We decreased his diuresis goal
to even or 0.5L daily given the suspicion of a primary pulmonary
process. We entertained the possible need for right heart
catheterization to evaluate his PCWP, filling pressures to
better understand his diastolic function in the setting of his
respiratory decompensation, but this was deferred. Hif formal
2D-Echo/TEE showed mild to moderate mitral regurgitation in
spite of a well-seated mitral annuloplasty ring with moderate
tricuspid regurgitation and moderate pulmonary arterial systolic
hypertension; LVEF 50-55%. Given these findings, we assumed his
lung issues were the primary concern for his respiratory
failure, with a component of diastolic heart failure. We
attempted to maintain his home heart failure regimen, but held
many of his medications given his diastolic dysfunction and
hypotension. We continued his Coreg at a lower dose initially.
We intermittently dosed IV Lasix for diuretic effect given his
diastolic failure. He seems to be currently euvolemic to mildly
hypervolemic.
# CORONARIES - The patient presented with 3-vessel coronary
artery disease status post-CABG in [**2091**] and a re-do in [**2099**]
(SVG-LAD, SVG-OM1), PCI with LCx proximal Cypher stent in [**2110**] ??????
stress testing with myocardial perfusion imaging [**2119-9-1**] showing
stable moderate predominantly fixed defect in the inferior,
inferolateral walls and apex with inferior wall hypokinesia and
an LVEF of 34% with no anginal symptoms on stress testing. He
presented with no chest pain this admission; EKG on admission
was without ST-changes, V-paced. Troponin 0.02 (times 2-sets) in
the setting of renal insufficiency, CK-MB 3. He was initially
continued on his home Aspirin dosing, but this was discontinued
given the concern for DAH. His statin medication was continued.
Serial EKGs were closely monitored.
.
# RHYTHM - The patient has a history of chronic atrial
fibrillation and is status-post ablation in [**2114**], with placement
of a biventricular device and ICD previously. His EKG
demonstrates a V-paced rhythm. For his atrial fibrillation, his
CHADs-2 score is 6 and Coumadin and Aspirin were utilized at
home. Given his findings of diffuse alveolar hemorrhage and
hematuria issues in the setting of coagulopathy, his
anticoagulation was initially held. His INR trended down nicely.
Given his 2 prior ischemic stroke events, we judiciously held
anticoagulation when his INR dropped below 2, but his bleeding
concerns were more of an issue at the time. His Coumadin was
resumed on [**2119-11-14**] after his INR and coagulopathy had
normalized and his diffuse alveolar hemorrhage concerns
subsided.
..
# SUPRATHERAPEUTIC INR, COAGULOPATHY, ANEMIA AND
THROMBOCYTOPENIA ?????? Patient presented on Coumadin for chronic
atrial fibrillation with a supratherapeutic INR of 10.1 given
his recent initiation of sulfa drug (Bactrim) for presumed lower
extremity cellulitis vs. chronic venous stasis changes. His INR
could also have been elevated in the setting of poor PO intake.
He had no evidence of bleeding on admission. His HCT was 28.7%
on admission guaiac positive in the ED with some mixed
blood-stool on rectal exam, but remained hemodynamically stable.
His INR was serially trended and improved following
administration of vitamin K and FFP while holding his
anticoagulation. Given the concern for diffuse alveolar
hemorrhage (see above), his anticoagulation was held, we
transfused him 2 units of packed red cells for a HCT of 21%, 4
units of fresh frozen plasma for INR reversal and dosed 5 mg of
PO Vitamin K. An active type and screen with adequate IV access
was maintained at all times. He developed significant marcocytic
anemia, thrombocytopenia to the 70s over his length of stay. A
DIC panel was overall reassuring, with some transient
hyperbilirubinemia, but negative peripheral smear. Hemolysis was
considered, but a DAT was negative. Hematology was consulted and
felt that marrow suppression was most likely, but other factors
were contributing, such as low iron utilization in the setting
of chronic renal insufficiency, vitamin B12 deficiency, and iron
deficiency anemia and active infection. He was supportively
managed and overall improved.
.
# ACUTE ON CHRONIC RENAL INSUFFICIENCY ?????? The patient presented
with a baseline creatinine of 1.8 to 2.5 based on our records;
renal insufficiency has been attributed to diabetic nephropathy
in combination with diastolic dysfunction and poor perfusion
pressures. His history of intolerance to ACEI/ARBs has been
noted. Now presented with creatinine of 3.0, hyponatremia to 132
and some hyperkalemia with evidence of volume overload on exam
during admission ?????? urine lytes demonstrate FeUrea of 38.45%
(FeNa of 1.73% but on diuretics) consistent with intra-renal or
post-renal process ?????? concern for ATN vs. intrinsic renal process
given poor forward perfusion pressures in the setting of acute
congestive heart failure exacerbation vs. intrinsic renal
process which could tie together his pulmonary hemorrhage and
renal failure (Goodpasture??????s vs. Wegeners or other medium-vessel
vasculitidies). As noted above, vasculitides studies were sent
but were all reassuring. His electrolytes were closely
monitored, his creatinine was trended and we avoided nephrotoxic
medications and renally dosed his medications. Nephrology was
consulted and agreed with overall management. His creatinine
steadily improved.
.
# LOWER EXTREMITY PURPURA, PETECHIAE; VENOUS STASIS CHANGES ?????? He
has evidence of chronic venous stasis changes of the lower
extremity; was started on Clindamycin and then Bactrim by his
PCP for presumed [**Name9 (PRE) 24093**] MRSA coverage and lower
extremity cellulitis vs. erysipelas. Exam on admission was
notable for prominent ecchymoses in many stages of evolution
with superimposed chronic venous insufficiency changes.
Dermatology was consulted given the irregular appearance and the
concern for a vasculitis. They thought the lesions could be
venous stasis changes vs. coagulopathy-induced ecchymoses vs.
capillaritis vs. a leukocytoclastic vasculitis (LCV). The most
likely etiology was coagulopathy-induced purpuric changes.
.
# HYPERTENSION ?????? At home, has been on Hydralazine, Isosorbide
mononitrate and Spironolactone. His Hydralazine was held given
concerns for vasculitis, and his aldosterone antagonist was held
given concerns for hyperkalemia initially.
.
# CONCERN FOR SEIZURE ACTIVITY - The patient presented with no
history of seizure activity or epilepsy, but was noted to have a
single episode of some mild, myoclonic jerking motions which
prompted a head CT which showed a stable prior ischemic infarct
in the left posterior temporal/occipital areas, unchanged from
[**2115**]. There was no new hemorrhage, infarct or mass effect. An
EEG was obtained and was without epileptiform foci or concerning
activity.
.
# HYPERLIPIDEMIA - We continued him on Simvastatin 40 mg PO
daily.
.
# GERD - We continued Ranitidine 150 mg PO daily intially, but
this was switched to Protonix 40 mg IV daily in the setting of
guiac positive stools. An H pylori antigen returned positive,
however after discussion with his PCP and gastroenterologist Dr.
[**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 679**], we decided against triple therapy as the risks of
infection outweighed the benefit of treatment.
.
# NUTRITION - On day 3 of intubation, while the patient remained
NPO, we started Isosource tube feeds for a goal rate of 45 cc/hr
given Nutrition's recommendations, which he tolerated well. Once
his delerium cleared, he passed speech and swallow video study
on [**2118-11-28**], and was advanced to a dysphagia diet.
.
TRANSITION OF CARE ISSUES:
1. Heparin bridge to coumadin (goal INR [**12-29**]) for a fib with RVR
(per his cardiologist Dr. [**Last Name (STitle) **] [**Name (STitle) 24094**] he should be on
lifelong anticoaggulation.
Medications on Admission:
Confirmed
- Home Oxygen 2L NC at rest. 4L Nasal cannula on activity.
- insulin glargine 18 Units Subcutaneous at bedtime
- ferrous sulfate 300 mg (60 mg iron) Tablet PO DAILY
- torsemide 80 mg Tab by mouth twice a day
- Carvedilol 9.375 mg Tab by mouth twice a day
- sulfamethoxazole-trimethoprim 800 mg-160 mg Tab twice daily
(thursday last)
- Aspirin 81 mg Tab by mouth once a day
- hydralazine 25 mg Tab three times daily
- Simvastatin 40 mg Tab 1 Tablet(s) by mouth QPM
- isosorbide mononitrate ER 30 mg 24 hr Tab by mouth daily
- spironolactone 25 mg Tab 1 Tablet(s) by mouth once a day
- Docusate Sodium 100 mg Cap twice a day
- warfarin 4 mg on monday, 2mg on other days
- ranitidine 150 mg Tab 1 Tablet(s) by mouth twice a day
Discharge Medications:
1. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. ferrous sulfate 300 mg (60 mg iron)/5 mL Liquid Sig: One (1)
TAB PO DAILY (Daily).
4. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) TAB PO Q6H
(every 6 hours) as needed for fever, pain.
5. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. isosorbide mononitrate 10 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for SOB and Wheeze.
8. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for SOB and Wheeze.
9. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily) as needed for constipation.
10. insulin glargine 100 unit/mL Solution Sig: Twenty (20)
Subcutaneous at bedtime.
11. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
12. warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM.
13. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
14. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
15. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
16. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
17. 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.
18. heparin (porcine) in D5W 25,000 unit/250 mL Parenteral
Solution Sig: One (1) Intravenous ASDIR (AS DIRECTED): Please
bridge for 48 hours of therapeutic INR ([**12-29**]) and then stop
heparin gtt.
19. Pantoprazole 40 mg IV Q24H
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. Furosemide 80 mg IV BID
Hold for SBP<100
22. insulin aspart 100 unit/mL Solution Sig: One (1)
Subcutaneous once a day: Sliding scale insulin.
Discharge Disposition:
Extended Care
Facility:
Radius [**Hospital1 392**]
Discharge Diagnosis:
Diffuse alveoloar hemorrhage
Coagulopathy
Delerium
Acute on chronic systolic congestive heart failure
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
Completed by:[**2119-11-28**]
|
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"782.7",
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"428.0",
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icd9cm
|
[
[
[]
]
] |
[
"33.24",
"96.72",
"96.6",
"88.72"
] |
icd9pcs
|
[
[
[]
]
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30675, 30728
|
14755, 27803
|
325, 443
|
30874, 30874
|
7289, 7289
|
6289, 6404
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28589, 30652
|
30749, 30853
|
27829, 28566
|
6419, 7270
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5208, 5428
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8202, 9183
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471, 5082
|
7305, 8188
|
30889, 31187
|
5459, 5817
|
5126, 5188
|
5833, 6273
|
9200, 14732
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,690
| 121,080
|
27295
|
Discharge summary
|
report
|
Admission Date: [**2193-1-1**] Discharge Date: [**2193-1-7**]
Date of Birth: [**2124-11-26**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
anemia, hypocalcemia
Major Surgical or Invasive Procedure:
tunneled catheter line
hemodialysis
History of Present Illness:
This is a 68 yo F from the [**Location (un) 3156**], russian speaking only, with
a past medical history of polcystic kidney ds with ESRD,
followed by Dr. [**Last Name (STitle) 4883**], creatinine of late [**10-27**], HTN, who was
sent to the ED from renal clinic after she was found to have a
hct of 16 (baseline 23-25), symptomatic with dyspnea on
exertion, a creatinine of 16, bicarb of 6 and corrected calcium
of 5. She was guaiac negative.
In the emergency department, her vitals were T 97.9, HR 83, BP
117/43, RR 14, O2sats 99% room air. She was found to also have
elevated pancreatic enzymes and was sent for RUQ u/s. Renal saw
the patient in the ED and plan to place tunnelled cath in AM and
initiate HD. She also received 4g Ca++gluconate and 1 unit of
pRBC's. She was found to have a UTI and was given 1 dose of
ciprofloxacin.
VBG with pH of 7.1 and was initiated on Na+bicarb.
.
.
ROS: She admits to progressive worsening of fatigue worst over
last year; +n/v about 1 week ago and +RUQ pain for 3 days,
although has had right flank pain for "a while" ?beginning of
[**Month (only) **]. +chills, +constipation, +back pain (chronic), +HA.
Past Medical History:
Polycystic Kidney Disease: Creatinine 5.5 [**5-20**], evaluated by
renal at that time, started on phos binder; refused HD in the
past and on most recent admission.
H/o AG/Non-gap acidosis
H/o of Kidney stone
Hematuria: attributed to cyst rupture
HTN
Anemia: attributed to renal failure.
Uterine prolapse
Social History:
Lives in [**Country 532**] in the [**Location (un) 3156**], here about 5 month visiting
family, denies past or current tobacco, illicit drug use.
Occasional EtOH, never heavy.
Family History:
Uncle w/ [**Name (NI) 18048**], father deceased in [**Name (NI) **], maternal aunt w/ CVA
Physical Exam:
VS: Temp: 96.1 BP: 136/64 HR: 94 RR: 15 O2sat: 99% RA
GEN: pale, tired appearing 68 yo F, no acute distress
HEENT: PERRL, EOMI, anicteric, pale conjunctiva, MM dry, op
without lesions.
NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no
goiter palpated.
RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl, III/VI SEM heard throughout the
precordium, best at LUSB, radiates to carotids.
ABD: soft, ND/+BS, tender to palpation along the right flank. No
rebound/guarding. Mild ttp across epigastrium. - [**Doctor Last Name **]
EXT: 1+ pitting edema to knees. no c/c, warm, good pulses
SKIN: no rashes/no jaundice
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated. 2+DTR's-patellar
and biceps. Resting tremor. No asterixis.
.
Pertinent Results:
EKG: 1st degree AV block. Compared with prior from [**2192-10-18**],
there is no significant change.
.
Imaging:
.
CXR: IMPRESSION: Superior mediastinal widening may be due to a
thyroid goiter, tortuous vessels, or lymphadenopathy. Further
evaluation starting with a dedicated PA and lateral chest
radiograph are recommended.
.
Abd U/S: IMPRESSION:
1. Normal gallbladder with no evidence of cholecystitis.
2. Massive polycystic kidneys with no definite evidence of
hydronephrosis,
though evaluation is very limited.
3. No ascites identified.
[**2193-1-1**] 10:25AM PT-13.8* PTT-36.8* INR(PT)-1.2*
[**2193-1-1**] 10:25AM NEUTS-80.6* BANDS-0 LYMPHS-15.3* MONOS-2.7
EOS-1.2 BASOS-0.2
[**2193-1-1**] 10:25AM WBC-11.9* RBC-1.93*# HGB-5.4*# HCT-16.7*#
MCV-87 MCH-27.8 MCHC-32.1 RDW-17.8*
[**2193-1-1**] 10:25AM PTH-662*
[**2193-1-1**] 10:25AM calTIBC-220* HAPTOGLOB-230* FERRITIN-326*
TRF-169*
[**2193-1-1**] 10:25AM TOT PROT-6.7 ALBUMIN-3.9 GLOBULIN-2.8
CALCIUM-5.6* PHOSPHATE-8.3*# MAGNESIUM-1.6
[**2193-1-1**] 10:25AM IRON-158
[**2193-1-1**] 10:25AM TOT PROT-6.7
[**2193-1-1**] 10:25AM LIPASE-823*
[**2193-1-1**] 10:25AM ALT(SGPT)-32 AST(SGOT)-24 ALK PHOS-129*
AMYLASE-240* TOT BILI-0.2 DIR BILI-0.2 INDIR BIL-0.0
[**2193-1-1**] 10:25AM UREA N-167* CREAT-16.2*# SODIUM-133
POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-6* ANION GAP-27*
[**2193-1-1**] 02:15PM URINE RBC-[**3-19**]* WBC-[**6-24**]* BACTERIA-FEW
YEAST-NONE EPI-0-2
[**2193-1-1**] 02:15PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR
[**2193-1-1**] 02:44PM HGB-5.2* calcHCT-16
.
IMPRESSION:
1. Superior mediastinal widening not seen on current study. No
tracheal displacement or impression to suggest goiter or
lymphadenopathy.
2. No acute cardiopulmonary process.
Brief Hospital Course:
Imp: 68 yo F with polcystic kidney disease and ESRD, presenting
with anemia, acute on chronic renal failure, hypocalcemia and
abdominal pain.
HOPSITAL COURSE BY PROBLEM:
.
#. Acute on Chronic Renal Failure: The patient was initially
admitted to the MICU with progessive worsening of ESRD secondary
to [**Month/Day/Year 18048**] as described above. She had significant metabolic
acidosis. The renal service was involved and recommended the
placement of a tunnelled line to initiate HD. On [**1-2**] the line
was placed and dialysis was initiated. The patient's acid-base
status normalized with several session of HD and the patient was
set up for an out-patient HD schedule.
.
#. Anemia: This was felt to be secondary to her known ESRD. Her
hematocrit improved significantly with the initiation of epopgen
at dialysis.
.
#. Dyspnea on exertion: the patient's rogressive fatigue and
dyspnea on exertion felt most likely to be secondary to marked
anemia from ESRD. A chest x-ray showed no evidence of pneumonia.
Her symptoms resolved with improvement of her hematocrit.
.
#. Abdominal discomfort: The patient had mild right lateral
abdominal pain. RUQ U/S and CT abdomen and pelvis were
unremarkable for any acute process. Her symptoms were felt to
most likely br secondary to her [**Month/Year (2) 18048**]. At the time of dicharge
her symptoms had largely resolved.
.
#. UTI: The patient was placed on ciprofloxacin with a planned
course of ten days to be completed as an out-patient.
.
#. HTN: As an out-patient she was on toprol and norvasc. Her
norvasc was discontinued and lisinopril was initiated given
potential vascular benefits.
.
# F/E/N: The patient was placed on a renal/low sodium diet.
.
# PPx: The patient was place on pneumoboots.
.
# Code Status: Full, consent signed through Russian interpreter.
.
# Communication: Daughter, [**0-0-**]
.
Medications on Admission:
iron supplements [**Hospital1 **]
calcium acetate
amlodipine 5mg qdaily
compazine prn
Toprol XL
Sodium bicarbonate powder
trazadone 25mg qhs
Discharge Medications:
1. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*180 Capsule(s)* Refills:*2*
2. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
3. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
5. Lisinopril 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO at bedtime as
needed for insomnia.
Discharge Disposition:
Home
Discharge Diagnosis:
acute on chronic renal failure
polycystic kidney disease
Discharge Condition:
good, stable on current dialysis schedule
Discharge Instructions:
You were admitted for acute on chronic renal failure. You
underwent placement of a tunnel catheter to initiate dialysis.
You underwent several dialysis sessions and tolerated them well.
You will go to dialysis as an outpatient.
.
If you develop fever, chills, pain/redness at the site of the
tunnel catheter, shortness of breath, chest pain, abdominal
pain, nausea, vomiting, or diarrhea, burning on urination, leg
swelling please contact your doctor or go to the emergency room.
.
Please take you medications as prescribed and follow up with the
appointments below.
Followup Instructions:
You should return to [**Hospital1 69**] for
dialysis on Thursday [**2193-1-10**] and Saturday [**2193-1-12**]. On both
days you should report to the [**Hospital Ward Name 121**] building, [**Location (un) 436**] at 7:00
AM. This is where you received in-patient dialysis. Dr. [**Name (NI) 66932**] office will make arrangements for further out-patient
dialysis at another site. If you have any questions, you may
contact his office at [**Telephone/Fax (1) 60**].
You should follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] in the next 2 weeks. Her phone number is
[**Telephone/Fax (1) 32247**].
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2193-1-22**]
10:45
|
[
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"585.6",
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"790.5",
"285.21",
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] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"86.07",
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icd9pcs
|
[
[
[]
]
] |
7581, 7587
|
4844, 6702
|
333, 370
|
7688, 7732
|
3019, 4821
|
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|
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|
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|
6728, 6871
|
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|
2190, 3000
|
273, 295
|
398, 1547
|
1569, 1875
|
1891, 2068
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,534
| 159,636
|
48335
|
Discharge summary
|
report
|
Admission Date: [**2141-1-11**] Discharge Date: [**2141-2-6**]
Date of Birth: [**2088-8-24**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
52F patient w/ HIV last cd4 134 ([**12/2140**]) and viral load 239
([**9-/2140**]) discharged from [**Hospital1 2177**] yesterday, went home and did crack
cocaine, was found unresponsive at [**Location (un) **]T stop. Admits
crack yesterday, denies any drug use today. Remains altered but
through ED course MS has improved and pt. has been able to wake
up and answer questions and was A/Ox3. Some labs faxed over from
[**Hospital1 2177**] (unable to locate them in the chart but per ED notes says
they had them) but pt. has not been able to consent for records
release yet. pt. did endorse Hx of cocaine CMP. Serum tox in the
ED was negative and on labs was noted to have hypoglycemia, ARF
and hyponatremia similar to recent [**1-9**] [**Hospital1 2177**] labs.
.
In ED has altered between sleeping and agitation. Workup showed
hyponatremia which is apparently old as Na a week ago at [**Hospital1 2177**] was
128 per ED attending notes, acute on chronic renal failure (last
cr at [**Hospital1 2177**] was 5.2 now 7), elevated BNP at 4200, mildly elevated
trop (0.06 X 2) with new TWF in inferior leads and TWI V4-V6.
Tox screen was positive for cocaine only. CXR showed right-sided
effusion. Received ASA. CT head showed a small SDH. neurosurgery
was consulted and did not recommend any intervention currently
but Q2H neuro checks and repeat CT in 12 hours. Seizure ppx also
needed -> dilantin ordered . Sleeping currently. Ua was positive
for blood after foley inserted and 300 Ketones. Patient was also
noted to be hypoglycemic to 50s in ED so was given an amp.
.
Admitted to ICU for Q2H neuro checks.
.
VS prior to transfer: 98, 87, 135/76, 15, 95% RA.
.
On arrival to the floor patient was sleeping but arousable. Able
to answer questions and knows where she is and the date. Denied
pain and shortness of breath. Other ROS unable to obtain as
patient does not answer questions.
Past Medical History:
# ? cocaine CMP
# ? CKD with creatinine one week ago at [**Hospital1 2177**] 5.2
# HIV - CD4 138, VL 239 on [**9-13**]
# Histoplasmosis (pulmonary)
# Cocaine use
# Renal Failure (?chronic)
# HTN
# CVA (ischemic left parietal and hemorraghic pons)
# HCV (genotype I)
# Beta thalassemia/G6PD Defeciency
# Hypothyroidism
# Hypothyroid cancer s/p thyroidectomy
Social History:
Lives with her uncle. Does not want her uncle or mother to be
involved in her medical care. Cocaine use +, and alcohol use in
past per OSH records, currently denies other drugs.
Family History:
Unknown
Physical Exam:
Admission Exam
Vitals: T: 97 BP: 130/79 P: 90 R: 15 O2: 97% RA
General: Somnolent, will arouse after repeated voice prompts and
give one word answers before going back to sleep. No acute
distress, skin very dry appearing.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: able to bend chin to chest passively and easy movement
side to side, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Multiple small round slightly raised lesions on the skin
of the arms and legs
Neuro: Pupils sluggish but reactive bilaterally. A+OX 2, speech
slightly slurred. Moving all for extremities.
Pertinent Results:
On admission:
[**2141-1-11**] 09:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2141-1-11**] 11:00PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-POS amphetmn-NEG mthdone-NEG
[**2141-1-11**] 10:30PM GLUCOSE-58* UREA N-47* CREAT-7.0* SODIUM-126*
POTASSIUM-4.3 CHLORIDE-90* TOTAL CO2-22 ANION GAP-18
[**2141-1-11**] 09:24PM GLUCOSE-56* LACTATE-1.7 K+-4.8
[**2141-1-11**] 10:30PM CALCIUM-8.5 PHOSPHATE-5.2*# MAGNESIUM-2.0
[**2141-1-11**] 09:20PM ALT(SGPT)-5 AST(SGOT)-30 ALK PHOS-58 TOT
BILI-0.3
[**2141-1-11**] 09:20PM WBC-7.1 RBC-4.08* HGB-10.2* HCT-31.7*
MCV-78*# MCH-25.0*# MCHC-32.2 RDW-19.0*
.
Pre Discharge
Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2141-2-4**] 06:40 841 38* 4.2* 128* 4.0 102 17* 13
.
PEP IgG IgA IgM IFE
[**2141-1-14**] 04:18 NO SPECIFI1 3898* [**Telephone/Fax (1) 101814**]* INCREASES 2
T LYMPHOCYTE SUBSET [**2141-1-23**] 09:50
WBC Lymph Abs [**Last Name (un) **] CD3% Abs CD3 CD4% Abs CD4 CD8% AbsCD8
CD4/CD8
5.6 17* [**Telephone/Fax (2) 101815**] 195* 71 677 0.3*
Imaging:
CT head ([**1-11**]): IMPRESSION: Small right parietal subdural
hematoma measures 5mm in thickness. Chronic white matter
disease, could be related to HIV.
Follow up CT Head:
. Stable 5-mm right parietal subdural hemorrhage.
2. Small vessel ischemic disease and cerebral volume loss out of
proportion
to age, which could be related to HIV.
CXR ([**1-11**]): Cardiomegaly with pulmonary edema. Cannot exclude
superinfection. Followup post-diuresis recommended.
CXR [**1-14**]:
FINDINGS: As compared to the previous radiograph, there is
marked
improvement. The pre-existing pulmonary edema has cleared. The
size of the
cardiac silhouette is minimally smaller than on the previous
examination. No
pleural effusions. No focal parenchymal opacity suggesting
pneumonia. Mild
tortuosity of the thoracic aorta. Known right healed rib
fractures
Renal US:
IMPRESSION: Echogenic kidneys bilaterally, indicative of medical
renal
disease. There is no hydronephrosis
.
CT Chest:
1. Diffuse nodular ground-glass opacities, most pronounced in
the left upper
lobe; the differential for which is somewhat broad, but includes
inflammatory
or infectious (atypical pathogens) etiologies.
2. Widespread lymphadenopathy.
3. Small right and trace left pleural effusions.
4. Post-surgical changes seen in the right upper lung lobe and
around the
thyroid.
.
.
.
TEE [**2141-2-2**]
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium or left atrial appendage. Mild spontaneous echo
contrast is seen in the body of the right atrium. Right atrial
appendage ejection velocity is good (>20 cm/s). No thrombus is
seen in the right atrial appendage No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers (patient intermittenty cooperative). No
late contrast is seen in the left heart (suggesting absence of
intrapulmonary shunting). There is moderate global left
ventricular hypokinesis (LVEF = 30 %). No masses or thrombi are
seen in the left ventricle. Right ventricular chamber size and
free wall motion are normal. The ascending, transverse and
descending thoracic aorta are normal in diameter and free of
atherosclerotic plaque to 45 cm from the incisors. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion. No masses or vegetations are seen on the aortic
valve. There is no aortic valve stenosis. Mild to moderate
([**2-5**]+) aortic regurgitation is seen. The mitral valve leaflets
are structurally normal. No mass or vegetation is seen on the
mitral valve. Moderate (2+) mitral regurgitation is seen.
Moderate [2+] tricuspid regurgitation is seen. There is no
pericardial effusion.
IMPRESSION: No intracardiac source of thromboembolism
identified. Moderately depressed global left ventricular
systolic function. Mild to moderate aortic regurgitation.
Moderate mitral regurgitation. Moderate tricuspid regurgitation.
.
Microbiology
Sputum: AFBx negative x3
TOXOPLASMA IgG ANTIBODY (Final [**2141-2-2**]):
NEGATIVE FOR TOXOPLASMA IgG ANTIBODY BY EIA.
0.0 IU/ML.
Reference Range: Negative < 4 IU/ml, Positive >= 8 IU/ml.
If acute infection is suspected request IgM antibody
testing and/or
submit convalescent serum in [**3-9**] weeks.
CMV Viral Load (Final [**2141-1-31**]):
CMV DNA not detected.
Performed by PCR.
Detection Range: 600 - 100,000 copies/ml.
FOR RESEARCH USE ONLY. NOT FOR USE IN DIAGNOSTIC
PROCEDURES.
This test has been validated by the Microbiology
laboratory at [**Hospital1 18**].
CRYPTOCOCCAL ANTIGEN (Final [**2141-1-29**]):
CRYPTOCOCCAL ANTIGEN NOT DETECTED.
Performed by latex agglutination.
(Reference Range-Negative).
A negative serum does not rule out localized or
disseminated
cryptococcal infection.
Appropriate specimens should be sent for culture.
HIV-1 Viral Load/Ultrasensitive (Final [**2141-1-26**]):
12,000 copies/ml.
Performed using the Cobas Ampliprep / Cobas Taqman HIV-1
Test.
Detection range: 48 - 10,000,000 copies/ml.
This test is approved for monitoring HIV-1 viral load in
known
HIV-positive patients. It is not approved for diagnosis of
acute HIV
infection.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB (Final [**2141-1-26**]): POSITIVE BY
EIA.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB (Final [**2141-1-26**]): POSITIVE
BY EIA.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM AB (Final [**2141-1-26**]):
NEGATIVE <1:10 BY IFA.
CSF Studies
GRAM STAIN (Final [**2141-1-19**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2141-1-25**]): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
VIRAL CULTURE (Preliminary): No Virus isolated so far.
CRYPTOCOCCAL ANTIGEN (Final [**2141-1-19**]):
CRYPTOCOCCAL ANTIGEN NOT DETECTED.
(Reference Range-Negative).
HIV-1 Viral Load/Ultrasensitive (Final [**2141-1-20**]):
9,280 copies/ml.
Performed using the Cobas Ampliprep / Cobas Taqman HIV-1
Test.
Detection range: 48 - 10,000,000 copies/ml.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS QUANTITATIVE-COMPETITIVE PCR
LABORATORY REPORT
Test Result- CSF
-----------
200 EBV genomes/10(5) lymphocytes
RAPID PLASMA REAGIN TEST (Final [**2141-1-15**]):
NONREACTIVE.
Reference Range: Non-Reactive.
Brief Hospital Course:
52F HIV/AIDS admitted for encephalopathy and subdural hematoma
after crack cocaine use, found to have subdural hematoma,
myxedema coma, acute on chronic CRI, chronic systolic CHF, ruled
out for TB and worked up for abnormal brain MRI signals before
discharge to [**Hospital3 **].
.
ACTIVE ISSUES:
# Multifactorial Encephalopathy: Presented with acute changes in
mental status in setting of recent history of crack/cocaine and
medication non-compliance after discharge from [**Hospital3 9947**]. Etiology likely multifactorial including myxedema coma,
drug effects/withdrawal, HIV encephalopathy, concussion in
setting of recent fall, hypothyroidism, and hyponatremia.
Hypothyroidism was treated with IV levothyroxine (see below).
The patient had evidence for a small subdural hematoma, but this
was unlikely to be contributing given the small size
(Neurosurgery and Nueorlogy consulted). Other infectious work-up
negative (I.D. Consulted) Patient underwent two LPs that
revealed EBV in CSF but negative workup for primary CNS
lymphoma. The patient was AOX3 at the time of discharge.
.
# Myxedema Coma: s/p thyroidectomry and radioiodine ablation for
papillary thyroid cancer. Hx of non-compliant with her
levothyroixine as her TSH was severely elevated (greater then
assay). Endo consulted. Repleted with levothyroxine 100mcg
daily. Adrenal insuficiency was investigated in setting of both
hypothyrodism + hypoglycemia. [**Last Name (un) **] stim test was negative,
cortisol had appropriate increase 17-->33. Thyroglobulin test
was negative, without signs of relapsed cancer. Pt's TSH
improved during hospitalization from >100 to 63.
-- Follow-up TSH within 4 weeks of discharge
.
# Multiple Cerebral Emboli: Pt complained of vertigo [**1-14**] with
both motion and when lying down. negative Epley . Neurology was
consulted. 1st LP with lymphocytic pleocytosis with elevated
protein that was thought most likely [**3-8**] HIV neuro-cognitive
disorder. CSF EBV PCR was positive. Pt's vertigo improved during
the hospitalization and it was ultimately attributed to
post-concussion vs phenytoin use vs thromboemoblic event with
cerebellar involvement. MRI brain was performed which revealed
possible thromboembolic event (multiple small acute-subacute
infarcts crossing vascular territories) in addition to FLAIR
hyperintensity along the splenium of the corpus callosum which
might represent. 2nd LP ruled out Primary CNS lymphoma was
negative. TTE was negative. TEE showed no intracardiac
defects/asd and no valvular vegetations.
--neurology recommends f/u MRI and Protein C,S and ATIII as
outpatient. F/u in late [**2140-2-5**]. Will arrange MRI at the
time as necessary.
.
# Acute on Chronic Kidnery: Unclear baseline Cr. Cr peaked at 7
and trended down until time of discharge. Renal US [**Hospital 101816**]
medical renal disease (echogenic kidneys bilaterally). DDx
includes cocaine induced, systolic CHF exacerabation (see below)
HIV related. The pt was diuresed with 80 PO lasix daily. Lasix
was held for hyponatremia, and restarted at 40 mg PO qday for
diuresis. Can be held for persistent hyponatremia or increased
for fluid overload in the presence of acute worsening of heart
failure.
- f/u chem panel within 1 week of discharge.
- f/u with outpatient Nephrologist
.
# Subdural Hematoma: Small subdural hematoma on CT (right
parietal lobe).Stable on repeat CT. Neurosurgery consulted and
recommended no intervetion. Provided phenytoin for seixure
prophylaxis x 1 week.
--follow up with neurosurgery to have repeat head CT.
.
# Epistaxis: Pt had epistaxis episode during hospitalization.
Possibly [**3-8**] recent cocaine use. Pt had HCT drop from 31-->18.8.
Profuse bleeding possible complicated by uremic platelets. Her
nose was packed and she was given nasal spray, Oxymetazoline.
She was transfused 4 U PRBC and HCT stabalized.
.
# Hyponateremia: The patient's serum sodium dropped as low as
125. Hyponatremia was thought to be due to poor nutrition and
poor PO intake coupled with SIADH due to pulmonary/intracranial
issues. It improved after giving fluids, po food, and holding of
Lasix. Stabalized at 128. Fluctuates to as low as 125.
Patient non-complaint with urine electrolyte testing, IVF
repelteition. Hyponatremia is a chronic issue and most likely
not etiology of admission MS changes. Restarted on 40 mg po
lasix for ICM, should recheck sodium.
--recheck sodium within 5 days of discharge.
# Elevated lipase: The patient's lipase was elevated at 200 and
trended down to 169. She has history of chronic pancreatitis. Pt
clinically had no signs of pancreatitis and was tolerating foods
with no abd pain.
.
# Crack/cocaine use: Social work was consulted to offer support
and resources to pt. She declined resources at this time.
.
# HIV: The patient's most recent CD4 count was CD4 138 on
[**1-/2141**] , VL 239 on 8/[**2140**]. Pt has had PCP and histoplasmosis,
for which she takes atovaquone and itraconazole. She was
continued on these medications but consistently would refuse the
atovaquone. ID was consulted to start HAART therapy to treat the
EBV positive CSF in addition to protecting against future
opportunistic infections. She was restarted on ARVs and arranged
follow up with [**Hospital 2177**] [**Hospital **] clinic.
.
# ECG changes: The patients ECG had T-wave changes concerning
for ischemia. Her cardiac enzymes were stable x3 (0.06-0.04
range) and she denied any chest pain, nausea, vomiting, or
diaphoresis. Pt with renal failure, likely explaining her
elevated troponins.
.
#CHF: Pt with known cardiomyopathy with depressed EF of 30%. Was
given lasix for diuresis and started on low dose B-Blockers.
Discharged on 40 mg po lasix qday.
-f/u metabolic panel for electrolyte status
.
.
PENDING LABS AT DISCHARGE: None
Transitional Issues: Patient continues to have issues with
noncompliance with medications. Stressed importance of at least
taking AIDS medications as scheduled everyday. Regarding
cocaine use, patient said she would stop but declined addiction
counseling at this interval.
Medications on Admission:
From [**Hospital1 2177**] discharge [**2141-1-10**]:
Synthroid 125 mcg daily
plavix 75 mg daily
Fluticasone inhaler 44 mcg 2 puffs [**Hospital1 **]
albuterol inhaler
Famotidine 20 daily
Itraconazole 200 mg [**Hospital1 **]
cefpodoxime 200 mg x 5 days
atovaquone 1500 mg daily
Aranesp 40 qWednesday
Calcium carbonate 1000 tid
Ferrous gluconate 324 mg tid
Vit D [**Numeric Identifier 1871**] U Qsunday
Calcitriol 0.25 mcg daily
Zofran 4 mg q8hr prn
Diltiazem XL 240 daily
lasix 80 daily
NaHCO3 650 mg tid
calcium acetate 667 mg tid
Colace
APAP
Discharge Medications:
1. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
2. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) Puff Inhalation Q4H (every 4 hours) as needed for
wgeezing, SOB.
5. atovaquone 750 mg/5 mL Suspension Sig: Two (2) PO DAILY
(Daily).
6. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
8. levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
11. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily) as needed for constipation.
12. raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
13. lamivudine 10 mg/mL Solution Sig: Five (5) PO DAILY
(Daily).
14. abacavir 300 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
15. itraconazole 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
16. mupirocin calcium 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
17. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
18. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary Diagnoses:
- Subdural Hematoma
- Encephalopathy
- Hypothyroidism
- Acute Renal failure
- Anemia
- Epistaxis
- Vertigo
.
Secondary Diagnosis:
-Acquired Immunodeficiency Syndrome
-Chronic Histoplasmosis
-Hyponatremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname 449**],
You were admitted to the hospital for a bleed in your brain. You
fell and hit your head. Fortunately, the bleed was small and you
suffered no permanent neurological changes. You were given
dilantin, a medication to prevent seizures. You no longer need
to take this medication.
.
Your kidneys showed signs of renal failure. It is very important
to follow up with your kidney doctors [**First Name (Titles) **] [**Last Name (Titles) 2177**].
.
You were found to be severely hypothyroid, a condition where you
do not produce enough throid hormone. This is likely from not
remembering to take your thyroid medications every day. It is
very important to remember your medications every single day.
Severe hypothyroidism can cause you to be very sleepy and even
go into a coma if it is not controlled.
.
You had some dizziness for several days. The dizziness was
ultimately attributed to your concussion from the fall as well
as maybe from the phenytoin that we gave you. We stopped the
phenytoin.
.
There have been several changes to your medications:
.
YOU HAVE RESTARTED YOUR HIV MEDICATION. PLEASE CONTINUE TO TAKE
AS DIRECTED AND FOLLOW UP WITH YOUR INFECTIOUS DISEASE DOCTOR
FOR FURTHER CHANGES
.
LaMIVudine 50 mg DAILY
Abacavir Sulfate 300 mg [**Hospital1 **]
Raltegravir 400 mg [**Hospital1 **]
.
Other Medications:
Levothyroxine Sodium 150 mcg - take everday for your
hypothyroidism!
Metoprolol Tartrate 25 mg [**Hospital1 **] (increased from 12.5 mg)
Atovaquone Suspension 1500 mg by mouth DAILY
Calcitriol 0.25 mcg by mouth DAILY
Calcium Acetate 667 mg by mouth three times a day W/MEALS
FoLIC Acid 1 mg DAILY
Itraconazole 200 mg 2x a day with [**Location (un) 2452**] juice or cola
Thiamine 100 mg daily
Lasix 40 mg daily
..
It has been a pleasure taking care of you [**Known firstname **]!
Followup Instructions:
Department: Nephrology
Name: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 101817**]
When: Tuesday, [**2-7**] at 2pm
Location: [**Hospital6 **], [**Location (un) 20473**] Family Bldg.
[**Location (un) **], [**Location (un) **],[**Numeric Identifier 101818**], [**Location (un) **], RENAL DEPT.
Phone: [**Telephone/Fax (1) 55132**]
Department: Primary Care
Name: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4427**]
When: Tuesday [**2141-1-24**] at 10:30 AM
Location: [**University/College **] ST NEIGHBORHOOD HEALTH CTR
Address: [**Hospital3 **], [**Location (un) **],[**Numeric Identifier 81399**]
Phone: [**Telephone/Fax (1) 35879**]
Notes:** A request from your inpatient hospital team has been
made for you to see an ENDOCRINOLOGIST, this is very important.
Please discuss this request with your Primary Care Provider at
this visit.Please ask him to refer you to a new Endocrinologist
if you dont have one involved in your care**
Department: RADIOLOGY
When: TUESDAY [**2141-2-14**] at 11:30 AM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: [**Hospital6 29**] [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: SPINE CENTER
When: TUESDAY [**2141-2-14**] at 12:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6214**], MD [**Telephone/Fax (1) 3736**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: NEUROLOGY
When: WEDNESDAY [**2141-3-1**] at 1 PM
With: [**Name6 (MD) 2341**] [**Last Name (NamePattern4) 2342**], M.D. [**Telephone/Fax (1) 2343**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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icd9cm
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[
[
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] |
[
"88.72",
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icd9pcs
|
[
[
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|
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|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,348
| 103,267
|
9089
|
Discharge summary
|
report
|
Admission Date: [**2182-3-20**] Discharge Date: [**2182-3-24**]
Date of Birth: [**2130-8-26**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Fentanyl
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
hematemesis
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
51F with ETOH cirrhosis with varices, chronic pancreatitis,
asthma, presented with hematemesis. Of note, she was recently
admitted [**Date range (1) 28561**] with abdominal pain and ETOH intoxication and
subsequent withdrawal. Subsequently she was admitted [**2182-3-15**] for
abdominal pain but patient signed out AMA on the same day after
IV narcotics were not given. She was at [**Hospital6 2752**]
on [**2182-3-19**] for domestic abuse by a friend but appears to have
left there AMA. She then started drinking vodka. She developed
symptoms of nausea, vomiting, and abdominal pain. She devoped
hematemesis which she describes as bright red blood mixed with
the vomit. She called for an ambulance and was taken to [**Hospital1 18**].
In ED vs 98.9, 105, 108/74, 18, 96%RA. Pt was intoxicated
with ETOH 333. She was admitted to [**Hospital Unit Name 153**] initially on octreotide
gtt given concern for hematemesis. However the hct was 32.7,
stable from 32.8 several days prior. Hct dropped to 28.8 the
following morning after hematemesis and roughly 3L IVF. She has
required no transfusions and hct has remained roughly stable
since. EGD [**2182-3-21**] showed 4 cords of grade I varices at the lower
third of the esophagus with portal hypertensive gastropathy and
2 small nonbleeding ulcers in duodenum.
Past Medical History:
- Alcoholic cirrhosis (dx: [**2178**])- complicated by varices,
ascites, encephalopathy
- Chronic pancreatitis (dx: [**2172**]) - on pancrease
- EtOH abuse - history of DT
- Low back pain (dx: [**2172**]) - degenerating L4-6 discs, seen in
pain clinic 8 years ago and received fentanyl patch and
oxycodone
- Asthma (since birth) - history of intubation in the past
- Uterine and cervical CA s/p hysterectomy ([**2166**])
Social History:
She is a former nurse who lives in apt in subsidized housing in
[**Location (un) 583**] alone. Divorced x2. She has one son, 30yo who lives in
[**State 15946**]. She is disabled from severe low back pain. She smokes
[**12-21**] ppd and recent heavy alcohol use, up to a gallon of vodka at
a time. Has tried AA. No illicit drug use
Family History:
Mother died at age 72 from a GIB, "blood clot in stomach" ;
Father died in mid-70s from cancer, possibly mesothelioma
(worked in shipping). Mother, father, paternal grandfather have
history of alcoholism.
Physical Exam:
VS: Temp: 98.4 BP: 108/70 HR: 72 RR: 18 O2sat: 96 3L
.
Gen: In awake, in bed, NAD
HEENT: PERRL, EOMI. No scleral icterus.
Neck: Supple, no LAD, no JVP elevation. EJ peripheral IV
Lungs: mild occasional wheezes
CV: RRR, no murmurs, rubs, gallops.
Abdomen: soft, NT, ND, NABS
Extremities: warm and well perfused, no cyanosis, clubbing,
edema.
Neurological: alert and oriented X 3,
Skin: bruising noted on shoulders and neck
Psychiatric: Appropriate.
Pertinent Results:
[**2182-3-20**] 09:45PM URINE HOURS-RANDOM
[**2182-3-20**] 08:58PM GLUCOSE-90 UREA N-17 CREAT-0.6 SODIUM-142
POTASSIUM-3.3 CHLORIDE-103 TOTAL CO2-22 ANION GAP-20
[**2182-3-20**] 08:58PM GLUCOSE-90 UREA N-17 CREAT-0.6 SODIUM-142
POTASSIUM-3.3 CHLORIDE-103 TOTAL CO2-22 ANION GAP-20
[**2182-3-20**] 08:58PM ALT(SGPT)-66* AST(SGOT)-227* CK(CPK)-111 ALK
PHOS-121* TOT BILI-4.2*
[**2182-3-20**] 08:58PM LIPASE-77*
[**2182-3-20**] 08:58PM cTropnT-<0.01
[**2182-3-20**] 08:58PM CK-MB-3 cTropnT-<0.01
[**2182-3-20**] 08:58PM ASA-NEG ETHANOL-333* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2182-3-20**] 08:58PM WBC-7.0 RBC-3.47* HGB-11.4* HCT-32.7* MCV-94
MCH-33.0* MCHC-35.0 RDW-18.5*
[**2182-3-20**] 08:58PM NEUTS-59.1 LYMPHS-30.1 MONOS-5.1 EOS-5.3*
BASOS-0.3
[**2182-3-20**] 08:58PM PLT COUNT-39*#
[**2182-3-20**] 06:48PM URINE HOURS-RANDOM
[**2182-3-20**] 06:48PM URINE GR HOLD-HOLD
[**2182-3-20**] 06:48PM URINE COLOR-Amber APPEAR-Hazy SP [**Last Name (un) 155**]-1.027
[**2182-3-20**] 06:48PM URINE BLOOD-NEG NITRITE-POS PROTEIN-TR
GLUCOSE-NEG KETONE-50 BILIRUBIN-SM UROBILNGN-12* PH-6.5 LEUK-TR
[**2182-3-20**] 06:48PM URINE RBC-0 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2182-3-20**] 06:48PM URINE MUCOUS-MOD
.
EGD:
Protruding Lesions 4 cords of grade I varices were seen in the
lower third of the esophagus.
Stomach:
Mucosa: Erythema, congestion and mosaic appearance of the
mucosa were noted in the whole stomach. These findings are
compatible with portal hypertensive gastropathy.
Duodenum:
Mucosa: 2 small nonbleeding ulcers were seen.
Impression: Varices at the lower third of the esophagus
Erythema, congestion and mosaic appearance in the whole stomach
compatible with portal hypertensive gastropathy
Abnormal mucosa in the duodenum
Otherwise normal EGD to third part of the duodenum
Recommendations: Avoid all NSAIDS and [**Doctor Last Name **]-2 inhibitors. Take
tylenol for pain (max dose of 2 grams per day).
D/C Octreotide.
Continue IV PPI [**Hospital1 **].
Carafate 1 gm po four times per day.
Continue cipro 400 mg IV BID for total of 3 days.
Clear liquid diet this PM.
Brief Hospital Course:
This is a 51 yo F with h/o ETOH cirrhosis with varices, chronic
pancreatitis, and asthma, who presented with hematemesis after
binge drinking. She was initially admitted to the ICU,
stabilized, and then called out to the general medicine floor.
The following is her course by problem.
.
# Upper GI bleed: Initially admitted to the ICU and started on
octreotide gtt. Admission hct was 32.7, stable from 32.8 several
days prior. Hct dropped to 28.8 the following morning after
hematemesis and roughly 3L IVF. The hct has remained roughly
stable since without transfusion. EGD [**2182-3-21**] showed 4 cords of
grade I varices at the lower third of the esophagus with portal
hypertensive gastropathy and 2 small nonbleeding ulcers in
duodenum. She was continued on [**Hospital1 **] PPI, carafate, and
prophylaxis with cipro for a 3 day course. Hct remained stable
at 30 at discharge.
.
# Alcoholic cirrhosis: The patient has met with SW during
previous admissions and attempts have been made to arrange for
detox and patient has had difficulty with compliance with
recurrent etoh use and missed appointments. T Bili and LFTs
elevated mildly above baseline on admission. She has remained
off lasix/aldactone over past month due to numerous binges/poor
po intake. Lactulose and nadolol were continued. Hepatology
followed the pt while in house, and the pt has follow up with
hepatology in [**4-27**].
.
# ETOH abuse/withdrawl: Pt has a history of DTs in the past.
She was treated here with valium per CIWA scale, thiamine, and
folate.
.
# Abdominal pain/Chronic pancreatitis: Pt had epigastric pain
with guarding on exam. Likely due to both vomiting, ulcers,
gastropathy, and chronic pancreatitis. Patient treated briefly
with IV narcotics, changed to po and then discharged off opiates
due to her well-documented history of opiate abuse. On multiple
occasions, she attempted to manipulate the medical staff to
maintain IV opiates for pain or to increase her pain med doses.
Her complaints of pain were out of proportion with her
functional status. She threatened to leave AMA when her
narcotics were changed from IV to oral. However, this was still
done and she backed down and stayed in hospital.
.
# Asthma: Noted mild wheezes on exam. Advair was started and pt
received Albuterol nebs PRN.
.
# Pancytopenia: Likely due to marrow suppression from ETOH abuse
as well as splenic sequestration. Platelets in 30s, hct stable
at 28. Last iron studies were borderline, and B12/folate were
WNL.
.
# Tobacco abuse: Written for nicotine patch
.
# Coagulopathy: secondary to cirrhosis.
.
Medications on Admission:
1. Albuterol 90 Two (2) Puff Q4H PRN
2. Sucralfate 1 gram PO QID
3. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO QIDWMHS
4. Lactulose Thirty (30) ML PO TID
5. Docusate Sodium 100 mg PO BID
6. Senna 8.6 mg PO DAILY as needed.
7. Nadolol 20 mg PO once a day.
9. Thiamine HCl 100 mg PO once a day.
10. Omeprazole 20 mg PO twice a day.
Discharge Medications:
1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
2. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
Disp:*1 bottle* Refills:*2*
3. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
5. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Capsule, Delayed
Release(E.C.) PO QIDMWHS.
6. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily): DO NOT USE IF YOU ARE SMOKING!!.
Disp:*30 Patch 24 hr(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Hematemesis
Anemia of acute GI bleed
Duodenal Ulcers
Grade 1 Esophageal Varices
Pancreatitis, ETOH
ETOH Abuse
Severe Thrombocytopenia
Discharge Condition:
Vital Signs Stable
Discharge Instructions:
Patient should return to the ED if hse is vomiting blood, has
large amounts of blood in her stool, has persistent high fevers.
YOU HAVE BEEN REPEATEDLY COUNSELLED AND STRONGLY INSTRUCTED TO
STOP DRINKING ALCOHOL COMPLETELY. ALCOHOL IS CAUSING MANY OF
YOUR MEDICAL ISSUES. WITHOUT STOPPING DRINKING ALCOHOL, THESE
MEDICAL ISSUES WILL WORSEN AND YOUR ABDOMINAL PAIN WILL WORSEN.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 2878**] [**First Name8 (NamePattern2) 26**] [**Last Name (NamePattern1) 2879**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2182-3-26**] 11:00
Provider: [**Name10 (NameIs) 1382**] [**Name11 (NameIs) 1383**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2182-5-6**] 9:30
|
[
"577.1",
"493.90",
"287.5",
"456.21",
"578.9",
"571.2",
"303.01",
"572.3",
"286.9",
"305.1",
"537.89",
"532.90",
"285.1",
"284.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
9055, 9061
|
5297, 7879
|
295, 300
|
9238, 9258
|
3142, 5274
|
9687, 10013
|
2448, 2654
|
8317, 9032
|
9082, 9217
|
7905, 8294
|
9282, 9664
|
2669, 3123
|
244, 257
|
328, 1640
|
1662, 2084
|
2100, 2432
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,459
| 142,993
|
12483+56369
|
Discharge summary
|
report+addendum
|
Admission Date: [**2195-1-28**] Discharge Date: [**2195-2-2**]
Service: CARDIAC CRITICAL CARE UNIT
HISTORY OF PRESENT ILLNESS: The patient is an 84 year-old
white female with multiple medical problems including
hypertension, severe peripheral vascular disease, awaiting
revascularization recently admitted to NABH for preoperative
catheterization, which was complicated by severe groin
bleeding. She was transferred to [**Hospital1 190**] with hypertension and severe pain. The
patient had a right lower extremity ulcer. She recently
underwent peripheral vascular workup including noninvasive
studies, which revealed right and left superficial femoral
artery occlusion with collateralization on the left. The
patient was initially scheduled to undergo an elective RLE
angiogram by Dr. [**Last Name (STitle) **] on [**1-30**]. The patient had a preoperative
workup. She underwent Dobutamine echocardiogram at NABH on
[**1-21**], which had anterior and septal ischemia, which prompted
an elective catheterization. By report the catheterization
from left groin revealed 90% mid left anterior descending
coronary artery lesion at D1 bifurcation and 90 to 95%
proximal left circumflex occlusion with 40% posterior
descending coronary artery. The patient had posterior basal
HK on left ventriculogram. The patient's cardiac output was
4.7 on right heart catheterization. Postoperative course was
complicated by groin hematoma and bleeding requiring 4 units
of packed red blood cells and emergent operative care by
vascular surgery. Postoperatively, the patient experienced
severe pain and received morphine and Fentanyl. The patient
had also runs of nonsustained ventricular tachycardia.
On her pain management the patient became very somnolent,
disoriented. She had altered mental status so she underwent
a head CT, which was negative. On [**1-26**] the patient was more
awake and oriented as her pain medication was tapered off,
but experienced elevated blood pressures as high as 240/50.
The patient was begun on a Diltiazem drip and nitroglycerin
drip and transferred to [**Hospital1 69**]
for further management. As per her daughter the patient's
baseline mental status is alert and oriented times three.
PAST MEDICAL HISTORY: 1. Labile hypertension. 2. Severe
peripheral vascular disease. 3. History of atrial
fibrillation. 4. Bell's palsy. 5. History of MR/AR. 6.
Congestive heart failure question 40% EF. 7.
Myeloproliferative disorder/CML. 8. Hypothyroid. 9.
Chronic renal insufficiency. 10. Status post hysterectomy.
ALLERGIES: Codeine and beta blocker, causing bronchospasm in
the past, but tolerating beta blocker recently.
MEDICATIONS ON TRANSFER: Albuterol and Atrovent nebulizers
b.i.d., Procardia XL 30 mg q.d., Clonidine .4 mg q week,
Lasix 20 q.d., Prevacid 30 q.d., aspirin 81 q.d., Diovan 320
mg q day, Hydrea 500 mg q three days, Levoxyl .05 q.d.,
Digoxin .125 mg q.d., magnesium oxide 400 mg b.i.d.,
Diltiazem drip, nitroglycerin drip titrated to blood
pressure.
SOCIAL HISTORY: The patient lives in [**Location 4310**] with her
daughter. [**Name (NI) **] history of tobacco or alcohol use.
PHYSICAL EXAMINATION ON ADMISSION: Temperature 101.5, blood
pressure 150/40. Heart rate 90s. Respiratory rate 18.
Oxygen saturation 99% on 4.5 liters. Generally, elderly
female, frail, hard of hearing, no acute distress. HEENT
shows pupils are equal, round, and reactive to light and
accommodation. Extraocular movements intact. Mucous
membranes are moist. Heart regular rate and rhythm without
murmurs, rubs or gallops. Lungs bibasilar crackles one third
of the way up bilaterally. Abdomen soft, nontender,
nondistended. Left lower quadrant site of prior surgical
drains with surrounding ecchymosis. Extremities no edema,
RLE markedly tender to manipulation, large left groin
hematoma with previously marked origins. Left groin staples
in place, dried blood surrounding, but otherwise clean and
dry. Neurological alert and oriented to person, not place,
time or year.
LABORATORIES ON ADMISSION: White blood cell count 47.8,
hematocrit 30, platelets 275, sodium 135, potassium 3.7,
chloride 99, bicarb 25, BUN 10, creatinine 1.4, glucose 162,
magnesium 1.2. Chest x-ray borderline cardiomegaly, left
hemidiaphragm obscurations, small pleural effusion on left
side. Electrocardiogram was pending.
IMPRESSION/PLAN: The patient is an 84 year-old female,
labile hypertension, severe peripheral vascular disease,
congestive heart failure with a recent catheterization with
left anterior descending coronary artery and left circumflex
stenosis with catheterization complicated by groin hematoma
requiring operative repair, transferred with hypertension and
transferred to [**Hospital1 69**] for
intervention of her coronary arteries.
1. Coronary artery disease: The patient's left anterior
descending coronary artery and left circumflex stenosis on
catheterization [**1-22**], the patient will get cardiac
intervention via Dr. [**Last Name (STitle) **] prior to lower extremity
revascularization. The patient may need to be deferred if
febrile. If intervention is planned, question what approach
will be taken. Will continue aspirin. Will check her
fasting lipid profile in the a.m., add statin if needed. She
has a history of beta blocker intolerance. We will contact
her physician to find out the extent of this. It looks as if
Dobutamine beta blocker was tolerated at NABH. Will continue
Diltiazem drip for now for blood pressure and heart rate
control and will continue [**Last Name (un) **].
2. Congestive heart failure: Patient with MR/AR. EF is not
known, although cardiac output looks well on catheterization
at 4.7, continue Lasix and [**Last Name (un) **], follow volume status, diurese
as needed.
3. Hypertension/heart rate: Elevated blood pressure on po
Lasix. Continue [**Last Name (un) **], continue Procardia and Clonidine. Now
the patient is on nitroglycerin and Diltiazem GTT. Will
continue above po regimen for now, but discuss alternating it
in the morning per attending physician. [**Name10 (NameIs) **] patient will get
a trial of po Hydralazine. Attempt to wean off
nitroglycerin.
4. EP: Patient run of nonsustained ventricular tachycardia
by report. Will check electrocardiogram and monitor on
telemetry.
5. Infectious disease: The patient is febrile on admission.
Will check chest x-ray, urinalysis and cultures. Wound does
not appear infected. Must also consider left lower extremity
ulcer, large groin hematoma as possible source of infection.
Will defer starting antibiotics for now pending chest x-rays
and cultures and monitoring temperature.
6. Vascular: Patient originally scheduled for right lower
extremity angiogram, potential revascularization per Dr. [**Last Name (STitle) **].
We will follow up with this and continue wet to dry dressing
changes for a right lower extremity ulcer.
7. Renal: Chronic renal insufficiency, creatinine okay now.
Follow Is and Os and lytes.
8. Neurological: Possible delirium secondary to stress of
acute illness versus pain. The patient appears comfortable.
Will follow mental status and give low dose morphine and/or
Percocet for pain control.
9. Hematology: As per heme/onc at NABH, the patient
received Epogen for hematocrit of less then 35, white blood
cell count seems baseline for the patient. Continue Hydrea.
[**Month (only) 116**] need to discuss the issue of anticoagulation with a
history of CML.
10. Fen: The patient is on a cardiac diet. NPO since
midnight. Replete electrolytes as needed.
11. Disposition: The patient's two daughters are involved
in her care. The patient is full code.
HOSPITAL COURSE: The patient had cardiac catheterization
with intervention on [**2195-1-29**]. The patient had a stent placed
in her left anterior descending coronary artery. The patient
had stent placed in her left circumflex successfully. The
patient's left anterior descending coronary artery 0%
residual. The patient's left circumflex 0% residual. The
patient had ballooning of her obtuse marginal one with 10%
residual.
Hospital course after catheterization, unremarkable. The
patient continued to do well. The patient's mental status
trending almost at baseline. The patient is on minor pain
control using Percocet prn. The patient's Diltiazem drip as
well as nitroglycerin drip were weaned to off. The patient
was placed on beta blocker and has been doing well with no
bronchospasm or issues due to allergies. The patient's blood
pressure medications have been titrated to maximum for better
blood pressure and heart rate control. The patient did have
an EF measured at 45%. The patient did have a temperature
spike to just above 101 degrees Fahrenheit, but has continued
to remain afebrile since then. The patient did have a seven
day course of Levaquin for a urinary tract infection. The
goal is for the patient to go to rehabilitation. Once she is
discharged from rehabilitation she can then have the
revascularization surgery once she is stable from a cardiac
standpoint. The patient did have ABIs done prior to
discharge, which the impression was significant right
superficial femoral artery and bilateral tibial disease and
probable right superficial femoral artery occlusion. The
patient had markedly decreased ABI index.
Status post cardiac catheterization the patient did have a
hematoma at the site of catheterization. On discharge there
was no oozing or bruit heard. The hematoma has not enlarged.
The patient's hematocrit is relatively stable. The patient
on the day of discharge is having no issues, no shortness of
breath, chest pain or pain in her lower extremities. The
patient's mental status is improved and approximately at
baseline. The patient is [**Age over 90 **]% on room air. The patient will
be discharged to [**Hospital 46**] Rehabilitation. The patient will
have follow up with Dr. [**First Name4 (NamePattern1) 2174**] [**Last Name (NamePattern1) 2912**] for cardiology and
primary care. The patient will also be followed by Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for possible femoral popliteal bypass in the
future. The patient at rehab will need continued blood
pressure monitoring for titration of blood pressure
medications.
MEDICATIONS ON DISCHARGE: Lasix 20 mg once a day, Diovan 320
mg once a day, Digoxin .125 mg once a day, Atrovent/Albuterol
nebulized treatments, Procrit 30,000 once a week, Levoxyl .05
mg once a day, aspirin 81 mg once a day, Hydrea 500 mg q
three days, Protonix 40 mg once a day, magnesium oxide 400 mg
twice a day, Plavix 75 mg once a day, Lopressor 37.5 mg three
times a day, Procardia 120 mg once a day, Tylenol as needed.
CONDITION ON DISCHARGE: Stable and improved.
DISCHARGE STATUS: Stable.
DISCHARGE DIAGNOSES:
1. Coronary artery disease, cardiac intervention status post
stent of left anterior descending coronary artery and left
circumflex.
2. Hypertension.
3. CML.
4. Hypothyroid.
[**Name6 (MD) **] [**Name8 (MD) **], MD [**MD Number(1) 21980**]
Dictated By:[**Last Name (NamePattern1) 4724**]
MEDQUIST36
D: [**2195-2-2**] 12:36
T: [**2195-2-2**] 12:47
JOB#: [**Job Number 38745**]
Name: [**Known lastname 6997**], [**Known firstname 3591**] Unit No: [**Numeric Identifier 6998**]
Admission Date: [**2195-1-28**] Discharge Date: [**2195-2-3**]
Date of Birth: [**2110-12-11**] Sex: F
Service:
DISCHARGE SUMMARY ADDENDUM: The patient was discharged on
[**2195-2-3**]. Over night events uneventful. The patient is
eating well.
Discharge status condition: Improved.
No changes to prior discharge summary. The patient's vital
signs are stable. The patient discharged to [**Hospital 6999**]
Rehabilitation Center for cardiac rehabilitation.
The patient's follow up appointments and medicines no changes
as per discharge summary dated [**2195-2-2**].
The patient's labs on discharge: White blood cell count 36.4
consistent with her CML. The patient's hematocrit is stable
at 36.1. The patient's BUN and creatinine are unchanged,
slightly elevated. Other chem 7 laboratories normal.
The patient will be followed by Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 2164**] as
planned.
Dictated By:[**Last Name (NamePattern1) 563**]
MEDQUIST36
D: [**2195-2-3**] 11:49
T: [**2195-2-6**] 09:22
JOB#: [**Job Number **]
|
[
"599.0",
"998.2",
"427.1",
"440.23",
"414.01",
"244.9",
"205.10",
"998.12",
"593.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.55",
"99.20",
"37.22",
"88.48",
"36.05",
"36.06"
] |
icd9pcs
|
[
[
[]
]
] |
10848, 11991
|
10350, 10752
|
7714, 10323
|
12011, 12466
|
138, 2232
|
4072, 7696
|
2704, 3029
|
2255, 2678
|
3046, 3181
|
10777, 10827
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,457
| 179,807
|
37617
|
Discharge summary
|
report
|
Admission Date: [**2197-9-8**] Discharge Date: [**2197-9-16**]
Date of Birth: [**2147-8-12**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Loxapine
Attending:[**First Name3 (LF) 11415**]
Chief Complaint:
Right acetabular fracture
Major Surgical or Invasive Procedure:
[**2197-9-11**]: ORIF Right acetabular fracture
History of Present Illness:
Mr. [**Known lastname 84394**] is a 50 yearold man who had a fall from his bike.
He was taken to [**Hospital3 **] Hospitan and found to have a right
acetabular fracture. He was then transferred to the [**Hospital1 18**] for
further evaluation and care.
Past Medical History:
Bipolar
Social History:
+smoker
Family History:
n/a
Physical Exam:
Upon admission
Alert and oriented
Cardiac: Regular rate rhythm
Chest: Lungs clear bilaterally
Abdomen: Soft non-tender non-distended
Extremities/Pelvis: +TTP over ASIS and hip joint on right.
Cannot range hip at all. +sensation/pulses.
Pertinent Results:
[**2197-9-8**] 10:20PM GLUCOSE-80 LACTATE-1.6 NA+-139 K+-4.2 CL--106
TCO2-20*
[**2197-9-8**] 10:20PM HGB-14.5 calcHCT-44
[**2197-9-8**] 10:10PM GLUCOSE-77 UREA N-9 CREAT-0.7 SODIUM-136
POTASSIUM-4.2 CHLORIDE-108 TOTAL CO2-20* ANION GAP-12
[**2197-9-8**] 10:10PM estGFR-Using this
[**2197-9-8**] 10:10PM LIPASE-43
[**2197-9-8**] 10:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2197-9-8**] 10:10PM WBC-18.1* RBC-4.35* HGB-13.0* HCT-38.3*
MCV-88 MCH-29.9 MCHC-34.1 RDW-13.8
[**2197-9-8**] 10:10PM PLT COUNT-155
[**2197-9-8**] 10:10PM PLT COUNT-155
[**2197-9-8**] 10:10PM PLT COUNT-155
[**2197-9-8**] 10:10PM PT-13.1 PTT-28.1 INR(PT)-1.1
[**2197-9-8**] 10:10PM FIBRINOGE-231
[**2197-9-14**] 07:15AM BLOOD WBC-7.7 RBC-4.01* Hgb-11.7* Hct-34.4*
MCV-86 MCH-29.2 MCHC-34.0 RDW-14.2 Plt Ct-201
[**2197-9-13**] 07:10AM BLOOD WBC-6.9 RBC-3.87*# Hgb-11.4*# Hct-32.9*
MCV-85 MCH-29.5 MCHC-34.6 RDW-14.5 Plt Ct-156
[**2197-9-14**] 07:15AM BLOOD Plt Ct-201
[**2197-9-13**] 07:10AM BLOOD Plt Ct-156
[**2197-9-13**] 07:10AM BLOOD PT-11.9 PTT-26.5 INR(PT)-1.0
[**2197-9-14**] 07:15AM BLOOD Glucose-87 UreaN-8 Creat-0.6 Na-139 K-4.2
Cl-103 HCO3-29 AnGap-11
[**2197-9-8**] 10:10PM BLOOD Fibrino-231
[**2197-9-8**] 10:10PM BLOOD Lipase-43
[**2197-9-14**] 07:15AM BLOOD Calcium-8.7 Phos-4.4 Mg-1.9
[**2197-9-8**] 10:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2197-9-8**] 10:20PM BLOOD Glucose-80 Lactate-1.6 Na-139 K-4.2
Cl-106 calHCO3-20*
[**2197-9-8**] 10:20PM BLOOD Hgb-14.5 calcHCT-44
Brief Hospital Course:
Mr. [**Known lastname 84394**] presented to the [**Hospital1 18**] on [**2197-9-8**] via transfer
from [**Hospital6 1597**] with a right acetubular fracture. He
was evaluated by the the orthopaedic and trauma surgery service.
He was admitted and taken to interventional radiology for
arteriogram to look for bleeding. The arteriogram showed no
active bleeding. On [**2197-9-10**] he was transferred to the
orthopaedic surgery service. On [**2197-9-11**] he was prepped and
consented, and then taken to the operating room for an ORIF of
his right acetabular fracture. He tolerated the procedure well,
was extubated, transferred to the recovery room and then to the
floor. On the floor he was seen by physical therapy to improve
his strength and mobility. On [**9-12**]/109 he was transfused with
2 units of packed red blood cells due to actue blood loss
anemia.
Neuro: pain was initially controlled with PCA and transitioned
to po pain meds; pt was neurologically intact distally
throughout hospital course
ID: pt received standard perioperative cefazolin
GI: regular diet
GU: foley d/c'd post-operatively after the epidural was d/c'd
Activity: pt was TDWB on the operative side, pt worked with
physical therapy while in-house, and was cleared by PT prior to
discharge
Pt was discharged home afebrile, with pain well-controlled,
after having cleared by PT, to follow-up with Dr. [**Last Name (STitle) 1005**]
The rest of his hospital stay was uneventful with his lab and
vital signs within normal limits and his pain controlled. He is
being discharged today in stable condition.
Medications on Admission:
paxil daily
clonazepam 1mg TID
neurontin 300mg prn anxiety (up to QID)
oxazepam prn insomnia
Discharge Medications:
1. Hydromorphone 2 mg Tablet Sig: 1-3 Tablets PO Q4H (every 4
hours) as needed for pain: Do not drive or operate machinery
while taking this medication.
Disp:*70 Tablet(s)* Refills:*0*
2. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) syringe
Subcutaneous Q12H (every 12 hours).
Disp:*60 syringe* Refills:*0*
3. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for bipolar.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
s/p fall from bike
Right acetabular fracture
Acute blood loss anemia
Discharge Condition:
Stable
Discharge Instructions:
Continue to be touchdown weight bearing on your right leg and
weight bearing as tolerated on your left leg
Continue your lovenox injections as instructed
Please take all your medications as prescribed
If you have any increased redness, drainage, or swelling, or if
you have a temperature greater than 101.5, please call the
office or come to the emergency department.
You have been prescribed a narcotic pain medication. Please
take only as directed and do not drive or operate any machinery
while taking this medication. There is a 72 hour (Monday
through Friday, 9am to 4pm) response time for prescription refil
requests. There will be no prescription refils on Saturdays,
Sundays, or holidays. Please plan accordingly.
Physical Therapy:
Activity: Activity as tolerated
Right lower extremity: Touchdown weight bearing
Left lower extremity: Full weight bearing
Treatments Frequency:
Staples/sutures out 14 days after surgery
Keep incision clean and dry
Followup Instructions:
Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP in orthopaedics in 2
weeks, please call [**Telephone/Fax (1) 1228**] to schedule that appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**] MD, [**MD Number(3) 11417**]
Completed by:[**2197-9-16**]
|
[
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icd9cm
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[
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icd9pcs
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2578, 4170
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299, 350
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6227, 6579
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705, 710
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5109, 5180
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4196, 4290
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5234, 5964
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725, 968
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5982, 6110
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6132, 6204
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234, 261
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378, 633
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655, 664
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680, 689
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,253
| 171,045
|
8571
|
Discharge summary
|
report
|
Admission Date: [**2170-1-2**] Discharge Date: [**2170-1-8**]
Date of Birth: Sex: F
Service:
DEATH SUMMARY:
HISTORY OF THE PRESENT ILLNESS: The patient is a 79-year-old
gentleman with a history of metastatic renal cell carcinoma
who presented to [**Hospital1 **] - [**Hospital3 **] on [**2169-12-29**]
with right-sided weakness and difficulty swallowing and was
also noted to be in atrial fibrillation. Head CT
demonstrated a lesion in the left frontal lobe consistent
with metastatic renal carcinoma. The patient was started on
Decadron and subsequently had a seizure and was started on
Dilantin. Over a relatively short period of time, his
right-sided weakness improved. He was noted to have
intermittent word-finding difficulties and a lumbar puncture
was performed with cytology pending. At that time that the
patient was transferred to the [**Hospital1 **]
Hospital. Prior to transfer, he underwent electrical
cardioversion on [**2169-12-31**] and he was started on amiodarone.
He was noted to have had a low ejection fraction of 35 to 40
percent, as well as focal wall motion abnormalities that were
new since [**2168-1-12**] in the distal anterior apical
region. Carotid ultrasound was performed which showed 60 to
79 percent right internal carotid artery stenosis. He was
subsequently transferred to the [**Hospital3 **] on [**2170-1-2**], and initially admitted to the Medicine Service.
PAST MEDICAL HISTORY:
1. Renal cell carcinoma, diagnosed in [**2168-1-12**]. The
patient had no metastases to the lung and skull. He received
interleukin-2 therapy in [**2168-1-12**] with improvement in
his lung metastases. He underwent a left radical nephrectomy
in [**2168-4-11**]. In [**2169-5-12**], he underwent surgical
removal of a skull metastasis. In [**2169-7-12**], he underwent
x-ray therapy of his brain.
2. Non-insulin-dependent diabetes.
3. Atrial fibrillation.
4. Hypertension.
5. Coronary artery disease, status post non-Q-wave
myocardial infarction in [**2169-5-12**]. Subsequent cardiac
catheterization demonstrated three-vessel coronary artery
disease.
6. Chronic renal insufficiency with baseline creatinine of
2.0 to 2.5.
MEDICATIONS ON ADMISSION:
1. Lipitor 10 q.d.
2. Prilosec 20 q.d.
3. Nitroglycerin p.r.n.
4. Lopressor 75 b.i.d.
5. Plavix 75 q.d.
6. Aspirin 325 q.d.
7. Demadex 25 q.d.
8. Colace p.r.n.
9. Isordil 30 t.i.d.
10. Hydralazine 25 q.i.d.
11. Tylenol p.r.n.
12. Amiodarone 200 mg b.i.d. to be decreased to 200 mg q.d.
13. Decadron 4.0 q.i.d.
14. Dilantin 300 q.d.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Married. No history of tobacco use. Rare
alcohol use.
FAMILY HISTORY: No history of coronary artery disease or
malignancy.
PHYSICAL EXAM: Vital signs were normal. The patient's
general exam was significant for decreased breath sounds at
the apices bilaterally. A II/VI systolic ejection murmur was
noted. On initial neurologic examination he was described as
having full power in the extremities bilaterally with intact
cranial nerve exam on the Medicine neurologic examination
LABORATORY RESULTS ON ADMISSION: Head MRI demonstrated a
mass along the superior sagittal sinus and left parietal
convexity without herniation or mass affect. Initial lumbar
puncture demonstrated 908 RBCs which cleared to 395 RBCs on
tube four. No organisms were noted on Gram's stain. Glucose
was 76 and protein was 146. EKG demonstrated T-wave
inversions in the inferior leads as well as V3. The QT
interval was prolonged at 511.
SUMMARY OF HOSPITAL COURSE: A Neurology consult was obtained
with Dr. [**Last Name (STitle) 724**] and it was felt that the patient's right
hemiparesis was likely secondary to [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 555**] paralysis. On
[**1-4**], the patient underwent an MRI of the head,
subsequently found to have evidence of a complete right
internal carotid artery occlusion and underwent angiography
for possible revascularization. He was subsequently
transferred to the Neurology Service in the Neurosurgical
Intensive Care Unit. The MRI scan was performed in the
setting of incoherent speech, evidence of left-sided neglect
and right gaze deviation. During angiography, the patient
was found to have 100 percent occlusion of the internal
carotid artery on the right and this lesion was not amenable
to stenting. ........... venogram showed decreased flow in
the superior sagittal sinus.
The patient was started on heparin on [**2170-1-4**].
Repeat MRI scan did not show evidence of DII abnormalities
despite complete right internal carotid artery occlusion. On
[**1-5**] he was noted to be less responsive. A stat.
head CT and his heparin was discontinued.
On exam, he could follow simple commands in the extremities,
particularly on the right. Head CT did not show evidence of
bleed but there were hypodense regions along the right
centrum semiovale. The patient subsequently developed a
fever and he was started on aspirin and Plavix. On [**1-6**], the patient had an episode of tachycardia with a drop in
his blood pressure to a systolic of approximately 130. He
was felt to be in rapid atrial fibrillation and was restarted
on amiodarone. The patient also received diltiazem IV and he
subsequently underwent electrical cardioversion to normal
sinus rhythm. On [**1-7**], the patient was noted to be
less responsive and had pupillary asymmetry with a dilated
pupil on the right. He underwent stat. head CT to rule out
herniation and there was evidence of significant mass affect
with right hemisphere edema. Neurosurgical consultation was
obtained, who felt that craniotomy was not warranted, given
the patient's comorbid medical issues. The patient's code
status was changed to DNR/DNI. On [**1-8**], the patient
subsequently had a systolic arrest and was pronounced dead at
3:40 a.m.
[**Name6 (MD) 725**] [**Name8 (MD) 726**], M.D. [**MD Number(1) 727**]
Dictated By:[**Doctor First Name 30101**]
MEDQUIST36
D: [**2171-12-31**] 14:18
T: [**2172-1-1**] 14:37
JOB#: [**Job Number 30102**]
|
[
"427.31",
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"197.0",
"780.39",
"250.00",
"434.91",
"V10.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.61",
"88.41",
"96.6"
] |
icd9pcs
|
[
[
[]
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] |
2696, 2750
|
2217, 2604
|
2767, 3130
|
3579, 6129
|
3145, 3550
|
1456, 2191
|
2622, 2679
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,987
| 137,720
|
52368+52369+52370+52383+59421+59422
|
Discharge summary
|
report+report+report+report+addendum+addendum
|
Admission Date: [**2105-12-26**] Discharge Date: [**2106-1-16**]
Date of Birth: [**2037-5-26**] Sex: M
Service: MICU/ORANG
HISTORY OF PRESENT ILLNESS: This is a 68 year old male with
a past medical history of MGUS and hypertension who presents
from outside hospital. He was in usual state of health until
three days prior to arrival at outside hospital when
experienced rapid onset of shaking chills, cough and
shortness of breath. On [**12-21**], he had a temperature to 101.6
F., was found confused, disoriented. EMS was activated;
positive thirst, orthostatic and pre-syncopal and he was
admitted to outside hospital.
EMS noted on arrival to patient's house on [**12-21**], acute
distress, respiratory rate of 42, pO2 of 72, four liters
bumped to 90% on non-rebreather with decreased breath sounds
at the left base. In the Emergency Department of outside
hospital, temperature was 38.9 C., pulse of 126; respiratory
rate 44; blood pressure 149/68. Received Tequin, Lasix and
500 cc normal saline bolus. Chest x-ray at this time showed
right upper lobe and left lower lobe pneumonia.
Pulmonary consult recommended the addition of C-PAP and
started on Cefotaxime and Gatifloxacin. Hematology was
consulted for a question of MGUS/leukopenia, recommended
S-PEP, U-PEP, B12, quantitative IgGs. TTE done at this time
was a technically limited study. Left ventricle was within
normal limits; no other abnormalities were noted.
INTENSIVE CARE UNIT COURSE AT OUTSIDE HOSPITAL: The patient
got antibiotics, Celexa, Pepcid, Vitamin K and Lovenox and
initially tolerated C-PAP but was intubated for persistent
hypoxemia on [**12-21**] with an arterial blood gas of 7.39/42 and
63. On [**12-23**], the patient was noted to have worsening
oxygenation. FIO2 increased to 1.0 but then decreased to
0.8. DIC screen was negative at this time. The patient had
19% bands in differential. Cultures grew Streptococcus
pneumonia in blood, four out of four bottles, pan sensitive
Staphylococcus aureus in sputum. Tequin and Cefotaxime were
changed to ampicillin. TPN was started and insulin drip was
started for hyperglycemia.
On [**12-24**], the patient had an SPO2 of 93 on an FIO2 of 70%.
The patient was sedated on Versed and Propofol. The
patient's white count increased to 16. On [**12-25**], the
patient's white count increased to 20. Albumin was noted at
1.1. The patient was noted to have worsening hypoxia and
SPO2 of 88%. Received Lasix 40 mg intravenously and SPO2
increased to 92%. IgG returned normal at this time.
On [**12-26**], the patient had worsening oxygenation and was
transferred to [**Hospital1 69**] for
non-conventional ventilator strategies. On arrival, the
patient was on pressure-control ventilation with a driving
pressure of 30, PEEP of 10, respiratory rate of 22 and FIO2
of 1 with arterial blood gas of 7.39, 48 and 80.
PHYSICAL EXAMINATION: Vital signs at admission, blood
pressure 109/68; pulse of 80; respiratory rate 28;
temperature 99.8 F.; pulse oximetry 94%. A vent was on
pressure control ventilation, driving pressure of 30, PEEP of
10, 24 respiratory rate, I:E ratio of 1:1.8, total volume of
890. Arterial blood gas was 7.42, 37/71. On physical
examination the patient was intubated and sedated, not
responsive to stimuli. Ventilated. Conjunctivae were pink.
Pupils equally round and reactive to light, reactive from 3
mm to 2 mm. No icterus. Mucous membranes are moist. Neck:
Unable to appreciate jugular venous pressure. Cardiac:
Regular rate and rhythm. S1, S2, no murmurs, rubs or gallop.
Lungs had increased rales at left base. Extremities show no
cyanosis and trace [**Hospital1 **]-pedal edema. The abdomen was soft,
distended mildly, absent bowel sounds. Skin: Showed
erythema, patchy on the left posterior thigh.
LABORATORY: Outside labs, IgG level was 2160, IgM was 11,
S-PEP was consistent with MGUS. Blood cultures at outside
hospital [**12-21**], Strep pneuma, four out of four bottles,
pan-sensitive.
On [**12-21**], BTT culture grew few [**Female First Name (un) 564**] albicans and
Staphylococcus aureus, rare, pan-sensitive.
EKG was normal sinus rhythm at 79; positive Q in AVL.
Chest x-ray at admission, stable right upper lobe and left
lower lobe opacities, increase in bilateral interstitial
infiltrates consistent with ARDS.
Original labs at [**Hospital1 18**] showed a white count of 20.8,
hematocrit of 20.0, platelets of 203. This included a
differential of 89 segments, 5 bands, zero lymphs, 1
monocyte, 4 metamyelocytes. Sodium was 132, potassium 4.1,
chloride 98, CO2 28, BUN 19, creatinine 0.6, platelets 222.
INR 1.2, PT 13.2, PTT 33.6, albumin 1.8, calcium 7.9,
magnesium 1.7, phosphorus at 4.0.
ASSESSMENT AND PLAN: This was a 68 year old male with past
medical history of MGUS and hypertension who presents with
Pneumococcal sepsis/pneumonia complicated by ARDS. At this
time, he was thought to possibly have hospital-acquired
pneumonia with transfer from an outside hospital and report
of spiking fevers, increased white count and leukemoid
reaction on differential. The patient was also possibly
thought to have cardiogenic pulmonary edema in addition to
ARDS. On evaluation of intakes and outputs data from outside
hospital he was positive nine liters over six days.
BRIEF SUMMARY OF HOSPITAL COURSE:
1. Pulmonary: The patient has a diagnosis of pneumonia,
Pneumococcal in origin, complicated by ARDS. The patient was
kept on pressure controlled ventilation and the settings were
changed and driving pressure was decreased to 25 and PEEP was
increased to 15. The patient was given paralysis and
sedation with Doxacurium, Fentanyl and Ativan. On [**12-27**], the
patient was on pressure control ventilation with an FIO2 down
to 68%, total volumes of 790, respiratory rate of 22 and
inspiratory pressure of 25, a PEEP of 15 and I:E ratio of
1:1.5. Arterial blood gas at this time revealed a gas of
7.35, pCO2 of 52 and pO2 of 95.
Throughout his hospital stay, the patient had a goal oxygen
saturation of greater then 90%. The patient's ARDS improved
throughout his hospital stay. On [**12-29**], the patient was
changed to AC-volume controlled ventilation 580 by 22 with an
FIO2 of 50 and a PEEP of 15, and an I:E ratio of 1:1.73. On
[**12-30**], the patient had Doxacurium stopped and Fentanyl and
Ativan were weaned slightly. The patient's chest x-ray
throughout his hospital stay was consistent with ARDS. The
patient was maintained on AC-550 by 19 with a PEEP of [**11-21**]/2
until [**1-11**]. The patient had FIO2 weaned down to 40%. This
produced an arterial blood gas of 7.42/71/87. The patient's
CO2 had climbed throughout his hospital stay as total volumes
were attempted to be kept down to keep the driving pressure
less than 35 and a total volume of between 6 and 8 cc per
kilogram. The patient's PAO2/FIO2 ratio improved as well as
his compliance. As this improved, the patient's pCO2 dropped
to the low 60s and then to the high 50s. The patient had a
tracheostomy done on [**1-12**]. On [**1-13**], the patient had PEEP
decreased to 10 and an arterial blood gas was 7.45/61/80 on
[**1-14**].
On [**1-15**], the patient was changed to pressure support and
C-PAP. The patient had been asynchronous with the vent and
once changed to pressure support and C-PAP of 12 and 10,
continued to draw good volumes and maintain a good
respiratory rate between 17 and 25. On the morning of [**1-15**],
the patient had an arterial blood gas of 7.47/58/85. At this
time, PEEP was decreased to 7.5. This was with persistent
FIO2 of 40%. Ultimate goal in this patient was for
extubation.
On the morning of [**1-15**], the patient seemed to be heading in
this direction for an extubatable PEEP of 5.
2. Infectious Disease: The patient had diagnosis at
outside hospital of Strep pneuma in blood, four out of four
bottles, in Staphylococcus aureus and sputum. On [**2105-12-26**],
the patient was started on Vancomycin and Ceftazidime for a
possible hospital-acquired pneumonia and coverage for
Streptococcus pneumoniae. The patient had multiple blood
cultures drawn throughout his hospital stay including blood
cultures on [**1-5**], [**12-31**], [**1-1**], and [**1-3**], all of
which did not grow anything. The patient also had numerous
ETT sputum Gram stains and cultures which were unrevealing.
The patient also had unrevealing urinalyses throughout his
hospital stay.
The Infectious Disease team was following and recommended a
21-day course of Vancomycin and Ceftazidime which the patient
finished on [**1-15**]. At original presentation, the patient
originally defervesced and then had spiking temperatures on
[**1-1**] to 102.2 F. At this time, chest x-ray did not reveal
any new infiltrate. His NG tube was changed to an OG tube.
The patient had a small right pleural effusion which was
tapped under ultrasound guidance. It was consistent with a
transudate and thought to be secondary to congestive heart
failure and not infectious.
On [**1-5**], the patient had last temperature spike to 100.6 F.
After this, the patient defervesced and remained afebrile
throughout the hospital stay up to [**2106-1-15**]. No other
source of infection was found. The patient did grow out
yeast 10 to 100,000 colonies on a urine culture from [**1-10**]
and the patient's Foley catheter was changed.
3. Cardiology: The patient had a diagnosis of possible
congestive heart failure at admission. The patient had an
echocardiogram done on [**2105-12-28**], which showed an ejection
fraction of 60 to 65%, moderate two plus tricuspid
regurgitation, moderate pulmonary artery systolic
hypertension, no pericardial effusion, no evidence of
endocarditis. Left ventricular cavity size normal in size.
Right ventricular systolic function normal. Aortic valve
leaflets structurally normal with good leaflet excursion.
Mitral valve leaflets are structurally normal.
The patient had a thoracentesis which was consistent with a
transudate thought to be secondary to congestive heart
failure. In light of the patient's nine liters positive at
an outside hospital, the patient was managed with Lasix 20 mg
intravenous p.r.n., usually requiring two to three doses per
day to keep negative. The patient responded and was minus
5.8 liters on length of stay on [**2106-1-15**]. The patient was
to be continued on gentle diuresis as tolerated.
4. Endocrinology: The patient had mild glucose
intolerance and originally had blood sugar in the 200 to 240
range. The patient was covered with sliding scale and NPH
insulin. The patient's sugars were well controlled and
ranged from 140 to 180 throughout much of his hospital stay.
The patient was started on tube feeds and settled out at
Peptamen 60 cc per hour. The patient tolerated tube feeds at
this goal nutrition for most of his hospital stay. The
patient had electrolytes repleted as necessary.
5. Gastrointestinal: The patient was maintained on
prophylaxis throughout his hospital stay and had no acute
gastrointestinal issues.
6. Hematology: The patient had an original hematocrit
of 28. Throughout his hospital stay, the patient had a
varying hematocrit between 23 and 28. The patient was guaiac
negative and hemolysis work-up including bilirubin, LDH,
haptoglobin, and reticulocyte count were all negative for
hemolysis times two. The patient had iron studies which were
consistent with anemia of chronic disease. This, combined
with patient's diagnosis of MGUS, the patient was not
actively transfused during his hospital stay for his
hematocrits of 23 to 28. If the patient's hematocrit dipped
below 22, there was a thought to transfuse.
The patient did receive one unit of packed red blood cells
early in his hospital course, but afterwards, hematocrit
remained stable.
7. Neurological: The patient was sedated on
Doxacurium, Fentanyl and Ativan. Doxacurium was discontinued
on [**2105-12-30**]. The patient had sedation weaned beginning on
[**1-10**] and on [**1-15**], the patient was on an Ativan drip of 5
per hour and a Fentanyl drip of 280 per hour.
8. Lines: The patient had originally a left subclavian
placed on [**2105-12-26**], as well as a right arterial line. The
patient had left subclavian and right arterial line
discontinued in favor of left arterial line and right
internal jugular because of persistent temperatures on [**1-4**].
The patient's right internal jugular eventually fell out on
its own and at this time it was thought that the patient
could be managed with peripheral intravenous and arterial
line for arterial blood gases. Culture tips of previously
mentioned central line did not grow any data from a
microbiological standpoint.
9. Prophylaxis: The patient was maintained on
intravenous Zantac as well as subcutaneously heparin and
Venodyne throughout his hospital stay.
10. Communication: The patient's wife and daughter
visited patient daily throughout his hospital stay and good
communication was maintained between them and the hospital
staff.
11. Renal: The patient maintained a stable BUN and
creatinine throughout his hospital stay and good urine
output. The patient had mild metabolic alkalosis from Lasix.
This resolved as patient was returned to pressure support and
CO2 was able to be exhaled.
12. CODE: The patient was a full code throughout his
hospital stay.
DISCHARGE DIAGNOSES:
1. Pneumococcal pneumonia/sepsis.
2. Adult respiratory distress syndrome.
3. Mild congestive heart failure.
4. Monoclonal gammopathies of undetermined significance.
DISCHARGE MEDICATIONS:
1. Miconazole powder three times a day p.r.n. to affected
area.
2. Celexa 20 mg p.o. q. day.
3. Zantac 50 mg intravenously q. eight.
4. Regular insulin sliding scale.
5. Reglan 10 mg intravenous three times a day.
6. Fentanyl gtt titrated to minimal sedation.
7. Ativan gtt titrated to minimal sedation.
8. Heparin 5000 units subcutaneously twice a day.
9. NPH insulin 12 units subcutaneously twice a day.
10. Tube feeds, 60 cc per hour of Respalar.
11. Artificial tears one to two gtts three times a day p.r.n.
12. Dulcolax suppositories, one to two tablets p.r. twice a
day p.r.n.
13. Lasix 20 mg intravenously p.r.n. to maintain fluid
balance.
ADDENDUM: This report was dictated on [**2106-1-15**]. At this
time, it was thought that the patient may be transferred to
Main given stable respiratory status. This discharge summary
will be addended with final plan.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**]
Dictated By:[**Last Name (NamePattern1) 1324**]
MEDQUIST36
D: [**2106-1-15**] 15:17
T: [**2106-1-15**] 15:46
JOB#: [**Job Number **]
Admission Date: [**2105-12-26**] Discharge Date: [**2106-2-4**]
Date of Birth: [**2037-5-26**] Sex: M
Service:
ADDENDUM: This discharge summary will continue where the
prior discharge summary left off on [**1-22**].
HOSPITAL COURSE: On [**1-22**] the patient was stable on
CPAP and pressure support. Repeat chest x-ray was performed
and ARDS was noted to be about the same. The patient was
continued on the same vent settings and ativan and Fentanyl
were weaned in order to wake the patient up for potential
extubation. The patient's bronchoalveolar lavage culture was
negative and antibiotics Ceftazidime and Vancomycin were
discontinued at that time. The patient continued to tolerate
CPAP and pressure support and required occasional Albuterol
prn. The patient was also diuresed conservatively with a
goal of -500 cc per day in anticipation of extubation. PEG
tube was placed on [**1-26**] and after this procedure
sedation was weaned successfully. The patient's Ativan was
weaned to off in four days and Fentanyl was changed from drip
to patch on [**2-3**]. The patient required less and less
Haldol and this was eventually discontinued on [**2-4**].
The patient tolerated trach collar beginning on [**2-1**]
and was also given a Passy-Muir valve for potential for
communication. He did well with the Passy-Muir valve. The
patient's current pulmonary status is on trach collar 12
liters 50%. His last arterial blood gas on these settings
was 751, 51, 74.
Cardiovascular: The patient continued to have hypotensive
episodes. These began to resolve on [**1-24**] and
hypertension began to become a problem at that point. His
Captopril, which was at 6.25 mg t.i.d. was increased and
reached 37.5 mg t.i.d., which is where it is at on [**2-4**]. His Lopressor was also restarted and increased
eventually reaching 50 mg t.i.d. on [**2-4**]. The patient
received occasionally prn Lasix for his congestive heart
failure.
Hematologic: The patient was noted to have an inappropriate
response to the transfusion of 2 units packed red cells. On
[**1-22**] he was given an additional packed red cell and his
hematocrit bumped appropriately. No further hematologic
workup was done. The patient was stable from this
perspective.
Infectious disease: The patient had low grade temperatures
to 100.0 and continued to have low grade temperatures to 99.5
to 99.8 over the next two weeks. After Ceftazidime and
Vancomycin were discontinued, no further antibiotics were
restarted. The patient's fevers were presumed secondary to
atelectasis rather then an infectious source. His secretions
were not significant and repeat chest x-ray on [**2-2**]
did not demonstrate an infiltrate. The patient continued NPH
and regular insulin sliding scale for treatment of his
diabetes.
Rheumatologic: The patient's joint effusions were noted to
be resolving on [**1-27**]. No pain on passive motion of his
extremities. The patient's comfort level was maintained,
however, he was given a three day course of Vioxx 50 followed
by a taper to Vioxx of 25, which provided relief of his pain.
Discussion with his private rheumatologist revealed that
these effusions take place three to four times a year, are
osteoarthritic in nature and do not require diagnostic
arthrocentesis. Occasionally they respond to therapeutic
arthrocentesis, however, given the rapid resolution of his
effusions, this procedure was not performed.
FEN: The patient had a PEG placed on [**1-26**] and was
quickly advanced to his goal tube feeds. Reglan was
discontinued as this may have been contributing to the
patient's mental status issues. He tolerated tube feeds at
goal for one week including the day of dictation [**2-4**].
DISPOSITION: Discharged to a rehab facility. He is
currently being screened and working with physical therapy.
DISCHARGE MEDICATIONS: Respalor at 60 cc an hour, regular
insulin sliding scale, NPH 12 and 12, heparin 5000 units subQ
b.i.d., Celexa 20 mg po q.d., Vioxx 25 mg po q.d., Lopresor
50 mg po t.i.d., Prevacid 30 mg po q.d., Captopril 37.5 mg po
t.i.d., Colace 100 mg po q.d., Fentanyl patch 50 micrograms
to derm change q 72 hours, lactulose 15 cc po q.d., Ativan 1
mg intravenous q 8 prn.
The patient is being screened for a rehab right now.
DISCHARGE CONDITION: Guarded.
DISCHARGE DIAGNOSES:
Identical to those listed on his prior discharge summary.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**]
Dictated By:[**Last Name (NamePattern1) 5476**]
MEDQUIST36
D: [**2106-2-4**] 08:11
T: [**2106-2-4**] 08:41
JOB#: [**Job Number 108237**]
Admission Date: [**2105-12-26**] Discharge Date: [**2106-2-9**]
Date of Birth: [**2037-5-26**] Sex: M
Service:
ADDENDUM: The patient's events from [**2-5**] to the
present will be in this discharge summary. On [**2-5**]
overnight the patient was noted to be tachycardic with a
desaturation at 66%. He was suctioned and his O2 sats were
restored. He also coughed up 30 cc of blood at the time.
Chest x-ray was obtained and it showed a right sided
infiltrate. The patient was also given 40 of Lasix
intravenous at the time and was left on pressure support,
which he was changed to from trach collar in no apparent
distress. Bronchoscopy was performed on the 15th, which
showed no lesions, however, the left side was not
visualized. The patient's white count was noted to be 20 on
the 15th and decreased to 15 on the 16th after Vancomycin and
Levofloxacin were started. EAL culture obtained at the time
of the bronchoscopy grew out staph aureus, which was
sensitive to Oxacillin. The patient continued to tolerate
tracheostomy collar on the [**2-7**] to the present
and was changed over to the Passy-Muir valve once again. He
continued to produce minimal to moderate blood tinged sputum
and his chest x-ray showed resolution of the right sided
infiltrate.
The patient's Fentanyl patch was discontinued on [**2-9**].
The patient's current medications as of this dictation of
this discharge summary are a regular insulin sliding scale,
tube feeds, Respalor 60 cc per hour, NPH insulin 12 and 12,
heparin 5000 subQ b.i.d., Celexa 20 po q.d., Vioxx 25 po
q.d., Lopressor 50 po t.i.d., Levaquin 500 mg po q.d. day
number five of a ten day course, Prevacid 30 mg po q.d.,
Lactulose 15 cc po q.d., Colace 100 mg po t.i.d., Senna two
tabs po b.i.d., Captopril 50 mg po t.i.d., prn Ativan 1 mg
intravenous. The patient is currently being screened for
placement in a rehab facility. He will require rehab for
severe deconditioning that took place during his six week
Intensive Care Unit stay.
DR.[**Last Name (STitle) **],[**First Name3 (LF) 7853**] 12-869
Dictated By:[**Last Name (NamePattern1) 5476**]
MEDQUIST36
D: [**2106-2-9**] 10:01
T: [**2106-2-9**] 10:09
JOB#: [**Job Number 108238**]
Admission Date: [**2105-12-26**] Discharge Date: [**2106-2-16**]
Date of Birth: [**2037-5-26**] Sex: M
Service:
ADDENDUM: The patient did not leave the hospital on [**2-15**] as planned, but instead on [**2-16**] for the reason that
there was no bed availability at the rehab facility that he
was being transported in [**State 1727**]. However, he was able to
leave on [**2106-2-16**].
[**Name6 (MD) 7853**] [**Last Name (NamePattern4) 7854**], M.D.
[**MD Number(1) 7855**]
Dictated By:[**Last Name (NamePattern1) 3033**]
MEDQUIST36
D: [**2106-2-16**] 11:06
T: [**2106-2-16**] 11:28
JOB#: [**Job Number 108252**]
Name: [**Known lastname 9609**], [**Known firstname 77**] Unit No: [**Numeric Identifier 17689**]
Admission Date: [**2105-12-26**] Discharge Date: [**2106-1-16**]
Date of Birth: [**2037-5-26**] Sex: M
Service: MICU/ORANG
THE PATIENT WAS TRANSFERRED TO THE FLOOR FROM THE MEDICAL
INTENSIVE CARE UNIT TO THE [**Hospital1 248**] INTERNAL MEDICINE SERVICE
ON [**2106-2-9**].
Since the patient has been on the floor, he has progressed
#1. CARDIOVASCULAR: The patient has been maintained with
decent blood pressures on Metoprolol 150 mg p.o. t.i.d. and
Captopril 50 mg p.o. t.i.d. That has also been used to
treatment his hypertension and coronary artery disease. The
patient has had no issues electrophysiologically. Regarding
the CHF, he has had no signs.
#2. PULMONARY: The patient finished his 10-day-course of
Levofloxacin 500 mg p.o.q.d. Saturations have remained well
at 92%. Most significantly he came to the floor in [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) 17690**]-Muir valve. He was then capped and then he had the
tracheostomy tube pulled on Friday, [**2-12**]. He
tolerated this very well with decent oxygen saturations. He
remains merely with gauze and tape over the site.
#3. RENAL: The patient has had fluid and electrolyte
balance.
#4. GASTROINTESTINAL: The patient was maintained on tube
feeds. For a period of time he had a little bit of
increasing residuals. He was restarted on Reglan 10 mg p.o.
t.i.d. In the meantime, between the 22nd and the 25th, the
patient actually began to tolerate p.o. nutrition pretty
well. So, it will be determined ultimately by the
nutritionist to when the tube feeds can be ceased based on
the patient's nutritional goal, although he is not at that
point yet.
#5. NEUROLOGICAL: The patient was on Ativan, which was
leading to some mental confusion. He was only oriented
really to person when he arrived on the floor. By [**2106-2-15**], he was maintained on a standing regimen of
Olanzapine 2.5 mg p.o.q.a.m. and 5 mg p.o.q.p.m. with 2.5 mg
p.r.n.q.6h., but no benzodiazepines and his mental status has
now improved to the point where he is alert and oriented
times three. He still has an essential tremor, which has
remained about the same, perhaps a little bit of a decrease
over time and we anticipated that that will decrease even
further as his mental status and physical condition improves.
PROPHYLAXIS: He was maintained on subcutaneous heparin and
Prevacid. As his p.o. intake improves, he can theoretically
be changed over to Protonix 40 mg p.o.q.d. instead of the
Prevacid 30 mg p.o.q.d.
He remains full code. He is stable for discharge. Of note,
the laboratory values show him to be VRE negative and MRSA
negative.
In summary, the patient's diagnosis include pneumococcal
sepsis status post tracheostomy, now decannulated;
hypertension; monoclonal gammopathy of undetermined
significance; type 2 diabetes mellitus; degenerative joint
disease status post PEG placement; and resolving delirium.
He also will leave on the following medications:
DISCHARGE MEDICATIONS:
1. Tube feeds Promote with fiber 90 cc an hour.
2. Olanzapine 2.5 mg p.o.q.a.m. 5 mg p.o.q.p.m.,
2.5 mg p.o.6 to 8 hours p.r.n.
3. NPH insulin 12 units subcutaneously q.a.m., 12 units
subcutaneously q.p.m.
4. Heparin 5000 units subcutaneously b.i.d.
5. Celexa 20 mg p.o.q.d.
6. Captopril 50 mg p.o.t.i.d.
7. Dulcolax one to two tablets p.o./pr,q.d.p.r.n.
8. Ambien 5 mg p.o./PEG q.h.s.p.r.n., may repeat times one.
9. Vioxx 25 mg q.d.
10. Lopressor 50 mg p.o.t.i.d.
11. Prevacid solution 30 mg/PEG q.d.
12. Lactulose 15 cc p.o.PEG b.i.d. titrated to one bowel
movement per day and also on a regular insulin sliding scale.
The patient was discharged in improved condition on
[**2-15**], to a rehabilitation facility in [**State 4488**].
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 17691**]
Dictated By:[**Last Name (NamePattern1) 771**]
MEDQUIST36
D: [**2106-2-15**] 10:51
T: [**2106-2-15**] 10:56
JOB#: [**Job Number 17692**]
Name: [**Known lastname 9609**], [**Known firstname 77**] Unit No: [**Numeric Identifier 17689**]
Admission Date: [**2105-12-26**] Discharge Date: [**2106-2-16**]
Date of Birth: [**2037-5-26**] Sex: M
Service: Medicine
The attending physician is [**Name9 (PRE) **] [**Name9 (PRE) **], [**Name Initial (PRE) **].D.
[**Name6 (MD) 1662**] [**Last Name (NamePattern4) 4337**], M.D. [**MD Number(1) 4338**]
Dictated By:[**Last Name (NamePattern1) 771**]
MEDQUIST36
D: [**2106-2-15**] 10:58
T: [**2106-2-15**] 11:05
JOB#: [**Job Number 17693**]
|
[
"428.0",
"719.09",
"481",
"790.2",
"038.2",
"276.3",
"518.82",
"293.0",
"273.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.72",
"43.11",
"96.56",
"31.1",
"34.91",
"96.6",
"38.93"
] |
icd9pcs
|
[
[
[]
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] |
19061, 19071
|
19092, 25425
|
25448, 27085
|
15007, 18596
|
5342, 13409
|
2907, 5314
|
173, 2884
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,128
| 138,247
|
33873
|
Discharge summary
|
report
|
Admission Date: [**2139-7-9**] Discharge Date: [**2139-7-13**]
Date of Birth: [**2094-6-5**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Zantac / Morphine / Tylenol / Naprosyn / ketorolac
/ Potassium
Attending:[**First Name3 (LF) 4095**]
Chief Complaint:
chest pain and hypotension
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
This is a 45 year-old female with a pmh hypotension on Florinef,
ESRD, DMII, and borderline personality disorder, who presents
with complaints of chest pain that began yesterday during
dialysis. Pain localizes without radiation to the left upper
quadrant of the chest. It is stabbing in nature. She denied any
fevers at home. She did complain of nausea and 1x emesis
yesterday. Her CP recurred, therefore she was brought to the ED.
She has a history of hypotension which was worked up by
endocrine last admission. It was thought to be [**12-31**] dysautonomia.
Of note she had an admission to the ICU 2 weeks ago with the
same presentation, and was started on levophed in the ED, but
was quickly weaned in the ICU given her known hypotension.
.
ED Course: She was hypotensive to the 80s and symptomatic with
lightheadedness. She was given 1.25L of IVF and her BP responded
to the 100s. She was given 1g of vanco and 4.5g of Zosyn out of
concern for infection. Her pain was treated with 0.5mg IV
dilaudid.
.
On the floor, she was awake and sitting up drinking a large
glass of water. She was asymptomatic and denied fevers, chills,
chest pain (currently), SOB, cough, diarrhea, rhinorrhea,
myalgias, sore throat or any vaginal complaints.
Past Medical History:
1. Hypotension (likely mineralocorticoid deficient, hypo-renin,
hypo-aldosterone, not likely complete adrenal insufficiency vs.
autonomic dysfunction on Florinef)
2. ESRD on HD M/W/F (RUE AV-fistula)
3. type 2 diabetes mellitus
4. coronary artery disease (inferior MI, cardiac cath [**2129**], EF
65%, inferior hypokinesis; MIBI [**11/2138**] no perfusion defects, no
ischemic ST changes)
5. h/o LLE DVT (no longer on coumadin), popliteal DVT ([**7-/2136**])
s/p IVC filter placement
6. hypertension
7. GERD
8. h/o positive MRSA swab ([**2138**])
9. hyperlipidemia
10. chronic abdominal pain (no etiology identified, extensive
work-up including MRA abdomen, strongyloides serologies, RUQ
U/S, multiple KUBs)
11. borderline personality disorder
12. drug-seeking behavior, ? suicidality
13. left eye prosthesis (followed by ophthalmology at [**Hospital1 2177**])
14. Bilateral IJ and SC DVTs
Social History:
Social History: Born in [**Country 2045**] and moved from [**State 108**]; divorced,
has two daughters. Worked as a CNA. Now resides in long term
care facility.
- Tobacco: Denies
- Alcohol: Denies
- Illicits: Denies
Family History:
Mother died from diabetes complications, brother died from the
same as well; Sister and daughter have diabetes.
Physical Exam:
Admission Exam:
Vitals: T: 96.9 BP: 125/71 P: 85 R: 16 O2: 98% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, left eye
prosthesis
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops, non-tender to palpation, 2 cm sebaceous cyst in center
chest
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 or
edema
.
Discharge Exam:
Vitals: T 99.3, BP 127/63, P 84, R 20, 100% RA
Gen: NAD, A&Ox3.
HEENT: Prosthetic L eye, reactive right pupil, MMM
Cards: RRR S1/S2 heard. [**1-4**] holysystolic ejection murmur, no
gallops/rubs.
Chest: L breast larger than right, and L firmer than right, but
non TTP
Pulm: CTAB
Abd: soft, NT ND, +BS. no organomegaly.
Extremities: no edema, no rashes/discoloration.
Skin: warm and dry
Pertinent Results:
Admission labs:
[**2139-7-9**] 04:35PM BLOOD WBC-5.3 RBC-4.49 Hgb-14.0 Hct-42.2 MCV-94
MCH-31.1 MCHC-33.1 RDW-18.6* Plt Ct-195
[**2139-7-9**] 04:35PM BLOOD Neuts-68.0 Lymphs-19.4 Monos-5.8 Eos-6.2*
Baso-0.6
[**2139-7-9**] 04:35PM BLOOD PT-12.8 PTT-28.3 INR(PT)-1.1
[**2139-7-9**] 04:35PM BLOOD Glucose-216* UreaN-22* Creat-6.9*# Na-137
K-4.6 Cl-92* HCO3-31 AnGap-19
[**2139-7-9**] 04:35PM BLOOD cTropnT-0.05*
.
[**2139-7-10**] 04:50AM BLOOD CK-MB-3 cTropnT-0.04*
[**2139-7-10**] 04:50AM BLOOD Lipase-23
.
Discharge Labs
[**2139-7-13**] 12:16PM BLOOD WBC-3.4* RBC-3.47* Hgb-10.9* Hct-33.2*
MCV-96 MCH-31.4 MCHC-32.8 RDW-19.0* Plt Ct-167
[**2139-7-13**] 12:16PM BLOOD Neuts-52.6 Lymphs-30.6 Monos-5.6
Eos-10.7* Baso-0.4
[**2139-7-13**] 12:16PM BLOOD Glucose-251* UreaN-32* Creat-9.1*# Na-133
K-4.3 Cl-91* HCO3-32 AnGap-14
[**2139-7-13**] 12:16PM BLOOD Calcium-9.0 Phos-4.6* Mg-2.9* Iron-48
[**2139-7-13**] 12:16PM BLOOD calTIBC-200* Ferritn-570* TRF-154*
[**2139-7-10**] 04:50AM BLOOD Hgb A-PND Hgb S-PND Hgb C-PND
.
CXR [**2139-7-9**]
Single AP upright portable view of the chest was obtained. There
are relatively low lung volumes, which accentuate the
bronchovascular markings. Given this, no focal consolidation,
large pleural effusion, or
evidence of pneumothorax is seen. The cardiac and mediastinal
silhouettes are unremarkable. Right-sided vascular stent is
unchanged. Cardiac and
mediastinal silhouettes are stable.
IMPRESSION: No acute cardiopulmonary process.
Brief Hospital Course:
45 year old female with pmh of pmh hypotension on Florinef,
ESRD, DMII, and borderline personality disorder, who presents
with complaints of chest pain, hypotension, fluid responsive in
the ED.
.
ACUTE
Hypotension: Likely secondary to agressive dialysis, as had HD
the day prior to admission and UF the day of admission. She was
fluid responsive in the ED and admitted to the MICU for close
observation. She was afebrile and without any other symptoms or
signs concerning for infection. In the ICU, she required no
further fluids and maintained a SBP 80s-100s, which appears to
be her baseline. Home florinef was continued. She was called out
to the medical floor after being observed in the ICU overnight.
Pt did not need any fluids while on the floor and tolerated 1 kg
removal with dialysis on [**7-11**].
.
Chest Pain: Etiology was unclear, though most likely to be
gastrointestinal in nature as patient had relief of symptoms
with maalox-lidocaine. Cardiac source was considered, and
thought to be highly unlikely given that her EKG (including
right-sided lead EKG) was unchanged from prior, troponin
measurements were less than baseline (though higher than normal
given her ESRD) and had normal CKMB. Cardiology reviewed her
EKGs and did not see evidence of ischemia. Sickle cell acute
chest was considered, though it is less likely given her absence
of anemia and lack of history, but hemoglobin electrophoresis is
currently pending. Pulmonary embolism is also unlikely given the
absence of tachycardia and hypoxia, though she does have a
history of DVT with a filter in place. Pt had refused heparin
in-house and was educated on the risks of this and pt understood
this can cause clots in the lungs that can lead to death.
Pulmonary embolism was considered unlikey to explain her
symptoms. She was continued on her home ASA, statin, and her
home pain regimen of PO dilaudid. IV dilaudid and IV benadryl
were requested by the patient and were not given.
.
ESRD: Currently getting hemodialysis on Monday, Wednesday,
Friday. Pt had no acute electrolyte abnormalities. Had dialysis
while in-house on [**7-11**] and [**7-13**]. She was continued on sevelamer
and vitamins. Dr. [**First Name (STitle) 805**], who is her outpatient nephrologist
was aware of admission and saw her while in-house.
.
DMII: Pt with labile finger stick blood sugars. Very high levels
(400s) in the morning while on Lantus 6 units at night and so
was increased to 12 units for more adequate basal coverage. Pt
on levemir at home, but placed on glargine while in house. Pt
had episodes of very low blood sugars after administration of
insulin via the sliding scale so was titrated down. After
adjusting the lantus and her [**Name (NI) **], pt had better glucose control.
After discharge, her finger stick glucose should be closely
monitored and insulin regimen adjusted accordingly.
.
Breast swelling: Pt had new complaints of left breast swelling
on the day of discharge, report it felt bigger and firmer than
her right, which she has never experienced before. Physical exam
did not demonstrate any erythema, warmth, lumps, or any evidence
of an abscess. She has a history of left subclavian vein
occlusion and collaterals from the right and thrombus in the
right innominate vein graft, mild breast assymetry is likely
related to increased interstitial fluid in the left breast.
Further evaluation with age-appropriate screening is
recommended.
.
CHRONIC
Psych: continued quetiapine.
.
Eye irritation: Continued home latanoprost. discontinued
tobramycin-dexamethasone seh was discharged with opthalmology
followup as she has not been seein in >2 years.
.
GERD: Continued omeprazole 20mg
.
TRANSITIONAL
# Recommend follow-up with primary care doctor to review
medication list, diabetes management, and for follow-up of the
hemoglobin electrophoresis.
.
# Recommend follow-up with nephrologist to monitor ESRD
medications.
.
# Recommend further evaluation of left breast swelling and
age-appropriate screening.
Medications on Admission:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. dicyclomine 10 mg Capsule Sig: Two (2) Capsule PO QID (4
times a day).
4. erythromycin 250 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO TID (3 times a day).
5. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
6. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. sevelamer carbonate 800 mg Tablet Sig: Three (3) Tablet PO
TID W/MEALS (3 TIMES A DAY WITH MEALS).
10. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
11. tizanidine 2 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
12. hydromorphone 2 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6
hours) as needed for pain.
13. lorazepam 1 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for anxiety.
14. quetiapine 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
15. tobramycin-dexamethasone 0.3-0.1 % Ointment Sig: One (1)
Appl Ophthalmic TID (3 times a day).
16. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
powder PO DAILY (Daily) as needed for constipation.
17. Levemir 100 unit/mL Solution Sig: Six (6) units Subcutaneous
at bedtime.
18. insulin aspart 100 unit/mL Solution Sig: sliding scale
sliding scale Subcutaneous every six (6) hours.
19. fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
20. Dilaudid 2 mg Tablet Sig: 0.5 Tablet PO 3 times weekly:
M/W/F on HD days.
21. bisacodyl 10 mg Suppository Sig: One (1) supp Rectal at
bedtime as needed for constipation.
22. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
mL PO every six (6) hours as needed for constipation.
23. bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO once a day as
needed for constipation.
24. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO every
six (6) hours as needed for itching.
25. lorazepam 1 mg Tablet Sig: One (1) Tablet PO M/W/F: three
times weekly.
26. Aranesp (polysorbate) 40 mcg/0.4 mL Syringe Sig: Forty (40)
mcg Injection once a week.
27. gabapentin 100 mg Capsule Sig: One (1) Capsule PO at
bedtime.
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime.
4. dicyclomine 10 mg Capsule Sig: Two (2) Capsule PO QID (4
times a day).
5. erythromycin 250 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO TID (3 times a day).
6. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
7. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. sevelamer carbonate 800 mg Tablet Sig: Three (3) Tablet PO
TID W/MEALS (3 TIMES A DAY WITH MEALS).
10. latanoprost 0.005 % Drops Sig: One (1) Drop(s) in each eye
Ophthalmic HS (at bedtime).
11. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
12. quetiapine 50 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
13. fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
14. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for itching.
15. gabapentin 100 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
16. hydromorphone 2 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6
hours) as needed for pain for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
17. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
18. tizanidine 2 mg Tablet Sig: 0.5 Tablet PO at bedtime.
19. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
dose PO once a day.
20. Dilaudid 2 mg Tablet Sig: 0.5 Tablet PO Three times weekly
for 3 doses: M/W/F on HD days.
Disp:*3 Tablet(s)* Refills:*0*
21. bisacodyl 10 mg Suppository Sig: One (1) suppository Rectal
at bedtime as needed for constipation.
22. lorazepam 1 mg Tablet Sig: One (1) Tablet PO three times
weekly: M/W/F on HD days.
23. Aranesp (polysorbate) 40 mcg/0.4 mL Syringe Sig: One (1)
syringe Injection once a week.
24. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea for 4
doses.
Disp:*4 Tablet, Rapid Dissolve(s)* Refills:*0*
25. Maalox Maximum Strength 400-400-40 mg/5 mL Suspension Sig:
10-20 MLs PO twice a day as needed for abdominal/chest pain for
1 doses.
26. Humalog (Subcutaneous) 100 unit/mL Solution.
Humalog (Subcutaneous) 100 unit/mL Solution.
Sig: dispense QAM, QNoon, and QPM according to the following
scale:
BG <150: no coverage
BG 150-199: 2 units,
BG 200-249: 4 units,
BG 250-299: 6 units,
BG 300-349: 8 units,
BG Over 350: 10 units,
At bedtime use the following scale
BG <150: no coverage
BG 150-199: 0 units,
BG 200-249: 2 units,
BG 250-299: 4 units,
BG 300-349: 6 units,
BG Over 350: 8 units,
27. Lantus 100 unit/mL Solution Sig: Twelve (12) Units
Subcutaneous at bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 16662**] Nursing and Rehab Center - [**Street Address(1) **]
Discharge Diagnosis:
Primary
Hypovolemic Hypotension
Secondary
Chest pain, etiology unknown, likely GI related
Chronic kidney disease
diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 78242**],
It was a pleasure taking care of you while you were in the
hospital. You were admitted because of your chest pain and low
blood pressure after dialysis on Wednesday, [**7-8**], and then
ultrafiltration on [**7-9**].
Your blood pressure improved when we hydrated you with fluids.
Your chest pain was relieved with maalox-lidocaine, which means
that your chest pain is likely caused by your gastrointestinal
tract. We ran tests, which indicated that the pain was not
caused by your heart. The gas pain you had improved with stool
softeners and laxatives. Please be careful with how much
narcotics you take because this can worsen constipation and
increase your abdominal pain.
.
It's important for you to follow-up with your primary care
physician and your kidney doctor to review your medications.
.
Please continue taking your home medications, with the following
changes:
1. STOP taking tobramycin dexamethasone eye ointment
2. STOP taking magnesium hydroxide
3. STOP taking Levemir
4. STOP taking Aspart
5. Start taking Humalog
6. Start taking Glargine
7. START taking maalox for your chest pain
8. START taking ondansetron for your nausea
Followup Instructions:
Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.
Diaylsis [**Location (un) **]
Phone: [**Telephone/Fax (1) 5972**]
Nephrologist-Dr.[**First Name (STitle) 805**]
[**Name (STitle) 57321**]/W/F
**Dr. [**First Name (STitle) 805**] will follow up with you at your next scheduled
diaylsis appointment.
Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.
Diaylsis [**Location (un) **]
Phone: [**Telephone/Fax (1) 5972**]
Nephrologist-Dr.[**First Name (STitle) 805**]
[**Name (STitle) 57321**]/W/F
**Dr. [**First Name (STitle) 805**] will follow up with you at your next scheduled
diaylsis appointment.
Department: [**Hospital3 1935**] CENTER
When: WEDNESDAY [**2139-7-22**] at 9:30 AM
With: [**First Name11 (Name Pattern1) 354**] [**Last Name (NamePattern4) 3013**], M.D. [**Telephone/Fax (1) 253**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**Last Name (LF) 679**], [**Name8 (MD) 1158**] MD
Department: Gastroenterology
Address: [**Doctor First Name **],STE 8A, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 682**]
Appointment: Wednesday [**2139-7-22**] 10:30am
Completed by:[**2139-7-15**]
|
[
"585.6",
"583.81",
"403.91",
"301.83",
"276.52",
"530.81",
"250.40",
"E879.1",
"272.4",
"786.59",
"V12.51",
"458.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
14945, 15044
|
5477, 9466
|
362, 370
|
15220, 15220
|
3984, 3984
|
16576, 17940
|
2807, 2921
|
11938, 14922
|
15065, 15199
|
9492, 11915
|
15371, 16553
|
2936, 3562
|
3578, 3965
|
296, 324
|
398, 1638
|
4000, 5454
|
15235, 15347
|
1660, 2554
|
2587, 2791
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,157
| 113,250
|
12901
|
Discharge summary
|
report
|
Admission Date: [**2103-8-21**] Discharge Date: [**2103-8-28**]
Date of Birth: [**2036-12-27**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Latex
Attending:[**First Name3 (LF) 3645**]
Chief Complaint:
I had the pleasure of seeing Mr. [**Known lastname 6330**] in orthopedic spine
clinic
for his chief complaint of back problems.
Major Surgical or Invasive Procedure:
1. C4-C5 anterior arthrodesis.
2. Application of interbody VG2 device.
3. Anterior cervical decompression C4-C5.
4. Posterior laminectomy, medial facetectomy, foraminotomy,
C3-C4, C4-C5, C5-C6.
5. Posterior arthrodesis C3-C4, C4-C5, C5-C6, C6-C7.
6. Posterior instrumentation C3-C7 segmental.
7. Application and removal of tongs.
8. Application of local autograft.
9. Application of morcelized allograft.
10. Spinal cord monitoring with motor evoked NSCCP's.
History of Present Illness:
As you know, he is a 66-year-old gentleman with acute and
chronic back pain. For the past six months, he states his back
pain has been increasing. At
this time, he states his back pain is [**8-7**] at rest and [**11-7**]
with activity. He does not complain of any changes in his
bowel, bladder, or balance. He denies any numbness or tingling
of the lower extremities. He also denies any weakness or calf
pain with walking. He states that there was no specific
accident but this has just gradually kind of come on. He also
complains of medial left thigh pain. He says any activity makes
it worse and he has not had any physical therapy prior to this
exam.
Past Medical History:
Significant for high blood pressure, which he states is under
control. He has had thyroid disease. Specifically, he does
have Addison's disease. In addition, he has been on steroid
medications for approximately fifteen years. He states that
over the last six months, due to his last hospitalization, they
upped his steroids to 150 mg per day, he has since backed off to
30 mg per day.
Social History:
He states he is currently working. He smokes a pipe and he has
approximately two or three drinks per week. He lives at home
with his wife.
Family History:
Family history is significant for cancer on his mother's side
and heart disease on his father's side.
Physical Exam:
On physical exam, he is approximately 5 feet 8 inches tall,
weighing 225 pounds with a blood pressure of 115/70. His gait
is quite antalgic. He is able to stand on his heels and toes.
His gait is very small steps steppage gait with a narrow base.
He has negative Romberg. Lower extremity strength is [**6-2**] in all
fields. He is neurologically intact to light touch in all
fields. Reflexes of his lower extremities when compared to his
reflexes of his upper extremity exhibit hyperreflexia. He does
have clonus x4 on the right and a sustained clonus on the left.
He also has a large degree of pitting edema in his lower
extremities. He states he believes that this is secondary to
the increase to his steroid medication and the removal
hydrochlorothiazide from his medical regimen. Physical exam of
his upper extremity, he has good strength 5/5 in all fields of
bilateral upper extremities and he is neurologically intact to
light touch. He does state he has some numbness and tingling in
his pinky of both hands.
Pertinent Results:
[**2103-8-22**] 03:00AM BLOOD WBC-13.7* RBC-4.17* Hgb-13.3* Hct-38.8*
MCV-93 MCH-31.9 MCHC-34.3 RDW-15.3 Plt Ct-229
[**2103-8-23**] 01:56AM BLOOD WBC-20.5* RBC-4.27* Hgb-14.0 Hct-41.1
MCV-96 MCH-32.8* MCHC-34.1 RDW-15.0 Plt Ct-252
[**2103-8-23**] 06:14AM BLOOD WBC-15.6* RBC-3.95* Hgb-12.7* Hct-38.3*
MCV-97 MCH-32.1* MCHC-33.1 RDW-14.9 Plt Ct-276
[**2103-8-24**] 01:08AM BLOOD WBC-12.5* RBC-3.62* Hgb-11.8* Hct-34.1*
MCV-94 MCH-32.7* MCHC-34.7 RDW-15.2 Plt Ct-221
[**2103-8-25**] 03:52AM BLOOD WBC-12.8* RBC-3.64* Hgb-11.9* Hct-34.8*
MCV-96 MCH-32.7* MCHC-34.2 RDW-15.1 Plt Ct-268
[**2103-8-23**] 06:15AM BLOOD CK(CPK)-575*
[**2103-8-24**] 01:08AM BLOOD ALT-30 AST-35 LD(LDH)-177 AlkPhos-211*
Amylase-49 TotBili-1.3
[**2103-8-23**] 06:15AM BLOOD CK-MB-13* MB Indx-2.3 cTropnT-0.03*
[**2103-8-24**] 01:08AM BLOOD Albumin-3.1* Calcium-8.3* Phos-2.8 Mg-2.0
[**2103-8-25**] 03:52AM BLOOD Calcium-8.5 Phos-2.6* Mg-2.2
[**2103-8-21**] 02:47PM BLOOD Type-ART PEEP-5 pO2-120* pCO2-46* pH-7.41
calTCO2-30 Base XS-4 Intubat-INTUBATED
[**2103-8-21**] 10:14PM BLOOD Type-ART pO2-187* pCO2-40 pH-7.41
calTCO2-26 Base XS-1
[**2103-8-22**] 03:07AM BLOOD Type-ART pO2-154* pCO2-46* pH-7.40
calTCO2-30 Base XS-3
[**2103-8-23**] 01:39AM BLOOD Type-ART pO2-97 pCO2-106* pH-7.07*
calTCO2-33* Base XS--2
[**2103-8-23**] 04:21AM BLOOD Type-ART Rates-20/ Tidal V-600 PEEP-8
FiO2-60 pO2-73* pCO2-41 pH-7.34* calTCO2-23 Base XS--3
Intubat-INTUBATED
[**2103-8-23**] 01:55PM BLOOD Type-ART pO2-169* pCO2-30* pH-7.52*
calTCO2-25 Base XS-2
[**2103-8-23**] 02:47PM BLOOD Type-ART pO2-116* pCO2-41 pH-7.42
calTCO2-28 Base XS-2
[**2103-8-23**] 06:11PM BLOOD Type-ART pO2-295* pCO2-41 pH-7.42
calTCO2-28 Base XS-2
[**2103-8-23**] 07:42PM BLOOD Type-ART Rates-0/10 FiO2-40 pO2-146*
pCO2-43 pH-7.42 calTCO2-29 Base XS-3 Intubat-INTUBATED
Vent-SPONTANEOU
[**2103-8-24**] 01:33AM BLOOD Type-ART Temp-38.6 Rates-/10 FiO2-40
pO2-184* pCO2-47* pH-7.40 calTCO2-30 Base XS-3 Intubat-INTUBATED
Vent-SPONTANEOU
[**2103-8-24**] 04:18AM BLOOD Type-ART Temp-38.1 Rates-/12 PEEP-8
FiO2-40 pO2-178* pCO2-47* pH-7.39 calTCO2-30 Base XS-3
Intubat-INTUBATED Vent-SPONTANEOU
[**2103-8-24**] 06:22AM BLOOD Type-ART Temp-37.5 Rates-/13 Tidal V-560
PEEP-5 FiO2-40 pO2-163* pCO2-45 pH-7.42 calTCO2-30 Base XS-4
Intubat-INTUBATED Vent-SPONTANEOU
[**2103-8-24**] 08:40AM BLOOD Type-ART pO2-177* pCO2-34* pH-7.48*
calTCO2-26 Base XS-3
[**2103-8-24**] 10:52AM BLOOD Type-ART pO2-89 pCO2-48* pH-7.38
calTCO2-29 Base XS-1
[**2103-8-24**] 06:55PM BLOOD Type-ART pO2-99 pCO2-44 pH-7.44
calTCO2-31* Base XS-4
Brief Hospital Course:
Mr. [**Known lastname 6330**] was brought to [**Hospital1 18**] for treatment of his cervical
stenosis with myelopathic changes.
Medications on Admission:
hydrocortisone 20 mg
Altace 10 mg
Norvasc 10 mg
Protonix 40 mg
testosterone 7 mL
Discharge Medications:
1. Hydrocortisone 5 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
2. Hydrocortisone 5 mg Tablet Sig: Three (3) Tablet PO QAM (once
a day (in the morning)).
3. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours.
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Southeastern
Discharge Diagnosis:
1. Cervical myelopathy.
2. Cervical stenosis.
3. Morbid obesity.
4. Panhypopituitarism from pituitary tumor
5. Hypertension
Discharge Condition:
Stable to home with physical therapy.
Discharge Instructions:
Please keep your incision clean and dry. You may shower but
please do not soak the incision. Please reusme all your home
medication as prescribed by your primary care. If you notice
redness or drainage from your incision or if you have a fever
greater than 100.5, please call the office at [**Telephone/Fax (1) **].
Please refer to the discharge sheet for questions on activity
and follow up.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 1352**] two weeks from the date of
surgery.
Completed by:[**2103-9-5**]
|
[
"401.9",
"278.01",
"799.02",
"721.1",
"253.7",
"458.29",
"518.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"81.02",
"81.63",
"96.04",
"81.03"
] |
icd9pcs
|
[
[
[]
]
] |
6518, 6561
|
5887, 6017
|
399, 873
|
6734, 6774
|
3319, 5864
|
7218, 7340
|
2154, 2258
|
6149, 6495
|
6582, 6713
|
6043, 6126
|
6798, 7195
|
2273, 3300
|
232, 361
|
901, 1566
|
1588, 1979
|
1995, 2138
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,891
| 129,613
|
2664
|
Discharge summary
|
report
|
Admission Date: [**2193-11-6**] Discharge Date: [**2193-11-14**]
Date of Birth: [**2129-8-14**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Gluten
Attending:[**First Name3 (LF) 11415**]
Chief Complaint:
Pedestrian struck by car
Major Surgical or Invasive Procedure:
1. Removal of external fixator and knee spanning construct.
2. Open reduction internal fixation proximal tibia fracture
with 9-hole [**Last Name (un) 101**] plate.
3. Closed treatment of fibular fracture.
4. Closed treastment of L clavicle fracture
History of Present Illness:
64 yo F pedestrian struck by a car at 30 mph causing her to
crack the windshield of the car. Pt denied LOC but was unable to
stand secondary to dizziness. On arrival to the ED she was found
to be hemodynamically stable,
alert, oriented, and complaining of significant LUE and LLE
pain.
Imaging revealed SAH, SDH, L distal displaced clavicle fx, L
displaced prox tib/fib fx. Neurosurgery and Orthopaedic surgery
were consulted.
Past Medical History:
Fibromyalgia, Hypothyroid
Social History:
lives with husband. no [**Name2 (NI) **], no ETOH
Family History:
Noncontributory
Physical Exam:
Physical Exam;
VSS, Afeb, NAD, AOx3 anxious
Small amount of swelling/resolving brusing over the occiput.
Minimal tenderness.
L shoulder in soft sling. Brusing over distal clavicle. Slightly
elevated skin over the distal clavicle (stable/improving).
Tender over clavicular protrusion. No skin breakdown or concern
for skin tenting/devitalization. Pt unable to actively ROM L
shoulder [**1-15**] pain but PROM intact. SILT distally (R/U/M
distributions). +EPL/APB/ADQ, WWP w/ brisk cap refill, palp
radial pulse
LLE: hinged long knee brace in place. Wounds are CDI without
significant oozing. Moderate brusing throughout the lower leg
extending into the foot. The L foot is swollen but WWP. Palp
DP/PT. No signs of skin breakdown. SILT distally.
+GS/TA/[**Last Name (un) 938**]/FHL. Pt resistent to active ROM at knee [**1-15**] pain but
PROM to at least 90 degrees of flexion and 0-5 degrees of
extension (brace locked 0-90).
Otherwise physical exam is unremarkable and WNL
Pertinent Results:
[**2193-11-6**] 05:50PM BLOOD WBC-5.7 RBC-4.06* Hgb-12.8 Hct-37.5
MCV-92 MCH-31.6 MCHC-34.3 RDW-12.6 Plt Ct-190
[**2193-11-7**] 12:49AM BLOOD WBC-8.2 RBC-2.48*# Hgb-8.2*# Hct-23.0*#
MCV-93 MCH-33.0* MCHC-35.4* RDW-12.6 Plt Ct-152
[**2193-11-7**] 03:59AM BLOOD Hct-29.4*#
[**2193-11-8**] 01:51AM BLOOD WBC-5.3 RBC-3.19*# Hgb-10.3*# Hct-28.7*
MCV-90 MCH-32.5* MCHC-36.1* RDW-14.0 Plt Ct-97*
[**2193-11-10**] 09:20AM BLOOD WBC-5.6 RBC-3.09* Hgb-9.9* Hct-27.9*
MCV-90 MCH-31.9 MCHC-35.4* RDW-13.8 Plt Ct-154#
[**2193-11-12**] 05:15AM BLOOD WBC-7.2 RBC-2.96* Hgb-9.7* Hct-28.4*
MCV-96 MCH-32.7* MCHC-34.1 RDW-14.1 Plt Ct-236
[**2193-11-6**] 05:50PM BLOOD PT-12.9 PTT-21.7* INR(PT)-1.1
[**2193-11-7**] 12:49AM BLOOD PT-14.2* PTT-25.3 INR(PT)-1.2*
[**2193-11-10**] 09:20AM BLOOD PT-13.2 PTT-23.4 INR(PT)-1.1
[**2193-11-12**] 05:15AM BLOOD PT-13.1 PTT-22.4 INR(PT)-1.1
[**2193-11-7**] 12:49AM BLOOD Glucose-173* UreaN-7 Creat-0.5 Na-140
K-3.7 Cl-111* HCO3-24 AnGap-9
[**2193-11-8**] 01:51AM BLOOD Glucose-111* UreaN-9 Creat-0.4 Na-136
K-3.6 Cl-106 HCO3-23 AnGap-11
[**2193-11-10**] 09:20AM BLOOD Glucose-65* UreaN-11 Creat-0.3* Na-141
K-3.3 Cl-106 HCO3-22 AnGap-16
[**2193-11-12**] 05:15AM BLOOD Glucose-80 UreaN-9 Creat-0.5 Na-141 K-3.8
Cl-108 HCO3-18* AnGap-19
Brief Hospital Course:
Ms. [**Known lastname **] presented to the [**Hospital1 18**] on [**2193-11-6**] after being
struck by a car traveling at 30mph while the pt was crossing the
street. She was brought to the [**Hospital1 18**] ED where she was evaluated
by the neurosurgery and orthopaedic surgery service and found to
have a SDH and SAH, a L clavicular fx, and a L tib/fib fx. Her
C-spine and spine was cleared and the rest of her trauma exam
was negative. Pt was initially admitted to the trauma SICU
overnight for close monitoring. On [**2193-11-7**] pt recieved 3 U PRBC
for acute blood loss with an appropriate increase in her HCT. On
[**11-8**] pt was stable and cleared for surgery by the trauma
surgery service as well as the neurosurgery service. She was
subsequently taken to the OR for external fixation/stabilization
of her L tib/fib fracture. External fixation was utilized to
stabilize the leg while swelling decreased and the quality of
the overlying skin could be assessed. Pt tolerated the procedure
well and was admitted to the orthopaedic surgery service. After
daily evaluations of her swelling, skin quality, and medical
condition, on [**11-11**], pt taken to the operating room and
underwent an ORIF of her left tib/fib. She tolerated the
procedure well, was extubated, transferred to the recovery room,
and then to the floor. Post operatively pt recovering well
albeit with some difficulty with pain controll due to
"lightheadedness" following PO narcotic pain medications. On the
floor she was
seen by physical therapy to improve her strength and mobility.
The rest of her hospital stay was uneventful with her lab data
and vital signs within normal limits and her pain controlled.
She is being discharged today in stable condition.
Medications on Admission:
Boniva, synthroid, Vitamin D, tylenol prn
Discharge Medications:
1. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO QID (4 times a day) as needed for
heartburn.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
5. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO Q4H (every 4
hours) as needed for Pain.
Disp:*45 Tablet(s)* Refills:*0*
7. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
8. diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for ms spasm.
9. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous
DAILY (Daily) for 4 weeks.
10. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]
Discharge Diagnosis:
1. Left tibia and fibula fracture
2. Left distal clavicle fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
(walker, cane, or crutches).
Discharge Instructions:
Wound Care:
-Keep Incision dry.
-Do not soak the incision in a bath or pool.
Activity:
-Continue to be non weight bearing on your Left upper arm and
touchdown weight bearing on your left leg.
Other Instructions
- Resume your regular diet.
- Avoid nicotine products to optimize healing.
- Resume your home medications. Take all medications as
instructed.
- Continue taking the Lovenox to prevent blood clots.
-You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so plan ahead. You can either have them mailed
to your home or pick them up at the clinic located on [**Hospital Ward Name 23**] 2.
We are not allowed to call in narcotic (oxycontin, oxycodone,
percocet) prescriptions to the pharmacy. In addition, we are
only allowed to write for pain medications for 90 days from the
date of surgery.
- Narcotic pain medication may cause drowsiness. Do not drink
alcohol while taking narcotic medications. Do not operate any
motor vehicle or machinery while taking narcotic pain
medications. Taking more than recommended may cause serious
breathing problems.
If you have questions, concerns or experience any of the below
danger signs then please call your doctor at [**Telephone/Fax (1) 1228**] or go
to your local emergency room.
Physical Therapy:
Activity: Activity as tolerated
Right lower extremity: Full weight bearing
Left lower extremity: Touchdown weight bearing
Full ROM of Left knee at least QID
Continue to work with pt on L foot dorsiflexion exercises to
prevent contracture.
Continue to ambulate pt at least QID
Treatments Frequency:
Please remove staple on postoperative day 14.
Followup Instructions:
Please follow up with the [**Hospital 13308**] Clinic in 2 weeks after
discharge. You will see [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP. You will need to
call the office at [**Telephone/Fax (1) 1228**] to schedule an appointement.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**] MD, [**MD Number(3) 11417**]
|
[
"882.0",
"733.00",
"285.1",
"873.0",
"729.1",
"958.7",
"348.5",
"823.02",
"244.9",
"579.0",
"800.22",
"810.00",
"721.0",
"E814.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.06",
"78.17",
"79.36",
"78.67"
] |
icd9pcs
|
[
[
[]
]
] |
6205, 6350
|
3449, 5191
|
298, 553
|
6461, 6461
|
2170, 3426
|
8361, 8754
|
1145, 1162
|
5284, 6182
|
6371, 6440
|
5217, 5261
|
6655, 6655
|
1177, 2151
|
7992, 8268
|
8290, 8338
|
234, 260
|
6667, 7974
|
581, 1010
|
6476, 6631
|
1033, 1061
|
1077, 1129
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,275
| 164,608
|
43674
|
Discharge summary
|
report
|
Admission Date: [**2136-2-29**] Discharge Date: [**2136-3-3**]
Date of Birth: [**2078-11-11**] Sex: M
Service: SURGERY
Allergies:
Penicillins / Iodine; Iodine Containing / Carbamazepine
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
purulent drainage from avg left arm
Major Surgical or Invasive Procedure:
Removal of infected AV graft
History of Present Illness:
prior LUE av graft placed. noted drainage and fever on dialysis
now presents for graft removal.
Past Medical History:
- seizures since childhood, which began as generalized
tonic-clonic. He was treated with phenobarbitol and Mysoline.
Later, was changed to Depakote and Dilantin. Depakote was
discontinued roughly 4 years ago due to elevated ammonia levels.
Since, then his seizures have increased in frequency and
severity. As a result, muliple medications inculding Lamictal,
Trileptal, Tegretol and Keppra have been tried and he has most
recently been on combination of Keppra and Lamictal. His
seizures have been occuring about once every 1-2 months. Usual
episodes are characterized by confusion and disorientation with
rare, generalized tonic clonic episodes. As per OMR notes, he
has a history of non-convulsive status which presented as
confusion in the past and responded to ativan.
-ESRD on HD, due to idiopathic glomerulonephritis, s/p two
failed renal transplants
-hypertension
-hypothyroidism
-peripheral [**First Name3 (LF) 1106**] disease
-hypoparathyroidism
-hepatitis C
-CHF-diastolic dysfunction (EF>30% in [**4-/2135**])
-SVT/AVNRT s/p ablation
-multiple fistulas
-H/O MRSA line infection
-Recent admission [**2136-2-29**] for infected L upper arm AV fistula.
Social History:
Smoked since he was young; used to smoke heavier, now 0.5 ppd,
denies alcohol or IVDs. Has been on disability since [**2115**].
Family History:
mother with breast CA; father alive with CAD & CHF; sons
healthy.
Physical Exam:
erythema and purulent drainage form Left arm AV graft incisions.
Pertinent Results:
[**2136-2-29**] 05:38PM GLUCOSE-77 UREA N-60* CREAT-7.6* SODIUM-133
POTASSIUM-5.2* CHLORIDE-92* TOTAL CO2-25 ANION GAP-21*
[**2136-2-29**] 05:38PM CK(CPK)-25*
[**2136-2-29**] 05:38PM CK-MB-NotDone cTropnT-0.04*
[**2136-2-29**] 05:38PM CALCIUM-8.1* PHOSPHATE-6.9* MAGNESIUM-2.0
[**2136-2-29**] 05:38PM WBC-8.1 RBC-3.59* HGB-10.8* HCT-30.5* MCV-85
MCH-29.9 MCHC-35.3* RDW-19.2*
[**2136-2-29**] 05:38PM PLT COUNT-199
[**2136-2-29**] 01:50PM GLUCOSE-82 UREA N-60* CREAT-7.5* SODIUM-136
POTASSIUM-6.0* CHLORIDE-91* TOTAL CO2-27 ANION GAP-24*
[**2136-2-29**] 01:50PM WBC-6.9 RBC-4.15* HGB-13.1* HCT-36.7* MCV-88
MCH-31.5 MCHC-35.7* RDW-19.3*
[**2136-2-29**] 01:50PM NEUTS-67 BANDS-0 LYMPHS-14* MONOS-14* EOS-0
BASOS-2 ATYPS-3* METAS-0 MYELOS-0
[**2136-2-29**] 01:50PM PLT COUNT-187
Brief Hospital Course:
graft excised, treated with antibiotics. wounds packed open and
dressing changed on POD #2. d/c home on IV antibiotics.
Discharge Medications:
1. Lamotrigine 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
2. Nifedipine 60 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO DAILY (Daily).
3. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily).
4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Levetiracetam 250 mg Tablet Sig: 1.5 Tablets PO BID (2 times
a day).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
8. Calcium Acetate 667 mg Capsule Sig: Three (3) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Left arm arteriovenous graft infection
Discharge Condition:
Good
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Please change your dressing at least 2 times per day. Call
office Monday to arrange appointment to be seen this week for
wound check. Return to the Emergency Department for fever,
increased swelling, increased pain, drainage of pus, or redness
around the incisions. You should continue to receive vancomycin
at dialysis for the next 2 weeks (starting [**2136-2-29**]).
Followup Instructions:
Call Dr.[**Name (NI) 670**] office on Monday to arrange a follow-up
appointment this week.
|
[
"518.0",
"996.62",
"428.0",
"E879.9",
"440.20",
"414.01",
"403.91",
"428.30",
"790.7",
"E878.2",
"585.6",
"458.29",
"041.85",
"070.70",
"E849.8",
"780.39"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"39.49",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
3860, 3866
|
2842, 2965
|
350, 381
|
3949, 3956
|
2022, 2819
|
4476, 4570
|
1854, 1922
|
2988, 3837
|
3887, 3928
|
3980, 4453
|
1937, 2003
|
275, 312
|
409, 506
|
528, 1691
|
1707, 1838
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,847
| 138,905
|
16576
|
Discharge summary
|
report
|
Admission Date: [**2166-11-5**] Discharge Date: [**2166-11-19**]
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: The patient is an 80 year old
male with known coronary artery disease, status post inferior
myocardial infarction in [**2156**] presenting with two weeks of
shortness of breath with cough and chest discomfort. At the
outside hospital, white blood count was 14 with 27% bands,
creatinine kinase and troponin I were elevated.
The diagnosis of pneumia was made. Electrocardiogram was
consistent with anterior ST changes.
The patient was transferred to [**Hospital6 2018**]. At Emergency Department Cardiology was consulted and
he was felt to be ruling in for anterior myocardial
infarction.
PHYSICAL EXAMINATION: 98.7, 86/52, 83, 95% on room air,
respiratory rate 14. Neck: No jugulovenous distension.
Cardiovascular: Regular rate and rhythm, no murmurs, rubs or
gallops. Pulmonary: Bibasilar crackles, right greater than
left. Extremities: No edema.
LABORATORY DATA: Laboratory data on admission revealed white
blood count 12.5, creatinine kinase 301, MB fraction 11,
index 3.7, creatinine 1.4.
HOSPITAL COURSE: The patient was admitted on [**11-5**] as
above to the Cardiac Service. He was started on Metoprolol
25.5 b.i.d., ACE inhibitor and sputum cultures were sent.
The patient was brought to catheterization on [**2166-11-5**] which showed left anterior descending occlusion of 20%,
main coronary artery occlusion of 70%, and left circumflex
with moderate stenosis and a totally occluded right coronary
artery with left ventricular ejection fraction of 20%. Four
vessel disease precluded percutaneous coronary angioplasty.
Cardiothoracic Surgery Service was consulted. The risks and
benefits of coronary artery bypass graft were explained to
the patient in detail. In the interim, his medical problems
were treated which included the administration of
antibiotics for pneumonia, transfusion for a low hematocrit
from chronic
anemia. The patient was brought to the Operating Room on
[**11-11**], where three vessel coronary artery bypass graft
was performed (left internal mammary artery to ramus,
saphenous vein graft to distal left anterior descending,
saphenous vein graft to obtuse marginal). He tolerated the
procedure well and was transferred to the Cardiothoracic
Intensive Care Unit. On postoperative day #2 the patient had
minimal but present left-sided weakness and neurological
consult was obtained.
Computerized tomography scan showed a small bleed in the
parietal occipital area. His weakness has since resolved
rapidly and the patient is currently at baseline. The patient
remains on Levofloxacin for prophylaxis of pneumonia secondary
to atelectasis.
DISCHARGE CONDITION: Excellent.
FOLLOW UP PLAN: The patient is to follow up with Dr. [**Last Name (STitle) **]
in four weeks and follow up with his primary care physician
in one week.
Diagnosis: CAD sp CABG, pneumonia, blood loss anemia and
anemia of chronic illness, congestive heart failure.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 14176**]
MEDQUIST36
D: [**2166-11-19**] 17:25
T: [**2166-11-19**] 18:27
JOB#: [**Job Number **]
|
[
"414.01",
"401.9",
"285.1",
"458.2",
"410.11",
"997.02",
"412",
"428.0",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"89.68",
"39.61",
"88.53",
"36.12",
"99.20",
"36.15",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
2754, 3306
|
1163, 2732
|
752, 1145
|
138, 729
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,835
| 124,748
|
24968
|
Discharge summary
|
report
|
Admission Date: [**2101-7-13**] Discharge Date: [**2101-7-19**]
Service: SURGERY
Allergies:
Demerol
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
s/p ACDF C4-C6 [**2101-7-14**]
History of Present Illness:
[**Age over 90 **] yo male s/p fall into creek bed, sustaining C4-C5 fracture;
denies LOC at time of event.
Past Medical History:
Hypertension
Anxiety
Vertigo
Social History:
Lives alone, has supporive daughter and grandaughter
Denies ETOH/tobacco
Family History:
Noncontributory
Physical Exam:
VS on admission to trauma bay:
154/84 64 16 98.6 rectally room air Sats 97%
GCS 15
HEENT-NCAT PERRLA
Neck-collared
Chest-CTA bilaterally
Cor-RRR
GI-soft, NT, ND, FAST negative
GU-no flank tenderness
Neuro-CN II-XII intact
Motor-5/5 strength all 4 extremities
Pertinent Results:
[**2101-7-13**] 03:51PM GLUCOSE-113* LACTATE-2.4* NA+-143 K+-4.4
CL--103 TCO2-21
[**2101-7-13**] 03:44PM UREA N-16 CREAT-1.0
[**2101-7-13**] 03:44PM AMYLASE-134*
[**2101-7-13**] 03:44PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2101-7-13**] 03:44PM PLT COUNT-325
[**2101-7-13**] 03:44PM FIBRINOGE-408*
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **] year old man with C4/C5 fx facet, examine for cord
compression
REASON FOR THIS EXAMINATION:
eval for cord compression
There has been a problem with the transcription of the report.
Instead of the complete report a first incomplete version has
been transcribed. The complete report is in the dictation system
but cannot be transcribed before Monday due to technical
reasons. The full extent of the findings, however, was
communicated to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 955**], chief resident on the
trauma service at 4 pm on [**2101-7-14**] as Dr. [**Last Name (STitle) 363**] was not
reachable, and it was verbally verified with Dr. [**Last Name (STitle) 955**] that
she had communicated the relevant findings to Dr. [**Last Name (STitle) 363**]
personally, including: anterior dislocation C4 over C5, facet Fx
C4 and transverse process Fx of C5, ligamentous injury involving
ant. long. ligament C4-C6; post. long. lig. C4/5 and poss.
C5-C7; interspinous lig. C2/3 and C3/4, C4/5 and C5/6; and poss.
lig. injury at clivus-odontoid with instability. INDICATION:
Status post fall with C4/5 fracture of facet, examine for cord
compression.
TECHNIQUE: Multiplanar T1- and T2-weighted imaging was obtained
without contrast.
FINDINGS: No prior MR studies are available for comparison.
Previously reported on a CT of the cervical spine, there is
anterior dislocation of C4 over C5 with unilateral locked facet
on the right and fracture of the inferior facet of C4 on the
right and fracture of the transverse process on the right of C5.
There is a rupture of the anterior collateral ligament at C4/5
level and possibly also at C5/6 level. There is injury of the
interspinous ligaments at C4/5 and C5/6. There is malalignment
at the cranicervical junction with anterior displacement of the
odontoid in relationship to the clinoid. Although no clear
signal changes that would indicate ligamentous tear are present,
there is concern of a ligamentous injury at this location. There
is a tear of the posterior longitudinal ligament at the C4/5
level. There is compression of the spinal cord at the C3/4 level
and C4/5 level; however, there is no abnormal hyperintensity on
the T2-weighted images that would suggest spinal cord injury.
There are degenerative changes at C5/6 level with osteophyte
formation anteriorly and posteriorly.
ABDOMEN (SUPINE ONLY) [**2101-7-18**] 6:08 PM
ABDOMEN (SUPINE ONLY)
Reason: r/o obstruction
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **] year old man with abd pain
REASON FOR THIS EXAMINATION:
r/o obstruction
INDICATION: Abdominal pain.
COMPARISONS: CT abdomen [**2101-7-14**].
SINGLE VIEW ABDOMEN: There are no dilated loops of large or
small bowel seen to indicate obstruction. No free
intraperitoneal air is seen. There is degenerative change within
the lower lumbar/sacral spine.
IMPRESSION: No evidence of obstruction.
Brief Hospital Course:
Patient admitted to the trauma service. Orthopedic Spine service
was consulted for his acute cervical spine fractures. MRI
performed following trauma series radiologic exams. Discussions
with patient and his family with Dr. [**Last Name (STitle) 363**] to proceed with
cervical fusion/discectomy. Patient was taken to the operating
room on [**2101-7-14**] for ACDF C4-C6. Urology was consulted for gross
hematuria following several foley attempts; a 22 Fr 3-way foley
was placed and patient started on bladder irrigation.
Recommendation from Urology was to d/c foley once patient more
ambulatory; hold irrigation; hold anticoagulants (ASA) for 1
week; follow up with primary urologist (h/o TURP in [**2065**]) and
d/c antibiotics, was being treated with Levofloxacin ([**4-29**] WBC
with negative nitrite in urine). A KUB was performed secondary
to complaints of abdominal pain and distention; obstruction was
ruled out; patient's bowel reg imine was adjusted; he is now
having bowels movements. He began experiencing frequent stool
following laxatives and softeners, a stool for C-diff was sent;
results pending at time of this summary. Patient was seen and
evaluated by Speech and Swallow for dysphagia; found no signs
and symptoms of aspiration at bedside; was able to swallow thi
liquids and regular consistency solids. Recommendations for
sitting upright for all meals and snacks. Geriatrics was also
consulted given patient's age and mechanism of injury; they have
recommended that patient follow up with his PCP for slightly
elevated blood sugars after d/c from rehab.
Medications on Admission:
Alprazolam, "blood pressure pill"
Discharge Medications:
1. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Racepinephrine 2.25 % Solution Sig: One (1) ML Inhalation
Q2-3H (every 2-3 hours) as needed.
5. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q2-3H (every 2-3 hours) as needed.
6. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO three
times a day.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
10. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
11. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
Discharge Disposition:
Extended Care
Facility:
[**Doctor Last Name **] [**Doctor Last Name **] hospital
Discharge Diagnosis:
s/p Fall
Right C4-C5 Fracture Dislocation
Anterolisthesis C3-C5
Discharge Condition:
Stable
Discharge Instructions:
1.Follow up with Orthopedic Spine in 1 week
2.Follow up with your Primary Care Doctor regarding your
slightly elevated blood sugars after your discharge from rehab
3.Follow up with your primary urologist after discharge from
rehab
4.You must sit completely upright for all meals and snacks per
recommendation of your Swallow evaluation
Followup Instructions:
Call [**Telephone/Fax (1) 3573**] for an appointment in 1 week with Dr. [**Last Name (STitle) 363**],
Orthopedic Spine
Call for an appointment with your Primary care Doctor [**First Name (Titles) **] [**Last Name (Titles) 62742**]t after your discharge from rehab
Completed by:[**2101-7-19**]
|
[
"805.04",
"401.9",
"599.0",
"E884.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.02",
"02.94",
"93.41",
"81.62",
"80.51"
] |
icd9pcs
|
[
[
[]
]
] |
6923, 7006
|
4196, 5773
|
223, 256
|
7114, 7123
|
865, 1215
|
7507, 7803
|
551, 568
|
5857, 6900
|
3762, 3808
|
7027, 7093
|
5799, 5834
|
7147, 7484
|
583, 846
|
175, 185
|
3837, 4173
|
284, 393
|
415, 445
|
461, 535
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,373
| 121,613
|
8659+8660
|
Discharge summary
|
report+report
|
Admission Date: [**2198-5-5**] Discharge Date: [**2198-6-5**]
Date of Birth: [**2148-10-18**] Sex: M
Service: [**Doctor First Name 147**]
Allergies:
Penicillins
Attending:[**First Name3 (LF) 30324**]
Chief Complaint:
Oxycodone/trazadone overdose
Major Surgical or Invasive Procedure:
none
Past Medical History:
1. . Hepatitis C diagnosed in [**2179**],
most likely secondary to tatoos. Hepatitis C cirrhosis on
transplant list. 2. Status post heroine overdose and
respiratory failure with hypoxic encephalopathy in [**2190**]. 3.
Status post cholecystectomy. 4. Status post appendectomy.
5. Status post hernia repair. 6. History of
thrombocytopenia. 7. History of anemia. 8. Status post
recent admission in [**2197-12-21**] for ascites and hyponatremia
treated with experimental drugs for free-water excretion,
with good results. 9. Anal fissure. 10. Barrett's
esophagus. 11. Glaucoma. 12. insomnia
Social History:
The patient was a heavy alcohol user; he quit in [**2190**]. History
of snorting heroine. No IV drug use.
No current tobacco use. Former mail worker. He lives with
sister, who is his care taker.
Family History:
Father died at age 35 from a cerebral aneurysm.
Physical Exam:
Vital signs:
General: Jaundiced male, lethargic.
HEENT: Extraocular movements intact. Pupils equal, round and
reactive to light. Oropharynx clear. No ulcerations.
Neck: Supple. No lymphadenopathy. No jugular venous distention.
Chest: Clear to auscultation bilaterally.
Cardiovascular: Regular rate and rhythm, nl S1S2, III/VI
systolic murmur LLSB
Abdomen: Very distended. Non-tender. No rebound. No guarding.
BS+
Positive fluid wave. No masses.
Extremities: He had 2+ edema to thigh bilaterally.
Neurological: Alert and oriented times three. No flap. Strength
[**4-25**] throughout. Sensation intact throughout
Pertinent Results:
[**2198-5-4**] 11:50AM WBC-6.8 RBC-2.51* HGB-9.7* HCT-29.3* MCV-117*
MCH-38.7* MCHC-33.2 RDW-21.6*
[**2198-5-4**] 11:50AM ALT(SGPT)-42* AST(SGOT)-87* ALK PHOS-101 TOT
BILI-12.6*
[**2198-5-4**] 11:50AM UREA N-37* CREAT-0.4* SODIUM-122*
POTASSIUM-5.3* CHLORIDE-94* TOTAL CO2-22 ANION GAP-11
[**2198-5-5**] 06:40PM ASA-NEG ETHANOL-NEG ACETMNPHN-7.5
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
Brief Hospital Course:
1. Neuro: increased lethargy in setting of chronic liver
disease, hyponatremia, hypercalcemia, increased WBC, and opiod
overdose. Head CT neg. Tox (-). Improved on narcan gtt in [**Hospital Unit Name 153**].
2. Psych: presumed suicide overdose: the patient was seen by the
psychiatry service who felt that this was not an organized
attempt at suicide, but instead an impulsive act. The patient
was felt to be too medically ill to be transfered to inpatient
psychiatry, so he was followed by the psych service and had a 1
to 1 throughout his stay.
3. ESLD, w/ decreased MS. ammonia stable, cont lactulose. He had
two ultrasounds which showed that his TIPS was patent, and there
was ascites present. He was continued on his cipro/flagyl for
SBP prophylaxis.
4. Heme: anemia of chronic disease: He did not require any
transfusions during his stay.
5. Renal: hyponatremia - improved with free water restriction to
1 liter.
On [**5-13**] the patient was transferred to the MICU in the setting
of worsening mental staus in the setting of rising bilirubin and
worsening hyponatremia despite fluid restriction. He was
tranferred to the ICU for hypertonic saline and closer
evaluation. The remainder of this dictation will be completed by
the ICU team.
Medications on Admission:
1. Ciprofloxacin HCl 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).Disp:*30 Tablet(s)* Refills:*2*
2. Amitriptyline HCl 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q4H (every
4 hours) as needed.
4. Metoclopramide HCl 10 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
5. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane
QID (4 times a day).
9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QD (once a day).
10. Multivitamin Capsule Sig: One (1) Cap PO QD (once a day).
11. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
12. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) as needed.
13. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) as needed.
14. Trazodone HCl 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).Disp:*30 Tablet(s)* Refills:*2*
15. Metronidazole 250 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).Disp:*60 Tablet(s)* Refills:*2*
Discharge Medications:
to be completed on discharge.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
attempted suicide, trazadone/oxycodone overdose.
HCV cirrhosis s/p TIPS [**3-25**]
anemia of chronic disease.
refractroy hyponatremia s/p xperimental Tolvapton
thrombocytopenia/anemia/coagulopathy
Barrett's esphagus;
anal fissure;
glaucoma
Discharge Condition:
stable.
Discharge Instructions:
Take all medications as instructed.
Followup Instructions:
to be scheduled on discharge.
Completed by:[**2198-5-25**] Admission Date: [**2198-5-5**] Discharge Date: [**2198-6-5**]
Date of Birth: [**2148-10-18**] Sex: M
Service: TRANSPLANT SURGERT
ADDENDUM: The rest of the [**Hospital 228**] hospital course was
unremarkable. Upon discharge the patient was afebrile with
stable vital signs. Well controlled fingersticks of 120 to
157. Tolerating p.o.'s in addition to tube feeds. The
patient has adequate urine output. The [**Initials (NamePattern4) 228**] [**Last Name (NamePattern4) 1661**]-
[**Location (un) 1662**] drain was discontinued the day prior to discharge. On
examination, the patient's abdomen was soft, non-tender with
mild distention. The incision was clean, dry and intact.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSES: Hepatitis C cirrhosis status post
orthotopic liver transplant on [**2198-5-20**]. Co-morbidities
of acute bacterial peritonitis, ascites, encephalopathy,
Barrett's esophagitis, depression, heroin addiction, anal
fissure status post TIPS procedure, status post inguinal and
umbilical hernia repairs, status post appendectomy, status
post cholecystectomy, insulin-dependent diabetes mellitus.
DISPOSITION: Rehabilitation where he will be receiving tube
feeds at Nephro 60 cc/hour cycled at night for 14 hours. The
patient will be receiving physical therapy. Wound checks and
vitals are to be provided.
DISCHARGE MEDICATIONS:
1. Prednisone 50 mg p.o. q. day.
2. CellCept [**Pager number **] mg p.o. q.i.d.
3. Neoral 250 mg q. 12h., dose by level.
4. Bactrim single strength one tab p.o. q. day.
5. Epivir 100 mg p.o. q.o.d.
6. Protonix 40 mg p.o. q. day.
7. Fluconazole 200 mg p.o. q. day.
8. Heparin 5000 units subcu q. 8h.
9. Valcyte 450 mg p.o. q. day.
10. Ursodiol 300 mg p.o. b.i.d.
11. Lasix 40 mg p.o. b.i.d.
12. Glargine 10 units q. hs.
13. Regular insulin sliding scale.
14. Lamivudine 100 mg p.o. q.o.d.
FOLLOW UP: The patient was to follow up at the [**Hospital 1326**]
Clinic. Appointment made per transplant coordinator.
Patient to receive blood work every Monday and Thursday
morning including CBC, Chem-7, calcium, magnesium,
phosphorus, albumin, AST, ALT, alk phos, total bilirubin,
direct bilirubin and immunosuppressive levels. The patient
is to follow up at the [**Hospital 3208**] Clinic for diabetes diagnosed
post transplant.
As mentioned patient's discharge condition is stable and
disposition is to rehabilitation center.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD, PHD[**Numeric Identifier **]
Dictated By:[**Last Name (NamePattern1) 30325**]
MEDQUIST36
D: [**2198-6-5**] 12:22:49
T: [**2198-6-5**] 13:16:27
Job#: [**Job Number 30326**]
|
[
"276.1",
"789.5",
"070.44",
"286.9",
"584.9",
"965.09",
"571.5",
"572.4",
"287.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"54.91",
"96.6",
"99.07",
"50.59",
"38.95",
"38.93",
"87.54"
] |
icd9pcs
|
[
[
[]
]
] |
4955, 5026
|
2286, 3534
|
321, 328
|
5310, 5319
|
1867, 2262
|
5403, 6167
|
1170, 1219
|
6223, 6829
|
6852, 7367
|
5047, 5289
|
3560, 4878
|
5343, 5380
|
1234, 1848
|
7379, 8179
|
252, 283
|
350, 941
|
957, 1154
|
6192, 6201
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,258
| 154,238
|
29824
|
Discharge summary
|
report
|
Admission Date: [**2126-8-15**] Discharge Date: [**2126-8-22**]
Date of Birth: [**2071-4-9**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1928**]
Chief Complaint:
bleeding, hematemesis
Major Surgical or Invasive Procedure:
1. Laryngoscopy and biopsy of right tonsil.
2. Right Neck Biopsy
3. Rigid esophagoscopy.
4. Flexible bronchoscopy through the endotracheal
tube.
5. EGD (2)
History of Present Illness:
Ms. [**Known lastname **] is a 55 year old female with past medical history of
HIV (viral load in [**2126-4-5**] was undetectable) and COPD on 3.5
liters of oxygen at home who presents from the PACU. She was
noted to have a right neck mass, presumably squamous cell
carcinoma based on earlier biopsies, with unknown primary site,
and had presented today for surgical biospy of right tonsil.
According to the ENT team, today in the OR the patient underwent
a biopsy of an enlarged right tonsil, which was inconclusive
based on frozen path sections. A right neck mass excisional
biospy was then completed, which was also inconclusive on
pathology sections. After the procedure, she was extubated, and
reported to vomit approximately 200cc of blood. At that point,
she was re-intubated by anesthesia and her oropharynx was
re-examined. There was some bleeding of her right tonsil which
was treated with electrocautery and stitches. She was noted to
have some blood in her nose, felt to be from her tonsils. Per
ENT team, an organzied clot was then noted in her ETT.
At that point, the interventional pulmonary team was contact[**Name (NI) **],
and patient underwent bronchoscopy. She was noted to have clot
in her distal airways that was cleaned out, without any evidence
of active bleeding.
After bronchoscopy, her sedation was lightened, and again she
was noted have an episode of hematemesis. GI was consulted and
patient underwent EGD. She was noted to have a large amount of
clot in the antrum of her stomach without visible bleeding or
ulcer. It was recommended that she remain intubated and be
transferred to the ICU for further monitoring, with IR
intervention in event of re-bleed, and plan for repeat EGD in 1
day.
The ENT team also noted that she was transiently hypotensive to
a systolic of 70 during the surgery, possibly due to being given
labetolol. She was briefly on pressors however those were
weaned. She received 2.5 liters of intravenous fluid in the OR,
and a type and cross was sent.
She was stabilized in the ICU, successfully extubated and then
transferred to the floor.
Review of sytems: The patient denies hematemesis prior to
present episode. Also denies hemoptysis, reflux, dysphagia,
hoarseness of voice, abdominal pain, fevers/chills, night
sweats, lymphadenopathy, hematochezia, melena, diarrhea, change
in bowel habits, cp, increased sob above baseline.
Past Medical History:
- HIV, last viral load undectable [**2126-4-5**]
- Neck mass, biopsy at [**Hospital3 **] [**2126-5-6**], consistent with
squamous cell carcinoma
- COPD on 3.5 liters oxygen at baseline
- Psoriasis
- Status-post tubal ligation
- Status-post lung biopsy, further details unknown
- Question of sleep apnea (noted in anesthesia chart)
Social History:
She lives with her brother and one of her daughters. She used
to be a long-term smoker for about 30 years, she quit five years
since the diagnosis of COPD. She does not alcohol abuse. She
used to work as a house painter, but not
being able to work because of her respiratory compromise. She
contracted HIV from her second husband who died from
complications of HIV and lung cancer. She denies use of herbal
supplements, recreational drugs.
Family History:
Her father died at a young age of 30 of coronary artery disease.
Her mother lives alone. Her mother had uterine cancer in her
50s. There is no other history of cancer.
Physical Exam:
ADMISSION:
Vitals: Temperature: 99.0 BP: 112/50 Heart rate: 93 Respiratory
rate: 13 Oxygenation: 100%
General: Intubated, sedated, appears comfortable, occasionally
opens eyes, no acute distress
HEENT: Sclera anicteric, ETT in place, dried blood in nares
Neck: Enlargement of right side of neck, hard mass appreciated,
dressing in place clean/dry/intact
Lungs: Occasional wheezes scattered throughout anteriorly, no
rales or rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: Foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, pneumoboots in place
Neuro: Occasionally opens eyes, moving extremities equally
TRANSFER TO FLOOR:L
Pertinent Results:
[**2126-8-15**] 11:50AM BLOOD WBC-8.9 RBC-3.77* Hgb-10.7* Hct-33.3*
MCV-88 MCH-28.2 MCHC-32.0 RDW-14.6 Plt Ct-265
[**2126-8-15**] 11:50AM BLOOD Neuts-64.7 Lymphs-25.8 Monos-7.1 Eos-2.1
Baso-0.3
[**2126-8-15**] 11:50AM BLOOD PT-11.4 PTT-17.5* INR(PT)-0.9
[**2126-8-15**] 03:33PM BLOOD Glucose-178* UreaN-16 Creat-0.7 Na-142
K-4.9 Cl-102 HCO3-27 AnGap-18
[**2126-8-15**] 03:33PM BLOOD ALT-27 AST-30 LD(LDH)-387* CK(CPK)-106
AlkPhos-105 TotBili-0.2
[**2126-8-15**] 03:33PM BLOOD CK-MB-3 cTropnT-<0.01
[**2126-8-15**] 03:33PM BLOOD Albumin-3.6 Calcium-8.6 Phos-4.7* Mg-2.0
[**2126-8-16**] 05:01AM BLOOD Lactate-1.9
Biopsies:
I. Right tonsil biopsies #1 (A):
Tonsilar tissue and squamous mucosa with mild chronic
inflammation. No malignancy identified.
II. Right tonsil biopsies #2 (B):
Tonsilar tissue and squamous mucosa with mild chronic
inflammation. No malignancy identified.
III. Right neck mass, biopsy (C-D):
Invasive squamous cell carcinoma, moderately differentiated.
IV. Right neck, true cut needle biopsy (E):
Invasive squamous cell carcinoma, moderately differentiated.
V. Tissue in trachea (F):
Blood clot and clusters of atypical squamous cells.
Imaging:
[**2126-8-15**] CXR: Bibasilar atelectasis, cannot rule out infectious
process, would recommend followup if clinically warranted.
[**2126-8-15**] CXR: AP single view of the chest has been obtained with
patient in
supine position. Available for comparison is a preceding similar
study
obtained three hours earlier during the same date. The ETT
remains in
unchanged position. An NG tube has now been placed and is seen
to reach far below the diaphragm. No pneumothorax has developed,
and no new parenchymal infiltrates are seen. On previous
postoperative supine film identified atelectasis in the left
lower lobe area is clearing up and only a plate atelectasis
remains.
[**2126-8-16**]: CXR: Opacities at the right and left base have worsened
since a day prior, with increase in size of a small left pleural
effusion. The upper lungs are clear and there is no
pneumothorax. An endogastric tube courses below the diaphragm,
tip off the film. The endotracheal tube is unchanged in
position. IMPRESSION: Worsening bibasilar opacities may reflect
aspiration.
[**2126-8-16**]: CXR: The ET tube tip is 5.5 cm above the carina. The
cardiomediastinal silhouette is stable. Compared to the prior
study, there is improvement of basilar aeration with no new
abnormalities such as consolidation to suggest infectious
process/aspiration.
[**2126-8-17**]: CXR: The current study again demonstrates development
of volume overload and bibasal opacities that appears to be very
similar to [**2126-8-16**] study obtained at 06:16 a.m. thus
suggesting fluctuations in the lung appearance; it might be
consistent with pulmonary edema. The ET tube tip is 6 cm above
the carina.
[**2126-8-16**]: EGD: Blood clot at Fundus. Clot not movable. No active
bleeding.
Otherwise normal EGD to third part of the duodenum
[**2126-8-21**]: EGD: In the posterior pharynx there was oozing noted
and an area of irregular ulcerated mucosa. Normal mucosa in the
esophagus. Normal mucosa in the duodenum. Normal mucosa in the
stomach. Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
Assessment and Plan: 55 yo woman with h/o HIV, severe COPD,
recently diagnosed with squamous cell CA with neck mass now
presenting with hematemesis.
# Hematemesis: Pt [**Doctor First Name 1638**] h/o reflux symptoms, ulcers etc. Per
ENT team and outpatient pulmonary notes, she had been taking
ibuprofen (800 mg TID, including this morning [**Name8 (MD) **] RN notes), so
this would put her at higher risk for peptic ulcer disease and
gastritis. However, should be noted that per patient she rarely
takes NSAIDs and only in last 2 weeks prior to admission she had
taken 400 mg of ibuprofen per day. She is also being worked up
for SCC malignancy, which would be rare in the stomach, however
she could have esophageal SCC (though nothing reported on EGD in
esophagus). Other possibilities include AVM or Dieulfoy's
lesion. Per GI team, no active bleeding noted. The patient was
followed with serial hematocrits which remained stable. Repeat
EGD showed oozing from the posterior pharynx near biopsy site,
but was otherwise normal. She was started on a PPI and H.pylori
ab was positive, so she was started on a two week course of
clarithromycin and amoxicillin.
# Right-sided neck mass: The patient presented to the hospital
for biopsy of a right neck mass and R enlarged tonsil She has
been followed by Dr. [**First Name8 (NamePattern2) 916**] [**Last Name (NamePattern1) **] and Dr. [**Last Name (STitle) 71327**] in oncology.
Path from neck mass showed squamous cell carcinoma, but R tonsil
shows just inflammatory changes. Of note, the R tonsil has been
chronically enlarged over years. Prior outpatient PET CT did
not show any clear other sites. The patient will follow-up with
her oncologist (Dr. [**First Name (STitle) **], radiation oncology (Dr.
[**Last Name (STitle) 3929**] and ENT (Dr. [**Last Name (STitle) 1837**].
# HIV: Discontinued anti-retrovirals per her primary HIV MD.
Will follow-up with Dr. [**Last Name (STitle) **].
# COPD: The patients' COPD remained stable. Her oxygen
saturation remained adequate near her baseline oxygen
requirement with home duoneb treatments.
# Diffuse back / Abdominal wall pain: The patient had new onset
back pain in scapular region bilaterally and mild abdominal wall
pain that was felt to be musculoskeletal in nature. Her pain
was controlled with IV dilaudid, ultram, and tylenol. On
discharge she had not back pain, only pain at the site of her
tumor, which was well controlled with ultram.
# Code: Full (discussed with patient)
Medications on Admission:
ALBUTEROL - (Prescribed by Other Provider) - 90 mcg Aerosol -
one inhalation nebulizer once a day
EFAVIRENZ-EMTRICITABIN-TENOFOV [ATRIPLA] - 600 mg-200 mg-300 mg
Tablet - one Tablet(s) by mouth at bedtime
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - (Prescribed by Other
Provider) - 500 mcg-50 mcg/Dose Disk with Device - one disk
inhaled twice a day
FUROSEMIDE - 40 mg Tablet - one Tablet(s) by mouth once daily
IBUPROFEN [MOTRIN] - 800 mg Tablet - one Tablet(s) by mouth
twice
a day
TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - (Prescribed by
Other Provider) - 18 mcg Capsule, w/Inhalation Device - one
capsule inhales each morning
Discharge Medications:
1. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer treatment Inhalation Q4H
(every 4 hours).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day for 12 days.
Disp:*24 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever.
5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
7. Ibuprofen 800 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for pain.
8. Amoxicillin 500 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 14 days.
Disp:*56 Tablet(s)* Refills:*0*
9. Clarithromycin 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 14 days.
Disp:*28 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses: Squamous Cell Cancer of the Neck. Upper GI
Bleed from posterior pharynx biosy site.
Secondary Diagnoses: HIV, COPD, Psoriasis, ? Obstructive Sleep
Apnea.
Discharge Condition:
Stable
Discharge Instructions:
You presented to the hospital for a biopsy of a right neck mass
and your right tonsil. The biopsies showed squamous cell cancer
of the right neck mass and nonspecific inflammatory changes in
the right tonsil. After the biopsy you vomited blood.
Bronchoscopy was performed and showed blood in your large
airways, but no source of bleeding. EGD showed a large clot in
your stomach that was adherent to the stomach and unable to be
removed in order to evaluate a source for the clot. You were
intubated to secure your airway and transferred to the intensive
care unit for monitoring. You remained stable there and were
transferred to the medical floor. EGD was repeated two more
times with the final EGD showing a normal esophagus and stomach.
You were tested for an infection of your stomach that can cause
stomach problems called H.pylori and the test was positive. You
were started on anti-biotics and a drug to reduce stomach acid
for this infection. You will need to follow-up with Dr.
[**First Name (STitle) **] and Dr. [**Last Name (STitle) **] regarding your neck mass and HIV.
The following changes were made to your medications:
For your h.pylori infection,
You were started on pantoprazole 40 mg by mouth twice daily.
You were started on clarithromycin 500 mg by mouth twice daily.
You were started on amoxicillin 1 g by mouth twice daily.
Your atripla was stopped.
If you experience any of the following symptoms you should call
your primary doctor or go to the emergency room: vomiting,
coughing up blood, abdominal pain, blood in your stool or very
dark stools, difficulty swallowing, changes in your voice,
swelling in your face, fevers or chills, chest pain, shortness
of breath.
Followup Instructions:
Provider: [**First Name4 (NamePattern1) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 41**]
Date/Time:[**2126-8-23**] 8:40
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6198**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2126-8-28**] 3:30
|
[
"998.11",
"276.50",
"696.1",
"285.1",
"V08",
"458.29",
"199.1",
"496",
"327.23",
"518.5",
"198.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"31.42",
"42.23",
"83.21",
"33.23",
"28.11",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
12243, 12249
|
8008, 10511
|
336, 494
|
12469, 12478
|
4756, 7985
|
14229, 14529
|
3747, 3920
|
11197, 12220
|
12270, 12375
|
10537, 11174
|
12502, 14206
|
3935, 4737
|
12397, 12448
|
275, 298
|
2638, 2913
|
522, 2620
|
2935, 3268
|
3284, 3731
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,914
| 130,250
|
24737+57417
|
Discharge summary
|
report+addendum
|
Admission Date: [**2142-12-31**] Discharge Date: [**2143-1-11**]
Date of Birth: [**2112-9-20**] Sex: F
Service: MEDICINE
Allergies:
Vancocin Hcl
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
CC:[**CC Contact Info 62384**]
Major Surgical or Invasive Procedure:
permenant pacemaker
L PICC line
History of Present Illness:
HPI: 30 year old female recently discharged ([**12-27**]) from trauma
service s/p multiple gunshot wounds with resultant spinal cord
injury and quadriplegia resulting in tracheostomy and PEG tube
placement, who was at [**Hospital3 **] where she was noted on the
day of admission to have desaturation and bradycardia with trach
tube suctioning, as well as a seizure. Per their report, on the
day prior to admission her HR went into the 20s while being
suctioned. Her SaO2 at the time was mid-70% and while bagging
her she reportedly had a seizure with a post-ictal period
following. Prior to these events the patient had been
repositioned by the aide.
.
Of note, during her long recent hospitalization she underwent a
lengthy fever workup for frequent fevers as high as 103. ID was
involved, and ultimately no etiology was found.
.
Past Medical History:
PMH:
1) adjustment disorder
2) C6 spinal cord injury resulting in paraplegia in [**2142-11-18**]:
C6-T1 burst injury.
.
PSH: ant&post fixation of cervical vertebra, trach, G-tube, IVC
filter
Social History:
SOC HX: Living at [**Hospital1 **] since shooting, for trach care, etc.
Family History:
non-contributory
Physical Exam:
PE: 99.5, 92, 108/59, 24, 100% on AC 600x12, 50%, 10 Peep
Gen: Comfortable appearing african american female, with trach
in place, responding to questions by mouthing words and nodding
yes and no.
HEENT: PEARL, anicteric sclerae, moist MM.
Cor: RR, normal rate, no m/r/g.
Lungs: Difficult to evaluate over coarse sounds of trach.
Abd: NABS, soft, NT/ND, G-tube with dressing in place,
non-tender.
Extr: Trace bipedal edema.
Neuro: Able to move upper extremities against gravity but not
force. Grasp very weak.
Pertinent Results:
[**2143-1-2**] 04:09AM BLOOD WBC-10.4 RBC-3.23* Hgb-9.8* Hct-29.2*
MCV-91 MCH-30.3 MCHC-33.5 RDW-15.6* Plt Ct-356
[**2143-1-1**] 01:43PM BLOOD WBC-13.0*# RBC-3.10* Hgb-9.6* Hct-28.1*
MCV-91 MCH-30.9 MCHC-34.1 RDW-15.7* Plt Ct-342
[**2142-12-31**] 01:30AM BLOOD WBC-8.4 RBC-3.37* Hgb-10.0* Hct-30.0*
MCV-89 MCH-29.6 MCHC-33.2 RDW-14.7 Plt Ct-316
[**2143-1-1**] 01:43PM BLOOD Neuts-76.4* Lymphs-17.3* Monos-3.4
Eos-2.6 Baso-0.3
[**2142-12-31**] 01:30AM BLOOD Neuts-75.2* Lymphs-18.1 Monos-3.0 Eos-3.5
Baso-0.3
[**2142-12-31**] 01:30AM BLOOD ESR-100*
[**2143-1-2**] 04:09AM BLOOD Glucose-100 UreaN-12 Creat-0.3* Na-136
K-4.8 Cl-103 HCO3-24 AnGap-14
[**2142-12-31**] 01:30AM BLOOD Glucose-139* UreaN-12 Creat-0.3* Na-141
K-3.9 Cl-104 HCO3-23 AnGap-18
[**2143-1-1**] 01:43PM BLOOD ALT-132* AST-36 LD(LDH)-225 CK(CPK)-49
AlkPhos-103 Amylase-249* TotBili-0.2
[**2143-1-1**] 01:43PM BLOOD Lipase-270*
[**2143-1-1**] 06:27PM BLOOD CK-MB-5 cTropnT-0.03*
[**2143-1-1**] 01:43PM BLOOD CK-MB-5 cTropnT-0.03*
[**2143-1-1**] 01:43PM BLOOD Albumin-3.2* Calcium-8.9 Phos-4.2 Mg-2.3
[**2142-12-31**] 01:04AM BLOOD Lactate-1.5 K-4.3
_____________________________________
____________________________________
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW
Plt Ct
[**2143-1-9**] 04:10AM 9.7 3.40* 10.2* 30.1* 89 30.0 33.8 14.1
237
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2143-1-9**] 04:10AM 144* 10 0.2* 136 4.2 99 25 16
_
_
_
_
_
_
_
_
_
_
________________________________________________________________
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2143-1-10**] 5:03 AM
CHEST (PORTABLE AP)
Reason: Please eval for lead position and ptx.
[**Hospital 93**] MEDICAL CONDITION:
30 year old woman vent dependent, s/p trauma s/p c spine
fixation now s/p perm pacer placement.
REASON FOR THIS EXAMINATION:
Please eval for lead position and ptx.
INDICATION: 30-year-old woman with vent dependent. Status post
permanent pacemaker placement. Evaluate for lead position and
pneumothorax.
COMPARISON: [**2143-1-9**].
SEMI-ERECT AP PORTABLE CHEST: The lung apices are partially
excluded from examination. The tip of the tracheostomy tube
remains in similar position. The leads of the pacemaker again
project over the expected locations of the right atrium and
right ventricle in this single view. Sternal wire sutures are
again noted. A PICC entering from the left upper extremity ends
just beyond the left axilla. The heart size is unchanged. The
left retrocardiac opacity persists. The visualized portions of
the right lung remain clear. No pneumothorax is seen.
IMPRESSION:
1. Unchanged pacemaker lead position in this single projection .
A conventional two-view chest examination could confirm their
positions.
2. Persistent left retrocardiac opacity probably representing
atelectasis.
3. No pneumothorax seen, although this examination is somewhat
limited, as above.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DR. [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1508**]Approved: [**First Name8 (NamePattern2) **] [**2143-1-10**] 11:43 AM
_
_
_
_
_
_
_
_
_
________________________________________________________________
RADIOLOGY Final Report
CT ABDOMEN W/O CONTRAST [**2143-1-3**] 10:47 AM
CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST
Reason: please evaluate for abscess, pseudocyst, evidence of
pancrea
Field of view: 46
[**Hospital 93**] MEDICAL CONDITION:
30 year old woman with fevers and elevated amylase and lipase
REASON FOR THIS EXAMINATION:
please evaluate for abscess, pseudocyst, evidence of
pancreatitis
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 30-year-old with fever, elevated amylase and lipase,
assess for abscess or pancreatitis.
TECHNIQUE: CT of the abdomen and pelvis without IV contrast. The
patient did not receive IV contrast due to lack of IV access.
No prior abdominal CTs for comparison.
CT OF THE ABDOMEN WITHOUT IV CONTRAST: There are atelectatic
changes at both lung bases, somewhat more focal at the left lung
base. There is a small pericardial effusion. Evaluation of the
superior part of the liver is somewhat limited due to streak
artifact from the patient's arms. The remainder of the liver,
gallbladder, spleen, pancreas, adrenals, and kidneys are
unremarkable in appearance allowing for the lack of IV contrast.
A minimal amount of stranding is seen just inferior to the
pancreas in the mid abdomen. There is no focal fluid collection.
A percutaneous gastrostomy tube is present. An inferior vena
cava filter is present. No free fluid, free air, or pathologic
lymphadenopathy is seen. The intra-abdominal large and small
bowel are unremarkable.
CT OF THE PELVIS WITHOUT IV CONTRAST: The rectum, sigmoid,
bladder, uterus, and ovaries are normal in appearance. A Foley
catheter is present with a small amount of resultant air within
the bladder. A few small non- pathologically enlarged lymph
nodes are seen within both inguinal regions. There is no free
fluid or lymphadenopathy in the pelvis.
Osseous structures are unremarkable. The soft tissues are
normal.
IMPRESSION:
1. Bibasilar atelectasis. More focal consolidation at the left
base is not excluded.
2. No evidence of pancreatitis or intra-abdominal abscess.
_
_
_
_
_
_
_
________________________________________________________________
OBJECT: EVALUATE FOR SEIZURES.
REFERRING DOCTOR: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] [**Doctor Last Name **]
FINDINGS:
BACKGROUND: The background remained in the 9 Hz frequency range
throughout the majority of the recording. At times, overlying
beta
activity could be seen.
HYPERVENTILATION: Could not be performed.
INTERMITTENT PHOTIC STIMULATION: Could not be performed.
SLEEP: The patient progressed from wakefulness to drowsiness but
did not
enter stage II sleep.
CARDIAC MONITOR: Showed a generally regular rate and rhythm.
IMPRESSION: This is a normal EEG in the awake and drowsy states.
No
focal or epileptiform activity was seen. Note is made of
overlying
muscle activity over both temporal regions. No epileptiform
activity
was observed.
INTERPRETED BY: [**Last Name (LF) **],[**First Name3 (LF) 1216**] S.
([**5-/3159**]F)
_
_
_
_
_
_
_
________________________________________________________________
[**2143-1-2**] 8:25 pm URINE
**FINAL REPORT [**2143-1-4**]**
URINE CULTURE (Final [**2143-1-4**]):
ACINETOBACTER BAUMANNII. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ACINETOBACTER BAUMANNII
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- 4 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN----------<=0.25 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**2143-1-9**] 5:48 am URINE
**FINAL REPORT [**2143-1-10**]**
URINE CULTURE (Final [**2143-1-10**]): NO GROWTH.
_
_
_
_
_
_
_
_
_
________________________________________________________________
[**2142-12-31**] 12:45 am SPUTUM Site: ENDOTRACHEAL
**FINAL REPORT [**2143-1-3**]**
GRAM STAIN (Final [**2142-12-31**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final [**2143-1-3**]):
MODERATE GROWTH OROPHARYNGEAL FLORA.
STAPH AUREUS COAG +. MODERATE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
GRAM NEGATIVE ROD(S). RARE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=1 S
Brief Hospital Course:
A/P: 30 year old female with recent C6 spinal injury secondary
to gunshot wounds and resultant paraplegia, tracheostomy,
G-tube, and IVC filter placement, sent from rehab for
bradycardia with suctioning and associated desaturation and
questionable seizure.
.
#) Bradycardia and asystolic episode at rehab: [**Month (only) 116**] be secondary
to vagal response to mucous plugging or suctioning. No further
events during hospital stay . EP does not think patient has
underlying conduction problem and some of this may be related to
prior anoxic brain injury which could have affected brainstem.
Permenant pacemaker placed on [**2142-1-9**].
.
#) ?Seizure: Per report from aide and RN at rehab. If indeed
seizure, could possibly have been secondary to brief period of
anoxia. Bleed ruled out by non-contrast head CT. No signs of
ongoing seizures, and patient doesn't seem to have had much of a
post-ictal period (minutes by report, it seems). Nevertheless,
for completeness sake, will check EEG.
--f/u EEG
.
#) Fever: Had UTI with acinobacter treated with a 7 day course
of ciprofloxacin and ceftazidime. Follow up urine culture
negative. Has new LLL infiltrate vs atelectasis on CXR and
fever on [**2143-1-10**]. Holding off antibiotics at this point. Would
watch her clinically and increase pulmonary toilet . If does not
get better or has increased vent requirement would consider
bronchoscopy to look for mucous plug. Has history of MRSA
pneumonia. Also has history of redman syndrome with vancomycin.
On SSRI which will interact with linezolid. If is persistently
febrile, has increased secretions, or increased radiographic
evidence of PNA would begin treatment.
.
#) Ventilator dependence: Stable settings during
hospitalization. Patient has been ventilator dependent for
unclear reasons since her trauma. Her spinal lesion is at C6
which should not affect diaphragm and she has no apparent lung
parencyhmal process that would keep her from weaning off the
vent. [**Month (only) 116**] be secondary to brainstem dysfunction in the setting
of possible anoxic brain injury after her gunshot trauma. Had
NIF of 17 [**1-3**].
.
#) Tachycardia - Episode of tachycardia going as fast as 180 on
[**2143-1-6**]. Pt given adenosine which slowed down the rate. Slow
rhythm with clear p waves in leads 2, and VII with PR ~0.08,
?atrial tachycardia.
- EP consult felt it was sinus tachcardia.
-Cont. metoprolol.
.
#) FEN: On promote with fiber TF . Goal rate 75 cc/hour.
.
#) IVC filter: Seems to have been placed for prophylactic
purposes as no documented LE DVTs or PE.
Medications on Admission:
MEDS:
SQH
Percocet Elixir
Gabapentin 300
Ranitidine
Lorazepam
Mirtazapine
ISS
Flonase
Albuterol
Ipratropium
Discharge Medications:
1. Oxycodone 5 mg/5 mL Solution Sig: Fifteen (15) mg PO Q3H
(every 3 hours) as needed for pain.
2. Mirtazapine 15 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime).
3. Buspirone 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
4. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day).
5. Acetylcysteine 20 % (200 mg/mL) Solution Sig: 3-5 MLs
Miscell. Q4-6H (every 4 to 6 hours) as needed.
6. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
7. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
8. Ibuprofen 100 mg/5 mL Suspension Sig: 200-400 mg PO Q6H
(every 6 hours) as needed for fever or pain. mg
9. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
10. Docusate Sodium 150 mg/15 mL Liquid Sig: One Hundred (100)
mg PO BID (2 times a day).
11. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
12. Acetaminophen 160 mg/5 mL Solution Sig: Six [**Age over 90 1230**]y
(650) mg PO Q4-6H (every 4 to 6 hours) as needed for fever or
pain.
13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day): groin.
14. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
15. Calcium Carbonate 500 mg/5 mL Suspension Sig: Five (5) ML PO
BID (2 times a day).
16. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
17. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
18. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
19. Cephalexin 250 mg/5 mL Suspension for Reconstitution Sig:
Five Hundred (500) mg PO Q8H (every 8 hours) for 6 doses.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Spinal cord injury
Respiratory failure
Urinary tract infection
Seizure Disorder
Bradycardia
Discharge Condition:
good
Discharge Instructions:
Please take medications as prescribed.
.
If you have questions please contact [**Name (NI) 13771**] [**Last Name (NamePattern1) **], MD at
[**Telephone/Fax (1) 3183**]
Followup Instructions:
Please check CXR on [**2143-1-11**]
Please also check CBC on [**2143-1-11**]
L PICC line pulled back and is now a mid-line. If pt does not
require antibiotics in the next week please remove PICC line.
Completed by:[**2143-1-10**] Name: [**Known lastname 10227**],[**Known firstname **] Unit No: [**Numeric Identifier 11207**]
Admission Date: [**2142-12-31**] Discharge Date: [**2143-1-11**]
Date of Birth: [**2112-9-20**] Sex: F
Service: MEDICINE
Allergies:
Vancocin Hcl
Attending:[**First Name3 (LF) 2097**]
Addendum:
Due to bed availability problems at Rehab center, Ms.[**Known lastname **]
remained at [**Hospital1 8**] for one additional night. A bronchoscopy was
performed on [**2143-1-10**] which found large amounts of
mucous/secretions in the LLL. Washings were sent and the gram
stains showed 4+PMNs and 3+ mixed organisms consistent with OP
flora. A CXR on [**2143-1-11**] showed persistence of LLL opacity. Her
respiratory status has remained stable after the procedure.I
would still recommend follow up CXRs and CBC. Also follow up the
results of the BAL culture. No antibioticswere started as the
pt's hemodynamic and pumlonary status is stable.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 41**] - [**Location (un) 42**]
[**First Name11 (Name Pattern1) 126**] [**Last Name (NamePattern4) 2098**] MD [**MD Number(1) 2099**]
Completed by:[**2143-1-11**]
|
[
"780.6",
"518.83",
"907.2",
"348.1",
"344.00",
"780.39",
"V45.4",
"E969",
"427.81",
"V55.0",
"599.0",
"V46.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"00.14",
"96.6",
"37.72",
"37.78",
"33.24",
"37.83"
] |
icd9pcs
|
[
[
[]
]
] |
16901, 17131
|
10667, 13245
|
304, 337
|
15435, 15442
|
2085, 3761
|
15659, 16878
|
1521, 1539
|
13404, 15206
|
5636, 5698
|
15320, 15414
|
13271, 13381
|
15466, 15636
|
1554, 2066
|
235, 266
|
5727, 10644
|
365, 1198
|
1220, 1413
|
1430, 1505
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,620
| 120,592
|
8121
|
Discharge summary
|
report
|
Admission Date: [**2104-5-13**] Discharge Date: [**2104-6-3**]
Date of Birth: [**2033-11-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Vancomycin
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Angina
Major Surgical or Invasive Procedure:
[**2104-5-14**] Coronary Artery Bypass Graft x 3 (LIMA to LAD, SVG to
Ramus, SVG to PDA with patch angioplasty), Aortic Valve
Replacement w/ 23mm CE Magna pericardial tissue valve, IABP
placement
History of Present Illness:
70 y/o male with increased chest pain over the past few months.
He had a positive stress test and was referred for cardiac cath.
Cath on day of admission revealed severe 3 vd with 95% prox.
LAD. Referred for surgical revascularization.
Past Medical History:
Diabetes Mellitus, Peripheral Vascular Disease w/ Carotid
Stenosis, Peripheral Neuropathy, Hypertension, Sleep Apnea,
Obesity, Gout, Neurogenic bladder
Social History:
Denies tobacco and ETOH use. Divorced and lives alone.
Family History:
Non-contributory
Physical Exam:
Admission
Neuro: Grossly intact
Pulm: CTAB -w/r/r
Heart: RRR 2/6 systolic murmur
Abd: Obese, soft, NT/ND, +BS
Ext: Warm, unable to palpate distal pulses
Discharge
VS T 98.5 HR 88SR BP 96/54 RR 18 O2sat 94% RA
Gen: NAD
Neuro A&Ox3 non focal exam
Pulm: CTA Bilat
CV RRR, open sternal wound w/VAC dressing in place. clean
margins
Abdm: Soft. NT/ND/+BS
Ext: no edema, PVD skin color changes
Pertinent Results:
[**5-13**] Cath: 1. Selective coronary angiography of this right
dominant system revealed multi-vessel disease. The LMCA had no
significant disease. The LAD had a proximal 95% lesion, a 95%
first diagonal lesion, and an occluded 2nd diagonal. The LCX had
a 50% proximal stenosis. The RCA had a 60% mid stenosis and a
60% PDA lesion. 2. Left ventriculography revealed a calculated
ejection fraction of 59%. 3. LVEDP was elevated at a 21mmHg.
[**5-13**] CNIS: Findings as stated above which indicate an
approximately 50-59% ICA stenosis bilaterally.
[**5-14**] Echo: PRE CPB The left atrium is moderately dilated. The
left atrium is elongated. No spontaneous echo contrast is seen
in the body of the left atrium or left atrial appendage. Mild
spontaneous echo contrast is seen in the body of the right
atrium. No atrial septal defect is seen by 2D or color Doppler.
There is mild symmetric left ventricular hypertrophy with normal
cavity size. Overall left ventricular systolic function is
normal (LVEF>55%). [Intrinsic left ventricular systolic function
is likely more depressed given the severity of mitral valvular
regurgitation.] Right ventricular systolic function is normal.
There are simple atheroma in the aortic arch. There are focal
calcifications in the aortic arch. The descending thoracic aorta
is mildly dilated. There are complex (>4mm) atheroma in the
descending thoracic aorta. There are three aortic valve
leaflets. The aortic valve leaflets are moderately thickened.
The right coronary cusp displays little mobility. There is
moderate aortic valve stenosis (area 1.1 - 1.3 cm2). Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Moderate (2+) mitral regurgitation is seen.
There is a trivial/physiologic pericardial effusion. POST CPB
The patient is receiving epinephrine, norepinephrine, and
milrinone by infusion. There is borderline normal right
ventricular systolic function. There is a left ventricular EF of
about 65% but this is in the setting of moderate to moderate to
severe mitral regurgitation. No obvious focal wall motion
abnormalities are seen. The mitral regurgitation is slightly
worse then pre bypass. There is a bioprosthesis located in the
aortic position. It appears well seated. The leaflets are very
poorly seen. There is trace valvular AI. The poor views prevent
ruling out a trace perivalvular jet. The maximum gradient
through the aortic valve is about 20 mm Hg. There is no aortic
stenosis. An intra-aortic balloon pump is located in the
descending thoracic aorta. Its tip is about 3 cm below the
distal arch.
[**5-20**] CXR: A linear atelectasis is noted in the left base. There
is also atelectasis of the lower lobes, bilaterally with
moderate bilateral pleural effusions. No infiltrates are noted
in the upper poles. The cardiac silhouette is enlarged. The
patient is status post CABG with median sternotomy. There is no
pneumothorax present. A prosthetic valve is present. There is
diffuse ossification of the anterior longitudinal ligament
consistent with DISH.
[**2104-5-13**] 09:00AM BLOOD WBC-12.0* RBC-4.11* Hgb-12.9* Hct-36.4*
MCV-89 MCH-31.3 MCHC-35.3*# RDW-14.5 Plt Ct-248
[**2104-5-16**] 03:06AM BLOOD WBC-23.2* RBC-3.19* Hgb-10.1* Hct-27.8*
MCV-87 MCH-31.6 MCHC-36.3* RDW-15.4 Plt Ct-100*
[**2104-5-13**] 09:00AM BLOOD PT-12.8 PTT-28.1 INR(PT)-1.1
[**2104-5-19**] 02:41AM BLOOD PT-13.1 PTT-28.9 INR(PT)-1.1
[**2104-5-13**] 09:00AM BLOOD Glucose-124* UreaN-41* Creat-1.1 Na-136
K-4.4 Cl-104 HCO3-23 AnGap-13
[**2104-5-19**] 02:41AM BLOOD Glucose-80 UreaN-31* Creat-0.9 Na-138
K-3.8 Cl-101 HCO3-30 AnGap-11
[**2104-5-21**] 07:40AM BLOOD WBC-20.5* RBC-3.75* Hgb-11.6* Hct-34.8*
MCV-93 MCH-31.0 MCHC-33.4 RDW-14.7 Plt Ct-402#
[**2104-5-21**] 07:40AM BLOOD Glucose-65* UreaN-29* Creat-1.2 Na-136
K-5.0 Cl-99 HCO3-28 AnGap-14
Brief Hospital Course:
As mentioned in the HPI, Mr. [**Known lastname 28944**] [**Last Name (Titles) 1834**] a cardiac cath on
day of admission. Cath revealed severe three vessel disease and
he was admitted to the CCU for urgent CABG. He [**Last Name (Titles) 1834**] usual
pre-operative work-up and on the following day he was brought to
the operating room where he [**Last Name (Titles) 1834**] a coronary artery bypass
graft x 3. Please see operative report for surgical details.
Following surgery he was transferred to the CSRU for invasive
monitoring with a IABP in serious but stable condition.
Post-operatively he required multiple blood products for post-op
bleeding. Over the next couple of days his balloon pump and
multiple pressors were slowly weaned off (IABP removed on
post-op day two). On post-op day three he was weaned from
sedation, awoke neurologically intact and extubated. A swallow
evaluation was performed after extubation which found him to
swallow thing liquids and regular food without difficulty. Beta
blockade, aspirin and a statin were started. His chest tubes and
epicardial pacing wires were removed per protocol. The wound
care nurse [**First Name (Titles) **] [**Last Name (Titles) 4221**] for assistance with areas of integrity
breakdown and proper precautions were taken. On post-operative
day five he was transferred to the telemetry floor for further
care. He was gently diuresed towards his preoperative weight. On
post-op day seven his upper sternal wound was cultured due to
drainage and vancomycin, levofloxacin and flagyl were started
for coverage. The plastic surgery service was [**Last Name (Titles) 4221**] who
suggested a Vacuum assisted dressing and it was applied. During
his entire post-op course he was followed by physical therapy
for strength and mobility. Mr. [**Known lastname 28944**] developed a rash and the
dermatology service was [**Known lastname 4221**]. A drug rash was suspected and
the likely offending agents were discontinued. Topical steroids
were used on the areas with urticaria and an antifungal was
prescribed for his groins. On [**2104-5-27**], Mr. [**Known lastname 28944**] developed a
period of hypotension without an obvious reason. An echo was
performed which showed no signs of tamponade or other
abnormalities.He was transferred to the CSRU for monitoring. No
further episodes of hypotension occurred. As longterm
intravenous antibiotcs were recommemended, successful placement
of a left brachial vein 45 cm double lumen PICC line was placed
on [**2104-5-27**]. ID consult on [**5-28**] resulted in vanco being
discontinued (due to rash) and linezolid was started. His
sternal waond is superficially open with a VAC dressign in
place. This is being managed by the plastic surgery service,
and he should follow up with Dr. [**First Name (STitle) **]. The VAC should be
changed every 3rd day. He was transferred back to the floor on
[**5-29**]. He has remained hemodynamically stable, his WBC has
remained WNL, and he is ready to be discharged to rehab.
Medications on Admission:
Lisinopril 10mg qd, Glipizide 50mg qd, Metformin 500mg qd,
Allopurinol 300mg qd, Simvastatin 10mg qd, Ditropan XL 10mg qd,
Indocin 50mg qd, Aspirin 325mg qd
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours): Continue until ID follow-up on [**6-9**].
9. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed.
11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
12. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours): Continue until see in follow-up with ID on [**6-9**].
13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
14. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
16. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 Units
Units Injection TID (3 times a day): until fully ambulatory.
17. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
18. Ranitidine HCl 75 mg Tablet Sig: One (1) Tablet PO once a
day for 2 weeks.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3
Aortic Stenosis s/p Aortic Valve Replacement
PMH: Diabetes Mellitus, Peripheral Vascular Disease w/ Carotid
Stenosis, Peripheral Neuropathy, Hypertension, Sleep Apnea,
Obesity, Gout, Neurogenic bladder
Discharge Condition:
stable
Discharge Instructions:
Patient should shower daily, no baths.
No creams, lotions or ointments to incisions.
No driving for at least one month.
No lifting more than 10 lbs for at least 10 weeks from the date
of surgery.
Monitor wounds for signs of infection. Please call cardiac
surgeon if start to experience fevers, sternal drainage and/or
wound erythema.
Followup Instructions:
Make appointments with the following physicians:
Dr. [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 1504**]
Dr. [**Last Name (STitle) **] in [**12-29**] weeks
Dr. [**Last Name (STitle) 28945**] in [**11-27**] weeks (please ask for follow-up for ?
spinal stenosis, pain service vs. neurologist, vs. neurosurgeon)
Dr. [**Last Name (STitle) **] (vascular surgeon) at time of appt. with Dr.
[**Last Name (STitle) 914**] ([**Telephone/Fax (1) 9393**]
Infectious Disease Clinic Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2104-6-9**]
2:00,
Dr. [**First Name (STitle) **] (plastic surgery)on [**6-10**] @ 2:30PM([**Telephone/Fax (1) 1429**])
Completed by:[**2104-6-3**]
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69,234
| 120,720
|
35952
|
Discharge summary
|
report
|
Admission Date: [**2109-11-18**] Discharge Date: [**2109-12-18**]
Date of Birth: [**2076-11-25**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Oxycodone Hcl/Acetaminophen
Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
Abdominal pain, Nausea and Vomiting
Major Surgical or Invasive Procedure:
mechanical ventilation
central line placement
History of Present Illness:
Ms. [**Known lastname 59885**] is a 32 yo woman with no significant PMH who
initially presented to an OSH on the evening of [**11-17**] with
abdominal pain, nausea and vomiting. She was found to have acute
hepatitis with worsening LFTs and so was transferred to [**Hospital1 18**]
for further care.
.
She reports that she was in her USOH until approximately one
week prior to transfer. She reports that on the evening of
[**11-11**], she developed nausea and profuse vomiting in the middle
of the night. Throughout the next day ([**11-12**]), she continued to
have vomiting and then developed profound diarrhea, such that
everything she took in went out one way or the other. During
this time, she began to take acetaminophen-diphenhydramine to
help her sleep. She reports that she took ~4 pills daily for the
past week.
.
Her gastrointestinal symptoms improved over the next 2 days, and
she reports feeling relatively well on the morning of [**11-14**]. She
removed her Nuvaring on [**11-14**] as well. She had a normal meal
that day and had two glasses of wine that evening. She continued
to have mild nausea and diarrhea of the same consistency but far
less frequently. She had 3 or 4 beers on the evening of [**11-15**],
and her overall condition started to improve.
.
However, early in the morning of [**11-17**] (about 3 a.m.) she awoke
with intense right upper quadrant pain and worsening nausea and
vomiting. The diarrhea did not recur, and she could not tolerate
the pain, so she presented to an OSH in the evening.
.
At the OSH, she had a significant transaminites that worsened on
the day of transfer. In addition, she had leukocytosis to 20.2,
thrombocytopenia to 78, an anion gap metabolic acidosis, a
negative pregnancy test, a lactate of 6.4 and an acetaminophen
level of 38 that came down to less than assay on the morning of
[**11-18**]. Also on [**11-18**], her INR was measured as 9.4. A RUQ U/S
demonstrated pericholecystic fluid with gallbladder wall
thickening, a hypoechogenic liver and no gallstones. There was
normal flow in the main, right and left portal veins. She
received ondansetron for nausea control, 10 mg Vitamin K and
N-Acetylcysteine IV drip.
.
Other than the EtOH and acetaminophen-diphenhidramine, she has
not used any other drugs, either illicit, prescription or
over-the-counter. She denies fevers or chills. She reports
myalgias, but no joint pains. She denies headache or change in
her vision or hearing. She does report slight confusion and
sometimes having the inability to complete a thought. She denies
bleeding or bruising easily. She denies rash. She denies animal
or insect contacts. [**Name (NI) **] 3 [**11-22**] [**Name2 (NI) **] son was ill with a GI bug
(vomiting and diarrhea for about 24 hours) about 2 weeks prior
to presentation (1 week prior to the start of her illness). She
has not eaten out at restaurants, and she has not had any
undercooked meat (to her knowledge). She is sexually active with
one partner. She does not use barrier protection. She denies
ever having any sexually transmitted infections. She has oral
Herpes but has never had genital Herpes.
Past Medical History:
s/p c-sxn ~3 1/2 years ago
Social History:
Smokes 1 pack per week, drinks nearly daily, 3-4 beers per day,
has never had a problem with stopping drinking; denies current
illicit drug use, but has snorted cocaine, done LSD and smoked
marijuana in the past; she is sexually active with one partner
and does not use barrier protection.
Family History:
HTN, brother recently diagnosed witrh [**Name (NI) 4522**]
Physical Exam:
Vitals: 97.8 108 157/82 18 98%
General: Awake, alert, NAD, pleasant, appropriate, cooperative.
HEENT: NCAT, PERRL, EOMI, no scleral icterus, MM dry, no lesions
noted in OP
Neck: supple, no significant JVD
Pulmonary: Lungs CTA bilaterally, no wheezes, ronchi or rales
Cardiac: tachycardic, hyperdynamic precordium, nl S1 S2, no
murmurs, rubs or gallops appreciated
Abdomen: soft, slightly tender in LUQ, LLQ and RLQ, exquisitely
tender in RUQ, liver palpated below the costal margin,
hypoactive bowel sounds.
Extremities: No edema, 2+ radial, DP pulses b/l
Skin: no rashes or lesions noted.
Neurologic: No asterixis. Alert, oriented x 3. Able to relate
history without difficulty. Cranial nerves II-XII intact. Normal
bulk, strength and tone throughout. No abnormal movements noted.
No deficits to light touch throughout. No nystagmus, dysarthria,
intention or action tremor. 2+ biceps, patellar reflexes and 2+
ankle jerks bilaterally. Plantar response was flexor
bilaterally.
Pertinent Results:
Echo: The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). The estimated cardiac index is high
(>4.0L/min/m2). Transmitral Doppler and tissue velocity imaging
are consistent with normal LV diastolic function. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
leaflets are structurally normal. There is no mitral valve
prolapse. No mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Normal regional and global biventricular systolic
function. Normal diastolic function. No pathologic valvular
abnormality seen.
SPECIMEN SUBMITTED: LIVER CORE BIOPSY. (1 JAR)
Procedure date Tissue received Report Date Diagnosed
by
[**2109-12-12**] [**2109-12-12**] [**2109-12-16**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/vf
DIAGNOSIS:
Liver, needle core biopsy:
1. Submassive hepatic necrosis with collapse and severe
cholestasis.
2. Mild to moderate mixed inflammation including prominent
plasma cells, neutrophils, and occasional eosinophils.
3. Marked regenerative changes with hepatocellular swelling and
cholestasis.
4. Bile duct proliferation.
5. Trichrome and reticulin stains show extensive collapse with
no definite increased fibrosis.
6. Iron stain shows no stainable iron.
7. No immunoreactivity seen for HSV I and II.
Note: The findings are consistent with acute hepatitic process
with submassive necrosis. Possible etiologies include toxin
induced, viral and autoimmune.
Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] was given a preliminary diagnosis by phone
[**12-13**]/09.
Clinical: Tylenol overdose, ? additional source of hepatitis.
Gross: Received in a formalin-filled container, labeled with the
patient's name, "[**Known lastname 59885**], [**Known firstname **]" and additionally labeled
with the medical record number is one green-brown tissue core
measuring up to 1.8 cm, all submitted in cassette A.
CT ABD
IMPRESSION:
1. Large amount of free fluid in the abdomen, new since an
abdominal
ultrasound done on [**11-18**]. No visible adverse sequelae of
pancreatitis.
The study and the report were reviewed by the staff radiologist.
.
Brief Hospital Course:
This is a 32 yo female who presented with fulminant hepatic
failure.
.
# Acute hepatitis/fulminant hepatic failure: When the patient
presented, the history that she had taken a large amount of
tylenol was not initially obtained. Therefore, a very thorough
workup was completed including viral etiology, toxins, vascular
or, less likely, autoimmune. She had not had any significant
trauma or blood loss to suggest shock liver. Serologies were
sent. Hepatitis A was positive, however IgM negative all other
serologies were negative. Acute hepatitis secondary to HSV was
considered as the patient's LFTs, INR and T. Bili all continued
to worsen. Acyclovir was empircaly given from [**11-24**] to [**11-28**] but
then stopped when HSV was ruled-out. After the history was
obtained that she took a large amount of tylenol per her
boyfriend. This was not the first time she had attempt to end
her life according to the family and boyfriend.
N-acetylcysteine was initiated. The patient continued to worsen
clinically, max AST 13,311 and ALT 7986, and the patient became
acutely encephalopathy. She was then started on vancomycin and
zosyn for prophylaxis per the hepatology team. The hepatology
team considered a liver transplant, however she was denied based
on her social situation. The patient had to be intubated and
placed on mechanical ventilation during this episode given her
inability to protect her airway. She received sedation for
ventilatory support. She was not arousable for many days
following discontinuing sedation. Multiple head CT's were
completed along with an EEG all of which was just consistent
with encephalopathy. Eventually, 4 days after discontinuing
sedation, the patient started to move her lower extremities and
head. Within 24 hours she was awake and alert. She was then
extubated. Durign her MICU stay, she was covered empirically
with Vanc and Zosyn with negative cultures; abx were thus
stopped before she was called-out.
On the floor, her LFT's graduaully improved with NAC, which she
again received from [**12-4**]-->[**12-9**]. Because it was not clear that
the patient had in fact overdosed on Tylenol, and in the setting
of sluggish laboratory improvement, a liver biopsy was obtained
that demonstrated:
1. Submassive hepatic necrosis with collapse and severe
cholestasis.
2. Mild to moderate mixed inflammation including prominent
plasma cells, neutrophils, and occasional eosinophils.
3. Marked regenerative changes with hepatocellular swelling and
cholestasis.
4. Bile duct proliferation.
5. Trichrome and reticulin stains show extensive collapse with
no definite increased fibrosis.
6. Iron stain shows no stainable iron.
7. No immunoreactivity seen for HSV I and II.
The findings are consistent with acute hepatitic process with
submassive necrosis. Possible etiologies include toxin induced,
viral and autoimmune.
The patient subsequently did very well on the floor. Her highest
TBili was 30.2 (up from about 20 on admission). By time of
discharge, it was trending down 5.0- 5.6. Her jaundiced
continued to be marked, but this is to be expected and she will
likely be jaundiced for quite some time. On day of discharge,
ALT = 45. AST = 65 with Alk Phos = 141. The patient is now
medically clear for discharge.
.
# Pancreatitis: The patient was found to have elevated amylase
and lipase (lipase = 1017 on [**12-1**]) after patient started to
have fevers. Tube feeds were temporarily stopped in the MICU.
Once the patient was more awake and extubated, she did not
report any abdominal pain, nausea or vomiting. Fevers resolved.
The patient reported being very hungry. It was unclear if she
had true clinical pancreatitis. CT showed Large amount of free
fluid in the abdomen, new since the abdominal
ultrasound done on [**11-18**]. There was no visible adverse
sequelae of pancreatitis. The patient's lipase was under 500 by
[**11-29**] and the patient was abdominal-pain free. The patient
is medically clear for discharge.
.
# Coagulopathy: Hypotheszied to be secondary to hepatic
failure. The patient's INR reached a max of 15.6 on [**11-19**], but quickly improved to 2.8 by [**11-20**]. The patient
received one dose of vit K, and FFP prior to line placement, and
required 3 bags of FFP before her liver biopsy. She did complain
of occasional epistaxis, but hemostasis was always easily
achieved. At time of discharge, the patient's INR was
consistnetly under 2.0. The patient is medically clear for
discharge.
.
Psych: Given question of previous h/o drug abuse and suicide
attempts, the patient was sectioned after psychiatric evaluation
was obtained. However, the patient demonstrated willingness to
go to an inpatient facility to ("start her new life") even
though she ascknowledged she missed her family and son very
much. She demonstrated insight and willingness to co-operate
with recommnedations and seemed genuinely eager to get well. She
was followed by social work and psychiatry throughout the
hospitalization.
.
# Thrombocytopenia: Likely related to hepatitis/hepatic failure.
82 on admission. Resolved to 162 by day of discharge.
.
#FEN/Lytes: The patient was tolerating a full diet with
excellent (>[**2100**] cal) intake in the last three weeks of
hospitalization.
.
#Prophylaxis: The patient was given pneumoboots while in the
ICU. Thereafter, she was ambulatory, and walked routinely
throughout the day.
.
#Code status: Remained FULL CODE throughout.
Addendum - [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
The patient admitted cocaine use as well as the prodromal
illness for which she took 2 tylenol PM tabs twice daily. She
never admitted intentional suicide attempts to me. Indeed, she
vehemently denied this stating that she had spent $15,000 to
gain custody of her son and would not want to lose him.
There are several features of her illness that do not fit
tylenol overdose and are suggestive of possible Fulminant HSV
hepatitis: the low therapeutic tylenol levels measured; she
evidently had an induced abortion three weeks rior to her
illness; the severe RUQ pain that precipitated her presentation
to the ED; the very early rise in her INR which was 6 at
presentation to [**Hospital1 51816**]; the AST/ALT ratio that flipped
dramatically after she was started empirically on acyclovir; the
reduction of her INR after FFP was maintained after acyclovir;
the normal Cr levels throughout; the hyperesthesia that she
complained of during the illness;; the persistent
hyperbilirubinemia suggestive of the rare persistent cholestasis
that can follow acute HAV; etc.
HSV IgG was positive; the negative IgM does not rule out HSV
FHF. The liver biopsy is inconclusive.
It is important to continue to monitor the natural history of
this ilness and to continue to follow her clinically with the
understanding that the etiology of her FHF is undetermined
Medications on Admission:
Nuvaring
tylenol pm
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed.
3. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed.
4. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) as needed for itching.
5. Outpatient Lab Work
Check CBC, Chem 10, AST, ALT, ALK PHOS, Total Bilirubin, PT/INR,
PTT on [**2109-12-23**] and [**2109-12-30**].
Fax results to Dr [**First Name8 (NamePattern2) 2943**] [**Name (STitle) 696**], [**Hospital1 18**] LIVER CENTER, phone
([**Telephone/Fax (1) 1582**].
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Fulminant Hepatic Failure
Respiratory Failure
Tylenol overdose
???Suicide Attempt
Discharge Condition:
Medically stable for inpatient psychiatric treatment
Discharge Instructions:
You were admitted with fulminant hepatic failure (liver
failure). This failure may have been due to Tylenol toxicity,
although the exact cause is not clear. You initialy required
intubation in the ICU. At time of discharge, your mental and
respiratory status was excellent and your liver laboratory
values were improving.
.
You should not drink ANY alcohol in the future. You should not
take more than 2 grams (4 extra strength tylenol) in any 24 hour
period. You should not take any other illegal drugs. Check
with your doctor before taking any over the counter medications.
.
You are being discharged to an inpatient psychiatric unit for
continued care. You should have your blood drawn as per the
prescription that accompanies this discharge packet.
.
Seek immediate medical care if you develop nausea, vomiting,
worsening jaundice (yellow skin), feeling weak or dizzy or any
other concerning symptoms.
Followup Instructions:
You will be discharged to inpatient psych unit.
Follow up with Dr [**Last Name (STitle) 696**] or another doctor in the Liver Clinic
within 1 week of leaving the psych unit. Call ([**Telephone/Fax (1) 1582**] to
schedule this appointment.
Completed by:[**2109-12-18**]
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3912, 3972
|
14367, 15071
|
15130, 15214
|
14323, 14344
|
15314, 16226
|
3987, 4966
|
263, 300
|
413, 3538
|
3560, 3588
|
3604, 3896
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,456
| 147,813
|
53140
|
Discharge summary
|
report
|
Admission Date: [**2123-7-15**] Discharge Date: [**2123-7-23**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4588**]
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
87 year old woman with history of hypertension, coronary artery
disease, mild systolic heart failure, severe aortic stenosis,
mitral regurgitation, osteoporosis (with h/o compression
fractures) presenting from [**Hospital 100**] Rehab nursing home after an
unwitnessed fall in the bathroom without loc.
Briefly, the patient was initially admitted to the trauma
service for suspected cervical neck injury. Trauma series
revealed a non displaced, left patellar fracture and a C7
compression fracture. Patient however was found to be
hypotensive and cardiac ezymes were checked and revealed a
rapidly raising trend. She was transferred to the medical
service for further management.
In the medical floor, the patient was found to have systolic
pressures in the 90's, which decreased further to 80's. Patient
was given two 250ml boluses with little response in hypotension,
at this time request for MICU transfer was made.
Past Medical History:
Coronary artery disease
--(RCA 90% stenosis s/p POBA in 89')
Aortic Stenosis
-- valve Area 0.7cm2
-- Peak gradient (echo) 61mmHg
Systolic Heart Failure
-- EF 45-50%
Mitral Regurgitation
-- Torn mitral cordae
Depression
Anemia
Raynaud's
Rotator cuff tendonitis
Chronic lower extremity edema
Osteoporosis
-- Compression fractures
SURGICAL HISTORY:
Cholecystectomy
Right rotator cuff repair
Social History:
She is a resident of [**Hospital 100**] Rehab (5West) and has a son that
lives in [**Name (NI) 47**].
Family History:
Non-contributory
Physical Exam:
vitals T 99.2 BP 100/47 AR 73 RR 19 O2 sat 96% on 3L
General Appearance: No acute distress
Eyes/Conjunctiva: Conjuncitival discharge from right eye
Cardiovascular: Normal S1/S2, high pitched, V/VI early peaking
RUSB murmur and low pitched IV/VI murmur at apex.
Peripheral [**Name (NI) **]: 2+ DP/PT pulses bilaterally
Respiratory / Chest: CTAB, crackles at posterior bases
posteriorly
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right: Trace, Left: Trace, erythema bilaterally
Skin: Warm
Neurologic: Attentive, Follows simple commands
Pertinent Results:
ECG:
[**2123-7-15**] 16:45
Sinus rhythm at 86, with very late R wave progression, axis with
mild leftward deviation and 1mm ST elevations in leads III and
aVF as well as AvR and V1-V2, with 1-2mm concave ST depressions
on I, aVL. Diffuse T-wave flattening. Q waves noted on II and
aVF, more prominent than in [**2119**].
[**2123-7-16**] 17:49
Sinur rhythm at 68, with very late R wave progression, new
T-wave inversion along III, aVF and flat at II. 1mm ST
depression at I and aVL, with q waves in III and aVF.
Relevant Imaging:
KNEE X-RAY ([**2123-7-15**]): Nondisplaced-nondistracted transverse
fracture through the patella as above.
L SPINE X-RAY ([**7-15**]):Nearly nondiagnostic study. There are
multiple compression type deformities throughout the lumbar
spine and at least two in the mid and lower thoracic spine.
Levels are difficult to discern, but approximately in the region
of T5, T6 and T10, T11 and likewise possibly involving L1, L3
and L4. The acuity of these fractures is unknown. Posterior
retropulsion is unknown.
CHEST X-RAY ([**7-15**]): Bibasilar atelectasis. No evidence of
pneumonia or congestive heart failure.
CT Head ([**7-15**]): No acute intracranial hemorrhage.
CT C-SPINE ([**7-15**]): Several levels of spondylolisthesis and
anterior wedging of the C7 vertebral body. While these findings
may be chronic, in the setting of trauma, an acute injury cannot
be excluded, and if concern remains for injury to the cervical
spine, an MRI is recommended.
CT T-SPINE ([**7-15**]): Anterior wedging of the C7 vertebral body of
indeterminate age. Mild wedge deformities of other thoracic
vertebral bodies as described. No spondylolisthesis.
CT L SPINE ([**7-15**]): Compression deformities involving the L2 and
L3 vertebral bodies. Mild, grade 1 anterolisthesis of the L4-5
level.
KNEE X-RAY ([**7-15**]): Deformity of the patella is likely chronic,
given history of remote fracture. No acute fracture.
Brief Hospital Course:
Mrs. [**Known lastname **] is a 87 year old woman with CHF, aortic stenosis,
HTN, CAD admitted for right patellar fracture and acute versus
chronic C7 compression fracture with a hospital course
complicated by hypotension, troponin leak, and constipation.
1. C7 Compression fracture: Patient was diagnosed with a acute
versus chronic C7 compression fracture. Neurosurgery was
evaluated and did not consider the patient a surgical candidate.
She was instructed to wear a soft cervical collar and to
follow-up with outpatient neurosurgery in 4 weeks.
2. Patellar fracture: Per orthopedics, patellar fracture of
acute versus chronic nature. She was evaluated by orthopedic
trauma, which did not feel that she was a surgical candidate.
Conservative management was recommended with a knee brace and
limited mobility. She will need to follow-up with outpatient
ortho clinic at [**Hospital 100**] Rehab in 1 week.
3. Aortic stenosis: Patient has severe aortic stenosis. She was
evaluated by cardiology, who do not feel that she is currently a
surgical candidate. She was instructed to follow-up with
cardiology as an outpatient.
4. Foley catheter: On admission, patient had a dirty urinalysis
that, when repeated, was clean. Both urine cultures ([**7-16**], [**7-18**])
speciated as Corynebacterium species. The patient also failed
two voiding trials during hospitalization, and thus was
discharged with a foley catheter. A urinalysis and urine
culture was sent on the day of discharge that will need to be
followed up on.
5. Elevated cardiac enzymes: Patient initially had elevated
troponins up to 0.77 with flat MBI. She was evaluated by
cardiology, which felt that the troponin leak was secondary to
demand ischemia.
6. Hypotension: Patient presented with transient hypotension
likely secondary to hypovolemia. An occult bleed was also on the
differential given her drop in hematocrit. Her blood pressure
quickly normalized after receiving several fluid boluses and a
transfusion of 2 units PRBC. There were no signs of an
infection. She was normotensive in the MICU and remained so
upon transfer to the general medicine floor. Home lisinopril
was restarted on discharge.
7. Anemia: Patient presented with acute Hct drop during her
hospital stay. She received 2 units pRBCs with an appropriate
bump. Etiology to the patient anemia is currently unknown.
Patient was guaiac positive during this admission, which may
require further outpatient evaluation. On discharge, patient's
hematocrit was stable.
8. Systolic heart failure: Patient does not seem significantly
volume overloaded on physical exam. Diuretics and
anti-hypertensives were being held in light of her hypotension.
Lisinopril was restarted on discharge. As the patient was
euvolemic on discharge, lasix was not restarted.
9. Constipation: Patient had severe constipation secondary to
opiod analgesia during hospital admission requing laxative,
enema, and manual disimpaction. On the day of discharge, she
had a large bowel movement with symptomatic relief. Patient was
discharged with bowel regimen including colace and senokot. As
she was complaining of some mild abdominal discomfort/gassiness,
she was also discharged with PRN maalox.
10. Conjunctivitis: Patient was started on Ciprofloxacin eye
drops for 7 day course (stop on [**7-25**]).
11. Hyperlipidemia: On admission, the patient was noted in her
paperwork to be on zocor, which was being held for 14 days. Her
statin therapy was held on admission and at discharge, and
should be restarted as an outpatient by her PCP.
12. Electrolyte repletion: Patient's serum phosphate level the
morning of discharge was low at 1.9 mg/dL. She refused oral
repletion with neutra-phos, and will need to be repleted.
13. Prophylaxis: Patient received heparin SQ for DVT prophylaxis
during her hospital stay.
Medications on Admission:
aspirin 81 mg daily
calcitonin NS
calcium carbonate 650 mg po bid
vitamin D 1000 units daily
vitamin B12 q28 days
colace 250 mg daily
feso4 325 mg po bid
lasix 30 mg daily
lidoderm patch to back
lisinopril 2.5 mg q6pm - on hold for SBP <90
prilosec 40 mg daily
ultram 12.5 mg q12 hours
tylenol 650 mg po q4 hours ATC
zocor 20 mg qhs - on hold X 14 days
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray Sig:
One (1) Nasal DAILY (Daily).
3. Calcium 600 600 mg (1,500 mg) Tablet Sig: One (1) Tablet PO
twice a day.
4. Cholecalciferol (Vitamin D3) 1,000 unit Capsule Sig: One (1)
Capsule PO once a day.
5. Vitamin B-12 Oral
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
8. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical Q24H (every 24 hours).
9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) for 7 days.
10. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
11. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO q6PM.
12. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for pain: Not to exceed 2gram/day.
13. Ciprofloxacin 0.3 % Drops Sig: 1-2 Drops Ophthalmic Q4H
(every 4 hours): STOP ON [**7-25**].
14. Maalox 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO four
times a day as needed for Constipation or abdominal discomfort.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Primary
1. Right patellar fracture
2. C7 compression fracture
3. Constipation
4. Aortic stenosis
Secondary
CAD s/p angioplasty 14 years ago
CHF
Hypertension
Depression
Anemia
Raynaud's
Rotator cuff tendonitis
Chronic lower extremity edema
Osteoporosis with h/o compression fractures
Surgeries: s/p cholecystectomy, s/p "R capsulotomy"
Discharge Condition:
Patient was discharged in stable condition.
Discharge Instructions:
1. You were admitted from [**Hospital 100**] Rehab after a fall. You were
found to have a fractured right patella. You were evaluated by
orthopedics, which did not feel that this was an operative
injury. You will need to have a follow-up with orthopedic
surgery clinic at [**Hospital 100**] Rehab in 1 week.
2. You were also found to have a compression fracture of your
neck of unknown age. Neurosurgery evaluated you and you will
need to wear the soft cervical neck collar. You will need to
follow-up with neurosurgery in 4 weeks.
3. You also have severe aortic stenosis. Cardiology evaluated
you during your hospital stay and you will need to follow-up
with them as described below.
4. You had a foley catheter placed while hospitalized. We
attempted twice to discontinue the catheter, but you were unable
to void spontaneously. A urinalysis and urine culture was drawn
on the day of discharge that will need to be followed up on.
5. You were diagnosed with conjunctivitis, which is being
treated with ciprofloxacin drops that will need to be continued
for 7 days (stop on [**7-25**])
6. Please resume all of your medications as taken prior to
admission unless otherwise indicated. It is very important that
you take all of your medications as taken prior to admission to
the hospital.
7. It is very important that you make all of your doctors
[**Name5 (PTitle) 4314**].
8. If you develop a fever, chest pain, shortness of breath, or
other concerning symptoms, please call your PCP or go to your
local Emergency Department immediately.
Followup Instructions:
Please follow-up with orthopedic surgery clinic at [**Hospital 100**] Rehab
in 1 week.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2123-8-3**] 4:00
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 1669**]
Date/Time:[**2123-8-11**] 2:00
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2123-8-10**] 10:00
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 871**] ([**Doctor First Name **]) [**Doctor First Name **] LMOB (NHB)
Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2123-8-18**] 2:30
Provider: [**Name10 (NameIs) 14633**],EQUIPMENT Date/Time:[**2123-8-18**] 2:30
Completed by:[**2123-7-23**]
|
[
"401.9",
"372.30",
"733.00",
"733.13",
"V45.89",
"443.0",
"272.4",
"822.0",
"275.3",
"410.71",
"E935.2",
"276.52",
"578.1",
"E885.9",
"726.10",
"424.1",
"921.2",
"428.20",
"428.0",
"424.0",
"414.01",
"564.09",
"285.9",
"756.12",
"311"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9864, 9949
|
4337, 5878
|
267, 274
|
10328, 10374
|
2379, 2892
|
11976, 12797
|
1770, 1789
|
8580, 9841
|
9970, 10307
|
8203, 8557
|
10398, 11953
|
1804, 2360
|
5895, 8177
|
223, 229
|
2910, 4314
|
302, 1222
|
1244, 1634
|
1650, 1754
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,536
| 134,719
|
21772
|
Discharge summary
|
report
|
Admission Date: [**2142-10-8**] Discharge Date: [**2142-10-20**]
Date of Birth: [**2067-7-16**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Nph, Human Insulin Isophane / Lantus / Codeine
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Ear infection/chest pressure
Major Surgical or Invasive Procedure:
[**2142-10-8**] - left heart catheterization, coronary angiogram, left
ventriculogram
[**2142-10-15**] - Off-Pump coronary artery bypass grafting x 2 (Left
internal mammary artery->Left anterior descending artery, Radial
artery->Obtuse marginal arerty.)
History of Present Illness:
this 75 year old amle with type 1 diabetes presented to [**Hospital 6451**] Hospital on [**2142-10-3**] after an episode of chest pain
and ear infection. He states that the night prior to admission
he had been feeling increased pressure and pain in his right
ear. He went to bed and awoke at 2:00 AM with chest pressure.
This resolved and he went back to sleep, but awoke again at 4:30
with ear pain bad enough that he called his primary care doctor
who recommended he go to the ED.
Initial vitals in the ED were a pulse of 60 and BP of 128/54.
He was given 3325mg of ASA and SL nitro. He was also given at
dose of Plavix 75 mg and lovenox 100 mg. Intial CK was 125, MB
of 5.2, and Troponin of 0.18. ECG with sinus brady at 55 and
non-specific ST changes. Upon transfer to [**Hospital1 18**], vital signs
were T- 97.2, BP- 173/65, HR- 53, RR- 18, SaO2- 100% on RA. He
reported ear pain was improving. He had not had any episodes of
chest pain since last week.
Of note, the patient was recently hospitalized with recurrent
syncope and was diagnosed as having orthostatic hypotension and
patient started on midodrine and fludocrocortisone.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
S/he denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
Type 1 DM since age 19
diabetic nephropathy
diabetic neuropathy.
hyperlipidemia
gastroesophageal reflux
Diverticulitis
s/p colonic resection
s/p bilateral rotator cuff surgery
s/p penile implant
s/p resection of basal cell carcinoma
Social History:
Married and lives with wife.
-Tobacco history: none
-ETOH: none
-Illicit drugs: none
Family History:
Father with MI in 50's and passed at 74 of MI. Mother died [**12-18**]
DM in 70s. 2 sisters with DM
Physical Exam:
Admission:
VS: T- 97.2, BP- 173/65, HR- 53, RR- 18, SaO2- 100% on RA
GENERAL: WDWN 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 6 cm. No LAD. No carotid bruits heard
CARDIAC: Regular rate and rhythm. No m/r/g. Normal S1, S2. No
thrills, lifts. No S3 or S4.
LUNGS: Clear to auscultation b/l. Good respiratory effort- resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e.
SKIN: Signs of stasis dermatitis in b/l LE. Scaly skin with
multiple ulcers noted on b/l LE. Erythematous. Non-tender to
palpation.
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
Pertinent Results:
TTE ([**2142-10-9**]):
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Trace aortic regurgitation is seen. Mild (1+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal global and regional biventricular systolic function. No
significant valvular disease seen. Mild pulmonary hypertension.
[**2142-10-19**] 01:47AM BLOOD WBC-6.7 RBC-2.79* Hgb-8.4* Hct-25.9*
MCV-93 MCH-30.2 MCHC-32.5 RDW-15.2 Plt Ct-223
[**2142-10-17**] 04:59AM BLOOD WBC-8.9 RBC-3.07* Hgb-9.2* Hct-28.7*
MCV-93 MCH-29.8 MCHC-31.9 RDW-15.6* Plt Ct-154
[**2142-10-19**] 01:47AM BLOOD Glucose-145* UreaN-40* Creat-3.0* Na-140
K-3.8 Cl-102 HCO3-26 AnGap-16
[**2142-10-18**] 06:30AM BLOOD UreaN-38* Creat-2.6* K-4.3
[**2142-10-13**] 06:15AM BLOOD Glucose-246* UreaN-42* Creat-2.2* Na-138
K-4.6 Cl-104 HCO3-23 AnGap-16
[**2142-10-12**] 05:25AM BLOOD Glucose-232* UreaN-39* Creat-2.1* Na-140
K-4.8 Cl-106 HCO3-25 AnGap-14
Brief Hospital Course:
Mr. [**Known lastname 19862**] was admitted to the [**Hospital1 18**] on [**2142-10-8**] for further
management of his myocardial infarction. He underwent a cardiac
catheterization which revealed two vessel coronary artery
disease. Given the severity of his disease, the cardiac surgical
service was consulted for surgical revascularization.
He was worked-up in the usual preoperative manner including a
carotid duplex ultrasound which showed a less the 40% stenosis
in the bilateral internal carotid arteries. Vein mapping was
also obtained. This revealed a small piece of vein in the right
thigh.
An Otolaryngology consult was obtained given his right otitis
externa. Augmentin was started as well as Ciprodex ear drops.
Plavix was allowed to wash out. On [**2142-10-15**], Mr. [**Known lastname 19862**] was taken
to the Operating Room where he underwent off-pump coronary
artery bypas grafting to two vessels. Please see operative note
for details. There was no venous conduit found ,therefore, a
radial artery was harvested for conduit. He weaned from bypass
on Neosynephrine and Propofol. Over the next 24 hours, he awoke
neurologically intact, weaned from pressors and was extubated.
Plavix and Imdur were started given his radial artery graft and
his off-pump procedure. On postoperative day one, he was
transferred to the step down unit for further recovery.
He was gently diuresed towards his preoperative weight. The
Physical Therapy service was consulted for assistance with
postoperative strength and mobility. Beta blockade was resumed.
On POD 3 he experienced some hallucinations which cleared on the
same day and narcotics were discontinued.
A 10 day course of oral and topical antibiotics were given at
the recommendation of the ENT service and follow up will be with
his primary care provider. [**Name10 (NameIs) **] renal function fluctuated from a
baseline of 2.2 to 3.0 and diuresis was discontinued as he
neared his preoperative weight.
Medications on Admission:
ASA 81
Gabapentin 600 mg at 8AM, 300 mg at NOON, 600 mg at 8 PM
Rosuvastatin 5 mg
Calcitrol 2.5 mg daily
Oxazepam 15 mg QHS PRN insomnia
Midodrine 5 mg TID
Fludricortisone 0.1 mg daily
Omeprazole 20 mg daily
Novolog insulin pump
Vitamin D
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for Pain.
3. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO below: two
at morning aand evening, one at noon.
Disp:*150 Capsule(s)* Refills:*2*
5. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day for 3
months.
Disp:*30 Tablet(s)* Refills:*2*
6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. Midodrine 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Crestor 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Lopressor 50 mg Tablet Sig: 0.5 Tablet PO twice a day.
Disp:*30 Tablet(s)* Refills:*2*
10. Dexamethasone 0.1 % Drops, Suspension Sig: Three (3) Drop
Ophthalmic TID (3 times a day) for 3 days.
Disp:*qs 1* Refills:*0*
11. Amoxicillin-Pot Clavulanate 250-62.5 mg/5 mL Suspension for
Reconstitution Sig: One (1) PO Q 8H (Every 8 Hours) for 3 days.
Disp:*qs 1* Refills:*0*
12. Ciprofloxacin 0.3 % Drops Sig: Three (3) Drop Ophthalmic TID
(3 times a day) for 3 days.
Disp:*qs 1* Refills:*0*
13. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
14. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for PAIN for 4 weeks.
Disp:*50 Tablet(s)* Refills:*0*
15. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for TEMP.
16. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Coronary artery disease
s/p off-pump coronary artery bypass grafts
Type I diabetes mellitus
chronic kidney disease
hyperlipidemia
hypertension
Discharge Condition:
Good. Vital signs stable. Ambulating well
Discharge Instructions:
Monitor wounds for signs of infection. These include redness,
drainage or increased pain. In the event that you have drainage
from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 4044**].
Report any fever greater then 100.5.
Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1
week.
No lotions, creams or powders to incision until it has healed.
Shower daily, gently pat the wound dry. Please shower daily.
No bathing or swimming for 1 month.
No lifting greater then 10 pounds for 10 weeks from date of
surgery.
No driving for 1 month or while taking narcotics for pain.
take all medications as directed.
Followup Instructions:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**11-17**] weeks.([**Telephone/Fax (1) 6699**]
Dr. [**First Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 170**])
Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 8725**])
[**Hospital Ward Name **] 6 wound clinic in 2 weeks
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2142-10-20**]
|
[
"250.41",
"585.9",
"403.90",
"250.61",
"272.4",
"357.2",
"427.31",
"V45.85",
"780.1",
"440.0",
"414.01",
"530.81",
"583.81",
"382.01",
"410.71",
"380.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"37.22",
"88.56",
"36.11"
] |
icd9pcs
|
[
[
[]
]
] |
9172, 9227
|
5128, 7093
|
342, 598
|
9414, 9460
|
3707, 5105
|
10164, 10667
|
2682, 2784
|
7382, 9149
|
9248, 9393
|
7119, 7359
|
9484, 10141
|
2799, 3688
|
274, 304
|
626, 2306
|
2328, 2562
|
2578, 2666
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,641
| 177,705
|
27969
|
Discharge summary
|
report
|
Admission Date: [**2153-8-26**] Discharge Date: [**2153-8-31**]
Date of Birth: [**2096-9-11**] Sex: M
Service: MEDICINE
Allergies:
Percocet
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Transfer from [**Hospital3 417**] Hospital with pericardial effusion
Major Surgical or Invasive Procedure:
Pericardiocentesis with placement of drain.
History of Present Illness:
This is a 56 year-old man with a recent history of pericarditis
who presented to [**Hospital3 417**] on [**2153-8-26**] with shortness of
breath. Patient's most relevant history dates to [**8-8**] when he
presented to [**Hospital3 **] with chest pain, had negative stress
test/myoview and was noted to ahave small pericardial effuision
on CT, EKG consistent with pericarditis. Treated with NSAIDs. He
was cathed here on [**8-17**] and had clean coronaries. EF of 60-70%.
.
Over the past 2 weeks he has had shortness of breath and some
pleuritic chest pain. Denies fevers. Generally not feeling
himself. Also reports GERD. SOB described as inability to take
full breaths.
.
At [**Hospital3 417**] EKG consistent with pericarditis, no
alternans, ?decreased voltage and CXRAY demonstrating
cardiomegaly consistent effusion. Blood pressure in 120-130's
by documentation. Transferred to [**Hospital1 **] for further management.
Past Medical History:
hyperlipidemia
GERD
Lyme disease-remote, 20 years ago-knee effusion
kidney stones requiring lithotripsy and ureteral stent
Social History:
Civil judge. No smoking, occasional alcohol, no drug use.
Family History:
father and siblings with prostate cancer
Physical Exam:
Temp:tmax 101.3 at OSH, 99 here BP: 140/90 HR:80 RR:18
96%rm airO2sat Weight: 190lbs. pulsus:5
general: pleasant, comfortable, NAD
HEENT: PERLLA, EOMI, ano scleral icterus, MMM, op without
lesions, no supraclavicular or cervical lymphadenopathy, jvp
10-12cm, no carotid bruits
lungs: CTA b/l with good air movement throughout although no
deep breath secondary to pain
heart: RR, S1 and S2 wnl, +friction rub
abdomen: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
extremities: no edema
skin/nails: no rashes/no jaundice/no splinters
neuro: AAOx3. Cn II-XII intact. 5/5 strength throughout.
Pertinent Results:
[**2153-8-27**] 05:02AM WBC 9.2 HCT 32.4* Plt 268
[**2153-8-29**] 05:39AM ESR 23*
.
ECHO Study Date of [**2153-8-26**]
Conclusions: The left atrium is normal in size. Left
ventricular wall thickness, cavity size, and systolic function
are normal (LVEF>55%). Right ventricular chamber size is
relatively small with preserved free wall motion. There is a
large circumferential pericardial effusion with sustained right
atrial and right ventricular diastolic collapse, consistent with
impaired fillling/tamponade physiology.
IMPRESSION: Large circumferential pericardial effusion with
evidence for
increased pericardial pressure/tamponade physiology.
.
ECHO Study Date of [**2153-8-30**] (follow-up post-drain placement)
GENERAL COMMENTS: Left pleural effusion.
Conclusions:
1. Left ventricular wall thickness, cavity size, and systolic
functionare
normal (LVEF>55%). Regional left ventricular wall motion is
normal.
2. There is a small pericardial effusion. There are no
echocardiographic signs of tamponade.
3. Compared with the prior study (images reviewed) of [**8-29**]/200,
the
pericardial effusion is smaller.
.
ECHO Study Date of [**2153-8-31**]: The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size is normal. Right
ventricular systolic function is normal. There is a small
partially echo dense/organized pericardial effusion. There are
no echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of [**2153-8-30**],
findings are similar.
Brief Hospital Course:
This is a 56 year-old man with recent dx of pericarditis [**8-8**],
subsequent negative ischemic work-up, d/ced NSAIDs secondary to
GERD symptoms with shortness of breath over the past 2-3 weeks,
transferred from [**Hospital3 417**] for further management of
pericardial effusion.
.
1)CV:
-Ischemia: No CAD by recent cath. Continue statin.
-pump: large, primarily posterior, pericardial effusion with
slight impingement of rv filling. JVP to 10-12 cm, bp's in
130's to 140, heart sound not distant, positive rub, slightly
decr voltage by ekg, small pulsus parodoxus. [**Doctor First Name **] to lab for
drainage. Revealed tamponade physiology. 860 cc drained in lab.
Transferred back to CCU with drain in place. 400 more drained
that day. Echo revealed question of loculated posterior portion,
but continued to drain for 2 more days with aggressive flushing.
Cardiac surgery followed for possible pericardial window. Window
uneccessary. Drain eventually pulled without event. Follow-up
echocardiogram revealed stable pericardial effusion.
-valves: no valcular dz
-rhythm: normal sinus
Medications on Admission:
Atorvastatin 20
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*6*
Discharge Disposition:
Home
Discharge Diagnosis:
Idiopathic pericarditis w/ pericardial and pleural effusions
Discharge Condition:
Stable
Discharge Instructions:
Please return to the hospital if you have symptoms of shortness
of breath, chest pain or fever.
Followup Instructions:
Please follow up with your PCP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] within one week of
discharge.
.
Please follow up with your primary cardiologist, Dr. [**Last Name (STitle) **],
one week after discharge.
|
[
"272.4",
"493.81",
"420.91",
"511.9",
"V13.01",
"423.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.0",
"37.21"
] |
icd9pcs
|
[
[
[]
]
] |
5136, 5142
|
3859, 4946
|
339, 384
|
5247, 5256
|
2263, 3836
|
5400, 5638
|
1583, 1625
|
5012, 5113
|
5163, 5226
|
4972, 4989
|
5280, 5377
|
1640, 2244
|
230, 301
|
412, 1343
|
1365, 1490
|
1506, 1567
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,126
| 178,908
|
34928
|
Discharge summary
|
report
|
Admission Date: [**2119-8-30**] Discharge Date: [**2119-9-4**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Altered MS - found to have several ICH at OSH
Major Surgical or Invasive Procedure:
TEE
History of Present Illness:
The pt is a [**Age over 90 **] year-old right-handed man with multiple medical
problems including seizures, melanoma, afib on Coumadin and a
pacer. He was transferred this evening from [**Hospital3 19345**]. I contact[**Name (NI) **] the [**Hospital3 **] where he lives however
there was only limited documentation regarding the events
of this evening, therefore the majority of this history is from
the transfer records as the patient is unable to provide
details.
Per report, this evening he had "metal status changes"
howeverdetails of this are not available. He did not have a
history offalls. He was therefore transferred to an OSH. There
he was found to have multiple ICH, largest on the R parietal
region with a fluid level. His INN there was 3.6 and he was
given vitamin K and 2 units of FFP.
Of note, Mr. [**Known lastname **] was recently admitted to [**Hospital1 79921**] for medical management of a L hip
fracture which occurred on [**7-24**] in the same rehab parking lot -
he was visiting his wife who was admitted after stroke. Since
his admission there he has been noted to have baseline dementia
and a history of intermittent delirium, especially at night
("looking for the shot gun" the night prior).
ROS: limited, but pt denies HA, dizziness, vision changes, N,
SOB or CP.
Past Medical History:
- asthma
- HTN
- Afib s/p ablation and currently has a pacemaker.
- aortic stenosis
- Hypothyroid
- L hip fx
- seizures
- anemia
- pacer x2
- melanoma s/p surgical resection of R ear [**2-19**] - was initially
diagnosed 12 yrs ago. Recurrence in [**2-19**] - s/p R ear resection
and was diagnosed as Stage IIa. No other intervention.
Social History:
-remote tobacco hx
-denies EtOH or drugs
-lives at [**Hospital6 1293**] ([**Telephone/Fax (1) 79922**]) next
to his [**Age over 90 **] yo spouse who also resides there - been there since L
hip fracture in [**7-24**].
-HCP is son, [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 79923**]
-PCP is [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 66439**] at [**Location (un) 5028**] [**Telephone/Fax (1) 65735**]
- Code status DNR/DNI, confirmed per son, HCP.
Family History:
NC
Physical Exam:
Vitals: T: 98.1 P: 110 R: 16 BP: 127/70 SaO2: 98% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, R ear has large section of prior resection no
scleral icterus noted, MMM, no lesions noted in oropharynx
Neck: Supple, carotids have audible bruit however this may be
transmitted sounds as the same bruit is heard throughout the
precordium. No nuchal rigidity
Pulmonary: Lungs have decreased breath sounds at the bases
bilaterally
Cardiac: irregular, systolic ejection murmur
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: L ankle hyperpigmentation, L hip internally rotated
with severely restricted ROM in all directions
Neurologic:
-Mental Status: drowsy but easily arousable, oriented to person,
month and year but not place, purpose or location. Unable to
relate history. Inattentive, unable to name DOW forward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt. was able to name high frequency objects. Unable to read (but
does not have his [**Location (un) 1131**] glasses). Speech was not dysarthric.
CN
I: not tested
II,III: unable to cooperate with formal VF testing; pupil
1.5-.1mm bilaterally, unable to visualize fundi due to myosis
III,IV,V: EOMI aside from decreased upgaze; no ptosis; R
esotropia; No nystagmus
V: sensation intact V1-V3 to LT
VII: L NLF flattening
VIII: decreased hearing to voice bilaterally
IX,X: palate elevates symmetrically, uvula midline
[**Doctor First Name 81**]: SCM/trapezeii 5-/5 bilaterally
XII: tongue protrudes midline, mild tongue atrophy
Motor: diffusely decreased bulk throughout; motor impersistence
and paratonia; pt does not sustain elevated arms long enough to
test pronator drift. Antigravity in arms and has 5- finger
flexion; the R leg is antigravity, but the left is not. He is
able to flex and extend without at the knee. Further testing
against resistence of the L leg was deferred given his recent
hip
fracture
Reflex: No clonus
[**Hospital1 **] Tri Bra Pat An Plantar
C5 C7 C6 L4 S1 CST
L 1---------- tonically up
R 1---------- tonically up
-Sensory: responds to pain in all extremities symmetrically
-Coordination: pt does not cooperate with formal testing
-Gait: Deferred
Pertinent Results:
[**2119-8-30**] 12:55AM BLOOD WBC-16.0* RBC-3.50* Hgb-10.6* Hct-32.1*
MCV-92 MCH-30.4 MCHC-33.1 RDW-14.9 Plt Ct-308
[**2119-8-30**] 12:55AM BLOOD Glucose-85 UreaN-26* Creat-1.2 Na-142
K-4.3 Cl-106 HCO3-15* AnGap-25*
[**2119-8-30**] 12:55AM BLOOD ALT-15 AST-16 LD(LDH)-298* AlkPhos-136*
TotBili-0.5
[**2119-8-30**] 06:10AM BLOOD Calcium-9.0 Phos-3.2 Mg-2.0 Cholest-159
[**2119-8-30**] 06:10AM BLOOD %HbA1c-5.5
[**2119-8-30**] 06:10AM BLOOD Triglyc-97 HDL-44 CHOL/HD-3.6 LDLcalc-96
[**2119-8-30**] 06:10AM BLOOD TSH-3.8
[**2119-8-30**] 06:10AM BLOOD Phenyto-5.3*
[**2119-8-30**] 09:44AM BLOOD Lactate-1.1
TTE: The left atrial volume is markedly increased (>32ml/m2).
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
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 number of aortic valve leaflets
cannot be determined. The aortic valve leaflets are moderately
thickened. There is severe aortic valve stenosis (area <0.8cm2).
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Moderate (2+) mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] There is moderate pulmonary
artery systolic hypertension.
CT HEAD [**8-30**]: Multiple round, hyperattenuating supratentorial
lesions,
including one with hematocrit level, likely related to
anticoagulation.
Underlying hemorrhagic metastases cannot be excluded, and close
correlation with available clinical data is imperative; if
warranted, enhanced MRI could be obtained for further
characterization.
Brief Hospital Course:
The pt is a [**Age over 90 **] year-old RH man with melanoma and multiple
metastasis, an extensive PMH including afib on Coumadin,
seizures, and a pacemaker. He was transferred from an OSH after
an episode of altered
mental status at the OSH and found to have multiple ICH with no
history of trauma. He was given FFP and vitamin K at the OSH to
reverse his INR. Additionally, his labs were remarkable for a
significant anion gap of 21 and a leukocytosis with L shift. He
also has Pseudomonas UTI plus positive C.diff for which he was
started on Flagyl 2 days before admission.
His brain hemorrhages were attributed to be due to metastatic
melanoma.
He was admitted to ICU and underwent TTE which showed intact
LVEF but significant AS with area < 0.8cm2.
As for his Pseudomonas UTI, he was started on Zosyn and for his
Cdiff, he was maintained on contact precautions and treated with
PO vancomycin.
On HD #3, he was transferred to neurology floor.
head CT: No change in the appearance of multiple
intraparenchymal
hematomas.
The CTA demonstrates narrowing and irregularity of the distal
left vertebral
artery, the basilar artery, and the right middle cerebral
artery, with a
pattern that suggests atheromatous disease. There are no
vascular
abnormalities associated with the hematomas.
His family has decided to focus on comfort, no resuscitation
(DNR/DNI) and their priority now is to facilitate his return to
[**Hospital3 **] where his wife is also a patient. Son is HCP and
is in the [**Hospital3 **] area today. Grandson says that the
whole family is in agreement with comfort-focused care, do not
rehospitalize.
As per his paliative care:
1) If able to swallow, continue his usual cardiac meds
(such as b-blocker) to prevent rapid afib. However, if
swallowing is now difficult, can forgo these meds.
2) morphine 5-15 mg SL q2h prn pain or dyspnea - would use the
concentrated oral solution 20 mg/mL. This is available on POE
3) Continue for ativan prn
4) haldol 0.5-1 mg SL q2h prn agitation/delirium - He has no
signs of agitation currently. Haldol is available commercially
in a liquid form and anticipate that can be used at rehab
facility
Medications on Admission:
- Dilantin Extended 100 mg Cap Oral 1 Capsule(s) Twice Daily
- Lopressor 25mg Solution(s) Twice Daily
- Captopril 75mg Tablet(s) Three times daily
- Synthroid 0.025mg Tablet(s) Once Daily
- Lasix 40 mg Tab Oral 1 Tablet(s) Once Daily
- K-Dur 10 mEq Tab Oral 1 Tab Sust.Rel. Once Daily
- Procardia 10 mg Cap Oral 3 Capsule(s) Once Daily
- Coumadin 2.5 mg Tab Oral 1 Tablet(s) mon wed fri sun
- Restoril as needed
Discharge Medications:
1. Sodium Chloride 0.9% Flush 3 mL IV PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
2. Lorazepam 0.5-2 mg IV Q4H:PRN anxiety
3. Morphine Sulfate 1 mg IV Q4H:PRN as needed for pain
4. Lopressor 50 mg Tablet Sig: One (1) Tablet PO once a day.
5. Synthroid 25 mcg Tablet Sig: One (1) Tablet PO once a day.
6. Procardia 10 mg Capsule Sig: Three (3) Capsule PO once a day.
Discharge Disposition:
Extended Care
Facility:
Port Rehab & Skilled Nursing - [**Location (un) 5028**]
Discharge Diagnosis:
melanoma, Afib, HTN, seizure
Discharge Condition:
His family has decided to focus on comfort, no resuscitation
(DNR/DNI) and their priority now is to facilitate his return to
[**Hospital3 **]
Discharge Instructions:
Mr. [**Known lastname **] is a [**Age over 90 **] yo man with melanoma, Afib, HTN, seizure who
was admitted on [**8-30**] for altered mental status, found to have
multiple sites of intracranial hemorrhage (probably due to brain
metastasis of melanoma).
His family has decided to focus on comfort, no resuscitation
(DNR/DNI) and their priority now is to facilitate his return to
[**Hospital3 **] where his wife is also a patient. Son is HCP and
is in the [**Hospital3 **] area.
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2119-9-4**]
|
[
"V54.13",
"493.90",
"008.45",
"424.1",
"197.0",
"244.9",
"041.7",
"401.9",
"578.9",
"599.0",
"198.5",
"E934.2",
"276.2",
"V58.61",
"431",
"345.90",
"790.92",
"197.7",
"427.31",
"V45.01",
"V10.83",
"198.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
9728, 9810
|
6665, 7619
|
307, 312
|
9883, 10027
|
4853, 6642
|
2542, 2546
|
9294, 9705
|
9831, 9862
|
8857, 9271
|
10051, 10651
|
2561, 3244
|
222, 269
|
340, 1637
|
7628, 8831
|
3259, 4834
|
1659, 1997
|
2013, 2526
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,200
| 128,285
|
44912
|
Discharge summary
|
report
|
Admission Date: [**2126-9-29**] Discharge Date: [**2126-10-3**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
fever, altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 410**] is a [**Age over 90 **] yo M with h/o CAD s/p MI, systolic CHF (EF
45%), NSCLC, dementia, and recurrent LE edema c/b recurrent
cellulitis who was admitted to MICU for lethargy, urinary
incontinence and hypotension. Of note, pt had a course of
Vancomycin for LE cellulitis during a recent hospitalization
([**August 2126**]), then with suppressive Keflex at outpatient follow-up.
Pt had fevers up to 103 with SBP 80s with tachy 110-120s in ED
requiring 4L IVF in ED. Admitted to MICU overnight, received
2.5L in MICU, with improved SBP 110s and improved UOP. Patient
with cellulitis on left leg, currently on vanco/cefepime. CXR
Also with possible infiltrate on RLL. Patient NPO with
aspiration, undergoing S/S eval.
.
Upon transfer to the floor, pt appears comfortable. Doesn't
remember being in the MICU or why he is in the hospital. Has no
complaints, except mentions that he has an infection in his left
leg. Denies fevers, pain, shortness of breath, chest pain.
.
In the [**Name (NI) **], pt received levofloxacin and zosyn empirically. LENIs
were negative, but LUE US showed DVT. CTA chest negative for PE.
CXR negative for pneumonia. CT head negative. In the ED, HR went
up to 110-120s, and systolic BP dropped to 80s. At that time,
the ED physician spoke with the patient's daughter about central
line and pressors, and the daughter refused. [**Name2 (NI) 7092**] status was
confirmed DNR/DNI.
.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
Past Medical History:
Dementia
CAD s/p STEMI [**2106**], PTCA in [**2124**]
Chronic Systolic CHF, EF 45%
Chronic LE edema
Benign prostatic hypertrophy
stage IIIA NSCLC daignosed [**2126-3-22**], offered chemo and refused
Cellulitis
Social History:
The patient is currently a resident at [**Street Address(2) 58042**](not a
nursing home, but part of [**Hospital1 **] system). The patient is widowed
with 3 children, his daughter lives in the area.
ADL: The patient sometimes ambulates with a cane or a walker. He
makes his own breakfast but has help bathing and cleaning.
Tobacco: 100 pack-year
ETOH: None
Illicits: None
Family History:
Mother with MI
Physical Exam:
Vitals - T:96.8 BP: 126/69 HR: 71 RR: 20 02 sat: 96% on 2L NC.
GENERAL: NAD, pleasant
HEENT: Oropharynx clear, no plaques or exudates.
Neck: supple. No LAD.
CARDIAC: RRR. No murmurs.
LUNG: good air movement, but decr breath sounds in right base.
no crackles or wheezes.
ABDOMEN: Soft, NT, ND. No masses. No rebound or guarding.
EXT: WWP. Erythema and 2+ edema in LLE upto proximal leg, warm
to touch, no TTP, 2+ distal pulses, ROM intact
NEURO: Alert to person, place, not time
Pertinent Results:
MICROBIOLOGY:
[**9-29**] Urine culture pending
[**9-29**] Blood culture pending
.
STUDIES:
[**9-29**]: CTA
1. No acute PE.
2. Unchanged appearance of the large subcarina mass, compatible
with the known adenoCA.
3. Unchanged emphysema.
.
[**2126-9-29**] LENIs: No LE DVT
.
[**2126-9-29**] Left upper extremity US:
1. thrombus in left basilic vein.
2. small-caliber Left IJ with evidence of flow.
.
CT head: No acute intracranial process.
.
EKG: NSR @ 103bpm. Nl axis. No ST segment changes. Unchanged
from prior on [**2126-8-28**].
.
CXR: No infiltrates or pleural effusions. Small nodules seen
bilaterally. Largely unchanged from prior x-ray. early PNA
cannot be ruled out.
.
[**9-26**] EGD:
Abnormal motility of the esophagus was noted. There were
continuous vigorous contractions throughout the esophagus. The
LES was not hypertonic. The esophagus was tortuous. There were
no intrinsic or extrinsic lesions seen. Normal stomach. Normal
duodenum.
Impression: Abnormal esophageal motility
Otherwise normal EGD to third part of the duodenum
.
[**2126-10-1**] video swallow study:
FINDINGS: Oropharyngeal swallowing videofluoroscopy was
performed in
conjunction with the speech and swallow division. Multiple
consistencies of barium were administered. Barium passed freely
through the oropharynx and esophagus without evidence for
obstruction. There is evidence of esophageal dysmotility with
the lack of primary peristaltic waves. There was no gross
aspiration. Penetration was noted for free liquids. There was
free spill noted.
IMPRESSION:
1.Penetration with thin liquids was noted.
2.Esophageal dysmotility with the lack of primary peristaltic
waves.
.
[**2126-9-30**] CXR:
FINDINGS: In comparison with the earlier study of this date,
there is little change. Bibasilar opacifications appear more
suggestive of atelectasis than pneumonia. However, in view of
the clinical symptom of fever, the possibility of pneumonia can
certainly not be excluded.
On the lateral view, there is evidence of bilateral pleural
effusions.
No evidence of cardiomegaly or pulmonary vascular congestion at
this time.
Brief Hospital Course:
Pt is a [**Age over 90 **] yo M with h/o CAD, Systolic CHF (EF 45%), NSCLC,
dementia, and recurrent LE edema complicated by recurrent
cellulitis who was admitted with fever, altered mental status,
and worsening LLE cellulitis.
.
# Fever/Cellulitis: Pt remained afebrile, had no leukocytosis.
Blood cultures were negative to date at time of discharge, urine
cultures showed no growth. Pt was briefly on Cefepime for
possible pneumonia, but since CXR did not show consolidation, it
was discontinued. The fever was likely due to recurrent
cellulitis. Pt was started on IV Vancomycin for it. Dr.
[**Name (NI) 5461**], pt's outpatient ID physician was [**Name (NI) 653**] and per
his recs, pt was then switched to Keflex 500mg PO q6h and
Bactrim 1 DS PO BID for a 2week course. Pt has a follow-up
appointment with him soon at which time the current antibiotic
regmen can be reassessed. Pt's chronic venous stasis of lower
extremities were treated with compression stockings and legs
were kept elevated. Potassium was monitored as pt was newly
started on Bactrim (4.3 on day of discharge).
.
# Altered mental status: Patient's mental status was quickly
back at baseline per family. Vit B12 and TSH were wnl. EKG was
unchanged from baseline, and CEs were neg. Head CT was negative.
Head MRI from [**2126-3-22**] was negative for mets. LFTs were not
elevated. A video swallow study was performed because there was
a question of aspiration. The results indicated that the pt can
be advanced to a diet, and the pt has been tolerating it well.
.
# LUE basilic vein thrombus: Pt was started on Lovenox [**Hospital1 **] for
a small thrombus that was seen by Doppler U/S. It was then
decided that the risks outweigh the benefits of anticoagulation
at this point and thus we did not proceed with bridging to
Coumadin. This decision was discussed with pt's daughter, and
she was in agreement. The Lovenox was sunsequently discontinued
as the pt became more ambulatory with physical therapy.
.
# Hypotension: Was likely [**12-24**] dehydration due to infection. It
resolved with IVF.
.
# Chronic systolic CHF: Patient has EF of 45%. Received 4L IV
fluids in ED and 2.5L in MICU. Pt was noted to have bilat
plerual effusions on CXR. Pt showed no symptoms or findings on
physical exam to indicate volume overload.
.
# CAD s/p MI in [**2106**], PTCA in [**2124**]: EKG was unchanged from
baseline. Pt had no chest pain during stay. Pt was continued on
home ASA, Atorvastatin, Plavix. Pt's home Metoprolol was
initially held due to hypotension, but then restarted the day
prior to discharge.
.
# Dementia: Stable, pt was continued on home Donepezil.
.
# BPH: Stable, pt was initally with Foley which was subsequently
removed. Pt was continued on home Finasteride and Oxybutynin.
.
# Pt was on a cardiac healthy diet, (soft solids, thin liquids,
small pills whole with puree, large pills crushed with puree per
Speech and Swallow evaluation). Pt was on Lovenox intially, then
on SC Heparin for DVT ppx once Lovenox was discontinued. Pt was
DNR/DNI, which was confirmed with daughter (HCP). Desired no
central lines, no pressors. Per family meeting on the day of
discharge with primary team, social work, case management,
patient, patients 3 daughters and 2 son-in-laws, it was decided
that the patient will be discharged back to his apartment at a
senior living facility in [**Location (un) **], with an escalation of
nursing services he receives there. Pt will also require home
PT services for his deconditioning. It was also decided at this
meeting that the patient's overall goals of care and prevention
of frequent hospitalizations in the future will be addressed
with his PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] and Ms. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP.
Medications on Admission:
1. Metoprolol Tartrate 6.25 mg PO BID
2. Multivitamin one tab po daily
3. Atorvastatin 10 mg po daily
4. Docusate Sodium 100 mg po daily
5. Oxybutynin Chloride 5 mg po daily
6. Finasteride 5 mg po daily
7. Donepezil 10 mg po qhs
8. Aspirin 81 mg po daily
9. Clopidogrel 75 mg po daily
10. Heparin 5,000 u sc tid
11. Senna 8.6 mg po qhs PRN constipation
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.25 Tablet PO BID (2
times a day).
8. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 14 days.
Disp:*28 Tablet(s)* Refills:*0*
9. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 14 days.
Disp:*56 Capsule(s)* Refills:*0*
10. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
11. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO once a
day.
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for constipation.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] Family & [**Hospital1 1926**] Services
Discharge Diagnosis:
cellulitis
Discharge Condition:
good, ambulating with walker, satting >94% on RA
Discharge Instructions:
You were admitted to [**Hospital1 18**] because you were found to be
unresponsive and had a fever. You were found to have a low
blood pressure that was corrected with IV fluids. You were also
treated for a recurrent infection of your leg with antibiotics,
after taking advice from your ID doctor, Dr. [**Last Name (STitle) 5461**]. You
were initially on a blood thinner for a small clot found in your
arm, which was subsequently stopped because it was thought the
risks of bleeding outweigh the benefits.
Please make the following changes to your medications:
1. START Keflex 500mg every 6 hours for 14 days
2. START Bactrim DS 1 tab twice a day for 14 days
Please weigh yourself every morning and call your PCP if weight
goes up more than 3 lbs. Also, adhere to 2 gm sodium diet and
fluid restrict to 2L per day.
Please seek immediate medical attention if you have high fevers,
chest pain, shortness of breath or any other concerning
symptoms.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) 5461**] in Infectious Disease Clinic in
the Basement of the [**Last Name (un) 2577**] Building on [**10-8**] at 1:30 PM. Ph#
([**Telephone/Fax (1) 1353**]. At this appointment, Dr. [**Last Name (STitle) 5461**] will
evaluate you and recommend any changes to your current
antibiotic regimen.
You will be seen by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP at your apartment in [**Street Address(2) 96065**]. shortly to evaluate you after discharge from
hospital. She will subsequently set up an appointment with Dr.
[**Last Name (STitle) **] if necessary. At this time, your potassium level should
be checked as you have been started on a new antibiotic that can
affect its level. Also, you and your family can communicate
with Ms. [**Name13 (STitle) **] and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at this time about your
intentions regarding your health and prevention of frequent
hospitalizations in the future as discussed during the family
meeting during this hospitalization.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
Completed by:[**2126-10-3**]
|
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icd9cm
|
[
[
[]
]
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[
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] |
icd9pcs
|
[
[
[]
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2260, 2635
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,032
| 106,825
|
40357
|
Discharge summary
|
report
|
Admission Date: [**2173-12-16**] Discharge Date: [**2173-12-18**]
Date of Birth: [**2108-5-10**] Sex: M
Service: MEDICINE
Allergies:
Simvastatin
Attending:[**First Name3 (LF) 7299**]
Chief Complaint:
hypotension, melena, hematemesis
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
This is a 65 year old male with PMH of coronary artery disease
s/p MI with PCI and stent placed in [**2167**], type 2 diabetes
mellitus c/b diabetic retinopathy, hypertension,
hypercholesterolemia, and recently diagnosed unresectable 3.6cm
x 3.2cm pancreatic adenocarcinoma s/p metallic biliary stent
placement [**12-15**] and fiducial placement for Cyberknife earlier
this AM now presenting with hematemesis and melena hours s/p the
procedure. The patient tolerated his fiducial placement well
earlier today, but on the way home in his car, he developed
frank hematemesis. He says that he had about a cupful of blood
at that time. He was them transported directly to the ED.
At triage, his BP was measured to be in the 60s systolic and his
HR was in the 100s. In the ED, he received 2 units of pRBCs and
his Hct and vitals subsequently stabilized despite an anomalous
hct of 15 and witnessed episodes of hematemesis and melena.
Vitals upon transfer was SBP in the 120s, HR in the 80s, and
satting 100% RA.
GI performed an EGD upon admission to the ICU and did not see
any active bleeding or stigmata of recent bleeding despite
witnessed hematemesis and an NG lavage in the ED which was
positive for bright red blood which did not clear. He has since
had 2 episodes of melena in the setting of stable vitals and
hct.
Past Medical History:
CAD, NIDDM, HTN, hypercholesterolemia, diabetic retinopathy,
cataracts
Social History:
Works as dispatcher. Lives with wife. Smokes 1.5 ppd. No EtOH
Family History:
noncontributory
Physical Exam:
VS: As above
GEN: AOx3, NAD
HEENT: PERRLA. MMM. no LAD. no JVD. neck supple.
Cards: RRR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: No dullness to percussion, CTAB no crackles or wheezes
Abd: soft, NT, +BS. no rebound/guarding. neg HSM. neg [**Doctor Last Name 515**]
sign.
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: no rashes or bruising
Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities.
DTRs 2+ BL. sensation intact to LT, cerebellar fxn intact (FTN,
HTS). gait WNL.
Pertinent Results:
Admission Labs:
[**2173-12-15**] 11:15AM BLOOD WBC-6.9 RBC-3.45* Hgb-11.5* Hct-34.0*
MCV-99* MCH-33.4* MCHC-33.8 RDW-16.4* Plt Ct-140*
[**2173-12-16**] 09:45AM BLOOD WBC-9.2 RBC-3.63* Hgb-11.9* Hct-35.5*
MCV-98 MCH-32.8* MCHC-33.6 RDW-16.5* Plt Ct-152
[**2173-12-16**] 02:45PM BLOOD WBC-10.6 RBC-3.05* Hgb-9.9* Hct-29.6*
MCV-97 MCH-32.6* MCHC-33.6 RDW-16.6* Plt Ct-203
[**2173-12-16**] 03:00PM BLOOD Hgb-5.3*# Hct-15.7*#
[**2173-12-16**] 06:29PM BLOOD Hct-33.1*#
[**2173-12-17**] 03:51AM BLOOD WBC-8.5 RBC-3.53* Hgb-11.2*# Hct-32.0*
MCV-91 MCH-31.8 MCHC-35.0 RDW-16.6* Plt Ct-114*
[**2173-12-15**] 11:15AM BLOOD ALT-132* AST-96* AlkPhos-435* Amylase-41
TotBili-12.2* DirBili-7.9* IndBili-4.3
[**2173-12-16**] 09:45AM BLOOD ALT-122* AST-99* AlkPhos-400* Amylase-45
TotBili-12.0*
[**2173-12-16**] 02:45PM BLOOD ALT-99* AST-80* AlkPhos-319* TotBili-9.9*
[**2173-12-17**] 03:51AM BLOOD ALT-93* AST-76* LD(LDH)-182 AlkPhos-272*
TotBili-9.9*
[**2173-12-16**] 02:45PM BLOOD Albumin-2.5* Calcium-8.2* Phos-3.7 Mg-1.6
[**2173-12-17**] 03:51AM BLOOD Glucose-211* UreaN-14 Creat-0.7 Na-135
K-3.9 Cl-105 HCO3-24 AnGap-10
[**2173-12-15**] 11:15AM BLOOD PT-11.4 PTT-23.4 INR(PT)-0.9
[**2173-12-17**] 03:51AM BLOOD PT-14.0* PTT-24.6 INR(PT)-1.2*
.
Imaging:
[**12-15**] ERCP: IMPRESSION: Stricture of mid common bile duct with
replacement of a plastic stent with metal stent. Gallstones.
Filling defects in cystic and common bile duct, likely air
bubbles, though stones cannot be excluded.
[**12-16**] CTA Ab-Pelvis: IMPRESSION:
1. Stable pancreatic mass as described.
2. Increase in size and number of liver metastases consistent
with rapid
disease progression from CT 1 month ago.There is also new
ascites.
3. No evidence of retroperitoneal hematoma.
[**12-18**] CT Chest: 1. No evidence of metastatic disease in the
chest.
2. Linear atelectasis in the right lower lobe which is similar
to the prior study.
3. Mild irregularity of the pleural surface bilaterally which is
new as
compared to the prior studies. Attention on followup is
recommended.
4. Suspicion for focal liver lesion in segment VI of the liver
measuring 1.2 cm. Further evaluation is recommended by CT of the
abdomen or MRI.
5. Pneumobilia with stent in place.
6. Diffuse mild enlargement of the left adrenal gland, without
evidence of
focal lesion.
[**12-15**] EGD
A plastic stent previously placed in the biliary duct was found
in the major papilla.
A small sphincterotomy was successfully performed in the 12
o'clock position using a needle-knife over the existing plastic
biliary stent.
The plastic stent was then removed with a snare.
Cannulation of the biliary duct was performed with a
sphincterotome using a free-hand technique
A single irregular stricture of malignant appearance that was 2
cm long was again seen at the mid-CBD.
A 60mm by 10mm [**Company 2267**] Wallfex fully covered metal
biliary stent was placed successfully with excellent drainage of
bile and contrast
[**12-16**] EGD
Erythema in the stomach body c/w NG trauma. No fresh or old
blood was noted.
Stent in the second part of the duodenum. No fresh or old blood
was noted.
Otherwise normal EGD to second part of the duodenum
[**12-16**] EUS
EUS was performed using a linear echoendoscope at 7.5 MHz
frequency
An approximately 2.5cm ill-defined mass was again noted in the
head of the pancreas.
Four fiducials were placed into the pancreas mass
[**2173-12-18**] 01:30PM BLOOD WBC-8.0 RBC-3.48* Hgb-11.3* Hct-32.2*
MCV-93 MCH-32.6* MCHC-35.1* RDW-16.1* Plt Ct-130*
[**2173-12-16**] 02:45PM BLOOD Neuts-83.1* Lymphs-10.6* Monos-5.4
Eos-0.4 Baso-0.4
[**2173-12-18**] 01:30PM BLOOD Plt Ct-130*
[**2173-12-18**] 01:51PM BLOOD Type-ART pO2-89 pCO2-38 pH-7.45
calTCO2-27 Base XS-2
[**2173-12-18**] 01:51PM BLOOD Hgb-11.2* calcHCT-34
Brief Hospital Course:
65 year old male with PMH of coronary artery disease s/p MI with
PCI and stent placed in [**2167**], type 2 diabetes mellitus c/b
diabetic retinopathy, hypertension, hypercholesterolemia, and
recently diagnosed unresectable 3.6cm x 3.2cm pancreatic
adenocarcinoma s/p metallic biliary stent placement [**12-15**] and
fiducial placement for Cyberknife earlier this AM now presenting
with hematemesis and melena hours s/p the procedure.
.
# Upper GI bleed: EGD performed in the ICU showed no evidence of
ongoing bleeding or stigmata of chronic bleed. It was felt that
the bleed was likely secondary to the EUS with fiduciary
placement. The patient was transfued 4 units of pRBCs and his
Hct stabilized. All anticoagulants were held and patient
remained hemodynamically stable. He was transferred to the floor
and monitored after restarting Aspirin 81mg without any evidence
of recurrent bleeding. Pt was restarted on all his home
anti-hypertensives but plavix was not restarted given that this
stents were placed >5 yrs prior to this presentation with life
threatening bleed. Pt was encouraged to discuss this further
with his PCP/cardiologist after discharge.
.
# Fiducial placement: Continued on augmentin per GI and was
discharged on this medication for a total course of 5 days.
.
# Pancreatic adenocarcinoma. The patient has unresectable
adenocarcinoma and plans to undergo Cyberknife with fiducials
placed on [**2173-12-16**]. Per the patient's request and in conjunction
with his oncologist, he underwent CT-Chest the day of discharge.
Dr. [**Last Name (STitle) 1852**] has agreed to follow the results of this imaging
with the patient at his follow up appopintment schedule for
[**2173-12-20**].
.
# CAD / DM2: As discussed above, anti-hypertensives were held in
the acute setting and restarted prior to discharge. No changes
were made to the patient's DM regimen. Aspirin was restarted
though we continued to hold plavix which should be discussed
with his PCP/cardiologist.
Medications on Admission:
-AMLODIPINE-BENAZEPRIL 10mg-20 mg Capsule by mouth once a day
-CLOPIDOGREL 75 mg by mouth once a day
-FUROSEMIDE 20mg QD
-GLYBURIDE-METFORMIN 5 mg-500mg Tablet by mouth twice a day
-METOPROLOL TARTRATE 100mg by mouth twice a day
-OMEPRAZOLE 20 mg by mouth
-PIOGLITAZONE 30 mg by mouth once a day
-PROCHLORPERAZINE MALEATE 10 mg by mouth Q6 hour as needed for
nausea/vomiting
-ASPIRIN 81 mg by mouth once a day
-MULTIVITAMIN Daily
Discharge Medications:
1. amlodipine-benazepril 10-20 mg Capsule Sig: One (1) Capsule
PO once a day.
2. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. glyburide-metformin 5-500 mg Tablet Sig: One (1) Tablet PO
twice a day.
4. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
5. omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
6. pioglitazone 30 mg Tablet Sig: One (1) Tablet PO once a day.
7. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
every six (6) hours as needed for nausea.
8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. multivitamin Capsule Sig: One (1) Capsule PO once a day.
10. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
11. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*2*
12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
-Endoscopy related bleed
-Pancreatic Cancer
Secondary Diagnoses:
-Coronary artery disease
-Diabetes type 2
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It has been a privilege to take care of you in the hospital.
You were hospitalized because you were vomiting blood after your
endoscopic ultrasound procedure. You were transfused blood
because of your bleeding and monitored in the ICU. Your blood
levels stabilized after these transfusions. In the ICU, the
gastrointestinal doctors saw [**Name5 (PTitle) **] and performed an endoscopic
grastroduodenscopy to look for active bleeding in your stomach -
they found no active bleeding and no signs of old bleeding,
which led them to believe that your blood loss was due to the
endoscopic ultrasound procedure you had happened several hours
before the bleeding started. You will need to continue your
antibiotics as prescribed by the gastrointestinal doctors.
.
Your cancer doctors have asked that you undergo an outpatient
CT-Scan after you are discharged. Please attend the appointment
scheduled below.
.
We temporarily held some of your blood thinners and
anti-hypertensive medications when you were losing blood, but we
are restarting MOST - but not ALL - upon discharge. Please take
all of your other medications as previously prescribed.
.
# STOP Plavix - It is very important that you follow-up with
your PCP regarding whether to restart this medication for your
heart
# START Augmentin for post-endoscopy antibiotic treatment
# START Senna for constipation
# START Colace for constipation
Followup Instructions:
Department: RADIOLOGY
When: MONDAY [**2173-12-20**] at 7:45 AM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: [**Hospital6 29**] [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: MONDAY [**2173-12-20**] 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: MONDAY [**2173-12-27**] at 9:00 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
|
[
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"578.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.13"
] |
icd9pcs
|
[
[
[]
]
] |
9804, 9810
|
6180, 8168
|
307, 312
|
9981, 9981
|
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|
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|
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|
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|
1769, 1833
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,209
| 152,675
|
42441
|
Discharge summary
|
report
|
Admission Date: [**2177-12-31**] Discharge Date: [**2178-1-21**]
Date of Birth: [**2099-6-23**] Sex: M
Service: MEDICINE
Allergies:
Cephalosporins / Ace Inhibitors
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Respiratory failure, seizure
Major Surgical or Invasive Procedure:
Intubation, central venous access, arterial line placement,
surgical tracheostomy, down-sizing of tracheostomy collar,
placement of NG feeding tube
History of Present Illness:
78 y/o man with HTN, HLD, CKD,DM, critical carotid disease b/l
s/p L CEA on [**12-23**] who is transferred from OSH for status
epilepticus. To summarize all
transfer documents, his wife reported that she had been out
hanging laundry (for 10-15 minutes) and came in to find her
husband at 10:39 AM experiencing seizure-like activity with
snoring respirations. EMS was called at 10:41 AM. During
transport from scene to [**Hospital3 22439**], he was reported to
be
having non-stop seizure activity. There was some bleeding from
his mouth noted during the seizure activity and suction was
unable to be performed due to locking of jaw. He arrived at
[**Hospital3 22439**] at 10:51 AM with continued seizure activity.
He was given Ativan 4 mg IV, which by report stabilized him; he
was then intubated for airway protection and was subsequently
loaded with Dilantin. Seizure was reported as lasting between
20-30 minutes. Per [**Hospital3 22439**] notes, the seizure
activity
was "predominantly RUE with flaccid LUE." At OSH, he was sent
for
NCHCT and CTA head and neck, which showed no hemorrhage, old
left
occipital infarct and patent left carotid artery but extremely
stenotic right carotid. He we sent to [**Hospital3 **] Hospital for
further evaluation and was subsequently transferred to [**Hospital1 18**] for
further evaluation and treatment.
He is not known to have a history of seizures. According to
notes sent with his transfer paperwork, he had an episode of
confusion at the end of [**2176**] and NCHCT at that time was
suggestive of left sided infarct. Carotid dopplers showed
critical right ICA stenosis and a subcritical left ICA stenosis.
He underwent left CEA on [**2177-12-23**], with plan to perform right CEA
in 8 weeks from that time.
Past Medical History:
-bilateral carotid artery stenosis (right noted as being >90%
stenotic)
-s/p L CEA [**2177-12-23**]
-CAD
-DM (30 years, with retinopathy, nephropathy and neuropathy)
-HTN
-HLD
-CKD
-BPH
-PVD s/p LLE stent
-s/p hip replacemebt b/l
Social History:
He is retired from the retail business. No smoking or
ETOH use.
Family History:
Positive for diabetes
Physical Exam:
On admission:
Vitals: T: 97.8 (@ OSH) P: 80 R: 20 BP: 172/53
vent CPAP
Examined immediately upon arrival, with Propofol having been
running during transport
General: intubated, sedated
HEENT: ET tube in place
Neck: Supple
Pulmonary: lcta b/l anteriorly
Cardiac: RRR, S1S2
Abdomen: soft, nondistended. hypoactive BS
Extremities: warm, well perfused
Neurologic: No eye opening. Does not follow any commands. Pupils
in midline; they are 1 mm and minimally reactive to light. No
Doll's eyes appreciated. Brisk corneals b/l. Intact cough and
gag. He is moving his LUE spontaneously. No other spontaneous
movements noted. He withdraws left lower extremitiy antigravity
to noxious stimuli but did not do so right lower extremity.
Grimmaces to noxious stimulus throughout. Reflexes 1+ and
symmetric at biceps, brachioradialis and patlla. Unable to
elicit
ankle jerks. Toes are tonically in extensor position.
On day of discharge:
Tmax: 36.6 ??????C (97.9 ??????F)
Tcurrent: 36.6 ??????C (97.9 ??????F)
HR: 54 (43 - 55) bpm
BP: 94/53(62) {83/43(52) - 159/99(115)} mmHg
RR: 11 (11 - 16) insp/min
SpO2: 100%
General Appearance: Thin
Eyes / Conjunctiva: PERRL, Pupils dilated, Conjunctiva pale
Head, Ears, Nose, Throat: NCAT
Cardiovascular: Bradycardic, no m/r/g
Respiratory / Chest: CTAB
Abdominal: Soft, Non-tender, non distended, no r/r/g
Extremities: No edema
Neurologic: A/Ox3, non focal
Pertinent Results:
Admission Labs:
[**2177-12-31**] 07:14PM BLOOD WBC-10.7 RBC-3.47* Hgb-11.2* Hct-34.1*
MCV-98 MCH-32.3* MCHC-32.9 RDW-13.3 Plt Ct-192
[**2177-12-31**] 07:14PM BLOOD Neuts-89.9* Lymphs-6.4* Monos-3.6 Eos-0.1
Baso-0.1
[**2177-12-31**] 07:14PM BLOOD PT-12.9* PTT-26.9 INR(PT)-1.2*
[**2177-12-31**] 07:14PM BLOOD Glucose-420* UreaN-32* Creat-1.8* Na-141
K-5.2* Cl-106 HCO3-25 AnGap-15
[**2178-1-1**] 02:16AM BLOOD ALT-16 AST-21 CK(CPK)-280 AlkPhos-55
TotBili-0.3
[**2177-12-31**] 07:14PM BLOOD cTropnT-0.09*
[**2178-1-1**] 02:16AM BLOOD CK-MB-6 cTropnT-0.09*
[**2178-1-1**] 09:45AM BLOOD CK-MB-9 cTropnT-0.09*
[**2178-1-1**] 02:16AM BLOOD Albumin-2.5* Calcium-7.3* Phos-3.8 Mg-1.6
Cholest-107
[**2178-1-1**] 02:16AM BLOOD %HbA1c-6.7* eAG-146*
[**2178-1-1**] 02:16AM BLOOD Triglyc-79 HDL-47 CHOL/HD-2.3 LDLcalc-44
[**2178-1-1**] 09:06AM BLOOD Phenyto-11.7 Phenyfr-2.1* %Phenyf-18*
[**2177-12-31**] 07:14PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2177-12-31**] 07:17PM BLOOD Type-ART PEEP-5 pO2-233* pCO2-49* pH-7.35
calTCO2-28 Base XS-0 Intubat-INTUBATED
[**2178-1-1**] 10:27PM BLOOD freeCa-1.02*
[**2177-12-31**] 07:00PM URINE Blood-SM Nitrite-NEG Protein-100
Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2177-12-31**] 07:00PM URINE RBC-4* WBC-6* Bacteri-NONE Yeast-NONE
Epi-0
[**2177-12-31**] 07:00PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.030
[**2177-12-31**] 08:48PM URINE bnzodzp-POS barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
[**2177-12-31**] 08:52PM CEREBROSPINAL FLUID (CSF) TotProt-53*
Glucose-194
[**2177-12-31**] 08:52PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-1* Polys-8
Lymphs-64 Monos-28
MICROBIOLOGY:
[**2177-12-31**] CSF;SPINAL FLUID GRAM STAIN-negative; CULTURE
negative
[**2177-12-31**] BLOOD CULTURE negative
[**2177-12-31**] BLOOD CULTURE negative
[**2177-12-31**] URINE CULTURE negative
SPUTUM CX [**2178-1-8**] NEGATIVE
SPUTUM [**2178-1-11**] NEGATIVE
BCX [**2178-1-11**]
BCX [**2178-1-11**]
BCX [**2178-1-12**]
UCX [**2178-1-11**]
.
Reports:
EEG [**2177-12-31**]: This is an abnormal ICU continuous video EEG due
to the
severely attenuated low voltage background of [**1-26**] Hz throughout
the
recording indicative of a severe encephalopathy. There are no
epileptiform discharges or electrographic seizures.
EEG [**2178-1-1**]: This is an abnormal ICU continuous video EEG due
to the
severely attenuated low voltage background of [**1-25**] Hz briefly
reaching up
to [**3-29**] Hz during periods of stimulation, for example during
physical
examination. These findings are indicative of a moderate
encephalopathy. There is a single pushbutton activation for left
hand
tremor which does not have electrographic evidence of seizure
activity.
Compared to the previous day's recording, there is minimal
improvement
in background frequency.
EEG [**2178-1-2**]: This is an abnormal ICU continuous video EEG due
to the
presence of severely attenuated low voltage background of [**1-25**] Hz
during
the initial phase of the recording. After a period of
disconnection,
the background appears higher voltage at 4 Hz but still
consistent with
a moderate to severe encephalopathy. There are intermittent
bilateral
frontal broad- based sharp wave discharges with a right frontal
emphasis
which occurred, at times, in a periodic fashion at 1 Hz lasting
20-30
seconds without evolution to suggest ongoing seizure activity.
There is
no clinical change during this. These findings are indicative of
bifrontal cortical irritability, particularly in the right
frontal
region with an increased propensity to seizures. There are no
clear
electrographic seizures.
EEG [**2178-1-3**]: This is an abnormal ICU continuous video EEG due
to the
severely attenuated low voltage background of 4 Hz with
reactivity
consistent with a moderate to severe encephalopathy. There are
infrequent periodic broad-based sharp waves in the bilateral
frontal
region lasting 5-10 seconds at a time without evolution to
suggest
ongoing seizure activity. There is no clinical change during
this.
These findings are indicative of bifrontal cortical irritability
particularly in the right frontal region with an increased
propensity
to seizures. Additionally, new 2 Hz delta frequency slowing is
seen in
the left frontal central region starting around 4:30 a.m., but
it does
not have a good field, and likely represents artifact. There are
no
clear electrographic seizures.
EEG [**2178-1-4**], EEG [**2178-1-5**]: This is an abnormal continuous ICU
monitoring study because of diffuse attenuation and mild slowing
of background consistent with a mild to moderate diffuse
encephalopathy of non-specific etiology. No epileptiform
discharges or electrographic seizures are present in the
recording.
NCHCT [**2178-1-1**]: 1. No acute intracranial process. Focal
hypodensity within the right frontal lobe may reflect a prior
ischemic stroke. If clinically indicated, could consider further
evaluation with an MRI.
MRI Head: An area of T2/FLAIR hyperintensity in the left
occipital lobe. It shows hyperintense signal on DWI images,
however there is no corresponding low signal on ADC images. This
likely represents sequela of old infarct. Areas of
encephalomalacia in bilateral frontal lobes and right parietal
lobes which are likely sequelae of old infarcts. Mild
generalized cerebral volume loss with moderate atrophy of
bilateral
medial temporal lobes. Moderate changes of chronic small vessel
ichemic disease.
Carotid U/S: There is 70 to 79% stenosis in the right internal
carotid artery. There is no significant stenosis in the left
internal carotid artery.
CXR [**2177-12-31**]: ET and NG tubes appear to be positioned
appropriately though the tip of the NG tube is not included in
the field of view. No gross
consolidation, effusion, pneumothorax.
CXR [**2178-1-3**]: Lung volumes are lower, reflected in increasing
moderate-to-severe bibasilar atelectasis, and there has also
been an increase in moderate bilateral pleural effusion,
moderate cardiomegaly and vascular engorgement of the lungs and
mediastinum, not yet presenting as pulmonary edema. Right
internal jugular line ends at the thoracic inlet. No
pneumothorax.
.
TTE [**1-6**] The left atrium is elongated. The right atrium is
moderately dilated. 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 70%). Right ventricular chamber size
and free wall motion are normal. The number of aortic valve
leaflets cannot be determined. The aortic valve leaflets are
moderately thickened. The aortic valve is not well seen. There
is mild aortic valve stenosis. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined. The
pulmonary artery is not well visualized. There is no pericardial
effusion.
.
CT Neck [**1-12**] 1. Limited examination demonstrating retained
secretions and probable narrowing of the hypopharynx and
extrathoracic trachea, likely due to retropharyngeal edema. No
focal masses or circumferential strictures
identified.
2. Near-complete opacification of the mastoid air cells and
middle ear
cavities. Please evaluate for otitis media and mastoiditis.
CT Neck [**1-18**]: 1. No evidence of retropharyngeal mass or abscess.
2. Tracheostomy tube is in place.
3. A 1.7 cm nodule in the left parotid gland, is not completely
characterized
in this study.
4. Mild subglottic narrowing, without evidence of focal mass in
this limited
non-contrast CT
.
CT head [**1-18**]: No acute intracranial pathology. Left occipital
lobe
hypodensity, likely corresponds to the old infarct seen in the
prior study. If there is concern for an acute infarct, an MRI
with DWI can be obtained
.
[**1-18**] DVT U/S Upper ext: No right upper extremity deep vein
thrombosis
.
Post Pyloric Tube Placement ([**2178-1-21**]): At the time of discharge,
final read of imaging conforming post-plyoric tube placement was
pending. However, the tube was advanced under fluoroscopy with
Interventional Radiology and palcement was confirmed by the
Interventional Radiology team.
Brief Hospital Course:
Mr. [**Known lastname **] is a 78 y/o man with PMH significant for HTN, HLD, CKD,
DM, critical carotid disease b/l s/p L CEA on [**12-23**] who was
transferred from OSH for status epilepticus on [**2177-12-31**].
.
#Seizures: Patient was found by his wife in status epilepticus
and underwent traumatic intubation in the field for airway
protection. Seizure was reported as lasting between 20-30
minutes and appeared predominantly in the RUE with flaccid LUE.
At OSH, he was sent for NCHCT and CTA head and neck, which
showed no hemorrhage, old left occipital infarct and patent left
carotid artery without indwelling thrombus but extremely
stenotic right carotid. He was transferred to [**Hospital1 18**] for further
evaluation and treatment. He is not known to have a history of
seizures. According to notes sent with his transfer paperwork,
he had an episode of confusion at the end of [**2176**] and NCHCT at
that time was suggestive of left sided infarct. Carotid dopplers
at our institution showed critical right ICA stenosis and a
subcritical left ICA stenosis. He underwent left CEA on [**2177-12-23**],
with plan to perform right CEA in 8 weeks from that time. He was
intially admitted to the NEURO ICU and had an EEG which showed
diffuse encephalopathy but no seizure activity. Overnight on the
day of admission he had episodes of bradycardia and hypotension
which were unexplained. EP consult felt this could have been
seizure related. His encephalopathy was thought to possibly be
dilantin related as he was noted to have poor creatinine
clearance, and may have been becoming toxic on his dosing. He
was switched to keppra, but remained encephalopathic. He was
able to have an MRI once it was confirmed his leg stents were
MRI compatible, and that showed no acute strokes or lesions.
After taken off the vent, the patient became increasingly
confused, was restarted on the vent, and a head CT was obtained
which showed no evidence of new acute process. Pt's mental
status improved on Keppra, and he is maintained on Keppra 500mg
[**Hospital1 **], with no acute change in mental status prior to D/C.
#Upper Airway Obstruction, edema: As he had no seizure activity
documented on his EEG, he was initially extubated on [**1-2**].
However, he was found to have large blood clots in his throat,
and ENT felt pt had a paralyzed L vocal cord likely from
traumatic intubation. He was reintubated for airway protection
and started on a course of IV dexamethasone to help improve the
edema. After three days of having a cuff leak, patient's
swelling was felt to have improved to the point where he could
be extubated on [**1-12**]. Within hours of extubation, despite
adequate saturations and good ABGs, he became notably
stridorous. ENT was called to examine the patient again and felt
he continued to have persistent airway edema that severely
compromised his airway and necessitated re-intubation. Reason
for persistent airway edema was unclear. CT Neck showed
retropharyngeal edema but no focal signs of infection. MRI could
not be obtained due to patient's kidney function. Due to
repeated failures with extubation, patient underwent
tracheostomy on [**1-16**]. Patient was weaned off the mechanical
ventilator on the same day and the trach cuff was changed on POD
#5. He experienced an episode of respiratory distress and
hypoxemia, attributed to mucus plugging, resolved with
bronchoscopy, and resuming mechanical ventilation. Successfully
liberated from mechanical ventilation within 24 hrs and remained
off mechanical ventilation, breathing comfortably on trach
collar. ENT downsized the tracheotomy tube on the day of
discharge.
.
# Acute Kidney Injury: Patient has chronic renal insufficiency
with baseline creatinine of 1.8. During his hospitalization, his
creatinine peaked at 3.3 though was otherwise stably elevated in
the 2-2.3 range likely due to ATN from hypotension given the
granular casts seen on sediment. A subsequent rise in creatinine
occurred in the setting of overdiuresis while trying to optimize
patient for extubation. Throughout, patient's electrolytes and
urine output remained robust, and he is currently in the 2.0-2.4
range at time of discharge.
.
# Labile HTN: Initially required a nicardipine gtt but was
eventually transitioned to oral labetalol, in addition to
amlodipine.
.
# Hyperglycemia: While on the dexamethasone burst, patient
initially required an insulin drip to cover his elevated blood
sugars. He was transitioned to a SC insulin regimen once off
steroids.
.
# Fevers and leukocytosis: Felt to be related to VAP or
non-occlusive upper extremity DVT. Retropharyngeal process
considered but not supported by imaging. Patient completed eight
day course of vanc and zosyn on [**1-16**], and has since been
afebrile, off of antibiotics.
.
Transitional care:
# CODE: FULL
# Contacts: daughter [**Name (NI) 501**]
# Medical management:
- f/u with ENT
Medications on Admission:
-Plavix 75 mg daily
-ASA 81 mg daily
-Hytrin 4 mg qhs
-Simvastatin 40 mg daily
-Amlodipine 10 mg daily
-NPH Insulin 50 units qAM and 30 units qPM
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) inj
Injection TID (3 times a day).
2. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily).
3. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. terazosin 1 mg Capsule Sig: Four (4) Capsule PO HS (at
bedtime).
5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. docusate sodium 50 mg/5 mL Liquid Sig: [**11-24**] tsp PO BID (2
times a day).
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
9. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for wheezing.
11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for wheezing.
12. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever/pain.
13. fluticasone 110 mcg/actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
14. quetiapine 25 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
15. labetalol 200 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
16. levetiracetam 500 mg/5 mL Solution Sig: Five (5) ml
Intravenous [**Hospital1 **] (2 times a day).
17. pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours).
18. lorazepam 2 mg/mL Syringe Sig: One (1) mg Injection Q6H
(every 6 hours) as needed for agitation.
19. hydromorphone (PF) 1 mg/mL Syringe Sig: 0.25-0.5 mg
Injection Q2H (every 2 hours) as needed for pain.
20. NPH insulin human recomb 100 unit/mL Suspension Sig: Forty
Five (45) units Subcutaneous twice a day: Please take in morning
and PM. .
21. insulin regular hum U-500 conc 500 unit/mL Solution Sig:
1-12 units Injection qachs as needed for sliding scale: Please
give 2 units of regular humalog for blood sugars above 100, and
an additional 2 units for every additional 50mg/dl of blood
sugar.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Hospital1 8**]
Discharge Diagnosis:
Altered mental status, status epillepticus, airway swelling,
subglottal stenosis, pneumonia,
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 in the intensive care unit
at [**Hospital1 69**].You were admitted to
while having a very bad seizure. You had been intubated prior to
coming to us, meaning that a tube was needed to breath for you.
You developed a severe [**Last Name 91894**] problem that required mechanical
ventilation in the Intensive Care Unit. Our surgeons needed to
place a tube into your trachea to help you breath. You developed
pneumonia, which required antibiotics to treat. We gave you
anti-seizure medications, which you will continue to take. These
medications have prevented further seizures. We also needed to
control your blood pressure with new medications. It is
important that you continue to take these medications at your
facility, and monitor your blood pressure carefully.
The following is your new medication regimen:
heparin (porcine) 5,000 unit/mL Solution Sig: One (1) inj
Injection TID (3 times a day).
bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily).
amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
terazosin 1 mg Capsule Sig: Four (4) Capsule PO HS (at
bedtime).
clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
docusate sodium 50 mg/5 mL Liquid Sig: [**11-24**] tsp PO BID (2
times a day).
senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for wheezing.
albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours)
as needed for wheezing.
acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every
6 hours) as needed for fever/pain.
fluticasone 110 mcg/actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
quetiapine 25 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
labetalol 200 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
levetiracetam 500 mg/5 mL Solution Sig: Five (5) ml
Intravenous [**Hospital1 **] (2 times a day).
pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours).
lorazepam 2 mg/mL Syringe Sig: One (1) mg Injection Q6H
(every 6 hours) as needed for agitation.
hydromorphone (PF) 1 mg/mL Syringe Sig: 0.25-0.5 mg
Injection Q2H (every 2 hours) as needed for pain.
NPH insulin human recomb 100 unit/mL Suspension Sig: Forty
Five (45) units Subcutaneous twice a day: Please take in morning
and PM. .
insulin regular hum U-500 conc 500 unit/mL Solution Sig:
1-12 units Injection qachs as needed for sliding scale: Please
give 2 units of regular humalog for blood sugars above 100, and
an additional 2 units for every additional 50mg/dl of blood
sugar.
Followup Instructions:
Please see Ear nose and throat in 3 weeks with Dr.
[**Last Name (STitle) 1837**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Please call [**Telephone/Fax (1) 41**] to schedule
an appointment with Ear Nose and Throat.
Please follow up with our resident Neurology by calling:
[**Telephone/Fax (1) 3294**]. Please see Dr. [**Last Name (STitle) **] in one to three months.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
Completed by:[**2178-1-27**]
|
[
"357.2",
"414.01",
"362.01",
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"V58.67",
"584.5",
"518.81",
"250.40",
"250.50",
"433.10",
"507.0",
"348.30",
"345.70",
"443.9",
"519.19",
"E879.8",
"276.8",
"272.4",
"478.31",
"585.3",
"403.90",
"250.60",
"997.31",
"478.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.05",
"31.1",
"29.11",
"03.31",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
19546, 19617
|
12385, 17288
|
322, 472
|
19754, 19754
|
4076, 4076
|
22869, 23449
|
2608, 2633
|
17485, 19523
|
19638, 19733
|
17314, 17462
|
19932, 22846
|
2648, 2648
|
254, 284
|
500, 2256
|
4092, 12362
|
2662, 4057
|
19769, 19908
|
2278, 2510
|
2526, 2592
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,762
| 145,354
|
33396+57848
|
Discharge summary
|
report+addendum
|
Admission Date: [**2129-5-18**] Discharge Date: [**2129-6-30**]
Date of Birth: [**2051-12-20**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Sulfa (Sulfonamides) / Heparin Agents
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Fatigue/DOE/Chest pain
Major Surgical or Invasive Procedure:
[**2129-5-19**] - 1) CABGx6 (Left internal mammary->left anterior
descending artery, Saphenous vein graft (SVG)->Diagonal artery,
SVG->Obtuse marginal first and second artery, SVG->Posterior
descending and Posterior lateral branch. 2) Aortic Valve
Replacement (19mm CE Magna Tissue). 3) Ascending Aorta
Replacement (24mm Gelweave graft).
[**2129-5-19**] Re-exploration for bleeding
[**2129-5-24**] - Embolectomy of Upper Right Extremity
[**2129-6-2**] expl. lap/cholecystectomy/G-J tube placement
[**2129-6-7**] tracheostomy
History of Present Illness:
Ms. [**Name13 (STitle) 22917**] is a very nice 77-year-old female with a known
history of aortic stenosis, which has been followed by serial
electrocardiograms who was found to have severe left main and
three-vessel disease during a cardiac workup prior to elective
breast surgery. This workup also revealed a very heavily
calcified ascending aorta. Given these findings, she was
deferred surgery in [**State 108**] due to her elevated risk. Currently,
she complains of significant fatigue, dyspnea on exertion, and
occasional chest pain. She now presents to me for surgical
evaluation for her aortic valve and her coronary artery disease.
A cardiac catheterization from [**2129-4-28**] showed a right
dominant system with 80% left main coronary artery stenosis, 90%
stenosed left anterior descending artery, 80% stenosed diagonal
artery, 90% stenosed left circumflex artery,
90% right coronary artery stenosis, and an 80% posterior
descending artery stenosis. The ejection fraction is 70%. She
has no mitral regurgitation and her aortic valve area is
calculated at 0.7 cm2. An echocardiogram from [**2128-8-1**] showed
severe aortic stenosis with an aortic valve area mean of 61
mmHg,
mild aortic insufficiency, trace mitral regurgitation, mild
tricuspid regurgitation, and ejection fraction of 75%.
Past Medical History:
Past medical history is notable for aortic stenosis, coronary
artery disease, hypertension, Hyperlipidemia, and a breast mass
which was recently biopsied and found to be negative for
malignancy, basal cell skin cancer on her back, and breast
cancer
status post her right mastectomy in [**2090**]. Other than the biopsy
and mastectomy, there is no significant surgical history.
Social History:
Currently, she is retired. She is a nonsmoker. She
occasionally drinks alcohol. She has full dentures. She lives
with her friend in [**Name (NI) 77501**], [**Name (NI) 108**].
Family History:
Her family history is remarkable for a brother who had an MI at
the age 62 with her mother and father both also having coronary
artery disease.
Physical Exam:
Admission
HR 84 and regular. RR 14. BP rt arm is deferred d/t mastectomy.
On left 158/62.
Ht 5'4" Wt 144 lbs.
Gen well-developed and well-nourished elderly female who is
somewhat
anxious and tearful. Skin is warm and dry without clubbing or
cyanosis. She has a well-healed right mastectomy scar. HEENT
examination shows her to be normocephalic and atraumatic.
Pupils
are equal, round, and reactive to light. Sclerae are anicteric
and oropharynx is benign. Her neck is supple with full range of
motion and no JVD. Her lungs show mild decrease in breath
sounds
at the left base but otherwise clear. Her heart shows a regular
rate and rhythm without a IV/VI very loud and harsh systolic
ejection murmur. Her abdomen is soft, nondistended, and
nontender with normoactive bowel sounds. Extremities are warm
and well perfused with 1+ bilateral lower extremity edema. She
has positive varicosities noted on her left thigh and left lower
extremity as well as her right lower extremity. Neurologic
exam,
she is alert and oriented x3 without any focal deficits. Pulses
in her femoral are 2+ bilaterally, DP is 1+ bilaterally, PT is
1+
bilaterally,, and radial is 2+ bilaterally. There is a bruit
versus transmitted murmur heard over both her carotid arteries.
Discharge
VS T 99 HR 88 SR BP 155/58 RR 28 O2sat 100% 50% trach
collar
Gen Trached, NAD
Neuro Alert-responsive-interactive, follows commands
Pulm Diminished in bases L>R
CV RRR, no murmur. Sternum stable, incision CDI
Abdm soft, NT. G-j tube site CDI. Midline incision w/VAC, clean
margins
Ext Left foot w/necrotic areas of distal toes. Rt BKA, flap
w/staples-CDI
TLD Trach, G-J tube, foley, Left arm PICC
Pertinent Results:
[**2129-5-18**] 07:02PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2129-5-18**] 07:49PM PT-12.1 PTT-29.1 INR(PT)-1.0
[**2129-5-18**] 07:49PM PLT COUNT-259
[**2129-5-18**] 07:49PM WBC-6.1 RBC-3.55* HGB-10.6* HCT-31.7* MCV-89
MCH-29.9 MCHC-33.5 RDW-14.6
[**2129-5-18**] 07:49PM ALT(SGPT)-14 AST(SGOT)-17 LD(LDH)-173 ALK
PHOS-88 AMYLASE-67 TOT BILI-0.2
[**2129-5-18**] 07:49PM GLUCOSE-138* UREA N-22* CREAT-1.3* SODIUM-145
POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-30 ANION GAP-14
[**2129-6-30**] 02:39AM BLOOD WBC-12.6* RBC-3.67* Hgb-10.6* Hct-32.7*
MCV-89 MCH-28.9 MCHC-32.4 RDW-20.3* Plt Ct-206
[**2129-6-30**] 02:39AM BLOOD Plt Ct-206
[**2129-6-30**] 02:39AM BLOOD PT-25.8* PTT-33.4 INR(PT)-2.6*
[**2129-6-30**] 02:39AM BLOOD Glucose-135* UreaN-66* Creat-1.2* Na-144
K-4.3 Cl-114* HCO3-24 AnGap-10
[**2129-6-14**] 02:41AM BLOOD ALT-29 AST-29 AlkPhos-152* TotBili-0.9
[**2129-6-8**] 06:04PM BLOOD Lipase-33
[**2129-5-18**] 07:49PM BLOOD %HbA1c-6.2*
[**2129-6-29**] 11:01AM BLOOD TSH-9.0*
Chest CT
1. Marked ascending aortic calcification, with less extensive
calcifications in the descending aorta
2.Right apical fibrosis, traction bronchiectasis and volume
loss. Given calcified component and granulomas within the lungs,
sequela of prior granulomatous disease is the most likely
etiology, although prior radiation therapy may also be a
contributing factor.
3. Probable minimal subpleural basilar fibrosis. Differential
diagnosis would include NSIP or early UIP. Recommend correlation
with pulmonary functio4/16/08 .
n tests if warranted clinically. Lung findings could also be
confirmed and further characterized with prone HRCT, if
warranted clinically.
4. Coronary artery calcifications.
5. Findings suggestive of recent intervention within the left
breast. Please correlate with clinical history.
[**2129-5-18**] Vein Mapping
Duplex evaluation was performed of bilateral lower extremity
veins. The greater saphenous veins are patent from the groin to
the ankle bilaterally. On the right, vein diameters range from
0.28-0.72. On the left, vein diameters range from 0.24-0.53 cm.
[**2129-5-18**] Carotid Ultrasound
Bilateral less than 40% carotid stenosis.
[**2129-5-18**] CXR
Calcified right apical pleural thickening is better assessed on
CT from earlier today. No evidence of pneumonia or CHF.
[**2129-5-19**] ECHO
Prebypass
1. Mild spontaneous echo contrast is present in the left atrial
appendage. A left-to-right shunt across the interatrial septum
is seen at rest. A small secundum atrial septal defect is
present.
2.There is moderate symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%).
3. Right ventricular chamber size and free wall motion are
normal.
4. There are complex (>4mm) atheroma in the ascending aorta.
There are complex (>4mm) atheroma in the aortic arch. There are
complex (>4mm) atheroma in the descending thoracic aorta.
5.The aortic valve leaflets are severely thickened/deformed.
There is severe aortic valve stenosis (area <0.8cm2). Mild (1+)
aortic regurgitation is seen.
6.The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen. Dr. [**Last Name (STitle) **] was notified in
person of the results on [**2129-5-19**] at 800am.
Post Bypass
1. Patient was being AV paced and subsequently in sinus rhythm.
2. Biventricular systolic function is unchanged.
3. Bioprosthetic valve seen in the aortic postion. Leaflets move
well and the valve appears well seated. Trace to mild aortic
sufficiency present.
4. There was systolic anterior motion of the mitral valve
associated with moderate mitral regurgitation that resolved with
administration of volume and reducing the heart rate as well as
myocardial contractility.
5. Atrial septal defect is present with bidirectional flow.
6. Patient brought back to the OR for bleeding immediately after
entering the ICU.
7. Biventricular function is unchanged.
8. Small pericardial effusion. No evidence of tamponade.
9. Small clot seen in the left atrium attached to the coumadin
ridge. Dr [**Last Name (STitle) **] made aware. No action to be taken.
[**2129-5-24**] ECHO
1) A 1cm X 1cm homogenous echodensity seen attached to the tip
of the coumadin ridge with a lot of mobility.
2) There is a similar 1cm X 0.5 cm homogenous echodensity seen
on the atrial aspect of the interatrial septum with no mobility.
3) There are 2 distinct 1cm X 1cm homogenous echodensity seen in
the distal aortic arch close to the left sublclavian and mid
thoracic aorta (35cm of the incisors) which are freely mobile.
4) A ragged edge of the thoracic aorta is seen.
5) Preserved biventricular systolic functon.
6) The LV cavity is small with chordal [**Male First Name (un) **] and no resting
gradients at this point of time (HR 56/min).
7) Moderate Tricuspid regurgitation and mild mitral
regurgitation.
8) Aortic prosthesis seems entirely normal.
9) There is a right to left interatrial shunt as noted before.
Comment:
Compared to the previous TEE on [**5-19**] at 8pm, there are new clots
in the interatrial septum and possibly in the thoracic aorta.
RADIOLOGY Final Report
MRI ABDOMEN W/O CONTRAST [**2129-5-31**] 2:47 PM
MRI ABDOMEN W/O CONTRAST
Reason: assess for stenosis/[**Hospital 77502**]
[**Hospital 93**] MEDICAL CONDITION:
77 year old woman s/p asc ao replacement/avr/cabg w/HOT symptoms
REASON FOR THIS EXAMINATION:
assess for stenosis/thrombus-flow
CONTRAINDICATIONS for IV CONTRAST: acute renal failure
MRI ABDOMEN
INDICATION: Ascending aorta replacement/aortic valve
replacement/coronary artery bypass graft. Possible HIT. Assess
for stenosis or thrombus in renal arteries or veins.
TECHNIQUE: Multiplanar T1- and T2-weighted imaging was performed
through the renal vasculature. Intravenous contrast could not be
administered in view of renal impairment. Breath-hold
independent imaging was performed as suspension of respiration
with the available ventilator equipment was not possible.
Strategies to evaluate the vasculature without gadolinium
including time-of- flight imaging and FIESTA sequences were
employed.
COMPARISON: Renal ultrasound, [**2129-5-30**].
FINDINGS:
The renal veins are patent bilaterally. The renal arteries are
not adequately assessed as the study had to be performed
independent of breath holding. Some flow in the right renal
artery is demonstrated, but the renal arteries are incompletely
assessed.
There is generalized anasarca with extensive subcutaneous edema.
There is ascites. There is a large right pleural effusion. There
is a small left pleural effusion or left basal pulmonary
airspace infiltration.
There is a left renal upper pole cyst measuring 1.1 cm in
diameter. The left kidney measures 9.8 cm in diameter. The right
kidney measures 8.7 cm in diameter. Limited assessment of the
pancreas is within normal limits. No significantly sized focal
liver lesions are detected.
There is a 2.7 cm area of high signal at the inferior aspect of
the left breast, likely representing a seroma as a sequelae of
previous biopsy (documented on CareWeb notes).
IMPRESSION:
1. Limited study demonstrating patency of bilateral renal veins.
2. Renal arteries not adequately assessed.
3. Generalized subcutaneous edema, ascites, and large right
pleural effusion.
4. Small left pleural effusion and left basal pulmonary airspace
opacification.
5. Seroma at inferior aspect of left breast, likely representing
sequelae of previous biopsy.
6. Left renal cyst.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Name (STitle) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4343**]
Approved: FRI [**2129-6-3**] 1:49 PM
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2129-6-28**] 11:15 AM
CHEST (PORTABLE AP)
Reason: ? infiltrate
[**Hospital 93**] MEDICAL CONDITION:
77 year old woman with s/p avr
REASON FOR THIS EXAMINATION:
? infiltrate
HISTORY: Cardiac surgery, for comparison.
FINDINGS: In comparison with the study of [**6-26**], there is little
change in the appearance of the cardiomediastinal silhouette.
Bibasilar atelectasis is seen. There is more haziness in the
left hemithorax, raising the possibility of some increasing
pleural fluid. The right lung remains essentially clear.
DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**]
RADIOLOGY Final Report
[**Numeric Identifier **] PICC W/O PORT [**2129-6-28**] 4:29 PM
Reason: please evaluate for picc needs antibiotics hx of
thrombosis
[**Hospital 93**] MEDICAL CONDITION:
77 year old woman with s/p asc aorta replacement
REASON FOR THIS EXAMINATION:
please evaluate for picc needs antibiotics hx of thrombosis and
rt embolectomy please call with questions - please evaluate flow
prior to insertion - call with questions thanks [**Female First Name (un) **] [**Pager number 77503**]
PICC LINE PLACEMENT
INDICATION: IV access needed for antibiotics. History of
subclavian thrombosis and HITT.
The procedure was explained to the patient. A timeout was
performed.
RADIOLOGIST: Dr. [**Last Name (STitle) 12919**] and [**Doctor Last Name 9441**] performed the procedure.
Dr. [**Last Name (STitle) 380**] the Attending Radiologist, was present and supervised
the entire procedure.
TECHNIQUE: Using sterile technique and local anesthesia, the
left basilic vein was punctured under direct ultrasound guidance
using a micropuncture set. Hard copies of ultrasound images were
obtained before and immediately after establishing intravenous
access. A peel-away sheath was then placed over a guidewire and
10 ml of Optiray was injected for a limited venogram
demostrating occlusion of the left brachiocephalic vein just
distal to the confluence of the left sublavian and left internal
jugular vein with collateral vessel formation. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] line
measuring 56 cm in length was then placed through the peel- away
sheath with its tip positioned in the left brachiocephalic vein
near the clavicular head proximal to the occlusion with
fluoroscopic guidance. Position of the catheter was confirmed by
a fluoroscopic spot film of the chest.
The peel-away sheath and guidewire were then removed. The
catheter was secured to the skin, flushed, and a sterile
dressing applied.
The patient tolerated the procedure well. There were no
immediate complications.
IMPRESSION:
Ultrasound and fluoroscopically guided [**Last Name (un) **] line placement
via the left basilic vein. Final internal length is 32 cm, with
the tip positioned in the distal subclavian/proximal left
brachiocephalic vein.
Limited venogram demonstrating occlusion of the left
brachiocephalic vein proximally with collateral vessel
formation.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
DR. [**First Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
Brief Hospital Course:
Mrs. [**First Name (STitle) 22917**] was admitted to the [**Hospital1 18**] on [**2129-5-18**] for surgical
management of her aortic valve and coronary artery disease. She
was worked-up in the usual preoperative manner including a
carotid duplex ultrasound whisch showed less then 40% stenosis
of her bilateral internal carotid arteries. Vein mapping was
also obtained which showed a dilated but usuable bilateral
greater saphenous vein. A CT scan was also performed to evaluate
her aortic calcification which revealed marked ascending aortic
calcification, with less extensive calcifications in the
descending aorta. On [**2129-5-19**], Ms. [**Known lastname **] was taken to the
operating room where she underwent coronary artery bypass
grafting to six [**Last Name (LF) 56207**], [**First Name3 (LF) **] aortic valve replacement with a
tissue bioprosthesis and replacement of her ascending aorta.
Please see operative note for details. Postoperatively she was
transferred to the intensive care unit for monitoring. As her
chest tube output was high, she was promptly returned to the
operating room where she underwent a re-exploration for
bleeding. Hemostasis was acheived. Please see separate dictated
operative note for details. She was again transferred to to the
intensive care unit. Pressors were slowly weaned off. Amiodarone
was started for atrial fibrillation. On postoperative day 3, she
awoke neurologically intact and was extubated. She was
pancultured for leukocytosis and vancomycin, cefepime and flagyl
were started.
On postoperative day four, she was reintubated for acidosis and
respiratory distress. She was noted to have an ischemic right
hand and the vascular surgery service was consulted. An emergent
embolectomy was performed of her right brachial, radial and
ulnar arteries with good result. Thrombus was noted in the aorta
and embolism was noted of all 4 extremities. Argatroban was
started as HIT was suspected however an initial HIT antibody was
negative. She was however thrombocytopenic. The hematology
service was consulted who performed further studies to rule out
a hypercoagulable state. Increased levels of LDH and nucleated
red cells were noted on a peripheral blood smear. Coumadin was
held. Sputum showed pseudomonas and levaquin was added to
cefepime. Renal consult obtained on POD #10. Head CT negative on
[**6-1**] for obvious stroke. HIT serotonin assy negative, but
argatroban continued for hypercoagulable symptoms with
continuing necrosis of distal digits. Coumadin
restarted.Hematology consult also done.
Evaluated for an acute abdomen on [**6-2**] and taken to OR by Dr.
[**First Name (STitle) **] for exploratory lap/cholecystectomy and G-J tube
placement.Lupus panel also was negative. Maroon-colored stools
noted on [**6-4**] and GI consult done. Argatroban held. Elevated INR
negated endoscopy at that time.Diuresis continued. Trach
performed by Dr. [**Last Name (STitle) **] on POD #19. Wound care nurse [**First Name (Titles) 5983**] [**Last Name (Titles) 17037**]d for blistering. Apex and mid-abdominal incision opened
for evacuation of pus at bedside on [**6-9**]. Argatroban restarted
and started on coumadin. VAC dressing with white foam first and
then black foam was placed to her abdominal wound on [**6-13**].
She tolerated 40 mintues of trach collar on [**6-14**]. She was seen
by podiatry for her BLE gangrene and conservative therapy was
recommended until the lesions demarcated. She was seen by
plastic surgery for her necrotic fingers, and no intervention
was recommended, the fingers will auto-necrose and
auto-amputate. She continued with adaptic dressing changes to
her toes. As she became more alert it was determined that she
had almost complete hearing loss. She had bilateral pleural
effusions and awaited subtherapeutic INR prior to undergoing
thoracentesis on [**6-15**] and 15. Blood and wound cultures were
positive for bacteroides and she was seen by infectious disease
and she continued on cefepime for MSSA (vanco and cipro dc'd)
and pseudomonas in sputum and was started on falgyl for the
bacteroides. She was also started on fluconazole for [**Female First Name (un) **] in
wound cultures.
On [**6-20**] she underwent a right BKA with vascular surgery. They
also recommended accuzyme to her foot ulcer and knee immobilizer
to BKA stump. Argatroban and coumadin were restarted the
following day.
She continued on trach collar trials during the day and vent
support at night.
Courses of diflucan and cefepime completed on [**6-23**].
Passy muir valve was placed on [**6-23**], and she tolerated it for
10 minutes. ENT consult is recommended to evaluate vocal cords
given that she was unable to produce voicing with the valve in
place. Follow up speech and swallow evaluation and treatment are
also recommended.
On [**6-24**] WBC rose and TLC was discontinued, and she was
pancultured. INR was 4.1 and argatroban was dc'd, coumadin
continued. Urine culture grew yeast and sputum grew gram
negatives and she was started on fluconazole and zosyn. Zosyn
was switched to cefepime and levofloxacin for pseudomonas. WBC
improved.
She developed melanotic stools, was started on [**Hospital1 **] PPI and was
seen by GI. She was transfused, and COumadin was held. She was
managed conservatively given [**Hospital 7235**] medical issues and need
for anticoagulation. Melena continued to decrease, and HCT
stabilized.
Cefepime changed to ceftazidime on [**6-28**] due to resistance.
Midline was placed on [**6-28**].
VAC was last changed on [**6-29**].
Medications on Admission:
Lisinopril 20 mg once daily, Crestor 5 mg once daily, Imdur 60
mg once daily, Metoprolol 100 mg once daily, Clonidine 0.1 mg as
needed, Aspirin 325 mg once daily, Xanax 0.25 mg as needed,
Multivitamins, Fish Oil, Calcium with Vitamin D,
Plavix 75 mg once daily, Lexapro 10 mg once daily.
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Ascorbic Acid 90 mg/mL Drops Sig: One (1) PO DAILY (Daily).
3. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO DAILY
(Daily).
4. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: Five (5)
ML PO Q6H (every 6 hours) as needed.
9. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff
Inhalation Q6H (every 6 hours) as needed.
10. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
12. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
13. Papain-Urea 830,000-10 unit/g-% Ointment Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day).
14. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment Sig: One (1)
Appl Rectal PRN (as needed).
15. Insulin Glargine 100 unit/mL Solution Sig: Twenty Five (25)
Subcutaneous BREAKFAST (Breakfast).
16. Pantoprazole 40 mg IV Q12H
17. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
18. Warfarin 1 mg Tablet Sig: dose adjusted to INR Tablet PO
DAILY (Daily): Target INR 2-2.5
Restart after INR<2.0.
19. Ceftazidime 2 gram Recon Soln Sig: Two (2) gm Injection Q12H
(every 12 hours) for 2 weeks.
20. Levofloxacin in D5W 500 mg/100 mL Piggyback Sig: Five
Hundred (500) mg Intravenous Q24H (every 24 hours) for 2 weeks.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
AS/CAD s/p CABG/Ascending Aorta Replacement/Aortic Valve
Replacement
Hyperlipidemia
HTN
Aortic thrombus with limb emboli
acute renal failure
Left benign breast mass
Basal cell skin cancer
Right breast cancer s/p mastectomy
Discharge Condition:
Stable
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks
6) No driving for 1 month.
7) Call with any questions or concerns.
Followup Instructions:
Follow-up with Dr. [**First Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**]
Follow-up with Dr. [**Last Name (STitle) **] [**Name (STitle) **] in [**2-2**] weeks.
Follow-up with Dr. [**Last Name (STitle) **] in 2 weeks.
Follow-up with Dr. [**First Name (STitle) **] (Surgery) in 4 weeks
Please call all providers for appointments.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2129-6-30**] Name: [**Known lastname **],[**Known firstname **] V Unit No: [**Numeric Identifier 12545**]
Admission Date: [**2129-5-18**] Discharge Date: [**2129-6-30**]
Date of Birth: [**2051-12-20**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Sulfa (Sulfonamides) / Heparin Agents
Attending:[**First Name3 (LF) 265**]
Addendum:
Lasix 40mg QD added to medication schedule.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 14**] & Rehab Center - [**Hospital1 15**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**]
Completed by:[**2129-6-30**]
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2822, 2968
|
21742, 23408
|
13440, 13489
|
23531, 23756
|
21429, 21719
|
23810, 24504
|
2983, 4662
|
279, 303
|
13518, 15841
|
897, 2206
|
2228, 2608
|
2624, 2806
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,710
| 175,234
|
52690
|
Discharge summary
|
report
|
Admission Date: [**2164-8-21**] Discharge Date: [**2164-8-28**]
Date of Birth: [**2083-5-13**] Sex: F
Service: MEDICINE
Allergies:
Zocor
Attending:[**First Name3 (LF) 2782**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
ERCP with sphincterotomy
History of Present Illness:
The patient is an 81 year old female with CAD, hypertension,
DM2, and prior colectomy for diverticular disease who was
transferred from [**Hospital3 10310**] after presenting with weakness
and crampy abdominal pain. Patient went to beach on Sunday and
starting feeling unwell after returning home with crampy
epigastric and RUQ abdominal pain. Nausea with several episodes
of vomiting. No diarrhea or blood in stool. She had subjective
fever and chills, but did not check her temperature. No
dysuria, no increased urinary frequency. No CP/SOB/cough. She
stayed at a relative's home and continued to feel unwell,
eventually presenting to the OSH ED on Monday.
.
In the OSH ED, her initial vitals were T 103.1, HR 112, BP
128/58, RR 28, and SpO2 95% on RA. Labs were notable for WBC
9.6 with 14% bands, creatinine 1.0, and Troponin 0.42. UA was
positive with many WBCs and bacteria, no squamous epithelial
cells. EKG showed ST depressions in V4-V6. RUQ ultrasound at
the OSH showed evidence of sludge and [**Doctor Last Name 5691**] in gallbladder,
moderate wall thickening, and pericholecystic fluid. She was
given Ceftriaxone 1000 mg and Flagyl 500 mg. She was
transferred to [**Hospital1 18**] for further management.
.
In the ED, initial vitals were: T 98.7, HR 109, BP 110/54, RR
20, and SpO2 97% on RA. RUQ US was repeated and showed a small
8 mm cystic structure in the body of the pancreas communicating
with the duct, slightly distended gallbladder and mild focal
gallbladder wall edema, without ductal dilatation. U/A was
remarkable for likely UTI with significant epithelial cells,
glucose and ketones. WBC notable for a bandemia of 3% (WBC
10.9) and anemia with Hct of 31.9. BUN/Cr elevated (1.2) and
glucose 382 with significant transaminitis and obstructive
pattern. Of note, initial EKG showed ST depressions in V4-V6
with troponin leak to 0.49, improving to 0.33 on repeat with
resolution of ST depressions. ERCP was notified and will see
today. She was started on Zosyn for coverage of biliary
infection and suspected UTI and given a total of 4L IVF. Her
BPs were labile, dropping as low as 80s/40s, prompting admission
to the ICU.
.
In the ICU, she continued to have epigatric and RUQ abdominal
pain, but improved from admission. She denied any current
fevers, chills, chest pain, SOB, or nausea. She denied any
lightheadedness or dizziness. She continued to have malaise and
subjective generalized weakness, but was mentating well.
.
Review of systems:
(+) Per HPI. Subjective fevers and chills at home. Slight
cough today nonproductive of sputum.
(-) Denies recent weight loss or gain. Denies headache, sinus
tenderness, rhinorrhea, or congestion. Denies shortness of
breath or wheezing. Denies chest pain, chest pressure,
palpitations, or weakness. Denies diarrhea, constipation, or
changes in bowel habits. Denies dysuria, frequency, or urgency.
Denies arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
# Hypertension
# Hypercholesterolemia
# CAD s/p CABG x5 ([**2151**])
# Diabetes Mellitus
# Diverticulitis
-- Colectomy and pouch [**2148**], Colostomy for diverticular disease
-- Takedown in [**2148**]
# Chronic back pain
# Atrial Fibrillation -- patient unaware of diagnosis
# Pterygium removal -- bilateral
Social History:
# Tobacco: denies
# Alcohol: denies
# Illicits: denies
Family History:
Multiple family members with CAD. Husband recently deceased.
Son recently died from lung cancer at age 57.
Physical Exam:
ADMITTING PHYSICAL EXAM:
Vitals: T 98.0, BP 131/49, HR 72, RR 18, SpO2 100% on 2L NC
General: Alert, oriented, no acute distress
HEENT: Sclera with some injection, post-op changes from
bilateral pterygium removal, dry mucous membranes, oropharynx
clear, dentures
Neck: supple, JVP not elevated, no LAD
Lungs: Few crackles at right base but otherwise clear
CV: Regular rate and rhythm. Normal S1 and S2. No murmurs, rubs,
or gallops.
Abdomen: Well healed midline abdominal incision. Bowel sounds
present. Soft, tender to palpation in RUQ. Mildly distended.
No rebound tenderness or guarding. No organomegaly.
GU: Foley catheter in place with somewhat dark urine
Ext: Warm, well perfused, 2+ pulses. No clubbing, cyanosis or
edema.
Pertinent Results:
ADMISSION LABS:
[**2164-8-21**] 12:30AM URINE RBC-7* WBC->182* BACTERIA-MANY
YEAST-NONE EPI-10 TRANS EPI-<1
[**2164-8-21**] 12:30AM URINE BLOOD-SM NITRITE-POS PROTEIN-30
GLUCOSE-1000 KETONE-40 BILIRUBIN-SM UROBILNGN-2* PH-6.0
LEUK-MOD
[**2164-8-21**] 12:30AM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.019
[**2164-8-21**] 12:30AM PT-15.6* PTT-23.4 INR(PT)-1.4*
[**2164-8-21**] 12:30AM PLT COUNT-179
[**2164-8-21**] 12:30AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2164-8-21**] 12:30AM NEUTS-91* BANDS-3 LYMPHS-4* MONOS-1* EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-0
[**2164-8-21**] 12:30AM WBC-10.9# RBC-3.95*# HGB-11.3*# HCT-31.9*#
MCV-81* MCH-28.5 MCHC-35.3* RDW-13.7
[**2164-8-21**] 12:30AM ALBUMIN-3.4*
[**2164-8-21**] 12:30AM CK-MB-7
[**2164-8-21**] 12:30AM cTropnT-0.49*
[**2164-8-21**] 12:30AM LIPASE-12
[**2164-8-21**] 12:30AM ALT(SGPT)-296* AST(SGOT)-259* ALK PHOS-147*
TOT BILI-5.5* DIR BILI-4.5* INDIR BIL-1.0
[**2164-8-21**] 12:30AM GLUCOSE-382* UREA N-22* CREAT-1.2* SODIUM-134
POTASSIUM-3.5 CHLORIDE-98 TOTAL CO2-23 ANION GAP-17
[**2164-8-21**] 04:52AM cTropnT-0.33*
Brief Hospital Course:
81 year old female with CAD, hypertension, DM2, and prior
colectomy for diverticular disease who was transferred from
[**Hospital3 10310**] after presenting with weakness and crampy
abdominal pain with RUQ US showing evidence of cholecystitis and
an obstructive pattern on her LFTs.She had labile blood pressure
in the ED with SBP intermittently down to the 80s. She was
given a total of 4L IV fluids, with improvement in her BP. Shee
was admitted to the ICU from the ED.
# Cholecystitis / Cholangitis:
-S/P ERCP with sphincterotomy [**2164-8-21**]
-treated with Unasyn until [**8-26**], chanced to PO Cipro and Flagyl
then
-LFTs improved and she tolerated food
-Will need cholecystectomy in approximately 3 months (post
cardiac cath, see below)
-Will need EUS for incidental cyst of pancreas seen on ERCP with
Dr. [**Last Name (STitle) **] in 4 weeks
#Acute blood loss anemia:
-Her Hct dropped from 31.0 to 25.3 following the ERCP, and she
was transfused 1 unit PRBCs on [**2164-8-22**] with an appropriate
increase in her Hct
#Acute MI, Type II (NSTEMI)
-EKG in the ED initially showed ST depressions in V4-6, which
resolved when she became normotensive. She did not have any
symptoms consistent with anginal equivalent. She has know CAD
(S/P CAB in [**2151**]) and multiple risk factors (DM, HTN,
hyperlipidemia).
-Toponin peaked at 0.49 on [**8-21**]
-Stress MIBI off beta blockers on [**8-24**] was positive: a moderate,
partially reversible perfusion defect in the mid-anterior and
mid-anterolateral walls with corresponding mild hypokinesis, and
a drop in EF from 55% to 45% with stress (compared to at
rest/baseline)
-Cardiology followed pt and recommended a) maximizing medical
management, b)outpatient cardiology evaluation, followed by
c)cardiac cath as an outpatient
-Medical management: beta blocker (dose increased until limited
by HR; lisinopril; ASA. Reportedly allergic to statins.
#DM II, uncontrolled with complications
-on glipizide 10 mg [**Hospital1 **] at home. Hemoglobin A1c = 8.6,
suggesting needs better control
-initially on ISS, when switched to home regimen FSBS was in the
200-300 range.
-we added Metformin 850mg and she can f/u with pcp regarding
glucose control, she is on janumet at home this should be held
if she is just on metformin (she should call pcp if glucose
>200)
#Fever
-On [**8-26**] pt developed a low-grade fever. Workup, which included
CDiff toxin assay, CXR, UA, urine culture, blood cultures, and
lower extremity noninvasives showed no DVT, no UTI, and slight
LLL pulmonary infiltrate but no clinical signs of pneumonia and
an improving wbc. although she had low grade fever on [**8-27**], she
was afebrile on the day of discharge and looked clinically
well...given that she will be completing a course of
cipro/flagyl no other abx were started for the cxr findings.
cdiff neg.
she should have close follow up with her Pcp if she develops
higher fever, cough, dyspnea
--recommend outpatient repeat cxr in [**3-9**] weeks to document
resolution of infiltrate
Medications on Admission:
Aspirin 81 mg PO daily
Simvastatin 60 PO QHS
Atenolol 12.5 mg PO BID
Lisinopril 20 mg PO daily
Glipizide 10 mg PO BID
Janumet (Sitagliptin/Metformin 50/100 mg) PO BID
Vit D [**2153**] units PO daily
Discharge Medications:
1. aspirin, buffered 325 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
3. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
4. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
7. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q 8H
(Every 8 Hours) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
8. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every six
(6) hours as needed for pain.
10. metformin 850 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Cholangitis
Cholecystitis
Acute myocardial infarction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for obstruction of your bile ducts from
stones, and infection of the gallbladder and the bile ducts.
This was treated with antibiotics and a procedure called an
ERCP. You will need to complete the antibiotics at home. A fluid
collection near the pancreas was also found and Dr. [**Last Name (STitle) **]
would like to see you in four weeks to perform an endoscopic
ultrasound (EUS) in order to better characterize that fluid
collection.
You also had a heart attack during this hospitalization. You had
a positive nuclear stress test (MIBI) which showed that you may
be at risk for another heart attack in the future. We restarted
medications which can help protect you against another heart
attack and Cardiology (Dr. [**Last Name (STitle) **] would like to see you in his
office on [**2164-9-7**]. At that appointment he will talk to
you about a cardiac catheterization. Before you see him, please
avoid doing strenuous activity like lifting heavy objects (more
that [**6-12**] punds) or climbing stairs. You can (and should) walk
and do other household activities normally. Call a doctor
immediately if you feel unwell in any way, especially if you
develop chest, neck, arm, or jaw pain, shortness of breath,
nausea or vomiting.
Your diabetes also needs to be better controlled please measure
your blood sugar before each meal amd at bedtime and enter these
values with the time and date in a log and bring that to your
primary care doctor. Call your primary care doctor if you
fingerstick blood glucose is less than 60 or more than 350.
Your xray showed a small possible pneumonia in the L lung you
should have a repeat xray in the next 2-4 weeks with your PCP.
[**Name10 (NameIs) **] your doctor if you have shortness of breath, high fever,
cough
You will need to have your gallbladder removed surgically in
approximately 3 months, after you are cleared by your
Cardilogist to have this procedure. You can have this done at
your local hospital or make an appointment with one of our
general surgeons if you wish to have it performed at the [**Hospital 61**].
Followup Instructions:
Department: CARDIAC SERVICES
When: FRIDAY [**2164-9-7**] at 10:20 AM
With: [**Name6 (MD) **] [**Name8 (MD) 163**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: ZILBER,DMITRIY A.
Location: [**Hospital3 **]-[**Hospital1 420**]
Address: [**Doctor Last Name **], [**Hospital1 420**],[**Numeric Identifier 15489**]
Phone: [**0-0-**]
Appointment: Monday [**2164-9-10**] 9:00am
Department: DIGESTIVE DISEASE CENTER
When: FRIDAY [**2164-9-21**] at 12:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2839**], MD [**Telephone/Fax (1) 463**]
Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 1951**]
Campus: EAST Best Parking: Main Garage
Department: ENDO SUITES
When: FRIDAY [**2164-9-21**] at 12:00 PM
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,081
| 104,815
|
27758
|
Discharge summary
|
report
|
Admission Date: [**2132-5-29**] Discharge Date: [**2132-6-7**]
Date of Birth: [**2055-10-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
Atrial flutter ablation & D/C cardioversion ([**2132-5-30**])
Intubation for respiratory distress ([**2132-5-30**])
Left & right heart cardiac catheterization ([**2132-6-2**] & [**2132-6-6**])
Placement of ICD ([**2132-6-4**])
History of Present Illness:
76 y/o man with h/o CAD, s/p MI ([**2107**], [**2131**]), CHF EF 20%, DM, a.
fib/flutter admitted to [**Hospital3 417**] hospital on [**2132-5-21**] for
SOB. Of note, the pt had been admitted to [**Hospital3 417**]
hospital on [**2132-4-26**] with the same complaints. At that time, he
pt was found to be in respiratory distress and was intubated and
diuresed (and extubated 1 day following intubation). His
respiratory decompsensation on [**4-26**] was thought to be due CHF
after missing 2 days of lasix. On [**5-21**], the pt's wife called
911 after the pt became acutely SOB at home. EMS intubated the
pt en route to [**Hospital3 417**] hospital. Again, the pt was
diuresed with rapid improvement, leading to extubation within
days. There was question of PNA, for which he was tx'd with
abx. Myoview stress testing during the admission was reportedly
negative for ischemia. Echo on [**5-22**] showed EF = 10%. Pt found
to be in AFR Creatinine w/ Crt peaking at 2 upon admission but
came back to baseline (thought to be ~1.7). Additionally,
during this admission to [**Hospital3 **], the pt was in afib. (The pt
does not know when his afib started, and has never undergone
electrocardioversion. He was started on coumadin in early [**Month (only) **].)
On [**2132-5-29**], the pt was transferred to [**Hospital1 18**] to undergo EP
evaluation and possible intervention.
.
Upon review of systems, the pt reported that he can walk the
length of the hallway before getting short of breath. He denies
lightheadedness, orthnopnea, PND, leg edema, or ascites. He had
self-limited palpitations yesterday. No current SOB, and is
comfortable and ambulatory on room air.
Past Medical History:
1. a-fib - [**2132-5-13**] INR 3.0
2. CHF EF 20%
- [**2132-4-27**] Echo: EF 20-25% with global hypokinesis, Trace TR, mild
pulmonary hypertension.
- [**2132-5-22**] Echo: severe global hypokinesis and EF of 10% c/w
ischemic cardiomyopathy, mild LA enlargement, RV systolic
function mildly reduced, moderate MR, IVC dilated.
3. MI in [**2107**]
4. LBBB
5. COPD
6. diabetes
7. hyperlipidemia
8. CRI with baseline Cr of 1.7 on [**2132-5-5**]
9. Anemia
Social History:
SH: retired, formerly worked as a carpenter. Has been married
for 33 years with his second wife, has 7 children with his first
wife. [**Name (NI) **] [**Name2 (NI) 1818**], 63 pack years. Rare alcohol use, no
illicit drug abuse history.
Family History:
FH: No h/o CAD, no HTN. grandmother and brother with diabetes.
Brother with laryngeal cancer, mom died of stomach cancer at 73,
father died of aneurysm at 73.
Physical Exam:
Vitals T: 97.0oF HR: 88 BP: 110/50 RR: 16 O2sat: 96% RA
Ht: 5??????9?????? Wt: 154lbs Glucose 465
Gen pleasant, NAD
Derm skin normal coloration and texture for age, nails without
clubbing or cyanosis. No rash. Hair of normal texture for age
HEENT Anicteric. conjunctiva pink. PERRLA, EOMs normal, VFs
full. Oropharynx clear. Mucous membranes moist. Trachea midline.
Neck supple. No cervical LAD, no enlarged or tender thyroid.
Pulm CTAB. No crackles or wheezes
CV JVP 8 cm above the sternal angle at 45&#[**Numeric Identifier 18014**]; elevation.
irregularly irregular pulse, pulsus alternans. normal S1, S2. No
c/m/r/g.
Pedal and radial pulses symmetrical and strong,.
Abd Non-distended. No scars/herniae. +BS. No aortic/renal artery
bruits. Hollow to percussion. S/NT/ND. Liver, spleen not
palpable.
Ext no c/c/e.
Neuro MSE: alert, Ox3. Rest of MMSE not performed
CN: II-XII intact to direct testing.
Sensory: Light touch intact in UEs and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **].
Motor: Good bulk and tone, ROM full and smooth. Strength 5/5
throughout.
Coordination: Gait normal.
Pertinent Results:
[**2132-5-29**] 09:57PM GLUCOSE-358* UREA N-46* CREAT-2.6* SODIUM-135
POTASSIUM-4.8 CHLORIDE-92* TOTAL CO2-31 ANION GAP-17
[**2132-5-29**] 09:57PM CALCIUM-9.2 PHOSPHATE-4.3 MAGNESIUM-2.2
IRON-68
[**2132-5-29**] 09:57PM calTIBC-397 FERRITIN-135 TRF-305
[**2132-5-29**] 09:57PM WBC-10.2 RBC-3.27* HGB-10.2* HCT-28.8* MCV-88
MCH-31.1 MCHC-35.3* RDW-14.0
[**2132-5-29**] 09:57PM PLT COUNT-358
[**2132-5-29**] 09:57PM PT-15.5* PTT-27.8 INR(PT)-1.4*
[**2132-5-29**] 09:57PM RET AUT-4.0*
[**2132-6-6**] 11:37PM BLOOD Type-ART pO2-74* pCO2-39 pH-7.48*
calTCO2-30 Base XS-5
[**2132-6-7**] 11:57AM BLOOD Glucose-151*
[**2132-6-7**] 11:57AM BLOOD Hgb-8.7* calcHCT-26 O2 Sat-62
[**2132-6-6**] 05:08AM BLOOD freeCa-1.04*
[**2132-6-6**] 10:02PM BLOOD CK(CPK)-1035*
[**2132-6-7**] 06:02AM BLOOD CK-MB-38*
[**2132-6-7**] 06:02AM BLOOD Calcium-8.2* Phos-3.1 Mg-1.7
[**2132-6-7**] 06:02AM BLOOD Glucose-182* UreaN-15 Creat-1.9* Na-137
K-3.6 Cl-97 HCO3-30 AnGap-14
[**2132-6-7**] 06:02AM BLOOD WBC-11.1* RBC-2.88* Hgb-8.9* Hct-25.1*
MCV-87 MCH-30.8 MCHC-35.3* RDW-14.7 Plt Ct-398
.
TTE [**2132-5-30**]:
1. The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. The left atrial appendage emptying velocity is
depressed (~0.2m/s). No atrial septal defect is seen by 2D or
color Doppler.
2.The left ventricular cavity is dilated. Overall left
ventricular systolic function is severely depressed 15-20%.
3.There are complex (>4mm) atheroma in the descending thoracic
aorta.
4.The aortic valve leaflets (3) are mildly thickened. No aortic
regurgitation is seen.
5.The mitral valve leaflets are structurally normal. Moderate
(2+) mitral
regurgitation is seen.
6.There is no pericardial effusion.
.
Cardiac Cath [**2132-6-2**]:
COMMENTS:
1. Selective coronary angiography of this left dominant system
revealed
a one vessel coronary disease. The LMCA was without flow
limiting
stenosis. The LAD was a large vessel that gave rise to three
diaginal
branches. Proximal LAD had a diffuse 40% stenosis with a
superimposed
90% focal stenosis before a take off of a major diagonal branch
(D3).
The LCx was a dominant vessel with a 30% proximal stenosis and a
30%
stenosis of OM3. The RCA was a small non-dominant vessel with a
mild
diffuse disease throughout.
2. Left ventriculograhy was deferred given renal insufficiency.
3. Resting hemodynamics revealed a moderately high left sided
filling
pressures with a PCWP of 18. The CI was 2.47.
3. The proximal LAD lesion was predilated with a 2.5 x 15
maverick
balloon and stented with a 3.0 x 28 balloon. The final angiogram
showed
TIMI III flow with no residual stenosis, no dissection, no
embolisation
and no perforation (see PTCA comments)
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Moderately elevated left sided filling pressures.
3. Successful PTCA/stent of the proximal LAD with excellent
result.
Brief Hospital Course:
I would like to mention at the onset that the patient has
refused further care during this hospitalization and wants to go
home. Fllowing is his brief hospital course:
Upon arrival to [**Hospital1 18**], the pt underwent TEE followed by electric
cardioversion and Aflutter albation. Post procedure, the pt was
transferred to the floor and was noted to be agitated by wife.
[**Name (NI) **] became hypertensive with SBP in 180s, tachypnic & hypoxemic.
He was intubated, given IV lasix and nitro gtt and transfered to
the CCU. After receiving lasix, the pt diuresed well and showed
rapid improvement. No other cause of resp distress was found,
other than acute pulmonary edema. Thus, he was extubated the
following day.
24hrs s/p extubation the pt became anxious & SOB again,
progressing to respiratory distress. He was found, as before,
to be in acute pulmonary edema. Intubation was averted after
giving morphine, nitro gtt, lasix, ativan and starting BiPAP.
On [**2132-6-2**], pt underwent right & left heart cath with PTCI of
LAD with drug eluting stent placement. On [**2132-6-4**], the pt
underwent ICD placement. Despite medical therapy & the above
interventions, the patient continued to have repeated episodes
of acute pulmonary edema, each episode treated with morphine,
lasix, ativan, +/- nebulizers and BiPAP, avoiding intubation in
each instance. These episodes of acute (or "flash") pulmonary
edema were triggered in some cases by a small to moderate volume
load (for cardiac catheterization, for instance); however, other
episodes were triggered by seemingly inocuous causes such as
transfering onto a bed pan. The pt expressed the desire to not
be intubated again, though he wants to have BiPAP therapy should
he develop respiratory distress again. After discussing his
prognosis and options for therapy with both him & his wife, he
decided to be DNR/DNI on [**2132-6-5**]. He also expressed the desire
to minimize interventions and the amount of time hospitalized.
His goal is to go home, knowing that he could die there in his
condition. His wish is to spend as much time with his wife as
possible at home, though he does not want to undergo extensive
hospital care and therapy to accomplish this.
After making these decisions, the pt again went into acute
respiratory distress on the AM of [**2132-6-6**]. He was treated with
the same regimen as described above. His cardiac enzymes were
elevated (w/ a troponin of 1.29). The pt agreed to undergo
diagnostic catheterization to determine if his LAD stent had
occluded and also to determine his hemodynamic numbers. If the
stent was found to be occluded or a new lesion was found, he
agreed to treatment through PTCI--with the aim of optimizing his
condition before going home. At catheterization, the in-stent
thrombosis was re-stented
Additional Hospital Course Issues:
## CV:
# CAD - From the outset, it was thought that the pt very likely
had extensive baseline ischemia--given his h/o CAD, diabetes,
smoking, and thick ventricle (diastolic failure). Based on
this, he was taken for a diagnostic cath on [**6-2**], where he was
found to only have LAD disease, which was stented with drug
eluting stent. Based on these results, it was concluded that he
most likely has idiopathic ischemic cardiomyopathy. He was
treated medically with ASA, plavix, BB, & statin.
On [**2140-6-5**], pt's SBP dropped & his anti-hypertensives were held.
It is thought that a new ischemic event may have contributed to
this.
# [**Name (NI) **] - Pt's initial TEE revealed global hypokinesis (EF ~20%).
Right heart cath on [**6-4**] showed PCWP 18 and cardiac index of
2.47. Post-LAD stenting echo revealed no improvement in LV
function (estimated EF ~15%).
# Rhythm - Pt was in flutter upon arrival at [**Hospital1 18**]. He
underwent a.flutter ablation and cardioversion into NSR. His
rhythm degenerated into afib after the procedure. Pt treated
with heparin and later coumadin for afib. Pt underwent ICD
placement and cardioversion on [**6-5**] (prior to deciding to be
DNR/DNI). Given his disorganized atrial arrhythmias at times
and his left atrial flutter and the apparent benefit of him
being in sinus rhythm, he was started on amiodarone therapy
(recommended by EP for month at 200mg [**Hospital1 **] and thereafter 200mg
QD).
.
## Respiratory Failure - Intubated on [**2132-5-30**] after developing
respiratory distress, which was thought to be due to acute pulm
edema as above. Pt extubated following day ([**5-31**]).
.
#Agitation/anxiety: likely contributed to episodes of shortness
of breath. Pt started on ativan 0.5mg [**Hospital1 **], which was changed to
longer acting clonazepam (started on [**6-3**]).
.
## COPD - Though not previously documented, pt's appears to have
COPD--CXR reveals significant hyperinflation of lungs. He
refuses to stop smoking. Pt given spiriva inhalers & albuterol.
.
## Anemia- reportedly has h/o anemia, though cause unknown.
Pt's hct dropped during admission & he was transfused 1uPRBCs
during admission. Hct stabilized thereafter. No obvious source
of bleeding.
.
## DM - Pt's outpt glipizide & NPH held. He was treated with
RISS and NPH [**7-1**] (when not NPO).
.
## CRI - baseline creatinine estimated to be approximately 1.7.
Had ARF thought to be pre-renal in nature with Crt peaking at
2.3. ARF now resolved with Crt at 1.6.
.
## Hyperlipidemia - atorvastatin continued.
.
## code - DNR/DNI
## Communication - wife [**Name (NI) 382**], who is legally blind
Medications on Admission:
1. digoxin 0.125mg qday
2. esomeprazole magnesium 40mg
3. salmeterol/fluticasone 250 1 puff [**Hospital1 **]
4. tiotropium bromide 18mcg qday
5. atorvastatin 20mg qday with supper
6. Mylanta 30mL q6h prn
7. aspirin 325 mg qday
8. furosemide 80mg qAM and 40mg qHS
9. glipizide 10mg [**Hospital1 **]
10. metoprolol 100mg [**Hospital1 **]
11. enoxaparin qday
12. acetaminophen 325-650mg q4-6h prn
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Clopidogrel 75 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Digoxin 125 mcg Tablet Sig: 0.125mg Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Morphine Concentrate 20 mg/mL Solution Sig: 5-20 mg PO q1hr
prn as needed for shortness of breath or wheezing.
Disp:*60 cc* Refills:*0*
5. Ativan 1 mg Tablet Sig: 1-2 Tablets PO q2hr as needed.
Disp:*10 Tablet(s)* Refills:*0*
6. Scopolamine Base 1.5 mg Patch 72HR Sig: One (1) patch
Transdermal every seventy-two (72) hours.
Disp:*10 patches* Refills:*0*
7. Levsin/SL 0.125 mg Tablet, Sublingual Sig: One (1) tab
Sublingual four times a day as needed for secretions.
Disp:*30 * Refills:*0*
8. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
Disp:*1 mdi* Refills:*0*
9. Combivent 103-18 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation twice a day.
Disp:*1 mdi* Refills:*0*
10. Morphine 10 mg/5 mL Solution Sig: 5-20 mg PO q1hr as needed
for shortness of breath or wheezing.
Disp:*120 ml* Refills:*0*
11. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
12. 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*
13. Glipizide 5 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
14. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO three times
a day.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **]
Discharge Diagnosis:
Severe diastolic & systolic CHF with acute pulmonary edema, CAD,
ischemic cardiomyopathy, afib & COPD
Discharge Condition:
Stable but patient has refused any further care
Discharge Instructions:
Continue taking aspirin and clopidogrel daily as instructed. DO
NOT STOP these medications unless given permission by your
cardiologist.
Please take all medications as prescribed
If you have chest pain, shortness of breath, dizziness,
palpitations, pain in abdomen, vomitting, diarrhea please call
your primary care provider
Followup Instructions:
Please call your PCP Dr [**Last Name (STitle) 17025**] ([**Telephone/Fax (1) 3183**]) to make a
follow up appointment
Completed by:[**2132-6-7**]
|
[
"414.8",
"414.01",
"785.51",
"584.9",
"496",
"250.00",
"412",
"585.9",
"427.31",
"996.72",
"518.5",
"427.32",
"410.11",
"428.43",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"96.04",
"97.44",
"88.72",
"37.23",
"37.61",
"00.66",
"37.34",
"37.26",
"00.17",
"99.20",
"88.45",
"99.04",
"96.71",
"93.90",
"00.45",
"00.40",
"37.94",
"36.07",
"36.06"
] |
icd9pcs
|
[
[
[]
]
] |
14927, 14978
|
7489, 12819
|
335, 564
|
15124, 15174
|
4309, 7118
|
15548, 15695
|
3012, 3172
|
13263, 14904
|
14999, 15103
|
12845, 13240
|
7135, 7297
|
15198, 15525
|
3187, 4290
|
276, 297
|
592, 2269
|
2291, 2742
|
2758, 2996
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,516
| 138,539
|
8154+55918
|
Discharge summary
|
report+addendum
|
Admission Date: [**2107-2-16**] Discharge Date: [**2107-2-27**]
Date of Birth: [**2047-3-27**] Sex: M
Service: Medicine
HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old
gentleman with a history of end-stage renal disease (on
hemodialysis) and cirrhosis.
The patient presents from [**Hospital1 700**] with
hypotension of 68/45. The patient was recently discharged
from [**Hospital1 69**] on [**1-6**] with
congestive heart failure and fluid overload secondary to
inadequate hemodialysis.
The patient was admitted to [**Hospital3 8544**] on [**1-6**]
after being found unresponsive by his wife right after he was
discharged from our hospital. On presentation to the outside
hospital, he was found to have atrial fibrillation with a
fingerstick blood sugar of 12 in the field. The patient
stayed in the Intensive Care Unit for three weeks. Please
see the outside hospital medical record for details of his
Intensive Care Unit course.
The patient was discharged to rehabilitation on [**2-10**].
On the day of admission, the patient was noted at
rehabilitation to be hypotensive to 68/45 with a heart rate
of 126. The patient was transferred back to our hospital.
In the Emergency Department, the patient was found to have a
fever to 101.6 degrees Fahrenheit as well as a blood pressure
of 83/60. His culture from the outside hospital was shown to
have beta streptococcus in [**12-26**] bottles.
On arrival to [**Hospital1 69**], the
patient's heart rate was 141 with atrial flutter. His
pressor was changed to phenylephrine, and his mean arterial
pressures were 70 to 80s. The patient was admitted to our
Medical Intensive Care Unit. An abdominal ultrasound showed
a small amount of ascites as well as an accidental finding of
a pericardial effusion with poor right ventricular motion.
The patient has received 500 mg of intravenously levofloxacin
given at the outside hospital, and the patient has received
intravenous vancomycin as well as ceftazidime in our
Emergency Department.
PHYSICAL EXAMINATION ON PRESENTATION: Temperature was 100.1
degrees Fahrenheit, his heart rate was 100, his blood
pressure was 117/68, his respiratory rate was 24, and his
oxygen saturation was 100% on 5 liters. In general, the
patient was alert and oriented times three but has
occasionally drifting alertness. The patient was in no
apparent distress. Head, eyes, ears, nose, and throat
examination revealed the pupils were equal, round, and
reactive to light. The extraocular movements were intact.
The mucous membranes were dry. Neck had positive jugular
venous pressure. Cardiovascular examination revealed heart
rate was tachycardic with a [**2-26**] holosystolic murmur at the
left sternal border. Positive left ventricular heave. His
lung examination was consistent with decreased breath sounds
at the bases bilaterally. The abdomen was soft and slightly
distended. There were positive bowel sounds. The patient
had an ostomy with urine in the right abdomen. He had
positive hepatomegaly. Extremity examination revealed there
was no cyanosis, clubbing, or edema. The patient had 2+
dorsalis pedis pulses. Neurologic examination revealed the
patient was alert and oriented. He was moving all
extremities.
PERTINENT LABORATORY VALUES ON PRESENTATION: The patient's
white blood cell count on admission was 6.1, his hematocrit
was 36.8, and his platelets were 65. His INR was 1.3.
Electrolytes revealed sodium was 144, potassium was 5.1,
chloride was 104, bicarbonate was 31, blood urea nitrogen was
42, creatinine was 4.9, and his blood glucose was 89. His
liver function tests were all within normal limits.
PERTINENT RADIOLOGY/IMAGING: His chest x-ray was consistent
with bilateral pleural effusion and was positive for
congestive heart failure.
His electrocardiogram revealed a atrial flutter at a rate of
140.
His abdominal ultrasound showed some free intra-abdominal
fluid. Also had some gallbladder calculous with a collapsed
gallbladder with intrahepatic or extrahepatic biliary ductal
dilatation. His ultrasound was otherwise unremarkable.
A chest computed tomography showed no evidence of pulmonary
embolism but was positive for bilateral pleural effusion as
well as pericardial effusion and ascites. There was marked
vascular calcification as well as associated atelectasis and
hyperdense appearance of the lung; may be related to both the
bilateral pleural effusion and drug toxicity.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:
1. STATUS POST SEPSIS/HYPOTENSION/TACHYCARDIA AND FEVER
ISSUES: The patient was started on vancomycin. The etiology
of his sepsis was unknown. His line was pulled on [**2-19**], and his blood cultures while he was in the hospital have
all been negative upon discharge. Although, from [**Hospital3 418**] Hospital on [**2-16**], there were showing 1/4
bottles of blood cultures growing positive for group B beta
streptococcus that was pan-sensitive.
The patient remained afebrile with a good blood pressure and
heart rate throughout the rest of his hospital course and
with the continuation of vancomycin. The patient was to be
discharged with another one week worth of vancomycin.
2. RIGHT VENTRICULAR FAILURE WITH SEVERE PULMONARY
HYPERTENSION ISSUES: Cardiology was consulted on [**2-19**]. They indicated the patient was not a good surgical
candidate. Per Cardiology recommendation, the patient should
be on aspirin 81 mg by mouth once per day, lisinopril 2.5 mg
by mouth every day, and a beta blocker - low-dose metoprolol
at 12.5 mg by mouth twice per day.
The patient may not be a good candidate for anticoagulation
for his paroxysmal atrial fibrillation given he had a high
risk of bleeding. This issue can be discussed as an
outpatient.
3. ADRENAL INSUFFICIENCY ISSUES: The patient was started on
hydrocortisone/fludrocortisone for seven days and was to
continue with a prednisone taper over the next two weeks
after discharge.
The patient was shown to have cortisone stimulation test that
was positive for adrenal insufficiency at the outside
hospital.
4. PERICARDIAL EFFUSION ISSUES: Without signs of tamponade
on echocardiogram; although right-sided pressures were very
high. So far, the patient had no indication for drainage.
5. END-STAGE RENAL DISEASE ISSUES: The patient is on
hemodialysis. The patient was to continue hemodialysis on
Monday, Wednesday, and Friday course and was also to continue
sevelamer, and vancomycin dose should be dosed renally.
6. CIRRHOSIS ISSUES: There was a small amount of ascites.
If the patient spikes, need to consider spontaneous bacterial
peritonitis.
7. THROMBOCYTOPENIA ISSUES: The patient's platelets
increased after discontinuation of heparin. Likely due to
heparin-induced thrombocytopenia antibody. The patient
should not receive heparin. If the patient on heparin,
should monitor his platelets very carefully.
8. PHYSICAL CONDITION ISSUES: The patient was severely
deconditioned due to his long-term hospitalization. Physical
Therapy was working with him, and the patient needs 2-person
assistance for almost all activities including going from bed
to chair and ambulating. Therefore, the patient was to go to
rehabilitation for reconditioning.
CONDITION AT DISCHARGE: Condition on discharge was fair.
The patient can only ambulate with 2-person assistance.
DISCHARGE STATUS: Discharge status was to rehabilitation.
DISCHARGE DIAGNOSES:
1. Hypotension.
2. End-stage renal disease.
3. Cirrhosis.
4. Right ventricular failure.
5. Pulmonary hypertension.
6. Pericardial effusion.
7. Pulmonary effusion.
8. Sepsis.
MEDICATIONS ON DISCHARGE:
1. Pantoprazole 40 mg by mouth once per day.
2. Sevelamer 800 mg by mouth three times per day.
3. Docusate 100 mg by mouth twice per day as needed.
4. Nystatin 100,00 units per mL suspension 5 mL by mouth
three times per day.
5. Aspirin 81 mg by mouth once per day.
6. Lisinopril 2.5 mg by mouth once per day (hold for a
systolic blood pressure of less than 100).
7. Metoprolol 12.5 mg by mouth twice per day (hold for a
systolic blood pressure of less than 100 or a heart rate of
less than 60).
8. Prednisone taper starting with 10 mg by mouth once per
day for four days and then decrease to 5 mg by mouth once per
day for five days and then 2.5 mg by mouth once per day for
another five days and then off.
9. Nephrocaps 1 by mouth every day.
DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was instructed
to follow up with his primary care doctor in three to four
weeks.
DISCHARGE DIET: The patient was to be on a renal diet with
vanilla Reneph for breakfast and dinner.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(2) 8038**]
Dictated By:[**Name8 (MD) 18513**]
MEDQUIST36
D: [**2107-2-23**] 15:55
T: [**2107-2-22**] 16:14
JOB#: [**Job Number 29035**]
Name: [**Known lastname 5084**], [**Known firstname **] J Unit No: [**Numeric Identifier 5085**]
Admission Date: [**2107-2-16**] Discharge Date: [**2107-2-27**]
Date of Birth: [**2047-3-27**] Sex: M
Service:
ADDENDUM:
There were no further hospital events. The patient was just
waiting either to go to rehabilitation or go to home with
services and finally decided to go home with some home
services. We have set up everything. The patient was
discharged without any further events.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D.
Dictated By:[**Name8 (MD) 2742**]
MEDQUIST36
D: [**2107-2-27**] 10:24
T: [**2107-2-27**] 15:15
JOB#: [**Job Number 5086**]
|
[
"427.31",
"785.52",
"571.5",
"428.0",
"038.0",
"789.5",
"403.91",
"287.4",
"255.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
7446, 7629
|
7655, 8409
|
8444, 9659
|
4508, 7260
|
7275, 7425
|
170, 4474
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,253
| 185,074
|
410
|
Discharge summary
|
report
|
Admission Date: [**2146-7-15**] Discharge Date: [**2146-7-18**]
Service: MEDICINE
Allergies:
Valium
Attending:[**First Name3 (LF) 594**]
Chief Complaint:
abdominal pain and distention
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Age over 90 **]yo from [**Hospital **] rehab with h/o HTN, osteoperosis, and chronic
resp failure [**1-5**] to parkinson's disease, trached and peged d/t
multiple aspiration events admitted for abdominal distension x 7
days and LLQ abdominal pain.
.
The patient has a several-year history of bowel difficulty
attribtued to parkinson's disease and medication side-effect.
Now he presents with 7 days of abdominal distention and RLQ
abdominal pain relieved intermitently by bowel movements. Worse
over last 2 days. No emesis or fevers. The patient has been
followed at [**Hospital **] rehab where KUB on [**7-13**] showed mildly dilated
bowel with increased gas. In [**Hospital **] rehab, erythromycin was
started to promote peristalsis and a flexiseal was placed. The
patient had a large black guiac neg BM on day of admission but
continued to complain of abdominal discomfort.
.
Of note on [**6-24**] was seen in [**Hospital1 **] ED for leg pain and swelling as
well as abdominal pain. HCT was baseline. LENI was neg for DVT.
CT was initially read as unremarkable. Patient was d/c'ed to
rehab, final read identified new left anterior iliac bone
fracture. At rehab patient was noted to be in considerable pain
and grimacing with minimal manipulations. He was given ultram
for pain control. He was initially on prophylactic lovenox but
this was d/c'ed after Hct of 23.2 on [**7-14**] down from 27.2 on [**7-12**],
for which he recieved 1 unit of PRBC.
.
On admission to ED, VS were 99.7 60 129/46 20 99%. Labs showed
UA leukocytes +++, Bacteria +++; ABG 7.36/45/84; Cr/BUN 1.1/14
(from [**12-31**] [**6-13**] and 0.7/23 [**7-13**]); lactate 1.0. The patient did
not have a leukocytosis. He was given IV morphine 4mg + 6mg.
Past Medical History:
1. h/o aspiration PNA - Tx with levo, unasyn, vanco/zosyn in the
past
2. h/o aspiration s/p swallow eval with swallowing difficulty,
s/p [**Month/Year (2) 282**] placement on [**10-9**] - pt continues to feed for pleasure
at Heb Reb
3. Parkinson's
4. Osteoporosis
5. T11/12 compression fx
6. LLE osteomyelelitis as a child/Chronic osteomyelitis,
quiescent.
7. granulomatous liver disease
8. LUE rotator cuff tear
9. Prostate cancer s/p orchiectomy in [**2126**]
10. s/p laminectomy L4-5
11. Cataracts s/p surgery
[**46**]. Glaucoma
13. Hypertension
14. h/o of treatment for pseudomonas and aspiration PNA at heb
reb
15. s/p Trach with night ventilator support.
16. s/p wrist fx
17. chronic constipation
18. Chronic abd pain- per Heb Reb notes
19. Recent admission following vasovagal event at heb/reb s/p
chest compressions complicated by PTX s/p chest tube
Social History:
The patient has a sixty-pack-year history of tobacco. He quit in
[**12/2098**]. He lives at [**Hospital **] rehab MACU for last 3 hrs. He is a
retired history professor. [**First Name (Titles) **] [**Last Name (Titles) **], no alcohol intake.
- Tobacco: none
- Alcohol: none
- Illicits: none
Family History:
Non-contributory
Physical Exam:
Admission Physical Exam:
T: 99.0 BP: 106/68 O2: 100% on CMV FIO2 30%, Vt 500, PEEP 5,
RR 14
General: patient appears in pain, grimaces to lightest touch, he
is Alert, cooperative and performs command, he is trached and
speech is hard to understand, orientation thus difficult to
assess.
HEENT: Sclera anicteric, right ptosis and myosis with minimally
reactive pupil, left surgical non reactive pupil, MMM,
oropharynx clear, poor dentition
Neck: trache in place clean, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally
CV: distant sounds, RRR, no murmurs, rubs, gallops
Abdomen: G-tube in place with clean skin and no discharge,
distended with diffuse guarding, lightest touch causes pain in
pelvis, bowel sounds present
GU: condom cath
Ext: warm, well perfused, no cyanosis or edema
Neuro: moves four limbs, hard to assess beyond that d/t patients
discomfort.
.
Discharge Physical Exam:
T: 98.2 BP: 117/70 O2: 99% on CMV FIO2 30%, Vt 500, PEEP 5,
RR 14
General: patient appears comfortable; alert, cooperative; he is
trached and speech is hard to understand, answers yes/no
questions
HEENT: Sclera anicteric, right ptosis and myosis with minimally
reactive pupil, left surgical non reactive pupil, MMM,
oropharynx clear, poor dentition
Neck: trache in place clean, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally
CV: RRR, no murmurs, rubs, gallops
Abdomen: G-tube in place with clean surrounding-skin and no
discharge; distended, mildly tender to palpation, focal pain in
pelvis and left lower quadrant, bowel sounds present
GU: foley catheter draining clear yellow urine
Ext: warm, well perfused, no cyanosis or edema
Neuro: moves four limbs, right side contracted > left
Pertinent Results:
Admission Labs:
[**2146-7-15**] 03:00PM BLOOD WBC-8.1 RBC-3.45* Hgb-9.7* Hct-29.4*
MCV-85 MCH-28.0 MCHC-32.9 RDW-16.9* Plt Ct-295
[**2146-7-15**] 03:00PM BLOOD Neuts-83.7* Bands-0 Lymphs-11.3*
Monos-3.8 Eos-0.7 Baso-0.5
[**2146-7-15**] 03:00PM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-NORMAL Ovalocy-1+
[**2146-7-15**] 03:00PM BLOOD Glucose-63* UreaN-14 Creat-1.1 Na-131*
K-3.9 Cl-96 HCO3-24 AnGap-15
[**2146-7-15**] 03:00PM BLOOD ALT-9 AST-16 LD(LDH)-185 AlkPhos-133*
TotBili-0.5
[**2146-7-15**] 03:00PM BLOOD Lipase-9 GGT-7*
[**2146-7-15**] 03:00PM BLOOD CK-MB-3
[**2146-7-15**] 06:26PM BLOOD Type-ART PEEP-5 pO2-84* pCO2-45 pH-7.36
calTCO2-26 Base XS-0 Intubat-INTUBATED
.
Discharge labs:
[**2146-7-18**] 05:30AM BLOOD WBC-6.5 RBC-3.36* Hgb-9.3* Hct-29.4*
MCV-88 MCH-27.8 MCHC-31.7 RDW-17.5* Plt Ct-339
[**2146-7-18**] 05:30AM BLOOD Glucose-79 UreaN-12 Creat-1.1 Na-133
K-4.1 Cl-101 HCO3-27 AnGap-9
[**2146-7-17**] 07:00PM BLOOD CK-MB-4 cTropnT-0.09*
.
Portable abdomen: No evidence of free intraperitoneal air.
Interposition of colon between the abdominal wall and the liver.
There is gas marking and mild distention of the ascending,
transverse and descending colon. Gas marking of at least two
small bowel loops. No radiographic evidence of bowel wall
thickening. No pathological air-fluid levels. The rectum cannot
be assessed because of contrast material in the bladder.
.
Chest Portable for line placement: As compared to the previous
radiograph, the patient has received a right-sided PICC line.
The course of the line is unremarkable, the tip of the line
projects over the inflow tract of the right atrium. No
complications, notably no pneumothorax. Otherwise unchanged
radiograph.
.
CT abdomen/pelvis with contrast:
1. No evidence for obstruction; gastrostomy tube positioned
within the
stomach. However, the balloon is oriented towards pylorus which
is approaches within 2-3 cm, so intermittent prolapse more
distally toward the pylorus could be a potential cause of
intermittent obstruction which could be considered clinically.
2. Stable appearance of fractures.
3. Marked bony demineralization.
4. Small bilateral pleural effusions.
.
Pelvic X-Ray: Assessment of fine detail is markedly limited by
osteopenia underpenetration and overlying soft tissues. In
addition, the bladder is opacified by contrast and obscures the
sacrum. There is suggestion of a nondisplaced fracture involving
left superior and inferior pubic rami. The known left iliac [**Doctor First Name 362**]
fracture is not well visualized on this examination.
Urine culture: ESCHERICHIA COLI > 100,000
|
AMIKACIN-------------- 4 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
Brief Hospital Course:
[**Age over 90 **] year old from [**Hospital **] rehab with osteoperosis and parkinson's
disease, trached and peged d/t multiple aspiration events,
admitted for abdominal distension and pain. The patient was
admitted to the MICU due to trach with chronic ventilator
dependence.
# abdominal distension/pelvic pain: The patient was admitted
with abdominal distention, pain, and evidence of ileus on
abdominal X-ray. He was also found to have 2 left pelvic
fractures (one new, one old comminuted). Pain and distention
are likely due to fractures and constipation. The patient was
seen by GI, who felt that constipation is most likely due to
medication effect (ultram, sinemet) and avoidence of increasing
abdominal pressure due to pain from his pelvic fractures. The
patient underwent CT scan with PO contrast, that did not show
evidence of intestinal obstruction. He was started on an
intensive bowel regimen that increased his stool output. He was
then transitioned to his home bowel regimen. Abdominal pain
improved.
.
# Pelvic fractures: On admission, patient was found to have a
new nondisplaced fracture involving left superior and inferior
pubic rami. He also had a known left iliac [**Doctor First Name 362**] fracture.
Patient continued to produce urine through his condom cath, with
minimal free fluid in pelvis per CT. He was seen by orthopedics
who recommended conservative management of fractures -
weight-bearing as tolerated, pain control. His pain was
controlled with oxycodone and acetaminophen. He was started on
calcium, vitamin D, and was given 1 dose of IV bisphosphonate.
Patient may transfer from bed to chair.
.
# UTI: On admission, patient was found to have a urinary tract
infection. It returned positive for resistant E. Coli. He was
started on a 7 day course of ceftriaxone on [**2146-7-18**]. He will
complete 6 days of ceftriaxone upon discharge.
.
# Elevated troponin: Patient was admitted with a troponin of
0.08, and CK-MB of 3. Positive trop likely [**1-5**] to low GFR. The
patient did not have ischemic symptoms throughout admission. He
does have chronic ECG changes. Troponin and CK-MB remained
stable throughout admission.
.
# respiratory: Patient chronically trached. He was continued on
home ventilator settings throughout admission with no
respiratory difficulties. He was continued on home nebulizer
treatments.
.
# Parkinson's disease: Chronic. Patient with severe dysphagia
and tracheostomy. He was continued on home parkinson's
medications.
# Code: DNR/DNI
Medications on Admission:
Carbidopa-Levodopa 50-500 PO 7 times daily at 5, 8, 11, 14, 17,
20, 23.
Pramipexole 0.5mg PO Qpm + 0.125 QID@05, 08, 11, 14
Entacapone 200 mg PO seven times: 05, 08, 11, 14, 17, 20, 23
Lorazepam 0.5mg Q4h
Fluticasone 50 mcg 1 Spray Nasal [**Hospital1 **]
Ipratropium-Albuterol Four Puff Inhalation [**Hospital1 **]
Dorzolamide-Timolol 2-0.5 % 1 Drop [**Hospital1 **] both eyes.
Latanoprost 0.005 % Drops 1 Drop HS both eyes.
GEntamycin nebulizer 80mg [**Hospital1 **]
Acetylcystein 100mg Intratracheal [**Hospital1 **]
RaceEpinephrin 0.5ml q2h
Omeprazole 40mg daily
Acorbic acid 500mg QD
Docusate Sodium 100mg [**Hospital1 **]
Lactulose 15ml PO BID
Bisacodyl 10 mg QAM
erythromycine ethysuccinate 400mg Q6H (started [**7-13**])
Simethicon 80mg [**Hospital1 **]
Tamsulocin 0.4mg QHS
Polyethylene Glycol PO DAILY (Daily).
Chlorhexidine Gluconate 115 ml Swish and spit QID
Acetaminophen 325-650 mg PO Q6H as needed for pain.
Tramadol 25mg Q8h started [**7-14**]
Discharge Medications:
1. bisacodyl 10 mg Suppository [**Month/Year (2) **]: One (1) Suppository Rectal
QAM (once a day (in the morning)). Suppository(s)
2. carbidopa-levodopa 25-100 mg Tablet [**Month/Year (2) **]: Five (5) Tablet PO
SEE COMMENT (): PO 7 times daily: 05, 08, 11, 14, 17, 20, 23.
3. lactulose 10 gram/15 mL Solution [**Month/Year (2) **]: Fifteen (15) ML PO TID
(3 times a day).
4. dorzolamide-timolol 2-0.5 % Drops [**Month/Year (2) **]: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day): to both eyes.
5. latanoprost 0.005 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic HS (at
bedtime): both eyes.
6. pramipexole 0.125 mg Tablet [**Hospital1 **]: One (1) Tablet PO four times
a day: At 0500, 0800, 1100, 1400.
7. pramipexole 0.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO QPM (once a
day (in the evening)).
8. entacapone 200 mg Tablet [**Hospital1 **]: One (1) Tablet PO see below ():
seven times daily: 05, 08, 11, 14, 17, 20, 23
.
9. tamsulosin 0.4 mg Capsule, Ext Release 24 hr [**Hospital1 **]: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
10. lorazepam 0.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO every four
(4) hours.
11. ipratropium-albuterol 18-103 mcg/Actuation Aerosol [**Hospital1 **]: Four
(4) Puff Inhalation twice a day.
12. docusate sodium 50 mg/5 mL Liquid [**Hospital1 **]: Ten (10) ML PO BID (2
times a day): (take 100 mg [**Hospital1 **]) .
13. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
[**Hospital1 **]: One (1) Tablet, Chewable PO TID (3 times a day).
14. cholecalciferol (vitamin D3) 400 unit Tablet [**Hospital1 **]: One (1)
Tablet PO DAILY (Daily).
15. erythromycin ethylsuccinate 200 mg/5 mL Suspension for
Reconstitution [**Hospital1 **]: Ten (10) ML PO Q6H (every 6 hours): (400 mg
q6h) .
16. polyethylene glycol 3350 17 gram/dose Powder [**Hospital1 **]: One (1)
PO DAILY (Daily).
17. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital1 **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
18. ceftriaxone in dextrose,iso-os 1 gram/50 mL Piggyback [**Hospital1 **]:
One (1) Intravenous Q24H (every 24 hours) for 6 days.
19. simethicone 80 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet,
Chewable PO BID (2 times a day).
20. fluticasone 50 mcg/Actuation Spray, Suspension [**Hospital1 **]: One (1)
Nasal twice a day.
21. racepinephrine 2.25 % Solution for Nebulization [**Hospital1 **]: 0.5 ML
Inhalation q 2 hrs prn as needed for shortness of breath or
wheezing.
22. omeprazole 40 mg Capsule, Delayed Release(E.C.) [**Hospital1 **]: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
23. ascorbic acid 500 mg Capsule, Extended Release [**Hospital1 **]: One (1)
Capsule, Extended Release PO once a day.
24. chlorhexidine gluconate 0.12 % Mouthwash [**Hospital1 **]: One
Hundred-Fifteen (115) ML Mucous membrane four times a day: swish
and spit .
25. acetaminophen 650 mg/20.3 mL Solution [**Hospital1 **]: One (1) PO TID
(3 times a day) as needed for fever or pain.
26. oxycodone 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
27. morphine 5 mg/mL Solution [**Hospital1 **]: Five (5) mg Injection every
four (4) hours as needed for pain: use for breakthough pain or
if unable to take by G-tube.
28.
Acetylcysteine 100 mg intratracheal [**Hospital1 **]
29.
Gentamicin nebulizer 80 mg [**Hospital1 **]
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary: New left superior pubic ramus fracture; comminunition
and lateral displacement of left iliac fractures;
ileus/constipation; urinary tract infection
Secondary: Parkinson's disease; Osteoporosis; Hypertension; s/p
Trach with ventilator support; chronic constipation
Discharge Condition:
Alert, able to answer yes/no questions
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Mr. [**Known lastname **],
You were admitted to the [**Hospital1 18**] ICU for abdominal pain. You were
found to have a new pelvic fracture and an old pelvic fracture
on your left side. You were seen by orthopedic surgery, who
recommended pain control managment of your fractures. Per
orthopedics, you may transfer from bed to chair with your hip
fractures. You were also found to have some constipation. You
underwent imaging studies that showed no evidence of bowel
obstruction. You were seen by gastroenterology, who felt that
your constipation may be a cumulative side effect of some of
your medications. However, these medications are important for
your parkinson's disease. You were put on an intensified
bowel-regimen for your constipation, then transitioned to your
home regimen. On admission, we also diagnosed you with a
urinary tract infection, and we started you on a 7 day course of
ceftriaxone. While in the hospital, you only completed one day
of your ceftriaxone. You should continue 6 more days when you
go back to [**Hospital3 **].
Medication changes made on admission:
START ceftriaxone x 6 days
START calcium carbonate
START cholecalciferol
START 5% lidocaine patch to left hip for pain - change daily
START oxydocone 5mg by G-tube every 4 hours as needed for pain
START tylenol 650 mg by mouth every 8 hours as needed for pain
START morphine 5 mg IV every 4 hours as needed for pain - use
for breakthrough pain
STOP ultram
Followup Instructions:
You are being discharged to a medical facility. Please follow
up with your medical doctors at your facility. Please follow up
with Dr. [**First Name (STitle) 572**] at your earliest convenience.
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,797
| 164,212
|
3904+55481
|
Discharge summary
|
report+addendum
|
Admission Date: [**2153-3-16**] Discharge Date: [**2153-4-4**]
Date of Birth: [**2072-7-6**] Sex: F
Service: CARDIOTHORACIC
Allergies:
metoprolol
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
[**2153-3-19**] Mitral (28mm ring) and Tricuspid valve (28mm ring)
repair
[**2153-3-16**] Cardiac cath
History of Present Illness:
Ms. [**Known lastname **] is n 80-year-old woman with longstanding MVP and
moderate-to-severe MR who is recovering from multiple
hospitalizations, most recently due to severe congestive heart
failure in [**2152-11-26**]. Currently she admits to feeling stronger.
Her endurance remains poor, and she continues to experience
exertional dyspnea. Her appetite is good, and she is eating
three meals per day and two snacks. The head of her bed remains
elevated at all times to prevent aspiration.
** Per cardiology, she is unable to tolerate dabigatran, and she
cannot have a TEE because of her esophageal issues. She is on
Warfarin **. Given mitral and tricuspid regurgitation with
worsening PA pressures, she was admitted for cardiac cath today
and found to have clean coronaries. She will be placed on
heparin drip and await MVR on [**2153-3-19**].
Past Medical History:
Mitral and Tricuspid valve regurgitation s/p mitral and
tricuspid valve repair
Past medical history:
- Congestive Heart Failure
- Pulmonary Hypertension
- History of Aspiration Pneumonia's
- Restrictive/Interstitial Lung Disease
- Osteoporosis
- "Patulous" esophagus/Achalasia - s/p botox injections
- Atrial Fibrillation
- History of Shingles
- Leiomyoma, s/p TAH [**2108**]
- Cyst on back removed in [**2103**].
- S/P tonsillectomy.
- s/p Breast fibroadenoma left aspiration, [**2137**]
Social History:
Lives with: Husband
Occupation: Retired Professor [**First Name (Titles) **] [**Last Name (Titles) 483**] Literature
Cigarettes: Quit smoking at 41, approximately 20-25 pk yr hx
ETOH: < 1 drink/week
Illicit drug use: Denies
Family History:
Father died of a heart attack in his 70's. Mother died of
congestive heart failure at age 88. She is married with three
stepchildren and four grandchildren.
Physical Exam:
Pulse: 112 Resp: 16 O2 sat: 94%
B/P Right: 111/67 Left: 113/70
Height: 5'4" Weight: 97lbs
General: Thin elderly female in no acute distress
Skin: Dry [X] intact [Stage I on coccyx]
HEENT: PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] Murmur [X] grade [**3-2**]
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] Edema - trace
right>left
Varicosities: None [X]
Neuro: Grossly intact [X]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 1+ Left: 2+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: cath site Left: 2+
Carotid Bruit Right: - Left: radiating
Pertinent Results:
[**2153-4-3**] 03:50AM BLOOD WBC-10.7 RBC-3.67* Hgb-11.2* Hct-36.6
MCV-100* MCH-30.5 MCHC-30.6* RDW-15.3 Plt Ct-417
[**2153-4-2**] 02:48AM BLOOD WBC-10.2 RBC-3.25* Hgb-10.0* Hct-32.1*
MCV-99* MCH-30.7 MCHC-31.1 RDW-14.5 Plt Ct-342
[**2153-4-1**] 04:46AM BLOOD WBC-8.9 RBC-3.21* Hgb-10.0* Hct-31.7*
MCV-99* MCH-31.2 MCHC-31.7 RDW-14.5 Plt Ct-330
[**2153-4-3**] 03:50AM BLOOD PT-17.2* PTT-27.9 [**Year/Month/Day 263**](PT)-1.6*
[**2153-4-2**] 02:48AM BLOOD PT-15.8* [**Year/Month/Day 263**](PT)-1.5*
[**2153-4-1**] 04:46AM BLOOD PT-13.7* PTT-28.1 [**Year/Month/Day 263**](PT)-1.3*
[**2153-3-31**] 01:53AM BLOOD PT-14.8* PTT-28.4 [**Year/Month/Day 263**](PT)-1.4*
[**2153-3-30**] 02:47AM BLOOD PT-15.6* PTT-28.9 [**Year/Month/Day 263**](PT)-1.5*
[**2153-3-29**] 02:46AM BLOOD PT-17.5* [**Year/Month/Day 263**](PT)-1.6*
.
[**2153-3-16**] Cath: 1. Selective coronary angiography in this right
dominant system demonstrated no angiographically apparent
flow-limiting CAD although atherosclerosis was evident. The
LMCA had an ostial 20% lesion. The LAD had a ostial 25% lesion,
large D2 and distal vessel that wraps around the apex. The LCX
had a 40% ostial stenosis and tortuous large OM3 and LPL. The
RCA had a vertical origin, luminal irregularities to 30% in the
mid and distal section. Tortuous RPDA, RPL1 and AM vessels were
noted as well as a modest caliber RPL2. 2. Resting hemodynamics
revealed elevated biventricular filling pressures with a mean
PCWP 35mm Hg and mean RVEDP 17mmHg at rest. Severe pulmonary
arterial hypertension with systolic, diastolic, and mean PA
pressures of 70/28/44mm Hg. Prominent V waves consistent with
significant mitral regurgitation was also noted. Low cardiac
output cardiac index was reduced at 1.50 L/min/m2. Entry PVR of
328 dyne-sec/cm5 and SVR of 3138 dyne-sec/cm5 was noted.
.
[**2153-3-19**] Echo: Unable to pass TEE probe. Resistance in upper
esophagous
Limited epicardial study
Prebypass: The aortic valve leaflets are mildly thickened. Trace
aortic regurgitation is seen. The mitral valve leaflets are
moderately thickened. Moderate to severe (3+) mitral
regurgitation is seen. Moderate [2+] tricuspid regurgitation is
seen. LV systolic function appeaqrs to be moderately globally
depress (LVEF-35-40%)
Post Bypass: The patient is on epinephrine 0.05 uck/kg/min LV
function now appears normal in the setting of inotropes (LVEF~
55%) There are ring prosthese in the mitral and tricuspid
position. No residual MR [**First Name (Titles) **] [**Last Name (Titles) **] is visualized.
.
[**2153-3-21**] Head CT
CT HEAD W/O CONTRAST Study Date of [**2153-3-21**] 11:58 AM
[**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG CSRU [**2153-3-21**] 11:58 AM
CT HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) 17413**]
Reason: eval for CVA in patient with right sided weakness,
lethargy
[**Hospital 93**] MEDICAL CONDITION:
80 year old woman s/p MV repair, TV repair
REASON FOR THIS EXAMINATION:
eval for CVA in patient with right sided weakness, lethargy
s/p MV repair, TV
repair
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Final Addendum
COMMENT: The above findings were made at 2:55 p.m, and discussed
with Ms.
[**First Name8 (NamePattern2) 3692**] [**Last Name (NamePattern1) **], N.P., Cardiac Surgery service (and not "Ms.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],
N.P." as incorrectly stated in the original report), via
telephone, at 3:00
p.m, on [**2153-3-21**].
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 17414**] [**Name (STitle) 17415**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7593**]
Approved: MON [**2153-3-26**] 1:54 PM
[**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG CSRU [**2153-3-21**] 11:58 AM
CT HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) 17413**]
Reason: eval for CVA in patient with right sided weakness,
lethargy
[**Hospital 93**] MEDICAL CONDITION:
80 year old woman s/p MV repair, TV repair
REASON FOR THIS EXAMINATION:
eval for CVA in patient with right sided weakness, lethargy
s/p MV repair, TV
repair
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Final Report
INDICATION: 80-year-old woman, status post mitral and tricuspid
valve repair,
with now right-sided weakness and lethargy.
COMPARISON: None.
TECHNIQUE: MDCT images were acquired through the head without
intravenous
contrast.
FINDINGS: There is no evidence of intracranial hemorrhage,
edema, mass, or
mass effect. A new relatively well-defined hypodense region in
the medial
left frontal lobe, in the ACA territory, is consistent with an
acute
infarction. A tiny focus of hyperdensity in the parasagittal
frontal location
(2:8) may represent a focal "hyperdense ACA" with intramural
thrombus versus
plaque. No intracranial hemorrhage is detected. There is mild
mass effect on
the frontal [**Doctor Last Name 534**] of the ipsilateral lateral ventricle. No
rightward shift of
midline structures is seen. The basal cisterns are normal. The
imaged
paranasal sinuses and mastoid air cells are clear.
IMPRESSION: Acute left ACA territory infarct, with possible
focal
hyperdensity in the A2/A3 segment of the left ACA, which may
represent in situ
thrombus versus embolized atheromatous plaque (or other
material).
COMMENT: The above findings were made at 2:55 p.m, and discussed
with Ms.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], N.P. (Cardiac Surgery service) at 3:00 p.m on
[**2153-3-21**].
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 17414**] [**Name (STitle) 17415**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7593**]
Approved: WED [**2153-3-21**] 4:55 PM
Imaging Lab
.
[**2153-3-22**] MR [**Name13 (STitle) 430**]
Final Report
INDICATION: Stroke, status post MVR.
COMPARISON: CT head [**2153-3-21**].
TECHNIQUE: MRI and MRA of the head was obtained without contrast
and MRA of
the neck was obtained before and after administration of
contrast per
department protocol.
FINDINGS:
MRI HEAD: There is an area of slow diffusion in the left frontal
lobe
extending into the corpus callosum with accompanying FLAIR
signal abnormality.
There is no signal abnormality on the gradient echo images to
suggest
hemorrhage. There is no mass effect or midline shift seen.
Ventricles and
sulci are age appropriate. The major intracranial flow voids
appear
preserved. A 6mm size T1 hyperintense lesion is noted within the
anterior
pituitary. Visualized orbits and mastoid air cells are
unremarkable. There is
mild mucosal thickening in the ethmoid air cells bilaterally.
MRA HEAD: The MRA of the head is compromised by motion
artifacts. In the
left A2 segment is not well visualized. Bilateral internal
carotid arteries,
vertebral arteries, basilar arteries are patent with no evidence
of
flow-limiting stenosis, occlusion, dissection or aneurysm
formation. The
right vertebral artery is dominant.
MRA NECK: Aortic arch shows normal three-vessel takeoff.
Bilateral common
carotid arteries, vertebral arteries in the neck and internal
carotid arteries
are patent with no evidence of stenosis, occlusion, dissection
or
pseudoaneurysm formation. The left vertebral artery is seen
arising directly
from the aortic arch.
IMPRESSION:
1. Left A2 occlusion with early subacute infarct in the left ACA
territory as
described above. No evidence of hemorrhagic transformation.
2. 6mm size T1 hyperintense lesion is noted within the anterior
pituitary, may
represent a Rathke cleft cyst, and less likely hemorrhagic
adenoma.
2. Unremarkable MRA of the neck.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) **] [**Name (STitle) **]
DR. [**First Name (STitle) **] [**Known lastname 12563**]
Approved: FRI [**2153-3-23**] 5:48 PM
Imaging Lab
.
[**2153-3-24**] Echo
Conclusions
The left atrium is elongated. No mass/thrombus seen in the left
or right atrium, but this study is not adequate to fully exclude
atrial/atrial appendage thrombus ((ie atrial appendages not well
visualized). There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is severe global left
ventricular hypokinesis (LVEF = 15 %). The estimated cardiac
index is depressed (<2.0L/min/m2). No masses or thrombi are seen
in the left ventricular apex. Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg). The
right ventricular cavity dilated with severe global free wall
hypokinesis. The aortic root is mildly dilated at the sinus
level. The aortic valve leaflets (3) are mildly thickened
without aortic stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. A mitral valve
annuloplasty ring is present. No mitral regurgitation is seen,
though cannot exclude fully due to acoustic shadowing from the
ring. The tricuspid valve leaflets are mildly thickened. A
tricuspid valve annuloplasty ring is present. Physiologic
tricuspid regurgitation is seen, though may be underestimated
due to shadowing. The estimated pulmonary artery systolic
pressure is normal. The pulmonic valve leaflets are thickened.
There is no pericardial effusion.
IMPRESSION: Severely reduced global systolic function of the
left and right ventricle. Mitral and tricuspid annuloplasty
rings present. No mass or thrombi seen in the atria, though
cannot fully exclude by transthoracic echocardiography. Mildly
dilated aortic sinus.
Compared with the prior study (images reviewed) of [**2153-1-31**], the
left ventricular function is markedly depressed. Mitral and
tricuspid annuloplasty rings are now noted.
If suspicion for atrial thrombus is high, consideration can be
given to other imaging studies (eg cardiac MRI, CT), as the
patient is unable to undergo TEE.
.
[**2153-3-25**] RUQ ultrasound
Final Report
INDICATION: 80-year-old woman with increasing LFTs, assess for
portal vein
thrombus.
COMPARISONS: [**2152-4-30**].
The liver is normal in echotexture without focal lesion, intra-
or
extra-hepatic biliary ductal dilatation. The portal vein and its
major
branches are patent. Pulsatile flow is seen in the portal vein
which may
reflect underlying cardiac dysfunction. Common bile duct is not
dilated
measuring 4 mm. Small amount of sludge is seen in the
gallbladder which is
otherwise unremarkable in appearance without wall thickening,
distention or
pericholecystic fluid to suggest cholecystitis. Trace
perihepatic ascites is
seen.
IMPRESSION:
1. Patent portal vein without evidence of thrombus. Pulsatility
in the
portal vein could reflect underlying cardiac disease.
2. Trace perihepatic ascites.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Name (STitle) 815**]
DR. [**First Name11 (Name Pattern1) 8711**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: MON [**2153-3-26**] 7:33 AM
.
Brief Hospital Course:
As mentioned in the HPI, Ms. [**Known lastname **] [**Last Name (Titles) 1834**] cardiac cath on [**3-16**]
and was admitted following cath. She was medically managed,
including Heparin, and [**Month/Year (2) 1834**] further surgical work-up. On
[**3-19**] she was brought to the operating room where she [**Month/Year (2) 1834**] a
mitral and tricuspid valve repair. She received Vancomycin and
Kefzol for prophylaxis given her inpatient length of stay
greater than 24 hours. Please see operative note for surgical
details. Following surgery she was transferred to the CVICU for
invasive monitoring in stable condition. Within 24 hours she was
weaned from sedation, and extubated. She was initially drowsy.
Later, on POD 1, she failed to follow commands and exhibited
right sided weakness. Neurology was consulted. Head CT
revealed left ACA infarct. Neurology continued to follow.
Anti-coagulation was initiated with heparin and coumadin. EEG
was instituted to assess for seizure activity. She remained in
atrial fibrillation. Digoxin was resumed and lopressor titrated
as tolerated. She was initially loaded with Keppra for seizure
activity noted on EEG, however due to worsening somnolence, it
was discontinued. Infarct was followed on CT to evaluate for
hemorrhagic conversion in the setting of anti-coagulation for
atrial fibrillation. LFTs became elevated. RUQ ultrasound did
not reveal acute findings. She remained in the CVICU for close
observation of airway protection in the setting of her infarct
and rhoncherous secretions. A Dobhoff tube was placed for tube
feeds. All lines and drains were discontinued per protocol.
Current clinical picture is consistent with Left ACA infarct
likely due to embolic
etiology and exam shows profound abulia with a right
hemiparesis. Her level of arousal is depressed. She remains
hemodynamically stable in rate controlled afib. In light of her
neuro status she [**Month/Year (2) 1834**] successful open J -tube on POD#13
and had been tolerating her tube feeds well. On POD 15 she was
discharged to [**Hospital3 **] in [**Hospital1 8**]. All follow
up appointments were advised.
Medications on Admission:
ATENOLOL 25 mg daily
DIGOXIN .0625 mcg daily
FUROSEMIDE 20 mg daily
WARFARIN - 5 mg Tablet - take 1 Tablet(s) by mouth once a day or
as directed by Anticoag coumadin clinic [**Hospital1 18**] (Dr. [**First Name (STitle) **]
****last dose [**2153-3-12**]
CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 600 + D(3)] - 600 mg-400
unit daily
Discharge Medications:
1. Outpatient Lab Work
Coumadin for AFib
Goal [**Month/Day/Year 263**] 2-2.5
Next [**Month/Day/Year 263**] check [**2153-4-4**], then please check Monday, Wednesday,
Friday x 2 weeks. Please arrange for coumadin follow-up prior
to discharge from rehab
2. magnesium hydroxide 400 mg/5 mL Suspension [**Month/Day/Year **]: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
3. warfarin 1 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY (Daily):
dose to change daily for goal [**Month/Day/Year 263**] 2-2.5.
4. bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Month/Day/Year **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
5. docusate sodium 50 mg/5 mL Liquid [**Month/Day/Year **]: One (1) PO BID (2
times a day).
6. ipratropium bromide 0.02 % Solution [**Month/Day/Year **]: One (1) Inhalation
Q4H (every 4 hours) as needed for SOB.
7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Month/Day/Year **]: One (1) Inhalation Q4H (every 4 hours) as
needed for SOB.
8. aspirin 81 mg Tablet, Chewable [**Month/Day/Year **]: One (1) Tablet, Chewable
PO DAILY (Daily).
9. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
10. metoprolol tartrate 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID
(3 times a day).
11. digoxin 125 mcg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO QOD.
12. acetaminophen 500 mg/5 mL Liquid [**Last Name (STitle) **]: [**11-27**] PO every [**3-2**]
hours as needed for fever or pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**]
Discharge Diagnosis:
Mitral and Tricuspid valve regurgitation s/p mitral and
tricuspid valve repair
Past medical history:
- Congestive Heart Failure
- Pulmonary Hypertension
- History of Aspiration Pneumonia's
- Restrictive/Interstitial Lung Disease
- Osteoporosis
- "Patulous" esophagus/Achalasia - s/p botox injections
- Atrial Fibrillation
- History of Shingles
- Leiomyoma, s/p TAH [**2108**]
- Cyst on back removed in [**2103**].
- S/P tonsillectomy.
- s/p Breast fibroadenoma left aspiration, [**2137**]
Discharge Condition:
Somnolent, Deconditioned
Incisional pain managed with oral analgesia
Incisions: Sternal - healing well, no erythema or drainage
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:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] Date/Time:[**2153-4-25**] 1:15
Cardiologist: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2003**], NP (for Dr. [**Last Name (STitle) 171**]
[**Telephone/Fax (1) 62**] Date/Time:[**2153-4-24**] 2:00
Please call to schedule appointments with your
Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**3-1**] weeks, [**Telephone/Fax (1) 2010**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2153-4-3**] Name: [**Known lastname 2547**],[**Known firstname 1940**] M Unit No: [**Numeric Identifier 2548**]
Admission Date: [**2153-3-16**] Discharge Date: [**2153-4-4**]
Date of Birth: [**2072-7-6**] Sex: F
Service: CARDIOTHORACIC
Allergies:
metoprolol
Attending:[**First Name3 (LF) 741**]
Addendum:
Ms. [**Known lastname **] remained in the hospital for one further day due to
insurance issues with the rehab. She was discharged to
[**Hospital3 **] on [**2153-4-4**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 41**]
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2153-4-4**]
|
[
"427.31",
"E878.8",
"707.22",
"515",
"496",
"416.8",
"V58.61",
"434.11",
"428.0",
"780.39",
"276.0",
"707.03",
"530.0",
"428.42",
"424.0",
"V15.82",
"733.00",
"348.30",
"997.02",
"263.9",
"342.90",
"397.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.33",
"88.56",
"46.39",
"96.6",
"37.23",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
21032, 21199
|
13996, 16135
|
283, 387
|
18720, 18859
|
2955, 5794
|
19782, 21009
|
2033, 2191
|
16514, 18120
|
6954, 6997
|
18209, 18288
|
16161, 16491
|
18883, 19759
|
2206, 2936
|
236, 245
|
7029, 13973
|
415, 1263
|
18310, 18699
|
1792, 2017
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,725
| 160,422
|
5065
|
Discharge summary
|
report
|
Admission Date: [**2157-9-12**] Discharge Date: [**2157-9-20**]
Date of Birth: [**2115-7-19**] Sex: F
Service: NEUROSURGERY
Allergies:
Lamictal / Motrin / Aspirin / Iodine / Zonisamide / Vancomycin
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
head ache, swelling in eyes
Major Surgical or Invasive Procedure:
Incision and drainage of cranioplasty wound, removal of
cranioplasty prosthetisis.
History of Present Illness:
42 y/o woman who is s/p a cranioplasty with a Porex prosthesis
by Dr. [**Last Name (STitle) 739**] on [**2157-8-30**], being transferred from Lakes
[**Hospital 12018**] Hosp. in [**Location (un) 11252**], NH (Dr. [**Last Name (STitle) 20889**], [**First Name3 (LF) **] physician). Ms.
[**Known lastname 20695**] paged me this AM and described symptoms of a "knot" on
her R neck, swollen R eye, and shaking chills. Patient told
come to the [**Hospital1 18**] ED for evaluation, but she declined,
preferring to go to her local ED. She was febrile at LRH to 103
F, and a contrast head CT showed enhancement of fluid
collections superficial and deep to her prosthesis. She
received a dose of clindamycin in OSH, blood culture sent only ,
then was transferred here for further care.
Past Medical History:
PMHx: 1) s/p recent cranioplasty, as mentioned above. She
underwent temporal lobe resection approximately 18 mo. ago for
intractable epilepsy, and did well until an MVA in [**11-11**]. Her
seizures returned, and she suffered a R head wound which
developed into MRSA osteo, requiring craniectomy. She wore a
helmet from that time until her cranioplasty on [**2157-8-30**].
2) asthma.
3) morbid obesity
Social History:
Lives at home with her husband. Denies EtOH or
tobacco.
Family History:
N/C
Physical Exam:
O: Tc: 102.5 (103 at OSH) BP: 127/66 HR: 107 (NSR) RR: 8
O2Sat.: 98%
Gen: Morbidly obese. In obvious distress, drowsy.
HEENT: Significant erythematous, non-fluctuant edema over R prox
neck, R eye and over cranioplasty. Some purulent drainage from
rostral aspect of incision.
Lungs: CTA bilaterally. No R/R/W.
Cardiac: RRR. S1/S2. No M/R/G.
Abd: Soft, NT, ND.
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Drowsy but arousable to voice. Cooperative with
exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Cranial Nerves:
I: Not tested
II: L Pupil 4mm and reactive to light. Fundus: L optic disc
margin sharp. Unable to see R pupil [**2-9**] significant
periorbitaledema.
III, IV, VI: Extraocular movements intact on L without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-12**] throughout on R, [**4-12**] throughout
on left. No pronator drift
Sensation: Intact to light touch and symmetric throughout.
Reflexes: B T Br Pa Ac
Right 1+--------->
Left 3+--------->
Toes downgoing bilaterally
3-4 beats of clonus on left.
Gait: unable to assess.
Pertinent Results:
[**2157-9-13**] GLUCOSE-184* UREA N-11 CREAT-0.8 SODIUM-138
POTASSIUM-3.6 CHLORIDE-104 TOTAL CO2-22 ANION GAP-16
[**2157-9-13**] CALCIUM-7.6* PHOSPHATE-3.1 MAGNESIUM-1.5*
[**2157-9-13**] WBC-16.9* RBC-4.06* HGB-11.3* HCT-32.9* MCV-81*
MCH-27.8 MCHC-34.3 RDW-15.0
[**2157-9-13**] PLT COUNT-245
[**2157-9-13**] PT-13.5* PTT-20.7* INR(PT)-1.2
[**2157-9-12**] URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2157-9-12**] URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG
KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG
[**2157-9-12**] URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE EPI-0
[**2157-9-12**] LACTATE-2.4*
Brief Hospital Course:
42 year old female s/p right craniectomy for wound infection
under general anesthesia without intraoperative complications on
[**2157-9-12**].Patient transferred to surgical ICU for close monitoring
postoperatively, extubated late afternoon of [**9-13**], did well after
extubation able to transfer to floor that night. Mannitol weaned
to off in 3 days.Post opertive Head CT was stable,
neurologically able to follow commands.
Her wound cultures were staph aureus coag +, sensativities to
Oxacillin. Her antibiotics were tailored to Oxacillin Q4, she
will be sent home with IV antibiotics from a home infusion
company.
Physical therapy cleared her as to be safe to go home.
Medications on Admission:
keppra
peroxetine
neurontin
Discharge Medications:
1. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
2. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Gabapentin Oral
8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Oxacillin Sodium 10 g Recon Soln Sig: [**1-12**] Recon Soln
Injection Q4H (every 4 hours) for 4 weeks: 2 GM Q4.
Disp:*36 Recon Soln(s)* Refills:*0*
10. Outpatient Lab Work
Please check CBC w/ diff, urinalysis, serum creatinine, BUN and
LFT's weekly. Fax results to [**Telephone/Fax (1) 1419**].
11. Outpatient Physical Therapy
Home PT - please evaluate and treat
Discharge Disposition:
Home With Service
Facility:
Infusion Solutions, [**Location (un) **] NH
Discharge Diagnosis:
Wound Infection
Discharge Condition:
Neurologically stable
Discharge Instructions:
1) Watch incision for redness, drainage, bleeding,increase
swelling, fever greater than 101.5 or any change in neurologic
status call Dr.[**Name (NI) 4674**] office.
2) Have your labs checked once weekly and have results faxed to
[**Telephone/Fax (1) 1419**], per your lab prescription.
3. Home PT
Followup Instructions:
1) Follow up for suture removal [**9-26**] with Dr. [**Last Name (STitle) **] call
[**Telephone/Fax (1) 2731**] for appt.
2) Dr. [**Last Name (STitle) 5840**] in [**Hospital **] clinic on [**10-17**] at 11:00.
3) Follow up with Dr. [**Last Name (STitle) 739**] at the time of your
Infectious Disease appointment, if possible. Call [**Telephone/Fax (1) 1669**]
for appt.
Completed by:[**2157-9-22**]
|
[
"278.01",
"324.0",
"719.41",
"730.28",
"493.90",
"780.39",
"996.69",
"438.30",
"041.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59",
"02.91",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
5740, 5814
|
3982, 4657
|
355, 440
|
5874, 5898
|
3317, 3959
|
6245, 6645
|
1770, 1776
|
4735, 5717
|
5835, 5853
|
4683, 4712
|
5922, 6222
|
1791, 2207
|
288, 317
|
468, 1251
|
2423, 3298
|
2222, 2407
|
1273, 1679
|
1695, 1754
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,195
| 173,653
|
41231
|
Discharge summary
|
report
|
Admission Date: [**2180-6-8**] Discharge Date: [**2180-6-10**]
Date of Birth: [**2129-6-17**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 32612**]
Chief Complaint:
Post-RFA bleeding
Major Surgical or Invasive Procedure:
[**2180-6-8**]: CT-guided RFA ablation of hepatic segment VII
History of Present Illness:
50F with metastatic invasive lobular carcinoma with recurrence
of liver lesions despite prior resection presents s/p RFA today
of segment VII lesion. The lesion was diagnosed in [**2179-4-6**],
then not seen with ultrasound in [**2179-11-6**]. However, in [**Month (only) 958**]
she had a CT scan with a 2.4 x 3.4 cm lesion in VII with
subsequent FNA showing poorly differentiated adenocarcinoma. She
saw Dr. [**Last Name (STitle) **] in clinic on [**2180-5-19**] where a resection was
recommended. Patient elected for RFA ablation instead, and
underwent said procedure on [**2180-6-8**].
Past Medical History:
PMH:
Breast cancer- invasive lobular, dx [**2175**] ER /PR + but HER-2
Negative,s/p rx with Zoladex, tamoxifen, Letrozole,
Liver mets, Hepatitis as a child NOS
PSH:
Partial mastectomy, ALND, partial liver resection [**2177**] lateral
seg?( [**Country 10181**]) a child, c-sections x2
Social History:
She is a stay at home mother of 2 children ages 23 and 17. She
is here in [**Location (un) 86**] for their schooling and her husband works in
[**Name (NI) 651**]. She denies any tobacco use or alcohol abuse.
Family History:
No family history of cancers. Both parents had HTN and
fatherdied from a stroke.
Physical Exam:
98.5 98.9 75 108/68 18 99%
GEN: NAD, A&Ox3
CV: RRR
PULM: CTAB
ABD: s/nt/nd; wound dressed, dressing c/d/i
EXT: warm, well-perfused
Neuro: grossly intact
Pertinent Results:
[**2180-6-8**] 01:47PM HGB-11.0* calcHCT-33 O2 SAT-99
[**2180-6-8**] 01:47PM GLUCOSE-129* LACTATE-0.8 NA+-136 K+-3.4
CL--105
[**2180-6-8**] 02:45PM WBC-5.3 RBC-2.37*# HGB-6.6*# HCT-21.1*#
MCV-89 MCH-27.7 MCHC-31.2 RDW-13.4
[**2180-6-8**] 05:08PM HGB-11.7* calcHCT-35
[**2180-6-8**] 05:47PM WBC-8.4# RBC-4.24# HGB-11.8*# HCT-36.8#
MCV-87 MCH-27.9 MCHC-32.1 RDW-13.6
[**2180-6-9**] 07:00PM BLOOD Hct-35.4*
[**2180-6-10**] 12:44AM BLOOD Hct-32.2*
CT Guided RFA/Abdomen: [**2180-6-8**]
Bilateral subsegmental atelectasis is seen. The visualized
portions of the heart are within normal limits. The patient is
status post
resection of segment II and III.
Reidentified is the hypoattenuating lesion in segment VII.
No other lesions are seen within the liver.
Post-procedurally, small extravasation focus and subcapsular
bleeding was
identified, as described. Small amount of perihepatic fluid is
seen. The
gallbladder is within normal limits. The spleen, pancreas, and
both adrenals are within normal limits. Both kidneys enhance and
excrete normally. No concerning lymphadenopathy is seen within
the abdomen. No free fluid is identified within the abdomen. The
aorta and its branches are within normal limits.
The portal vein, splenic vein, and SMV are of normal caliber and
patent.
OSSEOUS STRUCTURES: No concerning lytic or osteoblastic lesions
are seen.
Limited examination of pelvis revealed small amount of pelvic
fluid.
Brief Hospital Course:
he patient was admitted to the General Surgical Service for
serial hematocrit monitoring after RFA ablation of a liver
lesion with subsequent subcapsular bleeding. The reader is
referred to the procedure note for details. After a brief,
uneventful stay in the SICU, with NPO status and serial
hematocrit checks, the patient arrived on the floor on HD#2. The
patient was hemodynamically stable.
Neuro: The patient received IV dilaudid with good effect and
adequate pain control. When tolerating oral intake, the patient
was transitioned to oral pain medications.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored. Her blood
pressures remained stable, and as stated her hematocrits were
stable between 32 and 36 and was stable at 32 upon discharge.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored.
GI/GU/FEN: Post-procedure, the patient was made NPO with IV
fluids. Diet was advanced as tolerated on HD#2, which was well
tolerated. Patient's intake and output were closely monitored,
and IV fluid was adjusted when necessary.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection, of which there were
none.
Hematology: The patient's hematocrit was serially monitored; no
transfusions were required.
Prophylaxis: The patient wore venodyne boots during her stay;
she was encouraged to get up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. She will follow up with her
PCP and oncologist.
Medications on Admission:
Fosamax, Anastrozole, Vit D3, MVI
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain for 1 weeks.
Disp:*30 Tablet(s)* Refills:*0*
2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day for
2 weeks: when taking narcotics to prevent constipation.
Disp:*28 Capsule(s)* Refills:*0*
3. multivitamin Tablet Sig: One (1) Tablet PO once a day.
4. Vitamin D3 Oral
5. anastrozole 1 mg Tablet Oral
6. Fosamax Oral
Discharge Disposition:
Home
Discharge Diagnosis:
1. Metastatic breast cancer with recurrence of liver lesions
2. Status-post RFA ablation of liver lesions with post-RFA
bleeding
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
General Discharge Instructions:
Please resume all regular home medications, unless specifically
advised not to take a particular medication. You were
prescribed oxycodone, a pain medication, and should take it as
prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**6-15**] lbs and strenuous activity for the
next 4-6 weeks.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
Followup Instructions:
Please follow-up with your oncologist and PCP as they have
directed.
You may call Dr.[**Name (NI) 32613**] office at ([**Telephone/Fax (1) 86295**] to discuss
further follow-up/care regarding the lesion ablated on your
liver and surgery/additional procedures if indicated at that
time.
Completed by:[**2180-6-11**]
|
[
"197.7",
"V10.3",
"998.11",
"E878.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"50.24"
] |
icd9pcs
|
[
[
[]
]
] |
5690, 5696
|
3294, 5168
|
321, 385
|
5869, 5869
|
1832, 3271
|
6983, 7301
|
1555, 1638
|
5252, 5667
|
5717, 5848
|
5194, 5229
|
6020, 6020
|
6545, 6960
|
1653, 1813
|
6052, 6530
|
264, 283
|
413, 1005
|
5884, 5996
|
1027, 1314
|
1330, 1539
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,785
| 102,490
|
30112
|
Discharge summary
|
report
|
Admission Date: [**2156-5-2**] Discharge Date: [**2156-5-12**]
Date of Birth: [**2110-1-16**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2932**]
Chief Complaint:
rash, fevers
Major Surgical or Invasive Procedure:
bone marrow biopsy
axillary lymph node biopsy
History of Present Illness:
46 year o;d female with no significant medical history presented
with fevers and chills for the last 3 months. Her symptoms began
when she was in [**State 108**] on [**1-29**] with teeth chattering.
A few days later she developed a rash on her chest that looked
like chicken pox. Soon after she developed joint soreness in her
fingers, wrists, and ankles, and stiffness in her neck and jaw.
She was started on Naprosen for the joint pain. She had fevers,
chills, rigors which continued for 1-2 months. Her fevers were
almost exclusively in the evening, accompanied by malaise. On
[**4-12**] she was given a 7 day Doxycycline course given concern for
richettsial disease (subsequently negative serologies). During
the course of her illness she developed a nonproductive cough
and lymphadenopathy. Denies weight loss or anorexia. Over the
past week she has been unable to control her fevers with the
Meloxicam. The morning of presentation she awoke from sleep with
chills at 4-5 AM. She took her temperature at that time and it
was 104. She got up and it remained elevated at 103.6. She
presented to the ED for evaluation. In the ED her vitals were
temp 101.9, pulse 115, BP 105/54, RR 16, 98% on RA. She was
treated with Motrin and admitted to the general medicine floor
for further evaluation of her fevers, arthralgias, and cough.
Given hypotension (sbp 60s-70s), she was transferred to the ICU
for further management.
On transfer to the ICU she had a slight headache. She denied
lightheadedness, vision trouble, sore throat, chest pain or
shortness of breath. She had no abdominal pain, diarrhea or
urinary symptoms. She says her joints generally feel OK at this
time. (the joints felt very bad this last week). Her cough is at
its baseline, productive of clear/whitish sputum. She has some
emesis with the severe coughing. She states that she continues
to have the rash, it is currently on her legs and lower torso
but moves around intermittently.
Extensive outpatient work-up: blood cultures (negative), LFTs
(transaminitis in the 200s), parvovirus seroligies (IgG
positive, IgM negative), varicella IgG (positive), RSMF/R.
typhi/Q fever/Eherlichia (negative), malaria screen (negative),
R. typhi (negative), lyme ab (negative-varicella Ig G positive,
throat culture (negative), dengue (negative), West [**Doctor First Name **]
(negative), monospot (negative), EBV panel (c/w prior
infection), echocardiogram (unremarkable), hepatitis A/B/C
(negative), [**Doctor First Name **] (negative), RF 9, ANCA negative, and Ro/La
negative, HIBAb/VL (negative), CMV VL (negative), CT scan of
torso (bilateral axillary adenopathy, otherwise unremarkable).
She also had a skin biopsy [**4-21**] which showed neutrophil [**Doctor First Name **]
perivascular and interstitial dermatitis with rare eosinophils.
Past Medical History:
b/l breast implants '[**45**]
Botox injections
Social History:
Lives with husband and two kids, no longer working, no recent
travel out of the country, last trip was to [**Location (un) **] 2-3 years
ago, does travel to [**State 108**] regularly. no Smoking, rare Etoh
prior to these episodes. No IVDU. No camping, does walk outdoors
around swampy reserve area in [**State 108**]. She did have some bug
bites while in [**State 108**].
Family History:
Father died of colon CA
Physical Exam:
VS: Temp 98.7, Pulse 114, BP 85/59, RR 20, 95% on RA
Gen: alert, oriented, cooperative female in NAD
HEENT: MMM, OP clear, PERRL
Neck: anterior and posterior cervical lymphadenopathy
Lungs: clear to ausculatation bilatterally
CV: tachycardic, nl S1S2, no murmers
Axillary adenopathy
Abd: soft, non-tender, non-distended, positive BS
Ext: no edema, rash over upper area of legs and lower abdomen
Neuro: grossly inact
Pertinent Results:
Laboratory test on admission:
[**2156-5-2**]
WBC-17.8* HGB-10.3* HCT-31.1* MCV-82 RDW-16.7 PLT COUNT-328
NEUTS-90.3* LYMPHS-4.7* MONOS-2.6 EOS-1.8 BASOS-0.7
PT-13.0 PTT-31.3 INR(PT)-1.1
calTIBC-234* FERRITIN-1119* TRF-180*
ALBUMIN-3.2* CALCIUM-8.5 PHOSPHATE-3.0 MAGNESIUM-2.0 IRON-11*
ALT(SGPT)-22 AST(SGOT)-54* LD(LDH)-488* ALK PHOS-76 AMYLASE-46
TOT BILI-0.2
GLUCOSE-118* UREA N-10 CREAT-0.8 SODIUM-135 POTASSIUM-3.9
CHLORIDE-101
U/A: URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG
KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG
LACTATE-2.8*
Laboratory tests on discharge:
WBC-15.8* Hct-29.2* MCV-81* RDW-17.5* Plt Ct-535*
Neuts-81.6* Lymphs-10.9* Monos-2.8 Eos-4.1* Baso-0.6
Neuts-66.7 Lymphs-17.8* Monos-4.6 Eos-10.1* Baso-0.9
ALT-56* AST-92* LD(LDH)-474* AlkPhos-139* TotBili-0.2
Albumin-2.5* Calcium-8.3* Phos-4.5 Mg-2.2
Other laboratory tests:
ESR 46, ANCA (-), parasite smear (-), CRP 254.2, Lyme Ab (-),
CMV VL (-), ACE 53, SM/RNP (-), ssDNA Ab (-), Ro/la (-),
aldolase 98
.
Radiology
[**5-2**] CXR: The heart size and cardiomediastinal contours are
normal. There is normal pulmonary vascularity. Breast implants
cause homogeneous attenuation of the lower lung fields. No
parenchymal consolidation, pleural effusion, or pneumothorax.
Moderate convex left thoracolumbar scoliosis.
[**5-3**] CXR: Severe bilateral consolidation has developed since [**5-2**], with no change in heart size or mediastinal vascular
engorgement to suggest that this is pulmonary edema. This could
be pneumonia, particularly viral infection or noncardiogenic
edema, including response to sepsis or a pulmonary reaction to
medication or transfusion. Under the appropriate circumstances,
this could represent acute diffuse alveolar hemorrhage.
[**5-4**] CXR: Compared with [**2156-5-3**], there has been modest partial
interval clearing of the pulmonary edema. Small-to-medium sized
bilateral pleural effusions. Bibasilar atelectasis, with
possible consolidation at the right base.
[**5-5**] CXR: Compared with [**2156-5-4**], and the prior studies from [**5-2**]
and [**5-3**], the diffuse bilateral pulmonary opacities, which
developed acutely from [**5-2**] to [**5-3**] and partially cleared on
[**5-4**] have probably cleared further today, allowing for
superimposed breast shadows. There are increased lung volumes.
There appears to be a small left pleural effusion. No obvious
confluent infiltrates are seen.
[**5-8**] CXR: Relatively symmetric basal predominance, infiltrative
pulmonary abnormality has improved in the upper lungs compared
to [**5-6**] and [**5-7**] probably a reflection of decreasing
pulmonary edema, not necessarily cardiogenic. The heart is
normal size. Azygos distention suggests elevated central venous
pressure or volume. No pneumothorax. Heart size normal.
[**5-4**] TTE: The left atrium is mildly dilated. The estimated right
atrial pressure is [**4-15**] mmHg. Left ventricular wall thickness,
cavity size, and systolic function are normal (LVEF>55%).
Regional left ventricular wall motion is normal. Tissue Doppler
imaging suggests a normal left ventricular filling pressure
(PCWP<12mmHg). Right ventricular chamber size and free wall
motion are normal. There is abnormal septal motion/position. The
aortic valve leaflets are probably structurally normal but not
well visualized. There is good leaflet excursion. There is no
aortic valve stenosis. No 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.
IMPRESSION: No obvious vegetations visualized, although aortic
valve not
well-visualized. Normal biventricular systolic function. No
pathologic
structural valvular disease. Resting tachycardia.
Pathology:
[**5-7**] Bone Marrow Biopsy: Markedly hypercellular bone marrow
(80-90% cellular) with myeloid and megakaryocytic hyperplasia
and erythroid dysplasia. Absent iron stores. No granulomas or
lymphoid aggregates are seen; however a mild eosinophilia is
noted. Immunohistochemical studies will be performed to further
characterize interstitial lymphocytes and the findings reported
in an addendum. Overall, the findings are non-specific and
similar features can be seen secondary to an infectious,
toxic-metabolic, or immune insult. Primary myelodysplasia is
unlikely, however, correlation with clinical and cytogenetic
findings is recommended. CD20 highlights few scattered
interstitial B-cells (less than 5% of overall cellularity).
-cell markers CD3 and CD5 highlight a greater proportion of
interstitial T-cells present singly and in a loose cluster.
They are a mixture of CD4-positive T-helper cells and
CD8-positive T-suppressor cells. No CD30-positive cells are
seen. LMP stain for EBV is negative with nonspecific staining of
megakaryocytes noted.
[**5-7**] Bone marrow flow cytometry: Non-specific T-cell dominant
lymphoid profile; diagnostic immunophenotypic features of
involvement by a B- or T-cell lymphoproliferative disorder are
not seen in specimen.
Brief Hospital Course:
46 year old female presents with fever of unknown origin,
associated with rash, transaminitis, and progressive
lymphadenopathy. The patient was transferred to the ICU [**5-3**]
with hypotension and new pulmonary edema. Her blood pressure
stabilized, she was gently diuresed, and transferred back to the
general medical floor [**2156-5-8**].
1) Fever of unknown origin: As mentioned above, this was
associated with a rash, transaminitis, and progressive
lymphadenopathy (spread to involve axillary, groin, and
posterior cervical chain). See HPI for summary of outpatient
work-up. The patient was followed closely throughout her
hospital stay by the rheumatology, infectious disease, and
oncology services. Additional work-up included a parasite smear
(-), ASO screen (positive, however rheumatic fever was felt to
be unlikely), Lyme Ab (-), CMV viral load (negative), ACE 53,
SM/RNP (-) ss DNA Ab (-), ro & la (negative), aldolase 98
(mildly elevated). She underwent a bone marrow biopsy which
showed narkedly hypercellular bone marrow (80-90% cellular) with
myeloid and megakaryocytic hyperplasia and erythroid dysplasia.
No granulomas or lymphoid aggregates were seen; however a mild
eosinophilia was noted. Overall, these findings are non-specific
and similar features can be seen secondary to an infectious,
toxic-metabolic, or immune insult. She underwent a left
axillary lymph node biopsy, the final pathology of which was
pending at time of discharge. However, the preliminary pathology
report suggested atypical intrafollicular hyperplasia.
Molecular/clonality testing was pending at time of discharge,
which will help distinguish lymphoma vs reactive changes. The
patient will follow-up with infectious disease/oncology as an
outpatient to follow-up the final results of the biopsy. At time
of discharge, the patient was hemodynamically stable, afebrile X
72 hours on Naproxen and Tylenol. If the lymph node biopsy is
non-diagnostic, liver biopsy may be considered, given
transaminitis.
2) Pulmonary edema: This was felt to be secondary to capillary
leak in the setting of inflammation, along with third-spacing
due to low albumin (2.5). The patient had an echocardiogram,
which revealed an EF of >55% without regional wall motion
abnormalities. At time of discharge, the patient was stable on
room air and was auto-diuresing.
3) Anemia of chronic disease: The patient's iron studies were
consistent with anemia of chronic disease, however, her bone
marrow biopsy suggested low iron stores. For this reason, she
was started on iron supplementation. Outpatient work-up of
possible GI sources of bleeding (colonoscopy) can be pursued at
the discretion of the patient's PCP.
Full Code
Medications on Admission:
Meloxicam
Motrin prn
Discharge Medications:
1. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) Disk
with Device Inhalation Q12H (every 12 hours).
Disp:*1 device* Refills:*0*
2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Naproxen 250 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12
hours).
Disp:*120 Tablet(s)* Refills:*0*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
6. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours): don't exceed 2 grams per day.
Disp:*120 Tablet(s)* Refills:*0*
7. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
Disp:*60 Capsule(s)* Refills:*0*
8. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) as needed for itching.
Disp:*60 Capsule(s)* Refills:*0*
9. Albuterol 90 mcg/Actuation Aerosol Sig: [**12-9**] puff Inhalation
every 4-6 hours as needed for shortness of breath or wheezing.
Disp:*1 MDI* Refills:*0*
10. spacer
Use as directed
dispense: 1
refills: 0
11. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO
Q6H (every 6 hours) as needed for cough.
Disp:*100 ML(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: fever of unknown origin
Secondary: anemia of chronic disease, pulmonary edema
Discharge Condition:
Stable, afebrile X 72 hours
Discharge Instructions:
1) Please follow-up as indicated below
2) Please take all medication as prescribed.
3) Please come to the emergency room or see your primary care
physician if you develop lightheadedness, nausea, vomiting,
abdominal pain, shortness of breath, or other symptoms that
concern you.
Followup Instructions:
1) Infectious disease/oncology
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9561**], M.D. Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2156-5-18**] 10:00 p.m.
- basement of [**Hospital **] medical building
- you should have a white blood cell count and liver function
test panel checked at this time
2) Primary Care: Please follow-up with Dr. [**First Name8 (NamePattern2) 6177**] [**Last Name (NamePattern1) 43672**]
([**Telephone/Fax (1) 71782**]) within 1-2 weeks following discharge
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2937**]
Completed by:[**2156-5-13**]
|
[
"995.93",
"518.82",
"276.1",
"785.6",
"514",
"285.29",
"782.1",
"780.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"41.31",
"40.11"
] |
icd9pcs
|
[
[
[]
]
] |
13536, 13542
|
9356, 12052
|
327, 375
|
13673, 13703
|
4158, 4174
|
14030, 14701
|
3682, 3707
|
12123, 13513
|
13563, 13652
|
12078, 12100
|
13727, 14007
|
3722, 4139
|
4750, 9333
|
275, 289
|
403, 3206
|
4188, 4736
|
3228, 3277
|
3293, 3666
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,874
| 186,494
|
48928+48929
|
Discharge summary
|
report+report
|
Admission Date: [**2168-4-11**] Discharge Date: [**2168-4-28**]
Date of Birth: [**2114-3-14**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3376**]
Chief Complaint:
Stage I upper rectal cancer
Major Surgical or Invasive Procedure:
[**2168-4-11**]: Laparoscopic converted to open low anterior resection.
[**2168-4-14**]:
1. Examination under anesthesia and flexible sigmoidoscopy.
2. Contrast study per rectum done by Dr. [**Last Name (STitle) **].
3. Reopen laparotomy and drainage of pelvis.
4. Diverting loop ileostomy.
History of Present Illness:
The patient presented for surgical treatment of his stage I
upper rectal cancer.
Past Medical History:
PMH:
1. Anxiety
2. Hypertension
3. Prior urinary issues with frequent nocturia
4. H/o umbilical surgery repair with Kugel patch
PSH:
1. Umbo hernia
Social History:
He lives in [**Location 701**] currently with his daughter. [**Name (NI) **] has a son
who lives in [**Name (NI) 392**]. He works in finance. He quit smoking in
[**2165**], after smoking for 35 years, three quarters of a pack per
day. He rarely drinks alcohol.
Family History:
Both his parents have diabetes. He has one sibling, a brother
who is healthy.
Physical Exam:
[**2167-4-22**]
REVIEW OF SYSTEMS:
genl: +F per HPI
heent: no odynophagia, dysphagia, neck stiffness
cardiac: no cp, palpitations, orthopnea
pulm: no shortness of breath or cough
gi: n/v improved
gu: no dysuria/freq/urgency
cns: no sided weakness/numbness/HA
mskel: no weakness
heme: no bleeding, easy bruising
.
PHYSICAL EXAM:
T: 97.8F, Tm: 99.1F BP: 118/72 HR: 76 RR: 18 SaO2: 99% RA
General: pleasant, nad
HEENT: op clear, mmm, no lesions; no cervical LAD
Neck: supple, no LAD
Cardiovascular: RRR, no MRG,
Respiratory: CTA bilat w/o wheezes/rhonchi/rales
Back: no spinous process tenderness, no CVA tenderness
Gastrointestinal: Hypoactive BS, soft, mild-moderate diffuse
TTP,
worst in mid-abdomen.
JP in place in right flank, draining purulent fluid. Vertical
incision LLQ, open and packed at inferior margin. Small
horizontal incision lateral to this, with mild surrounding
erythema.
Genitourinary: Foley in place
Musculoskeletal: moving all extremities, no edema
Skin: erythema at site of prior IV site on dorsum of right hand
with mild streaking proximally and tenderness.
Neurological: aaox3, cn 2-12
Pertinent Results:
[**2168-4-28**] 05:35AM BLOOD WBC-16.4* RBC-3.96* Hgb-11.7* Hct-35.3*
MCV-89 MCH-29.5 MCHC-33.1 RDW-13.0 Plt Ct-593*
[**2168-4-27**] 05:56AM BLOOD WBC-20.4* RBC-3.97* Hgb-11.7* Hct-35.4*
MCV-89 MCH-29.4 MCHC-33.0 RDW-13.3 Plt Ct-578*
[**2168-4-26**] 05:35AM BLOOD WBC-17.5* RBC-3.81* Hgb-11.3* Hct-33.2*
MCV-87 MCH-29.6 MCHC-34.0 RDW-13.3 Plt Ct-605*
[**2168-4-25**] 05:59AM BLOOD WBC-24.2* RBC-3.84* Hgb-11.4* Hct-33.7*
MCV-88 MCH-29.7 MCHC-33.9 RDW-12.9 Plt Ct-594*
[**2168-4-24**] 05:04AM BLOOD WBC-23.0* RBC-3.82* Hgb-11.7* Hct-33.1*
MCV-87 MCH-30.6 MCHC-35.4* RDW-13.1 Plt Ct-572*
[**2168-4-23**] 05:07AM BLOOD WBC-20.8* RBC-3.94* Hgb-11.7* Hct-34.5*
MCV-88 MCH-29.8 MCHC-34.0 RDW-13.1 Plt Ct-550*
[**2168-4-22**] 09:00AM BLOOD WBC-20.2* RBC-4.03* Hgb-12.1* Hct-35.4*
MCV-88 MCH-30.1 MCHC-34.2 RDW-13.1 Plt Ct-540*
[**2168-4-21**] 07:04AM BLOOD WBC-21.7* RBC-4.06* Hgb-12.2* Hct-35.6*
MCV-88 MCH-30.0 MCHC-34.2 RDW-13.0 Plt Ct-497*
[**2168-4-26**] 05:35AM BLOOD Neuts-76.4* Lymphs-13.8* Monos-5.5
Eos-4.0 Baso-0.3
[**2168-4-23**] 05:07AM BLOOD Neuts-79.9* Lymphs-11.5* Monos-5.5
Eos-2.3 Baso-0.7
[**2168-4-19**] 05:37AM BLOOD Neuts-85* Bands-0 Lymphs-5* Monos-5 Eos-2
Baso-0 Atyps-1* Metas-0 Myelos-2*
[**2168-4-13**] 09:00PM BLOOD Neuts-85* Bands-8* Lymphs-6* Monos-1*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2168-4-19**] 05:37AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2168-4-13**] 09:00PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2168-4-13**] 07:05PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2168-4-28**] 05:35AM BLOOD Plt Ct-593*
[**2168-4-27**] 05:56AM BLOOD Plt Ct-578*
[**2168-4-26**] 05:35AM BLOOD Plt Ct-605*
[**2168-4-26**] 05:35AM BLOOD PT-14.4* PTT-30.5 INR(PT)-1.2*
[**2168-4-27**] 05:56AM BLOOD ESR-45*
[**2168-4-27**] 05:56AM BLOOD Glucose-112* UreaN-12 Creat-0.9 Na-133
K-4.7 Cl-97 HCO3-27 AnGap-14
[**2168-4-23**] 05:07AM BLOOD Glucose-130* UreaN-18 Creat-1.0 Na-132*
K-4.4 Cl-100 HCO3-24 AnGap-12
[**2168-4-22**] 09:00AM BLOOD Glucose-111* UreaN-18 Creat-0.9 Na-131*
K-4.3 Cl-98 HCO3-24 AnGap-13
[**2168-4-21**] 07:04AM BLOOD Glucose-112* UreaN-14 Creat-0.9 Na-131*
K-4.2 Cl-97 HCO3-26 AnGap-12
[**2168-4-20**] 04:41AM BLOOD Glucose-119* UreaN-18 Creat-1.0 Na-135
K-4.5 Cl-104 HCO3-25 AnGap-11
[**2168-4-19**] 05:37AM BLOOD Glucose-124* UreaN-21* Creat-1.0 Na-135
K-4.3 Cl-103 HCO3-24 AnGap-12
[**2168-4-18**] 01:00AM BLOOD Glucose-132* UreaN-16 Creat-0.9 Na-135
K-3.7 Cl-103 HCO3-25 AnGap-11
[**2168-4-20**] 04:41AM BLOOD ALT-16 AST-12 LD(LDH)-234 AlkPhos-61
TotBili-0.5
[**2168-4-15**] 04:24AM BLOOD CK(CPK)-464*
[**2168-4-15**] 12:42AM BLOOD CK(CPK)-330*
[**2168-4-20**] 04:41AM BLOOD Lipase-170*
[**2168-4-15**] 04:24AM BLOOD CK-MB-3 cTropnT-<0.01
[**2168-4-15**] 12:42AM BLOOD CK-MB-3 cTropnT-<0.01
[**2168-4-27**] 05:56AM BLOOD Calcium-8.6 Phos-2.9 Mg-2.1
[**2168-4-23**] 05:07AM BLOOD Calcium-8.4 Phos-3.2 Mg-2.4
[**2168-4-22**] 09:00AM BLOOD Calcium-8.4 Phos-3.2 Mg-2.5
[**2168-4-21**] 07:04AM BLOOD Calcium-8.4 Phos-3.0 Mg-2.4
[**2168-4-20**] 04:41AM BLOOD Calcium-8.0* Phos-2.5* Mg-2.1
[**2168-4-15**] 03:05PM BLOOD TSH-1.4
[**2168-4-27**] 05:56AM BLOOD CRP-61.3*
[**2168-4-25**] 04:18PM BLOOD Vanco-11.7
[**2168-4-23**] 11:10PM BLOOD Vanco-13.5
[**2168-4-22**] 09:00AM BLOOD Vanco-6.6*
[**2168-4-26**] 12:15 pm ABSCESS Site: PERIRECTAL
GRAM STAIN (Final [**2168-4-26**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
WOUND CULTURE (Preliminary):
Due to mixed bacterial types (>=3) an abbreviated workup
is
performed; P.aeruginosa, S.aureus and beta strep. are
reported if
present. Susceptibility will be performed on P.aeruginosa
and
S.aureus if sparse growth or greater..
DR. [**First Name (STitle) **] #[**Numeric Identifier 16672**] REQUESTED FURTHER WORK UP.
ENTEROCOCCUS SP.. SPARSE GROWTH.
ESCHERICHIA COLI. SPARSE GROWTH.
ENTEROCOCCUS SP.. RARE GROWTH. SECOND MORPHOLOGY.
GRAM NEGATIVE ROD #2. RARE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
ANAEROBIC CULTURE (Preliminary):
Mixed bacterial flora-culture screened for B. fragilis, C.
perfringens, and C. septicum.
TRANSTHORACIC ECHOCARDIOGRAM ([**2168-4-15**]):
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF 70%). 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 appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
Micro/Imaging:
[**2168-4-26**] abcess GPC 1+, PMN
[**2168-4-25**] Urine cx negative
[**2168-4-21**] Blood Cx No growth final
[**2168-4-21**] Urine Cx Negative
[**2168-4-20**] C.Diff Negative
[**2168-4-19**] Abscess (prelim)psuedomonas rare, GNR sparse,
enterocococcus sparse
[**2168-4-17**] Blood Cx Neg
Brief Hospital Course:
The patient was admitted to the inpatient [**Hospital1 **] after
laparoscopic converted to open low anterior resection of the
rectum. He remained NPO as the surgical team awaited return of
bowl function. The patient progressed very slowly and the
patient developed pain and nausea. His abdomen became
progressively distended and a nasogastric tube was placed. The
patient then became febrile. A fever work up was conducted as
well as repeat laboratory values. Blood cultures were negative.
The patient was started on broad spectrum antibiotics. [**2168-4-14**] a
portable abdominal film was taken which showed multiple
distended air-filled loops of large and small bowel likely
representing an ileus. At this time, because of concern of a
leak at the site of anastomosis, the patient was taken back to
the operating room. During this operative case an examination
under anesthesia and flexible sigmoidoscopy, contrast study per
rectum done by Dr. [**Last Name (STitle) **], reopen laparotomy and drainage of
pelvis, and Diverting loop ileostomy were all preformed.A
19-French [**Doctor Last Name 406**] drain was placed securely in the presacral space
and
stitched to the level of skin to drain the presacral abscess.
The patient had a previous umbilical hernia repair and this was
with a Kugel patch. This mesh had to be
excised from the umbilicus and the fascia around it. The
surgical incision was closed and the patient was transferred to
the [**Hospital Ward Name 332**] Intensive Care Unit.
While in the ICU, the patient developed AFib/flutter at 130-140s
with multiple episodes lasting 15 minutes to one hour.
Cardiology was consulted and recommended transthoracic
echocardiogram which showed no abnormality. Cardiology
attributed this arrythmia to fever and inflammation and
recommended a beta-blocker which was started. Due to the degree
of the patients abdominal distention preoperatively, distal
aspect of the midline surgical incision adjacent to the
ileoileostomy was not closely appropriately and was opened at
the bedside and packed with a wet to dry dressing to be changed
three times daily. This rhythm resolved and the patient was
stable for transfer to the inpatient [**Hospital1 **], the nasogastric tube
remained in place.
After admission to the inpatient [**Hospital1 **], the patient's bowel
function progressed appropriately. The patient was started on
clears, his pain was managed, and the nasogastric tube was
discontinued. The drain placed in the abscess site continued to
drain purulent drainage. The ostomy site output was large and
the patient was started on Imodium therapy which was effective.
Infectious disease was consulted and recommended IV therapy with
Zosyn and Vancomycin. [**2168-4-20**] a right basilic power PICC was
placed. The patient was seen and followed closely by the
wound/ostomy nursing team as well as physical therapy. Nursing
repeatedly attempted to remove the patient's Foley catheter
however the patient failed the trials to void which ultimately
resulted in the patient being discharged home with Foley and leg
bag. The Drainage in the [**Doctor Last Name 406**] drain dramatically decreased and
required aspiration to remove drainage from the abscess space.
This was attributed the size of the drain and the patient was
taken for CT guided upsizing of the drain to a 10 french flexima
catheter. After upsizing the drain, it continued to require
aspiration and the patient was discharged home with instructions
for this. Prior to discharge, the recommended antibiotic regimen
was changed to Ciprofloxacin 750 mg every 12 hrs and
Ertapenem 1 gram IV daily which will continue until the patients
follow-up with infectious disease. The patient progressed well
and was discharged home [**2168-4-28**] with visiting nurse with
instruction for wound car, drain care, Foley care, orders fir
blood draws, and appropriate follow-up instructions.
Medications on Admission:
Hytrin
Ativan
Discharge Medications:
1. Terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
2. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
4. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime)
as needed for insomnia.
5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
6. Loperamide 2 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
7. Ciprofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
Disp:*42 Tablet(s)* Refills:*0*
8. Ertapenem 1 gram Recon Soln Sig: One (1) Recon Soln Injection
DAILY (Daily).
Disp:*21 Recon Soln(s)* Refills:*0*
9. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Rectal Cancer
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 for surgical treatment of
rectal cancer. You were taken to the operating room for a rectal
ressection. After your surgery you developed a leak between the
rectum and intestine which required an additional surgical
procedure. You were found to have a collection of infection
called an abcess which now has a drain which is draining the
fluid from this abcess. You will return home with this drain.
Currently, the drain is requiring aspiration to continue to
remove the abcess drainage. The drain will need to be aspirated
with a syringe twice a day, the VNA will do this aspiration at
least once daily, if a family member can help with the second
aspiration this would be helpful. It is important to keep this
drain site clean, and you may apply a gauze drain sponge to the
site however, be sure to not kink the drain tube. Please monitor
and record the amount of drainage from the drain daily. Please
call if the drainage in the bulb drain increases to over 100
milliliters in 24 hours, you develop redness at the drain site,
or have other concerns.
Also, the second surgical procedure required that your intestine
be made into an ostomy to allow for the connection between your
rectum and intestine to heal. Please follow the instructions
given to you by the ostomy nurses and monitor the amount of
liquid stool drained from the ostomy bag. If you have less than
500 millileters or more than 1500 millileters from the ostomy
please call the office. Be sure to keep yourself well hydrated
and eat small frequent meals of foods that are easily digested
as to not cause blockage of the ostomy. Please monitor the
appearance of the intestinal stoma which should remain beefy
pink/red. If there is any change in the stoma please call the
office. The ostomy nurses have been following you here and you
will meet with them again on your follow-up visit with Dr.
[**Last Name (STitle) 1120**].
The surgical incsion of in the midline of your abdomen because
slightly infected and had to be left open to heal. This wound
will require saline wet to dry dressings to allow the wound to
heal from the inside out. These dressings will need to be
changed three times daily, if the dressing becomes saturated
with drainage you may change it more frequently. If you notice
that the drainage has become increasingly green or yellow,
increasingly malodorous, or increasingly painful please call the
office.
The nursing staff has attempted repeatedly to take out your
foley catheter however you have been unable to void on your own.
You will return home with the foley catheter and leg bag. Please
be sure to keep the area of the end of your penis very clean
while you are at home. The foley catheter increases your risk to
develop a urinary tract infection and keeping the area where the
catheter inserts into the penis clean can help prevent an
infection from developing. You will need to follow-up with
urology to have this catheter removed.
Your white blood cell count has improved, you have been able to
tolerate a regular diet, your pain is adequately controlled and
you are ready to return home with the help of family and
visiting nurses. You will continue antibiotic therapy for your
infection through your PICC line and this will be administered
to you with assistance of the visiting nurses. You will be sent
home on Ciprofloxacin which will be administered by mouth and
Ertapenem which will be IV. You will need to flush the PICC line
as instructed and the more independent you can be with this the
better. The visiting nurses will teaching you the proper way to
care for the PICC line. You will be able to shower however you
must keep the PICC line covered and dry with placetic wrap. You
may let the arm water run over your abdominal wound however, be
sure to rinse it well and apply a clean sterile dressing as soon
as possible after the shower. It is very important that you
monitor how you are feeling at home and if you become nauseated,
do not pass stool and gas in your ostomy, develop a fever, have
increased pain not relieved with medication, or any of the
symptoms listed below please seek medical attention.
Your heart rate was elevated while you were in the hospital and
you were started on an anti-hypertensive called metoprolol. We
will send you home with a prescription for this medication. You
should continue to monitor your blood pressures at home. You
should also schedule a follow-up appointment with your PCP to
see if this medication needs to be continued after discharge.
Followup Instructions:
You should follow-p with Dr. [**Last Name (STitle) 1120**]. call her office at ([**Telephone/Fax (1) 6316**] this week to schedule a follow-up appointment. She will
want your drain to be evaluated and for you to have a repeat CT
scan prior to your appointment with her. This can be set-up
through her office.
Please follow-up with the urology department in their outpatient
clinic to evaluate your foley catheter in 1 week. Please call
([**Telephone/Fax (1) 4376**] to set up an appointment.
Follow-up with Infectious Disease on [**2168-5-20**] @ 10:30 AM.
Weekly lab draws: CBC/Diff, BUN/Cr, LFT's to be faxed to
[**Telephone/Fax (1) 1419**].
Completed by:[**2168-4-28**] Admission Date: [**2168-5-2**] Discharge Date: [**2168-5-4**]
Date of Birth: [**2114-3-14**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3376**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
54 yo male presents two days after discharge on [**2168-4-29**] from
inpatient stay s/p open LAR for rectal cancer [**2168-4-11**] and
examination under anesthesia and flexible sigmoidoscopy,
contrast
study per rectum done by Dr. [**Last Name (STitle) **], reopen laparotomy and
drainage of pelvis, and diverting loop ileostomy on [**2168-4-14**]. On
return home the patient states that he felt lethargic and he and
his family felt overwhelmed by the amount of care he currently
requires. He denies any nausea, vomiting or abdominal pain, and
reports adequate appetite. His ileostomy has been putting out
stool and gas. The patient reports pain at the insertion site of
the [**Doctor Last Name 406**] drain in the right buttock, and moderate pain in his
lower back. His pain has been slightly relieved by 2-4mg of
Hydromorphone PO. The drain was being aspirated and emptied by
visiting nursing and the patient reports there to be 90cc of
drainage in the bulb of the drain daily and a moderate amout of
drainage via aspiration.
Past Medical History:
PMH:
1. Anxiety
2. Hypertension
3. Prior urinary issues with frequent nocturia
4. H/o umbilical surgery repair with Kugel patch
PSH:
1. Umbo hernia
2. Laparoscopic converted to open low anterior resection.
3. Reopen laparotomy and drainage of pelvis, [**Doctor Last Name 406**] drain
placement.
4. Diverting loop ileostomy.
Social History:
He lives in [**Location 701**] currently with his daughter. [**Name (NI) **] has a son
who lives in [**Name (NI) 392**]. He works in finance. He quit smoking in
[**2165**], after smoking for 35 years, three quarters of a pack per
day. He rarely drinks alcohol.
Family History:
Both his parents have diabetes. He has one sibling, a brother
who is healthy.
Physical Exam:
Vitals: afebrile, VSS
General: Patient appears well, however obvious weight loss.
Pleasant and interactive.
Neuro: A&OX3
CV: RRR
Pulm: Lungs clear to auscultation throughout all fields.
GI: Abd appears soft, non-distended,+ BS, non-tender to
palpation
+BS, Ostomy stoma beefy red w/ liquid stool and gas, lower
midline abdominal incision no purulent drainage. [**Year (4 digits) **] vac in
place
CNS: No obvious impairment.
Lower Extremity: +CSM, no edema noted
Skin: Right Upper Extremity PICC Line, small amount of erythema
at the insertion site. [**Doctor Last Name 406**] drain in right buttock, small
amount
erythema and small amount of purulent drainage at insertion
site,
draining moderate amounts pink/yellow drainage.
Pertinent Results:
[**2168-5-2**] 01:13PM URINE MUCOUS-FEW
[**2168-5-2**] 01:13PM URINE HYALINE-1*
[**2168-5-2**] 01:13PM URINE RBC-14* WBC-7* BACTERIA-NONE YEAST-NONE
EPI-0
[**2168-5-2**] 01:13PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2168-5-2**] 01:13PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.019
[**2168-5-2**] 07:30PM PT-14.4* PTT-29.0 INR(PT)-1.2*
[**2168-5-2**] 07:30PM PLT COUNT-505*
[**2168-5-2**] 07:30PM NEUTS-67.3 LYMPHS-21.0 MONOS-4.9 EOS-6.5*
BASOS-0.3
[**2168-5-2**] 07:30PM WBC-13.9* RBC-3.97* HGB-11.7* HCT-35.3*
MCV-89 MCH-29.5 MCHC-33.1 RDW-13.1
[**2168-5-2**] 07:30PM TSH-2.7
[**2168-5-2**] 07:30PM ALBUMIN-3.3* CALCIUM-9.2 PHOSPHATE-2.9
MAGNESIUM-2.3
[**2168-5-2**] 07:30PM ALT(SGPT)-25 AST(SGOT)-24 ALK PHOS-143* TOT
BILI-0.3
[**2168-5-2**] 07:30PM GLUCOSE-93 UREA N-13 CREAT-1.0 SODIUM-134
POTASSIUM-4.3 CHLORIDE-98 TOTAL CO2-25 ANION GAP-15
[**2168-5-2**] 09:45PM PLT COUNT-539*
[**2168-5-2**] 09:45PM WBC-14.1* RBC-4.32* HGB-12.5* HCT-38.0*
MCV-88 MCH-28.9 MCHC-32.9 RDW-13.0
[**2168-5-2**] 09:45PM CALCIUM-9.4 PHOSPHATE-2.8 MAGNESIUM-2.3
[**2168-5-2**] 09:45PM ALT(SGPT)-26 AST(SGOT)-23 ALK PHOS-146* TOT
BILI-0.3
[**2168-5-2**] 09:45PM GLUCOSE-108* UREA N-13 CREAT-1.1 SODIUM-137
POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-27 ANION GAP-14
Brief Hospital Course:
Re-admited for concern of worsening of the fluid
collection/abcess. CT scan of abdomen demonstrated fluid
collection/abcess appears to be drained well from the drain
currently inserted in your lower back. The lower abdominal
midline [**Month/Day/Year **] was monitored and wet to dry dressing changes were
done until it was decided a [**Month/Day/Year **] vac should be placed. The
[**Month/Day/Year **] vac was placed [**5-4**]. The ostomy continued to function
well. The drain was flushed with 20 cc saline (20 cc were
withdrawn back into syringe) [**Hospital1 **]. The patient was treated with
vancomycin and meropenem.
[**Hospital1 409**] culture [**5-2**] showed multuple species:
[**Month/Year (2) 409**] culture:GRAM STAIN (Final [**2168-5-2**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
FLUID CULTURE (Preliminary):
Due to mixed bacterial types (>=3) an abbreviated workup
is
performed; P.aeruginosa, S.aureus and beta strep. are
reported if
present. Susceptibility will be performed on P.aeruginosa
and
S.aureus if sparse growth or greater..
He was discharged to rehab facility for level of care. He will
continue vancomycin and meropenem for 1 week. His vac will
remain in his [**Month/Day/Year **] and is to be changed every 3 days. The
drain should continue to be irrigated and aspirated twice daily.
The ostomy will be managed by the ostomy/[**Month/Day/Year **] nurses as per
routine at the rehab facility. By time of discharge th epatient
was ambulating, tolerating regular diet and remained afebrile.
Medications on Admission:
hytrin, ativan, Ciprofloxacin 750mg [**Hospital1 **], Ertapenem 1gm daily
Discharge Medications:
1. Terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
2. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Lorazepam 1 mg Tablet Sig: 0.5 Tablet PO at bedtime as needed
for insomnia.
5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
8. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
9. Vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours) for 7 days.
10. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q6H (every 6 hours) for 7 days.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1439**] [**Last Name (NamePattern1) 13089**] Care Center - [**Location (un) 1439**]
Discharge Diagnosis:
Failure to Thrive
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were readmitted to the hospital after being discharged home
from your previous abdominal surgery because there was concern
of a possible worsening of the fluid collection/abcess and your
ability to take care of yourself at home. You had a CT scan of
your abdomen and this fluid collection/abcess appears to be
drained well from the drain currently inserted in your lower
back. The lower abdominal midline incision [**Location (un) **] is currently
open however appears to be healing well, you will have a VAC
dressing to this [**Location (un) **] at the extended care facility to increase
your [**Location (un) **] healing. You ostomy site is intact and functioning
well. Because of the level of care you currently need you will
be discharged to a rehabilitation facility where you will
recieve care until you can effectively manage your care at home.
You will be recieving intervenous antibiotics for one week.
These will be Vancomycin and Meropenem. Your pain will be
managed with Dilaudid by mouth. Your medications will be
administered by the registered nurses at the facility as will
your [**Location (un) **] care. The VAC dresssing will be changed every three
days. The drain will be irrigated and aspirated twice daily.
Your ostomy site will be managed per the ostomy/[**Location (un) **] nurses and
nursing policies of the rehabilitation facility.
Please continue to eat healthy foods and drink plenty of water
to assist in your healing. Ambulate frequently, and maintain
your strength.
Followup Instructions:
You no longer need to follow up with infectious disease.
Provider: [**Name Initial (NameIs) **]/OSTOMY NURSE Phone:[**Telephone/Fax (1) 13760**]
Date/Time:[**2168-5-18**] 2:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 19886**]
Date/Time:[**2168-5-18**] 2:30
Provider: [**First Name11 (Name Pattern1) 2353**] [**Last Name (NamePattern4) 37866**], MD Phone:[**Telephone/Fax (1) 19886**]
Date/Time:[**2168-5-18**] 2:30
Please check Vancomycin Trouch after forth dose.
|
[
"788.20",
"518.0",
"154.0",
"787.01",
"783.7",
"584.9",
"427.31",
"401.9",
"300.00",
"427.32",
"788.43",
"V15.82",
"V44.2",
"V64.41",
"567.29",
"V10.06",
"E849.7",
"600.00",
"998.59",
"997.1",
"E878.2",
"451.84",
"997.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.24",
"97.29",
"48.63",
"46.01",
"99.15",
"38.93",
"54.91",
"54.12"
] |
icd9pcs
|
[
[
[]
]
] |
26002, 26142
|
23095, 24155
|
19148, 19155
|
26204, 26204
|
21707, 23072
|
27883, 28417
|
20862, 20943
|
25033, 25979
|
26163, 26183
|
24935, 25010
|
26356, 27860
|
20958, 21688
|
1353, 1631
|
19094, 19110
|
6147, 7258
|
19183, 20212
|
7297, 8359
|
26219, 26332
|
20234, 20564
|
20580, 20846
|
24190, 24909
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,339
| 163,185
|
21847
|
Discharge summary
|
report
|
Admission Date: [**2135-11-10**] Discharge Date: [**2135-11-21**]
Date of Birth: [**2069-3-23**] Sex: M
Service: [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: The patient is a 66 year old
male with esophageal cancer versus high grade dysplasia. The
patient has a history of severe heartburn for the past ten to
fifteen years which has recently gotten worse. He has
intermittent episodes of dysphagia for the past six months.
He had an upper gastrointestinal series which showed some
irregularity in the distal esophagus. In addition, the
esophagogastroduodenoscopy showed a question of a small mass
at the gastroesophageal junction. This mass was biopsied and
showed chronic inflammation consistent with Barrett's with
high grade dysplasia. Repeat biopsy was confirmatory.
PAST MEDICAL HISTORY: His past medical health is excellent.
He denies heart disease, lung disease, and diabetes mellitus.
He has a history of arthritis in the knees.
ALLERGIES: He has no known drug allergies.
MEDICATIONS ON ADMISSION: Only medication is Protonix 40 mg
twice a day which has brought some relief to his dysphagia
and heartburn.
FAMILY HISTORY: He has no family history of gastrointestinal
cancer. His father had prostate cancer.
REVIEW OF SYMPTOMS: Otherwise negative in detail.
PHYSICAL EXAMINATION: He is a well-developed gentleman.
Head, eyes, ears, nose and throat was within normal limits.
The neck was supple without mass, node or thyromegaly. The
chest was clear to auscultation and percussion bilaterally.
The heart sounds were regular without murmurs or gallops. The
abdomen was soft, without tenderness, mass or organomegaly.
Extremities are without cyanosis, clubbing or edema. He is
neurologically intact.
LABORATORY DATA: On admission, significant for a white blood
cell count of 14.5, hematocrit 42.1, platelet count 227,000.
Panel seven showed a sodium 141, potassium 4.5, chloride 106,
bicarbonate 26, blood urea nitrogen 23, creatinine 0.9,
glucose 175. Magnesium 1.9, ionized calcium 0.94.
HOSPITAL COURSE: The patient underwent a laparoscopic and
thoracoscopic esophagectomy with feeding jejunostomy tube
placement on postoperative day number zero. The patient
tolerated this procedure well, received five liters of
lactated ringer's and had urine out of 345 cc and estimated
blood loss of 200 cc. The patient initially remained in the
Post Anesthesia Care Unit where he was extubated on
postoperative day number one. The patient continued to do
well in the Post Anesthesia Care Unit on postoperative day
number two with his pain being well controlled. On
postoperative day number three, however, the patient was
noted to be confused and paranoid, which did not respond to
Ativan but did respond to Haldol. The arterial line was
discontinued and tube feeds were begun. However, the patient
was also noted to be tachycardic and hypertensive and in
atrial fibrillation. He was started on Amiodarone and he had
Diltiazem drip for rate control. On postoperative day number
four, Metoprolol was increased slightly to 15 mg q4hours. In
addition, his chest tube placed in the operating room was
placed on water seal. The patient continued to be confused
and paranoid. On postoperative day number five, the patient
was transferred to the floor. His atrial fibrillation with
rapid ventricular response had resolved. The patient
underwent a barium swallow on postoperative day number five
which was noted to be negative with no leak. However, the
patient while no longer delirious and alert and oriented was
now showing symptoms of marked depression and the psychiatry
service was consulted. They believe that the patient had an
adjustment disorder with depressed mood and recommended
Trazodone q.h.s. which was initiated. The patient's mental
status improved significantly. In addition, his atrial
fibrillation continued not to be present. On postoperative
day number seven, the swallow, which was initially ordered
but not obtained because of the patient's depressed mood, was
noted to be negative. The patient had a bowel movement and
his chest tube and Foley were removed and [**Location (un) 1661**]-[**Location (un) 1662**] drain
remained. On postoperative day number eight, the patient
continued to do well. On postoperative day number ten, the
patient was noted again to be restless and agitated
overnight, was requiring increased amounts of Haldol.
However, on postoperative day number eleven, the patient
slept better with an increased dose of Trazodone and his
mental status was improved. The [**Location (un) 1661**]-[**Location (un) 1662**] drain was
discontinued and the patient was discharged home with
visiting nurses to institute tube feeds. The patient's
laboratory values on the final day of admission were
significant for a hematocrit of 40.2 and a white blood cell
count of 9.5. His electrolytes were all within normal
limits.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: To home with visiting nurses.
DISCHARGE DIAGNOSES: Atrial fibrillation.
Delirium.
Barrett's esophagus.
Adjustment disorder with depressed mood.
MEDICATIONS ON DISCHARGE:
1. Metoprolol 50 mg p.o. twice a day.
2. Metoclopramide one tablet p.o. four times a day, a.c. and
h.s.
3. Trazodone 50 mg p.o. at night.
4. Protonix 40 mg p.o. daily.
5. Tylenol with Codeine number three one tablet p.o. q4hours
p.r.n. for pain.
FOLLOW UP: The patient was instructed to follow-up with Dr.
[**Last Name (STitle) **] in one week. In addition because of some
difficulty obtaining insurance approval, tube feeds will not
be begun until Tuesday and the patient was instructed to
supplement all his meals with Boost and to take in as much
p.o. fluid as possible until tube feeds could be initiated.
[**First Name11 (Name Pattern1) 333**] [**Last Name (NamePattern4) 366**], [**MD Number(1) 367**]
Dictated By:[**Last Name (NamePattern1) 39725**]
MEDQUIST36
D: [**2135-11-21**] 18:35:02
T: [**2135-11-22**] 19:07:59
Job#: [**Job Number 57316**]
|
[
"309.0",
"427.31",
"401.9",
"530.85",
"293.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.39",
"96.6",
"42.42"
] |
icd9pcs
|
[
[
[]
]
] |
1172, 1311
|
5026, 5123
|
5149, 5403
|
1046, 1155
|
2065, 4922
|
5415, 6045
|
1334, 2047
|
185, 806
|
829, 1019
|
4947, 5004
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,807
| 198,320
|
49979
|
Discharge summary
|
report
|
Admission Date: [**2106-8-21**] Discharge Date: [**2106-8-25**]
Date of Birth: [**2032-7-14**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Transfer from OSH for possible ischemia, SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
74 y/o male with h/o CAD, PVD, T2DM, and psoriasis who presented
to [**Hospital3 **] with 5-7 days of non-specific symptoms
including SOB, fever, itchy eyes, vomiting, and nausea. He was
found to have a Troponin I elevation to 1.14 then 0.54, CK 48,
and BNP was 770. U/A was negative. CXR at OSH (report sent) was
normal. There was a concern for possible CHF exacerbation and he
was diuresed with IV Lasix. He was transferred to [**Hospital1 18**] for
further evaluation and treatment for possible ischemia.
According to EKG sent from OSH, the EKG revealed LBBB. Last
prior EKG in our system was from [**2099**] and did not reveal any
LBBB. There was also a question of hypotension and per transport
was 90/60s and responded to a small amount of IVF.
.
Upon arrival to the CCU, he was hemodynamically stable. He
denied any CP. He admitted to only a small amount of SOB and the
above mentioned symptoms. He denied orthopnea, PND, or syncope.
Past Medical History:
CAD
CHF
CRI
PVD s/p fem-[**Doctor Last Name **] bypass in [**2099**]
T2DM
Psoriasis
Buerger's disease
? PMR
Social History:
2 ppd for numerous years, quit 5 years ago. No EtOH. Lives
alone.
Family History:
N/C
Physical Exam:
PE:
Vitals: 96.7 96/56 65 97% RA
General: A/O x 3. NAD.
HEENT: PERRLA, EOMI. NC/AT.
Neck: No JVD.
CV: Normal S1, S2 with no m/r/g. Distant heart sounds.
Pulm: CTAB, no wheezes or crackles.
Abd: Soft, NT/ND with normoactive BS.
Ext: No c/c/e. 1+ DP B/L.
Skin: Extensive psoriatic lesions on arms, legs, and back.
Pertinent Results:
[**2106-8-21**] WBC-5.3 RBC-3.52* Hgb-10.7* Hct-32.5* MCV-92 MCH-30.3
MCHC-32.8 RDW-17.0* Plt Ct-215
.
[**2106-8-22**] WBC-6.8 RBC-2.92* Hgb-9.3* Hct-26.5* MCV-91 MCH-31.9
MCHC-35.1* RDW-16.9* Plt Ct-206
.
[**2106-8-23**] WBC-6.2 RBC-3.01* Hgb-9.5* Hct-28.0* MCV-93 MCH-31.7
MCHC-34.0 RDW-17.0* Plt Ct-243
.
[**2106-8-24**] WBC-6.0 RBC-2.79* Hgb-8.9* Hct-25.8* MCV-93 MCH-31.8
MCHC-34.4 RDW-17.0* Plt Ct-230
.
[**2106-8-25**] WBC-5.5 RBC-2.78* Hgb-8.8* Hct-26.0* MCV-94 MCH-31.7
MCHC-33.9 RDW-17.3* Plt Ct-238
.
[**2106-8-21**] Glucose-308* UreaN-32* Creat-2.1*# Na-136 K-4.9 Cl-98
HCO3-27 AnGap-16
.
[**2106-8-22**] Glucose-166* UreaN-44* Creat-2.1* Na-136 K-4.5 Cl-99
HCO3-26 AnGap-16
.
[**2106-8-23**] Glucose-178* UreaN-51* Creat-1.8* Na-140 K-4.9 Cl-102
HCO3-27 AnGap-16
.
[**2106-8-24**] Glucose-155* UreaN-48* Creat-1.6* Na-139 K-4.4 Cl-103
HCO3-27 AnGap-13
.
[**2106-8-25**] Glucose-272* UreaN-45* Creat-1.5* Na-138 K-4.7 Cl-103
HCO3-28 AnGap-12
[**2106-8-21**] ALT-13 AST-14 LD(LDH)-181 CK(CPK)-53 AlkPhos-58
TotBili-0.4
[**2106-8-21**] CK-MB-4 cTropnT-0.35*
[**2106-8-22**] CK-MB-3 cTropnT-0.30*
[**2106-8-21**] Albumin-3.5 Calcium-8.8 Phos-2.9 Mg-1.6 Cholest-151
[**2106-8-23**] Calcium-8.6 Phos-3.4 Mg-1.8
[**2106-8-24**] TotProt-5.5*
[**2106-8-22**] calTIBC-186* VitB12-1670* Folate-18.5 Ferritn-318
TRF-143*
[**2106-8-21**] %HbA1c-7.4*
[**2106-8-21**] Triglyc-131 HDL-41 CHOL/HD-3.7 LDLcalc-84
.
Imaging Studies
1. CXR [**2106-8-21**]
Lordotic positioning. The lungs are probably hyperinflated. The
right hemidiaphragm is elevated. There is possible mild
cardiomegaly. The aorta is calcified and mildly unfolded. There
is no CHF, focal infiltrate or effusion.
.
2. p-MIBI [**2106-8-23**]
1) Severe fixed myocardial perfusion defect involving distal
anterior wall and apex. 2) Moderate, fixed myocaridal perfusion
defect involving anteroseptal and inferoseptal walls. 3)
Moderately enlarged left ventricular cavity. 4) Apical akinesis
and diffuse hypokinesis. Calculated LVEF 30%. No anginal
symptoms with an uninterpretable ECG for
ischemia. Nuclear report sent separately.
.
4. Echo [**2106-8-23**]
The left atrium is mildly dilated. Left ventricular wall
thicknesses are
normal. The left ventricular cavity is mildly dilated. Overall
left
ventricular systolic function is moderately depressed. Tissue
velocity imaging E/e' is elevated (>15) suggesting increased
left ventricular filling pressure (PCWP>18mmHg). Resting
regional wall motion abnormalities include septal
hypokinesis/akinesis, apical hypokinesis/akinesis and anterior
hypokinesis. No definite LV thrombus seen (cannot definitively
exclude). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) are mildly thickened.
There is no aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion. Compared with the report of the prior
study (images unavailable for review) of [**2099-11-13**], overall LV
function is probably similar although segmental wall motion was
previously in a different territory. EF 35-40%.
.
SPEP negative
UPEP negative
Brief Hospital Course:
74 y/o male with h/o CAD, PVD, T2DM, and psoriasis who was
transferred from OSH for further management and evaluation of
possible ischemia after Troponin I was found to be elevated. The
following issues were addressed during this hospitalization.
.
1. Cardiac
The patient has no known documented history of CAD but has
numerous risk factors including T2DM and PVD. He was transferred
to [**Hospital1 18**] from OSH after troponin bump with the concern for
possible ischemia and need for cardiac catheterization. Upon
admission to [**Hospital1 18**], the patient had no symptoms to suggest ACS
nor did he have acute ST changes. Furthermore, the patient was
not interested in undergoing a cardiac catheterization. It was
decided to perform a stress MIBI during the [**Hospital 228**] hospital
stay. The specific results are above along with his echo
results. The stress MIBI revealed the presence of stable, fixed
lesions. Echo showed an EF of 35-40%. There was no urgent need
for cardiac catherization and the patient did not want to
undergo cardiac catheterization so the decision was made to
manage his CAD medically by optimizing his medications. He was
discharged home on a BB, ACEI, ASA, and statin. He will follow
up with a cardiologist referred by his PCP in his area. On
admission, there was a concern for a new LBBB but after
discussing the patient's case with his PCP the LBBB was indeed
not new. The etiology of the LBBB was likely secondary to
cardiomyopathy from prior ischemic events. There was an initial
concern for hypotension on transport with BP 90/60s and the
patient's home dose of Lasix was held. He was discharged on half
his home dose of Lasix with further adjustments to be made by
his PCP. [**Name10 (NameIs) **] was instructed to weigh himself everyday.
.
2. Acute Renal Failure on Chronic Renal Insufficiency
After talking to the patient's PCP, [**Name10 (NameIs) **] has a baseline creatinine
of 1.65. Initially, his creatinine was elevated to 2.1
indicating ARF on CRI. The patient's acute rise in creatinine
was most likely pre-renal in origin and it slowly came back to
baseline with IVF and holding the patient's Lasix and ACEI, both
of which were re-started once his creatinine returned to
baseline. The patient also had some difficulty with urinary
retention secondary to h/o an enlarged prostate. He refused any
urinary catheterization during this admission. He was started on
Flomax for his urinary symptoms. Further workup of the patient's
urinary retention and annual digital rectal examinations will be
done per his PCP as an outpatient. The patient has a history of
an elevated ESR and SPEP, UPEP were sent.
.
3. Anemia
The patient has chronic anemia per PCP which is consistent with
both iron deficiency and anemia of chronic disease. The
patient's HCT was stable throughout his entire hospital
admission.
.
4. Chronic corticosteroid use
It was unclear exactly why the patient was on chronic steroids.
We were unable to obtain further information regarding steroid
dose and indication from the patient's PCP. [**Name10 (NameIs) **] was given stress
dose steroids and OSH. We continued his home dose of prednisone
during this hospital admission. Further management of patient's
steroid regimen will be per his PCP.
Medications on Admission:
Medications at home:
Allopurinol 300 mg PO daily
Prednisone 5 mg PO BID
Metoprolol 25 mg PO BID
Glipizde 5 mg PO daily
Metformin 500 mg PO BID
Ferrous Sulfate
Verapamil SR 240 mg PO daily
Lasix 40 mg PO daily
Protonix 40 mg PO daily
Insulin
Lisinopril (? dose)
Quinine
.
Medications upon transfer
ASA 325 mg PO daily
Lasix 40 mg IV daily
Metoprolol 25 mg PO BID
Allopurinol 300 mg PO daily
Prednisone 20 mg PO daily
Hydrocortisone 100 IV once
Ferrous
Verapamil 240 mg SR PO daily
Protonix 40 mg PO daily
RISS
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. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day.
6. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2*
7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. NPH
NPH Sliding Scale 10-30 units
12. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
13. Glipizide 5 mg Tablet Sig: One (1) Tablet PO twice a day.
14. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Coronary Artery Disease
.
Secondary:
CHF
T2DM
PVD
Psoriasis
Discharge Condition:
The patient was discharged hemodynamically stable, afebrile with
appropriate follow up.
Discharge Instructions:
1. Please take all medications as prescribed. The following are
new medications:
Aspirin 325 mg PO daily
Tamsulosin 0.4 mg PO once at night
Lisinopril 5 mg PO daily
Simvastatin 40 mg PO daily
Metoprolol SR 50 mg PO daily
Your Lasix dose has been changed to 20 mg PO daily.
.
2. Please keep all follow up appointments.
.
3. If you experience worsening chest pain, shortness of breath,
dizziness, or any other concerning symptom please call your PCP
[**Last Name (NamePattern4) **]. [**Last Name (STitle) **] at [**Telephone/Fax (1) 53156**] or seek medical attention in the ED.
Followup Instructions:
Please follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] on Tuesday, [**9-7**]
at 4:15 PM.
.
Please follow up with a cardiologist. Obtain a referral from
your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] at your follow up appointment.
Completed by:[**2106-8-31**]
|
[
"285.29",
"788.20",
"443.9",
"696.1",
"428.0",
"414.01",
"403.91",
"584.9",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10382, 10388
|
5190, 8446
|
360, 367
|
10501, 10591
|
1923, 5167
|
11216, 11533
|
1570, 1575
|
9006, 10359
|
10409, 10480
|
8472, 8472
|
10615, 11193
|
8493, 8983
|
1590, 1904
|
276, 322
|
395, 1339
|
1361, 1471
|
1487, 1554
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,613
| 193,577
|
41957
|
Discharge summary
|
report
|
Admission Date: [**2123-9-22**] Discharge Date: [**2123-10-26**]
Date of Birth: [**2044-4-21**] Sex: F
Service: SURGERY
Allergies:
Zosyn
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
GIB
Major Surgical or Invasive Procedure:
EDG with clips
IR guided embolization
[**2123-10-10**] vagotomy, pyloroplasty, oversew of duodenal ulcer, J
tube placement
tunnelled line placement, Left IJ [**2123-10-18**]
picc line placement, left arm, [**2123-10-20**]
picc line repositioning [**2123-10-21**]
History of Present Illness:
79 yo F w/ h/o ESRD on HD (recently started), was at HD when she
developed aphasia (could not express words). Pt went to
[**Hospital 27217**] hospital, where head CT was wnl, and her symptoms
resolved. She was given one dose ASA 325. While there she used
the commode, she passed BRBPR and had episode of bright red
hematemesis. She got a bolus of protonix and was started on a
gtt. She was also started on octreotide, that was d/c'd, given
no history of liver disease. Hct in the low 20s, she was
transfused 2u pRBC and transferred to [**Hospital1 18**].
When arriving at [**Hospital1 18**], 2nd unit still going in when hct was
drawn. In the ED, initial VS were: 98.6, 68, 108/40, 18, 100%
on 2L. NG lavage cleared w/ 200 cc. Rectal exam guaiac +, no
melena. Trop 0.05, Cr 2.3, hct 24.4. HDS, VS 73, BP 122/43, RR
18. 18/22 gauge pivs.
Past Medical History:
hypertension,
hyperlipidemia,
diabetes (diet controlled),
ESRD on HD admitted
Social History:
Patient lives wtih husband. [**Name (NI) **] alcohol, no tobacco.
Family History:
Non-contributory
Physical Exam:
VS: 98.5, 80, 127/47, 14, 95% RA
General: Alert, oriented X3, pale, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NEURO: CN2-12 grossly intact, [**3-16**] muscle strength in RUE,
otherwise intact throughout.
Pertinent Results:
[**2123-10-10**] 12:13 am BLOOD CULTURE
**FINAL REPORT [**2123-10-12**]**
Blood Culture, Routine (Final [**2123-10-12**]):
STAPH AUREUS COAG +. FINAL SENSITIVITIES.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Aerobic Bottle Gram Stain (Final [**2123-10-10**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Reported to and read back by [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Numeric Identifier 91066**])
[**2123-10-10**] @1700.
Anaerobic Bottle Gram Stain (Final [**2123-10-10**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
LABS:
Test Name Value Reference Range Units
[**2123-10-26**] 05:45
RENAL & GLUCOSE
Glucose 125* 70 - 100 mg/dL
IF FASTING, 70-100 NORMAL, >125 PROVISIONAL DIABETES
Urea Nitrogen 66* 6 - 20 mg/dL
Creatinine 4.3* 0.4 - 1.1 mg/dL
Sodium 128* 133 - 145 mEq/L
Potassium 5.1 3.3 - 5.1 mEq/L
Chloride 86* 96 - 108 mEq/L
Bicarbonate 29 22 - 32 mEq/L
Anion Gap 18 8 - 20 mEq/L
CHEMISTRY
Calcium, Total 8.1* 8.4 - 10.3 mg/dL
Phosphate 6.0* 2.7 - 4.5 mg/dL
Magnesium 2.5 1.6 - 2.6 mg/dL
[**2123-10-26**] 05:45
Hematocrit 31.6* 36 - 48 %
[**2123-10-10**] 12:01
Report Comment:
Source: Line-aline
BASIC COAGULATION (PT, PTT, PLT, INR)
PT 13.9* 10.4 - 13.4 sec
PTT 28.1 22.0 - 35.0 sec
INR(PT) 1.2* 0.9 - 1.1
TTE [**2123-10-14**], EF 75%, The left atrium is mildly dilated. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity is unusually small. Left ventricular systolic
function is hyperdynamic (EF 75%). Right ventricular chamber
size and free wall motion are normal. The ascending aorta is
mildly dilated. There are focal calcifications in the aortic
arch. The aortic valve appears bicuspid. The aortic valve
leaflets are moderately thickened. The study is inadequate to
exclude significant aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Trivial mitral
regurgitation is seen. The left ventricular inflow pattern
suggests impaired relaxation. The tricuspid valve leaflets are
mildly thickened. The supporting structures of the tricuspid
valve are thickened/fibrotic. There is a small pericardial
effusion. The effusion is echo dense, consistent with blood,
inflammation or other cellular elements.
PERTINENT STUDIES
# Carotid US ([**9-23**])
FINDINGS: Duplex was performed of bilateral carotid arteries.
The left
carotid could not be visualized through the central line
placement and would recommend alternative imaging for further
characterization of this area. Right ICA demonstrates a
heterogeneous plaque with a peak velocity of 181/51. The right
CCA velocity is 63 and the right ECA velocity is 88. The ICA/CCA
ratio is 2.8. This is consistent with 60-69% right ICA stenosis.
The right vertebral is antegrade.
IMPRESSION: 60-69% right ICA stenosis. Unable to visualize the
left carotid system and therefore recommend alternative imaging.
.
# CTA ABD/PELVIS ([**9-23**])
1. Right rectus sheath and retroperitoneal hematoma with
overlying soft
tissue stranding without evidence for active bleeding.
2. Hyperdense foci in the duodenum suggesting active bleeding.
At the time
of this dictation, the patient is status post embolization by
interventional radiology.
3. Stenosis or occlusion of mid-superficial femoral arteries
bilaterally.
4. Right femoral catheter not definitively in the venous system.
These findings were discussed with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] by Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7867**] by telephone at 1:45 p.m. on [**2123-9-24**].
.
# ECHO ([**9-24**])
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size and free wall
motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) are mildly thickened. There is no valvular aortic stenosis.
The increased transaortic velocity is likely related to high
cardiac output. Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is borderline pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion.
.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal global and regional biventricular systolic function. Mild
mitral and aortic regurgitation. Elevated filling pressures and
borderline pulmonary hypertension.
.
# Angiography ([**9-24**])
1. SMA angiography demonstrates a focal area of extravasation
within the
second part of the duodenum corresponding to CTA findings. The
source of
bleeding came from likely two third order of branches of the
IPDA. Both of
these were successfully using Gelfoam and coils, with no active
extravasation identified post-embolization.
2. Celiac and GDA angiography demonstrates a patent proximal GDA
with filling of several GDA collaterals that were not embolized
previously. The proximal portion of the GDA was then coiled
additionally, with good stasis of flow and no filling of
additional GDA collaterals identified.
.
IMPRESSION: Active extravasation seen within the second part of
the duodenum from branches of the SMA, with successful
embolization as described above.
.
# CTA Head/neck ([**9-27**])
1. No evidence of acute intracranial abnormalities. MRI would be
more
sensitive for an acute infarction, if clinically indicated.
2. Multifocal irregularity and narrowing of the cervical and
intracranial
left vertebral artery. While this could be related to
atherosclerosis,
dissection cannot be excluded. Neck MRA with fat-suppressed
axial T1-weighted images is recommended to exclude dissection.
3. Atherosclerosis in the proximal right and left internal
carotid arteries, without evidence of a hemodynamically
significant stenosis.
4. Short segments of narrowing proximal M1 segment of the left
middle
cerebral artery and in the distal A1 segment of the left
anterior cerebral
artery may be related to atherosclerosis.
5. 2.3 cm right thyroid nodule. Recommend thyroid son[**Name (NI) 867**] for
further
evaluation, if not performed previously.
6. Emphysema. 7-mm spiculated density at the left lung apex.
Recommend
follow-up chest CT in three months.
.
Brief Hospital Course:
79 yo F w/ h/o ESRD on HD (recently started), presented w/
hematemesis and BRBPR, concerning for GI bleed, found to have
duodenal ulcer bleed and question of stroke.
She was admitted directly to MICU. Pt received immediate
transfusion and close HCT monitoring. She was intubated and EGD
was performed within 24 hours, which identified a duodenal ulcer
with high probability of bleed. The ulcer was clipped.
However, pt continued to have large volume maroon stool, drop in
HCT, and evidence of active bleeding by CTA. Massive
transfusion protocol was activated. She underwent repeated EGD,
and attempts of embolization twice in the IR suite. Eventually,
the EGA bleeding was stopped by coiling via SMA and celiac. Pt
received a total of 26u pRBC, 13u FFP and 5u platelets. The
resuscitation was complicated retroperitoneal bleed, which was
managed conservatively. She was transferred out of the ICU.
However, on [**10-5**], hct dropped to 29->25 w/ melena and coffee
grounds. She was retransferred to the MICU, where she received
2 units pRBC and post-transfusion 28. Her hct dropped to 25 and
patient was transfused 2 more units pRBC. Patient was intubated
for EGD that showed esophagitis, duodenitis and non-bleeding
duodenal ulcers. Repeat HCT remained stable between 32-35.
On [**10-6**] she was transferred out of the unit to floor. On
[**10-7**], she had more melenatic stool, underwent a tagged red
blood cell scan which showed bleed at 2nd part of the duodenum.
IR and surgery were contact[**Name (NI) **]. IR deferred to further intervene
unless absolutely necessary. She underwent another EGD with
side viewing camera, two clips were placed. Her HCT dropped to
24 after the procedure, she was transfused during hemodialysis.
On [**10-10**], she underwent truncal vagotomy and pyloroplasty,
Tru-Cut biopsy of the liver, and feeding jejunostomy for
bleeding duodenal ulcer, poor nutrition, end stage renal
disease. Surgeon was Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
Postop, she was kept NPO for approximately 6 days. Tube feeds
started via the J tube on postop day 2. A Gastrografin study was
performed on [**10-15**] demonstrating normal passage of contrast
through a patent pylorus through the duodenum and into the
jejunum without evidence of leaks. Diet was slowly started and
advanced. Intake was poor. Ensure supplements were encouraged.
She experienced frequent loose, non-bloody stools. Stool was
sent x3 for C.diff. This was negative. Imodium and Psyllium were
started with dose adjusted for persistent frequent stools. At
time of discharge to rehab she had 1 BM during the day.
Abdominal incision staples were removed on [**10-21**]. The medial
aspect of the wound had small amount of drainage and was not
well approximated. This was opened ~ 9cm x 2.5cm x 1.5cm and
packed loosely with normal saline damp gauze [**Hospital1 **].
# ESRD: Pt was recently started on hemodialysis. We resumed her
hemodialysis after achieving hemodynamic stability. She
received dialysis on T/Th/Sa. A temporary dialysis line had been
placed via the left IJ. Subsequently a tunnelled line was placed
on the left side as well. After evaluating the RUE AVF, it was
determined that this was mature enough to use for HD. The
temporary line was removed and tip was cultured. Culture was
negative. The left IJ tunnelled line remained in place. Plan was
to remove in [**12-13**] weeks once it was clear RUE AVF was functioning
well at dialysis sessions.
On [**2123-10-10**], blood cultures isolated MSSA 4/4 bottles. Nafcillin
was started. ID was consulted and recommended a TTE. TTE on [**10-14**]
was negative for vegetations. Given sub-optimal quality of
study, murmur and high grade bacteremia, ID recommended a full 6
week course of antibiotics. Nafcillin was continued started on
[**10-14**] and continued thru [**10-25**]. Kefzol was then started on [**10-26**]
after hemodialysis. Kefzol was to continue for 4 more weeks
dosed after HD (Tues-2grams, Thurs-2grams & Sat-3grams).
Surveillance blood cultures were negative on [**12-10**], [**10-15**]
and [**10-20**].
# Stroke: Pt presented to OSH for aphasia prior to transfer to
[**Hospital1 18**]. Initial neural exam showed LUE weakness. Code stroke
was called. However, full neural exam was limited by overall
weakness. Neurological imaging was deferred in the setting of
massive GIB. Of note, CT head at OSH showed no bleed. After pt
was stabilized, carotid US showed 60-70% stenosis on R; CTA Head
& Neck showed no acute intracranial process. No hemodynamically
significant carotid stenosis. On departure from MICU, neuro exam
was notable for right-sided pronator drift. PT evaluated and
worked with her recommending rehab. She was oob to chair with
assist and ambulating short distances with walker.
Bradycardia: During the EGD procedure, pt was bradycardic to
30s. EKG showed Weinkenbach blocks exacerbations of sinus
bradycardia consistent with increased vagal tone. Pt required
pretreatment with atropine to complete subsequent procedures.
She remained normal sinus rhythm during rest of the hospital
stay. We withheld all nodal agents initially. It is possible
that vagal episodes and heart block were the underlying cause
for her recurrent syncope.
# UTI: Pt developed fever on HD#4, and was found to have UA
concerning for UTI. Urine culture grew pansensitive E.coli. Pt
was initially treated with iv ceftriaxone, which was later
switched to cefpodoxime to complete an full 10 day course (last
dose 10/26).
.
# Sacral ulcer: pt was found to have a stage 1 gluteal ulcer.
Wound care was provided under the guidence of wound consult
service.
.
CHRONIC ISSUES
.
# Hypothyroidism - We continued her levoxyl 0.137 qd
TRANSITIONAL ISSES
- Surgical clips over the duodenal ulcer are not compatible with
MRI in the first month after placement
- Code status: Pt initially declared DNR/DNI. Her code status
was reversed during this hospital stay given need for
procedures. Will need to readdress after clinical improvement.
- Vagal tone: pt was found to have severe vagal tone during
procedures. The underlying Wenchenbach and severe vagal
episodes may be the underlying cause for her syncope. She will
need EP workup longterm
Disposition: Rehab, [**Location (un) 1121**] [**Hospital1 **] in [**Hospital1 3597**]. A bed was
available on [**10-26**]. She was transferred there in stable
condition after HD was done on [**10-26**].
.
Medications on Admission:
Furosemide 40 mg [**Hospital1 **]
Requip 0.25 mg qHS
Neurotin 300 mg qAM
Zocor 80 mg qd
Levoxyl 0.137 mg qd
Imdur 30 mg qd
metoprolol 100 mg qpm
ASA 325 mg qd
Prilosec 20 mg [**Hospital1 **]
vitamin D 50,000 qWK
Spetrum Silver
Iron [**Hospital1 **]
Ambien
Procrit 10,000 qmonthly
Vicodin (? taking it)
Discharge Medications:
1. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
2. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
PRN (as needed) as needed for itching.
3. insulin regular human 100 unit/mL Solution Sig: follow
sliding scale units Injection ASDIR (AS DIRECTED).
4. levothyroxine 137 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
6. miconazole nitrate 2 % Cream Sig: One (1) Appl Vaginal HS (at
bedtime) for 1 days: to complete a 7 day course.
7. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
9. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
hold for sbp <110 or HR <60 .
10. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection [**Hospital1 **] (2 times a day).
11. psyllium 1.7 g Wafer Sig: Three (3) Wafer PO BID (2 times a
day).
12. loperamide 2 mg Capsule Sig: Two (2) Capsule PO QID (4 times
a day).
13. cefazolin 1 gram Recon Soln Sig: Two (2) grams Intravenous
2x/week for 4 weeks: on Tuesdays and Thursdays at dialysis.
14. cefazolin 1 gram Recon Soln Sig: Three (3) grams Intravenous
once a week for 4 weeks: on Saturdays at dialysis.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **] [**Location (un) **]
Discharge Diagnosis:
UGIB, duodenal ulcer
ESRD
MSSA bacteremia
E.coli UTI
Depression
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 will be transferring to [**Location (un) 1121**] [**Hospital3 **] in
[**Hospital1 3597**]
-Hemodialysis should continue on a Tuesday-Thursday-Saturday
schedule
-Kefzol (antibiotic)to be given at dialysis for 4 weeks for MSSA
bacteremia
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**]
Date/Time:[**2123-11-3**] 2:40
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2123-10-26**]
|
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icd9cm
|
[
[
[]
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[
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18279, 18523
|
1649, 2203
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226, 232
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563, 1416
|
18110, 18255
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1438, 1517
|
1533, 1600
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
690
| 135,389
|
5744
|
Discharge summary
|
report
|
Admission Date: [**2188-2-11**] Discharge Date: [**2188-3-5**]
Date of Birth: [**2109-9-24**] Sex: M
Service: MEDICINE
Allergies:
Morphine / Codeine / Chocolate Flavor
Attending:[**First Name3 (LF) 6195**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
1) Heel wound debridement and late closure.
2) central venous line placement
History of Present Illness:
78M w/ESRD on HD, DM2, CAD presenting to the ED w/mental status
changes. His present illness began with an episode of
postherpetic neuralgia which he was seen for @ [**Company 191**] on [**1-10**] at
which time he was started on neurontin. He was seen in FU @ [**Company 191**]
[**2-1**] at which time he was experiencing euphoria and unsteady
gait, which were [**Month/Day (1) 2771**] to the neurontin. Neurontin was
subsequently tapered from 600HS to 300HS. [**2-6**] he was switched
to tegretol. On the day of presentation, his daughter called
[**Name (NI) 191**] to report severe pain and sx of
delirium (talking to self, confused) and temp 99. Emesis Sat
and today.
.
In the ED his temp was 101 and he was found to have pressures in
the 80's. He received 2 liters of fluid with immediate response
of his BP to the 100's. He was given ceftriaxone, vancomycin
and acyclovir in the ED and an LP showed 27 WBC and 1 RBC.
.
Family denies any travel. Only pet in house is a dog.
Past Medical History:
ESRD
Type 2 diabetes mellitus ('[**76**])
PVD, s/p R [**Doctor Last Name **]-dp BPG
Neuropathy
HTN
Hypercholesterolemia
Chronic anemia
Hiatal hernia
CAD, s/p CABG lima-lad, SVG RCA, OM [**3-27**]
Lower back pain s/p surgery for ?disk herniation
Social History:
The patient lives in [**Location 38**] with his wife who is his primary
caregiver. [**Name (NI) **] is an ex-smoker (approx 40yrs), quit 22 years
ago. Used to drink socially, no longer drinks.
Family History:
The patient's mother died of MI at 89, father had DM, ?heart dz
died at 79, paternal GM had DM. He reports other family members
with heart disease.
Physical Exam:
GEN: well developed, well nourished, in no acute distress, awake
and alert
HEENT: MMM, PERRL, EOMI, OP clear, no LAD, able to fully ROM
neck without pain, no meningismus
CV: RRR nl S1 S2 no murmurs
Lungs: CTA B no resp difficult, no increased resp effort
Abd; Soft NT ND + BS no RUQ TTP
Ext: 2+ radial pulses bilaterally, 1+ DP pulse on right foot,
doppler pulse on left DP, decreased sensation in bilateral
plantar surfaces of the feet with normal sensation above the
ankle on the right and above mid calf on the left, 5/5 strength
in RLE and BUE, [**3-31**] in LLE, large ulcer on left heel with
necrotic base and no bone evident, venostasis color changes of
left toes
Skin: dried red, crusted vesicles over the L3 dermatome of the
left buttocks and left medial aspect of thigh/ knee, very
painful/irritable to touch, open area of vesicle on left
buttocks, stage 1 sacral decub ulcer in midline of sacrum.
Pertinent Results:
Hematocrit: 34.2 on [**2-11**]. Low of 25.8 on [**3-1**], rose to 27.7 on
[**3-3**]. MCVs consistently high at 96-103.
.
Electrolytes: Patient was admitted with a Ca/Mg/Phos of
8.6/2.0/7.7 on [**2188-2-11**]. His phosphate continued to rise to
maximum of 9.3 on [**2188-2-19**]. His dose of Renagel was increased to
1600 mg tid, and he was started on lanthanum, with some
improvement. Haptoglobin was 206, LDH was 282 on [**2-18**], CK was
293 on [**2-19**], alkphos was normal at 77 on [**2-18**], not suggestive of
hemolysis, rhabdomyolysis or osteolysis. PTHrP <2.0 (neg) on
[**2-20**]. SPEP [**2-19**] showed IgG elevation without monoclonal band.
On discharge [**2188-3-4**], he had a phosphate of 6.6.
.
ESR: [**2-17**] 108, [**2-24**] 85. CRP: [**2-17**] 130.7, [**2-24**] 60.3
.
Endocrine: TSH 1.3 on [**2-18**]. PTH 91 on [**2-13**] on [**2-19**].
Cortisol 21.0 on [**2-18**].5 on [**2-24**].
.
ANCA negative [**2-17**] and [**2-28**].
.
Blood gas: [**2188-2-23**] ART 7.43/82/49/34
ART 7.46/57/49/36
CSF: [**2-11**]: 27 WBCs, 96% lymphs, 1 RBC
[**2-19**]: 12 WBCs, 97% lymphs, 41 RBCs
.
Micro: Blood Cx: [**2-11**] grew Enterobacter cloacae. All cultures
negative on [**1-25**], [**2-15**], [**2-16**], [**2-17**] (mycolytic/fungal),
[**2-18**], [**2-23**], [**2-24**], [**2-25**], [**2-26**].
.
CSF culture/PCR: [**2-11**] negative bacterial/fungal culture. [**2-19**]
negative bacterial/fungal/viral culture, negative cryptococcal
antigen, [**Male First Name (un) 2326**] virus PCR, Anaplasma titer. [**2-11**] and [**2-19**] negative
PCR for HSV, VZV, CMV.
.
Heel ulcer swab: [**2-15**] positive for MRSA and Enterobacter
cloacae.
.
Sputum culture: [**2-19**] positive for MRSA.
.
Imaging:
.
[**2-20**] EEG IMPRESSION: Mildly abnormal EEG mostly in the drowsy
state due to a
mildly slowed background in waking. This suggests a widespread
encephalopathy. Medications, metabolic disturbances, and
infection are
among the most common causes. There were no prominent focal
abnormalities, and there were no epileptiform features.
.
[**2-20**] CXR IMPRESSION: Stable appearance of the chest. No
pneumonia appreciated.
.
[**2-20**] MRI head IMPRESSION: Severely limited study. The
previously demonstrated subtle FLAIR
signal hyperintensity in the right mesial temporal lobe is no
longer apparent on the current exam.
.
[**2-13**] head MRI
IMPRESSION:
1. Subtle, asymmetric FLAIR signal hyperintensity in the right
mesial temporal lobe. While not specific for HSV encephalitis,
this is a classic location for signal abnormality in the setting
of this entity.
2. Multiple probable areas of chronic infarction.
.
[**2-12**] Heel XR
IMPRESSION: Increased size of ulcer along the plantar surface
of the heel with subcutaneous air, but no radiographic evidence
of bony involvement. If a more sensitive evaluation is needed,
bone scan or MRI could be helpful for further assessment.
.
[**2-11**] EKG
Sinus rhythm
Probable left atrial abnormality
Intraventricular conduction delay with left axis deviation - in
part left anterior fascicular block Delayed R wave progression -
could be in part left axis deviation/ intraventricular
conduction delay or possible prior septal myocardial infarction
Since previous tracing of [**2187-10-31**], low T wave amplitude
improved
.
[**2-11**] Head CT:
No intracranial hemorrhage or mass effect. Small foci of air in
the right frontal subcutaneous tissues of uncertain etiology.
.
[**2-11**] CXR:
Increased left lower lobe opacity again seen, concerning for
possible pneumonia.
.
Brief Hospital Course:
Mr. [**Known lastname 22883**] is a 78 year old male with ESRD on HD, CAD, PVD
presenting with delerium likely secondary to HSV or VZV
encephalopathy in addition to GNR bacteremia.
.
# Aseptic encephalitis: The patient presented with with
personality changes over the past month and was delirious in the
hospital, but improved during and after his ICu stay. Despite
the long time course and negative PCR for HSV/VZV/CMV/[**Male First Name (un) 2326**] and
crypto ag, erlichia, he could have had encephalitis, given his
history of recent zoster outbreak and classical findings on MRI.
A repeat LP on [**2-19**] showed findings similar to previous (99
prot, 54 glu, 17 WBC, 96% lymphs). EEG on [**2-20**] was read as a
diffuse encephalopathy, consistent with metabolic disturbance,
medication effect, or infection. A repeat MRI on [**2-26**] shows no
acute process. Patient has finished his course of acyclovir.
Viral/fungal cultures are negative thus far, and VDRL is
pending.
- The patient was previously on tegretol and neurontin prior to
his admission which caused changes in mental status. These
medications should be avoided. As his zoster has improved, it is
unlikely that he will need this in the future.
- He is to follow up with Dr. [**First Name (STitle) **] in [**1-29**] weeks.
.
# Enterobacter bacteremia: Blood cultures were positive on [**2-11**];
all subsequent cultures were negative. A left heel ulcer is
believed to be the source of bacteremia. He is on cipro/vanco
for 6 weeks secondary to osteomyelitis. Cipro should stop on
[**2188-3-24**]. Vancomycin will end on [**2188-3-30**].
- On ciprofloxacin and vancomycin for total six week course.
Vancomycin is to be dosed by levels (dose for level < 15) at
dialysis. Levels are to be drawn every other day starting
tomorrow, [**3-6**].
- Echo was negative for vegetation.
- Surveillance cultures were negative.
.
# Hypotension: The patient was hypotensive for several days.
This seems to have resolved for now. He has been weaned from
midodrine and is tolerating dialysis. He originally did not
respond to fluid bolus, and for severl days he was running even
for volume on dialysis,. He was ruled out for adrenal
insufficiency. No clear etiology was ascertained. However,
infection was possible but patient doing well on cipro/vanc.
Apparently, in the MICU, blood pressures were 20 points higher
on A line than with cuff. At the time of discharge, the
patient's blood pressures were in the 100-120 range
systolically. He was restarted on a low dose of his beta
blocker, toprol XL at 25 mg daily.
.
#. Ischemic optic neuropathy : Pathology was negative for
temporal arteritis. He is to be discharged on a prednisone taper
X 9 more days. Patient had covered his right eye with patch for
discomfort. He was encouraged to take off the patch. He is now
more comfortable but still minimal vision in right eye.
- Optho recs for ischemic optic neuropathy include continue ASA
daily, taper steroids, follow up with optho in next 6 months. He
has an appointment with Dr. [**Last Name (STitle) 22897**] in [**2188-5-27**].
- He was also encouraged to see his usual ophthalmology, Dr.
[**Last Name (STitle) **].
.
#.Delirium: Mental status currently at baseline and stable.
.
#. Renal Failure- The patient is to continue dialysis per renal
recs (T,TH,S) as an outpatient. He is on sevelamer for
hyperphosphatemia.
- He is set to be dialyzed tomorrow, [**3-6**]. He was last
dialyzed on [**3-4**].
.
#. Left heel ulcer: The patient was followed by [**Month (only) **]. The
ulcer probed to bone on exam. Intra-op cultures on debridement
grew MRSA and Enterobacter. X-rays performed which showed an
ulcer along the plantar surface of the heel with subcutaneous
gas, but no radiographic evidence of bony involvement. The ulcer
is now status post closure. As above, he will stay on cipro/vanc
for a total of six weeks. He will follow up with Dr. [**Last Name (STitle) **]
from [**Last Name (STitle) **] next week.
.
# hiatal hernia: He is to continue a PPI. He intermittently
complains of sensation of food getting stuck and has the urge to
vomit. He was followed by nutrition consult, who have suggested
giving moist, soft food, with some improvement. At the time of
discharge, he was tolerating a regular diet. He will attempt
fully solid foods but may prefer soft solids/ground food.
.
# Diabetes mellitus: His finger sticks have been running less
than 110, but increased to as high as 275 with improved PO
intake. We restarted his home glyburide at discharge.
.
# Chronic anemia: His hematocrit was stable but low, within
baseline range. B12/folate were checked for macrocytosis and
found to be WNL.
.
#Access: Central line was removed on the day of discharge
without complication. As the patient's vancomycin will be dosed
at dialysis, there was no need for more permanent access.
.
# High cholesterol: We continued his hyperlipidemia meds.
.
# CAD and HTN: His toprol was restarted prior to discharge. He
was maintained on ASA 81 mg daily.
.
# FEN: He tolerated a renal diet. He tolerates ground foods
without any difficulty. He can attempt to have a regular diet as
his symptoms allow.
.
#PPx: He is to continue SQ heparin until ambulatory, tolerating
PO diet on PPI. He should continue on an aggressive bowel
regimen as necessary.
.
#Full Code d/w family
.
#Comm: Wife and son, patient
Medications on Admission:
ASA 81mg QD
Calcitriol .75QD
fluticasone 100ug QD
furosemide 40mg QD
Gemfibrizol 600 [**Hospital1 **]
Glipizide 1.25 mg [**Hospital1 **]
Lipitor 80mg QD
Lomotil 2.5-.025mg
Niaspan 500mg QD
Percocet PRN
Prilosec 20mg QOD
Reglan 10mg Q6H PRN
Regranex .01%gel
Tegretol 200mg [**Hospital1 **]
Toprol 25 mg QD
Zetia 10mg QD
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily). Tablet, Chewable(s)
2. Calcitriol 0.25 mcg Capsule Sig: Three (3) Capsule PO DAILY
(Daily).
3. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: One (1)
Spray Nasal DAILY (Daily).
7. Niacin 500 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
8. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day) as needed for hyperphosphatemia.
9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
10. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
11. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*0*
12. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 20 days.
Disp:*20 Tablet(s)* Refills:*0*
13. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
gram Intravenous Q48H (every 48 hours) for 25 days: dosed when
level < 15 at dialysis. Goal level 15-20. to end on [**2188-3-30**].
Disp:*QS gram* Refills:*0*
14. Prednisone 5 mg Tablet Sig: as directed Tablet PO once a day
for 9 days: Start [**2188-3-6**]:
Take 20 mg X 3 days ([**3-6**], [**3-7**], [**3-8**]). Take 10 mg X 3 days ([**3-9**],
[**3-10**], [**3-11**]). Take 5 mg X 3 days ([**3-12**], [**3-13**], [**3-14**]). Then stop.
15. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
17. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day) as needed for constipation.
18. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
[**Hospital1 **] (2 times a day) as needed for constipation.
19. heparin Sig: 5000 (5000) U Subcutaneous three times a day:
while patient not ambulatory.
20. Outpatient Lab Work
Please check patient's electrolytes (sodium, potassium,
chloride, bicarbonate, BUN, creatinine, glucose), hematocrit,
and vancomycin level every other day, starting on Thursday,
[**3-6**]. Please fax results to ([**Telephone/Fax (1) 16691**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Northeast-[**Location (un) 38**]
Discharge Diagnosis:
Primary diagnoses: 1) Osteomyelitis (bone infection) of left
heel
2) Bacteremia (blood infection)
3) Aseptic meningoencephalitis
.
Secondary diagnoses: 1) Type II Diabetes
2) Ischemic optic neuropathy (right eye)
3) Hypotension
4) End Stage Renal Disease
5) Chronic Anemia
6) Hyperlipidemia
7) Hiatal hernia
Discharge Condition:
Afebrile, normotensive, comfortable on room air.
Discharge Instructions:
Please take your medications as prescribed. Please call your
doctor or return to the emergency room should you develop any of
the following symptoms: confusion or decreased alertness, fever
> 101, chills, nausea or vomiting with inability to keep down
liquids or medications, diarrhea, chest pain, difficulty
breathing, increased pain in your left heel, drainage from your
heel wound, increased redness or swelling of your left heel
wound or foot, or any other concerns.
.
You were evaluated for your confusion and low blood pressures.
It is likely that your confusion is secondary to inflammation
caused by your recent shingles infection. This seems to have
resolved. Your vision loss is likely due to low blood flow to
the arteries in your eye. This may improve slightly over time.
You should follow up with the neuroophthalmologist here at
[**Hospital1 18**]. You can also see your regular ophthalmologist.
.
You were found to have an infection in your blood and likely in
the bone of your left foot. You need a total of 6 weeks of
treatment with antibiotics. You will need to take one antibiotic
by mouth and another will be dosed at your dialysis. You should
not bear weight on your left leg for 4 more weeks. You will
follow up with Dr. [**Last Name (STitle) **] from [**Last Name (STitle) **] on [**2188-3-13**].
Followup Instructions:
Please return to see Dr. [**Last Name (STitle) **] on [**2188-3-13**] at 8:50
am. Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2188-3-13**] 8:50
.
Please call Dr.[**Name (NI) 11574**] office for an appointment within the
next 1-2 weeks. Phone number is [**Telephone/Fax (1) 250**].
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2188-4-18**] 1:50
Please return to see Dr. [**Last Name (STitle) **], the neuro-ophthalmologist, on
[**6-3**].
Provider: [**Name10 (NameIs) 6131**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2188-6-3**]
10:30
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6198**] MD, [**MD Number(3) 6199**]
Completed by:[**2188-3-5**]
|
[
"458.29",
"272.0",
"707.14",
"285.21",
"275.3",
"995.91",
"440.23",
"054.3",
"403.91",
"730.27",
"V15.82",
"V45.81",
"250.40",
"377.41",
"038.40"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"77.69",
"83.09",
"38.21",
"03.31",
"39.95",
"86.4",
"99.77"
] |
icd9pcs
|
[
[
[]
]
] |
14760, 14836
|
6601, 11948
|
319, 398
|
15188, 15239
|
3005, 6340
|
16607, 17530
|
1911, 2061
|
12317, 14737
|
14857, 14988
|
11974, 12294
|
15263, 16584
|
2076, 2986
|
15009, 15167
|
258, 281
|
426, 1414
|
6349, 6578
|
1436, 1682
|
1698, 1895
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,784
| 172,063
|
32021
|
Discharge summary
|
report
|
Admission Date: [**2143-8-23**] Discharge Date: [**2143-8-26**]
Date of Birth: [**2104-3-25**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
# [**First Name3 (LF) **] withdrawal
# [**First Name3 (LF) **] intoxication
Major Surgical or Invasive Procedure:
None
History of Present Illness:
39M from [**State 3706**], h/o HTN and anxiety who presented on [**2143-8-23**]
with [**Date Range **] intoxication. Pt reported binge drinking for 2
days prior to admission while in [**Location (un) 86**] on a business trip;
admission serum ETOH in 300's. Pt denied having a drinking
problem, although his wife recently suggested that he cut down.
He reported that he did not drink "everyday," and that he could
go "5 to 7 days without drinking." In later interviews, pt
stated that he had up to five drinks nightly. Pt reported that
he probably drank 15-18 days out of a month. Pt reported never
having had seizures or DTs. No prior hospitalizations.
.
Since hospitalization, pt had received diazepam via CIWA scale.
Over the last 24hr, pt had received over 200mg of PO diazepam
with little effect, and had remained tachycardic (HR 120s-160s).
Pt reported feeling jittery and anxious. BP stable. No SOB or
CP. Pt had received approximately 3L of IVF since admission
along with MVI, folate, and vitamin B12 (no thiamine). Of note,
CE were negative.
.
ROS: No fevers or chills. Pt concerned about making his flight
home on [**8-26**], and was willing to leave AMA. No SI or HI.
Past Medical History:
# HTN
# Anxiety
Social History:
# Personal: Lives with wife and 5 children (youngest 18 months
old) in [**State 3706**]
# Professional: Works for medical device company
# Tobacco: Reports no tobacco use
# [**State **]: As above
# Recreational drugs: Reports no recreational drug use
Family History:
# Father: HTN, DM (unclear which type)
# Mother: RA
Physical Exam:
VS: T:97.3 HR: 137 BP: 133/92 RR: 23 O2 98%RA
Gen: Slightly anxious-appearing man, answers questions
appropriately, A&Ox3, mildly diaphoretic.
HEENT: Bruise under L eye, injected, anicteric sclera, mucus
membranes slightly dry, EOMI, PERRL
CV: Tachy, regular rhythmn. No m/r/g. No JVD.
Chest: CTAB
Abdomen: Soft, NTND, BS+. No organomegaly
Extremities: WWP, no edema.
Neuro: A&O x 3, CNII-XII intact. Mild tremor noted in UE& LE,
strength 5/5, DTRs 2+
Skin: No rash
Pertinent Results:
Notable labs:
.
[**2143-8-23**] 12:15AM ASA-NEG ETHANOL-350* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
.
[**2143-8-23**] 08:30AM ASA-NEG ETHANOL-162* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
.
Notable studies:
.
EKG: Sinus tach at 106. Nml axis and intervals. S in I, Q wave
in III and TWI in III (present since [**8-23**]). Nml T-wave
progression. No ST-T changes.
.
[**2143-8-23**] CHEST, PA AND LATERAL. Frontal and lateral views of the
chest submitted without prior studies for comparison.
Cardiomediastinal silhouette and pleural spaces are normal. Lung
volumes are low, but the lungs are clear. Bony structures are
unremarkable.
Brief Hospital Course:
39M h/o [**Month/Day/Year **] abuse/overuse admitted after [**Month/Day/Year **] binge x2
days, now withdrawing and tachycardic.
.
# [**Month/Day/Year **] withdrawal: Pt. tachycardic, tremulous, mildly
diaphoretic, and anxious. Inadequately controlled on ~200mg PO
diazepam over last 24hr. Currently no hallucinations, delirium,
or seizures. CIWA frequency increased to diazepam 10mg Q30min,
and continued on MVI/thiamine/B12/folate. Psychiatry consult
obtained to assess capacity as pt is agitating to leave for
flight home.
.
# Tachycardia: Pt tachycardic [**12-28**] [**Month/Day (2) **] withdrawal,
hypovolemia, and anxiety. Repeat EKG demonstrated S1Q3T3
morphology with sinus tachycardia, but pt reported no pleuritic
CP. Cardiac enzymes negative x3 at 8 hours; CXR demonstrated
clear lungs. TSH normal. Pt received increased benzodiazepine
dosage with IVF hydration to manage tachycardia.
.
# Elevated LFTs: AST and ALT increased (AST approx 2x ALT),
indicating alcoholic hepatitis, which were monitored during this
admission.
.
# Hypokalemia: Pt's K was repleted in setting of ETOH use &
withdrawal.
.
# HTN: Pt was normotensive during this admission with home
regimen of amlodipine 5mg daily.
.
# Full code
.
# Dispo: Pt desired to leave AMA, because of (1) his flight at
8pm on [**8-26**], and (2) his obligations to his wife, family, and
work in [**State 3706**]. Team explained risks of [**State **] withdrawal,
and referred him to his PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 75005**] in [**Location (un) **] [**Doctor Last Name **] WI
([**Telephone/Fax (1) 75006**]).
Medications on Admission:
Home medications:
Amlodipine 5 mg PO daily: Pt reports not having taken this for
approximately one year.
.
Medications on MICU transfer:
Diazepam 30 mg PO Q2HOUR CIWA >10
Folate 1 mg PO daily
Multivitamins 1 cap PO daily
Amlodipine 5 mg PO daily
.
Allergies: NKDA
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
3. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
4. Thiamine HCl 100 mg IV DAILY Duration: 3 Days
5. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
# [**Telephone/Fax (1) **] intoxication
# [**Telephone/Fax (1) **] withdrawal
.
Secondary diagnosis:
# Hypertension
Discharge Condition:
Stable
Discharge Instructions:
You were admitted for [**Telephone/Fax (1) **] intoxication and you were
withdrawing from [**Telephone/Fax (1) **]. We advise you to stop drinking.
.
Please understand that you are leaving against medical advice.
We are concerned that you are still actively withdrawing from
[**Telephone/Fax (1) **] intoxication, which can lead to severe heart and related
problems.
.
We suggest that you obtain long-term treatment to manage your
[**Telephone/Fax (1) **] abuse, and that you follow up with your primary care
doctor [**First Name (Titles) **] [**Last Name (Titles) **] treatment.
.
Please call your doctor or return to the ER for chest pain,
shortness of breath, tremors, dizziness or other concerning
symptoms.
Followup Instructions:
We have made an appointment for you with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 75005**],
your primary care doctor. That appointment is to follow-up on
your [**Last Name (NamePattern1) **] withdrawal, which is a very dangerous condition.
.
Your appointment is this Thursday, [**8-29**], at 3:10 pm, 313
South Main, [**Location (un) **] [**Doctor Last Name **] WI.
.
Please call their office if you need to change this appointment.
Completed by:[**2143-8-26**]
|
[
"303.01",
"276.8",
"291.81",
"401.9",
"300.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"94.62"
] |
icd9pcs
|
[
[
[]
]
] |
5488, 5494
|
3192, 4841
|
391, 398
|
5673, 5681
|
2499, 3169
|
6442, 6932
|
1943, 1996
|
5156, 5465
|
5515, 5515
|
4867, 4867
|
5705, 6419
|
2011, 2480
|
4885, 5133
|
276, 353
|
426, 1618
|
5635, 5652
|
5534, 5614
|
1640, 1658
|
1674, 1927
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,127
| 157,135
|
23151
|
Discharge summary
|
report
|
Admission Date: [**2116-5-26**] Discharge Date: [**2116-6-3**]
Date of Birth: [**2062-8-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
right lower extremity cellulitis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
53M h/o HCV cirrhosis, HCC s/p RFA, HBV, pulmonary hypertension,
and ASD, p/w 10 days worsening RLE erythema, pain, and swelling,
diagnosed as cellulitis. He began treatment with Unasyn &
Vancomycin. On [**5-27**] he was transferred to the ICU with
increasing SOB and thought to be due to missed Sildenafil dosing
and worsening pHTN. He did not require intubation and his
breathing returned to baseline. Incidentally on an ABG, he was
found to have a Hct of 19 and workup for LE hematoma was
negative. His hct remained stable after transfusion of 2U pRBCs.
On [**5-28**] he was transfered to the hepatorenal service.
Past Medical History:
- Hepatocellular cancer s/p RFA [**7-15**]
- Hep C Cirrhosis with history of encephalopathy with rapid
decomp in past (including intubation)
- chronic nonocclusive portal vein thrombus
- Grade III variceal bleed with banding [**11-14**] at VA
- HCV - diagnosed [**2099**], s/p 2 incomplete trials of PEG
IFN/ribavirin
- Thrombocytopenia
- H/o seizure disorder - on Keppra
- s/p R mastoidectomy - for GSW to head, deaf in R ear
- H/o PTSD - s/p GSW
- Depression/anxiety
- IV drug use from [**2081**] to [**2109**]
- History of hepatitis B in [**2085**]
Social History:
Staying at mother's house. He is divorced and has an 8-year-old
daughter. Currently unemployed, on [**Social Security Number 59565**]social security. Volunteers
at VA. H/o heavy alcohol abuse [**2078**]-[**2107**], during which he drank
a pint to a quart of vodka per day, sober x 4 yrs. H/o IV heroin
use, last use 4yrs ago. + Tobacco use, 1 ppd x ~40y. H/o
incarceration for domestic abuse. Presently uses <1pp day
Family History:
Father died at age 62, had a history of emphysema, asthma, COPD,
lung cancer, stroke, alcoholism, hypertension, type 2 diabetes.
Mother and sister with breast cancer. Sister recently passed
away from breast CA.
Physical Exam:
Vitals: T:95.6 BP:98/68 P:84 R:20 SaO2:96 3L NC
General: Lying in bed, cooperative, mild distress from leg pain
HEENT: NCAT, PERRL, EOMI, mild scleral icterus, no conjunctival
injection, MM dry
Neck: Supple, slightly elevated JVP
Pulmonary: Mild bibasilar rales,
Cardiac: RRR, no murmurs, rubs or gallops appreciated
Abdomen: soft, NT, slightly distended, normoactive bowel sounds,
no masses, no fluid wave, no flank dullness
Extremities: LLE: chronic 3+ pitting edema with woody changes.
RLE: 3+ LE edema, significant erythema and warmth extending from
calf distally to foot, and proximally to posterior mid-thigh.
Leg very painful to palpation, not tense on exam. DPs
dopplerable. Erythematous area marked with pen. Limited ability
to flex and extend at knee and ankle [**1-11**] pain and swelling. 2
small superficial ulcers present on medal calf.
Skin: no rashes or lesions noted.
Neurologic: oriented x 3.No asterixis
Pertinent Results:
[**2116-5-26**] 02:30PM PT-23.2* PTT-40.3* INR(PT)-2.2*
[**2116-5-26**] 02:30PM PLT SMR-VERY LOW PLT COUNT-33*# LPLT-3+
[**2116-5-26**] 02:30PM HYPOCHROM-3+ ANISOCYT-2+ POIKILOCY-OCCASIONAL
MACROCYT-2+ MICROCYT-1+ POLYCHROM-1+ OVALOCYT-OCCASIONAL
BURR-OCCASIONAL
[**2116-5-26**] 02:30PM NEUTS-90.5* BANDS-0 LYMPHS-6.1* MONOS-3.1
EOS-0.1 BASOS-0.1
[**2116-5-26**] 02:30PM WBC-8.0# RBC-2.85* HGB-8.0* HCT-26.5* MCV-93
MCH-28.2 MCHC-30.3* RDW-21.1*
[**2116-5-26**] 02:30PM AMMONIA-14
[**2116-5-26**] 02:30PM ALBUMIN-3.2* CALCIUM-8.4 PHOSPHATE-4.0#
MAGNESIUM-2.4
[**2116-5-26**] 02:30PM CK-MB-NotDone proBNP-3293*
[**2116-5-26**] 02:30PM cTropnT-<0.01
[**2116-5-26**] 02:30PM LIPASE-40
[**2116-5-26**] 02:30PM ALT(SGPT)-33 AST(SGOT)-84* CK(CPK)-54 ALK
PHOS-60 TOT BILI-8.7*
[**2116-5-26**] 02:30PM estGFR-Using this
[**2116-5-26**] 02:30PM GLUCOSE-165* UREA N-35* CREAT-1.6* SODIUM-133
POTASSIUM-4.7 CHLORIDE-102 TOTAL CO2-16* ANION GAP-20
[**2116-5-26**] 02:45PM GLUCOSE-153* LACTATE-4.9* K+-4.3
[**2116-5-26**] 03:26PM LACTATE-3.7*
[**2116-5-26**] 05:51PM LACTATE-4.2*
[**2116-5-26**] 10:26PM HGB-6.2* calcHCT-19 O2 SAT-77 CARBOXYHB-2.2
MET HGB-0.4
[**2116-5-26**] 10:26PM LACTATE-3.5*
[**2116-5-26**] 10:26PM TYPE-ART PO2-46* PCO2-23* PH-7.48* TOTAL
CO2-18* BASE XS--3
[**2116-5-26**] 10:52PM freeCa-1.03*
[**2116-5-26**] 10:52PM O2 SAT-87
[**2116-5-26**] 10:52PM TYPE-ART PO2-63* PCO2-24* PH-7.46* TOTAL
CO2-18* BASE XS--4
[**2116-5-26**] PA lat cXR
IMPRESSION: No acute pulmonary process.
.
[**2116-5-26**] tib.fib ap/lat
IMPRESSION: Extensive leg edema as noted clinically. No
subcutaneous gas or underlying osteomyelitis.
.
[**2116-5-27**] CT right LE
IMPRESSION:
1. Arteries and veins appear patent as imaged from the mid thigh
to the calf.
2. Crescentic fluid collection layering just superficial to the
medial
compartment of the thigh superficial to the fascia, measuring 8
x 1.7 x 5.2 cm. This measures as fluid density and not as acute
hematoma. This
collection is incompletely imaged on this study.
3. Large degree of skin thickening and calf edema.
4. No osseous abnormality identified.
.
[**2116-5-27**] portable CXR
IMPRESSION: No acute intrathoracic pathology including no edema
or pneumonia.
.
[**2116-5-28**] b/l LENIs
IMPRESSION: No evidence of right or left lower extremity deep
vein
thrombosis.
.
[**2116-6-2**] CT thorax with PO and IV contrast
IMPRESSION:Status post RF hepatic ablation with no CT evidence
for recurrent ormetastatic disease.
2. Interval development of a moderate-to-large amount of
perihepatic ascites with underlying portal
hypertension/cirrhosis.
3. New widespread multifocal ground-glass opacities in the lungs
with upper
zone predominance. Diagnostic considerations include evolving
multifocal
infectious/inflammatory process or pulmonary interstitial edema.
Continued
surveillance is recommended.
Brief Hospital Course:
53M h/o HCV cirrhosis, HCC, pulmonary hypertension, and ASD, p/w
cellulitis, mild hypotension and acute hypoxia, who was intially
admitted to the MICU for acute hypoxia, and then transferred to
the floor the next day.
#Cellulitis: Patient presented with severe cellulitis of RLE,
with superficial calf ulcers as likely portal of entry. No
clinical evidence of compartment syndrome. CT RLE with no
evidence of abscess, hematoma, or DVT. No osteo on plain film.
Patient got 3 days of Vanc/Unasyn IV with improvement of
erythemia. He was then switched to 500mg TID augmentin for total
of 10 days of antibiotics. (Day 1: [**5-26**])
- CT negative for DVT, compartment syndrome, abscess,
osteomyelitis.
- bl LENI negative for DVTs
.
#Pulmonary HTN/Hypoxemia: Lungs with only minimal bibasilar
rales, CXR clear, although CT showed new widespread interstital
ground glass opacities. On 2L home O2 due to pulmonary
hypertension. Hypoxia thought to be due to combination of
pulmonary hypertension and shunting by known ASD in setting of
missed dose of sildenefil.
- Scheduled for out patient echocardiogram to evaluate for heart
failure
- Continue lasix 40mg [**Hospital1 **] and aldactone 100mg
- Continue Sildenafil
- continue Zonisamide
.
#Anemia: Patient received 2 units PRBCs and 1 u platelets for
HCT off of ABG of 19. On recheck was closer to baseline (24),
but did not respond appropriately to the 2 units (24->26).
Patient HCt was intially monitored [**Hospital1 **], and was stable, so was
then trended daily and remained stable throughout admission. It
was slightly lower than his baseline.
.
#Cirrhosis: Holding propranolol and spironolactone given
hypotension.
- propranolol was tapered from 40 mg [**Hospital1 **] to 10 mg [**Hospital1 **] due to
hypotension and Dr.[**Name (NI) 948**] recommendation
- Continue lasix/sprinonolactone
- Continue lactulose and rifaximin
.
#Diabetes: Likely [**1-11**] steroids. Will require insulin at home.
-met with diabetes educator
-met with Dr. [**Last Name (STitle) **] from [**Last Name (un) **] Center and has a scheduled follow
up appointment at [**Last Name (un) **]
-will go home with VNA to aid in insulin administration and
general diabetes education
.
#Adrenal insufficiency: It is unclear if this was diagnosed
appropriately via cosyntropin stimulation test or not. The
patient's home hydrocortisone dose was increased from 20 am and
10pm to 20 mg q 8 hours in the ICU due to stress and
hypotension.
-will be followed-up with by [**Hospital **] Clinic to determine the
appropriate dose and/or need for steroids in this patient
.
#Dispo: The patient was set up for home PT.
Medications on Admission:
. Levetiracetam 1500mg PO BID
2. Zonisamide 100mg PO QAM / 200mg PO qHS
3. Pantoprazole 40mg Tablet PO twice a day.
5. Rifaximin 200mg PO TID
6. Aspirin 81mg PO DAILY
7. Propranolol 40mg PO BID
8. Lactulose 30ML PO QID
9. Calcium Carbonate 500mg PO twice a day.
10. Sildenafil 25mg PO TID
11. Hydrocortisone 20mg PO QAM / 10mg PO qHS
13. Furosemide 40mg PO DAILY
14. Spironolactone 100mg PO DAILY
Discharge Medications:
1. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
2. Zonisamide 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. Zonisamide 100 mg Capsule Sig: Two (2) Capsule PO QHS (once a
day (at bedtime)).
4. Rifaximin 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Sildenafil 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
7. Hydrocortisone 20 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours).
8. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
9. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q8H (every 8 hours) for 2 days.
Disp:*4 Tablet(s)* Refills:*0*
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
13. Insulin NPH & Regular Human 100 unit/mL (70-30) Insulin Pen
Sig: 24u qam, 12u dinner Subcutaneous twice a day.
Disp:*1 1* Refills:*2*
14. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day). Tablet, Chewable(s)
15. Propranolol 10 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
16. Lancets, Super Thin Misc Sig: One (1) Miscellaneous
twice a day.
Disp:*60 lancets* Refills:*2*
17. Ultra Touch 2 Glucometer Kit Sig: One (1) Miscellaneous
once.
Disp:*1 machine* Refills:*0*
18. test strips Sig: One (1) blood glucose test strips for the
ultra touch 2 glucometer twice a day.
Disp:*60 test strips* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Caregroup
Discharge Diagnosis:
right lower extremity cellulitis
Discharge Condition:
good
Discharge Instructions:
You were found to have a skin infection in your right leg which
was treated with intravenous and oral antibiotics. You should
continue the oral antibiotic (amoxicillin-clavulinic acid also
called augmentin three times a day) until the evening of [**6-4**] which will complete a 10 day course.
You were also found to have high blood sugars while in the
hospital. For this reason, you should begin taking insulin at
home as instructed by the diabetes educator that you met with.
You will also have assistance with the insulin from a visiting
nurse that will come to your home and have been set up to
receive support from the [**Last Name (un) **] Diabetes Center.
You should continue to use 2 liters of oxgyen at home while at
rest. When you are active, you should increase your oxygen
level to 4 or 5 liters.
Your propranolol was decreased from 40 mg twice a day to 10 mg
twice a day.
You should pay close attention to any skin breakdown on your
legs. Small areas of skin breakdown may allow for bacteria to
enter the skin and can lead to future skin infections. If you
notice changes to your skin, you should make your regular care
provider [**Name Initial (PRE) 12309**].
If you develop increased pain, rash, redness, swelling, fever,
difficulty breathing, or any other concerning symptoms, please
call your primary care doctor or go to the emergency room.
Followup Instructions:
You have an appointment with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] TRANSPLANT SOCIAL WORK
on [**2116-6-5**] at 10:00 am.
You have an appointment with Dr. [**Last Name (STitle) **] at the [**Hospital **] [**Hospital 982**]
Clinic at [**Last Name (un) 3911**] [**Location (un) **] on [**2116-6-8**] at 4:30pm. (Phone:
[**Telephone/Fax (1) 2384**])
You have two appointments in the TRANSPLANT [**Hospital **] CLINIC on
[**2116-6-10**] at 9:20 am and 2:00 pm. (Phone:[**Telephone/Fax (1) 673**])
You have a follow up appointment for your cellulitis with Dr
[**Last Name (STitle) 59565**] on Wed [**6-17**] 1:30 pm at the [**Hospital 191**] clinic on the [**Location (un) **] of the [**Hospital Ward Name 23**] building on the [**Hospital Ward Name 516**] (Phone:
[**Telephone/Fax (1) 250**]).
You also have an echocardiogram appointment on [**2116-6-17**] at 3:00 pm
in the [**Hospital Ward Name 2104**] Building ([**Location (un) **]) on the [**Hospital Ward Name 516**].
|
[
"255.41",
"305.1",
"V17.3",
"584.9",
"707.12",
"V16.1",
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"456.21",
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"300.4",
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"745.5",
"345.90",
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"309.81",
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"682.6",
"V18.0",
"V12.09",
"285.9",
"287.5",
"070.54",
"458.9",
"V12.51",
"V17.1",
"E932.0",
"416.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
10929, 10970
|
6112, 8743
|
345, 352
|
11047, 11054
|
3203, 6089
|
12472, 13477
|
2029, 2243
|
9191, 10906
|
10991, 11026
|
8769, 9168
|
11078, 12449
|
2258, 3184
|
273, 307
|
380, 1003
|
1025, 1579
|
1595, 2013
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,479
| 147,694
|
51204
|
Discharge summary
|
report
|
Admission Date: [**2153-10-22**] Discharge Date: [**2153-11-3**]
Date of Birth: [**2085-11-19**] Sex: M
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 2932**]
Chief Complaint:
diarrhea
Major Surgical or Invasive Procedure:
upper endoscopy
colonoscopy
History of Present Illness:
67 year old male with PMH significant for HTN, hyperlipidemia,
NIDDM, CRI (baseline 1.7-1.9), admitted to the MICU with concern
for sepsis. He reports a history of several weeks of diarrhea
([**4-25**] BM/day), nausea, and vomiting, with associated decreased
food and fluid intake. He denies fevers, chills, abdominal pain,
hematemesis, hematochezia, melena, or BRBPR. He denies any
recent travel, sick contacts or antibiotic use. He denies any
fever, chills, chest pain or shortness of breath.
Of note, he was recently discharged on [**2153-10-18**] following
admission for diarrhea, nausea/vomitting. All studies at that
time were negative, with no findings on stool culture, KUB, or
CT scan to explain symptoms. He was discharged with plans for an
outpatient colonoscopy.
In ED - patient was hypotensive 86/47, afebrile. He received 4
Liters IV NS but had persistent hypotension as well as increased
lactate to 3.6 and a Cr of 4.0, up from baseline of 1.7-1.9, and
he was admitted to [**Hospital Unit Name 153**].
Past Medical History:
HTN
Hyperlipidemia
Type II diabetes
DVT in [**2149**], on coumadin
CRI - presumed [**12-21**] NIDDM/HTN nephropathy
PUD
GERD
hiatal hernia
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
DVT in [**11-21**] on coumadin
s/p CCY
s/p partial small bowel resection
Social History:
he lives alone in [**Location (un) **]; smokes [**6-27**] cigars/day; denies EtOH
use' denies illicit drug use; retired - used to work in the
garmet industry and polaroid industry
Family History:
Father and brother had coronary artery disease in their early
50s. Mother and brother also had diabetes.
Physical Exam:
Physical exam on admission
PE:
vs 70 123/56 25 99%RA
GEN: A/O NAD
HEENT: NCAT, dry MM, EOMI, PERRL
NECK: No Jvp
CV: RRR s1, s2, no M/G/R
RESP: CTA bl
ABD: soft, NT/ND, ?epigastric fullness
ext: no erythema, no edema
NEURO: non-focal, sensation intact
Pertinent Results:
Laboratory studies on admission
[**2153-10-22**]
PT-59.9 PTT-32.6 INR(PT)-7.4
PLT SMR-NORMAL PLT COUNT-337
NEUTS-67 BANDS-1 LYMPHS-9* MONOS-3 EOS-18* BASOS-1 ATYPS-0
METAS-1
WBC-30.5 (6.7 on discharge) HGB-9.9 HCT-30.9 (26 on
discharge)MCV-72 RDW-18.9
ALBUMIN-3.3 CALCIUM-7.7 PHOSPHATE-4.2
LIPASE-14
ALT(SGPT)-9 AST(SGOT)-11 LD(LDH)-210 ALK PHOS-138* AMYLASE-25
TOT BILI-0.1
GLUCOSE-97 UREA N-57* CREAT-4.0 (1.8 on discharge) SODIUM-136
POTASSIUM-3.8 CHLORIDE-107 TOTAL CO2-15
U/A: RBC-0 WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0-2 BLOOD-TR
NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG
UROBILNGN-NEG PH-5.0 LEUK-
LACTATE-3.6
[**10-22**] EKG: Baseline artifact. Sinus rhythm. Right bundle-branch
block. QTc interval appears prolonged but is difficult to
measure. Low QRS voltage. Clinical correlation is suggested.
Since the previous tracing of [**2153-10-13**] there may be no
significant change, but baseline artifact makes comparison
difficult
Radiology:
[**10-22**] CXR: Lung volumes are reduced. Cardiac, mediastinal, and
hilar contours are normal allowing for technique. The lungs are
clear. There is no free air under the diaphragm
[**10-22**] KUB: No gross evidence of toxic megacolon. Difficult to
exclude early or partial small bowel obstruction
[**10-24**] MRA Abdomen: Linear signal abnormality extending for 1.5 cm
in the celiac artery likely representing a small, focal
dissection of unknown acuity. The distal celiac and its branches
are patent. No MRI evidence of bowel ischemia. The SMA and [**Female First Name (un) 899**]
are widely patent. Mild signal changes in the mesentery may
represent mesenteric panniculitis as seen in the recent CT from
[**2153-10-13**]. Other entities cannot be completely excluded
and followup with noncontrast CT in three-six months is
recommended to assure stability. Non-distended terminal ileum
without inflammation of the mesentery around it; thickening of
the terminal ileum cannot be excluded on the basis of this study
[**10-26**] MR enterography: Normal-appearing terminal ileum. The bowel
and colon appear unremarkable on this examination
[**10-29**] colonoscopy: Polyp in the proximal descending colon
(polypectomy c/w adenoma). Normal mucosa in the whole colon
(tandom right colon biopsy normal). Diverticulosis of the
sigmoid colon
[**10-29**] upper endoscopy: Polyps in the small hypertrophic polyps
from PPI RX
Normal in the whole duodenum (biopsy normal). Otherwise normal
EGD to second part of the duodenum.
Brief Hospital Course:
67 year old man with h/o HTN, CRI admitted with persistent
nausea, vomiting, hypotension, and acute on chronic renal
failure. Initially in MICU given hypotension (resolved with
hydration), transferred to general floor [**10-24**].
1) Chronic diarrhea: Infectious etiologies were thoroughly
investigated. Between this and his recent prior admit, the
patient had C. diff (-) X 4, O&P (-) X 7, Yersinieae (-),
Campylobacter (-), E. coli 0157 (-), crypto/giardia DFA (-).
Strongyloides antibody was pending at time of discharge. Further
work-up included a 5HIAA, which was normal, and an EGD and
colonoscopy which showed no clear source of diarrhea (proximal
descending adenoma, see results section) with negative random
duodenal/right colon biopsies (no evidence of microscopic
colitis). MRI enterogram was without evidence of inflammation of
the ileum, and MRA of the abdomen showed only a small celiac
dissection (see below). The patient's diarrhea gradually
improved without intervention, and, at the time of discharge,
was only having [**11-20**] bowel movements a day. Further work-up,
including evaluation for celiac sprue, may be considered as an
outpatient. Of note, MRI of his abdomen showed mild signal
changes in the mesentery (see results section) which may
represent mesenteric panniculitis as seen in the recent CT from
[**2153-10-13**]. Other entities cannot be completely excluded
and followup with noncontrast CT in three-six months is
recommended to assure stability.
2) Anemia - iron deficiency and vitamin B12 deficiency: The
patient's hematocrit gradually trended down to a nadir 21.5 (26
at discharge). As mentioned above, EGD and colonoscopy did not
show source of bleeding, although iron studies were consistent
with iron deficiency. He declined blood transfusion and was
started on iron supplementation. Given low vitamin B12 level,
the patient received 1 week of daily IM vitamin B12 injections;
he should have one IM injection weekly for 1 month, followed by
monthly injections as an outpatient. Further work-up for occult
sources of GI bleeding, such as pill endoscopy, should be
considered as an outpatient at the discretion of his
PCP/gastroenterologist.
3) Acute on chronic renal failure: With hydration, the patient's
creatinine gradually trended down from 4 on admission,
indicating likely pre-renal etiology in the setting of
diarrhea/poor PO intake. At time of discharge, his creatinine
was 1.8. This should continue to be closely monitored as an
outpatient to ensure stability.
4) h/o DVT: The patient was restarted on Coumadin after his
colonoscopy/upper endoscopy and was transitioned with a heparin
drip until he was therapeutic at 2.3 on discharge. His INR will
need to continued to be monitored as an outpatient, with the
dose adjusted as needed for a goal INR [**12-22**].
5) Eosinophilia (new since [**9-24**]): Given diarrhea, there was
concern for a parasitic infection, however multiple O&Ps were
negative (see above). The patient had a normal a.m. cortisol
level, not consistent with adrenal insufficiency. Urine
eosinophils were normal and Strongyloides antibody was pending
at time of discharge. Further work-up should be pursued as an
outpatient; if this persists, than bone marrow biopsy may be
considered, particularly given the patient's history of
polycythemia [**Doctor First Name **].
6) Type II diabetes: The patient's Lantus dose was gradually
titrated to 14 units at discharge. He was continued on a Humalog
sliding scale
7) HTN: The patient's Lasix and Diovan were held throughout his
hospital stay, given his acute renal failure. These can be
restarted as an outpatient at the discretion of his PCP.
8) Celiac artery dissection: This was an incidental finding on
the MRA of his abdomen (see results section). The vascular
surgery service was consulted, who felt it was likely chronic
and recommended outpatient follow-up with Dr. [**Last Name (STitle) **].
Full Code
Medications on Admission:
Valsartan 80 mg Tablet 1 tablet po Q day
Calcium Carbonate 500 mg po QID prn
Metoprolol Tartrate 50 mg Tablet 1 PO BID
Simvastatin 10 mg @ tablets po daily
Pantoprazole 40 mg Q day
Calcitriol 0.25 mcg Capsule Sig: [**11-20**] Capsule PO DAILY
Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID
Coumadin 4mg po daily for 4 days 2mg po daily for 3days (weekly)
Discharge Medications:
1. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day).
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY
OTHER DAY (Every Other Day).
6. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO QMON (every Monday).
7. Coumadin 2 mg Tablet Sig: Two (2) Tablet PO at bedtime.
8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
9. Vitamin B-12 1,000 mcg/mL Solution Sig: One (1) ml Injection
once a week for 4 weeks: then 1 ml qmonth.
10. Lantus 100 unit/mL Solution Sig: Fourteen (14) units
Subcutaneous at bedtime.
11. Humalog 100 unit/mL Solution Sig: sliding scale
Subcutaneous qAC and qhs: resume prior sliding scale.
12. Outpatient Lab Work
INR, hematocrit, and creatinine checked on [**2153-11-5**]. These
results should be communicated to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 172**] [**Telephone/Fax (1) 133**].
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: chronic diarrhea
Secondary: iron deficiency anemia, vitamin B12 deficiency,
celiac artery dissection, history of DVT, eosinophilia, ARF,
Type II diabetes, hypertension.
Discharge Condition:
Stable, HCT 26.
Discharge Instructions:
1) Please follow-up as indicated below.
2) Please take all medications as prescribed. You have been
prescribed iron for your anemia. You should have vitamin B12
shots every week at your PCPs office for a month, followed by
once monthly. Lasix and valsartan have been held given your
renal failure. You should not restart these until instructed to
do so by your PCP
3) Please follow-up with your PCP or come to the emergency room
if you develop rectal bleeding, nausea, vomiting, abdominal
pain, lightheadedness, worsening diarrhea chest pain, or other
symptoms that concern you.
4) You have been provided with a prescription to have your
hematocrit, creatinine, and INR checked on Monday [**11-5**]. These
results should be communicated to your primary care doctor (Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 172**] [**Telephone/Fax (1) 133**])
5) Please decrease your glargine (Lantus) dose to 14 units at
bedtime, given your fingersticks have been lower than normal
while in he hospital. Check your fingersticks before each meal
and bedtime and call your doctor if your FS are persistently
>250. If your fingerstick is <70, drink some juice and recheck.
Followup Instructions:
1) Primary care: Please call to schedule an appointment with
your primary care physician (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 172**] [**Telephone/Fax (1) 133**])
within 1 week following discharge
- he may schedule you for an outpatient pill endoscopy to
evaluate for other sources of gastrointestinal bleeding
2) Vascular surgery: Please call to schedule an appointment with
Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 1241**]) to be seein within 1-2 weeks following
discharge
3) Renal
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D., PH.D.[**MD Number(3) 708**]:[**Telephone/Fax (1) 435**]
Date/Time:[**2154-1-16**] 11:00
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2937**]
Completed by:[**2153-11-5**]
|
[
"V58.61",
"211.3",
"585.9",
"787.91",
"280.9",
"276.2",
"584.9",
"403.90",
"530.81",
"238.4",
"250.40",
"443.29",
"428.0",
"272.4",
"281.1",
"288.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.16",
"45.42",
"45.25"
] |
icd9pcs
|
[
[
[]
]
] |
10392, 10398
|
4777, 8712
|
279, 309
|
10620, 10638
|
2262, 4754
|
11865, 12731
|
1870, 1976
|
9122, 10369
|
10419, 10599
|
8738, 9099
|
10662, 11842
|
1991, 2243
|
231, 241
|
337, 1359
|
1381, 1657
|
1673, 1854
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,663
| 174,722
|
43006
|
Discharge summary
|
report
|
Admission Date: [**2133-12-1**] Discharge Date: [**2133-12-4**]
Date of Birth: [**2074-10-24**] Sex: M
Service: MEDICINE
Allergies:
Interferons
Attending:[**First Name3 (LF) 8115**]
Chief Complaint:
LUE burning
Major Surgical or Invasive Procedure:
T1 Corpectomy and anterior cervical plating [**2133-12-3**]
History of Present Illness:
Mr. [**Known lastname 26438**] is a 59 yo with a PMHx s/f Cirrhosis secondary to
hepatitis C and metastatic HCC who presents for evaluation of
cord compression with resulting LUE "burning". Mr. [**Known lastname 26438**] had
been undergoing day 9 of XRT to his R shoulder and R hip for
pain related to metastatic lesions and complained to his
radiation oncologist of new onset burning symptoms in his LUE.
As a result of these symptoms an MRI was performed which
demonstrated a T1 lesion with cord compression. Mr. [**Known lastname 26438**]
also notes decreased strength on the L.
He has been noting burning and a relative loss of strength
on the LUE for approximately 1.5-2weeks which has progressively
worsened. He denies neck pain/back pain, incontinence of
stool/urine, fevers/chills, or other symptoms of
paresthesias/weakness elsewhere.
.
In the ED, Mr. [**Known lastname 26438**]' vitals were 96.6 66 151/95 18 100% on
RA, exam notable for no saddle anesthesia, but decreased rectal
tone. There he endoresed LUE paresthesias. He was given
dexamethasone 10mg and dilaudid 1 mg in the ED. CT of T and C
spine was obtained which demonstrated compression fracture at T1
with retropulsoin into the canal.
.
Review of Systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies blurry vision, diplopia, loss of vision,
photophobia. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain or tightness, palpitations, lower
extremity edema. Denies cough, shortness of breath, or wheezes.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
melena, hematemesis, hematochezia. Denies dysuria, stool or
urine incontinence. Denies rashes or skin breakdown. All other
systems negative.
Past Medical History:
[**Known firstname **] [**Known lastname 26438**] developed hepatocellular
carcinoma in the setting of hepatitis C cirrhosis. Screening
ultrasound [**2132-11-29**] raised concern for a mass in the
right liver, and his AFP was elevated at 56.9. MRI [**2132-12-20**]
showed a mass in segment V measuring 2.9 x 3.2 x 2.8 cm with
arterial enhancement and wash-out, consistent with
hepatocellular
carcinoma. Also seen was a thrombus in the subsegmental branch
of the right posterior portal vein. CT torso on [**2132-12-30**]
identified a 3.2 cm mass with arterial enhancement and wash-out
in segment VI/VII. Also seen were two 2-mm right lower lobe
pulmonary nodules as well as a fracture in the right 10th rib.
Bone scan was negative for metastases. EGD on [**2132-12-17**] showed
grade II varices which were banded. Mr. [**Known lastname 26438**] was treated
with transarterial chemoembolization [**2133-1-27**] to the right
liver, having received 60 mg doxorubicin without complications.
He underwent repeat TACE on [**2133-7-2**], again without
complication. Despite this his AFP continued to rise, and bone
[**2133-10-12**] identified numerous lesions concerning for bone
metastases. Bone biopsy performed [**2133-10-29**], confirmed the
finding of metastatic hepatocellular carcinoma. Mr. [**Known lastname 26438**]
was prescribed sorafenib 400 mg b.i.d. beginning [**2133-11-4**], but
discontinued after one dose due to nausea/vomiting.
.
.
PAST MEDICAL HISTORY:
Mr. [**Known lastname 26438**] lives with his wife and two daughters. [**Name (NI) **]
previously worked in construction, but has been out of work
since [**34**]/[**2129**]. Tobacco: One-half pack per day for more than 40
years, continues to smoke. Alcohol: History of abuse,
none since [**2111**]. Illicits: History of abuse, none since [**2111**].
Social History:
Mr. [**Known lastname 26438**] lives with his wife and two daughters. [**Name (NI) **]
previously worked in construction, but has been out of work
since [**34**]/[**2129**]. Tobacco: One-half pack per day for more than 40
years, continues to smoke. Alcohol: History of abuse,
none since [**2111**]. Illicits: History of abuse, none since [**2111**].
Family History:
His mother died at age 72 with metastatic breast cancer. His
father is alive without health concerns. His sister has
diabetes mellitus.
Physical Exam:
ADMISSION EXAM:
.
Vitals - T: 96.6 BP: 140/80 HR: 60 RR: 18 02 sat: 98% on RA
GENERAL: disgruntled gentleman, pacing around the room in
C-collar, talkative/conversant
SKIN: warm and well perfused, no excoriations, venous stasis
changes in b/l LE, no rashes
HEENT: in C collar, AT/NC, EOMI, PERRLA, anicteric sclera, pink
conjunctiva, patent nares, MMM, good dentition, nontender supple
neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no mrg
LUNG: CTAB
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
M/S: moving all extremities well, strength 5/5 diffusely, no
cyanosis, clubbing or edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, sensation intact in b/l UE/LE in all
major dermatomes.
.
DISCHARGE EXAM:
.
Vitals - 98.2/98.4 134/82 (120s-150s/50s-80s) 69 (50s-60s) 18
100%R
GENERAL: NAD, in [**Location (un) 2848**]-J, talkative/conversant
SKIN: warm and well perfused, greyish/blue chronic discoloration
of the lgs
HEENT: in [**Location (un) 2848**]-J collar, AT/NC, EOMI, PERRLA, anicteric sclera,
pink conjunctiva, no LAD, no JVD
CARDIAC: RRR, S1/S2, no mrg
LUNG: CTAB
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXT: 2+ pulses, chronic appearing bluish/grey changes of the LE
bilaterally. no edema
NEURO: [**5-14**] diffusely, CN 2-12 intact. No sensory deficits
PULSES: 2+ DP pulses bilaterally
Pertinent Results:
ADMISSION LABS:
.
[**2133-12-1**] 08:25AM BLOOD WBC-1.9* RBC-4.36* Hgb-13.9* Hct-40.4
MCV-93 MCH-32.0 MCHC-34.5 RDW-13.6 Plt Ct-43*
[**2133-12-1**] 08:25AM BLOOD Neuts-78.9* Bands-0 Lymphs-9.2* Monos-9.3
Eos-2.0 Baso-0.5
[**2133-12-1**] 08:25AM BLOOD PT-14.2* PTT-30.6 INR(PT)-1.2*
[**2133-12-1**] 08:25AM BLOOD Glucose-94 UreaN-12 Creat-0.7 Na-136
K-5.2* Cl-99 HCO3-32 AnGap-10
[**2133-12-1**] 08:25AM BLOOD ALT-237* AST-323* TotBili-2.0*
[**2133-12-1**] 08:25AM BLOOD Calcium-8.9 Phos-3.6 Mg-1.9
[**2133-12-1**] 08:31AM BLOOD K-4.0
.
DISCHARGE LABS
.
[**2133-12-4**] 05:45AM BLOOD WBC-1.1* RBC-3.18* Hgb-10.4* Hct-29.7*
MCV-93 MCH-32.5* MCHC-34.9 RDW-13.7 Plt Ct-53*#
[**2133-12-4**] 05:45AM BLOOD Glucose-81 UreaN-16 Creat-0.6 Na-136
K-3.8 Cl-102 HCO3-27 AnGap-11
[**2133-12-4**] 05:45AM BLOOD Calcium-7.8* Mg-1.8
.
CT SPINE [**2133-12-1**]:
IMPRESSION:
1. Cortical irregularity of the inferior endplate of T12,
possibly extending into posterior elements, likely representing
metastatic disease and better evaluated on recent MRI.
2. Lucencies within the vertebral bodies of T5, T8 and T11 also
corresponding to signal abnormality seen on recent MR and likely
representing metastatic disease. No evidence of cord compression
in the thoracic spine from T2 through T12.
3. Pathologic fracture of T1, as described on the cervical spine
CT from the same day.
4. Coarse calcifications of the liver, likely from prior TACE
procedure.
5. Incompletely imaged spleen, which appears enlarged.
.
[**2133-12-2**] T-SPINE XRAY IN THE OR: Limited evaluation of the
upper thoracic spine due to overlying soft tissue and bony
structures. Surgical instrument is seen at the C6-C7 disc space.
Status post T1 corpectomy and anterior fusion from C7 to T2. The
hardware appears intact. Please see the operative report for
further details.
.
[**2133-12-3**] C/T SPINE XRAY:
CERVICAL SPINE, THREE VIEWS: C1 through T1 are demonstrated on
the lateral
view. No prevertebral swelling is identified. Cervical lordosis
is
preserved. Vertebral body heights are intact. There is
intervertebral disc
space narrowing of C4-5. No cervical body vertebral fracture is
identified. Grade 1 retrolisthesis of C4 on C5 is present. No
focal lytic or sclerotic lesions.
THORACIC SPINE, TWO VIEWS: The patient is status post T1
corpectomy with
anterior fusion and cage placement from C7-T2. Hardware is
intact without
signs of complication. The alignment is normal. The remainder of
the
thoracic spine is unremarkable. The visualized lung fields are
normal.
IMPRESSION: Anterior fusion from C7-T2 and cage placement status
post T1
corpectomy without hardware complication.
.
Spine Tumor Pathology [**2133-12-2**]: Pending
Brief Hospital Course:
Mr. [**Known lastname 26438**] is a 59 year old with a PMHx s/f Cirrhosis
secondary to hepatitis C and metastatic HCC who presents for
evaluation of cord compression with resulting LUE "burning".
.
# Cord Compression from metastatic HCC: Likely secondary to T11
retropulsion from metastatic HCC. Pt with parastesias and pain
in his arms. Pt was given 10mg IV dexamethasone in the ED and
was maintained on dexamethasone 4mg q6h on admission. Pain was
controlled with MScontin and oxycodone as well as gabapentin for
neuropathic pain. On [**12-2**] he was brought to the OR for a T1
Corpectomy with cervical plating. He tolerated the procedure
well without complication. He spent 1 night in the SICU and was
called back out to the oncology floor on [**2133-12-3**].
Post-operatively he denied any parastesias or pain. His
strength remained [**5-14**] throughout during the admission. After
surgery he was ambulating well and advanced his diet. He
remained in a [**Location (un) 2848**]-J collar and will remain in it for 6 weeks
post op. He will follow up in spine clinic in 2 weeks. He was
given instructions to follow up with his oncologist. He
remained on his MS contin 60mg [**Hospital1 **], PRN oxycodone, and
gabapentin for pain on discharge. Given his baseline
thrombocytopenia he received a total of 7 units of platelets
throughout admission including in the operative setting. Spine
surgery recommended keeping his Plt>50 for 3 days post
operatively. On POD #2 he was at 53, so he received a unit of
platelets prior to discharge. He was cleared by Neurosurgery
and was deemed suitable to discharge.
.
# Cirrhosis with thrombocytopenia: Pt was continued on his
nadolol. His thrombocytopenia was likely secondary to his
Cirrhosis, and he received 7U of platelets during admission to
maintain Plt>50 in the perioperative setting to reduce risk of
bleed (see above section).
.
# Hypertension: Initially held HCTZ/Lisinopril given that he
was heading to the OR. These were restarted without
complication on discharge.
.
TRANSITIONAL ISSUES:
.
# Pathology from OR tumor specimen still pending
# Pt given instructions to follow up with spine surgery in 2
weeks after discharge
# He was encouraged to make a follow up appointment with his
primary oncologist
# Platelets should be monitored as an outpatient.
Medications on Admission:
GABAPENTIN - 300 mg Capsule - 1 Capsule(s) by mouth three times
per day
LISINOPRIL-HYDROCHLOROTHIAZIDE - (Prescribed by Other Provider)
- 20 mg-12.5 mg Tablet - 1 Tablet(s) by mouth
MORPHINE - (Dose adjustment - no new Rx) - 30 mg Tablet
Extended Release - 2 Tablet(s) by mouth q 12 hour
NADOLOL - 40 mg Tablet - 1 Tablet(s) by mouth daily
OXYCODONE - 5 mg Tablet - [**1-11**] Tablet(s) by mouth q4-6hours as
needed for shoulder pain
PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 Tablet(s) by mouth q
8 hour as needed for nausea/vomiting (take 1 pill with morphine)
Medications - OTC
MAGNESIUM OXIDE - (Prescribed by Other Provider) - Dosage
uncertain
Discharge Medications:
1. morphine 30 mg Tablet Extended Release Sig: Two (2) Tablet
Extended Release PO Q12H (every 12 hours).
2. nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
4. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. lisinopril-hydrochlorothiazide 20-12.5 mg Tablet Sig: One (1)
Tablet PO once a day.
8. gabapentin 300 mg Capsule Sig: One (1) Capsule PO every eight
(8) hours.
Discharge Disposition:
Home
Discharge Diagnosis:
T1 Spinal cord compression
Metastatic Hepatocellular carcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 26438**],
You were admitted to the hospital for compression of your spinal
cord due to your cancer. You underwent surgery to decompress
your spinal cord. You did well with this and are ready for
discharge. You received several units of platelets during
admission to decrease the risk of post-operative bleeding.
Immediately after the operation:
- Activity:You should not lift anything greater than 10 lbs
for 2 weeks. You will be more comfortable if you do not sit in a
car or chair for more than ~45 minutes without getting up and
walking around.
- Rehabilitation/ Physical Therapy:
o 2-3 times a day you should go for a walk for 15-30 minutes as
part of your recovery. You can walk as much as you can
tolerate.
- Swallowing: Difficulty swallowing is not uncommon after
this type of surgery. This should resolve over time. Please
take small bites and eat slowly.
- Cervical Collar / Neck Brace: You need to wear the brace
at all times.
- Wound Care:Remove the dressing in 2 days. If the
incision is draining cover it with a new sterile dressing. If
it is dry then you can leave the incision open to the air. Once
the incision is completely dry (usually 2-3 days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool. If the incision starts draining at anytime after
surgery, do not get the incision wet. Call the office at that
time. If you have an incision on your hip please follow the same
instructions in terms of wound care.
- You should resume taking your normal home medications.
Followup Instructions:
o Please Call the office and make an appointment for 2 weeks
after the day of your operation with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1352**]. Ph
[**Numeric Identifier 18919**]
o At the 2-week visit we will check your incision, take
baseline x rays and answer any questions.
o We will then see you at 6 weeks from the day of the
operation.
Please call the office if you have a fever>101.5 degrees
Fahrenheit, drainage from your wound, or have any questions.
[**Name6 (MD) **] [**Name8 (MD) 4908**] MD [**MD Number(2) 8116**]
|
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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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285, 347
|
12560, 12560
|
5999, 5999
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4377, 4517
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12474, 12539
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11076, 11732
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12711, 13050
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4532, 5306
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13333, 13709
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5322, 5980
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13083, 13315
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10785, 11050
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1609, 2136
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234, 247
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13720, 14303
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375, 1590
|
6015, 8697
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12575, 12687
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3633, 3989
|
4005, 4361
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,735
| 168,916
|
11185
|
Discharge summary
|
report
|
Admission Date: [**2115-1-3**] Discharge Date: [**2115-1-9**]
Service: NEUROSURG
HISTORY OF PRESENT ILLNESS: The patient is a 78 year old
gentleman with a complicated medical history who was
transferred from [**Hospital 38**] Rehabilitation after being
diagnosed with an L5-S1 epidural abscess and disc infection
from an outside MRI scan.
PAST MEDICAL HISTORY: Includes:
1. Right popliteal dorsalis pedis bypass graft here at [**Hospital1 35990**] on [**2114-10-10**].
2. Clostridium difficile colitis.
3. Diabetes mellitus, type 2.
4. Hypertension.
5. Stroke in [**2112**] with questionable left facial droop.
PREVIOUS HOSPITAL COURSE: The patient presented to [**Hospital1 1444**] on [**2114-9-27**], for a
non-healing traumatic right lateral tibial ulcer and
underwent the right popliteal-dorsalis pedis bypass graft on
[**10-10**], and developed C. difficile colitis postoperatively
which apparently resolved. The patient was transferred to
[**Hospital 38**] Rehabilitation on [**10-25**], and readmitted to [**Hospital3 **] septic from C. difficile colitis and bowel edema.
He was treated with Flagyl and oral Vancomycin, sent back to
[**Location (un) 38**] on [**2114-11-26**], and admitted to [**Hospital6 33**]
on [**2114-12-3**], for fever and rigors. C. difficile was
negative. The patient had a left upper gluteal decubitus and
right Achilles decubitus ulcer. Pseudomonas was cultured
from the sacral wound; blood cultures grew out Staphylococcus
aureus which was Methicillin resistant Staphylococcus aureus
and four plus yeast in the urine. The patient was treated
with Ceftizoxime, Imipenem, Vancomycin and Diflucan. He was
treated with those from [**12-3**] until [**12-12**]. He was started on
Rifampin on [**12-5**]. On [**12-11**], he had a transthoracic
echocardiogram which showed the sclerotic aortic valve with
mild aortic insufficiency and a question of either a density
or calcification vegetation on his aortic valve. A TEE on
[**12-15**] showed an ejection fraction of 60 to 65% with three
plus aortic insufficiency and no definitive vegetation or
abscess. He continued to have temperatures of 100.5 F., and
was discharged to [**Location (un) 38**] on [**12-27**].
The patient reported increased low back pain over the last
month and daughter and wife noted urinary incontinence and
occasional inability to feel bowel movements for the past
month. He has not been able to walk since the bypass surgery
in [**Month (only) 359**] and had plain films at the end of [**Month (only) 1096**] for
back pain which was suspicious for osteomyelitis.
PHYSICAL EXAMINATION: Temperature was 97.6 F.; heart rate
84; blood pressure 136/86; respiratory rate was 20. This was
a frail elderly man in no acute distress. His cardiac status
was regular rate and rhythm. His chest was clear to
auscultation. He had two plus pitting edema in the right
pedal area with a right 2 cm Achilles ulcer. He was alert
and oriented times three, moving all extremities. Pupils
equal, round and reactive to light. His extraocular muscles
are full. Face symmetric. Tongue and palate were midline.
His sensation to his face was intact. He had no drift. His
lower extremity strength: His IPs were four plus, quads were
five out of five; hamstrings five minus out of five; the
right AT was three plus, the right [**Last Name (un) 938**] was one. The left [**Last Name (un) 938**]
was four minus, the left AT was five minus; toes were mute.
His deep tendon reflexes: His patellar were one plus,
pinprick was down bilaterally at the L5 dermatome.
LABORATORY: Labs on admission were white count of 12,900,
hematocrit 31.7, INR 1.2. Sodium 141, potassium 4.8,
chloride 110, CO2 19, BUN 31, creatinine 1.1, glucose was
297.
HOSPITAL COURSE: The patient was admitted for urgent surgery
for the epidural abscess. The patient had an intact rectal
tone but decreased pinprick sensation to the saddle area.
The patient underwent L4, L5 laminectomy which showed
granulation tissue in the anterior portion of the thecal sac
without complication. The patient was transferred to the
Recovery Room and then to the floor.
The patient was seen by the Infectious Disease Service. The
patient was started on Vancomycin and Rifampin. ID also
recommended that the patient have audiology testing secondary
to question of decreased hearing due to Vancomycin toxicity
in the past which was completed and the results are pending.
The patient was also seen by the Cardiology Service and had
both transthoracic and repeat transesophageal echocardiograms
which showed no evidence of heart vegetation and stable
aortic insufficiency.
The patient had a PICC line placed which is in good position.
The patient will continue on Vancomycin and Rifampin for six
to eight weeks. The patient will have peak and trough levels
checked and will follow-up in the Infectious Disease Clinic
after discharge. The patient will also have Audiology
follow-up for hearing loss.
DISCHARGE INSTRUCTIONS:
1. The patient will follow-up in the Infectious Disease
Clinic on [**2-1**], at 09:30 a.m. and see Dr. [**First Name8 (NamePattern2) 1059**]
[**Last Name (NamePattern1) 1057**].
2. Audiology testing demonstrated moderate sensorineural
hearing loss and recommended patient be fitted for a
hearing aid and follow-up testing for auto-toxic effect
in the future.
3. In terms of patient's ulcers, the patient will need to
have his open ulcers cleaned with normal saline. A
Duoderm should be applied to the coccyx and use Tegaderm
on the edges. Question of sensitivity to paper tape.
That should be changed three times a day and p.r.n.
4. He should have a normal saline moist dressing twice a day
to his Achilles and Kling wrap over that.
5. His left malleolus requires no dressing at this time but
should be followed.
6. The patient should continue with the First Step mattress.
DISCHARGE MEDICATIONS: He was also started on multivitamin
one tablet p.o. q. day and Vitamin C 500 mg p.o. twice a day.
Other medications at time of discharge are:
1. Colace 100 mg p.o. twice a day.
2. Vancomycin 750 mg intravenously q. day.
3. Percocet, one to two tablets p.o. q. four hours p.r.n.
4. Rifampin 300 mg p.o. twice a day.
5. 10 units of NPH q. a.m.
6. Neurontin 300 mg p.o. twice a day.
7. Megace 800 mg p.o. q. day.
8. Remeron 30 mg p.o. q. h.s.
9. Zantac 150 mg p.o. twice a day.
The patient will follow-up in the Infectious Disease clinic
on [**2115-2-1**], and will follow-up with Dr. [**Last Name (STitle) 12585**] at [**Hospital 14852**] in three to four weeks time. The
phone number is [**Telephone/Fax (1) 14023**], for the follow-up appointment.
CONDITION ON DISCHARGE: The patient's condition was stable
at the time of discharge.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 33505**], M.D. [**MD Number(1) 33506**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2115-1-9**] 11:50
T: [**2115-1-9**] 11:50
JOB#: [**Job Number 33608**]
|
[
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icd9cm
|
[
[
[]
]
] |
[
"03.09",
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icd9pcs
|
[
[
[]
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5958, 6718
|
3779, 4983
|
5007, 5934
|
2624, 3761
|
122, 353
|
376, 641
|
6743, 7081
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,100
| 131,956
|
21537
|
Discharge summary
|
report
|
Admission Date: [**2136-12-15**] Discharge Date: [**2136-12-24**]
Date of Birth: [**2071-7-2**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
hematemesis, lightheadedness
Major Surgical or Invasive Procedure:
EGD
Paracentesis
TIPS
History of Present Illness:
65 y/o male with hx of ETOH abuse, HTN, cirrhosis, afib, who on
[**12-11**] vomited a large amount of blood upon wakening. +
lightheadedness. On arrival,HCT was 29 and SBP in 80s. EGD done
and revealed 3+ esophageal varices without evidence of a recent
bleed. Also evidence of portal gastropathy. Thus, bleed felt to
be nonvariceal related and patient maintained on [**Hospital1 **] PPI. His
HCT post procedure was 37.6. Then over 12H trended down to 33.4
and then to 26.4. Patient had repeat EGD and revealed [**4-19**]+
esophageal varicies with evidence of a recent bleed at a distal
varix. Patient underwent banding times 6 and transfused to HCT
29.1. Patient tranferred for further mgt and possible TIPS if
rebleeds. HCT prior to transfer was 37.2 and received a unit of
PRBCs.
Past Medical History:
ETOH abuse- stopped 7 months ago- prior to that [**2-17**] pint a day,
HTN, Cirrhosis, Afib- was on coumadin in past- but held in
setting of GIB, s/p hernia repair and s/p repair of deviated
septum
Social History:
Lives with wife; Retired meat cutter
+1ppd tobacco
+ETOH abuse, drank 1qt/day for several yrs, decreased to [**2-17**]
pint per day 1 year ago, now quit ETOH x 7 months.
Family History:
Brother w/ ETOH abuse
Father died at 63 secondary to ETOH, Ca
Physical Exam:
PE on tx to Medicine Service [**2136-12-16**]
Vitals: HR 112, BP 102/58, RR 26, 98% 02 on 3l
Gen: lying supine, coughing, NG tube in place
HEENT: EOMI/PERRLA. anicteric. petichiae under tongue, no active
bleed
PULM: decreased breath sounds at bases b/l. + expiratory
wheezing
CV: RRR. no m/r/g
ABD: protuberant; soft; dull flanks. + fluid wave. no tenderness
or rebound. no caput.
EXT: 2+ edema bilaterally. + palmar erythema
Skin: non-jaundiced, occ spider angiomas on anterior chest wall
Neuro: A&O x 3. CN II-XII intact. no lethargy or drowsiness.
conversating appropriately. no asterixis.
Pertinent Results:
PT-14.4* PTT-32.9 INR(PT)-1.3
WBC-5.1 RBC-3.29* HGB-10.4* HCT-29.6* MCV-90, Plt 52
HCV Ab-NEGATIVE, AFP-7.0, HBsAg-NEGATIVE HBs Ab-POSITIVE IgM
HBc-NEGATIVE
IgM HAV-NEGATIVE
ALBUMIN-2.8* CALCIUM-7.6* PHOSPHATE-2.7 MAGNESIUM-1.7
GLUCOSE-110* UREA N-8 CREAT-0.6 SODIUM-140 POTASSIUM-4.0
CHLORIDE-110* TOTAL CO2-20*
Childs [**Doctor Last Name 14477**] Score =9 (3 for Albumin, 3 for Bili, 3 for
ascites); 0 for INR (1.3), 0 for encephalopathy.
[**12-15**] Liver U/S:
1. Cirrhotic appearing liver with a large amount of ascites
within the
abdomen.
2. Gallbladder wall thickening is likely due to the ascites.
3. No definite evidence of portal vein thrombosis.
4. Right pleural effusion.
5. Splenomegaly (14cm)
[**12-18**] Paracentesis;
WBC =110, Total protein 0.8, Alb <1,
Culture: no growth
Brief Hospital Course:
Brief summary of hospital course:
65 y/o male with hx of ETOH abuse, HTN, cirrhosis, afib, who was
admitted for hematemesis +lightheadedness; Found to have 3 to 4+
esophageal varices,portal gastropathy. Banded x 6 at OSH. He was
transferred to the ICU here for management of HD stability. NGT
was placed in ED and he was initiated on octreotide and nadolol.
He was monitored overnight and was found to be hemodynamically
stable. He was transferred to the floor where octreotide and
nadolol were discontinued. The patient had noted bronchospasm in
relation to nadolol. Therefeore, he was subsequently started on
diltizem for rate-control of his afib. Anti-coagulation was
deferred given his risk of bleed. NGT was also discontinued
given his ability to tolerate PO's and absence of blood return.
He had noted large ascites by abdominal U/S. Paracentesis
demonstrated a WBC=110, Total protein 0.8, Alb <1 consistent
with portal hypertension (SAAG=1.8). Final cultures were
negative, so there was no evidence of bacterial peritonitis.
However, given his GI bleed/ascites, he was started on
prophylaxis w/ Levaquin and received a complete 7 day course.
Repeat screening EGD demonstrated gastric varices w/ cherry red
spot and he subsequently underwent TIPS without event.
Pre-procedure course was complicated by severe
wheezing/bronchospasm requiring intubation. He was subsequently
stabilized and TIPS was performed without complication. There
were no post-TIPS complications: No encephalopathy, No asterixis
pre or post procedure. He had a benign abdominal exam on
discharge. He was sent home on Cipro 750mg qweek for ongoing
prophylaxis. He is currently being evaluated for Liver
transplant, with f/u planned for 1 month with Dr. [**Last Name (STitle) 497**].
Of note, he was noted to have E.Coli UTI 10,000-100,000 R to
levaquin that we decided not to treat in absence of clinical
findings.
Discharge Medications:
1. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
2. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
3. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Hydrocortisone 1 % Cream Sig: One (1) Appl Topical QID (4
times a day) as needed.
6. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
7. Pantoprazole Sodium 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*
8. Ciprofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a
week.
Disp:*30 Tablet(s)* Refills:*2*
9. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): [**Month (only) 116**] increase as needed to achieve [**3-20**] stools/day.
Disp:*2700 ML(s)* Refills:*2*
10. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Esophogeal/gastric varices
2. ETOH cirrhosis
3. Atrial fibrillation
Discharge Condition:
Good. Hemodynamically stable. Pain free.
Discharge Instructions:
Please return to the ER if you develop fever, chills, vomiting,
abdominal pain, dark tarry stools, lightheadedness or increased
confusion or lethargy.
Followup Instructions:
Please return to see Dr. [**Last Name (STitle) 497**] as scheduled (his office will
call you in regards to your appt.) His office and # are below:
Liver Center
[**Last Name (NamePattern1) 11100**]
[**Location (un) 86**], [**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2422**]
Fax: [**Telephone/Fax (1) 4400**]
Please follow-up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 23388**] in [**3-20**] weeks; Call to
make an appointment at [**Telephone/Fax (1) 23387**]
|
[
"789.5",
"401.9",
"456.20",
"599.7",
"285.1",
"305.01",
"571.2",
"493.20",
"287.5",
"572.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"39.1",
"99.04",
"45.13",
"39.79"
] |
icd9pcs
|
[
[
[]
]
] |
6182, 6188
|
3115, 3121
|
344, 368
|
6303, 6345
|
2295, 3092
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6545, 7046
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1603, 1666
|
5034, 6159
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6209, 6282
|
6369, 6522
|
1681, 2276
|
3150, 5011
|
276, 306
|
396, 1179
|
1201, 1400
|
1416, 1587
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,076
| 170,098
|
46464
|
Discharge summary
|
report
|
Admission Date: [**2175-11-10**] Discharge Date: [**2175-11-20**]
Service: MEDICINE
Allergies:
Procardia / Verapamil
Attending:[**First Name3 (LF) 1620**]
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
History of Present Illness: [**Age over 90 **] yo M with CAD s/p MI x2, CABG in
[**2161**], HTN, AF on anticoag, recent admission for CP, depression,
now admitted for a change in mental status, found to have acute
on chronic subdural hematoma. Pt was sent to ED by nurse [**First Name (Titles) **] [**Hospital3 **] because of worsening MS over last few days.
Refused POs or ambulation. Became more withdrawn and confused,
eventually minimally responsive. Said he felt like he didn't
want to live. No history of trauma. Psych meds were recently
changed.
.
In the ED, his VS were 97.3, HR 87 in AF, BP 207/137, RR 30,
100%RA. FS was 156. He received labetolol 10 IV x2, nitro paste.
Labs without acute findings. UA unremarkable. EKG with ST
depressions in V5/6. Trop 0.03. Pt had gag reflex and was not
intubated. Head CT with acute on chronic SDH. Neurosurgery was
consulted and felt that MS change was not likely related to SDH
as no mass effect or midline shift. However, nipride gtt was
started to keep SBP less than 140. Anticoagulation was reversed
with ?proplex and Vit K 10mg IV x1. FFP was ordered but not
given. Pt was also started on Dilantin 1g IV and received 10mg
Lasix IV x1 as well as Narcan 0.2 IV with no response.
Past Medical History:
Past Medical History:
1. Coronary artery disease
- AMI ([**2139**])
- AMI ([**2161**])
- Status post CABG in [**2161**]
--> SVG-LAD, SVG-OM, SVG-RPDA and LIMA to D1
- PCI ([**7-16**])
--> SVG->LAD with drug-eluting stent
--> SVG->OM1 with drug-eluting stent
- Stress ([**4-16**]): MIBI showed normal myocardial perfusion with a
normal left ventricular cavity size and systolic function (EF
62%)
2. Atrial fibrillation, on coumadin
3. Pulmonary artery systolic [**Month/Year (2) **], moderate (noted on
echo in [**11-15**])
3. Vestibular schwannoma treated with chemotherapy at [**Hospital 98711**]
4. Prostate cancer s/p Total radical resection of the prostate
5. Irritable bowel syndrome
6. s/p Bilateral inguinal hernia repairs
7. [**Hospital **]
8. Depression
9. Anxiety
Social History:
SOCIAL HISTORY:
He lives [**Street Address(1) 83359**] [**Hospital3 400**]. He is retired from
working as a stitcher. He has a niece [**Name (NI) **] [**Name (NI) **] who lives
in the area who is involved in some of his day-to-day care. Her
home phone number is [**Telephone/Fax (1) 98712**]. Her cellular phone number is
[**Telephone/Fax (1) 98713**]. The patient also has a nephew Dr. [**First Name4 (NamePattern1) 6339**]
[**Known lastname 98584**] in [**State **] who is his healthcare proxy. The patient
has a social worker and a visiting nurse. He uses a walker or a
cane to ambulate. No alcohol or tobacco. He does have a
lifeline.
The patient is a Holocaust survivor, and lost both his wife and
son in the Holocaust. He survived by making shoes for the
Nazis. He was in 5 different concentration camps in [**Country 2784**] and
Poland. He is listed on the Shoah website.
Family History:
Family History:
N/C; lost his wife and son in the Holocaust.
Physical Exam:
Physical Exam on Admission:
.
VS: T96.8 122/79 HR 64 in AF RR 14 97% 2L
Gen: NAD, seems comfortable but not responding to questions
HEENT: head atraumatic, PERRL, dry MM, clear OP
Neck: supple, no JVD elevation
CV: irregularly irregular, S1 S2, II/VI systolic murmur at USB
(old)
Lungs: CTAB anteriorly
Abd: soft, nontender, nondistended BS +
Ext: no LE edema, DP's 2+ b/l
Neuro: responds to voice once but not thereafter, moves
extremities occasionally, no response to sternal rub. ?Slightly
catatonic (when lifting arm up, keeps it elevated briefly prior
to bringing it down again)
Pertinent Results:
Labs:
[**2175-11-10**] 05:50PM BLOOD WBC-5.7 RBC-5.40# Hgb-16.9# Hct-47.3#
MCV-88 MCH-31.2 MCHC-35.6* RDW-14.3 Plt Ct-229
[**2175-11-20**] 06:15AM BLOOD WBC-3.1* RBC-4.16* Hgb-13.3* Hct-37.5*
MCV-90 MCH-32.0 MCHC-35.5* RDW-13.6 Plt Ct-212
[**2175-11-10**] 05:50PM BLOOD Neuts-77.8* Lymphs-14.2* Monos-6.2
Eos-1.6 Baso-0.1
[**2175-11-11**] 04:08AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-3+
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Target-OCCASIONAL
Schisto-OCCASIONAL Burr-2+
[**2175-11-10**] 05:50PM BLOOD PT-18.8* PTT-31.6 INR(PT)-1.8*
[**2175-11-20**] 06:15AM BLOOD PT-27.1* PTT-35.6* INR(PT)-2.7*
[**2175-11-11**] 04:08AM BLOOD Ret Aut-3.6*
[**2175-11-10**] 05:50PM BLOOD Glucose-107* UreaN-13 Creat-1.0 Na-136
K-4.0 Cl-94* HCO3-28 AnGap-18
[**2175-11-20**] 06:15AM BLOOD Glucose-98 UreaN-27* Creat-0.9 Na-131*
K-3.7 Cl-97 HCO3-24 AnGap-14
[**2175-11-10**] 05:50PM BLOOD ALT-26 AST-27 CK(CPK)-93 AlkPhos-117
Amylase-85 TotBili-2.1*
[**2175-11-17**] 06:15PM BLOOD CK(CPK)-34*
[**2175-11-18**] 08:50AM BLOOD CK(CPK)-36*
[**2175-11-10**] 05:50PM BLOOD Lipase-45
[**2175-11-10**] 05:50PM BLOOD cTropnT-0.03*
[**2175-11-11**] 04:08AM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2175-11-11**] 02:24PM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2175-11-17**] 06:15PM BLOOD CK-MB-NotDone cTropnT-0.07*
[**2175-11-18**] 08:50AM BLOOD CK-MB-NotDone cTropnT-0.06*
[**2175-11-11**] 04:08AM BLOOD Calcium-9.6 Phos-3.9 Mg-2.4
[**2175-11-20**] 06:15AM BLOOD Calcium-8.7 Phos-2.7 Mg-2.1
[**2175-11-11**] 04:08AM BLOOD VitB12-675 Folate-18.3 Hapto-29*
[**2175-11-12**] 04:13AM BLOOD Osmolal-275
[**2175-11-11**] 04:08AM BLOOD TSH-0.44
[**2175-11-15**] 06:25AM BLOOD Phenyto-12.7
[**2175-11-10**] 05:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2175-11-17**] 10:28AM URINE Color-Straw Appear-Cloudy Sp [**Last Name (un) **]-1.019
[**2175-11-11**] 08:53AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.021
[**2175-11-10**] 08:00PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.009
[**2175-11-17**] 10:28AM URINE Blood-LG Nitrite-POS Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-9.0* Leuks-MOD
[**2175-11-11**] 08:53AM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2175-11-10**] 08:00PM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-15 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2175-11-17**] 10:28AM URINE RBC-10* WBC-36* Bacteri-RARE Yeast-NONE
Epi-<1
[**2175-11-11**] 08:53AM URINE RBC-[**2-13**]* WBC-0-2 Bacteri-OCC Yeast-NONE
Epi-<1
[**2175-11-10**] 08:00PM URINE RBC-[**5-21**]* WBC-0-2 Bacteri-OCC Yeast-NONE
Epi-0
[**2175-11-18**] 02:54PM URINE Hours-RANDOM UreaN-912 Creat-75 Na-52
[**2175-11-12**] 02:40PM URINE Hours-RANDOM Creat-43 Na-96
[**2175-11-18**] 02:54PM URINE Osmolal-599
[**2175-11-12**] 02:40PM URINE Osmolal-467
[**2175-11-10**] 08:00PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
.
Micro:
.
Blood Cx ([**11-10**]): No growth
Urine Cx ([**11-10**]): No growth
[**11-11**]: RPR nonreactive
.
Imaging:
.
EKG: AFib at 93, new ST depressions in V5 and V6
.
Head CT: There is a mixed-attenuation extra-axial fluid
collection layering over the left frontal and parietal cerebral
convexities with relative [**Name (NI) 13215**] seen posteriorly,
consistent with an acute/subacute on chronic subdural hematoma.
This measures 11 mm in greatest transverse dimension. There is
no shift of the normally midline structures or hydrocephalus.
There are age-appropriate involutional changes and a chronic
right basal ganglial infarct. Soft tissue thickening in the
posterior cervical region is stable.
The right frontal sinus is hypoplastic. No fracture is
identified. The paranasal sinuses and mastoid air cells are well
aerated.
IMPRESSION: Left frontal/parietal acute/subacute on chronic
subdural hematoma without evidence of herniation.
.
CXR ([**11-12**]): FINDINGS:
Since the prior study, there is mild interval increase in patchy
atelectasis at the left lung base. There is also mild patchy
atelectasis at the right lung base. Heart is mildly enlarged.
Mediastinum is within normal limits. There is mild tortuosity of
the aorta. There is mild prominence of the central pulmonary
vasculature suggestive of mild congestive failure.
There is mild blunting of the left costophrenic angle consistent
with a small pleural effusion.
IMPRESSION:
1. Patchy atelectasis at both lung bases. Mild congestive
failure. Mild cardiomegaly.
.
EEG ([**11-12**]): IMPRESSION: This is a mildly abnormal EEG in the
waking and drowsy states due to the mildly slow background
rhythm of 7 Hz. This may
be normal for age or may suggest an excessively drowsy state or
may
suggest a mild encephalopathy, which may be seen with medication
effect,
toxic metabolic abnormalities or infections. No epileptiform
discharges
and no electrographic seizures were noted.
.
CXR ([**11-18**]): IMPRESSION: Unchanged radiographic appearance in
comparison to [**2175-11-12**].
Brief Hospital Course:
# Acute on Chronic Subdural Hematoma: Head CT showed acute on
chronic SDH. However, SDH was not felt to contribute to the
patient's mental status changes per neurosurgery as there was no
mass effect of midline shift. No neurosurgical interventions
were required during the hospitalization. In the MICU, he was
started on Dilantin for seizure prophylaxis, a nipride drip to
keep systolic bp <140, and his anticoagulation was reversed with
proplex and vitamin K. The nipride drip was quickly weaned and
he was re-started on his home antihypertensive regimen in
addition to captopril (which was eventually changed to
Lisinopril). Dilantin was discontinued per neurology
recommendations as it was thought to be possibly contributing to
his delerium. Anticoagulation with heparin SC, Coumadin, and
Aspirin was restarted on hospital day 5 ([**11-14**]). The patient as
instructed to follow-up with Dr. [**Last Name (STitle) **] in neurosurgery in 4
weeks with a non-contrast head CT.
.
# Altered Mental Status: The patient had decreased
responsiveness, increased depressive symptoms and no PO intake
for 24-48 hours prior to admission. He initially appeared
slightly catatonic on exam. Acute on chronic subdural hematoma
without mass effect was not thought to account for his mental
status change. The patient has a history of depression
refractory to multiple medications and is followed by an
outpatient psychiatrist. Per nursing home report, he was
recently started on Zyprexa which was discontinued on [**11-7**]
because of hallucinations. He was also receiving Cymbalta prior
to admission which was held during this admission. A
toxic-metabolic work-up demonstrated no urine or blood
infection, CXR with no opacification. TSH, B12 and folate were
normal. RPR was nonreactive, Urine/Serum tox screens negative.
An EEG was also performed to evaluate for seizure as a cause of
mental status change, which showed no epileptiform discharges
and mild encephalopathy, which may be seen with medication
effect, toxic metabolic abnormalities or infections. His
altered mental status was thought to be due to psychiatric
medication effect. His mental status improved during the
hospitalization, and upon discharge he was alert and oriented X
3 with no focal neurologic findings. He did have episodes of
delirium agitation during his stay in the MICU which were
controlled with low-dose haldol (0.5-1.0mg IV as needed).
Neurology was consulted for his paucity of speech, and did not
find evidence of stroke on exam and did not believe any further
neuroimaging was needed. They recommended discontinuing
Dilantin as that may be contributing to his delerium and
bilateral horizontal nystagmus. The patient may have [**Last Name (un) 309**] body
dementia, as he had adverse response to neuroleptics. It is
recommeded to avoid neuroleptics and dopamine antagonists in
this patient. The patient's outpatient gerontologist Dr. [**Last Name (STitle) **]
was contact[**Name (NI) **] while he was in house, and will follow up with him
as an outpatient to decide if and when his psych meds should be
restarted. He will also follow up with his psychiatrist and a
behavioral neurologist. It should be noted that he and his
family had a very undesirable admission at the inpatient
geriatric psychiatry unit at [**Hospital3 2568**] in the recent past and
will not entertain any future stays at the facility.
.
# Coronary Artery Disease: The patient has a history of CAD s/p
myocardial infarction x2 and s/p CABG. EKG on admission
demonstrated ST depressions in V5/6. Trop T 0.03->0.03->0.02
with CK flat (93->61->55), so he ruled-out for MI. He was
monitored on telemetry in the MICU. His ASA was initially held
in the setting of SDH, but was restarted on hospital day 5. He
was continued on metoprolol for blood pressure control. Repeat
EKGs showed no evolving changes. He was kept on a cardiac diet.
Patient again complained of chest pain on [**11-17**], EKG unchanged,
tropT 0.07 -> 0.06 with CK flat 34 -> 36. Symptoms improved with
Nitro SL. The patient's family informed us that the patient
would not want a catheterization or any other heroic measures if
this chest pain was cardiac in nature. The patient was
discharged with a prescription for nitropaste prn.
.
# [**Month/Day (4) **]: In the ED, the patient's SBP was up to 207, and
he was given Labetolol IV and started on a Nipride drip to keep
SBP <140. The nipride drip was quickly weaned in the MICU on
hospital day 2. He was restarted on metoprolol and amlodipine
per his home regimen. He was also started on captopril, which
was changed to Lisinopril on the medicine floor. He was noted
to have bradycardia to 40s with metoprolol administration and
his dose was subsequently decreased to 12.5mg PO BID.
.
# Atrial Fibrillation: In the ED, his INR was therapeutic at 1.8
on Coumadin 2 mg daily. Anticoagulation was reversed with
proplex and Vit K 10mg IV x1, and FFP was ordered but not given.
Initially held anticoagulation given SDH, but Coumadin was
restarted on hospital day 5 ([**11-14**]). The patient was continued
on Metoprolol 12.5 [**Hospital1 **] for rate control.
.
# Chronic Kidney Disease: Baseline creatinine 1-1.3 and has
ranged 0.9-1.0 this admission. UrNa 96, UrCr 43, UrOsm 467.
FeNa 1.58 %. Repeat urine lytes: UNa 52, UCr 75, Uurea 912,
Uosm 599. FeNa 0.58, FeUrea 39.3%. Patient given IVF NS x 500
cc x2, and was encouraged to take PO fluids.
.
# Hyponatremia: Sodium was decreased to nadir of 127 on hospital
day 3. Lab values initially thought to be consistent with SIADH,
and he was subsequently fluid restricted. However, his urine
output increased on HD5, and SIADH was thought to be less
likely. His Na decreased to 131, and he was given NS 500 cc at
100 cc/hr x2. Na should be monitored closely as an outpatient.
.
# UTI: UA showed mod leuk, pos nitr, 36 WBC, rare bacteria.
Urine Cx with >100,000 GNRs, Proteus vulgaris sensitive to
Cipro. Patient was started on Cipro 250 mg PO bid on [**11-18**].
Continue to monitor coags while on a quinolone. Continue to
monitor Is/Os, and if retaining urine check a post-void
residual.
.
# Depression: The patient's outpatient psychiatrist is Dr. [**Last Name (STitle) 10166**].
He had a recent admission at [**Hospital3 **], and has a history of
refractory depression with multiple medication trials. He was
started on Zyprexa "recently" with development of hallucinations
3-4 days prior to presentation. Zyprexa was discontinued on
[**11-7**]. He was also on Cymbalta as outpatient. All of his
psychiatric medications were held during this admission, as they
were thought to be contributing to his altered mental status.
The patient will follow up with his outpatient psychiatrist.
.
# Hyperbilirubinemia: The patient was found to have T bili 2.1
and D bili slightly up at 0.4. Hemolysis labs: retic 3.6, LDH
210, hapto 29. Repeat labs showed T bili 0.5 and direct bili
0.2, so no further work up was indicated.
.
# FEN: Patient placed on Regular Cardiac Kosher diet. Given
Vitamin B12 200 mcg daily and Calcium plus vitamin D 600 mg-200
units t.i.d.
.
# Code Status: DNR/DNI confirmed with HCP
.
# Contact: nephew [**Name (NI) **] is his HCP [**Telephone/Fax (1) 98710**], niece [**Name (NI) **]
[**Name (NI) **] (cell [**Telephone/Fax (1) 98713**], home [**Telephone/Fax (1) 98712**])
Medications on Admission:
MEDICATIONS:
1. Amlodipine 5 mg daily
2. Aspirin 81 mg daily
3. Calcium plus vitamin D 600 mg-200 units t.i.d.
4. Vitamin B12 200 mcg daily
5. Colace 100 mg b.i.d. p.r.n.
6. Lorazepam 0.5 mg one to two tablets q.h.s. p.r.n.
7. Milk of magnesia of uncertain dosage daily p.r.n.
8. Metoprolol tartrate 25 mg b.i.d.
9. Nitroglycerin SL 0.3 mg t.i.d. p.r.n.
10. Metamucil of uncertain dosage
11. Coumadin 2 mg q.h.s.
12. Duloxetine 30 mg PO daily
Note: Zyprexa was stopped prior to admission, as he was
developing hallucinations.
.
ALLERGIES:
1. Procardia
2. Verapamil
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Calcium + Vitamin D 600 (1,500)-200 mg-unit Tablet Sig: One
(1) Tablet PO three times a day.
4. Cyanocobalamin 100 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
7. Nitroglycerin 2 % Ointment Sig: 0.5-2 inch Transdermal every
4-6 hours as needed for chest pain.
Disp:*1 bottle* Refills:*0*
8. Warfarin 2 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
9. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for indigestion.
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
13. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 9 doses.
Disp:*9 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
PRIMARY:
Altered Mental Status
Subdural Hematoma-Acute on Chronic
Hyponatremia
[**Location (un) **]
Hyperbilirubinemia
.
SECONDARY:
Atrial Fibrillation
Coronary Artery Disease
Chronic Kidney Disease
Depression
Discharge Condition:
Stable
Discharge Instructions:
1. You were admitted to the hospital for changes in mental
status. You had a CT of your head which showed an old area of
bleeding (subdural hematoma) with a small area of new with
improvement in your medical status.
2. Call your doctor or return to the hospital if you develop
- Changes in mental status
- New headache
- Seizure
- Fever, chills
- Nausea, vomiting
- Any other new or concerning symptoms
3. Please take all your medications as prescribe
4. Please attend all follow up appointments.
Followup Instructions:
You will need to make a follow-up appointment with Dr. [**Last Name (STitle) **] in
neurosurgery in 4 weeks. You will also need a repeat
non-contrast Head CT before the appointment. Call
([**Telephone/Fax (1) 1669**]) to make an appointment once you are discharged.
.
You have an appointment Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 77126**] in psychiatry
([**Telephone/Fax (1) 98714**]) on [**2175-11-23**] at 3:30 pm.
.
You have an appointment with Dr. [**First Name (STitle) 161**] DAS in urology
([**Telephone/Fax (1) 921**]) on [**2175-12-18**] at 10:30 in the [**Hospital Ward Name **] CENTER, [**Location (un) **] UROLOGY CC3.
.
You have an appointment with Dr. [**First Name (STitle) **] [**Doctor Last Name **] ([**Telephone/Fax (1) 719**]) on
[**2175-12-19**] at 10:00 in the [**Hospital Unit Name **], [**Location (un) **] GERONTOLOGY.
.
You have an appointment scheduled with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in
behavioral neurology ([**Telephone/Fax (1) 1690**]) on [**2175-12-26**] at 10:00 in the
[**Hospital Ward Name 516**], [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Location (un) 551**], [**Apartment Address(1) 16806**].
|
[
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"276.0",
"412",
"790.6",
"585.9",
"432.1",
"427.31",
"E939.0",
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"599.0",
"403.90"
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icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
18237, 18309
|
8970, 9966
|
253, 260
|
18563, 18572
|
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|
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192, 215
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316, 1523
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|
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|
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|
2354, 3224
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,743
| 164,459
|
53828
|
Discharge summary
|
report
|
Admission Date: [**2178-12-13**] Discharge Date: [**2179-1-11**]
Date of Birth: [**2142-1-9**] Sex: F
CHIEF COMPLAINT: Abdominal pain
HISTORY OF PRESENT ILLNESS: This is a 36 year old female
with a history of adult polycystic disease status post
peritoneal dialysis who presented with sudden onset of severe
epigastric pain with bilious emesis. The patient reports no
recent changes in peritoneal dialysis and peritoneal fluid
was clear. The patient denied radiation of pain to the back
or scapula. The history of relationship of the pain to the
eating was unclear. The patient denied chest pain, shortness
of breath, fever or chills. The patient denied dysuria and
patient reports no recent weight losses and no recent changes
in her appetite. She denies diarrhea or constipation. She
denies blood in the stool.
PHYSICAL EXAMINATION: Vital signs on admission revealed
temperature 98.4, heartrate 83, blood pressure 137/70 and
respiratory rate 16, oxygen saturation 98% on room air. The
patient appeared to be in mild distress. Oral cavity and
oropharynx was clear. Pupils were equal, round, and reactive
to light. Lungs were clear to auscultation bilaterally.
Heart revealed a regular rhythm, no murmurs appreciated. No
jugulovenous distension. Abdominal examination reveals
patient was tender to light palpation in the epigastric
region. No peritoneal signs. No guarding, no rebound and no
rigidity. Positive bowel sounds.
LABORATORY DATA: White count was 6.6, hematocrit 29.8,
platelets 442, sodium 138, potassium 5.0, chloride 97,
bicarbonate 29, BUN 90, creatinine 15, glucose 104, albumin
3.5, calcium 9.7, phosphate 7.7, magnesium 2.0, alkaline
phosphatase 218, lipase 890. ALT 41, total bilirubin 0.2,
amylase 248, AST 22, triglycerides 200. Ascites fluid, white
blood cells [**Pager number **], polymorphonucleocytes 14, lymphocytes 1,
monocytes 73, red blood cells 10. KUB showed no dilated
loops of bowel. Pneumoperitoneum was consistent with
peritoneal dialysis. Abdominal computerized tomography scan
showed free fluid in the abdomen and no retroperitoneal
hemorrhage. Liver shows fullness of the pancreas with fluid
stranding anterior to the pancreas. In the right lower lobe
there was atelectasis versus pneumonia.
PAST MEDICAL HISTORY: Hypertension, VRE infection, anemia of
chronic disease, cardiac tamponade (transudate, cx neg) seizure,
questionable
history of peritoneal endometriosis, cervical dysplasia, in
situ, Clostridium difficile colitis, status post bilateral
nephrectomy.
MEDICATIONS ON ADMISSION:
1. Clonidine .3 b.i.d.
2. Labetalol 400 b.i.d.
3. Dilantin 400 b.i.d.
4. Lactulose 30
5. Nephrocaps
6. Lipitor 20
7. Prednisone 10 mg q.d.
8. RenaGel 800
ALLERGIES: Penicillin, FK-506.
SOCIAL HISTORY: The patient lives with her four children.
She denies ethyl alcohol, tobacco or intravenous drug abuse.
FAMILY HISTORY: Polycystic kidney disease on the maternal
side.
HOSPITAL COURSE: 1. Peritonitis - The patient was treated
with intraperitoneal Vancomycin and initially gentamicin.
Subsequently gentamicin was discontinued. The patient's
ascitic fluid grew out pansensitive enterococcus. The
patient completed a 14 day course of Vancomycin which was
uncomplicated. The diagnosis of peritonitis in the setting
of pancreatitis was unclear, however, because this ascitic
fluid grew out enterococcus the patient was presumed to have
peritonitis.
2. Pancreatitis - The patient's amylase and lipase were
significantly elevated on admission. The patient was placed
NPO and given intravenous fluids. The patient was started on
Dilaudid for pain control. Over the four week course of the
hospitalization the patient had very slow to resolve
pancreatitis. Two weeks into the hospitalization the patient
had improvement in her pancreatic enzyme levels and her
abdominal pain. She was started on clear liquid diet,
however, she did not tolerate this diet. She subsequently
had nausea and vomiting and increased abdominal pain and
increasing Dilaudid requirements. After this trial the
patient was placed NPO for the remainder of her hospital
course of two weeks. The patient's Dilaudid requirement
ranged from 6 to 14 mg per day. Gastroenterology was
following the patient closely and believed that a
conservative management was most appropriate. Endoscopic
retrograde cholangiopancreatography was contact[**Name (NI) **] over the
course of the hospitalization and endoscopic retrograde
cholangiopancreatography was not deemed indicated secondary
to normal liver enzymes and normal total bilirubin. On
[**12-16**], the patient had a right upper quadrant
ultrasound which showed a 1.2 cm common bile duct, however,
no stones were visualized at that time. On [**1-4**], in
response to increased abdominal pain and increasing
pancreatic enzymes, the patient had another right upper
quadrant ultrasound which showed a hepatic common bile duct
measuring 8 mm in diameter. Again no stones were visualized.
On [**2178-12-23**], in response to increased abdominal pain
and increase in Dilaudid requirement, the patient had right
upper quadrant ultrasound which showed a common bile duct of
6.5 mm with no stones visualized. On [**1-17**], the
patient had MRCP which showed mild smooth tapered dilatation
of the common bile duct without evidence of cholelithiasis or
extrinsic cause of narrowing. The region of the ampulla at
the common bile duct was not well visualized due to metallic
artifact from surgical clips. There were dilated
sidebranches to the hepatic duct, likely to be a sequelae
from previous episodes of inflammation. There were multiple
simple cysts of the liver consistent with diagnosis of
polycystic kidney disease. On [**1-4**], the patient had
abdominal computerized tomography scan of the abdomen and
pelvis which showed moderate fracturing of the tail of the
pancreas with no discrete abscess or fluid collection. Cysts
of the liver were identified. There was a moderate amount of
free fluid within the abdomen and pelvis consistent with
history of peritoneal dialysis.
In summary, the patient was believed to have slow to resolved
pancreatitis in the setting of chronic renal failure. The
plan was conservative management with pain medication, NPO
and fluids as necessary. Gastroenterology suggested a trial
of Actigall 300 mg p.o. b.i.d. and the patient was discharged
on this.
3. Neurological - The patient has a history of seizures and
was on Dilantin prior to admission. The patient's Dilantin
level on admission was very low raising the concern that the
patient was not compliant with her medications. On hospital
day #2 the patient was found hypotensive and lethargic. The
patient was coded and had a seizure and subsequently became
unresponsive. The patient was intubated and put on pressors
and transferred to the Medicine Intensive Care Unit. Shortly
after transfer to the Medicine Intensive Care Unit the
patient was weaned off pressors and blood pressure was
subsequently stable. The patient was extubated on the same
day. The very next day the patient was doing well with
stable blood pressure and stable respiratory status. The
patient was transferred back to the floor. The patient at
that time was started on 400 mg Dilantin b.i.d. Free
Dilantin level showed that to be too high. Over the four
week course of the hospitalization the patient's Dilantin was
decreased until the end of the hospitalization the patient
was on Dilantin 100 mg t.i.d.
4. Renal - The patient has a history of adult polycystic
kidney disease, status post cadaveric renal transplant with
chronic rejection. The patient returned to hemodialysis in
[**2178-5-19**] and was started on peritoneal dialysis in [**2178-10-19**]. Since [**2178-10-19**] the patient had not had any
previous episodes of peritonitis. When the patient was on
peritoneal dialysis prior to the renal transplant the patient
had multiple episodes of peritonitis. During the course of
her hospitalization, the patient's peritoneal dialysis was
uncomplicated and she was subsequently discharged on her
evening cycler.
5. Cardiovascular - The patient had a longstanding history
of hypertension which was difficult to control during the
course of her hospitalization. The patient was treated with
Clonidine patch. On discharged the patient was on .5 mg per
day of Clonidine patch. Initially the patient was on p.o.
Labetalol. This was subsequently discontinued while the
patient was NPO. On [**1-11**], the patient decided that
she wanted to be home with her family for the holidays.
Because the patient was not tolerating p.o. medications or
p.o. intake she was advised that she should stay in the
hospital until her medical illnesses resolved. Despite this
advice the patient decided to leave Against-Medical-Advice.
Because of the holidays our case management was unable to
arrange for services for the patient.
6. Fluids, electrolytes and nutrition - The patient was
started on total parenteral nutrition two weeks into the
course of her hospitalization. The patient tolerated the
total parenteral nutrition well, however, her BUN continued
to increase while she was on total parenteral nutrition. She
showed no signs of uremia and the renal team felt that the
absolute level of BUN was not significant in the absence of
uremic signs. Nutrition suggested changing to French chain
aminoacid total parenteral nutrition, however, the renal team
felt that this was expensive and an unproven therapy,
therefore recommended against changing to French chain
aminoacids for the purpose of lowering the BUN. The patient
was not discharged on home total parenteral nutrition
secondary to inability to arrange those services over the
holidays.
MEDICATIONS ON DISCHARGE:
1. Clonidine patch .5 mg per 24 hour period q. week
2. Dilantin 100 mg p.o. t.i.d.
3. Prednisone 5 mg p.o. q.d.
4. Actigall 300 mg p.o. b.i.d.
5. Dilaudid 2 mg prn
6. Duragesic patch 100 mcg q. 72 hours prn
7. Triamcinolone cream
DISCHARGE STATUS: The patient left Against-Medical-Advice.
FOLLOW UP: The patient will follow up with her primary care
physician on Wednesday, [**1-13**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 17014**], M.D. [**MD Number(1) 17015**]
Dictated By:[**Name8 (MD) 4575**]
MEDQUIST36
D: [**2179-1-13**] 19:02
T: [**2179-1-13**] 19:40
JOB#: [**Job Number 110464**]
|
[
"780.39",
"996.68",
"285.9",
"577.0",
"401.9",
"567.2",
"585",
"753.13"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"96.04",
"54.98",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
2913, 2962
|
9781, 10080
|
2579, 2775
|
2980, 9755
|
10092, 10455
|
867, 2280
|
140, 156
|
185, 844
|
2303, 2553
|
2792, 2896
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,983
| 121,634
|
10332+10403
|
Discharge summary
|
report+report
|
Admission Date: [**2154-3-29**] Discharge Date: [**2154-4-12**]
Date of Birth: Sex: M
Service:
HISTORY OF PRESENT ILLNESS: Patient is an 86-year-old male
with atrial fibrillation on Coumadin with diabetes, coronary
artery disease who presented to [**Hospital3 7571**]Emergency
Department on [**2154-3-27**] with weakness and change in mental
status. Patient was found to be hypoglycemic, treated, and
sent home.
Patient presented again with similar symptoms and upper
respiratory congestion and workup revealed elevated liver
function tests as well as an elevated white blood cell count,
coagulopathy, and hypoxemia with bilateral lower lobe
infiltrates on chest x-ray. Patient was also found with
complaints of abdominal pain more so on the right side. A CT
of the abdomen showed a dilated gallbladder with wall
thickening and a large stone with mild common bile duct
dilatation. Patient's creatinine was elevated, as well,
showing acute and chronic renal failure. Patient was
transferred to [**Hospital1 **] for further management.
PAST MEDICAL HISTORY:
1. Diabetes.
2. Abdominal aortic aneurysm.
3. Carotid stenosis.
4. Anemia.
5. Spinal stenosis.
6. Atrial fibrillation.
7. Hypertension.
8. History of gallstones.
PAST SURGICAL HISTORY:
1. Abdominal aortic aneurysm repair.
2. Appendectomy.
3. Gastrectomy for peptic ulcer disease.
4. Left inguinal hernia repair.
ALLERGIES:
1. Angiotensin-converting enzyme inhibitors.
2. Amoxicillin.
HOME MEDICATIONS:
1. Hytrin.
2. Micronase.
3. Toprol.
4. Trental.
5. Coumadin.
SOCIAL HISTORY: Patient quit smoking tobacco in [**2128**]. Does
not drink alcohol.
PHYSICAL EXAMINATION: Temperature 97.3, heart rate 108,
blood pressure 130/71, respiratory rate 21, satting 98% on
30% face tent. Patient is somnolent and difficult to arouse
which improved with dextrose. Patient has decreased breath
sounds at the right base. Heart is regular rate and rhythm.
Belly is distended. It is soft and tender in the right upper
quadrant. No [**Doctor Last Name 515**] sign. No guarding. Extremities are
warm with trace edema. Patient moves all extremities.
LABORATORY DATA: Patient's laboratory values were
significant for a white count of 10 with 49% neutrophils, 47%
bands, and 1% lymphocytes. A D-Dimer was 72.61, creatinine
of 3.3, ALT of 110, AST 99, alkaline phosphatase 208, total
bilirubin 2.9, direct bilirubin 1.9. Arterial blood gases
7.34, 41, 87, 23, -3.
Right upper quadrant ultrasound showed a gallbladder with
wall thickening and sludge, a 1.5 cm stone, common bile duct
measuring 11 mm with mild intrahepatic ductal dilatation.
HOSPITAL COURSE: Patient was started on antibiotics,
Ampicillin, Levofloxacin, and Flagyl. He was also transfused
a unit of platelets for a platelet count of 26.
Patient was taken to the Operating Room for presumed
cholecystitis on [**2154-3-30**]. What was found included a
distal common bile duct/pancreas tumor with metastases to the
liver, hepatic abscess with a biliary leak. In addition to
the exploratory laparotomy, a cholecystectomy with
cholangiogram, a choledochoduodenostomy, T-tube placement,
abscess drainage, and liver biopsy times three were
performed. The patient received four units of platelets,
four units of packed red blood cells, one unit of fresh
frozen plasma to correct his intraoperative coagulopathy.
Postoperatively, the patient experienced some hypotension
requiring a Neo-Synephrine drip in the Recovery Room as well
as difficult-to-manage hypoglycemia requiring D10 drip.
When a room was made available the patient was transferred to
the Surgical Intensive Care Unit where a number of
interventions were continued as well as started, including
treatment for his hypoglycemia, treatment for his
coagulopathy. A Heparin-dependent antibody test was done,
although it came back negative. The patient had an
echocardiogram performed which showed an ejection fraction of
greater than 35%, moderate aortic valve stenosis, 3+ mitral
regurgitation, 2+ tricuspid regurgitation, and patient was
started on total parenteral nutrition. Antibiotics of
Ampicillin, Levofloxacin, Flagyl, and Fluconazole were
continued.
Patient was also treated for acute tubular necrosis. Patient
was also started on tube feeds once it was felt it would be
tolerated. A number of consulting services was requested,
including Hematology, Renal, Nutrition.
Toward the end of his stay the patient appeared to have
possibly had a seizure requiring Ativan treatment. Over the
approximately two weeks in the Intensive Care Unit, the
patient remained intubated with a difficult respiratory wean.
It was finally decided by family meeting that on, [**2154-4-12**],
the patient would be extubated and placed on a Morphine drip
for comfort and let nature take its course. This decision
made largely due to a) the patient's failure to wean and
failure to improve from a mental status point of view as well
as b) the patient's dismal prognosis secondary to his tumor
burden. On [**2154-4-12**] at 7:41 p.m. the patient went into
cardiopulmonary arrest and was pronounced dead by Dr. [**First Name (STitle) **]
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], M.D. [**MD Number(1) 2214**]
Dictated By:[**Last Name (NamePattern4) 12487**]
MEDQUIST36
D: [**2154-4-12**] 20:10
T: [**2154-4-14**] 13:52
JOB#: [**Job Number 34315**]
Admission Date: [**2154-3-29**] Discharge Date: [**2154-4-12**]
Date of Birth: Sex: M
Service:
HISTORY OF PRESENT ILLNESS: Patient is an 86-year-old male
with atrial fibrillation on Coumadin with diabetes, coronary
artery disease who presented to [**Hospital3 7571**]Emergency
Department on [**2153-3-26**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], M.D. [**MD Number(1) 2214**]
Dictated By:[**Last Name (NamePattern4) 12487**]
MEDQUIST36
D: [**2154-4-12**] 20:03
T: [**2154-4-14**] 13:48
JOB#: [**Job Number 34466**]
|
[
"038.9",
"584.9",
"403.91",
"156.0",
"572.0",
"518.5",
"197.7",
"995.91",
"576.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"87.53",
"50.12",
"51.11",
"96.72",
"51.22",
"51.36",
"54.59",
"99.15",
"50.29",
"96.6",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
2669, 5633
|
1285, 1492
|
1510, 1577
|
1687, 2651
|
5662, 6128
|
1091, 1262
|
1594, 1664
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,671
| 124,900
|
5247
|
Discharge summary
|
report
|
Admission Date: [**2146-6-4**] Discharge Date: [**2146-6-10**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1148**]
Chief Complaint:
Weakness, chills
Major Surgical or Invasive Procedure:
None
History of Present Illness:
88 yo man with CHF (EF 35%), CAD s/p CABG in [**2136**], AFib on
coumadin admitted with weakness and chills. The patient states
that he was in his usual state of health until the evening prior
to admission when he began to experience chills. The patient
notes associated weakness and the following morning (the day of
admission) the patient was too weak to get out of bed. EMS was
called.
.
In the ED, T 101.7, bp 80's/40's 97% 3L. Poor urine output.
Given 4L NS with sbp decreasing to 70's. CXR revealed a
left-sided pneumonia, the patient was placed on early
goal-directed sepsis protocol. He was started on levophed 0.15
for blood pressure support with a good response to the sbp
120's. He received levofloxacin 750mg x1.
.
ROS: Patient notes a single episode of emesis after drinking a
glass of cranberry juice the evening prior to admission. He
denies headache, blurry vision, photophobia, rhinorrhea, sore
throat, cough, sputum production, abdominal pain, nausea,
diarrhea, dysuria, skin breakdown, swollen or erythematous
joints. He denies chest pain, orthopnea, new edema or any change
in his exercise tolerance.
Past Medical History:
1. Coronary artery disease, status post coronary artery
bypass graft in [**2136**] times four.
2. Congestive heart failure with an ejection fraction
of 25% with diastolic and systolic dysfunction.
3. Hyperlipidemia.
4. Paroxysmal atrial fibrillation, on
Coumadin.
5. Status post appendectomy.
6. History of lower gastrointestinal bleed.
7. Glucose intolerance.
8. Right carotid stenosis of 60% to 69%.
9. History of Escherichia coli urosepsis.
10. History of low blood pressure
Social History:
The patient is retired and now lives with
sister (who is [**Age over 90 **]yo). The patient denies ever
smoking. He notes occasional wine consumption.
Family History:
positive for coronary artery disease and breast cancer.
Physical Exam:
PE: 99.1 67 122/50 (on levophed 10) 16 98% 2L NC SvO2 66% CVP 16
Gen: NAD.
HEENT: PERRL. Pink, moist oral mucosa without lesions.
CV: RRR. Normal S1 and S2. No M/R/G.
Pulm: Crackles in the left lower lung fields.
Abd: Soft, nontender.
Ext: Trace left lower extremity edema.
Pertinent Results:
[**2146-6-4**] 11:18AM PT-32.6* PTT-30.3 INR(PT)-3.5*
[**2146-6-4**] 11:18AM PLT COUNT-189
[**2146-6-4**] 11:18AM NEUTS-90* BANDS-0 LYMPHS-1* MONOS-9 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2146-6-4**] 11:18AM WBC-15.4*# RBC-4.32* HGB-12.7* HCT-36.0*
MCV-83 MCH-29.4 MCHC-35.3* RDW-17.2*
[**2146-6-4**] 11:24AM LACTATE-3.0* K+-5.1
[**2146-6-4**] 12:15PM URINE RBC-21-50* WBC-0-2 BACTERIA-FEW
YEAST-NONE EPI-0-2
[**2146-6-4**] 12:15PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-6.5 LEUK-NEG
.
FRONTAL CHEST RADIOGRAPH: Over the interval there are some
placement of a right-sided internal jugular central venous
catheter with tip in the cavoatrial junction. There has also
been increasing perihilar haziness consistent with devloping
pulmonary edema. The left costophrenic angle and portions of the
left hemithorax are incompletely evaluated. There is increasing
right basilar opacity.
IMPRESSION:
1. Mild pulmonary edema which is new compared to prior study.
2. Right lower lobe pneumonia
Brief Hospital Course:
A/P: 88 yo man with CHF (EF 35%), CAD s/p CABG in [**2136**], AFib on
coumadin admitted with weakness and chills, found to have right
sided pneumonia with relative hypotension and elevated lactate.
.
# Hypotension. Baseline sbp 90's. In the setting of fever and
elevated lactate this was believed to be SIRS/sepsis physiology
from pneumonia. He required pressors briefly in the ICU and was
able to be weaned after fluid resuscitation. Antihypertensives
and diuretics were initially held and then slowly added back.
At time of discharge enalapril had not been restarted; can
restart in the next few days at rehab if BP allows.
.
# Community acquired Pneumonia. Patient intially given IV
levofloxacin and then transitioned to po. His leukocytosis
resolved. He spiked a temperature to 101 and was broadened to
vanc and zosyn briefly. Blood cultures remained no growth and
cxr unchanged. Changed back to just levofloxacin with continued
improvement. Plan 14 days total antibiotics. Please continue
to monitor temperature. No other localizing symptoms.
Saturating well on room air at discharge. Cont nebs prn.
.
# Acute on chronic renal failure. Baseline Cr approximately
1.4-2.0; on admission was elevated but resolved with holding
diuretics and gentle volume resuscitation. Likely in part due to
hypovolemia, improved with re-hydration.
.
# Normocytic Anemia. Admission Hct of 36 near baseline (34-40).
Decline in Hct likely in part dilution due to IVF. Patient has a
history of lower GI bleed, though no signs of active hemorrhage
during this admission. Patient thought to be stable on home
anticoagulation, though supratherapeutic on admission. Also
element of AOCD with renal failure. Anticoagulation held for
elevated INR on admission and then restarted.
.
# CV. History of CAD, CHF and hyperlipidemia. Continued on
aspirin, statin. As noted above antihypertensives initially
held and all restarted before discharge except enalapril. This
should be restarted as outpatient. Patient with increased edema
in lower extremities at time of discharge from diuretics being
held; no evidence acute coronary event. Recent EF 35%.
.
# Paroxysmal atrial fibrillation. Supratherapeutic INR at 3.7.
Coumadin held and then became subtherapeutic. INR 1.8 on day of
discharge; repeat in 3 days and adjust coumadin prn.
.
# Hematuria: Patient noted to have hematuria on UA then had
traumatic incident with foley being pulled. Urine now clear but
should get repeat UA for signs of microscopic hematuria in [**4-15**]
weeks as outpatient to further follow up.
.
# Right carotid stenosis. Outpatient follow-up.
.
# Glucose intolerance. Last Hgb A1c 6.5 in [**2145-1-10**].
- Fingersticks were normal this admission without requirement
for insulin. Continued on diabetic, heart healthy diet.
.
# Code: DNR/DNI per discussion with patient.
Medications on Admission:
Pantoprazole 40 mg PO Q24H
Digoxin 125 mcg PO DAILY
Levothyroxine 25 mcg PO DAILY
Furosemide 120 mg PO QAM, 80mg QPM
Aspirin 81 mg PO DAILY
Atorvastatin 10 mg PO DAILY
Warfarin 7.5 mg PO HS
Fenofibrate Micronized 48 mg PO Daily
Metoprolol Succinate 25 mg Sustained Release PO QHS
Enalapril Maleate 5 mg PO BID
Spironolactone 12.5 mg PO DAILY
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Warfarin 7.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Fenofibrate Micronized 54 mg Tablet Sig: One (1) Tablet PO
once a day.
9. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO at bedtime.
10. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed.
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
13. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
14. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q6H (every 6 hours) as needed.
15. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
16. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 8 days.
17. Outpatient Lab Work
Please check INR on Monday [**2146-6-13**] and have followed up by
physician at [**Hospital 100**] Rehab. Goal INR [**2-12**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Community acquired pneumonia
Anemia of chronic disease
Atrial fibrillation
Hematuria
CHF, systolic
Discharge Condition:
Stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
.
You were admitted with a pneumonia. Please call your doctor or
return to the hospital if you develop high fevers, shortness of
breath, chest pain.
.
You had blood in your urine noted after your foley was placed
and then had bleeding after the foley was removed. Please get
your urine rechecked for blood as an outpatient.
Followup Instructions:
Please call your primary care doctor, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**] ([**Telephone/Fax (1) 21456**]) and make a follow up appointment in the next [**2-12**]
weeks.
.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1989**] Date/Time:[**2146-8-31**]
10:20
|
[
"V45.81",
"272.4",
"995.91",
"285.21",
"427.31",
"585.9",
"414.01",
"599.7",
"428.20",
"038.9",
"584.9",
"V58.61",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8340, 8406
|
3584, 6425
|
278, 285
|
8549, 8558
|
2511, 3561
|
9032, 9391
|
2142, 2200
|
6818, 8317
|
8427, 8528
|
6451, 6795
|
8582, 9009
|
2215, 2492
|
222, 240
|
313, 1436
|
1459, 1956
|
1972, 2126
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,521
| 118,874
|
25132
|
Discharge summary
|
report
|
Admission Date: [**2146-6-16**] Discharge Date: [**2146-6-19**]
Date of Birth: [**2090-4-28**] Sex: F
Service: MEDICINE
Allergies:
Percocet / Percodan
Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
gross hematemesis
Major Surgical or Invasive Procedure:
[**First Name3 (LF) **], [**First Name3 (LF) 63027**] of esophageal varices
intubation
History of Present Illness:
Ms. [**Known lastname **] is a 56-year-old female with hepatitis C cirrhosis
listed for liver [**Known lastname **] with a MELD score of 10. She has a
history of decompensation with previous variceal bleeding s/p
[**Known lastname 63027**], hepatic encephalopathy, ascites and spontaneous
bacterial peritonitis on prophy cipro. She presented to the ED
after awaking at 4 am this morning vomiting bright red blood.
She vomited once on the way to the hospital and several times in
the ED (estimated 3 L blood loss). Of note she had a recent
screening [**Known lastname **] on [**2146-6-9**] showing 2 cords of nonbleding grade I
varices. Currently on prophy nadolol. + lightheadedness and
dizziness, but denies melena or BRBPR.
.
In the ED, initial vs were: Temp 97.8F, HR 88, BP 102/87, R 16,
SaO2 100% RA. Initial Hct was 29.9. Given massive blood loss the
patient was transfused 3 units RBCs. The patient was intubated
for airway protection and an OG tube was placed. She was
sedated with propofol but remained hypertensive to 210/77. HR
was 80s and she was overbreathing the vent with RR 22 satting
100%. She was given zofran, octreotide, and started on PPI.
Evaluated by liver and will have [**Date Range **] this am.
Past Medical History:
- Hep C Cirrhosis
- Esophageal varices grade [**11-20**] seen on [**Month/Day (2) **] [**1-22**]
- DM, poorly controlled, with A1c 11.9% in [**9-24**]
- HTN
- Aortic stenosis: seen by Dr. [**Last Name (STitle) **] in [**8-24**], [**Location (un) 109**] 1 cm, peak
grad 63, mean grad 34. EF (75-80%). Normal persantine [**2-22**].
- Depression
Social History:
Used cocaine in the past. Moderate EtOH until [**2137**] then quit.
Lives in [**Location 2498**] with children and grandchildren. Has 5 kids.
not married.
Family History:
Father had CABG. Brother had lymphoma in his 20s. No liver
disease.
Physical Exam:
Vitals: T 98.7, Tm 99.6, BP 121/66, P 75, R 18, 98% on RA
General: WD/WN woman in NAD
Skin: No jaundice or rashes
HEENT: NC/AT, sclera anicteric, EOMI, MMM
Neck: Supple, no LAD, no JVD, trachea midline
Lungs: CTA bilaterally, no w/r/c
Heart: RRR, nml S1/S2, +[**1-22**] cres-decres murmur @ RSB, radiating
to carotids
Abd: +BS, soft, NT, liver edge palpated just below costal border
Extrem: WWP, no c/c/e, 2+ pedal pulses
Neuro: AAOx3, no asterixis
Pertinent Results:
Labs:
[**2146-6-16**]:
WBC-4.7 RBC-3.22* Hgb-10.5* Hct-29.9* MCV-93 MCH-32.6*
MCHC-35.2* RDW-14.3 Plt Ct-53*
PT-14.7* PTT-32.3 INR(PT)-1.3*
Glucose-296* UreaN-31* Creat-1.0 Na-138 K-5.5* Cl-105 HCO3-23
AnGap-16
ALT-64* AST-74* AlkPhos-82 TotBili-2.0*
Albumin-3.4* Calcium-8.7 Phos-3.6 Mg-1.9
.
[**2146-6-17**]:
WBC-2.8* RBC-3.04* Hgb-9.7* Hct-26.9* MCV-88 MCH-32.0 MCHC-36.2*
RDW-15.0 Plt Ct-31*
PT-15.6* PTT-33.9 INR(PT)-1.4*
Glucose-157* UreaN-38* Creat-1.1 Na-141 K-3.7 Cl-112* HCO3-22
AnGap-11
ALT-55* AST-71* LD(LDH)-260* CK(CPK)-127 AlkPhos-60 TotBili-2.0*
.
[**2146-6-18**]:
WBC-2.5* RBC-3.01* Hgb-9.5* Hct-26.9* MCV-90 MCH-31.5 MCHC-35.2*
RDW-14.7 Plt Ct-34*
PT-14.8* PTT-34.1 INR(PT)-1.3*
Glucose-90 UreaN-28* Creat-1.0 Na-138 K-3.5 Cl-110* HCO3-22
AnGap-10
ALT-57* AST-75* AlkPhos-59 TotBili-2.2*
Calcium-8.0* Phos-2.8 Mg-1.9
.
[**2146-6-19**]:
WBC-1.9* RBC-2.92* Hgb-9.5* Hct-26.2* MCV-90 MCH-32.5*
MCHC-36.3* RDW-14.7 Plt Ct-32*
Neuts-60.7 Lymphs-26.6 Monos-9.1 Eos-3.0 Baso-0.6
Glucose-105* UreaN-21* Creat-0.9 Na-140 K-3.7 Cl-110* HCO3-23
AnGap-11
Calcium-7.9* Phos-2.9 Mg-1.9
.
.
[**Month/Day/Year **] ([**2146-6-16**]): 2 cords of grade II varices were seen starting at
30 cm from the incisors in the lower third of the esophagus.
There were stigmata of recent bleeding. 2 bands were
successfully placed on the varix that had stigmata of recent
bleeding. The other varix was not banded. Varices at the lower
third of the esophagus (ligation). Blood in the whole stomach.
Blood in the duodenal bulb. Otherwise normal [**Month/Day/Year **] to third part
of the duodenum.
.
Portable CXR ([**2146-6-16**]): Cardiac size is top normal. Aside from
opacities in the left lower lobe consistent with atelectasis,
the lungs are clear. There is no pneumothorax or pleural
effusion.
Brief Hospital Course:
Ms. [**Known lastname **] is a 56 yo woman with Hep C (h/o variceal bleed
requiring [**Known lastname 63027**], encephalopathy, SBP), on liver [**Known lastname **]
list, who presented to the ED with bright red hematemesis, found
to have esophageal varices which were banded. Brief hospital
course by problem:
.
# Hematemesis: Given the massive blood loss the patient was
transfused 3 units of RBCs, intubated for airway protection, and
an OG tube was placed. An [**Known lastname **] showed varices with evidence of
recent bleeding and 2 bands were placed. Pantoprazole gtt and
octreotide gtt were started, and ciprofloxacin was increased to
500 mg Q12. She experienced a small amount of bloody vomitus
post-procedure and one small dark bowel movement, but
experienced no further bleeding. Her Hct remained stable above
26. Spironolactone, lasix, rifaximin, and naldolol were
restarted per home regimen.
- Pt will f/u with Dr. [**Name (NI) **] in 2 weeks for a repeat [**Name (NI) **]
with more [**Name (NI) 63027**]
- Continue ciprofloxacin 500 mg [**Hospital1 **] for 4 more days (total 1
week) and then resume home dosing
- Continue pantoprazole and sucralfate, and hold ferrous
gluconate until OP f/u with liver in 2 weeks
.
# HCV cirrhosis: Listed on liver [**Hospital1 **] list with MELD 10.
Current MELD 12. No evidence of asterixis or encephalopathy.
Held spironolactone and lasix given active bleeding, nadolol and
omeprazole were held while on octreotide and PPI gtts in the
MICU. Rifaximin was also held while NPO. Cipro was continued for
SBP prophylaxis at a higher dose (500 mg [**Hospital1 **]). Spironolactone,
lasix, rifaximin, and nadolol have since been restarted.
- F/u with liver in 2 weeks
.
# Iron deficiency anemia:
- Holding ferrous gluconate in the setting of a bleed.
.
# Diabetes: Stable.
- Resume home insulin schedule.
.
# Depression: Stable.
.
# Aortic stenosis: Stable.
Discharge Medications:
1. Alprazolam 0.25 mg Tablet Sig: 1-2 Tablets PO once a day as
needed for anxiety.
2. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 days: Take for 4 days and then resume
once daily dosing. .
Disp:*8 Tablet(s)* Refills:*0*
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Nadolol 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. Rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Calcium Carbonate-Vitamin D3 Oral
8. Insulin Glargine 100 unit/mL Solution Sig: Fifty Five (55)
units Subcutaneous at bedtime.
9. Novolog 100 unit/mL Solution Sig: Six (6) units Subcutaneous
every six (6) hours.
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*28 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
11. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO four times a
day for 2 weeks.
Disp:*56 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- Esophageal varices
.
Secondary:
- Hepatitis C
- Aortic stenosis
- Diabetes
- Iron deficiency anemia
- Depression
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
Ms. [**Known lastname **],
.
You were admitted to the hospital after vomiting blood. The GI
doctors did [**Name5 (PTitle) **] [**Name5 (PTitle) **] and found esophageal varices which were
banded. You are no longer having any more bleeding and your
blood counts are stable. You will neeed to have another [**Name5 (PTitle) **] in 2
weeks with the liver doctors for [**Name5 (PTitle) **] [**Name5 (PTitle) 63027**].
.
Please continue to take your home medications. We have made the
following changes:
- INCREASED ciprofloxacin to 500 mg twice daily for a total of 7
days
- STOPPED omeprazole and STARTED pantoprazole for 2 week course
- STARTED sucralfate for 2 week course
- HELD ferrous gluconate
.
Please make an appointment with your PCP and the GI doctors
[**Name5 (PTitle) 176**] 1-2 weeks.
.
It was a pleasure caring for you.
Followup Instructions:
Please schedule an appointment with your PCP and the GI doctors
[**Name5 (PTitle) 176**] 1-2 weeks.
.
Please call the liver center for an appointment with Dr.
[**Last Name (STitle) 1383**] in the next 2 weeks. You can call [**Telephone/Fax (1) 673**] for
an appointment
.
Department: [**Telephone/Fax (1) **]
When: WEDNESDAY [**2146-8-3**] at 8:40 AM
With: [**Year (4 digits) **] [**Hospital 1389**] CLINIC [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Department: CARDIAC SERVICES
When: WEDNESDAY [**2146-9-14**] at 11:20 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2146-6-19**]
|
[
"285.1",
"280.9",
"070.70",
"424.1",
"456.20",
"250.00",
"V49.83",
"401.9",
"571.5",
"311"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.07",
"42.33",
"96.71",
"99.04",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
7545, 7551
|
4565, 6468
|
299, 387
|
7719, 7719
|
2754, 4542
|
8722, 9599
|
2200, 2269
|
6491, 7522
|
7572, 7698
|
7867, 8699
|
2284, 2735
|
242, 261
|
415, 1645
|
7734, 7843
|
1667, 2011
|
2027, 2184
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
784
| 187,825
|
167
|
Discharge summary
|
report
|
Admission Date: [**2200-6-2**] Discharge Date:[**2200-7-8**]
Date of Birth: [**2131-8-1**] Sex: F
Service:
DATE OF DISCHARGE: Pending.
AGE: 68.
HISTORY OF THE PRESENT ILLNESS: [**Known firstname 1743**] [**Last Name (NamePattern1) 1744**] is a
68-year-old female who was at acute rehabilitation at
[**Location (un) 38**] after having a right-sided knee replacement on
[**2200-5-6**]. The patient had been on antibiotics following her
knee replacement and had developed abdominal pain two weeks
prior to admission with diarrhea. The patient was presumed
to have C. difficile and had been started on Flagyl. She was
taken to the [**Hospital1 69**] Emergency
Department and on presentation she had a white blood cell
count of 25,000, large amounts of nausea, and fevers up to
101.0 degrees. Of note, the patient had been on Flagyl since
[**5-21**], until the patient's presentation on [**2200-6-2**].
REVIEW OF SYSTEMS: Review of systems was negative for
dysuria.
PAST MEDICAL HISTORY: History was notable for the following:
1. Osteoarthritis.
2. Left sided breast cancer.
3. Diverticulitis.
4. Gastrointestinal bleed.
5. Fibromyalgia.
MEDICATIONS ON ADMISSION:
1. Coumadin.
2. Vistaril.
3. ....................
4. Tamoxifen.
5. Zoloft.
6. Protonix.
7. Ditropan.
8. [**Doctor First Name **].
9. Lasix.
ALLERGIES: The patient is allergic to SULFA AND IBUPROFEN.
SOCIAL HISTORY: The patient has no history of alcohol,
drugs, or smoking.
PHYSICAL EXAMINATION: On presentation, the patient's
physical examination revealed the following: Temperature
100.3, heart rate 109, blood pressure 149/74, respiratory
rate 18, oxygen saturation 97%. She was ill-appearing on
presentation with a diffusely tender abdomen with positive
rebound and no guarding. Stool was guaiac negative.
HOSPITAL COURSE: The patient was then admitted medical
service initially for management of her presumed C. difficile
colitis.
The patient was admitted to the medical service
postoperatively and then was noted to have pleural effusion
and then underwent a thoracocentesis of her effusion. On the
14th, the patient continued to have poor hospital course and
on [**2200-6-5**] due to difficult medical management of the
disease, surgical consultation was obtained and the patient
underwent a subtotal colectomy with ileostomy.
Regarding the patient's operation, please referred to
Dr. [**Name (NI) 1745**] operative note on [**2200-6-5**]. Postoperatively,
the patient was taken to the Medical Intensive Care Unit for
further management of her disease. She underwent numerous
transfusion of fresh-frozen plasma. The patient was
continued to be intubated. The patient was managed in the
Medical Intensive Care Unit with bilateral chest tubes placed
while the patient was in the Medical Intensive Care Unit.
The patient continued to have high fevers. Sputum culture
from [**2200-6-21**] demonstrated Methicillin-resistant
Staphylococcus aureus and transthoracic cardiac
echocardiogram demonstrated no pericardial effusion or no
obvious vegetations, while the patient continued to have
these fevers. The patient was continued on Vancomycin and
continued to be intubated for a long period of time until
[**2200-6-25**] when the patient was extubated successfully.
Post extubation, the patient had difficulty with her voice
and swallowing, and she was deemed an aspiration risk, so
Dobbhoff was placed. She was then transferred to the floor
and she continued to do well. Chest tubes were removed, and
she stopped having fevers. Physical therapy consultation was
obtained and the patient began to improved dramatically while
on the floor. She remained afebrile with stable vital signs
with reasonable respiratory parameters, and she was continued
on tube feeds or Promote with fiber at a goal rate of 70 cc
per hour.
The patient will be discharged to a rehabilitation facility
on the following regimen:
1. Lopressor 50 mg PO t.i.d.
2. Ambien 10 mg PO q.h.s.
3. Vancomycin 1 gram q.d.
4. Heparin 5000 units subcutaneously b.i.d.
5. Regular insulin sliding scale.
6. Protonix 40 mg IV q.d.
7. The patient will continue on her tube feeds, Promote with
fiber at 70 cc an hour.
FOLLOW-UP CARE: The patient will followup with Dr. [**Last Name (STitle) 519**] in
one to two weeks. The patient will followup with her primary
care physician at the time deemed appropriate by their
office.
OF NOTE: Portions of this chart were not available during
this dictation.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. [**MD Number(1) 521**]
Dictated By:[**Name8 (MD) 522**]
MEDQUIST36
D: [**2200-7-7**] 13:37
T: [**2200-7-7**] 13:57
JOB#: [**Job Number 1746**]
|
[
"038.11",
"276.2",
"557.0",
"276.8",
"482.41",
"V43.65",
"785.59",
"570",
"492.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.79",
"34.04",
"89.64",
"96.72",
"46.21",
"34.91",
"99.15",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
1197, 1408
|
1843, 4758
|
1507, 1825
|
947, 992
|
1015, 1171
|
1425, 1484
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,580
| 124,635
|
43775
|
Discharge summary
|
report
|
Admission Date: [**2131-10-30**] Discharge Date: [**2131-11-7**]
Date of Birth: [**2053-7-1**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 678**]
Chief Complaint:
Hyperglycemia, altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname 94057**] is a 78 year old woman with history of diabetes,
diastolic CHF, atrial fibrillation s/p PPM placement, and
hypertension who presents to the ED today for altered mental
status. She was noted by her caregiver to be increasingly
lethargic over the last day (not seen over the weekend). She
reports feeling tired and weak. Per her caregiver, she has had
waxing/[**Doctor Last Name 688**] mental alertness, mumbling, confusion, weakness,
and difficulty walking. She denies fevers, chills, nausea,
vomiting, cough, dyspnea, shortness of breath, chest pain,
urinary symptoms, diarrhea, and abdominal pain. She has noted
that her blood sugars have been more difficult to control
recently, with sugars in the 400's. She reports normal PO intake
and normal urine output.
.
She presented to clinic with FS 310, afebrile, with pulse 70.
She was sent to the ED for further workup. In the ED, her vital
signs were 97.7F, HR 73, BP 138/73, 92%RA which improved to 97%
on 2L. 2 peripheral IV's were placed. Blood cultures were drawn,
CXR showed no acute cardiopulmonary process, and she was given 1
liter of normal saline with 40mEq of KCl. She was found to have
a finger stick of 449 with anion gap of 16. She was admitted to
the MICU for DKA and altered mental status.
.
On arrival to the floor, stat blood gas demonstrated:
7.51/49/84/40. Her anion gap on repeat labs was 10. She was
restarted on her home insulin doses, given one liter of IVF over
several hours, and monitored. Diuretics were held.
Past Medical History:
-Hypertrophic obstructive cardiomyopathy with superimposed
diastolic dysfunction, s/p ethanol ablation in [**2126**]
-dCHF (EF-60%-70%, 2+ TR; 1+ MR)
-PAF on coumadin
-Hypertension
-S/P DDD pacemaker to induce LV delay compared to the right
ventricle in order to decrease the outflow tract obstruction.
-Mesenteric artery thrombosis
-Diabetes mellitus type 2
-Glaucoma
-Gout
-Chronic low back pain and lumbar stenosis s/p recent placement
of nerve stimulator
-Chronic renal insufficiency (1.1-1.2)
-cath in [**2126**] showed no obstructing disease in coronary arteries
Social History:
Lives alone in [**Location (un) 538**] but has 24-hour care 5 days a week.
The patient quit smoking many years ago. She drinks less than
one drink per week. She is from [**Country 4754**]. She lives alone but
has. Her son lives in [**Name (NI) 1411**].
Family History:
Mother has diabetes mellitus. Brother had a CABG, the details of
which are unknown.
Physical Exam:
VITALS: T 97.8F, BP 108/38, HR 74, RR 18, Sat 94%2L
GENERAL: Well-appearing, no acute distress
HEENT: Dry mucus membranes
NECK: Unable to appreciate JVD
CARD: RRR, normal S1/S2, no m/r/g
RESP: Bibasilar crackles
ABD: Obese, soft, non-tender, non-distended, + bowel sounds
EXT: Trace edema. LLE with erythematous scaling rash, intensely
pruritic; RLE with venous stasis changes
NEURO: A&O x 3, responds to commands and communicates
appropriately
Pertinent Results:
[**2131-10-30**] 10:58PM GLUCOSE-176* UREA N-98* CREAT-1.5*
SODIUM-132* POTASSIUM-3.5 CHLORIDE-86* TOTAL CO2-36* ANION
GAP-14
[**2131-10-30**] 10:58PM WBC-12.0* RBC-4.93 HGB-14.6 HCT-43.2 MCV-88
MCH-29.7 MCHC-33.9 RDW-16.5*
[**2131-10-30**] 10:58PM NEUTS-77.1* LYMPHS-16.2* MONOS-4.6 EOS-1.8
BASOS-0.3
[**2131-10-30**] 11:14PM GLUCOSE-163* LACTATE-1.5 NA+-130* K+-3.2*
CL--82*
[**2131-10-30**] 11:14PM TYPE-ART PO2-84* PCO2-49* PH-7.51* TOTAL
CO2-40* BASE XS-13
[**2131-10-30**] 10:58PM ALT(SGPT)-22 AST(SGOT)-25 LD(LDH)-331*
CK(CPK)-61 ALK PHOS-115 TOT BILI-0.5
[**2131-10-30**] 10:58PM PT-19.5* PTT-29.3 INR(PT)-1.8*
[**2131-11-7**] 05:45AM BLOOD WBC-8.6 RBC-4.18* Hgb-12.7 Hct-38.9
MCV-93 MCH-30.4 MCHC-32.6 RDW-16.6* Plt Ct-365
[**2131-11-5**] 01:43PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.012
.
[**2131-11-5**] 1:43 pm URINE Source: Catheter.
**FINAL REPORT [**2131-11-7**]**
URINE CULTURE (Final [**2131-11-7**]):
PROTEUS MIRABILIS. 10,000-100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
RADIOLOGY Preliminary Report
.
SHOULDER [**12-23**] VIEWS NON TRAUMA RIGHT [**2131-11-6**] 7:33 PM
.
SHOULDER [**12-23**] VIEWS NON TRAUMA
.
Reason: Please evaluate r-shoulder for pathology, interval
change.
.
[**Hospital 93**] MEDICAL CONDITION:
78 year old woman with diastolic HF, DM, HTN, c/o shoulder pain
with abduction. History of shoulder mass on [**2128**] imaging.
REASON FOR THIS EXAMINATION:
Please evaluate r-shoulder for pathology, interval change.
RIGHT SHOULDER, THREE VIEWS, [**2131-11-6**]
.
CLINICAL INFORMATION: Shoulder pain with abduction, history of
shoulder mass in [**2128**].
COMPARISON STUDY: [**2129-5-20**].
FINDINGS:
Since the prior study, there is marked interval narrowing of the
acromiohumeral distance and the humerus is high riding and now
articulates with the acromion, consistent with chronic rotator
cuff tear. There are marked degenerative changes at the
glenohumeral joint and the acromioclavicular joint. There are
large osteophytes arising from the femoral head. There are also
marked degenerative changes at the acromioclavicular joint.
IMPRESSION:
1. Chronic rotator cuff tear.
2. Degenerative changes at the acromioclavicular joint and
glenohumeral joint.
.
RADIOLOGY Final Report
.
CT HEAD W/O CONTRAST [**2131-11-5**] 9:35 AM
.
CT HEAD W/O CONTRAST
.
Reason: assess for interval change or development of new infarct
.
[**Hospital 93**] MEDICAL CONDITION:
78 year old woman with dCHF, PAF, DM, p/w DKA and now with
persistant AMS and leukocytosis despite negative w/u thus far
REASON FOR THIS EXAMINATION:
assess for interval change or development of new infarct
CONTRAINDICATIONS for IV CONTRAST: None.
.
INDICATION: CHF, PAF, DM, presenting with DKA and now with
persistent altered mental status and leukocytosis, despite
negative workup. Query interval change or development of new
infarct.
.
COMPARISON: [**2131-11-1**].
.
TECHNIQUE: Contiguous axial images were obtained through the
brain. No contrast was administered.
.
FINDINGS: The study is degraded by motion. No evidence of
hemorrhage or infarction. Ventricles are stable in size and
configuration. There is no shift of normally midline structures.
Again seen is left scleral band. The left lens has been
surgically removed. The paranasal sinuses and mastoid air cells
appear clear.
.
IMPRESSION: No impression of infarction, hemorrhage, mass
effect, or infection.
.
Neurophysiology Report EEG Study Date of [**2131-11-4**]
OBJECT: 78 YEAR OLD WITH ALTERED MENTAL STATUS; EVALUATE FOR
SEIZURES.
REFERRING DOCTOR: DR. [**First Name (STitle) **] [**Month (only) **]
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 43501**] [**Doctor Last Name 40719**]
.
FINDINGS:
ABNORMALITY #1: The background was slow, typically in the 7 Hz
frequency range, and was admixed with bursts of moderate
amplitude mixed
theta and delta frequency slowing in a generalized distribution.
BACKGROUND: As above.
HYPERVENTILATION: Could not be performed as this was a portable
study.
INTERMITTENT PHOTIC STIMULATION: Could not be performed as this
was a
portable study.
SLEEP: The patient progressed from the waking to drowsy state
but did
not attain stage II of sleep.
CARDIAC MONITOR: Showed a generally regular rhythm, although
with
varying QRS morphologies.
IMPRESSION: This is an abnormal portable EEG in the waking and
drowsy
states due to the slow background and admixed bursts of
generalized
mixed frequency slowing, consistent with a mild encephalopathy.
This
suggests dysfunction of bilateral subcortical or deep midline
structures. Medications, metabolic disturbances, and infections
are
among the common causes of encephalopathy. There were no
prominent
areas of focal slowing, although encephalopathic patterns can
sometimes
obscure focal findings. There were no epileptiform features.
There
were no electrographic seizures.
.
RADIOLOGY Final Report
L-SPINE (AP & LAT) [**2131-11-2**] 4:41 PM
.
L-SPINE (AP & LAT)
.
Reason: Please evaluate for interval change, evidence of occult
infe
.
[**Hospital 93**] MEDICAL CONDITION:
78 year old woman with DM, HTN, diastolic CHF, hypertrophic
obstructive cardiomyopathy, w/ prior posterior lumbar
decompression fusion surgery in summer of [**2130**] now a/w lethargy,
hyperglycemia.
REASON FOR THIS EXAMINATION:
Please evaluate for interval change, evidence of occult
infection.
L-SPINE ON [**11-2**]
.
HISTORY: Status post decompression, fusion surgery, now with
lethargy, question infection.
.
FINDINGS: There is diffuse osteopenia which somewhat limits this
examination. There is no significant interval change in the
alignment. If infection is of concern, this would be better
assessed with another imaging modality. There are multiple
nondilated loops of small and large bowel with gas and stool
seen throughout the colon. There is one prominent loop of bowel
in the right lower quadrant that measures up to 7 cm in
diameter, presumed to be cecum.
Brief Hospital Course:
Summary: 78yF with dCHF, DM, HTN, afib s/p PPM presents with
waxing/[**Doctor Last Name 688**] mental status, elevated blood sugars, and
dehydration.
.
#) Altered Mental Status: On admission patient was delerious.
Broad work-up was undertaken for toxic metabolic infectious
causes. Delerium steadily improved with resolution of her renal
failure. Blood cultures showed no evidence of infection and
only positive result deemed to be a contaminant. Urine was w/o
active infection. Neuro consult recommended head CT that showed
no acute intracranial processes, and EEG that demonstrated mild
encephalopathy and no eplieptiform discharges. Mental status
steadily cleared throughout her hospitalization with resolution
of her renal failure and metabolic derrangements. At discharge,
her mentation was near her baseline per her family, mostly
oriented to place and time, with mild inattention, cooperative,
appropriate. Will need to monitor mental status as she
continues to improve.
.
#) Hypoxia: Patient developed pulmonary edema in ICU in setting
of aggressive fluid hydration. Diuretics had been held on admit
due to concern for volume depletion/dehydration. However, as
her renal failure improved, her diuretics were added slowly,
first with Lasix 40-80mg. Her torsemide was restarted at 100mg
daily just before discharge. Her fluid status will require
monitoring, and as she can tolerate her torsemide can be
increased to her pre-hospitalization dose of 200mg, and her
aldactone restarted.
.
#) Hyperglycemia/Diabetes. Hyperglycemia improved with fluids,
though pt has continued to have elevated finger sticks. Glycemic
control improved with titration of insulin administration; the
patient was continued on home glipizide [**Hospital1 **]. She is also on
lantus and short acting insulin. She will need fingersticks and
monitoring of her sugars.
.
#) Bacteremia: On [**11-2**] one blood culture grew GPC. She was
empirically started on vancomycin. Echo was unremarkable for
infection. She remained afebrile with no localizing signs of
infection. Repeat cultures were no growth to date. Her culture
returned positive for coag negative staph. It was felt that
this was a contaminate and her vancomycin was stopped. She
remained clinically stable. Her follow up blood cultures were
negative at discharge and will need to be followed up to
finalization.
.
#) Leukocytosis: The patient had a leukocytosis during
admission, though no obvious infection. As her encephalopathy
and renal function improved, her leukocytosis improved. Culture
were unremarkable, except for an equivocal urine culture with
negative UA and no symptoms. Prior to discharge her white count
normalized. Would recommend observing her clinically for any
change.
.
#) Acute renal failure (baseline 1.1-1.4). Pt with mild ARF at
admission; her creatinine quickly trended back to baseline. This
was thought to most likely be due to volume depletion. A Foley
was placed temporarily; the patient consistently had good urine
outpt, foley was discontinued on the floor but had to be
replaced x1 for failed voiding trial. Repeat voiding trial
successful and patient w/o foley. Her renal function steadily
improved to baseline prior to discharge. Her diuretics were
restarted slowly at discharge
.
#) Diastolic congestive heart failure. The patient's oxygenation
remained adequate; she was without signs of overt failure on
exam. Her beta [**Month/Year (2) 7005**], calcium channel [**Month/Year (2) 7005**], metolazone,
torsemide and spironolactone were held in the setting of low
blood pressure at the time of admission. However, as she
improved her beta [**Last Name (LF) 7005**], [**First Name3 (LF) **], and torsemide (lower dose) were
added. She remained clinically stable thereafter. At
discharge, her calcium channel [**First Name3 (LF) 7005**] and aldactone were still
held, but can restarted as her blood pressure can tolerate. She
is to see Dr. [**First Name (STitle) 437**] in follow up in [**Month (only) 404**].
.
#) Hypertension. Anti-hypertensives held on admit. Restarted on
metoprolol 12.5 [**Hospital1 **] with resolution of her hypotension.
Diltiazem held and would recommend considering restart on
discharge.
.
#) Atrial Fibrillation: Remained in afib during
hospitalization. Warfarin was initally held due to possible LP.
However, when her mental status improved her warfarin was
restarted. Goal INR [**12-23**]. She will need frequent INR checks
until she is therapeutic. She is followed at the [**Hospital 191**]
[**Hospital3 **] at [**Hospital1 18**].
.
#) Lumbar Surgery: Her exam remained stable. Xrays were
relatively unremarkable. Questioned whether she could have had
an occult infection from the site, though her symptoms improved
without intervention. Will benefit from PT/OT and ortho follow
up as appropriate.
.
#) Code: FULL code for this admission. Has close family
support. Daughter is health care proxy.
Medications on Admission:
[**Hospital1 **] 81mg daily
Diltiazem 30mg TID
Aldactone 25mg daily
Torsemide 200mg daily
Toprol XL 12.5mg daily
Metolazone 2.5mg PO 30min prior to AM meds (Tues/Thurs/Sat)
Simvastatin 10mg daily
Coumadin 4mg daily (6mg on Monday)
Glipizide 5mg [**Hospital1 **]
Lantus 20-25U QAM (20U if FS < 120)
Regular Insulin 5U dinner, 5U bedtime
Ambien 5mg PO
Neurontin 300mg TID
Allopurinol 300mg
Paxil 20mg daily
Xalatan 0.005 1 drop right eye
Alphagem 0.2% 1 drop both eyes
Colace 100mg [**Hospital1 **]
Senna 1 tab [**Hospital1 **]
Ferrous sulfate 325mg daily
Lactulose 15mL PRN
Tylenol PRN
Pulmacort PRN
Albuterol PRN
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily).
3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO QHS (once a day
(at bedtime)): 6mg on Monday, 4mg every other day.
5. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Insulin Glargine 100 unit/mL Solution Sig: Thirty Two (32)
qAM Subcutaneous once a day.
7. Insulin Regular Human 100 unit/mL Solution Sig: Five (5)
units Injection twice a day: qdinner and qbed.
8. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
9. Torsemide 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
12. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed.
13. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
16. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
17. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
18. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
19. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
20. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
21. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
22. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
23. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Acute Renal Failure
Hypertension
Diastolic Heart Failure
Hypertrophic Obstructive Cardiomyopathy
Atrial Fibrillation s/p Permanent Pacemaker
Discharge Condition:
Hemodynamically stable
Discharge Instructions:
You were admitted to the hospital for evaluation of confusion
and lethargy. On admission, it was found that your kidneys were
not functioning as well as they normally would. You were given
IV fluids and your kidney function improved. Your confusion was
likely caused by the metabolic changes related to your decreased
kidney function. We also made some changes to your home
medications.
.
Please continue to take all medications as directed upon leaving
the hospital. Please call your doctor or return to the hospital
if you exerpience any sudden chest pain, shortness of breath,
increasing LE swelling, or any other complaint concerning to
you.
.
You have scheduled follow up appointments with your PCP [**Last Name (NamePattern4) **].
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 216**] as well as your cardiologist Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**]. It
is important that you keep these appointments.
.
It has been a pleasure caring for you in the hospital.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2131-12-11**]
1:40
.
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2131-12-17**]
2:00
.
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 3512**] Date/Time:[**2131-12-17**]
2:30
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 684**]
|
[
"428.0",
"V58.61",
"372.30",
"348.30",
"V45.01",
"276.52",
"250.12",
"041.6",
"427.31",
"599.0",
"585.9",
"403.90",
"428.32",
"274.9",
"584.9",
"788.20",
"425.1"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
17617, 17683
|
9975, 10138
|
308, 314
|
17868, 17893
|
3307, 5250
|
18966, 19462
|
2741, 2826
|
15583, 17594
|
9080, 9280
|
17704, 17847
|
14946, 15560
|
17917, 18943
|
2841, 3288
|
232, 270
|
9309, 9952
|
342, 1861
|
10153, 14920
|
1883, 2454
|
2470, 2725
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,660
| 176,919
|
6026
|
Discharge summary
|
report
|
Admission Date: [**2118-3-30**] Discharge Date: [**2118-4-9**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1148**]
Chief Complaint:
Aspiration pneumonia
Sepsis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Age over 90 **]f with recent pna, hypothyroidism, VVI pacer for bradycardia
and AV block awoke on morning of admit with dyspnea. She'd been
increasingly dyspneic over the past 2-3d before admit. She'd had
no chest discomfort, f/c, or significant cough. In the ED, she
was found to have a WBC of 16.8 with 7%bands so was treated with
levofloxacin; her o2 sat was 87% on ra in ED but rebound to 99%
on 2L-nc. She was found to have 4+ bilateral lower extremity
edema. Chest xray in ED was unchanged from prior with densely
calcified pleura due to fibrothorax. She had one meausre of O2
sat of 99% on 2 L. Her BNP in the ED was found to be 5455 (last
BNP was >6000). She was noted to have elevated WBC of 16 with 7
bands and was given dose of levofloxacin. She was HD stable in
the ED however her UOP has been none to minimal. She was given
dose of dexamethasone in the ED for concern of adrenal
insufficiency.
.
She was admitted to the [**Hospital Unit Name 153**] where she received ceftriaxone and
azithromycin and remained stable throughout the day, so was sent
to the floor. Here, she is frustrated over being ill and having
to be in the hospital, so she'd answer few questions, though
denies pain but does say she remains dyspneic.
.
Patient was recently admitted for SOB and weakness in [**1-16**] and
felt dyspnea could be secondary to PNA. Patient did have CT
chest on prior admission that showed pleural calcifications. At
that admission patient was noted to have B/L LE edema with
negative LENI and felt edema secondary to low albumin.
.
She was doing well on the wards until [**4-2**] when she began to be
hypothermic. Though she had been hypothermic in the ICU with
temperatures in the 95 range, she was more so on the floor with
temps in the 93 axillary range with as low as 91. The team
changed her abx from levoquin to vanc/zosyn for broader coverage
on [**4-2**]. She was also given increased lasix on [**4-2**] (recieved 10
PO and 20 IV at noon). Attempts to warm her were unsuccessful.
Approximately 9:30 PM on [**4-2**], she began to become hypotensive
as well with systolics in the 70's. She was given normal saline
boluses 250 x2 with minimal effect and transferred to the ICU.
Past Medical History:
1. Hospitalized 4 years ago for atypical chest pain, no MI
2. Hypothyroidism
3. Anemia, iron deficient
4. VVI Pacemaker [**2116**], for bradycardia and AV block
5. Query seizure disorder
6. s/p pneumothorax after pacemaker.
7. h/o falls
8. recent admission for pna
Social History:
The patient previously owned a flower store in [**Location (un) 669**]. She
lives in [**Location (un) 9226**] [**Hospital3 **] facility. She was
never married, though has a niece and nephew in the area who are
primary supports. She denies tobacco, ETOH, drugs. Her nephew is
her HCP.
Family History:
Non-contributory
Physical Exam:
PE: t 96.7, bp 130/60, hr 76, rr 16, spo2 96%2l
Pt defers exam
Appears non-tox, in NAD
Breathing without accessory muscle use
Neurologically, she can tell me she's at [**Hospital1 **]-hospital, just came
up from the [**Location (un) **] and that she was in an ICU, and that it's
[**2118**]; she's moving all extrm.
Pertinent Results:
[**2118-3-30**] CXR: Overall unchanged appearance of the chest with
densely calcified pleura due to fibrothorax and right upper lobe
pleural-based density. Evaluation of lung parenchyma is somewhat
limited.
.
[**2118-3-30**] ECG:
Technically difficult study
Ventricular pacing
Pacemaker rhythm - no further analysis
Probable dissociated atrial rhythm, rate 60-70 bpm
Since previous tracing, no significant change
.
[**2118-4-2**] CXR: The patient's head is slumped over resulting in
obscuration of the bilateral apices, right worse than left.
There is also significant rotation. The position of her chin
obscures the previously noted pleural-based entity in the right
apex. Of the visualized lung, most of it is obscured by the
underlying fibrothorax previously described. The aerated left
upper lung is clear.
IMPRESSION: Nearly nondiagnostic examination secondary to
multiple limitations detailed above.
.
[**2118-4-3**] CT CHEST: 1. No pulmonary embolism.
2. Extensive diffuse bilateral calcified pleural plaques and
pleural thickening/loculated pleural fluid causes marked volume
loss of both lungs, right greater than left. Again this is
consistent with exposure. There is some concern for underlying
pleural malignancy with evaluation for enhancing pleural mass
limited by the very early timing of IV contrast.
3. Increase in loculated pleural fluid of the medial right lower
chest and mildly so elsewhere.
4. Multifocal opacities of both lungs are probably mostly due to
scarring and atelectasis, slightly increased. Underlying lung
parenchymal infection cannot be excluded.
5. Moderate hiatal hernia.
.
[**2118-3-30**] 04:00AM WBC-16.8*# RBC-3.26* HGB-9.0* HCT-28.2*
MCV-87 MCH-27.8 MCHC-32.0 RDW-18.0*
[**2118-3-30**] 04:00AM NEUTS-72* BANDS-7* LYMPHS-11* MONOS-7 EOS-0
BASOS-0 ATYPS-3* METAS-0 MYELOS-0
[**2118-3-30**] 04:03AM GLUCOSE-148* LACTATE-1.3 K+-6.2*
[**2118-3-30**] 05:30AM ALBUMIN-3.1* CALCIUM-9.2 PHOSPHATE-4.1
MAGNESIUM-2.4
[**2118-3-30**] 05:30AM GLUCOSE-138* UREA N-24* CREAT-0.8 SODIUM-126*
POTASSIUM-5.3* CHLORIDE-93* TOTAL CO2-28 ANION GAP-10
[**2118-4-4**] 04:13AM BLOOD WBC-5.4 RBC-3.14* Hgb-8.8*# Hct-27.0*
MCV-86 MCH-28.0 MCHC-32.5 RDW-18.1* Plt Ct-233
[**2118-4-4**] 04:13AM BLOOD Plt Ct-233
[**2118-4-4**] 04:13AM BLOOD Glucose-87 UreaN-19 Creat-0.8 Na-139
K-3.8 Cl-105 HCO3-27 AnGap-11
[**2118-4-4**] 04:13AM BLOOD Calcium-8.8 Phos-3.2 Mg-2.2
Brief Hospital Course:
[**Age over 90 **] y/o female admitted for shortness of breath.
Hospitalization complicated by need for ICU care for hypothermia
and sepsis. Sepsis believed secondary to chronic aspiration
leading to pneumonia. Covered broadly for this. With advanced
age discussions had with patient and family of overall goals of
care. All agreed that patient would not want prolonging
measures. Patient stabilized in ICU with volume resucitation
but decision made not to transfer back to ICU if again became
sick. Day after transfer to floor patient again hypothermic.
Further discussions agreed to make patient CMO. Patient made
comfortable, visited by family. Slowly blood pressure trended
down; antibiotics and other medications stopped and patient
given oral and IV morphine in low dose prn. Died peacefully of
cardiac arrest.
Medications on Admission:
Levothyroxine 150 mcg PO DAILY
Ferrous Sulfate 325 PO DAILY
Latanoprost 0.005 % Drops Ophthalmic HS
Dorzolamide-Timolol 2-0.5 % Drops One QAM
Brimonidine 0.15 % Drops Ophthalmic [**Hospital1 **]
Levetiracetam 250 mg One PO QHS
Ibuprofen 400 mg One PO Q8H prn
Aspirin 81 mg One PO DAILY (Daily).
Lasix 10 mg PO once a day
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
aspiration pneumonia, sepsis
Discharge Condition:
Dead
Discharge Instructions:
Diet: Speech/swallow recommending soft solid po diet texture
with thin liquids. Po meds to be given either whole or crushed
in purees, as tolerated.
Followup Instructions:
None
|
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icd9cm
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[
[
[]
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[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,354
| 144,830
|
48141
|
Discharge summary
|
report
|
Admission Date: [**2112-1-14**] Discharge Date: [**2112-1-21**]
Date of Birth: [**2055-3-4**] Sex: M
Service: MEDICINE
Allergies:
Percocet / Percodan
Attending:[**Doctor First Name 7926**]
Chief Complaint:
CHF exacerbation
Major Surgical or Invasive Procedure:
[**Hospital1 **]-ventricular pacemaker placement
History of Present Illness:
56-year-old man with idiopathic dilated cardiomyopathy (EF 20%)
s/p ICD, CAD s/p post stenting of the LAD and RCA, and pAF w/ a
recent L femoral artery injury during an afib ablation procedure
(aborted for emergency vascular surgery), who presents with
worsening dyspnea, orthopnea. The patient is currently on
dofetilide 2.5mg daily, but has remained in atrial fibrillation.
His atrial fibrillation has been accompanied by progressive CHF
exacerbations, marked by paroxysmal nocturnal dyspnea, orthopnea
(1-> 2 pillows), and lower extremity edema. The patient's afib
has slow ventricular response causing him to be V-paced. The
patient has been cardioverted many times, last [**1-8**], without
effect.
.
The patient currently denies shortness of breath, cough, wheeze,
chest pain, palpitations. Last episode of PND last night. He
feels that his lower extremity edema has been progressive over
the past month. He continues to have an open left lower
extremity wound that has been weeping profusely with increase in
edema. Wound recently s/p dermabond and suturing by vascular
surgery.
.
REVIEW OF SYSTEMS
Patient states that he is always cold. Denies any prior history
of stroke, TIA, deep venous thrombosis, pulmonary embolism,
bleeding at the time of surgery, myalgias, cough, hemoptysis,
black stools or red stools. He denies recent fevers or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is positive for paroxysmal nocturnal
dyspnea, orthopnea, dyspnea on exertion, and ankle edema. It is
notable for absence of chest pain, palpitations, syncope or
presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: BMS to LAD, multiple BMS
to RCA in [**2100**]; [**2101**] ISRS of RCA and proximal RCA stent; [**2104**]
DES x2 to proximal and distal RCA
-PACING/ICD: [**Company 1543**] ICD (EF 15%)
3. OTHER PAST MEDICAL HISTORY:
1. Symptomatic atrial fibrillation
2. CAD s/p multiple PCIs
3. Dilated cardiomyopathy s/p ICD (EF 15%)
4. Hypertension
5. Hyperlipidemia
6. Melanoma ([**Doctor Last Name **] level IV) s/p resection
Social History:
lives with wife and son.
-Tobacco history: 40 pack years (quit 15 years ago)
-ETOH: Sober for 16 years
-Illicit drugs: Recreational cocaine and marijuana (distant,
none recently)
Family History:
Mom: Died at 88, cause unknown
Dad: Died at 77, CHF
Sibs: 2 brothers, 1 with dilated CMP
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Admission Physical Exam:
VS: T98 BP 101/62 HR 81 RR 18 O2 sat 96% RA Weight 91.8 kg
GENERAL: WDWN man in NAD laying comfortably in bed. 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 to angle of jaw.
CARDIAC: RR, normal S1, S2. [**3-22**] crescendo/decrescendo systolic
murmur. No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
unlabored, no accessory muscle use. Bibasilar crackles; no
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No femoral bruits. Left leg incision healing well,
separate wound covered by clean, dry bandage. 2+ edema to knee
SKIN: No ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 1+ PT 2+
Left: Carotid 2+ DP 1+ PT 2+
.
Discharge Physical Exam:
VS: 97.4 96/61 81 16 95%RA
Weight: 85.1 kg
GENERAL: Laying comfortably in bed in NAD; alert and oriented x
3
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple with JVP to angle of jaw
CARDIAC: RR, normal S1, S2. 3/6 systolic murmur. No thrills,
lifts. No S3 or S4.
LUNGS: bibasilar crackles; no wheezes or rhonchi
ABDOMEN: Soft, NTND. No HSM or tenderness.
SKIN: Mild amount of erythema surrounding site of pacemaker
placement; mildly tender to palpation
EXTREMITIES: non-edematous
PULSES:
Right: Carotid 2+ DP 1+ PT 2+
Left: Carotid 2+ DP 1+ PT 2+
Pertinent Results:
Admission labs:
[**2112-1-14**] 07:00PM BLOOD WBC-10.0 RBC-3.20* Hgb-9.9* Hct-30.3*
MCV-95# MCH-31.0 MCHC-32.7 RDW-17.3* Plt Ct-220
[**2112-1-14**] 07:00PM BLOOD PT-13.4* PTT-40.1* INR(PT)-1.2*
[**2112-1-14**] 07:00PM BLOOD Glucose-145* UreaN-72* Creat-1.5* Na-126*
K-3.4 Cl-84* HCO3-29 AnGap-16
[**2112-1-14**] 07:00PM BLOOD CK(CPK)-62
[**2112-1-14**] 07:00PM BLOOD CK-MB-4 cTropnT-0.02*
[**2112-1-14**] 07:00PM BLOOD Calcium-8.9 Phos-3.8 Mg-2.4
.
Chemistry trend:
[**2112-1-14**] 07:00PM BLOOD Glucose-145* UreaN-72* Creat-1.5* Na-126*
K-3.4 Cl-84* HCO3-29 AnGap-16
[**2112-1-15**] 06:10AM BLOOD Glucose-104* UreaN-75* Creat-1.5* Na-128*
K-3.1* Cl-90* HCO3-31 AnGap-10
[**2112-1-15**] 04:02PM BLOOD Glucose-108* UreaN-71* Creat-1.5* Na-129*
K-2.9* Cl-93* HCO3-26 AnGap-13
[**2112-1-16**] 12:16AM BLOOD Glucose-122* UreaN-66* Creat-1.4* Na-130*
K-3.4 Cl-91* HCO3-30 AnGap-12
[**2112-1-17**] 06:14AM BLOOD Glucose-111* UreaN-68* Creat-2.0* Na-120*
K-6.0* Cl-87* HCO3-27 AnGap-12
[**2112-1-17**] 08:50AM BLOOD Glucose-111* UreaN-69* Creat-2.0* Na-120*
K-5.9* Cl-86* HCO3-24 AnGap-16
[**2112-1-17**] 04:54PM BLOOD Glucose-125* UreaN-70* Creat-2.1*#
Na-120* K-5.9* Cl-88* HCO3-21* AnGap-17
[**2112-1-18**] 06:20AM BLOOD Glucose-98 UreaN-74* Creat-2.1* Na-121*
K-5.4* Cl-85* HCO3-27 AnGap-14
[**2112-1-18**] 12:35PM BLOOD Glucose-124* UreaN-74* Creat-2.1* Na-123*
K-5.0 Cl-86* HCO3-27 AnGap-15
[**2112-1-18**] 09:30PM BLOOD Glucose-106* UreaN-73* Creat-1.9* Na-127*
K-3.3 Cl-86* HCO3-28 AnGap-16
[**2112-1-19**] 06:00AM BLOOD Glucose-111* UreaN-72* Creat-1.8* Na-130*
K-3.4 Cl-88* HCO3-32 AnGap-13
[**2112-1-20**] 06:15AM BLOOD Glucose-141* UreaN-62* Creat-1.6* Na-133
K-3.6 Cl-93* HCO3-29 AnGap-15
[**2112-1-20**] 06:00PM BLOOD Glucose-123* UreaN-61* Creat-1.6* Na-129*
K-4.1 Cl-89* HCO3-29 AnGap-15
[**2112-1-21**] 06:00AM BLOOD Glucose-101* UreaN-60* Creat-1.6* Na-129*
K-3.3 Cl-86* HCO3-28 AnGap-18
.
Discharge Labs:
[**2112-1-21**] 06:00AM BLOOD WBC-10.0 RBC-3.05* Hgb-9.2* Hct-29.2*
MCV-96 MCH-30.0 MCHC-31.4 RDW-17.7* Plt Ct-243
[**2112-1-21**] 06:00AM BLOOD Glucose-101* UreaN-60* Creat-1.6* Na-129*
K-3.3 Cl-86* HCO3-28 AnGap-18
[**2112-1-20**] 06:15AM BLOOD ALT-130* AST-125* AlkPhos-76 TotBili-1.0
[**2112-1-21**] 06:00AM BLOOD Calcium-9.3 Phos-3.0 Mg-2.1
.
Other lab data:
[**2112-1-18**] 09:30PM BLOOD TSH-10*
[**2112-1-19**] 04:30PM BLOOD Free T4-1.0
[**2112-1-18**] 06:20AM BLOOD Cortsol-29.7*
[**2112-1-18**] 06:20AM BLOOD Digoxin-4.0*
[**2112-1-20**] 06:15AM BLOOD Digoxin-2.1*
.
Chest PA/Lat [**2112-1-16**]: Previous dense consolidation in the left
lower lobe has improved since early [**Month (only) 1096**]. Presumably this
was atelectasis. Small bilateral pleural effusions remain, and
there is still pulmonary vascular engorgement but no clear
pulmonary edema. The new transvenous left ventricular pacer lead
ends high along the lateral wall of the left ventricle close to
the projection of the interventricular septum. Two transvenous
right ventricular pacer defibrillator leads and a right atrial
pacer lead are all unchanged in their respective positions.
There is no pneumothorax or mediastinal widening to indicate any
complication.
.
ECHO [**2112-1-18**]: Severely dilated left ventricle with severely
depressed global left ventricular systolic function. Dilated,
mildly hypokinetic right ventricle. Mildly dilated ascending
aorta. Mild aortic regurgitation. Moderate to severe mitral
regurgitation. Moderate to severe tricuspid regurgitation.
Moderate pulmonary artery systolic hypertension. Diastolic
pulmonary hypertension.
.
Compared with the prior study (images reviewed) of [**2109-9-30**],
the left ventricular ejection fraction has decreased from 20-25%
to 15-20%. The right ventricle is now dilated and mildly
hypokinetic. The severity of tricuspid regurgitation has
increased to moderate to severe (previously mild). The severity
of mitral regurgitation has increased to moderate to severe
(previously mild to moderate).
.
CXR [**2112-1-18**]: The lungs are hyperinflated and the diaphragms are
flattened, consistent with COPD. Again seen is a left-sided
pacer device with multiple leads, grossly unchanged. There is
moderate cardiomegaly with left ventricular configuration. There
is upper zone redistribution and mild vascular blurring, also
unchanged. There is minimal blunting of the right costophrenic
angle, consistent with a small right effusion. There is probably
also a small effusion posteriorly. Increased density projecting
posteriorly on the lateral view, likely lies within the left
lower lobe and is unchanged. There is minimal right greater than
left [**Hospital1 **]-apical pleural thickening and old healed left-sided rib
fractures.
.
IMPRESSION:
1. COPD.
2. Cardiomegaly, with probable mild CHF.
3. Left lower lobe consolidation and small bilateral effusions,
essentially
unchanged.
Brief Hospital Course:
56-year-old man with dilated cardiomyopathy w/ EF 20% s/p ICD,
CAD s/p post stenting of the LAD and RCA, and pAF s/p multiple
cardioversions (last [**1-8**]) on dofetilide admitted for worsening
CHF; course complicated by hypervolemic hyponatremia.
.
# ACUTE ON CHRONIC CHF: Patient with progressive peripheral
edema, DOE, and episodes of PND and orthopnea over the past
month, related to dissynchrony from pacer. He was admitted for
worsening CHF and for upgrade of his single-lead pacer to a [**Hospital1 **]-V
pacer. On admission, patient was diuresed with a lasix drip at
5cc/hr with UOP 100+cc/hr. He had a biventricular pacemaker
placed on Friday ([**2112-1-15**]). Lasix drip was stopped following
marked improvement in volume status, and the patient was
transitioned to torsemide by mouth. 24 hrs after cessation of
lasix drip, the patient's ins and outs remained even, but he
became increasingly volume overloaded with predominantly
right-sided symptoms, and acutely worsening hyponatremia from
130 to 120. He was restarted on a lasix drip that was titrated
up to 12cc/hr with less responsive urine output (50-70cc/hr).
In addition, the patient was resumed on his home metolazone.
The patient underwent transthoracic ECHO that demonstrated
worsening of his cardiomyopathy (EF ~ 15%) with severe TR and
likely worsening of his MR ([**2-19**]+). He was transferred to the
CCU for possible augmentation of diuresis. In the CCU, the
patient began to diurese well with a lasix drip at 15cc/hr. He
was transferred to the floor. He diuresed to euvolemia, and was
transitioned to lasix 120 mg PO BID. The patient was discharged
to home. He will follow up with Dr. [**Last Name (STitle) 1911**] on [**2112-1-25**].
During admission, ramipril held for acute kidney injury and
eplerenone held for hyperkalemia. The patient was continued on
ASA, atorvastatin, clopidogrel, carvidilol, dabigatran.
Eplerenone was also resumed prior to discharge.
.
# PAROXYSMAL ATRIAL FIBRILLATION: Patient has a history of
paroxysmal atrial fibrillation with slow ventricular response
s/p single-lead pacemaker placement in [**2104**]. The patient is on
dofetilide, but has continued to be in atrial fibrillation. On
admission, the patient was in a V-paced rhythm at 80 BPM. He
was upgraded to a biventricular pacer to increase ventricular
synchrony. The patient was treated with IV vancomycin x 2 days,
and then transitioned to PO keflex x 5 days to complete 1 week
course s/p pacemaker placement. Digoxin was held for a
supratherapeutic level in the setting of acute kidney injury.
.
# HYPONATREMIA: The patient was admitted with a sodium of 126
(baseline approx. 130), likely due to hypervolemic hyponatremia
from CHF. Sodium improved to 130 with diuresis on a lasix drip.
24 hours following cessation of the lasix drip, the patient's
sodium acutely decreased from 130 to 120. The patient was seen
by nephrology, who confirmed the etiology of acute decline as
hypervolemic hyponatremia. Lasix drip was restarted, the
patient was placed on a strict free-water restriction, and
sodium began to slowly improve. At the time of discharge,
sodium had returned to baseline of 129. The patient will follow
up with his primary care physician for [**Name Initial (PRE) **] sodium check.
.
# ACUTE KIDNEY INJURY: On admission, the patient had acute
kidney injury associated with poor forward flow from fluid
overload. Creatinine worsened to 2.1 during admission, and
improved to 1.6 on discharge with diuresis. Medications were
renally dosed in the setting of [**Last Name (un) **]. Ramipril was held due to
[**Last Name (un) **]. Digoxin was also held, as it became supratherapeutic in
the setting of [**Last Name (un) **]. The patient will follow up with his PCP on
discharge for a creatinine check.
.
# LEUKOCYTOSIS: Patient with progressive leukocytosis during
admission. Had mild cough, without further infectious symptoms.
No fevers, chills. Urinalysis without evidence of UTI. Blood
cultures negative. Leukocytosis resolved without intervention.
.
# CORONARY ARTERY DISEASE: Patient s/p multiple interventions
to LAD and RCA. Last [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 2 to RCA in [**2104**]. Last cath in [**2110**]
with patent stents, but 60-70% stenosis in mid RCA. He was
continued on ASA, atorvastatin, clopidogrel, dabigitran
throughout admission.
.
# HYPOTHYROIDISM: Chronic. The patient was continued on home
levothyroxine. Upon worsening of his heart failure, the patient
was found to have a TSH of 10; Free T4 1.0. No dose adjustments
were made to the patient's levothyroxine given acute illness.
The patient should follow up with his primary care physician for
repeat TSH check following discharge.
.
# ANXIETY/INSOMNIA: Chronic. The patient was continued on home
oxazepam. Ambien was held during admission for possible mild
delirium on one occasion overnight. He was discharged on home
oxazepam and Ambien.
.
# LEFT THIGH WOUND: Wound has been present since vascular
surgery. Prior to admission, wound was adhesed with dermabond
and sutures. The patient was seen by vascular surgery on
admission, that felt the patient's wounds were healing well.
Sutures were removed prior to discharge.
.
# HX GOUT: Secondary to chronic diuretics. The patient did not
have an active gout flare during admission. He was continued on
allopurinol throughout admission. Dose was decreased to 150 mg
daily to adjust for acute kidney injury.
.
#CODE: full code
==================
TRANSITIONAL ISSUES
# Patient on levothyroxine with TSH 10 in setting of acute
illness. If persists as outpatient, may need higher dose of
levothyroxine (dose not changed as inpatient in setting of
illness)
# Ramipril was held at discharge for acute kidney injury. The
patient should discuss reinitiation of this medication with PCP
after BUN/Cr check.
# Digoxin was supratherapeutic during admission due to acute
kidney injury. It was held at discharge. The patient should
follow up with his cardiologist for a level check and
reinitiation of the medication.
Medications on Admission:
1. aspirin 81 mg daily
2. allopurinol 300 mg daily
3. digoxin 250 mcg daily
4. atorvastatin 60 mg daily
5. clopidogrel 75 mg daily
6. ezetimibe 10 mg daily
7. oxazepam 15 mg (patient states that he takes [**1-18**] tab at 4pm
and [**1-18**] tab at 10pm)
8. meclizine 12.5 mg PO Q12H PRN vertiginous symptoms
9. levothyroxine 50 mcg daily
10. dabigatran etexilate 150 mg PO BID
11. carvedilol 3.125 mg [**Hospital1 **]
12. tadalafil 5 mg Tablet once a day as needed.
13. omega-3 fatty acids 1,000 mg daily
14. [**Doctor First Name **] seed oil-omega 3-6-9 1,000(630-210- 72) mg daily
15. dofetilide 250 mcg [**Hospital1 **]
16. ramipril 2.5 mg PO daily
17. metolazone 5 mg every other day (usually MWF, but took today
(thurs [**1-14**])
18. eplerenone 25 mg daily
19. zolpidem 5 mg qHS PRN insomnia
20. furosemide 40 mg Tablet Sig: Take 3 pills in the morning and
2 pills in the evening.
21. potassium chloride 20 mEq daily
22. Keflex 250 mg PO QID
23. Miralax
24. Colace
Discharge Medications:
1. allopurinol 300 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
2. atorvastatin 40 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. oxazepam 15 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime) as needed for anxiety.
6. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. omega-3 fatty acids Capsule Sig: One (1) Capsule PO DAILY
(Daily).
8. dofetilide 125 mcg Capsule Sig: Two (2) Capsule PO Q12H
(every 12 hours).
9. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily).
12. eplerenone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
14. dabigatran etexilate 150 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
15. meclizine 12.5 mg Tablet Sig: One (1) Tablet PO twice a day
as needed for vertiginous symptoms.
16. tadalafil 5 mg Tablet Sig: One (1) Tablet PO once a day as
needed for activity .
17. [**Doctor First Name **] seed oil-omega 3-6-9 1,000(630-210- 72) mg Capsule Sig:
One (1) Capsule PO once a day.
18. metolazone 5 mg Tablet Sig: One (1) Tablet PO every other
day: M,W,F.
19. potassium chloride 20 mEq Packet Sig: One (1) PO once a
day.
20. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
21. Lasix 40 mg Tablet Sig: Three (3) Tablet PO twice a day.
Disp:*180 Tablet(s)* Refills:*0*
22. Keflex 500 mg Capsule Sig: One (1) Capsule PO twice a day
for 1.5 days.
Disp:*3 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: Acute on chronic systolic heart failure,
paroxysmal atrial fibrillation, hyponatremia
Secondary diagnosis: s/p biventricular pacemaker placement,
acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname **],
.
You were admitted to the hospital for worsening fluid overload
related to your atrial fibrillation. To help manage your fluid
overload, you were treated with a lasix drip. Your breathing
and leg swelling improved markedly. Your pacemaker was also
replaced with a [**Hospital1 **]-ventricular pacer to help the efficiency of
your heart. You did not have any immediate complications from
the procedure.
.
Your admission was complicated by worsening sodium that we
believe is due to fluid overload. Your sodium improved with
removal of fluid from your body and restricting your intake of
fluid. It is VERY IMPORTANT to restrict your daily fluid intake
to 1.2 liters or less. If you do not do this, your sodium could
drop, and you could experience complications such as seizures.
.
Your fluid overload also caused temporary injury to your
kidneys. At discharge, you should stop taking your ramipril and
digoxin because of your kidney function. You can likely resume
these medications in the near future. Please discuss
reinitiation of these medications with Dr. [**Last Name (STitle) 1911**]. You
should also decrease your allopurinol to 150 mg daily. Please
discuss increasing this medication with your primary care
physician.
.
Please continue to take your cardiac medications. Weigh
yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3
lbs.
.
Medications changed this admission:
INCREASE lasix to 120 mg by mouth twice a day
START keflex 500 mg by mouth twice a day (last day [**2112-1-22**])
STOP ramipril - Please discuss resuming this medication with Dr.
[**Last Name (STitle) 1911**] in the near future.
STOP digoxin - Please discuss resuming this medication with Dr.
[**Last Name (STitle) 1911**]
DECREASE allopurinol to 150 mg daily - Please discuss increasing
this medication with you primary care physician
Followup Instructions:
Department: CVI [**Location (un) **], [**Apartment Address(1) **]
When: [**Apartment Address(1) **] [**2112-1-25**] at 11:20 PM
With: [**Last Name (un) 1918**] [**Doctor Last Name **] [**Telephone/Fax (1) 11767**]
Building: [**Location (un) 20588**] ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
.
Name: RISK,[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Address: [**Location (un) 101484**], [**Hospital1 **],[**Numeric Identifier 89805**]
Phone: [**Telephone/Fax (1) 14358**]
When: Tuesday, [**2110-1-26**]:45 AM
|
[
"293.0",
"272.4",
"E879.0",
"V10.82",
"V45.82",
"428.0",
"585.3",
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"V53.32",
"276.1",
"244.9",
"425.4",
"300.00",
"427.31",
"276.7",
"428.23",
"403.90",
"327.23",
"584.9",
"564.09",
"998.83"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.51"
] |
icd9pcs
|
[
[
[]
]
] |
18373, 18379
|
9426, 15522
|
297, 348
|
18609, 18609
|
4562, 4562
|
20666, 21293
|
2806, 3010
|
16546, 18350
|
18400, 18400
|
15548, 16523
|
18760, 20643
|
6479, 9403
|
3050, 3954
|
2129, 2363
|
241, 259
|
376, 2035
|
18527, 18588
|
4578, 6463
|
18420, 18506
|
18624, 18736
|
2394, 2594
|
2057, 2109
|
2610, 2790
|
3979, 4543
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,692
| 183,895
|
3651
|
Discharge summary
|
report
|
Admission Date: [**2158-8-27**] Discharge Date: [**2158-8-29**]
Date of Birth: [**2097-1-26**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Iodine; Iodine Containing / Lipitor / Aspirin /
Zocor
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
cardiac catheterization s/p DES to RCA
History of Present Illness:
61 year old African-American female with a h/o CAD
s/p MI, s/p 1v CABG [**2157-5-31**], cholelithiasis, GERD,
hypertension,
type 2 diabetes mellitus who was in her usual state of health
until 4am today. She suddenly woke up with diffuse chest
pressure, shortness of breath, nausea, vomiting, and
diaphoresis. She says this pain is different from the pain that
she had with her previous MI. That was more L sided sharp pain,
where as this was more diffuse pressure.
.
Her husband immediately brought her to the [**Hospital1 18**] emergency
department. At 6:50am her vitals were T 97.2 HR 99 BP 119/71 RR
16 96% on RA. EKG showed ST elevations in leads II, III, aVF
with ST depressions in V2-V6. A Code STEMI was called. She
received full dose ASA, oxygen, plavix load, heparin bolus,
integrellin, morphine, and was started on a nitro gtt.
.
On review of systems, s/he denies any prior history of 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 paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.
.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, -Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-CABG: 1 vessel Saphenous vein graft to diagonal artery.
[**2157-5-31**]
-PERCUTANEOUS CORONARY INTERVENTIONS: See below
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
h/o atrial myxoma s/p surgical removal [**2157-5-31**]
GERD.
Chest pain syndrome
History of stroke with residual mild left-sided
hemiparesis and left facial tingling.
History of left breast cyst, status post excision which
was benign.
Status post hysterectomy and unilateral oophorectomy.
Statin-induced pancreatitis ([**3-31**])
Carpal Tunnel
Social History:
lives with husband, occasional tobacco use, no ETOH, no illicits
Family History:
Mother with DM, CAD (deceased)
3 brothers with DM
Physical Exam:
VS: BP=118/73 HR=95 RR=22 O2 sat= 98%
GENERAL: WDWN F 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 at clavicle.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No murmurs. 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: Warm well perfused. No LE edema. R groin, catheter
still in place. 3x3cm hematoma. Not tender to palpation. No
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:
[**2158-8-27**] 07:15AM BLOOD WBC-14.4*# RBC-5.37 Hgb-13.2 Hct-41.6
MCV-78* MCH-24.7* MCHC-31.8 RDW-14.6 Plt Ct-225
[**2158-8-27**] 07:15AM BLOOD PT-11.7 PTT-27.1 INR(PT)-1.0
[**2158-8-27**] 07:15AM BLOOD Glucose-318* UreaN-9 Creat-1.0 Na-139
K-3.5 Cl-101 HCO3-25 AnGap-17
[**2158-8-27**] 07:15AM BLOOD CK(CPK)-61
[**2158-8-27**] 04:32PM BLOOD Calcium-8.9 Phos-3.0 Mg-1.7
Day of discharge:
[**2158-8-29**] 05:25AM BLOOD WBC-12.3* RBC-4.50 Hgb-11.4* Hct-34.2*
MCV-76* MCH-25.4* MCHC-33.4 RDW-14.8 Plt Ct-215
[**2158-8-29**] 05:25AM BLOOD PT-11.8 PTT-31.8 INR(PT)-1.0
[**2158-8-29**] 05:25AM BLOOD Glucose-62* UreaN-16 Creat-0.8 Na-144
K-3.3 Cl-107 HCO3-26 AnGap-14
[**2158-8-29**] 05:25AM BLOOD Calcium-9.0 Phos-4.3 Mg-1.9
.
Troponin peaked at 1.04 on [**8-27**]/9.
.
Cath report:
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease presenting with
inferoposterior
STEMI.
2. Preserved cardiac output, mildly elevated right- and
left-sided
filling pressures and no evidence of RV infarction.
3. Successful urgent percutaneous thrombectomy, PTCA and
stenting of the
mid RCA with a 2.75x33 mm Taxus Liberte DES.
4. Successful closure of the arteriotomy site with a 6 French
closure
device.
Brief Hospital Course:
61 yo F with history of DM2, CAD s/p 1v CABG, and HTN who
presented to ED with STEMI this morning, s/p cath and DES placed
to RCA.
.
# STEMI: Known CAD s/p 1v CABG. s/p c. cath this AM with DES
placed to RCA.
pt had no chest pain after catheterization. Trop peak of 1.04,
CK 506 and MBI of 15.4. Pt was started on Plavix which she needs
to take every day for one year. Carvedilol was increased to 6.25
mg [**Hospital1 **], Aspirin was increased to 325 mg and pantoprazole was
changed to ranitidine to prevent interference with PLavix. Her
ACE was continued and a statin was not started because of her
severe allergies. She was instead referred to the lipid clinic
at [**Hospital1 18**] for further evaluation and her lipid panel is not at
goal.
.
# PUMP: EF 50-55%. No signs of heart failure. ECHO not done on
this admission, will be done in [**1-3**] months to evaluate for
persistant wall motion abnormalities. Pt has been on Lasix at
home for ankle edema, this was restarted at discharge.
.
# Leukocytosis: WBC 14.4. Likely from STEMI. No fevers or
other signs of infection. WBC almost normalized at discharge.
.
# DM-2: Pt A1C 12.3 previously. Pt states she has started to be
followed at [**Hospital **] clinic per her PCP [**Name Initial (PRE) **].
.
# GERD: Patient mentions that she has fairly severe GERD. Will
hold Pantoprazole given that she is on plavix, and try
ranitidine for now.
.
CODE: FULL -confirmed with patient
.
Medications on Admission:
1. Aspirin 81 mg po daily
2. Carvedilol 3.125 mg po bid
3. Lisinopril 2.5 mg po daily
4. Pantoprazole 40 mg po daily
5. Thiamine 100 mg po daily
6. Triamcinolone Acetonide 0.025 % Cream Sig: One (1) Appl
Topical PRN itching.
7. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) PRN chest pain.
8. Insulin Regular Human 100 unit/mL Solution Sig: Twenty Four
(24) units Injection BREAKFAST (Breakfast).
9. NPH 32 units qAM, 10 units qPM.
10. Furosemide 10 mg 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. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*11*
3. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual every 5 minutes as directed, max 3 tabs as
needed for chest pain, nausea.
Disp:*1 bottle* Refills:*0*
8. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: One
(1) Capsule, Sustained Release PO once a day: Take with
furosemide.
9. Humulin N 100 unit/mL Suspension Sig: Twenty Four (24) units
Subcutaneous once a day: 12 units every pm.
10. Niaspan 500 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO at bedtime.
11. Tramadol 50 mg Tablet Sig: 1-2 Tablets PO four times a day
as needed for pain.
12. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
ST elevation Myocardial Infarction/Coronary Artery disease
Diabetes Mellitus
Hypertension
Discharge Condition:
stable
BP:103/60
HR: 78
Temp: 98
O2 sat:100% RA
right groin with 2x3 cm hematoma, no bruit, no ecchymosis.
Right groin: 2x4cm hematoma, marked, point tenderness, no bruit,
no bruising.
Discharge Instructions:
You had a small heart attack and needed a drug coated stent
placed in your right coronary artery to restore blood flow to
your heart. You will need to take Plavix every day, do not stop
taking Plavix unless Dr. [**Last Name (STitle) 73**] tells you to. You have a
small hematoma (collection of blood) in your right groin where
the catheters were placed. This should go away slowly but you
may develop some superficial bruising as it heals. Please call
Dr. [**Last Name (STitle) 73**] or the catheterization lab if you notice the
hematoma is getting bigger, if it becomes more painful, red or
swollen. No lifting more than 10 pounds for one week. No driving
for two days. The physical therapist spoke to you about activity
for the next month.
Medication changes:
1. Plavix: to prevent the stent from clotting off and causing
another heart attack
2. Aspirin: increase to 325 mg daily to prevent the stent from
clotting off.
3. Stop taking Pantoprazole as it may intefere with the Plavix
4. START taking Ranitidine for your heartburn
5. INCREASE your Carvedilol to 6.25 mg twice daily
6. Nitroglycerin: to take if you have chest pain or trouble
breathing. Do not take more than 3 tablets, if you still have
symptoms, call 911.
7. We have not started you on a cholesterol medicine because of
your severe allergies. We have made an appt at the [**Hospital **] clinic
for assistance in lowering your cholesterol.
.
Please call Dr. [**Last Name (STitle) 73**] if you have any symptoms similar to
the ones you had on admission, any trouble breathing, fevers,
new cough, dark or tarry stools, bleeding or any other
concerning symptoms.
Followup Instructions:
Cardiology:
Provider: [**Name10 (NameIs) 900**] [**Name8 (MD) 901**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2158-8-31**] 3:20
Primary Care:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13960**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2158-10-2**] 8:20
GYN:
Provider: [**First Name8 (NamePattern2) 2671**] [**Last Name (NamePattern1) 16567**], MD Phone:[**Telephone/Fax (1) 5808**]
Date/Time:[**2158-10-5**] 3:40
[**Hospital **] clinic:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2201**] Phone: [**Telephone/Fax (1) 62**] Date/time: [**9-29**] at
8:30am. [**Hospital Ward Name 23**] [**Location (un) 436**]. This will be an appt with the
physician, [**Name10 (NameIs) 3690**] and nurse.
Completed by:[**2158-8-31**]
|
[
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"530.81",
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"414.01",
"250.00",
"438.6",
"401.9",
"998.12",
"410.31",
"V45.81",
"438.20",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"00.45",
"00.66",
"36.07",
"00.40",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
7936, 7942
|
4696, 6137
|
340, 380
|
8076, 8263
|
3479, 4260
|
9939, 10728
|
2469, 2521
|
6698, 7913
|
7963, 8055
|
6163, 6675
|
4277, 4673
|
8287, 9029
|
2536, 3460
|
1851, 1993
|
9049, 9916
|
289, 302
|
408, 1743
|
2024, 2370
|
1765, 1831
|
2386, 2453
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,293
| 179,697
|
42658
|
Discharge summary
|
report
|
Admission Date: [**2171-2-5**] Discharge Date: [**2171-2-12**]
Date of Birth: [**2088-10-27**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Zyprexa / Haldol / Morphine
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
colonoscopy
upper endoscopy
History of Present Illness:
Mr. [**Known lastname 92234**] is a 82 year old Italian speaking man with ESRD
on HD, internal hemmorhoids, h/o colon CA s/p R colectomy,
complete heart block with dual-V pacer, CAD s/p NSTEMI in [**2150**]
who presents with 24 hours of BRBPR. The patient was stable and
recovering from two recent hospitalizations at home, doing well
until the AM of [**2-4**], when he had a large bloody bowel movement
with bright red blood and clots. At this time, he denied any
abdominal pain, chest pain, shortness of breath, n/v/d, f/c,
lightheadedness/dizziness. Later, in the evening, he had another
3 similar bowel movements with bright red blood and clots, and
then another bloody BM the next morning on the day of admission.
He then went to his HD session in the morning, when the staff
there noticed a change in his Hgb from 11 at his prior session
to 6.5. After HD, the patient appeared pale and tired to his
daughter and complained of not being able to stand because he
felt "weak". At that point, his family brought him to the [**Hospital1 18**]
ED. Of note, the patient has had an active recent medical
history, having been hospitalized from [**Date range (1) 28665**] for AMS
secondary to high dose Valtrex for shingles, and then another
hospitalization on [**3-20**] for dyspnea and fever, presumably
secondary to extreme herpetic neuralgia and pain.
.
In the ED, initial vs were: T 98.2 P 61 BP 105/31 RR 24 O2 100%
RA. The patient was hemodynamically stable, but had a Hct of
19.5 measured ([**1-24**] Hct 29.8). Two 18G PIVs were placed and
patient was transfused 1u PRBC's and given 1L fluids. Surgery
and GI were both consulted. On the floor, the patient was stable
and receiving a 2nd unit of PRBC's, but was quite restless from
post-herpetic pain and was requesting his lidocaine patches.
.
Review of systems:
(+) Abdominal/back pain and itching
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias.
Past Medical History:
-h/o chronic lymphocytic exudative pleural effusions
secondary to chronic uremic pleurisy
-Colonic adenoma with high grade dysplasia / intramucosal
carcinoma; no mucosal invasion, all LN negative, s/p right
colectomy [**3-22**]
-CAD: NSTEMI in [**2150**], no perfusion defects [**3-/2168**] MIBI.
-Mod Pulm HTN, EF >70% 3/09 Echo
-Complete Heart Block S/P [**Company 1543**] Sigma DR [**Last Name (STitle) 26019**] PPM
in [**6-/2167**]
-Left internal carotid artery stenosis: (Carotid US in [**3-19**]
showed a L ICA 70-79% stenosis with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3098**]/LCCA index of 3.6, no
right ICA stenosis with a [**Country **]/RCCA index of 1. in [**2164**]) on
clopidogrel.
-ESRD: [**1-16**] HTN and diabetes, on HD, Receives hemodialysis on
Tuesday, Thursday and Saturday via a left AV fistula at [**Location (un) 1468**]
Dialysis Center.
-Type 2 DM: (last A1c 6% in [**7-22**]) on oral agents
-Hypertension
-Chronic anemia (baseline hct ~ 35)
-Hyperlipidemia
-Secondary hyperparathyroidism
-Bilateral cataracts s/p surgical intervention
-s/p ERCP for bile duct stenosis
-Mild dementia
-h/o urinary retention
Social History:
Lives with wife. One of his daughters is very involved in care,
also son [**Name (NI) **]. [**Name2 (NI) **] another son and daughter nearby. [**Name2 (NI) **] worked
as a bricklayer for many years. Reports a 45 pk/yr h/o tobacco
but quit over 20 yrs ago. Has glass of wine with lunch and
dinner occasionally. Occasional beer on a hot day.
Family History:
Non contributory.
Physical Exam:
Admission Exam:
Physical Exam:
Vitals: T: 98.7 BP: 134/49 P: 67 R: 18 O2: 98% RA
General: Alert, oriented, mildly agitated
HEENT: Sclera anicteric, MMM, poor dentition, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally but difficult to hear
with moaning sounds, no wheezes, rales, ronchi
CV: distant heart sounds, regular, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly. Herpetiform
purpuric purple rash on R abdominal wall and R lower back
GU: no foley
Ext: pulsatile L AVF without thrill; cool, well perfused, 2+
pulses, no clubbing, cyanosis or edema
Upon Discharge:
VS: 99% on RA at rest; desatted initially to mid 80s% on RA when
stood up but O2sat improved to 95% with deep breaths while
ambulating
LUNGS: clear to auscultation
Ext: pulsatile bruit Left forearm AVF, dilated with proximal
thrill
Pertinent Results:
Admission Labs:
[**2171-2-5**] 04:15PM BLOOD WBC-4.5 RBC-1.88*# Hgb-6.8*# Hct-19.5*#
MCV-104* MCH-36.4* MCHC-35.2* RDW-14.5 Plt Ct-256#
[**2171-2-5**] 05:53PM BLOOD PT-12.9 PTT-28.1 INR(PT)-1.1
[**2171-2-5**] 04:15PM BLOOD Glucose-126* UreaN-27* Creat-2.8*# Na-141
K-3.8 Cl-98 HCO3-32 AnGap-15
[**2171-2-5**] 04:15PM BLOOD ALT-17 AST-26 CK(CPK)-32* AlkPhos-118
TotBili-0.3
[**2171-2-5**] 04:15PM BLOOD cTropnT-0.22*
[**2171-2-6**] 04:27AM BLOOD CK-MB-4 cTropnT-0.22*
[**2171-2-7**] 01:01PM BLOOD CK-MB-5 cTropnT-0.18*
[**2171-2-5**] 04:15PM BLOOD Albumin-3.0* Calcium-7.9* Phos-2.6*
Mg-2.2
Radiology:
TTE (Complete) Done [**2171-2-11**] at 3:56:46 PM
The left atrium is mildly dilated. The right atrial pressure is
indeterminate. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). The estimated cardiac index is normal
(>=2.5L/min/m2). Tissue Doppler imaging suggests an increased
left ventricular filling pressure (PCWP>18mmHg). Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets are moderately thickened.
There is a minimally increased gradient consistent with minimal
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Minimal aortic valve stenosis. Pulmonary artery systolic
hypertension. Incresaed PCWP.
Compared with the prior study (images reviewed) of [**2169-4-4**],
minimal aortic valve stenosis is now identified and the
estimated pulmonary artery systolic pressure is higher.
Brief Hospital Course:
82 year old man with ESRD on HD, colon CA s/p resection,
diverticulosis, CAD, CHB s/p pacer, Afib who presented with
massive GIB, requiring multiple transfusions, while on plavix,
source of bleed not determined but thought to be duodenal versus
diverticular.
#Bright Red Blood Per Rectum:
Patient with history of colon CA s/p R colectomy, known
diverticulosis and internal hemmorhoids, and anticoagulation
from Plavix. Transfused 4u PRBCS 19.5 --> 30.6. Plavix and ASA
held. Received another 3 units over the next 24+ hours. On
[**2171-2-7**], GI scope showed red blood throughout the colon all the
way to ileocecal valve, likely [**1-16**] diverticular bleed, only 1
tic visualized due to blood. EGD was done as well, which showed
small amt coffee grounds but no clear upper source. Based on
bleeding during scope, patient underwent tagged RBC scan which
localized bleeding to RUQ, likely proximal small bowel (likely
duodenum). Patient then went to angio with IR but they were
unable to localize bleed. The next day, patient started on
regular diet despite possible need for surgery due to family
requests (understood risks). Patient then started to re-bleed
large amts of darker red blood. IR recommended CTA abdomen
which showed colonic diverticula but no active bleeding.
Hematocrits have remained stable for past 48 hours prior to
being transferred to floor.
On the floor, patient's hematocrit remained stable with no
further transfusion requirement. Definite source of bleed was
not clearly identified but thought to be duodenal and/or
diverticular, so patient was continued on pantoprazole on
discharge in setting of duodenal bleed and GERD symptoms.
Gastroenterology team felt that patient did not require
outpatient [**Month/Day (2) 4939**] with them at this time. Patient will have
Hct drawn on Saturday at HD and have results faxed to PCP.
[**Name10 (NameIs) **] PCP appointment is on Tuesday (one week from discharge
date). If patient were to re-bleed, he would likely require
surgical consultation, though he has already undergone Right
colectomy in the past.
.
#CAD:
Patient has TnT elevated beyond baseline to 0.22 in addition to
T-wave changes and ST depressions on his EKGs. This was thought
to be related to increased cardiac demand from hypovolemia in
addition to acute anemia decreasing myocardial oxygen delivery;
all in the setting of CAD. CE x2 stable. Metoprolol was held
initially in the setting of GI bleed but was restarted just
prior to discharge. Plavix will be held indefinitely; decision
to restart plavix will be made by outpatient physician. [**Name10 (NameIs) **]
does not have history of coronary stents.
.
#Post-herpetic neuralgia:
Patient continues to have considerable pain from his recent
episode of shingles. Given lidocaine patches and Gabapentin
100mg [**Hospital1 **].
.
#ESRD:
On HD, with L AVF. Received HD as scheduled by renal while
hospitalized. Patient had missed appointment with transplant
surgery for narrowing fistula because of this hospitalization.
There was some concern by Renal team that he may have some
evidence of proximal stenosis with dilated fistula and venous
collaterals upstream, so his AVF was evaluated by NP [**First Name8 (NamePattern2) 5969**]
[**Last Name (NamePattern1) 15170**] and Dr. [**First Name (STitle) **] who felt that fistula was working well
enough at this time but would need to be followed in the future.
No signs of steal syndrome on exam prior to discharge. No need
for fistulagram or intervention at this time.
.
#HTN:
Blood pressure medications were held in the setting of GI bleed.
Metoprolol tartrate was restarted upon discharge. Patient was
also restarted on home tamsulosin dose 2mg QHS upon discharge.
Blood pressures were up to 160s systolic prior to HD on day of
discharge, but improved to 120s post-HD. Nifedipine ER was held
on discharge to avoid restarting too many antihypertensives
simultaneously and may be restarted by outpatient physician at
[**First Name (STitle) 4939**] appointment next week. VNA will check blood pressures
and record them for PCP.
.
#HLD: Home simvastatin.
.
#DM: HbA1c in [**2167**] 6%. Off of oral agents, diet controlled.
Medications on Admission:
1. simvastatin 10 mg PO DAILY
2. clopidogrel 75 mg Tablet PO DAILY
3. nifedipine 30 mg Tablet Extended Release PO BID
4. baclofen 10 mg PO DAILY PRN FOR PAIN AFTER DIALYSIS
5. metoprolol tartrate 25 mg PO BID
6. B complex-vitamin C-folic acid 1 mg Capsule PO DAILY
7. terazosin 2 mg PO HS
8. lidocaine 5 %(700 mg/patch) x2 DAILY PRN pain from zoster
(apply one to back and one to abdomen on site of zoster)
9. [patient doesn't take] tramadol 50 mg Tablet Sig: 0.5 Tablet
PO Q6H PRN
10. gabapentin 100 mg PO BID
Discharge Medications:
1. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. baclofen 10 mg Tablet Sig: One (1) Tablet PO PRN DAILY () as
needed for after dialysis.
3. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
[**12-16**] Adhesive Patch, Medicateds Topical DAILY (Daily).
4. gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Nephrocaps Oral
7. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. terazosin 2 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
GI bleed, unknown source
Diverticulosis
HTN
Atrial Fibrillation
Complete Heart Block s/p Pacemaker
End stage renal disease.
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 92234**],
You were admitted with a significant bleed in the
gastrointestinal tract. You were given seven units of blood and
dialyzed several times while you were in the hospital. We have
determined that it is safe for you to go home and be treated by
physical therapy while at home.
We have discontinued plavix indefinitely. Although this
medication protects you from stroke and heart attacks, we feel
that it is too dangerous for you to take at this time. It could
potentially be restarted by one of your outpatient doctors in
the future.
We have taken tramadol off your medication list because you have
expressed to us that you do not take this medication.
The following changes have been made to your medications.
- Please STOP the plavix (as above) for now.
- Please also STOP your nifedipine for now -- this medication
may be restarted by your primary care doctor when you follow up
next week
- Please START pantoprazole 40mg daily.
Please have your visiting nurse check and record your blood
pressures, so that you may take this log of blood pressures into
your primary care physician's office at your appointment next
week.
You will need to have your blood counts drawn at Dialysis on
Saturday and have the results faxed to your primary care
physician's office.
[**Known lastname **] Instructions:
Please keep all of your [**Known lastname 4939**] appointments as listed below:
Department: [**Hospital1 18**] [**Location (un) 2352**]
When: TUESDAY [**2171-2-19**] at 10:10 AM
With: [**First Name4 (NamePattern1) 1575**] [**Last Name (NamePattern1) 1576**], MD [**Telephone/Fax (1) 1579**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: RADIOLOGY
When: MONDAY [**2171-2-25**] at 9:50 AM
With: RADIOLOGY [**Telephone/Fax (1) 327**]
Building: [**Hospital6 29**] [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: RADIOLOGY
When: MONDAY [**2171-2-25**] at 10:30 AM
With: RADIOLOGY [**Telephone/Fax (1) 327**]
Building: [**Hospital6 29**] [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: MONDAY [**2171-3-11**] 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
|
[
"V10.05",
"562.10",
"276.52",
"578.9",
"753.0",
"285.9",
"583.81",
"585.6",
"272.0",
"250.40",
"455.0",
"053.19",
"427.31",
"562.00",
"553.3",
"V45.01",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"45.23",
"88.47",
"45.13",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
12543, 12600
|
7081, 11255
|
328, 357
|
12768, 12768
|
5166, 5166
|
4150, 4169
|
11817, 12520
|
12621, 12747
|
11281, 11794
|
12951, 15443
|
4216, 4897
|
2203, 2600
|
283, 290
|
4913, 5147
|
385, 2184
|
5183, 7058
|
12783, 12927
|
2622, 3775
|
3791, 4134
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,155
| 140,340
|
24906
|
Discharge summary
|
report
|
Admission Date: [**2166-10-16**] Discharge Date: [**2166-10-22**]
Service: CARDIOTHORACIC
Allergies:
Penicillins / Warfarin
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
unstable angina and DOE with walking
Major Surgical or Invasive Procedure:
s/p CABGx2(LIMA->LAD, SVG->Diag) [**2166-10-16**]
History of Present Illness:
84 yo female with unstable angina and increased DOE, especially
with walking. She had an MI [**80**] years ago and had medical
management since then. Cardiac cath at [**Hospital1 **] in RI showed
calcified LM, 90% LAD, 80% diag, CX 30%, RCA 80%. Referred for
CABG to Dr. [**Last Name (STitle) **].
Past Medical History:
CAD
MI
renal calculi
S/P right THR
s/p ureteral repair
HTN
skin CA
Social History:
retired, lives alone, but son lives next door
no tobacco, one drink per month
Family History:
sister had CVA
Physical Exam:
4'[**71**]" 145#
HR70
NAD
no rashes, no carotid bruits
lower partial dentures
S1 S2 RRR, no m/r/g
lungs CTAB
abd soft, Nt, ND, extrems with no edema or varicosities
alert and oreinted x3 , MAE
2+ bilat. fem/ DP/PT/radial pulses
Pertinent Results:
[**2166-10-16**] 11:12AM BLOOD WBC-9.1# RBC-3.21*# Hgb-0*# Hct-31.1*#
MCV-97 MCH-32.3* MCHC-0*# RDW-13.9
[**2166-10-19**] 10:25AM BLOOD WBC-7.5 RBC-3.47* Hgb-11.4* Hct-31.1*
MCV-90 MCH-32.9* MCHC-36.7* RDW-15.2 Plt Ct-99*
[**2166-10-22**] 07:15AM BLOOD Hct-32.0*
[**2166-10-19**] 10:25AM BLOOD PT-13.7* PTT-23.0 INR(PT)-1.3
[**2166-10-19**] 10:25AM BLOOD Plt Ct-99*
[**2166-10-22**] 07:15AM BLOOD UreaN-19 Creat-0.7 K-4.0
[**2166-10-19**] 10:25AM BLOOD Calcium-8.8 Phos-1.9* Mg-1.7
pre-op EKG: ? old ASMI, SB @ 55
pre-op CXR: no acute cardiopulmonary changes
UA negative
Brief Hospital Course:
Admitted [**10-16**] and underwent cabg x2 by Dr. [**Last Name (STitle) **] (LIMA to LAD,
SVG to diag). Transferred to CSRU in stable condition on a
neosynephrine drip.Several hours later, the patient returned to
the OR for re-exploration of the mediastinum for bleeding. She
was then returned to the CSRU on a nitroglycerin drip. A small
right sternal fracture was found. Extubated later that night and
was alert and oriented. Transferred out to the floor on POD #1
in stable condition to begin increasing her activity level.
Chest tubes and JP drain were removed. Beta blockade and
diuresis were gently started. Pacing wires were removed without
incident on POD #5 She copntinued to make excellent progress and
was ambulating independently. CXR on [**10-21**] showed no PTX, and a
small right pleural effusion. She did a level 5 on [**10-22**] and was
cleared for discharge to home with VNA services on POD #6. CXR
on [**10-22**] showed small L pleural effusion, and stable right
pleural effusion.
T 98.4 HR72 wt 65.4 kg (pre-op 67.2) 96% RA sat. 117/57
Medications on Admission:
procardia 30 mg daily
corgard 20 mg daily
lopid 600 mg daily
plavix 75 mg daily (LD [**10-13**])
ASA 81 mg daily
MVi daily
glucosamine-chondroitin daily
Discharge Medications:
1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7
days.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1)
Tablet PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
5. Lopid 600 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
6. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA of [**Doctor Last Name **]
Discharge Diagnosis:
CABG x 2(LIMA->LAD, SVG->Diag) [**10-16**]
MI [**80**] years ago
Hypertension
skin CA
Discharge Condition:
Good.
Discharge Instructions:
Follow medications on discharge instructions.
Do not drive for 4 weeks.
Do not lift more than 10 lbs. for 2 months.
You should shower daily, let water flow over wounds, pat dry
with a towel.
Do not use powders, lotions, or creams on wounds.
Call our office for sternal drainage, temp.>101.5
Followup Instructions:
Make an appointment with Dr. [**Last Name (STitle) **] for 1-2 weeks.
Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks at [**Hospital1 **],
call [**Telephone/Fax (1) 62629**]
Completed by:[**2166-10-22**]
|
[
"428.0",
"401.9",
"V13.01",
"424.0",
"411.1",
"272.0",
"E878.2",
"414.01",
"998.11",
"412",
"807.2",
"V43.64",
"V10.83"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.09",
"34.03",
"99.04",
"89.68",
"36.12",
"39.61",
"36.15",
"99.07",
"99.05",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
3914, 3975
|
1733, 2797
|
275, 327
|
4105, 4113
|
1136, 1710
|
4452, 4677
|
856, 872
|
3000, 3891
|
3996, 4084
|
2823, 2977
|
4137, 4429
|
887, 1117
|
199, 237
|
355, 654
|
676, 745
|
761, 840
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,172
| 134,615
|
27737
|
Discharge summary
|
report
|
Admission Date: [**2152-7-4**] Discharge Date: [**2152-7-18**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Unresponsive episode
Major Surgical or Invasive Procedure:
ETT tube placement
CVL insertion
History of Present Illness:
The pt is an 86 year-old right-handed woman with a history of
stroke who presented from her living facility with episodes of
unresponsiveness and speech difficulties.
.
The pt was unable to offer a history at the time of my
encounter. Therefore, the following history is per the primary
team, the medical record, and the pt's son who was present for
the events.
The pt had been in her usual state of health. Her son was
visiting her at her [**Hospital3 **] facility this morning. She
was at her baseline and appeared well. At approximately 10am,
she was receiving her medications and abruptly let out an
"unusual cry" then became unresponsive for about thirty seconds.
Her son noted that her eyes were rolled back into her head.
She then woke up, was speaking "gibberish" (by this the son
means unintelligible, incomphrensible speech) and proceeded to
drink the [**Location (un) 2452**] juice she was given with her medications.
After another minute, she became unresponsive again. She
remained in this state and EMS was called. The pt was
subsequently brought to the [**Hospital1 18**] ED. The pt's sons noted that
this sort of event had never happened before. There was no
clear precipitant for the event. As above, the pt had voiced no
complaints prior to this episode.
.
The pt was unable to offer a review of systems.
Past Medical History:
Right MCA territory stroke in [**2141**] with resultant left
hemiplegia
-Seizure in [**2142**] (Semiology unknown)
-peripheral vascular disease, s/p abdominal aortogram with left
lower extremity runoff, angioplasty of left superficial femoral
artery, popliteal and anterior tibialis arteries, stenting of
left superficial femoral artery, below knee popliteal, and
anterior tibialis artery on [**2152-6-14**].
-hypertension
-dementia; at baseline the pt is able to recognize her loved
ones and carry out brief conversations, but has difficulty with
short-term memory and executive functioning. She is an [**Hospital1 1501**] and
requires help with ADLs due to underlying dementia and left
hemiplegia.
Social History:
Pt lives in an [**Hospital3 **] facility. No history of tobacco,
alcohol, illicit drug use
Family History:
No history of seizure
Physical Exam:
Vitals: T: 99.2F P: 88 R: 16 BP: 104/90 SaO2: 100% NRB
General: Lying in bed with eyes closed.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: supple, no JVD or carotid bruits appreciated. No nuchal
rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally
Skin: No rashes
.
Neurologic:
-mental status: Does not open eyes to verbal or noxious stimuli.
No verbal output. Does not follow commands.
.
-cranial nerves: PERRL 3 to 2mm and brisk. Funduscopic exam
revealed no papilledema, exudates, or hemorrhages. EOMI to
oculocephalic maneuver. Corneal reflex and nasal tickle present
bilaterally. Right facial droop. Gag reflex intact.
.
-motor: Normal bulk throughout. Tone increased in the left arm
and leg. Withdraws to briskly in the right arm and leg. Grimaces
but does not withdraw to noxious stimuli on the left. On three
occasions during the interview and exam, the pt demonstrated
myoclonic jerks of the left arm.
.
-sensory: Grimaces to noxious stimuli in all four extremities.
.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 1
R 3 3 3 3 1
.
Plantar response was extensor bilaterally.
Pertinent Results:
Admission Labs:
7.7> 14.4 <370
42.5
.
N:63.3 L:26.1 M:5.6 E:4.4 Bas:0.6
.
PT: 12.3 PTT: 20.8 INR: 1.1
.
[**Age over 90 **]|104|14 /160
4.6| 26|0.7\
.
CK: 19 MB: Notdone Trop-T: <0.01
.
Lactate: 3.3
.
EKG: Atrial fibrillation at 80bpm. LAD. TWI in V1-4.
.
Admission Head CT [**7-4**]:
1. Large area of encephalomalacia in the right frontal,
temporal, and
parietal lobes consistent with extensive remote MCA territorial
infarction, with multiple hyperdense areas within consistent
with mineralization, and advanced wallerian degeneration.
2. No definite acute intracranial hemorrhage.
3. Prominence of the right more than left lateral and third
ventricles, that likely primarily reflects ex vacuo dilatation
(no previous studies are available for comparison).
4. Partial opacification of both external auditory canals with
no obvious
osseous destruction, which may simply reflect impacted cerumen;
correlation clinically is recommended.
.
MRI Brain [**7-5**]:
1. MRI [**Month/Day (1) 4059**] a new left thalamic infarction.
2. Chronic changes from extensive remote middle cerebral artery
territorial infarction with associated ex vacuo dilation of the
ipsilateral lateral ventricle and Wallerian degeneration.
3. MR [**First Name (Titles) 20827**] [**Last Name (Titles) 4059**] decreased signal intensity in the
right
vertebral artery and right internal carotid and branches. There
is also
decreased signal in the left posterior cerebral artery.
.
EEG [**2152-7-5**]:
Markedly abnormal portable EEG due to the prominent focal
slowing seen broadly over the right hemisphere particularly in
more lateral areas and due to the occasional sharp waves in the
more posterior areas on the right. The background rhythm was
also slow and disorganized. The first abnormality signifies a
large area of subcortical dysfunction and suggests a structural
lesion. There were frequent sharp waves but no spike or sharp
and slow wave complexes or repetitive discharges to suggest
ongoing seizures at this time. The slow background indicates a
more widespread encephalopathy. Medications, metabolic
disturbances, and infection are among the most common causes.
.
TTE [**2152-7-5**]:
The left atrium is elongated. The right atrium is moderately
dilated. No
atrial septal defect is seen by 2D or color Doppler. 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 systolic function is
borderline normal. The descending thoracic aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Mild (1+) aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. There
is no mitral valve prolapse. Mild to moderate ([**1-3**]+) mitral
regurgitation is seen. The mitral regurgitation jet is
eccentric. The tricuspid valve leaflets are mildly thickened.
There is moderate pulmonary artery systolic hypertension. There
is an anterior space which most likely represents a fat pad.
.
Brief Hospital Course:
Pt. was admitted to the Neurology and SICU services. She was
loaded with Dilantin in the ED and this was continued in the
SICU. On HOD #2 she was noted to be more somnolent, and to have
a dilated and fixed L pupil. Repeat MRI head (see results
above) showed new L thalamic infarct and decreased signal in the
L PCA on top of her old known R MCA infarct. Pt. was intubated
for airway protection as she was not maintaining her secretions.
An EEG was performed and showed encephalopathy but no evidence
of seizure activity. Pt. was noted to be in A fib in the ED and
in the SICU on telemetry, and infarcts were felt to be [**2-3**] to
cardioemboli from paroxsymal atrial fibrillation. The team
discussed with the family starting Heparin and Coumadin to
prevent further cardioembolic strokes, but the family felt that
given the extent of her known strokes and her risk for bleeding
into old stroke that they did not want to pursue this therapy.
TTE was performed and showed no visible [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 2966**].
.
Over the next two weeks pt. was maintained on the ventilator,
which was weaned down to minimal settings (CPAP 5). Her exam
improved with increased level of alertness and increased ability
to follow commands. The Neurology and SICU teams had multiple
discussions with the family about prognosis and goals of care.
It was felt that pt. would not maintain her airway if she were
extubated and would need a tracheostomy to maintain ventilation
long term. The family did not feel that this was compatible
with the pt's wishes, and elected to extubate her and make her
comfortable instead.
.
Pt. was extubated on [**2152-7-17**]. Her breathing became labored and
her O2 sats dropped slowly over the next 24 hours. On 5:15 on
[**2152-7-18**] she stopped breathing. Pupils were fixed and dilated,
carotid pulse was not palpable, and no heart or breath sounds
were auscultated. Family was at the bedside and declined
autopsy.
Medications on Admission:
-nifedipine 30 mg PO DAILY
-Clopidogrel 75 mg PO DAILY
-Atorvastatin 40 mg PO DAILY
-Quetiapine 12.5mg in AM and 25mg before bedtime.
-Multivitamin PO DAILY
-vitamin B12 supplementation
-Metoprolol 25 PO BID
-recently finished a 10 day course of levofloxacin and linezolid
post-operatively
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary:
Top of the basilar syndrome with a new L thalamic/midbrain
infarction
Old R MCA ischemic stroke
Paroxsymal atrial fibrillation
.
Secondary:
Hypertension
Peripheral Vascular Disease
Dementia
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
Completed by:[**2152-7-20**]
|
[
"434.11",
"401.9",
"294.8",
"438.20",
"443.9",
"427.31",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.04",
"96.72",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9354, 9363
|
7006, 8984
|
283, 317
|
9605, 9614
|
3919, 3919
|
9667, 9813
|
2530, 2553
|
9325, 9331
|
9384, 9584
|
9010, 9302
|
9638, 9644
|
3170, 3900
|
2568, 3042
|
223, 245
|
345, 1680
|
3935, 6983
|
3057, 3152
|
1702, 2405
|
2421, 2514
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,734
| 128,964
|
301
|
Discharge summary
|
report
|
Admission Date: [**2157-3-29**] Discharge Date: [**2157-4-8**]
Date of Birth: [**2074-4-2**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Subdural Hematoma
Major Surgical or Invasive Procedure:
none
History of Present Illness:
82F w/ h/o multiple myeloma, peripheral neuropathy recently
hospitalized on neuro service for work-up of multiple falls
transferred from [**Hospital3 2783**] with dx of right SDH. The
patient was found down, awake, in the afternoon by staff at
nursing home where she lives. She was admitted at [**Hospital1 18**] about 2
weeks ago to work up the falls and at that time had negative
intracranial imaging (see detailed neurology note from [**2157-3-15**]).
The falls were thought to be due to a combination of neuropathy
post chemotherapy and mild cervical spondylosis and she was
discharged to a nursing home. The current fall was unwitnessed
and it is not clear if there was any LOC. Patient denies any
dizziness, lightheadedness, vertigo, nausea/vomiting. She also
comes with a new dx of PNA, possible aspiration PNA and was
treated with levaquin at OSH prior to arrival.
.
In the ED, initial vs were: T98.1, HR 80, BP 104/56, RR 14-16,
O2 99%RA. Patient was alert but somewhat confused. Head CT
showed no interval change in mid-line shift or size of SDH.
Neurosurgery recommended 6-pack of plt's, DDAVP, Vit K (10mg IV)
and 2L NS. Patient also received CTX for finding of pneumonia
on CXR. Was admitted to MICU for q1H neuro checks and treatment
of pneumonia. At time of transfer, VS 97.8, HR 80, Bp 96/41, RR
22 O2 97% 3L NC, RA sat of 93-94%
Past Medical History:
1. Multiple myeloma s/p chemotherapy, followed by Dr. [**First Name (STitle) 2856**]
at [**Company 2860**]. Seen by oncology for decreased counts on last admit
and recommended to receive pulse steroids.
2. HTN
3. Peripheral neuropathy due to chemotherapy
4. s/p both hips, knees replacement and L ankle surgery
5. OA
6. s/p cholecystectomy
7. s/p hysterectomy
8. Frequent falls
Social History:
SH: Was living alone until recent falls with subdural requiring
rehab - does not drive but pays own bills, takes own meds and
etc. Used to be a waitress. Has 2 grown children. No
cigarettes or EtOH.
Family History:
FH: NC
Physical Exam:
T97.3 HR 84, BP 92/60, O2 Sat 97% 3L NC
General Appearance: No acute distress, Thin, very pleasant and
comfortable appearing
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: No(t) Normal, Loud), No(t)
S3, No(t) S4, No(t) Rub, (Murmur: Systolic), At Erb's point
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Crackles : bilaterally)
Abdominal: Soft, Non-tender, Bowel sounds present, No(t)
Distended, No(t) Tender: , No(t) Obese
Extremities: Right: Absent, Left: Absent
Skin: Not assessed
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Oriented (to): place, knows why she is in
hospital, Movement: Purposeful, No(t) Sedated, No(t) Paralyzed,
Tone: Normal, [**6-7**] full strength in UE bilaterally, diminished
strength 4/5 b/l in LE, and nml cranial nerves
Pertinent Results:
[**2157-3-28**] 09:20PM PT-15.1* PTT-33.5 INR(PT)-1.3*
[**2157-3-28**] 09:20PM WBC-16.6*# RBC-2.69* HGB-9.2* HCT-25.5*
MCV-95 MCH-34.3* MCHC-36.1* RDW-19.7*
[**2157-3-28**] 09:20PM ALT(SGPT)-23 AST(SGOT)-41* ALK PHOS-67 TOT
BILI-1.6*
[**2157-3-28**] 09:39PM LACTATE-1.2
[**3-28**] CT Head:
IMPRESSION: Acute on chronic right subdural hematoma, unchanged
in comparison
study from five hours prior. 1-2mm of leftward shift of normally
midline
structures.
[**3-29**] CT Head:
Evolution of acute-on-chronic right subdural hematoma with
posterior layering of the acute component, now tracking along
the tentorium. There is no evidence for new hemorrhage,
increased mass effect, or edema.
[**4-2**] CT Head:
There has been not significant change in size of an acute on
chronic subdural hematoma, but evolution of blood products
within the
hematoma is seen. There is no shift of minimal mass effect on
subjacent right occipital gyri remains seen, and sulci are
unchanged in configuration. The sulci are otherwise prominent,
compatible with age-related involution. The ventricular
configuration is unchanged. Again seen is scattered
periventricular white matter hypodensities, consistent with
chronic microvascular ischemia.
Surrounding soft tissues and osseous structures are stable in
appearance.
There is no fracture. Imaged paranasal sinuses and mastoid air
cells are well aerated.
IMPRESSION: Evolution of right subdural hematoma without
evidence for new
hemorrhage or increased mass effect. No new hemorrhage.
[**3-28**] CT C-spine:
1. No fracture or prevertebral soft tissue swelling.
2. Multilevel degenerative changes, predominantly at C5-6 and
C6-7, unchanged in comparison to MRI [**2157-3-18**].
[**3-28**] Echo:
The left atrium is mildly dilated. The estimated right atrial
pressure is 10-15mmHg. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%). There is a mild resting left ventricular outflow tract
obstruction. Right ventricular chamber size and free wall motion
are normal. The number of aortic valve leaflets cannot be
determined. The aortic valve leaflets are mildly thickened.
There is no valvular aortic stenosis. The increased transaortic
velocity is likely related to high cardiac output. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Trivial mitral
regurgitation is seen. There is severe pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Preserved biventricular global and regional systolic
function. Mild resting outflow tract gradient, likely due to
vigorous left ventricular function. Severe pulmonary
hypertension.
Brief Hospital Course:
# Subdural Hematoma: Patient continued to have decreased level
of consciousness throughout the hospital stay. Neurosurgery was
consulted for acute on chronic SDH.
Vitamin K given for INR 1.3. ddavp given in ED given h/o aspirin
use. Neurosurgery was consulted and recommended transfusing
plt's with goal of >80, received 1 6-pack in ED. CT head and
subsequent MRI/MRA were significant for stable SDH but chronic
embolic events. Neurology was consulted and an EEG showed spike
and wave patterns consistent with pre-seizure activity. Dilantin
was given throughout the hospital course with no seizures noted.
.
# Hopsital Acquired Pneumonia. Has known PNA on CXR, treated
from the start. Abx treatment included vanco and cefepime
started [**3-29**]. Did get one dose of ceftriaxone. Was started on
levo for atypical coverage on [**3-29**] which was stopped [**4-2**].
Flagyl was started [**4-2**]. Culture data only positive for GPCs in
sputum, no speciation done. Remained tachypneic but
oxygentating well until the date of death. The patient continued
to require high O2 supplementation on [**2157-4-8**] and over the course
of the day, the O2 sat declined, with a sharp decline in HR and
BP. The patient became hypoxic and bradycardic, and expired in
the afternoon. The family was contact[**Name (NI) **] and came to the hospital
for viewing. The PCP was notified.
.
# Falls/?Syncope: recent admit with extensive work-up
attributing LE weakness and falls to cervical spondylosis and
multilevel degenerative disease with myelopathy and neuropathy.
Unclear if LOC with fall so would pursue syncope w/u, which is
likely [**3-7**] UE neuropathy, weakness, ? seizure in setting of SDH.
MRA showed no lesions.
.
# Myeloma: On pulse decadron as per heme-onc for tx of myeloma.
.
# Pancytopenia: [**3-7**] to myeloma. Stable.
.
# Renal Failure: At baseline from last admission. Unclear
etiology to CKD, but may represent complication from myeloma.
.
# Code: After family meeting, DNR/DNI was established.
Medications on Admission:
Medications: (On discharge from [**2157-3-21**])
1. Aspirin 325 mg Tablet
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.)
3. Pregabalin 25 mg Capsule Sig: One (1) Capsule PO BID
4. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO BID
5. Dexamethasone 4 mg Tablet Sig: Ten (10) Tablet PO DAILY
(Daily) for 4 days.
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice
a day.
7. Nifedipine 30 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1)
Tab,Sust Rel Osmotic Push 24hr PO once a day.
8. Gabapentin 600 mg Tablet Sig: One (1) Tablet PO twice a day:
Give qAM and qPM.
9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO once a day:
Afternoon dose.
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain.
11. Humalog insulin sliding scale
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary Diagnosis:
Acute on Chronic Subdural [**Hospital 2861**]
Hospital Acquired Pneumonia
Secondary Diagnosis:
Multiple Myeloma
Thrombocytopenia
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
Completed by:[**2157-5-9**]
|
[
"286.9",
"203.00",
"357.6",
"285.1",
"852.20",
"427.31",
"721.1",
"434.11",
"V43.64",
"276.6",
"715.90",
"E933.1",
"599.0",
"287.5",
"250.00",
"E888.9",
"787.91",
"507.0",
"780.09",
"458.9",
"780.93",
"585.9",
"921.2",
"416.8",
"V43.65",
"284.1",
"789.01",
"584.9",
"924.8",
"348.30",
"782.1",
"780.39",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"03.31",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9030, 9039
|
6152, 8157
|
331, 337
|
9231, 9240
|
3412, 3702
|
9292, 9325
|
2370, 2380
|
9060, 9060
|
8183, 9007
|
9264, 9269
|
2395, 3393
|
274, 293
|
365, 1723
|
4125, 6129
|
9175, 9210
|
9079, 9154
|
1745, 2133
|
2149, 2354
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,774
| 151,246
|
14711
|
Discharge summary
|
report
|
Admission Date: [**2136-5-18**] Discharge Date: [**2136-5-30**]
Service: CARDIAC
CHIEF COMPLAINT: Coronary artery disease.
HISTORY OF THE PRESENT ILLNESS: Mrs. [**Known lastname **] is a 78-year-old
female who is transferred here from an outside hospital
following an positive exercise treadmill test and positive
catheterization. She is to be evaluated for coronary artery
bypass graft. She has had three admissions at [**Hospital **]
Hospital in the past two months for what appears to be
ischemic pulmonary edema. She now appears to be failing
outpatient medical management. This included increasing her
beta blockers, increasing Lasix, instituting Aldactone, and
increasing her Norvasc. The recent echocardiogram was on
[**2136-4-10**], demonstrated apical dyskinesis with an
ejection fraction of 45% to 50%.
PAST MEDICAL HISTORY: History is notable for the following:
1. Coronary artery disease with early cardiomegaly.
2. Severe arthritis.
3. Lung cancer status post right lower lobe excision in
[**2126**].
4. Hyperlipidemia.
5. Non-Insulin-dependent diabetes mellitus.
6. Decreased hearing.
7. Chronic low back pain.
8. Gastritis.
9. Obesity.
ALLERGIES: The patient is not allergic to any medicines.
MEDICATIONS:
1. Norvasc 5 mg p.o.q.d.
2. Lasix 80 mg p.o.q.d.
3. Lopressor 100 mg p.o.b.i.d.
4. Protonix 40 mg p.o.q.d.
5. Diovan 80 mg p.o.q.d.
6. Ecotrin 81 mg p.o.q.d.
7. Plavix 75 mg p.o.q.d.
8. Imdur 90 mg p.o.q.d.
9. Glyburide 2.5 mg p.o.q.a.m.
10. Nystatin powder to the right groin b.i.d.
SOCIAL HISTORY: The patient does not drink alcohol or use
tobacco.
PHYSICAL EXAMINATION: On physical examination, she is noted
to be a pleasant female who is hard of hearing, but
otherwise, in no acute distress. Head, eyes, ears, nose,
throat and neck: she is without JVD. CHEST: Lungs were
clear to auscultation bilaterally: HEART: Regular rate and
rhythm. ABDOMEN: Soft, obese, nontender. The right groin
catheterization site on arrival had no hematoma and
peripherally the extremities are without clubbing, cyanosis
or edema.
HOSPITAL COURSE: The patient was admitted to Cardiac Surgery
Service and appropriate preoperative workup was obtained.
Pulmonary consultation was obtained for this patient's
underlying pulmonary hypertension. They believe that this
was in fact due to left ventricular failure and they
recommended treating her failure including continued
diuresis. They also noted that she had no pulmonary
contraindication to undergoing cardiac surgery. Therefore,
on [**2136-5-22**], the patient underwent coronary artery
bypass grafting times three. She had saphenous vein graft to
LAD, saphenous vein graft to OM, and saphenous vein graft to
RCA. Total cardiopulmonary bypass time was 75 minutes.
Cross clamp time was 41 minutes. Postoperatively, the
patient was taken intubated to the Cardiac Surgery Intensive
Care Unit. In the Cardiac Surgery Intensive Care Unit she
was extubated on the evening of her operation and some of her
pressors including Milrinone were weaned off. The chest
tubes were discontinued on the first postoperative day, as
was the J-P drain left in her leg. However, this ultimately
required a total of six postoperative days in the Intensive
Care Unit. This was primarily for aggressive pulmonary
toilet and for delirious mental status changes that responded
well to Haldol p.r.n. During this time she was continued on
her normal perioperative course of Vancomycin in addition,
possible sources of her delirium were aggressively sought and
non appeared to have been found. During all of the time the
white count remained stable in the 10 to 12 region and the
BUN and creatinine were also stable.
By the 7th postoperative day, the patient was transferred our
of Intensive Care onto the hospital floor. On the floor, the
Lopressor was sequentially increased to a final dose of 75
b.i.d. In addition, the Lasix was converted from IV to a
p.o. form as she continued to diurese and approached her
preoperative weight. In addition, the physical therapy team
assessed her and noted her severe impairment and mobility.
They recommended rehabilitation upon discharge and felt that
she had good potential for return to her prior level of
functioning.
The patient had no other acute events during her
hospitalization. It should be noted that the white blood
cell count on the day prior to her transfer did climb from 11
to 15. However, on the day of her transfer it went back down
to 12. During all this time, she remained afebrile.
On [**2136-5-30**], the patient was transferred to [**Hospital1 **]
TCU for further care. It should be noted that her care
originated at [**Hospital6 **]. She is asked to
followup with her primary care physician in approximately two
weeks and to see Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] in approximately four
weeks.
The patient is transferred on the following medications:
1. Lasix 20 mg p.o.b.i.d.
2. Potassium chloride 20 mEq p.o.b.i.d.
3. Heparin 5000 subcutaneously b.i.d.
4. Colace 100 mg p.o.b.i.d.
5. Enteric coated aspirin 325 mg p.o.q.d.
6. Protonix 40 mg p.o.q.d.
7. Glyburide 2.5 mg p.o.q.d.
8. Lopressor 75 mg p.o.b.i.d.
9. Ibuprofen 400 mg p.o.q.4h.to 6h.p.r.n.
10. Tylenol 650 mg p.o.q.4h.to 6h.p.r.n.
11. Sliding scale regular insulin.
Of note: Regarding the preoperative medications, we could
not find a definitive indication for Plavix and have not yet
restarted that, in addition to a likely need to have her
Norvasc, Diovan, and Lipitor restarted in the future, it is
unclear whether or not she will continue to need the higher
does of Lopressor or the higher dose of Lasix following her
operation. It is recommended that she be followed
clinically.
DISCHARGE DIAGNOSES:
1. Coronary artery disease, status post coronary artery
bypass grafting times three.
2. Pulmonary hypertension.
3. Hypertension, treated.
4. Non-Insulin-dependent diabetes mellitus treated.
5. Hyperlipidemia, treated.
6. Severe arthritis and chronic low back pain.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 9638**]
MEDQUIST36
D: [**2136-5-30**] 13:22
T: [**2136-5-30**] 13:42
JOB#: [**Job Number 43298**]
|
[
"414.01",
"724.2",
"250.00",
"V10.11",
"414.8",
"272.0",
"416.0",
"428.0",
"424.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"39.61",
"36.13",
"42.23"
] |
icd9pcs
|
[
[
[]
]
] |
5775, 6311
|
2109, 5754
|
1641, 2091
|
111, 834
|
857, 1549
|
1566, 1618
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,079
| 175,615
|
14448
|
Discharge summary
|
report
|
Admission Date: [**2180-6-21**] Discharge Date: [**2180-6-25**]
Date of Birth: [**2128-5-10**] Sex: M
Service: .
CHIEF COMPLAINT: Increasing dyspnea on exertion.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 42744**] is a 52 year old
gentleman with a history of adult onset diabetes mellitus,
hypertension, hyperlipidemia and ongoing tobacco abuse, who
noted increasing dyspnea on exertion for the past week.
Starting at noon on [**6-21**], he noted a constant substernal
chest pain for approximately ten hours. He presented at
[**Hospital6 3105**] when his pain persisted despite
aspirin and Nitroglycerin. He was transferred to [**Hospital1 346**] after elevated cardiac enzymes were
noted.
PAST MEDICAL HISTORY:
1. Adult onset diabetes mellitus.
2. Hypertension.
3. Hyperlipidemia.
SOCIAL HISTORY: One to two pack per day smoker with
occasional ethanol use.
FAMILY HISTORY: Family history is negative for coronary
artery disease.
MEDICATIONS:
1. Metformin.
2. Glipizide.
ALLERGIES: No known drug allergies.
REVIEW OF SYSTEMS: Negative for cerebrovascular accident or
transient ischemic attack. Negative for melena. All other
review of systems are negative.
PHYSICAL EXAMINATION: Vital signs were pulse 68, blood
pressure 110/70; respirations 18; O2 saturation 95% on room
air. The patient is afebrile. He is a pleasant gentleman in
no apparent distress. His heart is regular rate and rhythm.
Normal S1, S2. His lungs are clear to auscultation
bilaterally. His abdomen is soft, nontender, nondistended,
with normoactive bowel sounds. Extremities are without
cyanosis, clubbing or edema.
LABORATORY: EKG examination was remarkable for normal sinus
rhythm, Q waves in II, III and AVF.
Mr. [**Known lastname 42744**] was subsequently taken for cardiac catheterization
which revealed 80% mid - left anterior descending stenosis,
80% major diagonal stenosis, subtotal left circumflex with
99% major obtuse marginal stenosis, 90% proximal right
coronary artery stenosis and 80% distal right coronary artery
stenosis. His left ventricular ejection fraction was 45%.
Mr. [**Known lastname 42744**] was then subsequently evaluated for cardiac
surgery.
HOSPITAL COURSE: Mr. [**Known lastname 42744**] was taken to the Operating Room
on [**2180-6-21**], for a coronary artery bypass graft times
five. Grafts included left internal mammary artery to
diagonal 1 and left anterior descending; saphenous vein graft
to obtuse marginal 1; saphenous vein graft to patent ductus
arteriosus and P2. His procedure was performed without
complication and Mr. [**Known lastname 42744**] was subsequently transferred to
the Cardiac Intensive Care Unit.
He was extubated on postoperative day one, weaned off drips
and hemodynamically monitored. He was fluid resuscitated and
his chest tube was discontinued on postoperative day one. By
postoperative day two, Mr. [**Known lastname 42744**] was recovering well and
felt stable to be transferred to the floor.
Mr. [**Known lastname 42744**] did well upon transfer to the floor. He was
ambulating well and tolerating a good p.o. diet. His pain
was well controlled on oral pain medications.
On postoperative day four, Mr. [**Known lastname 42744**] completed a Level V
Physical Therapy evaluation and was felt to be stable to be
discharged home.
PHYSICAL EXAMINATION: Upon discharge, temperature 99.0 F.;
pulse 103; blood pressure 114/61; respirations 22; O2
saturation 91% on room air. Examination of his heart was
regular rate and rhythm. Lungs were clear to auscultation
bilaterally. Abdomen was soft, nontender, nondistended,with
normoactive bowel sounds. His extremities were remarkable
for trace edema in the bilateral lower extremities. His
incision was clean, dry and intact.
DISCHARGE MEDICATIONS:
1. Glipizide XL 10 mg p.o. q. day.
2. Metformin 500 mg p.o. twice a day.
3. Enteric-coated aspirin 325 mg p.o. q. day.
4. Docusate 100 mg p.o. twice a day while taking Percocet.
5. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mEq p.o. twice a day times 14 days.
6. Furosemide 20 mg p.o. twice a day times 14 days.
7. Metoprolol 50 mg p.o. twice a day.
8. Percocet one to two tablets q. four to six hours p.r.n.
as needed for pain.
9. Calcium carbonate 1000 mg three times a day for one week.
DISCHARGE INSTRUCTIONS:
1. Mr. [**Known lastname 42744**] is to follow-up with Dr. [**Last Name (STitle) 1537**] in four weeks.
2. He is to follow-up with Dr. [**Last Name (STitle) 41033**] in three to four
weeks.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: Mr. [**Known lastname 42744**] is to be discharged home.
DISCHARGE DIAGNOSES:
1. Status post coronary artery bypass graft times five.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Name8 (MD) 11235**]
MEDQUIST36
D: [**2180-6-25**] 17:38
T: [**2180-6-25**] 21:29
JOB#: [**Job Number 42710**]
|
[
"429.9",
"401.9",
"272.0",
"305.1",
"414.01",
"250.00",
"410.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.61",
"37.22",
"36.15",
"88.56",
"39.61",
"36.14",
"88.53"
] |
icd9pcs
|
[
[
[]
]
] |
919, 1059
|
4699, 5024
|
3816, 4349
|
2231, 3347
|
4373, 4566
|
3371, 3793
|
1079, 1213
|
153, 186
|
216, 726
|
748, 822
|
840, 901
|
4592, 4678
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,370
| 111,547
|
1017
|
Discharge summary
|
report
|
Admission Date: [**2137-12-2**] Discharge Date: [**2137-12-6**]
Date of Birth: [**2089-4-25**] Sex: M
Service: MEDICINE
Allergies:
Ziagen / Crixivan / Pravastatin
Attending:[**First Name3 (LF) 6701**]
Chief Complaint:
Myalgias
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
48yoM with HIV on HAART, HTN, HL, polysubstance abuse,
depression p/w 8-10 days of worsening watery diarrhea, nausea,
anorexia, diffuse myalgia, and chills. The patient states that
he began feeling ill about 10 days ago and that his symptoms
progressive worsened and have not improved. He states that he
has diarrhea at baseline from HIV meds, but that the diarrhea
has been especially severe - profuse, watery, some blood in
stool (not unusual as pt is s/p chemo/radiation for anal
cancer). He has had severe nausea, dry heaves without vomiting
because he hasn't eaten much in the past 10 days. He has tried
to drink fluids. He also endorses diffuse myalgia from his legs
to his jaw. No fevers, + chills - temp at home has been 95-96.0.
No sick contacts. [**Name (NI) **] has continued to take his HIV meds normally
and has continued to take his BP meds except for HCTZ, which he
discontinued the past 2 days. No rashes, no CP or SOB. No
dysuria. He describes vision changes this AM and feels
lightheaded upon standing. He did have the flu shot this year.
Pt was seen at HCP office at [**Name (NI) 778**] Clinic and BP in 70s/40s
with associated lightheadedness upon standing and with visual
changes this morning. Guarding on abd exam but no focal
tenderness. Hypothermic to 95-96.7 in office. He has been taking
2 of 3 BP meds despite illness (has continued atenolol 25 mg
qday and moexipril 15 mg qday). Does report blood in stool but
has history of this from anal ca s/p radiation/chemo.
In the ED, triage vital signs were: 97.1 73 79/45 18 98% RA. Pt
found to have a CK of [**Numeric Identifier 6702**], Cr of 27, anion gap of 30 and phos
of 18.9. Triggered in ED for hypotension, but was mentating,
awake. Received 4L NS bolus and now 1L D5W with 3 amps bicarb.
Now SBPs in 100's. No tachycardia. UA and CXR unremarkable.
Given vanc and zosyn and nephrology was consulted in ED. VBG
initially with pH 7.07. 2 18g PIVs were placed.
Past Medical History:
HIV diagnosed in [**2118-7-14**], with a recent CD4 count 355
([**8-/2137**])
Stage I Squamous Carcinoma of the Rectum s/p 5FU and cisplatin
and XRT
Anal condylomata treated multiple times with cryotherapy
syphilis in [**2129**]
hypertension
depression with suicidal
ideation in [**2133-5-14**]
ETOH abuse
polysubstance abuse
Social History:
He lives in [**Location 2251**]. He currently lives alone.
He did not have a partner at this time. He works as a book
keeper for a scrapyard on Monday, Wednesday, and Friday. He has
smoked a pack and a half of cigarettes since he was 15 years old
and drinks alcohol moderately.
Family History:
H/O ? heart disease in father when his father was in his late
30s; htn runs in the family
Physical Exam:
VS: Temp: 96 BP:102/68 HR:87 RR:16 O2sat 99RA
GEN: pleasant, NAD, shivering
HEENT: PERRL, EOMI, anicteric, MM dry, op without lesions, no
supraclavicular or cervical lymphadenopathy, no jvd, no carotid
bruits, no thyromegaly or thyroid nodules, occasional facial
muscle spasm
RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl, no m/r/g
ABD: somewhat distended, tympanic, +b/s, nt, no masses or
hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated. No pass-pointing on
finger to nose. 2+DTR's-patellar and biceps. No Chvosteks or
Trousseaus sign.
Pertinent Results:
ADMISSION LABS:
[**2137-12-2**] 04:45PM BLOOD WBC-5.6 RBC-3.11*# Hgb-11.0*# Hct-33.2*#
MCV-107* MCH-35.6* MCHC-33.3 RDW-13.7 Plt Ct-261
[**2137-12-2**] 04:45PM BLOOD Neuts-76.1* Lymphs-15.4* Monos-4.3
Eos-3.7 Baso-0.5
[**2137-12-2**] 04:45PM BLOOD PT-13.6* PTT-29.4 INR(PT)-1.2*
[**2137-12-2**] 04:45PM BLOOD Glucose-146* UreaN-208* Creat-27.7*#
Na-133 K-5.4* Cl-95* HCO3-8* AnGap-35*
[**2137-12-2**] 04:45PM BLOOD ALT-120* AST-206* CK(CPK)-[**Numeric Identifier 6702**]*
TotBili-0.8
[**2137-12-2**] 04:45PM BLOOD CK-MB-277* MB Indx-1.4 cTropnT-0.04*
[**2137-12-2**] 04:45PM BLOOD Calcium-6.5* Phos-18.9*# Mg-1.9
[**2137-12-2**] 05:17PM BLOOD Lactate-0.6 K-5.3
[**2137-12-2**] 05:17PM BLOOD freeCa-0.78*
URINE:
[**2137-12-2**] 07:44PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.011
[**2137-12-2**] 07:44PM URINE Blood-LG Nitrite-NEG Protein-150
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2137-12-2**] 07:44PM URINE RBC-[**2-15**]* WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-0
[**2137-12-2**] 07:44PM URINE Hours-RANDOM UreaN-414 Creat-132 Na-43
K-36 Cl-44
[**2137-12-2**] 07:44PM URINE Myoglob-PRESUMPTIV
[**2137-12-2**] 07:44PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
OTHER PERTINENT LABS:
[**2137-12-3**] 12:53PM BLOOD Ret Aut-1.0*
[**2137-12-2**] 04:45PM BLOOD CK(CPK)-[**Numeric Identifier 6702**]*
[**2137-12-2**] 08:50PM BLOOD CK(CPK)-[**Numeric Identifier 6703**]*
[**2137-12-3**] 12:40AM BLOOD CK(CPK)-[**Numeric Identifier 6704**]*
[**2137-12-3**] 05:10AM BLOOD CK(CPK)-[**Numeric Identifier 6705**]*
[**2137-12-3**] 09:02PM BLOOD CK(CPK)-[**Numeric Identifier 6706**]*
[**2137-12-4**] 05:35PM BLOOD CK(CPK)-6975*
[**2137-12-5**] 01:59AM BLOOD CK(CPK)-5275*
[**2137-12-5**] 05:38AM BLOOD CK(CPK)-5077*
[**2137-12-5**] 11:21PM BLOOD CK(CPK)-4104*
[**2137-12-6**] 05:48AM BLOOD CK(CPK)-3328*
[**2137-12-2**] 04:45PM BLOOD CK-MB-277* MB Indx-1.4 cTropnT-0.04*
[**2137-12-2**] 08:50PM BLOOD cTropnT-0.03*
[**2137-12-3**] 12:40AM BLOOD CK-MB-220* MB Indx-1.3 cTropnT-0.03*
[**2137-12-3**] 05:10AM BLOOD CK-MB-178* MB Indx-1.2 cTropnT-0.03*
[**2137-12-5**] 05:38AM Iron-117 calTIBC-302 VitB12-347 Folate-4.8
Ferritn-828* TRF-232
[**2137-12-4**] 08:17AM BLOOD TSH-1.7
[**2137-12-5**] 05:38AM BLOOD IgA-95
[**2137-12-5**] 05:38AM BLOOD tTG-IgA-PND
MICRO:
[**2137-12-2**] BCx: NGTD
[**2137-12-3**] MRSA screen: negative
[**2137-12-3**] Stool studies:
FECAL CULTURE (Pending):
CAMPYLOBACTER CULTURE (Final [**2137-12-5**]): NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final [**2137-12-4**]):
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
.
CHARCOT-[**Location (un) **] CRYSTALS PRESENT.
Cryptosporidium/Giardia (DFA) (Final [**2137-12-5**]):
NO CRYPTOSPORIDIUM OR GIARDIA SEEN.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2137-12-4**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
[**2137-12-5**] 03:26PM STOOL FECAL FAT, QUALITATIVE, RANDOM-PND
STUDIES:
[**2137-12-2**] CXR:
No acute intrathoracic process.
[**2137-12-2**] CT head:
No acute intracranial hemorrhage or fractures identified.
[**2137-12-5**] Renal U/S:
Normal study
DISCHARGE LABS:
[**2137-12-6**] 05:48AM BLOOD WBC-5.6 RBC-2.35* Hgb-8.3* Hct-24.3*
MCV-104* MCH-35.3* MCHC-34.1 RDW-14.0 Plt Ct-301
[**2137-12-6**] 05:48AM BLOOD Glucose-98 UreaN-129* Creat-14.7* Na-143
K-3.4 Cl-109* HCO3-17* AnGap-20
[**2137-12-6**] 05:48AM BLOOD CK(CPK)-3328*
[**2137-12-6**] 05:48AM BLOOD Calcium-6.7* Phos-8.7* Mg-1.6
[**2137-12-6**] 06:10AM BLOOD freeCa-0.85*
Brief Hospital Course:
Mr. [**Known lastname 6707**] is a 48 year old man with h/o HIV, on HAART, rectal
SCC, HLD on statin, who was admitted with acute renal failure
and rhabdomyolysis.
# Acute renal failure: Differential includes prerenal renal
failure d/t N/V, decreased PO intake, ATN secondary to low BP's
at home (pt was taking antihypertensive meds at home) and
heme-pigment induced ATN in the setting of rhabdomyolysis due to
tenofovir or statin. Nephrology saw muddy brown casts on urine
sediment, so most likely ATN pigment nephropathy provoked by
HAART meds. Pt was profoundly acidemic (pH 7.07) and
hyperphosphatemic on admission, but potassium was only mildly
elevated. Nephrology was consulted in the ED. Cr on admission
was 27.7, which has trended down to 14.7 on discharge. The
patient did not need HD initiation. He was started on aluminum
hydroxide. Currently auto-diuresing well.
# Rhabdomyolysis: CK elevated to 20,000 on admission, but pt
denies recent red/brown urine. Potential etiologies of rhabdo in
this pt include statin-induced, tenofovir related, viral,
hypothyroid. CK has trended down to 3300 on discharge. Statin
and fibrate have been discontinued. HAART medications were held
- can be restarted as an outpatient.
# Diarrhea: Patient has had chronic diarrhea, which has recently
worsened. Stool studies are negative to date - Cdiff negative,
no O&P, no crypto/giardia/campylobacter. Fecal fat and stool
culture still pending on discharge.
# Anemia: Pt with macrocytic anemia, HCT in mid 20s. No evidence
of bleeding during hospitalization. Given low retic count, may
have degree of marrow suppression from prior chemo, xrt, and
ARVs.
# Hypocalcemia: Occasional muscle spasm of facial muscles
concerning for tetany early in hospitalization, which resolved.
To prevent complications of hypercalcemia in recovery phase,
avoided calcium repletion in the absense of hypocalcemic
symptoms or severe hyperkalemia. Goal ionized Ca 0.8-0.9.
# Hypotension: In clinic pt was in the 70's systolic but able to
relate a history. In [**Name (NI) **] pt was in the 80's for SBP, which
improved with 4L IVF. SBP 100-110s while hospitalized. Atenolol
and HCTZ were held.
# HIV: Well controlled on current regimen. Held HAART regimen
given ARF.
# Rectal SCC: S/p chemotherapy (5FU, cisplatin) and XRT.
Followed in oncology by Dr. [**Last Name (STitle) **]. Currently stable.
# Insomnia: Continued on home seroquel and klonopin.
Medications on Admission:
TRUVADA 200-300 MG TABS 1 TAB daily
REYATAZ 150 MG 2 CAPS daily
NORVIR 100 MG CAPS 1 CAP daily
ATENOLOL 25 MG daily
VENTOLIN HFA 2puff q4-6 HOURS
ACYCLOVIR 800 MG q8 prn herpes
REMERON 30 MG qhs
PRAVASTATIN 40 MG daily
SEROQUEL 100 MG 1-2 tabs PO QHS
FENOFIBRATE 160 daily
KLONOPIN 1 MG QHS
HCTZ 12.5MG daily
UNIVASC 15 MG TABS (MOEXIPRIL HCL) 1 TAB BY MOUTH EACH DAY
IMODIUM A-D 2 MG TABS (LOPERAMIDE HCL) TAKE 1 TAB BY MOUTH EVERY
8 HRS PRN DIARRHEA
Discharge Medications:
1. Outpatient Lab Work
Please draw CBC/diff, CHEM10, ionized calcium, CK once a week
starting [**2137-12-9**] at [**Hospital1 778**] Health.
2. clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
3. quetiapine 200 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
4. aluminum hydroxide gel 600 mg/5 mL Suspension Sig: Thirty
(30) ML PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*1 bottle* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Rhabdomyolysis
Acute renal failure
Secondary Diagnosis:
HIV
Chronic diarrhea
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to [**Hospital1 69**] for
fatigue, malaise, and diarrhea. You were found to have
rhabdomyolysis and acute renal failure. You were treated with
fluids and electrolyte replacements. Your kidney function is
improving.
The following changes were made to your medications:
#. HOLD Truvada, Reyataz, Norvir
#. HOLD Atenolol, Hydrochlorothiazide
#. DISCONTINUE Pravastatin, Fenofibrate
#. START Aluminum hydroxide 3 times a day with meals
Followup Instructions:
Please call [**Hospital1 778**] Health at [**Telephone/Fax (1) 798**] early Monday morning
for an appointment. They will make sure that somebody can see on
Monday. You also need to have your blood drawn next Monday
[**2137-12-9**] at [**Hospital1 778**].
The following appointments have been made for you:
Department: NEPHROLOGY
When: TUESDAY [**2137-12-24**] at 3:00 PM
With: [**Known firstname 177**] [**Last Name (NamePattern4) 720**], M.D. [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6708**]
|
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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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301, 309
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,244
| 184,401
|
24055
|
Discharge summary
|
report
|
Admission Date: [**2107-12-16**] Discharge Date: [**2107-12-20**]
Date of Birth: [**2055-10-1**] 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:
[**2107-12-16**] Coronary artery bypass grafting times three (LIMA to LAD,
SVG to OM1, SVG to L PDA)
History of Present Illness:
Mr. [**Known lastname 61187**] is 52 yo Cantonese speaking man with complaints of
chest pain with exertion. He had an abnormal stress echo and was
referred for cardiac catheterization, which revealed
multi-vessel disease.
Past Medical History:
Hypertension
Hyperlipidemia
GERD
H.Pylori
Microscopic hematuria
Anxiety
Hammertoe deformities
Onychodystrophy
Past Surgical History:
s/p hemorrhoidectomy
Social History:
Mr. [**Known lastname 61187**] lives with his wife and two children. He is a waiter.
He denies tobacco or alcohol.
Family History:
Mr. [**Known lastname 61188**] daughter has cardiomyopathy at age 6.
Physical Exam:
Pulse:70 Resp:16 O2 sat:100% RA
B/P Right:119/72 Left: 124/75
Height:5'[**07**]" Weight:165 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: Dressing in place Left: +2
DP Right: +1 Left: +1
PT [**Name (NI) 167**]: +1 Left: +1
Radial Right: +2 Left: +2
Carotid Bruit Right: 0 Left:0
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 61189**] (Complete) Done
[**2107-12-16**] at 3:44:59 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
[**Street Address(2) 15115**]
[**Location (un) 15116**], [**Numeric Identifier 15117**] Status: Inpatient DOB: [**2055-10-1**]
Age (years): 52 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: CABG
ICD-9 Codes: 786.05, 786.51, 424.0
Test Information
Date/Time: [**2107-12-16**] at 15:44 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3318**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2010AW-1: Machine: [**Doctor Last Name 11422**]
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. Trivial
MR.
TRICUSPID VALVE: Physiologic 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. Trivial mitral
regurgitation is seen.
There is no pericardial effusion.
Post-CPB:
Preserved biventricular function
LVEF >55%
Aortic Contours intact
Remaining Exam is unchanged
All findingds discussed with surgeons at the time of the exam.
[**2107-12-20**] 06:45AM BLOOD WBC-9.9 RBC-3.46* Hgb-10.5* Hct-31.0*
MCV-90 MCH-30.2 MCHC-33.7 RDW-14.1 Plt Ct-186#
[**2107-12-20**] 06:45AM BLOOD Glucose-104* UreaN-12 Creat-0.7 Na-143
K-3.8 Cl-106 HCO3-28 AnGap-13
Brief Hospital Course:
On [**2107-12-16**] Mr. [**Known lastname 61187**] [**Last Name (Titles) 1834**] a coronary artery bypass grafting
times three (LIMA to LAD, SVG to OM1, SVG to L PDA). This
procedure was performed by Dr. [**Last Name (STitle) **]. Please see the
operative note for details. He tolerated this procedure well
and was transferred in critical but stable condition to the
surgical intensive care unit. He was extubated and weaned from
his pressors. His chest tubes were removed and he was
transferred to the step down floor. His epicardial wires were
removed and he was seen in consultation by the physical therapy
service. By post-operative day four he was deemed ready for
discharge to home by Dr. [**Last Name (STitle) **]. All follow-up
appointments wer advised.
Medications on Admission:
Atenolol 25mg po BID
Plavix 75 mg po daily
Nexium 40mg po daily
NTG 0.4mg SL PRN
Simvastatin 80mg po daily
ASA 81mg po daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
Disp:*270 Tablet(s)* Refills:*2*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
4. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
Disp:*7 Tablet(s)* Refills:*2*
7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 7
days.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
coronary artery disease
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with percocet prn
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**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
Please call to schedule appointments
Surgeon Dr [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Primary Care Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6431**] in [**12-10**] weeks [**Telephone/Fax (1) 1144**]
Cardiologist Dr [**First Name (STitle) **] [**Name (STitle) **] in [**12-10**] weeks
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2107-12-20**]
|
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880, 998
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,912
| 128,946
|
39366
|
Discharge summary
|
report
|
Admission Date: [**2108-8-22**] Discharge Date: [**2108-8-24**]
Date of Birth: [**2038-1-5**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6075**]
Chief Complaint:
Called by Emergency Department to evaluate
non-responsive patient sent by OSH for neuro eval.
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The pt is a 70 year-old female of unknown handedness with
history of HTN, HLD, CAD (reportedly had MI a few years prior),
CVA in past but unknown symptoms, ?known carotid disease,
vertigo
who presented to an OSH with nausea and vomiting, and by report
possible left arm weakness.
The history on this patient is unfortunately unknown for the
most
part. She was transferred from [**Hospital1 **] for unclear
reasons. She came with one phone number that turned out to be
her husband, but they separated 10 years prior. He reluctantly
gave us his daughter's number who also did not know the past
days
events, and then provided a family friend who also was unaware
of
what occurred. She was apparently taken to the ED by her
brother
who is in his 80s and was not available to speak at this time.
This is what was available through these family members and the
staff at [**Name (NI) **] [**Name (NI) 1459**]:
What is known is the patient is usually able to speak and
interact and is usually ambulatory. At some time over the last
week she had increased urinary frequency, and was concerned that
she had a UTI. She was apparently seen by her PCP who started
her on Cipro. She was seen by her estranged husband yesterday
and he said she was "fine" but just kept going to bathroom.
According to her daughter the patient was having some nausea
yesterday, unclear if there was vertigo and there was some
episodes of vomiting. There is a report from the OSH that the
patient had complained of difficulty with her left arm, but this
is not corroborated by the family available. She was taken in
to
[**Location (un) **] [**Location (un) 1459**] (according to the daughter) because of the
nausea. At the OSH they did not note any left sided weakness
however they felt she was not able to lift either of her legs.
The decided to get a head CT. At some point while at the OSH
the
patient become "incoherent" and less responsive. Based on the
note and exam at the OSH it does not appear that she is
following
commands or interacting with the examiner enough to do a formal
exam. Based on this she was sent to [**Hospital1 18**] for further
evaluation. There is no record of how interactive she was prior
to coming to the hospital, but according to family, at least as
recently as yesterday she was able to interact.
Here the patient will open her eyes but will not engage the
examiner at all. She will not speak, not follow commands, or
mimic the examiner. She is not able to provide any history of
today's events.
Past Medical History:
- MI (a few years prior)
- history of vertigo tx with meclizine
- HTN
- HLD
- CVA in [**2104**] (unclear what the symptoms were)
- carotid disease
- recent hospitalization ~4 week prior for diarrhea/UTI/vertigo
Social History:
Lives in a low income elder housing. Separated from
husband. [**Name (NI) **] brother and family friend who help take care of
her, usually able to do her own daily activities. Long smoking
history of unknown duration, no etoh or drug known
Family History:
Unknown, some cardiac disease
Physical Exam:
Awake, looks older than stated age, various areas of
mild skin breakdown
HEENT: NC/AT, no scleral icterus noted, dry mouth,
Neck: Supple, bruit on right sided of neck, No nuchal rigidity
Pulmonary: Lungs CTA
Cardiac: RRR, nl. S1S2, systolic murmur
Abdomen: soft, NT/ND, normoactive bowel sounds
Extremities: lesion on right sole - flaky and erythematous ?
psoriatic lesion.
Pertinent Results:
[**2108-8-22**] 09:45PM PT-12.4 PTT-46.9* INR(PT)-1.0
[**2108-8-22**] 04:30AM CEREBROSPINAL FLUID (CSF) PROTEIN-23
GLUCOSE-103
[**2108-8-22**] 04:30AM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-0 POLYS-1
LYMPHS-78 MONOS-21
[**2108-8-22**] 01:45AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-150
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-1 PH-7.0 LEUK-NEG
[**2108-8-22**] 01:15AM LACTATE-1.7
[**2108-8-22**] 01:00AM cTropnT-<0.01
MRI [**2108-8-22**]
FINDINGS: There is no intracranial hemorrhage. Diffusion
sequences
demonstrate bilateral and acute ACA territory infarcts extending
into the genu
of the corpus callosum and left posterior parietal parasagittal
cortex. There
is a small left posterior parietal infarct. There is para
sagittal gyral
edema. No evidence of midline shift, intracranial mass or mass
effect. The
ventricles and sulci are slightly prominent. There is no CP
angle mass.
There are scattered foci of T2 and FLAIR hyperintensities in the
subcortical
and deep white matter and pons in keeping with chronic
microangiopathic small
vessel disease.
IMPRESSION:
Bilateral acute ACA territory infarcts.
Brief Hospital Course:
Pt [**Name (NI) 4223**] was admitted for altered level of mental status. She
was found to be in a semi-comatose state. She was admitted to
the Neuro-ICU team for further evaluation. She was started on
heparin for a possible stroke while we obtained an MRI. An MRI
was completed which showed bilateral ACA infarcts resulting in
akinetic mutism. The family was made aware of the diagnosis and
decided to make the patient CMO. She was transferred to an
outside facility for this.
Medications on Admission:
- Imdur 30mg qd
- ASA 325mg qd
- Metoprolol 50mg [**Hospital1 **]
- Simvastatin 40mg qd
- Lisinopril 10mg qd
- Nitro PRN
- Meclizine 12.5mg TID prn
- Omeprazole 20mg qd
- Tylenol PRN
Discharge Medications:
n/a
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Senior Healthcare of [**Location (un) **]
Discharge Diagnosis:
Primary
- Bilateral ACA stroke
Discharge Condition:
Vegatative state.
Discharge Instructions:
You were admitted from an outside hospital for altered mental
status. You were initially admitted to the medicine team and
were then transferred to the Neuro ICU team for further care.
You had an MRI that showed a stroke on both sides of your brain.
This has led to something called akinetic mutism. You were made
comfort measures only by your family. You were discharged to an
extended care facility.
Followup Instructions:
No follow up.
Completed by:[**2108-8-24**]
|
[
"434.91",
"780.03",
"272.4",
"414.01",
"725",
"412",
"401.9",
"426.4",
"784.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
5801, 5886
|
5060, 5538
|
411, 417
|
5961, 5981
|
3918, 5037
|
6431, 6476
|
3475, 3507
|
5773, 5778
|
5907, 5940
|
5564, 5750
|
6005, 6408
|
3522, 3899
|
277, 373
|
445, 2963
|
2985, 3198
|
3214, 3459
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,208
| 115,054
|
6420
|
Discharge summary
|
report
|
Admission Date: [**2139-2-11**] Discharge Date: [**2139-2-17**]
Date of Birth: [**2063-4-26**] Sex: F
Service: MEDICINE
Allergies:
Vioxx / Compazine / Phenergan
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
AMS/sepsis
Major Surgical or Invasive Procedure:
Lumbar Puncture
Tunnel Cath Placement
History of Present Illness:
This is a 75 yo F with a history of HTN, CAD, ulcerative
colitis, ESRD nearing HD initiation, and h/o recurrent UTIs
including multiresistent organisms who is admitted from [**Hospital1 **] with hypothermia, altered mental status, sepsis.
The patient was admitted on [**2-1**] with a chief complaint of
weakness. She had been unable to ambulate and had progressive
decreased PO intake, inability to even ambulate to the bathroom.
She was initially started on ctx for a presumed UTI from
[**Date range (1) 24729**], switched to unasyn from [**Date range (1) 24730**]. On the 4th was
obtunded, bradycardic and hypothermic, and was transfered to the
ICU.
Changed abx on 4th to ceftaz, got IVF, on the 6th, went from 4L
NC to 80% FM and was intubated. CXR on [**2-9**] showed new effusions
(few CXR there). Abx - ctaz, ctx, acyclovir (concern for CNS
infection), 1x dose for tobramycin, then got one time dose of
vanc on 5th, ? linezolid at least on the day of transfer.
Of note, patient was admitted to [**Hospital1 18**] from [**2139-1-5**] to [**2139-1-8**]
with mental status changes likely [**3-9**] a Klebsiella UTI treated
with a 10 day course of Ciprofloxacin. She was also admitted to
the ICU in early [**Month (only) **] with severe metabolic acidosis
requiring bicarb gtt and worsening renal failure.
On arrival, the patient is intubated, and continues to be
hypothermic to around 95 degrees. She is unresponsive, appears
to decorticate with noxious stimuli. On minimal pressor support
with levophed.
ROS: Unobtainable
Past Medical History:
- Chronic UTIs, been on suppressive therapy in the past, last
abx course was Cipro, completed on [**1-17**], followed by [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 7443**]/[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in ID
- History of VRE
- End Stage Renal Disease: Stage V. C/b renal osteodystrophy.
Patient states that she is heading toward HD. Has plans for AVF,
but was initially postponed until infection-free. Followed by
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10083**] at [**Last Name (un) **] and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**] with Transplant
Nephrology
- History of Nephrolithiasis
- GERD with esophageal strictures and dysphagia, last balloon
dilatation [**12-12**]
- Ulcerative colitis status post colectomy and ileostomy
- Cervical spondylosis with chronic low back pain
- Hypertension
- S/p thyroid resection
- Vitamin D deficiency
- Macrocytic Anemia: B12 deficiency and CKD, baseline range
23-29
- Hypercholesterolemia
- CAD: last echo [**3-15**]. LVEF 70%. no h/o MI
- Pulmonary hypertension (mild PSH on ECHO [**3-15**])
- Venous insufficiency
- Sleep apnea: uses CPAP at night.
- Chronic LE cellulitis - treated with bilat unaboot
Social History:
Patient married. Lives in [**Location 3915**], MA with husband; daughter
and son-in-law live on different level of same house. 2
children, 3 grandchildren. Never a smoker. Denies EtOH use. Pt
not very ambulatory. Sleeps in chair with commode nearby.
Husband helps with her medications, has VNA but no home health
aide.
Family History:
Mother died of MI at age 62, father died of stroke in 70s.
Sister with HTN and DM.
Physical Exam:
On Presentation:
Vitals: T: 94.9 BP: 112/56 HR: 57 Intbated on AC satting 100% ,
Vt 500, RR 10, PEEP 5, FiO2 35%
GEN: Obese, unresponsive
HEENT: Pupils constricted, minimally reactive, sclera anicteric,
mild proptosis bilaterally, epistaxis from R nares, ETT in place
NECK: No JVD, no bruits, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses diminished
bilaterally
PULM: Lungs clear anteriorly, + rhonchi
ABD: Soft, NT, ND, +BS, no masses, ostomy in RLQ with guaiac +
watery output
EXT: Significant stasis dermatitis, multiple ecchymosis with
scabbed areas of skin, erythema without warmth
NEURO: Unresponsive, minimal reaction of pupils, responds to
noxious stimuli with grimace and internal rotation of arms
Pertinent Results:
ADMISSION LABS:
-[**2139-2-11**] 04:08PM WBC-8.4 RBC-2.56* HGB-9.4* HCT-28.8*
MCV-112* MCH-36.7* MCHC-32.6 RDW-15.6*
-[**2139-2-11**] 04:08PM CALCIUM-8.0* PHOSPHATE-4.3# MAGNESIUM-1.9
-[**2139-2-11**] 04:08PM GLUCOSE-195* UREA N-25* CREAT-2.1*
SODIUM-141 POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-16* ANION
GAP-26*
-[**2139-2-11**] 04:25PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-LG
[**2139-2-11**] 04:08PM PT-12.7 PTT-48.6* INR(PT)-1.0
IMAGING:
CT HEAD: No acute intracranial abnormalities or hemorrhage.
Sinus fluid
level and soft tissue changes could be related to intubation but
clinical
correlation recommended.
CT NECK:
No focal fluid collection is seen in the neck. Mild stranding of
the soft fat is identified bilaterally. Degenerative changes are
seen in the cervical spine. Opacity seen in partially
visualized right upper lung, for
which correlation with torso CT is recommended.
CT TORSO:
1. No evidence of retroperitoneal bleed.
2. Large bilateral pleural effusions with complete left lower
lobe and near
complete right lower lobe collapse. Patchy opacities in the
right upper lobe
in a bronchovascular distribution consistent with an infectious
vs
inflammatory process.
3. Findings suggestive of chronic dissection within the distal
abdominal
aorta without aneurysmal dilatation. Evaluation of the abdominal
aorta is
incomplete given lack of IV contrast administration.
4. Inferiorly oriented aneurysm of the aortic arch not fully
evaluated
without contrast administration.
5. Mildly enlarged mediastinal lymph nodes which are
nonspecific.
6. Mild coronary artery calcifications.
7. Anasarca.
8. Small amount of ascitic fluid surrounding the liver.
9. Small atrophic kidneys suggesting chronic renal insufficiency
with osseous findings suggesting renal osteodystrophy.
10. Extensive lower lumbar degenerative changes as described
above. MRI may be obtained for further evaluation as indicated.
CARDIAC ECHO:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen. Moderate [2+] tricuspid
regurgitation is seen (best appreciated on cine loop #63). There
is moderate pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global biventricular systolic function. Moderate
tricuspid regurgitation. Moderate pulmonary hypertension.
Pleural effusions.
EEG: Read pending
Brief Hospital Course:
MICU COURSE:
Ms. [**Name13 (STitle) **] is a 75 yo F with a history of HTN, CAD, ulcerative
colitis, ESRD nearing HD initiation, and h/o recurrent UTIs
including multiresistent organisms who was transferred from
[**Hospital3 7362**] with hypothermia, altered mental status, and
suspected urosepsis.
# Sepsis: On admission, patient met SIRS criteria with
hypothermia, elevated WBC, Likely sources are sputum growing
GNR, urine culture growing pseudomonas (though less than 100,000
colonies), all at OSH. [**Last Name (un) **] stim done at OSH, >9 point increase
in cortisol level. Pt was started on Vancomycin, Zosyn and
Flagyl, vasopressors. Prior to admission pt was noted to be
responsive only to painful stimuli with some witnessed
decortication posturing. Neurology was consulted for her altered
mental status, an LP was performed which showed no sign of
meningitis. HD was also administered for 3 sessions and showed
no improvement in mental status. A family meeting was held after
pt's mental status failed to improve, after in depth discussion
family decided on comfort measures only. Mrs. [**Known lastname 7474**] was
extubated and placed on a Morphine drip.
During the evening she developed asytole on the telemetry
monitor. On exam she was nonresponsive to voice or touch, she
had no spontaneous breathing or breath sounds present, and had
no heart sounds present. She was pronounced dead at 5:58 pm.
Her cause of death were listed as respiratory failure,
urosepsis. Her husband, son were at the bedside at time of
passing, they declined an autopsy.
Medications on Admission:
Home medications (per OSH discharge summary):
Folic acid 1 mg daily
Ditropan 5 mg [**Hospital1 **]
Protonix 40 mg [**Hospital1 **]
Sodium bicarb 650 [**Hospital1 **]
Lopressor 100 mg [**Hospital1 **]
Cardizem 60 mg QID
Norvasc 5 mg daily
Phoslo 667 mg [**Hospital1 **]
Tigan 300 mg daily
Lasix 20 mg daily
ASA 81 mg
Zyrtec 10 mg daily
Ferrous Sulfate 325 mg daily
Medications on transfer:
Miconazole powder 2% [**Hospital1 **]
Ceftaz 2 gm IV Q12H
Thiamine 100 mg daily
Hydrocortizone 50 mg IV Q8H
Linezolid 600 mg IV Q12H
Heparin 5000 u SQ Q12H
Protonix 40 mg IV Qday
Ativan 2 mg IV q2H prn
Morphine 2 mg IV q2H prn
Albuterol MDI 4 puff Q2H prn
Ipratropium MDI 17 mcg 4 puffs Q2H prn
Levophed gtt
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
[
"038.9",
"459.81",
"V44.2",
"599.0",
"682.3",
"518.81",
"403.91",
"585.5",
"530.81",
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"721.0",
"287.5",
"273.8",
"414.01",
"416.8",
"285.21",
"584.9",
"995.92"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"99.04",
"39.95",
"38.95",
"96.72",
"99.05",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
9648, 9657
|
7333, 8899
|
300, 339
|
9708, 9717
|
4376, 4376
|
9769, 9775
|
3529, 3613
|
9678, 9687
|
8925, 9290
|
9741, 9746
|
3628, 4357
|
250, 262
|
367, 1900
|
4898, 7310
|
4392, 4889
|
9315, 9625
|
1922, 3176
|
3192, 3513
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,738
| 196,355
|
5582
|
Discharge summary
|
report
|
Admission Date: [**2166-10-7**] Discharge Date: [**2166-10-17**]
Date of Birth: [**2085-2-13**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor First Name 1402**]
Chief Complaint:
ICD shocks
Major Surgical or Invasive Procedure:
Ventricular Tachycardia ablation
History of Present Illness:
81 yr old M with a PMH of CAD, three vessel disease s/p MI and
CABG in [**2142**] and subsequent LAD bare metal stenting in [**2163**]
complicated by anteroseptal aneurysm, ventricular aneurysms and
tachycarrhythmias, chronic a. fib, systolic CHF with EF of 25%,
ischemic cardiomyopathy s/p single chamber ICD, presents with
electric shock-like pain in his chest. Reports that over the
last four weeks, he has experienced 4 electric like shocks
located in his chest, that he attributes to his ICD firing.
Reports that he may have had palpitations prior to his shocks.
These events occurred when he was sitting at rest. Denies any
lightheadedness, loss of consciousness, shortness of breath,
chest pressure, nausea, vomiting, or diarrhea.
.
Admitted to EP/[**Hospital1 1516**] service for VT ablation today ([**10-9**]). Prior
to procedure patient went into recurrent VT leading to multiple
ICD shocks. He was loaded with intravenous lidocaine with
partial success. The VT was monomorphic and he was stable
hemodynamically. He was taken to EP for repeat ablation while in
VT. During the procedure patient required neosinephrine and
dopamine to support his blood pressure. Patient was admitted to
the CCU for monitoring overnight.
.
Of note, patient underwent VT ablation in [**10-14**] with ablation of
5 areas. Patient did well afterwards on amiodarone until he
developed mixed restrictive and obstructive pattern with
decreased DlCO.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
- DMII
- HTN
- CAD
- hyperlipidemia
.
2. CARDIAC HISTORY:
-CABG/Percutaneous interventions:
- CAD s/p CABG [**2142**] (LIMA-LAD, SVG-D1, SVG-OM1, SVG-PDA). His
last cardiac in [**8-/2163**] and it showed known occlusion of the LIMA
and SVG-D1 grafts. A bare metal stent (VISION 3 x 12) was placed
in the proximal LAD in 4/[**2163**]. He also has ischemic
cardiomyopathy with LVEF 30%, atrial fibrillation on chronic
coumadin therapy, and S/P ICD/PPM. His last INR is 1.7 and his
platelets are 116k. His serum creatinin is 1.3. He presented
with recurrent anginal symptoms with negative cardiac enzyme and
a unchanged ECG (Paced). He is referred for further evaluation.
- MI complicated by ventricular aneurysm and tachyarrhythmias
- three vessel CABG in [**2142**], and subsequent LAD stenting in [**2163**]
.
-PACING/ICD:
- left ventricular ejection fraction of 25%
- chronic atrial fibrillation
- [**Company **] teligen single chamber ICD, placed in [**2149**]
per pt at UPenn (Dr. [**Last Name (STitle) **].
- s/p VT ablation in [**10-14**] with ablation of 5 areas
- systolic congestive heart failure
HTN
DM 2- recently diagnosed, diet controlled
CAD s/ MIx2 , 3 vessel CABG [**2142**], and stenting [**4-/2163**], AFib on
coumadin, ischemic cardiomyopathy with EF 30%, NSVT with
Pacer/ICD
Hypothyroidism
Obstructive sleep apnea (on Bipap)
Left hemi diaphragm dysfunction
s/p Right inguinal hernia repair
Hard of hearing (bilateral aids)
Social History:
Lives in [**Hospital1 **] with his wife, has a very supportive family.
Normally active with no activity restrictions.
Tobacco history: Remote history. 16 pack year history, stopped
smoking 45 years ago
-ETOH: [**5-14**] ounces of gin daily
-Illicit drugs: Denies
Family History:
Grandfather with MI at age 74, Brother with strokes starting at
age 60.
Physical Exam:
VS: T= 96.2, BP= 100/49, HR=62, RR= 20, O2 sat= 97% RA
GENERAL: NAD. Alert and oriented x3.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP to mandible.
CARDIAC: left sided ICD implant. RRR, distant 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. Anterior breath sounds
CTA b/l.
ABDOMEN: Soft, NT, ND. No HSM or tenderness. Abd aorta not
enlarged by palpation.
EXTREMITIES: No c/c/e. No pedal edema appreciated.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Right: DP 2+ PT 2+, Left: DP 2+ PT 2+
Pertinent Results:
On admission:
[**2166-10-7**] 03:25PM GLUCOSE-148* UREA N-53* CREAT-1.9* SODIUM-140
POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-30 ANION GAP-15
[**2166-10-7**] 03:25PM CK(CPK)-80
[**2166-10-7**] 03:25PM CK-MB-NotDone cTropnT-0.01
[**2166-10-7**] 03:25PM WBC-8.4 RBC-3.75* HGB-13.3* HCT-39.7*
MCV-106* MCH-35.6* MCHC-33.6 RDW-15.1
[**2166-10-7**] 03:25PM PT-19.7* PTT-31.3 INR(PT)-1.8*
.
On discharge:
[**2166-10-17**] 06:00AM BLOOD WBC-8.7 RBC-3.23* Hgb-11.2* Hct-34.6*
MCV-107* MCH-34.7* MCHC-32.4 RDW-14.6 Plt Ct-205
[**2166-10-17**] 06:00AM BLOOD PT-20.3* PTT-33.0 INR(PT)-1.9*
[**2166-10-17**] 06:00AM BLOOD Glucose-116* UreaN-44* Creat-1.5* Na-141
K-4.5 Cl-106 HCO3-27 AnGap-13
[**2166-10-14**] 04:01AM BLOOD ALT-25 AST-24 LD(LDH)-144 AlkPhos-148*
TotBili-1.2
[**2166-10-17**] 06:00AM BLOOD Calcium-9.1 Phos-2.6* Mg-2.2
[**2166-10-8**] 06:00AM BLOOD TSH-1.8
.
Micro:
URINE CULTURE (Final [**2166-10-13**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
Blood cultures x2 from [**2166-10-14**]: no growth to date.
.
CXR [**2166-10-14**]:
INDICATION: 81-year-old male with history of ventricular
arrhythmia, now with
new fever. Evaluation for pneumonia.
TECHNIQUE: AP and lateral chest radiographs.
COMPARISON: Portable radiograph dated [**2166-10-11**] and PA and
lateral
radiographs dated [**2166-1-24**].
FINDINGS: There has been an interval increase in left lower
lobe atelectasis.
There is stable elevation of the left hemidiaphragm. A small
left-sided
pleural effusion cannot be fully excluded. The heart is enlarged
and stable.
There is no pneumothorax. There are three pacemaker leads
entering the right
ventricle. Sternal wires are in unchanged position.
IMPRESSION: Interval increase in left-sided atelectasis.
The study and the report were reviewed by the staff
radiologist.
.
EKG [**10-15**]:
Regular narrow complex rhythm. Since the previous tracing
ventricular pacing is not seen. Morphology suggests left axis
deviation. Possible myocardial
ischemia and anterior myocardial infarction. Intraventricular
conduction delay with ST-T wave abnormalities. There may be P
waves in the ST segments. Clinical correlation is suggested.
.
Note by Social Worker, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 805**]:
SOCIAL WORK: Pt referred to SW in POE and by nursing staff re:
concern about PTSD response from having several ICD discharges
prior to his cardiac ablation. SW met with pt and his wife in
his room on [**Name (NI) 121**] 3; wife provided initial hx of recent events as
pt is HOH. Wife reports pt has complained about poor sleep,
restlessness, and fear about potential ICD firing. She notes
today is the first in several days where she observed pt to
relax
enough to get some benefit from his C-pap machine, and get some
rest. Wife also noted pt is "very Scandinavian" and usually
reserved about sharing his emotions, to which pt agreed. Wife
reports pt gets anxious at night when family is getting ready to
leave, does not want to be left alone. Pt endorsed having
perseverative thoughts about potential for ICD to fire again.
He
reports having fear of the pain and discomfort of ICD firing and
worry about his mortality. Pt notes worry interrupts his sleep,
and that he has been having strange dreams, and feels he is
still
dreaming at times when he wakes up and interacts with staff. Pt
reports he has felt restless at night, wanting to get out of
bed,
and then feeling anxious when staff confine him to his bed. Pt
understands this is for his safety, but feels distress in the
moment. SW reviewed mindful breathing as a relaxation strategy
and advised him to practice as wife is leaving at night, and
when
he is trying to get back to sleep at night. SW normalized pt's
feelings/ worries and noted that sleep disturbance/ confusion at
night is multi-factorial and likely to abate as his symptoms
resolve.
ASSESSMENT: Pt experiencing anxiety and difficult adjustment to
illness and uncertainty about the future, notably ICD firing and
possible death.
PLAN:
-SW will follow while in hospital to provide supportive
counseling and psycho ed re: relaxation techniques.
-Pt/ wife anticipating rehab stay prior to returning home as pt
feels deconditioned, pt in process of being screened per Case
Manager.
Brief Hospital Course:
81 yr old M with a PMH of CAD, three vessel disease s/p MI and
CABG in [**2142**] and subsequent LAD stenting in [**2163**] complicated by
ventricular aneurysms and tachycarrhythmias, chronic a. fib,
systolic CHF with EF of 25% s/p single chamber ICD presents with
electric shock-like pain in his chest. Patient had VT storm and
required pressor support during ablation and was initially
admitted to CCU for monitoring.
.
#Ventricular Tachycardia:
Patient has [**Company **] teligen single chamber ICD. Past
week patient had recurrent ICD firing. Admitted for planned VT
ablation. Prior to procedure patient went into recurrent VT
leading to multiple ICD shocks. He was loaded with intravenous
lidocaine with partial success. During the procedure patient
required neosinephrine and dopamine to support his blood
pressure. Underwent VT ablation on [**10-9**] and was started on
Quinidine and Metoprolol after procedure. No VT since starting
quinidine. Discussion about upgrading ICD to BiV and adding
atrial lead now that pt in NSR. This will be deferred until
after discharge. Appt with Dr. [**Last Name (STitle) **] and the device clinic
later this month. Please check QTc every other day while pt is
on telemetry, last QTc 0.46. Needs to be followed for recurrent
VT. Please note that pt has been very anxious about ICD firing
and was seen by social work while here.
.
# Chronic Atrial Fibrillation.
Rhythm has been V paced alternating with AF. Good rate control
on Metoprolol and Quinidine. Pt was on heparin gtt for low INR
until INR therapeutic. Coumadin was increased from home dose of
5mg daily to 6mg daily, as INR 1.9. He will need freq INR
checks until INR > 2.0 and stable on current dose. Assume that
Warfarin may need to be decreased initiated because of
antibiotics.
.
#Hematuria and Urinary Retention.
Pt had a foley catheter for his procedure, initially had urinary
retention when the catheter was d/c'ed, then had hematuria after
catheter replaced. Now has no retention with PVR 50cc,
independently voiding and hematuria has cleared. A Urology appt
has been scheduled to assess for further workup. Please
encourage fluid intake of 1.5 liters per day
.
#Coronary Artery Disease:
MI complicated by ventricular aneurysm and tachyarrhythmias
Three vessel CABG in [**2142**], and subsequent LAD stenting in [**2163**]
Not an active issue during this hospital stay. No chest pain or
signs of ischemia. Pt was continued on ASpirin, Metoprolol and
restarted [**Last Name (un) **] on discharge.
.
#Acute on Chronic Kidney Failure
Creatinine increased to 1.9 during initial hospital course, now
is 1.5 which is baseline. ARF thought [**2-10**] hypotension and acute
illness, resolved spontaneously with improved BP. [**Last Name (un) **] was held
initially restarted at discharge.
.
#Sepsis [**2-10**] Urinary Tract Infection: Pt was febrile with
leukocytosis, UA/UCx showed E. Colic UTI. Pt was treated with
Cepodoxime [**Last Name (LF) **], [**First Name3 (LF) **] be discharged with 14 day total course.
.
#Acute on Chronic Systolic Heart Failure: ECHO this admission
demonstrates EF 30%. Appears euvolemic with no peripheral edema
or crackles on exam. Lasix and Elpleronone was held because of
hypotension, restarted at discharge along with [**Last Name (un) **] and
Metoprolol. Pt should have daily weights, careful assessment of
his fluid status and follow a 2 gram Na diet.
# Gout:
C/O recurring symptoms in bilat ankles, no redness, swelling,
sensitive to touch medially and laterally. Colchicine has helped
in the past. Allopurinol was not restarted during acute flare
but Colchicine was given QID for total of 3 days. Please titrate
to diarrhea and restart Allopurinol once acute flare is
resolved.
.
# DMII: hold amaryl while inpatient but restarted at discharge.
Rec'd QID Fingersticks that ranged from 110-160's. Would check
fingersticks for a few days after transfer to assess glucose
control.
.
# HTN: blood pressures well controlled during admission after
hypotension resolved. Metoprolol and Valsartan restarted. Will
be discharged on Toprol XL 50mg daily.
.
# Hypothyroidism: Stable, TSH at goal. Cont levothyroxine 100mcg
daily.
Medications on Admission:
- amaryl 1mg PO daily
- aspirin 81 mg PO daily
- cozaar 50mg PO daily
- digoxin 0.125 mcg PO daily
- lasix 80mg PO daily
- simvastatin 40mg PO daily
- toprol XL 50mg PO daily
- eplerenone 25mg PO daily
- coumadin 5mg PO daily
- levothyroxine 100mcg daily
- ranitidine 150mg PO daily
- allopurinol 100mg PO BID
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
6. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
7. Quinidine Gluconate 324 mg Tablet Sustained Release Sig: One
(1) Tablet Sustained Release PO Q8H (every 8 hours): Please hold
for SBP < 90.
8. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
9. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) for 2 days: End on [**2166-10-19**].
11. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 8 days: Last day [**10-25**].
12. Amaryl 1 mg Tablet Sig: One (1) Tablet PO once a day.
13. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a
day.
14. Eplerenone 25 mg Tablet Sig: One (1) Tablet PO once a day.
15. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
16. Warfarin 6 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Ventricular Tachycardia with Ablation
Hematuria
coronary Artery Disease
diabetes Mellitus type 2
Hypertension
Hyperlipidemia
Discharge Condition:
Temp Max: 99 Temp current: 98.3 HR: 61-78 RR: 18 BP:
114-121/60-70's O2 Sat: 95% RA
24 hour I= 1365 O= 1900 (-600)
8 hour I= 360 O= 600
Weight: 99.9 (98.5kg)
FS: 165/169/136/125
Discharge Instructions:
You had a ventricular tachycardia ablation and was started on
quinidine to control your heart rhythm. this seems to be working
well and there have been no other episodes of the tachycardia.
You had some urinary retention and some bleeding in your urine,
this has resolved. You will need to be seen by a urologist in
about a month to make sure your bladder and urethra is normal.
Weigh yourself every morning, call provider if weight goes up
more than 3 lbs in 1 day or 6 pounds in 3 days.
Adhere to 2 gm sodium diet
Fluid Restriction: 1500cc/day or about 8 cups.
Medication changes:
1. Start Quinidine to control your heart rhythm
2. Hold Allopurinol and Digoxin
3. Decrease Furosemide to 40 mg
.
Call Dr. [**Last Name (STitle) **] if you notice any dizziness, lightheadedness,
chest pain, trouble breathing, vomiting, or fevers.
Followup Instructions:
electrophysiology:
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2166-10-29**]
1:00
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2166-10-29**] 2:00
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2166-10-29**]
3:00
Urology:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone: ([**Telephone/Fax (1) 10426**] Date/Time: [**12-8**] at
3:30pm.
[**Hospital Ward Name 23**] clinical Center, [**Location (un) 470**], [**Hospital Ward Name 516**], [**Location (un) **].
|
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21,219
| 177,991
|
52522+59436
|
Discharge summary
|
report+addendum
|
Admission Date: [**2142-8-30**] Discharge Date: [**2142-9-22**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 83-year-old
man with a history of coronary artery disease and congestive
heart failure, who was transferred from an outside hospital
with complaints of shortness of breath and congestive heart
failure after ruling in for a non-Q wave myocardial
infarction. He also had a history of restrictive lung
disease, status post coronary artery bypass grafting,
multiple admissions for congestive heart failure with the
last being on [**2142-7-16**] and [**2142-8-9**], chronic renal
insufficiency and renal cell carcinoma status post right
nephrectomy and prostate carcinoma. He was transferred at
this time from [**Hospital3 417**] Hospital for continued
management of shortness of breath, congestive heart failure
and a non-Q wave myocardial infarction.
The patient was admitted to [**Hospital3 417**] Hospital from
[**Hospital 27838**] Rehabilitation on [**2142-8-13**] with shortness of
breath and desaturations to the 70s. He was treated for
congestive heart failure with diuresis, with minimal
improvement over several days. He ruled in for a non-Q wave
myocardial infarction on [**2142-8-14**] in the setting of
continued likely demand ischemia from hypoxia.
The patient underwent a pulmonary workup including a
ventilation perfusion scan, which was read as low probability
for pulmonary embolus, and a CT scan of the chest, which was
consistent with diffuse interstitial lung disease. The
patient was covered with an unknown antibiotic over an
unclear duration for assumed underlying pneumonia. Despite
this treatment and continued supplemental oxygen, the patient
continued to have low oxygen saturation, prompting intubation
on [**2142-8-17**]. He eventually extubated on [**2142-8-23**], but had
since remained tenuous, requiring BiPAP and 100%
nonrebreather.
On [**2142-8-28**], a pulmonary artery catheter was placed to
investigate pulmonary versus cardiac etiology of his hypoxia.
By report, the initial numbers were consistent with a cardiac
output of 5.1, a cardiac index of 2.5 and a pulmonary artery
diastolic pressure of 25. In the two to three days preceding
transfer, he had a worsening oxygen requirement, requiring
continuous BiPAP. On [**2142-8-29**], the patient complained of
chest pain and an electrocardiogram by report showed ischemic
changes. He was started on intravenous nitroglycerin and
received Lopressor and Lasix. His cardiac enzymes were
elevated with a positive troponin and CK MB. He was
transferred to the [**Hospital1 69**]
cardiac care unit for continued management. Upon arrival,
the chest x-ray was consistent with congestive heart failure,
rales were audible on examination and he was requiring BiPAP
to maintain his oxygen saturation.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post coronary artery
bypass grafting in [**2139**] with a left internal mammary artery
graft to the first diagonal artery, a saphenous vein graft to
the distal left anterior descending artery and a saphenous
vein graft to the first obtuse marginal artery, performed at
[**Hospital1 69**].
2. Congestive heart failure with hospitalizations in [**Month (only) **]
and [**2142-7-22**] and an ejection fraction of 20-30%.
3. Paroxysmal atrial fibrillation.
4. Renal cell carcinoma, status post right nephrectomy.
5. Prostate cancer.
6. Chronic renal insufficiency.
7. Chronic obstructive pulmonary disease secondary to
smoking with an FVC of 1.79 and an FEV1 of 1.43.
8. Coronary artery bypass grafting in [**2139**] complicated by
prolonged intubation and tracheostomy.
9. Gastroesophageal reflux disease.
10. Psoriatic arthritis, previously treated with
methotrexate.
11. Gastrointestinal bleed secondary to diverticulitis.
12. Degenerative joint disease of cervical spine.
13. Restrictive lung disease, consistent with pleural
fibrosis with bronchiectasis from severe postoperative
pneumonia or interstitial lung disease secondary to
methotrexate and/or deconditioning secondary to obesity.
14. Calcified right fibrothorax.
15. History of cerebrovascular accident.
MEDICATIONS ON TRANSFER:
1. Amiodarone 200 mg q.d.
2. Lipitor 20 mg q.d.
3. Lovenox 90 mg q.d.
4. Proscar 5 mg q.d.
5. Folate one tablet q.d.
6. Lasix 60 mg intravenous b.i.d.
7. Reglan 10 mg intravenous q.i.d.
8. Lopressor.
9. Inderal.
10. Zoloft.
11. Ativan.
12. Nitroglycerin drip.
13. Proventil.
ALLERGIES: The patient an allergy to morphine.
SOCIAL HISTORY: Prior to his hospitalization, the patient
was residing at [**Hospital 27838**] Rehabilitation. He had been
previously living with his daughter. [**Name (NI) **] was a former
pharmacist. He was a former cigar smoker, but had smoked no
cigarettes.
PHYSICAL EXAMINATION: The patient had a blood pressure of
113/58, a heart rate of 81 in atrial fibrillation, a
respiratory rate of 32, a temperature of 98.1??????F and an oxygen
saturation of 95% on 65% oxygen by BiPAP. In general, the
patient was an agitated, tachypneic male with BiPAP mask on.
On head, eyes, ears, nose and throat examination, we were
unable to assess jugular venous distention.
The lungs had rales halfway up bilaterally with dry crackles
audible halfway up. The patient had discreet decreased
breath sounds in the right upper lobe. The heart was
irregular with an S1 and S2 and no rubs, murmurs or gallops.
The abdomen was soft, nontender and nondistended with good
bowel sounds. The extremities had trace lower extremity
edema. On neurological examination, the patient was moving
all extremities had answered questions with nodes.
LABORATORY DATA: The patient had a white blood cell count of
14,200, hematocrit of 26.9, platelet count of 150,000 and MCV
of 91. Prothrombin time was 12.7, partial thromboplastin
time was 36.9 and INR was 1.1. There was a sodium of 145,
potassium of 3.6, chloride of 100, bicarbonate of 30, BUN of
81, creatinine of 2.2 and glucose of 93. ALT was 29, AST was
73, alkaline phosphatase was 110 and total bilirubin was 0.3.
Troponin was greater than 50 and CK was 89. Albumin was 3.0,
calcium was 8.7, phosphorus was 4.8 and magnesium was 1.8.
Arterial blood gases were 7.35/69/169.
RADIOLOGY DATA: A portable chest x-ray revealed bilateral
vascular congestion and cephalization with congestive heart
failure.
ELECTROCARDIOGRAM: An electrocardiogram was normal sinus
rhythm at 73 beats per minute, borderline left axis and left
ventricular hypertrophy by voltage criteria, primary
atrioventricular block with a P-R of 210, isolated [**Street Address(2) 4793**]
elevations in aVF also seen previously, Q waves in leads III
and aVF and ST depressions in V4 to V6.
TRANSESOPHAGEAL ECHOCARDIOGRAM: A transesophageal
echocardiogram from [**2142-7-11**] showed depressed left
ventricular and right ventricular function, 1 to 2+ mitral
regurgitation and no clot.
HOSPITAL COURSE: Briefly, the patient is an 83-year-old
gentleman with a complex past medical history, who presented
with hypoxic respiratory failure in the setting of a recent
non-Q wave myocardial infarction as well as underlying
interstitial lung disease and chronic obstructive pulmonary
disease. His hospital course is summarized by systems as
follows:
1. PULMONARY: The patient was intubated for hypoxic
respiratory failure on [**2142-8-31**]. He was diuresed for
suspected congestive heart failure with a Lasix drip. On
[**2142-9-1**], a sputum sample revealed Methicillin sensitive
Staphylococcus aureus which was treated with a 14 day course
of oxacillin. On [**2142-9-4**], a gallium scan was performed due
to a question of amiodarone toxicity versus methotrexate
toxicity. No evidence of an acute pulmonary process was seen
on the scan. On [**2142-9-8**], a sputum culture revealed
infection with Pseudomonas and treatment was begun with
levofloxacin and ceftazidime. The ceftazidime was later
discontinued, as the organism was found to be pansensitive.
A repeat sputum culture from [**2142-9-10**] again grew out
Pseudomonas and sensitivities for this were missing or
pending. On [**2142-9-9**], a CT scan of the chest revealed
bilateral lower lobe pneumonia, small pleural effusions and
persistent volume loss on the right; it also revealed
unchanged right fibrothorax.
Throughout his intensive care unit course, the patient
continued to produce thick secretions which required frequent
suctioning. On [**2142-9-21**], a tracheostomy was performed. The
patient had been switched to pressor support of 15 with 7.5
of PEEP and an FiO2 of 50% prior to the tracheostomy.
Following this procedure, the patient required a switch back
to assist controlled ventilation. Besides having his
pneumonia treated, the patient received Lasix and occasional
Diuril at increasing doses to treat his underlying congestive
heart failure. He also was started on albuterol and Atrovent
metered dose inhalers every four hours as well as Flovent
four puffs inhaled b.i.d.
2. CARDIOVASCULAR: As far as his pump function was
concerned, the patient was initially treated with intravenous
nitroglycerin and Lasix drips. He was subsequently weaned
off the Lasix drip and the nitroglycerin was discontinued.
He continued to receive Lasix and Diuril intermittently.
Late in his course, as his renal function improved, the
patient was started on Captopril for afterload reduction.
The patient required pressors intermittently during his
hospital course, once in the setting of a tachycardia with a
questionable left bundle branch block and hypotension. He
also required pressors following a hypotensive episode during
his tracheostomy on [**2142-9-21**].
As for his heart rhythm, he continued in atrial fibrillation
and flutter, which was rate controlled without medication.
His Lopressor was discontinued in the setting of his
hypotension. His anticoagulation was discontinued in the
setting of an episode of hemoptysis and a hematocrit drop
with occult blood positive stool. As far as his coronary
artery disease was concerned, following his initial ischemic
insult this remained stable with negative CKs after the
hypotensive episode. The patient was continued on aspirin
and Lipitor.
3. RENAL: The patient was status post nephrectomy. His
baseline creatinine was 2.2. At its height, the patient's
creatinine was 2.4 and then gradually improved over the
hospital course to a level of 1.5. The patient had a slight
rise in his creatinine after he was started on Captopril, but
this remained stable.
4. INFECTIOUS DISEASE: The patient grew Methicillin
sensitive Staphylococcus aureus in his sputum on [**2142-9-1**]
and was treated with oxacillin for 14 days. He grew
pansensitive Pseudomonas from his sputum on [**2142-9-8**] and was
treated with levofloxacin and ceftazidime. The ceftazidime
was discontinued. A 21 day course of levofloxacin will be
completed on [**2142-10-1**]. At the time of discharge, a sputum
sample from [**2142-9-18**] had grown Pseudomonas, for which
sensitivities were pending, as well as new gram-negative rod,
the identification of which was also pending.
In addition, the patient had several episodes of diarrhea and
Clostridium difficile assays were negative. He had numerous
blood cultures, which were negative for growth to date.
Finally, on [**2142-9-21**], the patient had a slight elevation in
his white blood cell count to 11,400. His right internal
jugular central venous line was changed over a wire and the
tip was sent for culture. This culture was pending at
discharge.
5. HEMATOLOGY: The patient was placed on Epogen for anemia
of chronic disease as well as for anemia of chronic renal
insufficiency. He received a total of four units of packed
red blood cells for a gastrointestinal bleed. He had no
frank blood; however, he had guaiac positive stools.
6. FLUID, ELECTROLYTES AND NUTRITION: The patient was
currently on total parenteral nutrition. He had been
receiving Criticare tube feeds at a goal of 60 cc/hour, which
were held prior to placement of a PEG-J tube (gastrojejunal
tube) and prior to his tracheostomy. The tube feeds are to
be restarted on [**2142-9-22**]. The total parenteral nutrition
should be discontinued when tube feeds are at 50% of goal.
7. PROPHYLAXIS: The patient is receiving 6000 units of
heparin and 150 mg of ranitidine in his total parenteral
nutrition. Subcutaneous heparin and a proton pump inhibitor
per the gastrostomy tube should be restarted when the
patient's total parenteral nutrition is discontinued.
8. ACCESS: The patient has a right internal jugular central
venous line, which was placed on [**2142-9-21**]. He also has a
left radial artery line, which was placed on [**2142-9-18**]. His
tracheostomy was performed on [**2142-9-21**]. His PEG-J tube was
placed on [**2142-9-20**]. He also has a Foley catheter and a
rectal tube.
9. CODE STATUS: After a lengthy discussion with the
patient's daughter and son, the patient's code status was
determined as no cardiopulmonary resuscitation and no
defibrillation or cardioversion. They do feel that pressors
and tracheostomy are appropriate.
10. COMMUNICATION: The patient's daughter, [**Name (NI) **], and son,
[**Name (NI) **], are actively involved in the patient's care. The
daughter, [**Name (NI) **] [**Name (NI) 98288**], can be reached by cell phone
([**0-0-**]), at work ([**Telephone/Fax (1) 108486**]) or at home
([**Telephone/Fax (1) 108487**]). [**First Name4 (NamePattern1) **] [**Known lastname 98288**], the son, can be reached by
cell phone ([**Telephone/Fax (1) 108488**]), by pager ([**Telephone/Fax (1) 108489**]), at home
([**Telephone/Fax (1) 108490**]) or at work ([**Telephone/Fax (1) 108491**]).
CONDITION ON DISCHARGE: Fair.
DISCHARGE DIAGNOSES:
1. Respiratory failure.
2. Interstitial lung disease.
3. Pneumonia.
4. Chronic obstructive pulmonary disease.
5. Coronary artery disease.
6. Atrial fibrillation.
DISCHARGE MEDICATIONS:
1. Levofloxacin 250 mg intravenous p.o. q.d. (to be
discontinued on [**2142-10-1**]).
2. Albuterol and Atrovent metered dose inhalers every four
hours.
3. Nystatin swish and swallow 4 to 6 ml p.o. q.i.d.
4. Nystatin cream 1% topically b.i.d.
5. Flovent four puffs inhaled b.i.d.
6. Ativan drip 1 to 10 mg intravenous, titrate to sedation.
7. Lipitor 10 mg p.o./p.g. h.s.
8. Criticare tube feeds with goal of 60 cc/hour.
9. Epogen 3000 units subcutaneous on Monday, Wednesday and
Friday.
10. Aspirin 325 mg p.o./p.r. q.d.
11. Captopril 25 mg p.o./p.g. t.i.d.
12. Neo-Synephrine gtt, titrate to mean arterial pressure of
greater than 65.
13. Lactulose p.r.n.
14. Dilaudid 1 to 2 mg intravenous p.r.n.
[**First Name11 (Name Pattern1) 4514**] [**Last Name (NamePattern4) 8867**], M.D. [**MD Number(1) 8868**]
Dictated By:[**Last Name (NamePattern1) 11548**]
MEDQUIST36
D: [**2142-9-21**] 19:48
T: [**2142-9-21**] 21:47
JOB#: [**Job Number **]
Name: [**Known lastname 15680**], [**Known firstname **] Unit No: [**Numeric Identifier 17748**]
Admission Date: [**2142-8-30**] Discharge Date: [**2142-9-25**]
Date of Birth: #14 Sex: M
Service: Medicine
ADDENDUM: The prior discharge summary described the events
up to [**9-21**]. At that time the patient was being prepared for
discharge to rehab after a long, complicated ICU course for
respiratory failure secondary to interstitial lung disease
and pseudomonas pneumonia. On [**9-21**] he underwent
tracheostomy. The procedure was successful, however, was
complicated by an episode of hypotension following
administration of sedation. Subsequently the patient had
developed additional episodes of hypotension which responded
to fluids. In subsequent days, the patient developed a low
grade leukocytosis and low grade fevers and became
increasingly hypotensive and required pressors,
Neo-Synephrine, to be added back to stabilize his blood
pressure. In addition, he developed a diffuse diarrhea which
was negative for clostridium difficile. Nevertheless, Flagyl
was started empirically for C. diff infection and the
patient's Levofloxacin was empirically changed for additional
pseudomonal coverage to Ceftazidime. The patient's condition
continued to deteriorate despite the new antibiotics and the
pressors. On pressors with hypotension, the patient's renal
function began to deteriorate. The patient also required
increased ventilatory support. Ultimately, given the
patient's complicated medical condition and his worsening
condition, the family decided to withdraw care. The patient
was made comfort measures only on [**9-25**]. They were at his side
when ventilatory and pressor support were withdrawn. The
patient passed away of respiratory failure at 10:46 p.m.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 11-316
Dictated By:[**Last Name (NamePattern1) 4499**]
MEDQUIST36
D: [**2143-1-28**] 18:13
T: [**2143-1-30**] 13:25
JOB#: [**Job Number 17749**]
|
[
"518.81",
"410.71",
"593.9",
"428.0",
"792.1",
"038.9",
"515",
"482.1",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"43.11",
"99.15",
"96.72",
"31.1",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
13775, 13944
|
13967, 17028
|
6925, 13722
|
4802, 6907
|
113, 2822
|
4178, 4512
|
2844, 4153
|
4529, 4779
|
13747, 13754
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
83,022
| 178,643
|
37342
|
Discharge summary
|
report
|
Admission Date: [**2108-12-7**] Discharge Date: [**2108-12-18**]
Date of Birth: [**2036-10-9**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
inability to respond to questions
Major Surgical or Invasive Procedure:
(IV tPA administration at OSH)
PEG placement on [**2108-12-17**]
History of Present Illness:
The pt is a 72 year old right-handed female history of a.fib
off coumadin, and HTN, who presents from an outside hospital
with
a likely MCA stroke after being given tPA at [**Hospital 4068**] hospital and
transferred here for possible intra-arterial intervention.
The patient was at home with her husband returning from a
[**Holiday **] dinner. They went to bed at 21:30. At around
22:15
the husband was [**Name2 (NI) 83992**] by a gurgling sound coming from his wife.
He looked over and asked her questions but she was unable to
respond. Her daughter came over and noted that her face was
asymmetric, but could not remember which side. She also noted
that the patient did not appear to comprehend. EMS arrived on
22:50, and she was taken to [**Hospital 4068**] hospital. She had a CT,
which
was reportedly read as normal (but on our read here has a
hyperdense MCA) and she was noted to have global aphasia, right
sided weakness and left gaze deviation. He put the NIH scale at
least 16 but he was not able to do a full scale secondary to
aphasia. She was bolused with tpA at 23:50 and started on the
infusion. She had finished the infusion by the time she arrived
at [**Hospital1 18**].
On arrival the patient was initial not responsive to voice and
commands per ED team. On arrival the patient was able to open
her eye to sternal rub, was spontaneously moving the left arm
and
had a leftward gaze deviation. The patient was globally
aphasic,
with no comprehension, and was not following commands. She was
intubated for airway protection. She then had a CTA/P, and it
was noted that there were new hemorrhages on the CT, and any
further intervention was deferred.
NIH Stroke Scale score was 32:
1a. Level of Consciousness: 2
1b. LOC Question: 2
1c. LOC Commands: 2
2. Best gaze: 2
3. Visual fields: 2
4. Facial palsy: 2
5a. Motor arm, left: 3
5b. Motor arm, right: 3
6a. Motor leg, left: 3
6b. Motor leg, right: 3
7. Limb Ataxia: 0
8. Sensory: 1
9. Language: 3
10. Dysarthria: 2
11. Extinction and Neglect: 2
On neuro [**Last Name (LF) **], [**First Name3 (LF) **] family the patient had not complained of a
headache. They noted that she had an episode of right leg
weakness 3 days prior which seemed to resolve on its own. She
had chronic back pain, and had some mild difficult walking at
baseline. No No bowel or bladder incontinence or retention.
On general review of systems, the family did not believe there
were any recent fever or chills, or infectious symptoms. No
cough/SOB, chest pain. No N/V.
Past Medical History:
- Atrial Fib, was on coumadin for 2 weeks ~ 1 year prior but per
family cardiologist stopped it for unknown reason
- HTN
- Sciatica
Social History:
Lives at home with husband. [**Name (NI) 23835**] nearby.
[**Name2 (NI) **] in all ADLs. Very active per family. No
etoh/tob/drug use. HCP [**Name (NI) **] [**Name (NI) 83993**]: [**Telephone/Fax (1) 83994**]
Family History:
Multiple members of family with stroke and CAD.
Physical Exam:
Exam on admission:
Physical Exam: (done pre-intubation)
Vitals: T:98.3 P:134 R: 16 BP:114/112 SaO2:100%
General: Opens eyes to nox stim, does not follow commands
HEENT: NC/AT, no scleral icterus noted,
Neck: Supple,
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: [**Last Name (un) 3526**] and tachy, slight flow murmur heard
Abdomen: soft, NT/ND, normoactive bowel sounds
Extremities: No C/C/E bilaterally,
Skin: no rashes, mild bruising on legs bilaterally
Neurologic:
-Mental Status: Will open eyes to loud voice and nox
stimulation.
Completely mute, does not follow commands. Does not appear to
attend to R side
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2.5mm and brisk. Appears to have right field cut
III, IV, VI: Left [**Hospital1 **] gaze deviation, eyes do not cross midline
to right
V: did not test
VII: R facial droop,
VIII: Not tested
IX, X: Gag intact
[**Doctor First Name 81**]: not tested
XII: not tested
-Motor: Normal bulk, slight decreased tone on right. Patient
was
moving left arm and leg spontaneously, not moving right. Small
amount of movement on right leg elicited with nox stim, trace
movement on right arm with nox stim
-Sensory: Sensation to pain intact at all 4 extremities
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 3 3 2 3 2
R 3 3 2 3 3
Toes, upgoing bilaterally, more on R
Did not test coordination and gait.
Pertinent Results:
Labs on admission:
[**2108-12-7**] 01:20AM BLOOD WBC-12.7* RBC-4.41 Hgb-13.7 Hct-39.7
MCV-90 MCH-31.1 MCHC-34.5 RDW-14.8 Plt Ct-217
[**2108-12-8**] 02:18AM BLOOD WBC-10.9 RBC-4.12* Hgb-12.8 Hct-38.0
MCV-92 MCH-31.0 MCHC-33.6 RDW-14.5 Plt Ct-188
[**2108-12-7**] 01:20AM BLOOD PT-14.5* PTT-31.9 INR(PT)-1.3*
[**2108-12-7**] 01:20AM BLOOD Glucose-152* UreaN-28* Creat-0.8 Na-143
K-4.3 Cl-
107 HCO3-24 AnGap-16
[**2108-12-11**] 07:25AM BLOOD Na-139
[**2108-12-11**] 01:47AM BLOOD Glucose-121* UreaN-19 Creat-0.8 Na-139
K-3.8 Cl-105 HCO3-27 AnGap-11
[**2108-12-8**] 02:18AM BLOOD Calcium-7.6* Phos-2.3* Mg-1.7
[**2108-12-8**] 04:48PM BLOOD Calcium-8.6 Phos-2.6* Mg-2.3
[**2108-12-8**] 06:22PM BLOOD Osmolal-296
[**2108-12-9**] 07:11AM BLOOD Osmolal-294
[**2108-12-10**] 09:13AM BLOOD Osmolal-300
[**2108-12-11**] 07:25AM BLOOD Osmolal-304
Imaging:
CTA/P of head [**12-7**]:
IMPRESSION:
1. Findings consistent with an acute left MCA infarct, with loss
of [**Doctor Last Name 352**]-
white matter differentiation in the left middle cerebral artery
territory,
including the insular region and left basal ganglia. There is
thrombus in the supraclinoid segment of the left internal
carotid artery extending into the bifurcation and into the left
middle cerebral artery. There is marked asymmetry in the flow of
the left middle cerebral artery territory, with corresponding
perfusion abnormalities as detailed above.
2. Curvilinear hypodensity within the carotid bulb on the left,
which may
represent atherosclerotic disease versus an artifact. A
dissection flap is
considered less likely given that curvilinear hypodensity is
localized to the carotid bulb.
3. There is subarachnoid hemorrhage in the left hemisphere, new
since the
outside head CT from [**Location (un) 620**] done only a short time prior to the
current
study.
4. Endotracheal tube in position. Orogastric tube incompletely
visualized.
5. Old right temporal infarct with encephalomalacia.
CTP: Image quality is degraded by poor signal to noise. There is
suggestion of asymmetric decreased cerebral blood volume and
blood flow,
without definite asymmetry on the mean transit time. This
correlates with the asymmetry on the CTA images in terms of the
enhancement, with the left
decreased compared to the right.
CTH [**12-7**] 1.30pm
IMPRESSION:
Unchanged acute ischemia in the left MCA territory and foci of
subarachnoid and subdural hemorrhage
CTH [**12-10**]
IMPRESSION:
1. Evolving left MCA distribution infarct with stable mass
effect on the left lateral ventricle.
2. Stable multifocal subarachnoid hemorrhage, with no new foci
of acute
hemorrhage.
CTH [**12-11**]:
Again seen is a large area of hypodensity within the left MCA
territory, consistent with expected evolution of infarct. The
degree of mass effect on the left lateral ventricle and
overlying sulcal effacement remains unchanged. The hyperdense
left MCA is again noted. Foci of subarachnoid hemorrhage are
also stable in extent and resolving. No new areas of hemorrhage
are seen. The ventricles remain stable in size.
IMPRESSION: Little change since prior study with evolving left
MCA
distribution infarct with stable mass effect. Stable extent of
multifocal
subarachnoid hemorrhage with no new areas of acute hemorrhage.
The study and the report were reviewed by the staff radiologist.
[**12-16**] KUB xray:
The colon is gas-filled. There are no dilated loops of small
bowel. There is no evidence of obstruction. The side port of the
endogastric tube is within the stomach. There is no obvious
pneumoperitoneum, although the lack of a decubitus view limits
assessment of pneumoperitoneum. Degenerative changes are noted
throughout the spine.
IMPRESSION: No evidence of obstruction.
Brief Hospital Course:
72 year old LEFT-handed woman with atrial fibrillation (off
Coumadin) and HTN who presented from OSH with an MCA stroke and
after receiving IV tPA was transferred to [**Hospital1 18**] for question of
an intra-arterial intervention. On initial examination she was
noted to be globally aphasic with R sided weakness and
hemianopia, and L
gaze deviation. She appeared to not have improved significantly
after IV tPA and in the ED and became drowsy, with minimal eye
opening to voice and sternal rub. She was eventually intubated
for airway protection.
On follow up CTA/P she was noted to have SAH in the cortical
left frontal and left parietal lobes, felt to be due to tPA as
well as a thrombus in the supraclinoid segment of the left ICA
extending into the bifurcation and into the left MCA. CT
imaging here showed a dense MCA sign, along with a CTP showing L
decreased BV and BF. Due to new SAH, she was not a candidate
for intraarterial tPA and was admitted to Neuro-ICU to complete
post CVA care.
NEURO. Patient's BP was maintained < 180, goal of -500 cc I/O,
ASA and all anticoagulation were held due to concern for SAH,
which was confirmed on a subsequent CT. CT on [**12-8**] also showed
mass effect due to increasing edema at the frontal [**Doctor Last Name 534**] of the
left lateral ventricle due to evolving infarct. At this time,
she was started on mannitol, HOB elevation and fluid restriction
w/ goal of -500 cc/day. With this treatment she slowly became
more alert and was extubated. Serial head CTs showed stable SAH
and evolving left MCA distribution infarcts with mass effect on
the left lateral ventricle without herniation.
Mannitol was weaned starting on [**2108-12-11**]. She was transferred to
the floor an completely weaned off the mannitol. Given the size
of the infarct it was decided not to start her an a heparin
drip. Coumadin was restarted on [**12-18**] and she will be titrated
for a goal INR of [**2-14**]. Here LDL was noted to be 111 and she was
started on a statin at a low dose. Her blood sugar tests were
normal.
She will be discharged to a rehab facility to continue working
on her weakness and speech deficits.
CV. Patient remained in atrial fibrillation and had an episode
of afib with RVR to 170s. She was treated with diltiazem gtt
and started on PO diltiazem in addition to atenolol (she did not
respond to IV metoprolol). Her final dosage of diltiazem was
90mg QID. She has been scheduled for outpatient cardiology
follow up to help determine a suitable treatment for her atrial
fibrillation.
PULM. Patient was extubated on HD#3 without complications.
RENAL. No issues.
GI. She was treated with famotidine and TFs. She was noted to
aspirate with all consistencies of nutrition thus was maintained
on NGT and TFs. She repeatedly failed speech and swallow
evaluations and required the placement of a PEG feeding tube.
This was placed on [**2108-12-17**] without complications and tube feeds
were started the next morning. Adjust PEG bumper in [**2-14**] days,
with care not to over-tighten, as fat necrosis can occur
Medications on Admission:
- Atenolol 50 [**Hospital1 **]
- Simvastatin 20mg QD stopped taking a few weeks prior as she
heard it can cause weakness
- Tylenol/Codiene PRN
Discharge Medications:
1. Atenolol 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) 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. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
5. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for apply between skin fold for yeast
infection.
8. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Vaginal HS (at
bedtime) for 4 days.
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
10. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebs
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
12. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime):
check INR for goal of [**2-14**].
13. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every six
(6) hours as needed for fever, pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]
Discharge Diagnosis:
Left Middle Cerebral Artery Stroke - likley embolic
Discharge Condition:
MS: Globally aphasic, does not follow commands, will mimic some
actions,
CN: R facial droop, EOM nearly intact, does not fully abbdict to
the right, will attend to both sides but has a right sided gaze
preference.
Motor: No spontaneous movement of R hemibody, withdraws very
slightly at RLE, Left upper and lower extremity move
spontaneously and do not appear to be impaired.
Sensory: grimaces to pain at all 4 ext
Gait: deferred
Coordination: could not evaluate
Discharge Instructions:
You were admitted as a transfer from an outside hospital for a
large stroke of the left side of your brain. You were initially
seen at an outside hospital were it was determined that you had
a large stroke of a blood vessel in your brain called the left
middle cerebral artery. You could not move your right side and
could not speak or understand language. You were given a clot
busting [**Doctor Last Name 360**] called tPa. You were not noted to improve
significantly and were transferred to [**Hospital1 18**] to see if there were
any other interventions that could be done. At [**Hospital1 18**] a follow
up CT scan of your brain showed that there was some small amount
of bleeding and it was determined that it was not safe to give
any other interventions, which could increase the bleeding.
You were transferred to the ICU, and were started on mannitol
because of concern of swelling of your brain. This was slowly
weaned off and you were transfered to the floor. You were
weaned of the mannitol. On the floor your exam has remained
largely unchanged but you have occasionally been able to make an
occasional sound. Physical therapy was able to have you bear
weight on your right leg.
As you were not able to swallow a PEG feeding tube has been
placed and your were started on tube feeds. You will be
transfered to a rehab facility to continue to work on improving
your strength.
Please take all medications as prescribed, please make all
follow up appointments. If you experience any of the symptoms
listed below please call your doctor or return to the nearest
emergency room.
Followup Instructions:
1) Dr. [**First Name (STitle) 162**], MD, Neurology, Phone:[**Telephone/Fax (1) 44**] [**2109-1-18**] 9:30
2) Please see Dr. [**Last Name (STitle) **], MD, Division of Cardiology, Phone:
[**Location (un) 83995**], RW-453 [**Location (un) 86**], [**Numeric Identifier 718**]
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2385**], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2109-1-14**] 8:00
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
[
"401.9",
"E934.4",
"784.3",
"430",
"434.11",
"438.20",
"427.31",
"348.5",
"V45.88"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.11",
"38.93",
"96.6",
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
13180, 13325
|
8651, 11737
|
350, 417
|
13421, 13886
|
4894, 4899
|
15533, 16053
|
3383, 3434
|
11931, 13157
|
13346, 13400
|
11763, 11908
|
13910, 15510
|
4098, 4875
|
3484, 3935
|
277, 312
|
445, 2980
|
4914, 8628
|
3950, 4081
|
3002, 3136
|
3152, 3367
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,824
| 158,457
|
43623
|
Discharge summary
|
report
|
Admission Date: [**2132-9-17**] Discharge Date: [**2132-9-23**]
Service: MEDICINE
Allergies:
Codeine / Cortisone / Lipitor / Lisinopril
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Positional occipital headache and dizziness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 84y/o F with PMH of atrial fibrillation on
coumadin, polycythemia [**Doctor First Name **], diastolic heart failure presenting
to ED with worsening positional occipital headache and dizziness
since last evening.
The patient reports intermittent headache since her discharge
from [**Hospital1 18**] on [**7-15**] from CHF exacerbation. Since discharge she
reports daily occipital headaches exacerbated with changes in
position. Reports pain as [**4-17**] and non-radiating. Last pm her
pain worsened in severity prompting her to call EMS. Pain not
relieved with tylenol. Associated symptoms includes dizziness
decribing a "spinning sensation in her head". No other
associated symptoms including N/V, vision changes, hearing
changes, photophobia, neck pain or LOC. Denies presyncopal
symptoms. In ED she also reported "veering to the left" with
ambulation.
.
Recently hospitalized in [**7-15**] with exacerbation of CHF due to
medication noncompliance. Pt. on amiodarone with slow HR and
first degree AV block. In outpatient cardiology appoint. pt.
reported occassional lightheadedness and dizziness that does not
appear to be positional. Physical activity minimal due to fear
to leave her home since her hospitalization. Pt. losing 1lb/day
since discharge. Wt. in clinic 163lb. Continued on lasix 40mg
daily, valsartan and amiodarone.
.
In ED orthostatics negative. FS 115. Vitals T97, HR 59, BP
160/82, RR 15, O2 Sat 97% RA. CT Head performed negative. Pt.
seen by neurology, exam notable for positional vertigo and
intention tremor L>R. Head CT negative for obvious mass. Given
positional nature of patient's symptoms and daily episodes since
[**Month (only) 216**], unlikely TIA or stroke.
.
On floor, Pt. complains that her head is "unclear". She reports
feeling tired and weak since her discharge from [**Hospital 100**] rehab.
She states she feels that she "veers" to the left due to
"breakage and pain" in her L foot. She denies palpitations,
shortness of breath and increased edema at home. No recent
medication changes.
Past Medical History:
1. A Fib- on coumadin
2. Diastolic CHF - EF 60%
3. TIA [**4-11**]
4. Polycythemia [**Doctor First Name **]-phlebotomized in past, maintained on
hydroxyurea
5. HTN
6. Hypercholesterolemia
7. Cataracts
8. known LBBB
9. asthma-dx in her 70's
10. peripheral neuropathy
11. First degree AV block
Social History:
Lives alone in [**Location (un) **]. Independent ADLs. previously worked as
a bookkeeper. Daughter who she would like to be her HCP although
not formally established lives in [**Location (un) **] and helps her
out as needed (Klickstein [**Telephone/Fax (1) 93800**]Smoked as a teenager and
no EtOH.
Family History:
Father died 61 of MI, mother died in 70's of an MI, brother died
age 43 of MI, no other hx of CAD, CVA, DMII
.
Physical Exam:
Vitals: Temp 98.6 Laying BP 120/76, HR 50, sitting 128/72 HR 54,
standing 122/78 HR 57, RR 16, O2 sat 97% RA Wt. 74.5 lb
Gen: alert and oriented X3, NAD
HEENT: PERRLA, EOMI, MMM, oropharnx clear
CV: RRR, nl S1/S2, III/VI systolic murmur radiating to neck,
II/IV DM loudest at base
Resp: decreased BS at bases, scattered crackles
Abd: soft, NT/ND, +BS
Ext: no edema, varicose veins B/L
Neuro: MS: alert, orientX4, memory recent and remote intact,
attention wnl, speech spontaneous and fluent
Strength 5/5 throughout, sensation decreases to light touch bl,
greater deficit in LLE to mid shin
Pt. with lightheadedness on moving from laying to sitting
position
Pertinent Results:
[**2132-9-23**]: INR 1.3, Hct 31.2, BUN 25, Cr 1.2, Vit B12 672, HbA1C
5.7%, TSH 7.3, free T4 pending.
[**2132-9-17**] 02:58AM WBC-11.6* RBC-4.49 HGB-10.4* HCT-33.5*
MCV-75* MCH-23.1* MCHC-30.9* RDW-19.6*
[**2132-9-17**] 02:58AM NEUTS-61.5 LYMPHS-32.6 MONOS-3.7 EOS-1.9
BASOS-0.3
[**2132-9-17**] 02:58AM PLT COUNT-640*
[**2132-9-17**] 07:05AM PT-42.6* PTT-44.2* INR(PT)-4.9*
[**2132-9-17**] 02:58AM GLUCOSE-93 UREA N-24* CREAT-1.3* SODIUM-139
POTASSIUM-5.0 CHLORIDE-102 TOTAL CO2-28 ANION GAP-14
[**2132-9-17**] 02:58AM ALT(SGPT)-20 AST(SGOT)-25 ALK PHOS-60
AMYLASE-80 TOT BILI-0.5
[**2132-9-17**] 02:58AM LIPASE-27
[**2132-9-17**] 04:52AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2132-9-17**] 09:28AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
.
Reports:
CXR [**9-17**] - Bedside AP and lateral views labeled "upright" with
lordotic positioning, are compared with most recent studies
dated [**7-27**] and [**2132-5-8**]. Allowing for technical differences, the
overall appearance is not much changed. There is moderate
cardiomegaly with left ventricular configuration, but no
pulmonary vascular congestion, pleural effusion, or other
evidence of CHF. There is linear scarring involving the left mid
lung, and minor atelectasis involving that lung base, but no
focal consolidation is seen. There are atherosclerotic changes
involving the thoracic aorta, without focal aneurysmal
dilatation. There is diffuse osteopenia with anterior wedging of
mid thoracic vertebrae and resultant kyphosis, unchanged, with
no acute thoracic compression seen.
IMPRESSION: Cardiomegaly without CHF or focal consolidation
.
CT HEAD - There is no intracranial hemorrhage, edema, mass
effect, or shift of normally midline structures. There is no
hydrocephalus. Density values of brain parenchyma are within
normal limits. The [**Doctor Last Name 352**]-white matter differentiation is
preserved.
Surrounding soft tissues and osseous structures are
unremarkable.
Mastoid air cells and the imaged paranasal sinuses are well
aerated.
IMPRESSION: No acute intracranial hemorrhage, mass effect, or
edema. No change from [**2132-7-27**]
.
ECG - Rate 55bpm, Sinus brady, LAD, LBBB, 1st degree AV block,
PR int 324ms
.
ECHO [**7-15**]:
Left Atrium - Long Axis Dimension: *4.2 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *6.1 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *5.3 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.4 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 2.8 cm
Left Ventricle - Fractional Shortening: 0.36 >= 0.29
Left Ventricle - Ejection Fraction: >= 60% >= 55%
Left Ventricle - Lateral Peak E': 0.14 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.05 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 13 < 15
Aorta - Sinus Level: 2.9 cm <= 3.6 cm
Aorta - Ascending: *3.6 cm <= 3.4 cm
Aortic Valve - Peak Velocity: *2.8 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *31 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 18 mm Hg
Aortic Valve - LVOT diam: 1.7 cm
Aortic Valve - Valve Area: *1.0 cm2 >= 3.0 cm2
Mitral Valve - E Wave: 1.2 m/sec
Mitral Valve - A Wave: 0.6 m/sec
Mitral Valve - E/A ratio: 2.00
Mitral Valve - E Wave deceleration time: 200 ms 140-250 ms
TR Gradient (+ RA = PASP): *33 mm Hg <= 25 mm Hg
Pulmonic Valve - Peak Velocity: 1.0 m/sec <= 1.5 m/sec
Findings
This study was compared to the prior study of [**2130-7-6**].
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%). [Intrinsic LV
systolic function likely depressed given the severity of
valvular regurgitation.] No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
Abnormal septal motion/position.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Mildly dilated ascending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mild
AS (AoVA 1.2-1.9cm2). Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Mild mitral annular calcification. Mild thickening of mitral
valve chordae. Moderate (2+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to
moderate [[**12-11**]+] TR. Mild PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
Physiologic (normal) PR.
PERICARDIUM: There is an anterior space which most likely
represents a fat pad, though a loculated anterior pericardial
effusion cannot be excluded.
Conclusions
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%) [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. There is abnormal septal motion/position. The
ascending aorta is mildly dilated. The aortic valve leaflets (3)
are mildly thickened. There is mild aortic valve stenosis (area
1.0 cm2). Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Moderate (2+) mitral regurgitation is seen. There is
mild pulmonary artery systolic hypertension. There is an
anterior space which most likely represents a fat pad.
IMPRESSION: Mild aortic stenosis. Moderate mitral regurgitation.
Preserved regional and global biventricular sytolic function.
Mild pulmonary hypertension. Biatrial enlargement.
Compared with the prior study (images reviewed) of [**2130-7-6**],
the severity of aortic stenosis is slightly increased. Estimated
pulmonary artery pressures are slightly higher.
.
MRI/MRA Head FINDINGS: Diffusion images demonstrate no evidence
of acute infarct. The ventricles and extraaxial spaces are
within normal limits and unchanged from previous study. No
evidence of territorial infarcts, midline shift or mass effect
identified. Subtle periventricular hyperintensities are
identified indicating minimal changes of small vessel disease
unchanged from previous study. Following gadolinium, no evidence
of abnormal parenchymal, vascular or meningeal enhancement
identified.
IMPRESSION: No enhancing brain lesions or acute infarcts
identified. No significant change since [**2129-4-22**].
MRA OF THE HEAD:
The head MRA demonstrates normal flow signal within the arteries
of anterior and posterior circulation. A fetal right posterior
cerebral artery is incidentally noted. A small distal left
vertebral artery is also incidentally noted ending in posterior
inferior cerebellar artery, a normal variation.
IMPRESSION: Normal MRA of the head.
.
BILATERAL LOWER EXTREMITY ULTRASOUND: [**Doctor Last Name **] scale, color and
Doppler son[**Name (NI) 1417**] of bilateral common femoral, superficial
femoral and popliteal veins was performed. These demonstrate
normal flow, compression and augmentation.
IMPRESSION: No deep vein thrombosis.
.
CHEST (PA & LAT) [**2132-9-21**] 12:26 PM
CHEST (PA & LAT)
Reason: improvement of edema, etiology of hemoptysis.
[**Hospital 93**] MEDICAL CONDITION:
84 year old woman with dizziness, confusion, pulmonary edema,
hemoptysis.
REASON FOR THIS EXAMINATION:
improvement of edema, etiology of hemoptysis.
HISTORY: Pulmonary edema.
PA and lateral radiographs of the chest demonstrate a similar
cardiomediastinal contour to that seen on [**2132-9-20**].
Mild-to-moderate COPD is again noted. Abnormal interstitial
pattern on the current study is attributable to COPD. No
evidence of pulmonary edema. There is a very small left-sided
pleural effusion and left basilar atelectasis. Trachea is
midline. Soft tissue anchor projects over the right humeral
head. Degenerative change is noted to involve the thoracic spine
without evidence of spondylolisthesis or fracture.
IMPRESSION:
Interval improvement of previously seen pulmonary edema.
Persistent small left basilar atelectasis and left-sided pleural
effusion.
Mild-to-moderate COPD.
Brief Hospital Course:
84F h/o atrial fibrillation on warfarin, AS/MR, chronic
diastolic CHF, admitted with weakness and worsening positional
occipital headache.
.
# Respiratory distress: Soon after transfer from the ED to the
floor, pt noted R-sided chest pain x 1 hour, then was acutely
'not feeling well.' Pt noted to be in respiratory distress by
the team. ABG 7.35/48/52, lactate 1.8, tachypneic to 30's, SaO2
low 70's on NRB, BP 170/110, HR 80's. Pt was intubated and
transferred to MICU. Given initially unclear etiology of
patient's hypoxic respiratory failure, EKG was done to r/o
possible acute ischemic event; this demonstrated questionable
pathology. Cardiac enzymes were negative. Transthoracic
[**Year (4 digits) 461**] was obtained and demonstrated new areas of wall
hypokinesis at the left and right ventricle. This new
pathology, patient's known medication noncompliance, existing
aortic stenosis, and chronic diastolic dysfunction, were
considered to be the likely contributors to her acute
respiratory decompensation. While intubated, patient initially
received nebulizers and furosemide drip; diuresis was moderated
given low BP. Valsartan was initially held in MICU given low
BP. Pt was extubated and then converted to home regimen of
furosemide PO before transfer to the floor. Sputum gram stain
obtained after intubation demonstrated gram-positive cocci in
clusters, and pt was started empirically on vancomycin for PNA.
Upon further review gram stain was read as gram positive cocci
in pairs, not clusters. She was switched to Levofloxacin before
transfer to the floor. She will need to continue levofloxacin
for three more days to complete a seven day course.
.
# Worsening positional occipital headache/Gait Instability: Pt
reported symptoms of lightheadedness on exam with positional
change, although orthostatics negative in ED and on floor. Pt
was at her baseline sinus bradycardia with 1st degree AV block,
with no pauses on ECG. CT and MRI head were negative for acute
pathology. Neurology was consulted and believe her headache and
gait instability may be a manifestation of cervical spondylosis.
Valsartan was considered a possible contributor to her headache
and dizziness, and was therefore discontinued in the ICU.
However, her dizziness persisted upon transfer to the floor. The
dizziness gradually improved and her valsartan was
re-administered the day before discharge. The patient worked
with physical therapy on the floor and was still experiencing
gait instability. In addition, she still experienced occasional
headaches.
.
# Weakness - Pt. reports that she "veers of to the left with
ambulation" she feels her left leg is weaker than right. On exam
she has peripheral neuropathy of both LE extremities. Unclear
etiology of neuropathy. No history of diabetes. Vit B12 is
normal, TSH is elevated and free T4 is pending. She has also had
recent hospitalization and illness and is likely decompensated
from baseline. Patient worked with PT and was still
experiencing gait instability at discharge. She will need to be
followed in neurology clinic upon discharge.
.
#Back Pain: Patient began complaining of left sided thoracic
back pain. EKG did not show new ischemic changes and her cardiac
enzymes were negative. She was later found to have point
tenderness just medial to her scapula on her back, and her pain
was attributed to musculoskeletal causes.
.
#Hemoptysis/Epistaxis: Patient began complaining of hemoptysis
while in the ICU, thought to be secondary to intubation in
setting of elevated INR. Her hemoptysis and epistaxis persisted
on transfer to the floor. The etiology is felt to be secondary
to CHF, in setting of pneumonia, and dry mucosa from increased
ipratropium, as she was receiving 6 puffs every 4 hours for six
days.
.
# Chronic diastolic CHF: Patient was previously being treated
for diastolic heart failure. Echo obtained in MICU demonstrated
new wall hypokinesis at the left and right ventricles, with
depressed ejection fraction at 40-50%. Patient was diuresed
with lasix gtt in the MICU, and was placed on her home lasix
dose upon transfer to the floor. She will be followed in
cardiology clinic as an outpatient.
.
# Atrial fibrillation: Pt had supratherapuetic INR and warfarin
was held in the MICU. Pt was continued on amiodarone 200mg
daily for rate control. Her INR gradually came down and on
presentation to the floor was at 2.7->1.8->1.5->1.3. She was
given warfarin 1mg PO on Monday, when her INR was 1.5. She was
administered warfarin 2mg PO on Tuesday, when her INR was 1.3.
Her INR will need to be monitored daily with warfarin dosed
accordingly to achieve therapeutic INR level of [**1-12**].
.
# Polycythemia [**Doctor First Name **]: Pt was noted to be anemic with
thrombocytosis, both at baseline. Pt was continued on home
regimen of hydroxyurea.
.
# Hypertension: Pt was noted to be hypertensive during
respiratory distress, although it was unclear whether HTN
preceded her respiratory decompensation. Soon after transfer to
the ICU she became hypotensive and her valsartan was
discontinued. Her blood pressure recovered and she was placed
back on valsartan the day before discharge.
Medications on Admission:
Amiodarone 200mg daily
Valsartan 40mg daily
Furosemide 40mg daily
Hydroxyurea 500mg every other day
Aspirin 81mg daily
Warfarin 1mg M-F, 2mg SaSun
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for HA/pain.
2. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation q4h:prn as needed for shortness of breath or
wheezing.
Disp:*1 inhaler* Refills:*0*
3. Hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO EVERY
OTHER DAY (Every Other Day).
4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Levofloxacin 500 mg Tablet Sig: 1.5 Tablets PO Q48H (every 48
hours) for 3 days: Take 750mg on [**9-24**], and 750mg on [**9-26**], then
stop.
Disp:*3 Tablet(s)* Refills:*0*
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Warfarin 1 mg Tablet Sig: 1-2 Tablets PO 1mg M-F, 2mg [**Last Name (LF) **],[**First Name3 (LF) **]:
Can dose 1 or 2mg until INR is therapeutic [**1-12**]. .
10. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation every six (6) hours.
Disp:*1 inhaler* Refills:*2*
11. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-11**] Sprays Nasal
TID (3 times a day) for 7 days.
12. Valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Outpatient Lab Work
Please measure PT/INR daily, until therapeutic. Goal INR is [**1-12**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Congestive Heart Failure--diastolic and systolic dysfunction
Acute pulmonary edema
Pneumonia
Atrial Fibrillation
Polycythemia [**Doctor First Name **]
Discharge Condition:
good
98.4 98.1 112/80 54 18 95%RA
Discharge Instructions:
You have been diagnosed with congestive heart failure with an
episode of acute pulmonary edema. You were found to have
pneumonia. We treated you with diuretics for your heart failure
and antibiotics for the infection of your lung. You will need to
continue the antibiotics for four more days. You were also
found to have cervical disc disease in your neck, causing your
headaches and neck pain. You will need to follow up in
neurology clinic for this.
Please follow-up as outlined below
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
.
Please return to the hospital or call your PCP if you experience
chest pain, shortness of breath, light headedness, difficulty
breathing, fever, or leg swelling.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 312**] [**Last Name (NamePattern4) 3015**], M.D. Phone:[**Telephone/Fax (1) 1803**]
Date/Time:[**2132-9-24**] 3:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9052**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2132-9-26**] 11:00
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 128**] Date/Time:[**2132-9-30**]
1:00
Please call Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 904**] to schedule an
appointment within the next two weeks.
appointment.
|
[
"428.0",
"721.0",
"355.8",
"518.81",
"396.2",
"427.31",
"428.33",
"784.7",
"786.3",
"272.0",
"V58.61",
"401.9",
"790.92",
"493.20",
"486",
"238.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
18819, 18885
|
12085, 17252
|
293, 299
|
19080, 19117
|
3829, 10374
|
19920, 20466
|
3023, 3136
|
17449, 18796
|
11180, 11254
|
18906, 19059
|
17278, 17426
|
19141, 19897
|
3151, 3810
|
210, 255
|
11283, 12062
|
327, 2375
|
10392, 11143
|
2397, 2689
|
2705, 3007
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,095
| 172,215
|
32446
|
Discharge summary
|
report
|
Admission Date: [**2155-12-21**] Discharge Date: [**2156-2-13**]
Date of Birth: [**2155-12-21**] Sex: F
Service: NB
The patient's post discharge name is [**Name (NI) 75738**] [**Name (NI) 24425**].
HISTORY OF PRESENT ILLNESS: This is the former 1.445 kg
product of a 30 and [**5-3**] week gestation pregnancy, born to a
30 year-old, G1, P0 woman. Prenatal screens blood type 0
positive, antibody negative, Rubella immune, RPR nonreactive,
hepatitis B surface antigen negative, group beta strep status
unknown. The pregnancy was complicated for premature rupture
of membranes which occurred on [**2155-12-17**]. The mother was
initially admitted to [**Hospital3 **] and then
transferred to [**Hospital1 69**]. She
received a full course of betamethasone. On the day of
delivery, labor progressed to a spontaneous vaginal delivery
under epidural anesthesia. There was no intrapartum fever or
other clinical evidence of chorioamnionitis. The mother
received intrapartum antibiotic therapy for greater than 4
hours prior to delivery. The infant emerged vigorous at
delivery. She received routine delivery room care. Apgars
were 8 at 1 minute and 8 at 5 minutes. The infant was
admitted to the Neonatal Intensive Care Unit for treatment of
prematurity.
Anthropometric measurements upon admission to the Neonatal
Intensive Care Unit: Weight 1.445 kg, 50th percentile.
Length 40 cm, 50th percentile. Head circumference 26.5 cm,
10 to 25th percentile.
PHYSICAL EXAM AT DISCHARGE: Weight 2.945 kg, 50th
percentile. Length 49 cm, 50 to 75th percentile. Head
circumference 34 cm, 75th percentile. General: Alert,
active, nondistressed infant with normal tone and cry. Skin:
Color pink in room air. Mongolian spot over sacrum. Shallow
scratches on face. Pink and well perfused. Head, ears, eyes,
nose and throat: Anterior fontanel open and flat. Sutures
apposed. Ears normally shaped and set. Positive red reflex
bilaterally. Eyes clear. Palate intact. Oral mucosa clear.
Neck supple. No masses. Chest: Occasional high pitched
stridor. Breath sounds clear and equal. Cardiovascular:
Regular rate and rhythm. Soft systolic murmur at the left
upper sternal border. Normal S1 and S2. Femoral pulses +2.
Abdomen soft, nontender, nondistended, no masses. Positive
bowel sounds. Cord healed. Genitourinary: Normal female.
Musculoskeletal: Spine straight, normal sacrum. Hips stable.
Moves all extremities well. Neuro: Symmetric tone and
reflexes. Positive suck, positive grasp, positive Moro.
HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY
DATA: RESPIRATORY: The infant was in room air upon
admission to the Neonatal Intensive Care Unit and remained in
room air until elective intubation for her patent ductus
arteriosus ligation on [**2155-12-31**]. She remained on vent
support for approximately 36 hours after surgery. She was
extubated to room air on postoperative day number 2. On day
of life 25, she was noted to have occasional stridor and 2
days subsequent, required nasal cannula oxygen, low flow 13
to 25 cc per minute. She transitioned to room air on day 40
but on day 48, again had to go back into nasal cannula 02.
She transitioned to room air on [**2155-2-11**] and has been in
room air for the 48 hours prior to discharge.
This infant was also treated for apnea of prematurity with
caffeine citrate. The caffeine was discontinued on
[**2156-1-7**]. Her last episode of spontaneous apnea and
bradycardia occurred on [**2156-1-26**].
Chest x-ray was within normal limits. Due to the ongoing
intermittent stridor, an otorhinolaryngology consult was
obtained. The infant had a bedside flexible bronchoscopy
performed that showed a left true vocal cord paralysis. She
will be followed by the otorhinolaryngology team at
[**Hospital3 1810**] 4 weeks after discharge. At the time of
discharge, she is breathing comfortably in room air with a
respiratory rate of 40 to 70 breaths per minute, oxygen
saturations greater than 95%. A barium swallow demonstrated
reflux, but no aspiration.
CARDIOVASCULAR: This infant has maintained normal heart
rates and blood pressures. A loud murmur was noted on day of
life #1 which persisted through day of life #4 when an
echocardiogram was performed which showed a 3 mm patent
ductus arteriosus with left to right flow, also a patent
foramen ovale. The infant received a 3 dose course of
indomethacin which was complicated by some renal
insufficiency. The repeat echocardiogram showed a persistent
3 to 4 mm patent ductus arteriosus and the decision was made
to go to patent ductus arteriosus ligation which occurred on
[**2155-12-31**], day of life 10. The infant tolerated the ligation
well. At the time of discharge, her baseline heart rate is
130 to 160 beats per minute. She does have a soft systolic
murmur which is thought to be the patent foramen ovale or an
innocent flow murmur. Recent blood pressure is 74/31 with a
mean arterial pressure of 46.
FLUIDS, ELECTROLYTES AND NUTRITION: This infant was
initially n.p.o. and treated with IV fluids. She had an
umbilical venous catheter and then a peripherally inserted
central catheter. Feedings were initiated on day of life one
but then were held for the course of indomethacin. She
resumed enteral feeds on her third postoperative day and has
gradually advanced to full volumes and the feedings have been
well tolerated. She received expressed breast milk, fortified
to 24 calories per ounce with Enfamil powder. Serum
electrolytes showed derangements in the sodium and the
potassium on the days immediately after the course of
indomethacin and have since normalized. Serum creatinine peaked
at 1.7 following indocin treatment. A repeat value in
mid-[**Month (only) 1096**] following treatmnet was 0.6 Weight on the day of
discharge is 2.945 kg.
INFECTIOUS DISEASE: The infant had a sepsis evaluation
performed on admission to the Neonatal Intensive Care Unit
for her prematurity and the prolonged premature rupture of
membranes. A complete blood count was within normal limits.
A blood culture was obtained prior to starting IV ampicillin
and gentamycin. The blood culture was no growth at 48 hours
and the antibiotics were discontinued. The infant did receive
a 3 dose course of Cefazolin perioperatively for the patent
ductus arteriosus ligation.
HEMATOLOGY: This infant is blood type B positive and is
direct antibody test negative. Hematocrit at birth was
52.3%. This infant did not receive any transfusion of blood
products. Most recent hematocrit was on [**2156-2-9**] at 25.6%
with reticulocyte count of 5.8%. She is being discharged home
on supplemental iron.
GASTROINTESTINAL: This infant required treatment for
unconjugated hyperbilirubinemia with phototherapy. The peak
serum bilirubin occurred on day of life 13, total of 11.4
mg/dl. She was treated with phototherapy for approximately 3
weeks. Her most recent rebound bilirubin was 8.2 mg/dl.
NEUROLOGY: This infant has had 3 normal head ultrasounds
performed on [**1-8**] and [**2156-1-22**]. She has a normal
neurologic exam at discharge and there were no neurologic
concerns at this time.
SENSORY:
Audiology: Hearing screening was performed with automated
auditory brain stem responses. This infant passed in both
ears.
Ophthalmology: This infant's most recent eye exam was
performed on [**2156-2-10**] showing mature retina in both eyes. A
follow-up examination is recommended in 9 months.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Home with the parents.
PRIMARY PEDIATRICIAN: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, [**Hospital 246**]
Pediatrics, [**Location (un) 75739**] II, [**Location (un) 246**], [**Numeric Identifier 62105**],
phone number [**Telephone/Fax (1) 37501**].
CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE:
1. Feeding ad lib p.o. or breast feeding. If p.o. feeding,
breast milk 24 calories per ounce with 4 calories of
Enfamil powder.
2. Medications:
Ferrous sulfate 25 mg/ml dilution, 0.5 ml p.o. once daily.
Goldline baby vitamins 1 ml p.o. once daily.
1. Iron and vitamin D supplementation:
Iron supplementation is recommended for preterm and low birth
weight infants until 12 months corrected age. All infants
fed predominantly breast milk should receive Vitamin D
supplementation at 200 i.u. (may be provided as a multi-
vitamin preparation) daily until 12 months corrected age.
1. Car seat position screening was performed. This infant
was observed in her car seat for 90 minutes without any
episodes of oxygen desaturation or bradycardia.
2. State newborn screens were sent on [**12-24**] and [**2156-1-4**].
The initial specimen showed an elevated methionine level
that was consistent with TPN administration. The repeat
specimen on [**2156-1-4**] had all results within normal
limits.
3. Immunizations:
Hepatitis B vaccine was administered on [**2156-1-21**].
Synagis was administered on [**2155-2-12**].
1. Immunizations recommended:
Synagis RSV prophylaxis should be considered from [**Month (only) **]
through [**Month (only) 958**] for infants who meet any of the following four
criteria: (1) Born at less than 32 weeks; (2) Born between
32 weeks and 35 weeks with two of the following: Day care
during RSV season, a smoker in the household, neuromuscular
disease, airway abnormalities or school age siblings; (3)
chronic lung disease or (4) hemodynamically significant
congenital heart disease.
Influenza immunization is recommended annually in the Fall
for all infants once they reach 6 months of age. Before this
age, and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out-of-home caregivers.
This infant has not received ROTA virus vaccine. The American
Academy of Pediatrics recommends initial vaccination of
preterm infants at or following discharge from the hospital
if they are clinically stable or at least 6 weeks but fewer
than 12 weeks of age.
FOLLOWUP:
1. Appointment with Dr. [**Last Name (STitle) **], primary pediatrician, within
3 days of discharge.
2. Pediatric otorhinolaryngology at [**Hospital3 1810**] 4
weeks after discharge. Dr [**Last Name (STitle) 28212**] was attending ENT physician
who saw patient.
DISCHARGE DIAGNOSES:
1. Prematurity at 30 and 4/7 weeks gestation.
2. Suspicion for sepsis ruled out.
3. Patent ductus arteriosus, status post ligation on
[**2155-12-31**].
4. Unconjugated hyperbilirubinemia.
5. Apnea of prematurity.
6. Anemia of prematurity.
7. Left true vocal cord paralysis.
8. Temporary renal insufficiency secondary to indomethacin
administration.
[**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern1) **], [**MD Number(1) 54604**]
Dictated By:[**Name8 (MD) 75740**]
MEDQUIST36
D: [**2156-2-13**] 03:23:50
T: [**2156-2-13**] 04:53:30
Job#: [**Job Number 75741**]
|
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"745.5",
"770.81",
"V05.3",
"778.4",
"779.81",
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icd9cm
|
[
[
[]
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[
"38.85",
"33.22",
"99.55",
"99.83",
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icd9pcs
|
[
[
[]
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7493, 8084
|
10297, 10913
|
1503, 7437
|
8995, 10276
|
249, 1488
|
8120, 8968
|
7462, 7469
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,001
| 123,036
|
6320
|
Discharge summary
|
report
|
Admission Date: [**2188-5-23**] Discharge Date: [**2188-5-29**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor Last Name 10493**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
Central line placement
History of Present Illness:
[**Age over 90 **] y/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4746**] with PMH CAD s/p NSTEMI, recent pna, GIB, presents
with hypotension and tachycardia. Pt recently d/c'd from [**Hospital1 **] on
[**4-19**] s/p NSTEMI which was medically managed and LLL pna, then
returned with C dif colitis on [**5-1**] and was discharged on
[**2188-5-9**]. At rehab, he had hypotension and new onset diarrhea the
day prior to admission to 61/35, and was given repeated fluid
boluses and started on empiric flagyl and ticarcillin. Prior to
admission, he developed tachycardia to the 130's, with return of
diarrhea. He had runs of SVT. He said to the staff at [**Hospital1 **]
"I just want to go to sleep and not wake up", but a discussion
was had with his son and the decision was made to transfer him
to the [**Hospital1 18**] emergency department for active management.
.
In the ED the patient was given 5 liters of fluids. CXR showed
persistent LLL pneumonia. He was persistently tachycardic to the
150's and was felt to be in a supraventricular tachycardia
versus atrial fibrillation, and was cardioverted at 50J once
without effect, then put on an esmolol drip with worsening
hypotension. His blood pressure continued to fall and a central
line was placed and he was started on levophedrine. He was
transferred to the ICU with clear DNR/DNI confirmation for
continuation of antibiotics, pressors, fluids, and close
monitoring.
.
In the MICU, the patient was treated broadly with
vanco/ctx/flagyl. His OSH blood cultures grew coag negative
staph resistent to oxacillin and his stool grew cdiff. His
antibiotics were narrowed to vanco/flagyl and his PICC was d/c.
His pressors were weaned on d2 and he maintained his pressure w/
intermittant fluid boluses. [**Last Name (un) **] stim showed him to be an
appropriate responder. He became tachycardic and was noted to
be in aflutter/afib w/ RVR. He was treated initially with a
diltiazem gtt but this was stopped when his BP dropped. After
this he was given dilt and metoprolol boluses but also
experienced hypotension with these and was started on an
amiodarone gtt. This was stopped on the evening prior to call
out and he was transitioned to oral amiodarone.
Past Medical History:
NSTEMI [**2187-4-18**], managed medically
paroxysmal atrial fibrillation and RBBB
CHF with EF 65% at [**Hospital1 **] [**4-14**]
h/o syncope, s/p pacemaker placement for SSS
BPH, s/p prostate surgery
lower back surgery years ago
cataracts, s/p surgery
hard of hearing
C dif colitis [**4-14**]
GI bleeding [**4-14**], pt refused endoscopy
meneire's disease
Social History:
He is married, lived previously in [**Location (un) 1468**] but recently at
[**Hospital **] rehab. History of smoking until recently (one pck every
36 hours) x many years. History of wine every night.
Family History:
noncontributory
Physical Exam:
VS: t98.8, HR 156 (88-156), BP 99/53 (88-120/48-70); O2 sat
98%RA
Gen: frail elderly male, RIJ in place, resting comfortably.
HEENT: edentulous, dry MM. RIJ in place. no JVD appreciated
CHEST: poor air movement. no wheezes, rales, rhonchi appreciated
CV: normal S2 and S2. tachycardic. No m,r,g.
Pertinent Results:
[**2188-5-23**] 10:00AM BLOOD WBC-10.6 RBC-3.83* Hgb-11.1* Hct-33.6*
MCV-88 MCH-29.1 MCHC-33.1 RDW-15.7* Plt Ct-266
[**2188-5-29**] 06:45AM BLOOD WBC-7.4 RBC-3.67* Hgb-10.3* Hct-32.0*
MCV-87 MCH-28.2 MCHC-32.4 RDW-16.3* Plt Ct-261
[**2188-5-23**] 10:00AM BLOOD Neuts-68 Bands-16* Lymphs-12* Monos-3
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2188-5-25**] 04:24AM BLOOD PT-14.1* PTT-40.2* INR(PT)-1.2*
[**2188-5-23**] 10:00AM BLOOD Glucose-123* UreaN-27* Creat-1.3* Na-142
K-3.9 Cl-104 HCO3-23 AnGap-19
[**2188-5-29**] 06:45AM BLOOD Glucose-96 UreaN-4* Creat-0.7 Na-142
K-4.1 Cl-109* HCO3-26 AnGap-11
[**2188-5-23**] 03:50PM BLOOD Albumin-2.7* Calcium-8.3* Phos-2.5*
Mg-1.2*
[**2188-5-29**] 06:45AM BLOOD Calcium-8.3* Phos-3.1 Mg-1.6
[**2188-5-23**] 03:50PM BLOOD Cortsol-33.3*
[**2188-5-23**] 05:30PM BLOOD Cortsol-58.2*
[**2188-5-23**] 06:00PM BLOOD Cortsol-71.1*
.
CXR [**2188-5-23**]: IMPRESSION: AP chest compared to [**2188-5-2**]:
Asbestos-related pleural calcification obscures large regions of
both lungs which are otherwise clear. The heart is top normal
size. Transvenous right ventricular and right atrial pacer leads
follow their expected courses. Indentation of the trachea at the
thoracic inlet, suggests an enlarged thyroid gland. No
pneumothorax or pleural effusion is present.
Brief Hospital Course:
A/P: [**Age over 90 **] year old man with recent hospitalizations for C diff,
NSTEMI, and pneumonia presented with septic shock, AFib with RVR
and hypotension.
.
1. Septic shock - The patient presented w/ hypotension and grew
MRSA. Also had cdiff colitis on admission. Was initially fluid
repleted and started on pressors but these were weaned quickly
by HD2. He was initially covered broadly with CTX, vancomycin,
and flagyl but the CTX was withdrawn when his culture data
returned. He is to complete 2wk courses of both vancomycin and
flagyl as an outpatient. He had an appropriate response to a
cortisol stim test and, thus, was not supported w/ stress dose
steroids. His PICC line on admission was d/c. He has
intermittantly required small fluid boluses to maintain his UOP
> 30cc/hr but was making good amounts of urine w/out boluses
upon d/c. His bblocker was held on admission [**3-13**] hypotension
but was restarted on d/c.
.
2. tachycardia - In afib w/ RVR on admission and cardioversion
failed in the ED. BBlocker and diltiazem administration
resulted in dropped pressure without rate response. He was
started on an amiodarone drip in the ICU w/ good rate control
and quickly transitioned to PO. He has a pacer in place and
continues to be in good rate control on the floor. He will
start his amiodarone maintenance doses on [**2188-6-9**] and will need
telemetry until this time.
.
3. Acute renal failure - He had a mild elevation of his
creatinine on admission but this trended back to baseline (0.9)
with fluid repletion.
.
4. code - DNR/DNI by discussion with PCP [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**], consistent
with previous discussions. Clarified with sons
Medications on Admission:
Meds at rehab:
asa 325 po qd
dig 0.125 po qd
furosemide 20 mg poqd
lopressor 12.5 po qd
lipitor 20 mg poqd
prevacid 30 mg poqd
flagyl 500 mg po tid (start [**2188-5-22**])
ticarcillin/clavulanate 3 g IV Q6H (start [**2188-5-22**])
atrovent nebs QID/Q2H prn
venodynes
PICC flushes
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day/Year **]: 5000 (5000)
units Injection Q8H (every 8 hours).
2. Metronidazole 500 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO TID (3
times a day) for 7 days.
3. Methylphenidate 5 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO BID (2
times a day).
4. Amiodarone 200 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO BID (2 times
a day) for 4 days.
5. Amiodarone 200 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO DAILY (Daily)
for 7 days.
6. Amiodarone 200 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY
(Daily).
7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
8. Vancomycin 1,000 mg Recon Soln [**Last Name (STitle) **]: One (1) g Intravenous
once a day for 7 days.
9. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO twice a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **]
Discharge Diagnosis:
MRSA sepsis, c. diff colitis, atrial fibrillation w/ RVR
Discharge Condition:
Stable; tolerating minimal PO, appropriate in conversation
Discharge Instructions:
Please take your medications as directed by the [**Hospital1 **]
Followup Instructions:
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2188-6-9**]
9:00
.
Please make arrangements to see your PCP [**Name9 (PRE) **],[**Name9 (PRE) **] [**Name Initial (PRE) **].
[**Telephone/Fax (1) 10492**] within the next several weeks
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**] MD, [**MD Number(3) 10495**]
Completed by:[**2188-5-29**]
|
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icd9cm
|
[
[
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[
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icd9pcs
|
[
[
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7854, 7897
|
4838, 6559
|
275, 300
|
7998, 8059
|
3517, 4815
|
8173, 8610
|
3167, 3184
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,282
| 105,104
|
39289
|
Discharge summary
|
report
|
Admission Date: [**2158-7-13**] Discharge Date: [**2158-8-31**]
Date of Birth: [**2092-6-29**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
Pancytopenia
Major Surgical or Invasive Procedure:
Subclavian central venous catheter placement and removal
Bone marrow biopsies
- Right subclavian triple lumen central venous catheter
placement and removal
- Bone marrow biopsies (three)
- Lumbar puncture and intrathecal methotrexate
History of Present Illness:
66yo M w/ PMH s/f HTN, seasonal allergies, osteoarthritis s/p L
TKA and R THA who is transferred from outside hospital with
pancytopenia, recent weight loss (semi-intentional), and found
to have blasts on peripheral smear by OSH hematologist. He
reports feeling mostly well prior to admission. He developed
headache last weekend that he felt was related to his sinuses,
given his h/o seasonal allergies. He then developed a sore
throat earlier this week. He went to the VA to be evaluated for
possible sinusitis/URI and CBC was checked which revealed WBC of
1.8. He was referred to OSH for further management. He was
evaluated in the ED and a hematologist was consulted who
examined the peripheral smear. Smear showed 50% lymphocytes, 28%
blasts, 2% metamyelocytes, 5% NRBCs. No clear cut Auer rods but
some blasts with significant granularity. Patient was transfused
2u PRBCs, started on allopurinol, 1/2NS w/ bicarb and K at OSH
and transferred here for further diagnostic workup. Of note, pt.
travels often to West Coast and spent 10 weeks in [**State 15946**] this
spring, returning [**2158-2-23**]. He reports allergic symptoms and
lots of dust. Also of note, pt. reports trying to lose weight
recently with 9-10lb weight loss in last 1-2 months. Denies
fever, chills, night sweats, fatigue, unintentional weight loss,
lymphadenopathy. Denies rash, joint pain, nausea, vomiting,
productive cough, diarrhea, BRBPR, melena.
Past Medical History:
Osteoarthritis, s/p L TKA, R THA
h/o negative colonoscopy-last [**2154**]
Hypertension
Seasonal Allergies
GERD
Social History:
Never married, no children. Lives alone. Retired fireman.
U.S.M.C. veteran. Denies ever smoking, no EtOH, no illicits.
Travelled to [**State 15946**] for 10 weeks, returning 4/[**2157**].
Family History:
Thinks he had an uncle w/ liver cancer. Father died of AAA,
mother of ?CHF. Multiple family members w/ CVA as cause of
death. No known h/o hematologic malignancies.
Physical Exam:
VS: 99.4 132/90 115 18 94%RA 231lbs
Gen: alert, anxious M appearing stated age in NAD
HEENT: NC/AT, PERRL, EOMI, OP w/o exudate/erythema, MM moist, no
oral lesions, good dentition, no scleral pallor
Neck: supple, no submental, submandibular, supraclavicular,
ant/post cervical, pre/post auricular LAD
Skin: No rash, well healed vertical incision over L knee,
bandaid over L chest
Cor: Tachycardic but regular, no murmurs/rubs/gallops, +S1/S2
Lungs: CTAB, good air entry b/l, no rales/rhonchi/wheezes
Abd: slightly firm, nontender, nondistended, +BS, no
hepatosplenomegaly, no rebound or guarding
Extremities: warm, no clubbing or edema, +onychomycosis on all
toenails
Pertinent Results:
Admission Labs:
[**2158-7-13**] 05:48PM BLOOD WBC-2.3* RBC-3.69* Hgb-10.5* Hct-31.8*
MCV-86 MCH-28.4 MCHC-32.9 RDW-17.1* Plt Ct-30*
[**2158-7-13**] 05:48PM BLOOD Neuts-16* Bands-1 Lymphs-20 Monos-0 Eos-2
Baso-0 Atyps-1* Metas-0 Myelos-0 Blasts-60* NRBC-5* Other-0
[**2158-7-13**] 05:48PM BLOOD Hypochr-1+ Anisocy-OCCASIONAL
Poiklo-NORMAL Macrocy-OCCASIONAL Microcy-NORMAL Polychr-1+
Ovalocy-2+
[**2158-7-13**] 05:48PM BLOOD PT-13.2 PTT-24.6 INR(PT)-1.1
[**2158-7-13**] 05:48PM BLOOD Fibrino-665*
[**2158-7-21**] 12:04AM BLOOD Fibrino-607*
[**2158-7-14**] 03:30PM BLOOD ESR-45*
[**2158-7-17**] 12:00AM BLOOD Gran Ct-163*
[**2158-7-13**] 05:48PM BLOOD Glucose-102* UreaN-25* Creat-1.0 Na-141
K-4.4 Cl-102 HCO3-31 AnGap-12
[**2158-7-13**] 05:48PM BLOOD ALT-47* AST-37 LD(LDH)-396* AlkPhos-125
TotBili-1.1
[**2158-7-13**] 05:48PM BLOOD Albumin-4.3 Calcium-9.6 Phos-4.3 Mg-2.1
UricAcd-5.2
[**2158-7-14**] 06:00AM BLOOD TSH-1.5
[**2158-7-14**] 06:00AM BLOOD [**Doctor First Name **]-NEGATIVE
.
Discharge Labs:
.
Pathology:
[**7-13**] Flow cytometry:
FLOW CYTOMETRY IMMUNOPHENOTYPING
The following tests (antibodies) were performed: CD2, CD3, CD4,
CD5, CD7, CD8, CD10, CD13, CD14, CD15, CD19, CD20, CD33, CD34,
CD41, CD11c, CD56, CD64, HLA-DR, KAPPA, LAMBDA, CD71, GlycA,
CD45, CD117.
RESULTS:
Three color gating is performed (light scatter vs. CD45) to
optimize blast yield.
An abnormal population of events cluster within the blast gate.
They comprise of approximately 37% of all events. These 'blasts'
express CD7, CD34, CD13 (dim), CD33, CD11c(dim) and CD71. CD19
expression is equivocal. They are negative for CD20, CD10, CD3
(and other T-cell markers except CD7), CD64, CD14 and CD56.
Lymphoid gated events are unremarkable.
INTERPRETATION
Increased blasts with predominantly myeloid markers, consistent
with acute myeloid leukemia. Morphological review shows blasts
(~58%) with high N:C ratio, rare Auer rods, scant paucigranular
cytoplasm, irregular nuclear contours, and open chromatin.
Findings discussed with Dr. [**Last Name (STitle) **] on [**2158-7-14**].
.
- [**7-14**] Bone Marrow: By morphology and immunophenotype, the
blasts appear to be of early myeloid differentiation (FAB M1-2).
However, cytogenetics and other molecular findings are necessary
and should be correlated for an appropriate current WHO based
classification.
MICROSCOPIC DESCRIPTION
Peripheral Blood Smear:
The smear is adequate for evaluation. Erythrocytes are
decreased in number and are normochromic and normocytic with
mild anisopoikilocytosis. Occasional ovalocytes, dacrocytes and
polychromatophilic cells seen, 2 nucleated RBCs, 100 nucleated
cells seen. The white blood cell count appears decreased.
There is a predominance of large, immature forms with high
nuclear cytoplasm ratio, scant agranular cytoplasm, prominent
nucleoli and fine chromatin consistent with blast forms. Rare
Auer rod identified. Platelet count appears decreased. Large
forms are seen. Giant forms are not present. Differential
shows 6% neutrophils, 0% bands, 0% monocytes, 28%
lymphocytes, 2% eosinophils, 0% basophils, 63% blasts seen.
- Aspirate Smear:
The aspirate material is adequate for evaluation. The M:E ratio
is 1.9:1. Erythroid precursors show normoblastic maturation
with occasional megaloblastoid forms, irregular nuclear
contours, and rare nuclear buds. Myeloid precursors consist of
a predominance of blast forms. Megakaryocytes are present in
decreased numbers; abnormal forms are seen and include small
hypolobated forms. Differential shows: 62% Blasts, 0%
Promyelocytes, <1% Myelocytes, 0% Metamyelocytes, 0%
Bands/Neutrophils, <1% Plasma cells, 3% Lymphocytes, 33%
Erythroid.
Blasts comprise 62% of the aspirate and are large with fine
chromatin, prominent nucleoli and scant cytoplasm.
Clot Section and Biopsy Slides:
The biopsy material is adequate for evaluation. Prominent
aspiration artifact is present. The overall cellularity of ~
70% with 80% blasts. The M:E ratio estimate is normal.
Erythroid precursors are decreased and exhibit normoblastic
maturation. Myeloid elements are decreased and consist of
predominantly blasts, without maturing hematopoiesis.
Megakaryocytes are markedly decreased.
Marrow clot section is similar to the biopsy.
Special Stains:
Iron stain is adequate for evaluation. Storage iron is normal.
Sideroblasts are present. Ringed sideroblasts are absent.
.
- [**7-14**] Cytogenetics: KARYOTYPE: 46,XY[20]
INTERPRETATION:
No cytogenetic aberrations were identified in 20
metaphases analyzed from this unstimulated specimen.
This normal result does not exclude a neoplastic
proliferation.
Mosaicism and small chromosome anomalies may not be
detectable using the standard methods employed.
-------------------INTERPHASE FISH ANALYSIS, 100-300
CELLS-------------------
nuc ish(D5S23,D5S721,EGR1)x2[100],(D7Z1,D7S522)x2[100],
(D20S108x2)[100]
FISH evaluation for a 5q deletion was performed with the
Vysis LSI EGR1/D5S23, D5S721 Dual Color Probe ([**Doctor Last Name 7594**]
Molecular) for EGR1 at 5q31 and D5S721/D5S23 at 5p15.2 and
is interpreted as NORMAL. Two EGR1 hybridization signals
were observed in 100/100 nuclei examined, which is within
the normal range established for this probe in the
Cytogenetics Laboratory at [**Hospital1 18**]. Up to 3% of cells in
normal samples can show apparent 5q deletion using this
probe set. A normal EGR1 FISH finding can result from
absence of a 5q deletion, from a 5q deletion that does not
involve the region to which this probe hybridizes, or from
an insufficient number of neoplastic cells in the specimen.
FISH evaluation for a 7q deletion was performed with the
Vysis D7S522/CEP7 Dual Color Probe ([**Doctor Last Name 7594**] Molecular) for
D7S522 at 7q31 and CEP7 (D7Z1) (chromosome 7 alpha
satellite DNA) at 7p11.1-q11.1 and is interpreted as
NORMAL. Two D7S522 hybridization signals were observed in
100/100 nuclei, which is within the normal range
established for this probe in the Cytogenetics Laboratory
at [**Hospital1 18**]. Up to 3% of cells in normal samples can show
apparent 7q deletion using this probe set. A normal
D7S522 FISH finding can result from the absence of a 7q
deletion, from a 7q deletion that does not involve the
region to which this probe hybridizes, or from an
insufficient number of neoplastic cells in the specimen.
FISH evaluation for a 20q deletion was performed with the
Vysis LSI D20S108 Probe ([**Doctor Last Name 7594**] Molecular) at 20q12 and is
interpreted as NORMAL. Two hybridization signals were
observed in 98/100 nuclei examined, which is within the
normal range established for this probe in the Cytogenetics
Laboratory at [**Hospital1 18**]. Up to 8% of cells in normal samples
can show apparent 20q deletion using this probe set. A
normal 20q FISH finding can result from absence of a 20q
deletion, from a 20q deletion that does not involve the
region to which this probe hybridizes, or from an
insufficient number of neoplastic cells in the specimen.
.
Bone marrow [**2158-7-27**]: Peripheral Blood Smear:
The smear is adequate. Erythrocytes are decreased and exhibit
moderate anisocytosis and poikilocytosis. Scattered microcytes,
echinocytes, elliptocytes, dacrocytes and red cell fragments are
seen. Rare shistocytes are seen on scanning. The white blood
cell count appears markedly decreased and includes large
immature myeloid forms consistent with blasts. Lymphocytes
include small mature and large reactive forms. Platelet count
appears moderately decreased. Large forms are seen. Differential
count shows 0% neutrophils, 0% bands, 4% monocytes, 89%
lymphocytes, 0% eosinophils, 7% blasts.
Aspirate Smear: The aspirate material is adequate for evaluation
and is predominantly comprised of large atypical myeloid forms
with one to several prominent nucleoli consistent with blasts.
Erythroid precursors are markedly decreased. Rare maturing forms
are present. Maturing myeloid precursors are greatly decreased
in number. Megakaryocytes are present in normal numbers.
Differential (300 cells) shows: 72% Blasts, 2% Promyelocytes,
<1% Myelocytes, <1% Metamyelocytes, <1% Bands/Neutrophils, 3%
Plasma cells, 18% Lymphocytes, 5% Erythroid.
Clot Section and Biopsy Slides: The biopsy material is adequate
for evaluation. The overall cellularity is approximately 40% and
is comprised almost entirely of large blast forms present in
large clusters. The blasts comprise 70-80% of overall marrow
cellularity. The remainder of the cellular components are made
up of lymphocytes, plasma cells and rare maturing myeloid and
erythroid precursors. Megakaryocytes are present.
.
- Bone marrow [**2158-8-16**]: <<<< >>>
.
Imaging:
- [**7-14**] TTE: The left atrium is elongated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). The estimated cardiac index is normal
(>=2.5L/min/m2). Right ventricular chamber size and free wall
motion are normal. The ascending aorta is mildly dilated. The
aortic valve leaflets are mildly thickened (?#). There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. No mitral regurgitation is seen. The pulmonary
artery systolic pressure could not be determined.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved global and regional
biventricular systolic function. Biatrial dilation.
.
- [**7-14**] CXR: No previous images. There is some apparent
hyperexpansion of the
lungs suggesting some chronic pulmonary disease. However, no
evidence of
acute pneumonia, vascular congestion, or pleural effusion.
Right subclavian PICC line extends to the mid portion of the
SVC. No evidenceof pneumothorax.
.
- [**7-20**] CXR: Aside from atelectasis in the left base the lungs
are clear. There are low lung volumes. Cardiomediastinal
contours are normal. Right PICC tip is in the mid SVC.
.
- [**7-24**] CT Chest w/o con: 4.5-mm right lower lobe nodule. Suggest
repeat examination in six months.Multifocal subsegmental
atelectasis, not obstructive. Coronary calcification.
.
- [**2158-7-28**] CT chest/abd/pelvis: No abnormal interstitial lung
process or site of infection identified. Interval increase in
number of mediastinal nodes extensively, but no single
pathologically enlarged lymph node.
.
- [**2158-7-30**] CTA chest: 1. Limited CT examination due to respiratory
artifact. No proximal or segmental pulmonary emboli identified.
More distal branches obscured due to poor filling and breathing
artifact. If a high clinical concern for embolus, a dedicated
V/Q scan could be obtained if patient is able to tolerate as the
lungs. Slightly increased linear atelectasis. 2. Unchanged small
mediastinal lymph nodes of uncertain etiology. 3.
Atherosclerotic calcification within the coronary vessels.
Small-to-moderate hiatal hernia. 4. Stable right-sided pulmonary
nodules as detailed above; can be followed in six months as
suggested on initial [**2158-7-24**] CT chest.
.
- [**2158-8-15**] CT abdomen/pelvis: Mild delayed right nephrogram with
high-density filling defect within the posterior calices of the
right upper pole, most consistent with underlying clot. There is
mild right hydronephrosis and proximal-mid hydroureter with
abrupt cutoff of contras column in the mid-distal ureter. This
may reflect more distal intraureteral clot, although a focal
obstructing lesion cannot be
completely excluded. Can consider correlation with follow up CT
or further
evaluation with dedicated MR urogram or ureteroscopy as needed.
-[**2158-8-16**] Bone marrow biopsy: MARKEDLY HYPOCELLULAR BONE MARROW
WITH FEATURES CONSISTENT WITH CHEMOTHERAPY-INDUCE MARROW
ABLATION. THERE IS NO MORPHOLOGIC EVIDENCE OF INVOLVEMENT BY
ACUTE MYELOID LEUKEMIA.
-[**2158-8-23**] Renal u/s: Mild to moderate right and mild left
hydronephrosis.
-[**2158-8-24**] MRI C and T spine, brachial plexus: No abnormal
cervical or thoracic spine enhancement. Limited study by
motion, but grossly normal MR appearance of the brachial plexus
bilaterally.
-[**2158-8-26**] CT chest w/o contrast: Redemonstration of tiny
pulmonary nodules as detailed above, the largest of which is
approximately 5 mm. Would recommend repeat evaluation with a
dedicated CT of the chest in approximately six months.
-[**2158-8-27**] Bone marrow biopsy: Hypocellular marrow with erythroid
dominant elements. Diagnostic features of involvement by acute
myeloid leukemia are not seen, By immunohistochemical stains,
CD34 reactive blasts comprised <5% of overall marrow
cellularity. E-cadherin expression is present in scattered
clusters of early erythroid precursors, while Glycophorin A
highlights numerous maturing erythroid forms.
-[**2158-8-28**] Urine cytology: Rare cluster of atypical but
degenerated urothelial cells.
Brief Hospital Course:
66yo M w/ unrelated PMH presented to OSH, found to have
pancytopenia w/ blasts in smear, transferred and found to have
AML on flow cytometry and bone marrow biopsy.
.
# AML: Patient was admitted and found to be pancytopenic but
asymptomatic except a chronic non-productive cough that was
attributed to seasonal allergies. He underwent TTE which showed
normal LVEF. He underwent bone marrow biopsy on [**7-14**] which
confirmed diagnosis of AML. A triple lumen subclavian CVL was
placed on [**7-14**]. He was started on 7+3 induction therapy on [**7-14**].
He tolerated the infusion well and his ANC fell to 0 on [**7-22**]. He
was thrombocytopenic and developed gingival bleeding with PLT in
the 30s and was transfused as needed. He was also anemic and
transfused as needed. Repeat bone marrow showed
hypercellularity. Patient was started on MEC therapy and
tolerated it well. His ANC remained 0. Repeat bone marrow on D14
of MEC showed hypocellularity. His counts gradually increased
and antibiotics were discontinued, he had been on broad coverage
with vancomycin, cefepime, and ambisome (spent a lot of time in
[**State 15946**]) and remained on these antibiotics until he was no
longer neutropenic or febrile. Counts continued to increase and
at the time of discharge pt was no longer neutropenic and WBC
was 4.1. Bone marrow biopsy on [**2158-8-28**] showed no clonal
cytogenetic aberrations and <5% blasts. However, skin biopsy
for a purple-pink papular rash on both forearms with biopsy was
consistent with leukemia cutis. Considering his bone marrow
response and the resolution of this rash, it was thought to be
rseolved. He will followup with Dr. [**Last Name (STitle) **] for futher
treatment.
.
# Febrile Neutropenia: As counts decreased, the patient was
febrile without obvious source in urine or lungs and was started
on cefepime and vancomycin and levofloxacin which had been
prescribed for cough was discontinued. Given the concern for
hemorrhoids and possible minor anal mucosal tear, see below,
Flagyl was added. Micafungin was added on day 4 after first
spike given continued fevers. Pt. felt well and was ambulatory,
taking PO during this time. Patient clinically improved, but
then developed high fevers, rigors, and whole-body rash,
respiratory distress (see ICU course below). He was pan-scanned
again, and CT sinus showed sinusitis. Coccidio, beta-glucan,
galactmannan, histoplasmosis, legionella, blood fungal cultures
were sent and were all eventually negative. ID was consulted and
suggested removing cefepime and micafungin as they might cause
rash. He was placed on vancomycin, meropenem, and ambisome (for
aspergillus and coccidiomycosis coverage). Patient had risen
LFTs which eventually trended down. He improved clinically and
antibiotic coverage was stopped on [**8-26**] when patient had been
afebrile for several days and ANC >1000. Beta glucan from [**8-26**]
was >500. ID was consulted again and advised to recheck beta
glucan, as it may have been an erroneous result, since he was
asymptomatic and had stable lesions on chest CT from [**8-26**], and
also requested a mycoF/lytic culture. These results are to be
followed up as an outpatient and no antifungal coverage or
liver/spleen imaging were advised unlses the he spiked a fever,
which he did not do.
.
# Guaiac positive stool: Patient reported hard and painful BM
during induction therapy. Bloody streaks were seen on stool,
minimal blood in toilet. Platelets transfused, Hct stable. Bowel
regimen increased and further BMs were guaiac neg and soft for
the rest of his hospital course.
#hematuria: noted to have hematuria [**8-15**] in the setting of
thrombocytopenia. CT abd/pelvis showed mild R hydronephrosis
and proximal-mid hydroureter on [**8-15**]. Hematuria resolved as
thrombocytopenia resolved, platelets were transfused for <10.
F/u ultrasound showed bilateral hydronephrosis in the setting of
increasing creatinine, urology was consulted concerning the
hydronephrosis and advised that he follow up as an outpatient
for a hematuria workup.
.
#Thrombocytopenia: pt had low platelets as expected and was
transfused PRN for platelets <10. On [**8-20**], had urticarial
reaction to crossmatched platelets that improved with tylenol,
PRA assay positive. Thrombocytopenia improved without
intervention as the rest of counts went up as well.
#Acute kidney injury: Patient's creatinine was elevated starting
[**8-24**] from baseilne of 0.9 to 1.8 on [**8-29**] despite removal of
nephrotoxic vancomycin and ambisome on [**8-26**]. Renal was
consulted and considering FeNa of 2.1, was thought to be due to
AIN, although it is unclear which medication caused this. He
did have a drug rash earlier in his hospital course, thought to
be related to micafungin or meropenem, but it is unclear what
caused the AIN. He will followup with renal service as an
outpatient.
#L 4th and 5th finger numbness: Patient had noted this
consistently for a week and mentioned it on [**2158-8-24**]. MRI T and
C spine and brachail plexus were ordered to eval for CNS spread
of disease, in addition LP was done. No lesions on MRI and no
evidence of CNS disease. Numbness may be [**12-27**] ulnar neuropathy,
he will follow up in neurology clinic and may get an EMG.
.
ICU Course ([**Date range (1) 29638**])
Hypoxia: Pt with increased O2 demand and some respiratory
distress which lead to his brief transfer from the onc service
to the [**Hospital Unit Name 153**]. Pt was initially given nebs, changed from NC to
facemask, and given IV lasix. He was redosed with lasix with
good urine output. CXR showed no change and ECHO was obtained.
Pt O2 requirement stabilized and he was titrated down to lower
dose nasal cannula.
.
Febrile Neutropenia: Temp of 101.4 at time of ICU transfer.
Broad spectrum antibiotics were continued but elevated LFTs
raised concern over the administration of fluconazole. Because
of the pts significant travel history to some fungal endemic
regions it was determined to treat emperically with Ambisome so
this was started and Fluconazole D/Ced. Near the end of the
first Ambisome infusion pt spiked a fever above 104 and had
chills/rigors. This calmed down with demerol and tylenol and was
thought likely due to the infusion vs an infectious cause.
.
Pancytopenia: This was thought [**12-27**] to AML and chemo with Hgb low
on ICU presentation. Over brief ICU course 1 unit of PRBC was
initially given followed by 2 units PRBC the next day. Pt had
mild temp at time of beginning of the 2nd transfusion but it was
administered in spite of this. Hct responded appropriately to
these infusions.
.
Medications on Admission:
Home:
Diovan 80mg PO daily
Aspirin 81mg PO daily
Omeprazole 20mg PO daily
Multiple vitamins, incl. MVI, B complex
.
On transfer:
Allopurinol 300mg PO daily
Ambien 5mg PO QHS prn insomnia
Colace 100mg PO BID
Dulcolax 10mg PO QAM prn constipation
Milk of Magnesia Q6h prn constipation
Mylanta 30ml PO Q4h prn
Procardia XL 30mg PO daily
Protonix 40mg PO daily
Reglan 10mg IV Q6h prn nausea
Robitussin 10mL PO Q4h prn cough
Tylenol 650mg PO Q6h prn
Zofran 4mg IV Q8h prn nausea
Discharge Medications:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
Disp:*60 Tablet(s)* Refills:*2*
3. nifedipine 30 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
Disp:*30 Tablet Extended Rel 24 hr(s)* Refills:*2*
4. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for coughing.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Acute Myelogenous Leukemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 86903**], you were admitted to the [**Hospital1 827**] because you had low blood count. We obtained a
bone marrow biopsy which showed that you had acute myelogenous
leukemia. You were started on chemotherapy. Your cell counts
dropped as expected, and you developed a fever. We did CT scans
of your sinus, chest, and abdomen to look for a source of
infeciton. We treated you with many antibiotics. One of the
antibiotics gave you a rash, which resolved after we stopped it.
You had a repeat bone marrow biopsy which still showed leukemia,
so you underwent a second round of chemotherapy. While you white
blood cell counts were at their nadir, you have difficulty
breathing and spiked high fevers with rigors for many days. We
continued with medications to treat bacterial or fungal
infections. You eventually got better and did not have any more
fevers and your white blood cell counts increased (including
neutrophil count) and we stopped your antibiotics. We did a
final bone marrow biopsy which showed <5% blasts, indicating a
good response. You will follow up with Dr. [**Last Name (STitle) **] on Friday
to discuss the next steps in your treatment.
Your creatinine was increasing (number that shows kidney
function), which we think is likely due to acute interstitial
nephritis (allergic reaction in your kidneys likely from
medications). You should follow up with urology clinic and
renal clinic about this and the blood in your urine you had a
couple of weeks ago. You should also follow up in neurology
clinic so they can check on the numbness in your left hand.
Your sutures can be taken out in one week (around [**9-7**]), this
can be done at clinic.
.
We made the following changes to your medications:
stop taking diovan
start taking nifedipine (procardia)
start taking acyclovir
Followup Instructions:
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) 162**] & [**Hospital1 **] Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2158-10-2**] 4:00 (neurology-finger numbness)
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 721**]
Date/Time:[**2158-9-25**] 3:00 (renal-kidneys)
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2158-9-1**] 2:00 (oncologist-leukemia)
[**2158-11-3**] 02:00p [**Last Name (LF) **],[**First Name3 (LF) 275**] C. (urology, for blood in your
urine)
Completed by:[**2158-9-1**]
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26,031
| 134,740
|
1973
|
Discharge summary
|
report
|
Admission Date: [**2148-4-24**] Discharge Date: [**2148-5-5**]
Date of Birth: [**2092-11-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Albumin Products / Lipitor / Mevacor / Ace Inhibitors /
Amiodarone
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Dyspnea and fatigue
Major Surgical or Invasive Procedure:
[**2148-4-26**]
1. Third time redo heart operation.
2. Mitral valve replacement with a 29-mm St. [**Male First Name (un) 923**] Epic mitral
valve bioprosthesis, serial number [**Serial Number 10858**], reference number
[**Serial Number 10859**].
3. Tricuspid valvuloplasty with a 28-mm [**Doctor Last Name **] MC3 ring, serial
number [**Serial Number 10860**], model number 4900.
4. Full left and right-sided Maze procedure with a combination
of [**Company 1543**] BP-2 bipolar irrigated RF system and the CryoCath.
[**2148-4-29**] ICD implant( [**Company 2267**] Guidant Endotak Reliance
Model 0157)
History of Present Illness:
This is a 54 year old male with complicated cardiac history who
presents with chronic systolic congestive heart failure. His
current symptoms include dyspnea on exertion, worsening fatigue
and decreased exercise tolerance. He is status post CABG in [**2140**]
followed by mitral valve repair (via right thoracotomy)in [**2142**].
Echocardiogram has revealed mod-severe mitral and tricuspid
regurgitation. He is currently in atrial fibrillation. His
symptoms have improved since being switched from Dofetilide to
Digoxin. Currently denies chest pain, orthopnea, PND and pedal
edema. He is now referred for surgical intervention.
Past Medical History:
- Mitral valve regurgitation
- Tricuspid valve regurgitation
- Chronic Systolic Congestive Heart Failure
- Coronary Artery Disease, s/p MI in [**2132**], s/p RCA and LAD PCI's
- Paroxysmal/Persistent atrial fibrillation s/p five prior
cardioversions
- History of NSVT (s/p VT ablations [**11-3**])
- Moderate Pulmonary artery hypertension
- Severe Hyperlipidemia(intolerant of statins, undergoes
plasmapheresis every two weeks at [**Location (un) 5450**] Kidney Center)
- Mild Anemia
- Obstructive sleep apnea (CPAP)
- Chronic Renal Insufficiency
- Carotid Disease
Past Surgical History
s/p AICD implant in [**2142**]
s/p Right thoracotomy, Mitral valve repair with a 28 mm [**Doctor Last Name 405**]
annuloplasty band [**2142**] @ [**Hospital1 18**]
s/p CABG (LIMA to LAD, SVG to OM, SVG to PDA to PLV) [**2140**] @ [**Hospital1 2025**]
s/p AV graft in the left arm [**2141**]
Social History:
Social History: Patient is married with two children. He
substitutes teaches in a local elementary school.
Race:Caucasian
Last Dental Exam: already cleared
Lives with: wife
[**Name (NI) 1139**]: quit over 20 years ago; 15-20 PYHx
ETOH: 2-3 beers per month
Family History:
mother and uncles with CAD
Physical Exam:
Pulse: 72 Resp: 18 O2 sat: 100% RA
B/P right arm 133/62
Height: 5'[**47**]" Weight: 205#
General:WDWN male in no acute distress
Skin: Dry [x] intact [x]. Well healed sternotomy, right
thoracotomy and left EVH incisions.
HEENT: PERRLA [x] EOMI [x]anicteric sclera; OP unremarkable
Neck: Supple [x] Full ROM [x]no JVD
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur - [**5-1**] HSM best heard at
left
lower sternal border
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] no HSM/CVA tenderness
Extremities: Warm [x], well-perfused [x] Edema - trace
Varicosities: None [x]
well-healed right groin and LUE AV fistula sites ( bruit heard
LUE)
Neuro: Grossly intact; MAE [**5-30**] strengths; nonfocal exam
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: left carotid bruit noted
Pertinent Results:
[**2148-4-25**] Carotid U/S: Right ICA with stenosis <40% .
Left ICA with stenosis 40-59%
[**2148-4-26**] Echo: Prebypass: No atrial septal defect is seen by 2D or
color Doppler. There is severe regional left ventricular
systolic dysfunction with akinesia of the inferior and
anteroseptal walls.. Overall left ventricular systolic function
is severely depressed (LVEF= 25 %). Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis. No aortic regurgitation is seen. A mitral
valve annuloplasty ring is present. Moderate to severe (3+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. Severe [4+] tricuspid regurgitation is seen.
There is no pericardial effusion. Dr. [**Last Name (STitle) 914**] was notified in
person of the results on [**2148-4-26**] at 900am.
Post CPB: Patient is AV paced and receiving an infusion of
phenylephrine, epinephrine, vasopressin and milrinone. LVEF=20%.
Bioprosthetic valve seen in the mitral position. It appears well
seated and there is trivial mitral regurgitation. Mean gradient
across the mitral valve is 7 mm Hg. Annuloplasty ring seen in
the tricuspid position. It appears well seated. There is mild
tricuspid regurgitation present.
[**2148-5-4**] 12:00PM BLOOD WBC-7.0 RBC-3.09* Hgb-9.9* Hct-29.3*
MCV-95 MCH-31.9 MCHC-33.7 RDW-14.9 Plt Ct-247
[**2148-5-4**] 12:00PM BLOOD PT-22.6* INR(PT)-2.1*
[**2148-5-4**] 12:00PM BLOOD Glucose-116* UreaN-65* Creat-2.1* Na-134
K-4.9 Cl-99 HCO3-25 AnGap-15
[**2148-5-4**] 12:00PM BLOOD Mg-3.0*
[**2148-5-1**] 04:35AM BLOOD TSH-2.2
[**2148-5-1**] 04:35AM BLOOD T4-3.9* T3-44*
Brief Hospital Course:
Mr. [**Known lastname **] was admitted prior to surgery to undergo surgical
work-up and initiation of Heparin. In addition he underwent a
ICD lead extraction by cardiology on [**4-25**]. On [**4-26**], he was
brought to the operating room where he underwent a
redo-sternotomy, mitral valve replacement, tricuspid valve
repair and MAZE procedure. Please see operative report for
surgical details. Following surgery he was transferred to the
CVICU for invasive monitoring in stable condition. He did
require multiple gtts following surgery, including Epinephrine,
Milrinone and Vasopressin. On post-op day one he was weaned from
sedation, awoke neurologically intact and extubated the next
morning. Nephrology was consulted on post-op day two because of
rising creatinine in the setting of acute kidney injury (ATN) on
chronic renal insufficiency. His creatinine ultimately came down
to 2.1 prior to discharge. EP service followed him as well and
an ICD was implanted [**4-29**]. He was also followed by the renal
service. He was gently diuresed toward his preop weight. Midline
was placed for access and then removed prior to discharge.
Transferred to the floor on POD #4 to begin increasing his
acitivity level. IV cefazolin started for sternal discharge
which stopped prior to discharge. He will continue on a short
course of oral keflex.Made good progress and cleared for
discharge to home with VNA services on POD #9. EP interrogated
his device [**5-5**]. Target INR 2.0-2.5. First blood draw [**5-6**]. All
f/u appts were advised.
Medications on Admission:
**Warfarin** 5 mg daily (last dose 3/27)
Carvedilol 25 mg twice daily
Digoxin 0.125 mg daily
Lasix 40 mg qam and 20mg qpm
Spironolactone 25 mg daily
Losartan 50mg daily
Aspirin 81 mg daily
Ambien 5-7.5 mg QHS
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
2. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**1-28**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
Disp:*2 bottles* Refills:*0*
3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
4. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
6. warfarin 1 mg Tablet Sig: Three (3) Tablet PO dose today only
[**5-5**]; then all further daily dosing per Dr. [**Last Name (STitle) 10861**]: ****3 mg
today [**5-5**]; target INR 2.0-2.5 for A Fib.
Disp:*50 Tablet(s)* Refills:*2*
7. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
8. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
9. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*1*
10. zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
Disp:*60 Tablet(s)* Refills:*0*
11. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day:
every morning.
Disp:*30 Tablet(s)* Refills:*1*
12. furosemide 20 mg Tablet Sig: One (1) Tablet PO Q PM: every
evening.
Disp:*30 Tablet(s)* Refills:*1*
13. cephalexin 250 mg Tablet Sig: One (1) Tablet PO four times a
day for 5 days.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
tba
Discharge Diagnosis:
Mitral and tricuspid regurgitation, Atrial fibrillation s/p
redo-sternotomy, mitral valve replacement and tricuspid valve
repair , ICD implant
Past medical history:
- Chronic Systolic Congestive Heart Failure
- Coronary Artery Disease, s/p MI in [**2132**], s/p RCA and LAD PCI's
- Paroxysmal/Persistent atrial fibrillation s/p five prior
cardioversions
- History of NSVT (s/p VT ablations [**11-3**])
- Moderate Pulmonary artery hypertension
- Severe Hyperlipidemia(intolerant of statins, undergoes
plasmapheresis every two weeks at [**Location (un) 5450**] Kidney Center)
- Mild Anemia
- Obstructive sleep apnea (CPAP)
- Chronic Renal Insufficiency c/b acute renal failure
- Carotid Disease
Past Surgical History
s/p AICD implant in [**2142**]
s/p Right thoracotomy, Mitral valve repair with a 28 mm [**Doctor Last Name 405**]
annuloplasty band [**2142**] @ [**Hospital1 18**]
s/p CABG (LIMA to LAD, SVG to OM, SVG to PDA to PLV) [**2140**] @ [**Hospital1 2025**]
s/p AV graft in the left arm [**2141**]
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Edema: bilateral pitting 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:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) 914**] on [**5-28**] at 1:30PM
Cardiologist: Dr. [**First Name (STitle) 437**] on [**5-29**] at 9:30AM
Wound check with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1637**] RN [**Hospital Ward Name **] 2A [**Telephone/Fax (1) 170**] on
Tuesday [**5-14**] at 10:30 AM
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2148-5-29**]
9:00
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 10861**] in [**4-30**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? Afib
Goal INR 2.0-2.5
First draw Monday [**5-6**]
Results to phone PCP [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10861**] [**Telephone/Fax (1) 10862**]
Completed by:[**2148-5-5**]
|
[
"397.0",
"585.9",
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"584.5",
"997.1",
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"416.8",
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"427.5",
"996.02",
"424.0",
"272.4",
"285.1",
"V53.32",
"412",
"327.23",
"427.31",
"V45.81",
"E878.1",
"V45.82"
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icd9cm
|
[
[
[]
]
] |
[
"37.79",
"35.14",
"35.23",
"37.77",
"37.94",
"39.61",
"37.33"
] |
icd9pcs
|
[
[
[]
]
] |
9026, 9056
|
5546, 7082
|
351, 954
|
10108, 10304
|
3819, 4731
|
11227, 12218
|
2802, 2830
|
7341, 9003
|
9077, 9221
|
7108, 7318
|
10328, 11204
|
2845, 3800
|
292, 313
|
982, 1611
|
9243, 10087
|
2545, 2786
|
4741, 5523
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
725
| 105,223
|
48763
|
Discharge summary
|
report
|
Admission Date: [**2106-8-23**] Discharge Date: [**2106-8-25**]
Date of Birth: [**2056-8-6**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: This is a 50-year-old male with
poorly controlled hypertension and hyperlipidemia with atrial
fibrillation refractory to cardioversion. The patient has
been cardioverted every few months since [**2103-5-3**], but
unfortunately remains in normal sinus rhythm for a few weeks
after cardioversion. A radiofrequency ablation was attempted
in [**2106-5-3**] but was aborted due to an episode of
hypotension in the catheterization laboratory.
He was admitted on [**2106-8-2**] and underwent an elective
radiofrequency ablation which was complicated by septal
perforation and cardiac tamponade with hypotension. A
pericardial drain was placed and drained for a few hours. It
was pulled after a repeat echocardiogram demonstrated no
re-accumulation of fluid.
He was then discharged home on [**2106-8-4**] and was without
complaints until three days prior to the current admission
when he noticed increased shortness of breath, chest pain,
and presyncopal symptoms. He followed up with his primary
care physician who sent him in for a transthoracic
echocardiogram which showed re-accumulation of pericardial
fluid.
He was brought to the catheterization laboratory at [**Hospital1 1444**] where he was found to have
equalization of pressures (right atrial was 17, right
ventricular was 40/25, pulmonary capillary wedge pressure
was 22, pulmonary artery pressure was 42/25). A
pericardicentesis was performed in which 350 cc of bloody
fluid was withdrawn. He was then admitted to the Coronary
Care Unit for hemodynamic monitoring and treatment with the
pericardial drain in place.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Asthma.
3. Hyperlipidemia.
4. Gout.
5. Atrial fibrillation.
6. Spinal cord injury, status post motor vehicle accident.
7. Peptic ulcer disease without symptoms for the last 20
years.
MEDICATIONS ON ADMISSION: Outpatient medications included
Lipitor 10 mg p.o. q.d., Losartan 100 mg p.o. q.d.,
atenolol 50 mg p.o. q.d., Rythmol 225 mg b.i.d.,
probenecid 500 mg p.o. b.i.d., aspirin 81 mg p.o. q.d.
ALLERGIES: ZESTORETIC causes gastrointestinal upset.
PENICILLIN (allergic reaction during childhood). ALLOPURINOL
causes facial swelling.
PAST SURGICAL HISTORY:
1. Neck surgery secondary to motor vehicle accident.
2. Laryngeal polyps which were removed as a teenager.
SOCIAL HISTORY: He denies any tobacco use, occasional
alcohol use.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on admission to the Coronary Care Unit revealed a temperature
of 100.1, blood pressure was 134/89, heart rate was 79 in
normal sinus rhythm, respiratory rate was 25, oxygen
saturation was 97% on room air. Swan numbers were pulmonary
artery pressure of 19/13, a CPP of 8. In general, the
patient was in no apparent distress. He was mildly obese and
was in moderate pain. Head, eyes, ears, nose, and throat
revealed the oropharynx was clear. Mucous membranes were
moist. There were no carotid bruits, and he had anicteric
sclerae. His chest was clear to auscultation bilaterally.
The pericardial drain was in place without any hematoma.
Cardiovascular examination revealed he was a regular rate.
He had a normal first heart sound and second heart sound.
There were murmurs, rubs or gallops. Abdominal examination
revealed his abdomen on examination was soft, nontender, and
nondistended. Normal active bowel sounds. There was no
hepatosplenomegaly. His extremities demonstrated no
cyanosis, clubbing or edema. His right femoral sheath was in
place; there was no hematoma or bruit. There were 2+
dorsalis pedis pulses and posterior tibialis pulse
bilaterally. His skin was warm and dry.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratory data
revealed a white blood cell count of 12.5, hemoglobin
was 12.3, hematocrit was 35.9, platelets were 410. Chemistry
revealed sodium was 135, potassium was 3.8, chloride was 103,
bicarbonate was 22, blood urea nitrogen was 16, creatinine
was 0.9, blood glucose was 102. PT was 13.9, INR was 1.4.
Pericardial fluid revealed total protein of 5.3, LDH was 585,
glucose was 101, amylase was 38, albumin was 3.2.
IMPRESSION: This is a 49-year-old male with recurrent atrial
fibrillation refractory to medications and cardioversion.
Radiofrequency ablation performed earlier this month was
complicated by septal perforation and tamponade. He returns
now with re-accumulation of fluid and cardiac tamponage
physiology, status post pericardiocentesis.
HOSPITAL COURSE: The patient was admitted to the Coronary
Care Unit with a pericardial drain in place which had
previously drained 350 cc in the catheterization laboratory.
About 50 cc were drained overnight, and a repeat
echocardiogram was done in the morning which showed a trivial
effusion. Therefore, the drain was pulled on [**2106-8-24**]
without complications.
The patient was started on his outpatient drug regimen and
started on a prednisone taper in order to decrease
pericardial inflammation. He was transferred to the floor on
the evening of [**2106-8-24**] in stable and improved
condition.
A follow-up echocardiogram was done on the day of discharge
which showed a normal ejection fraction, a decrease in size
of the effusion, with a thickened pericardium demonstrating
early constrictive physiology. The patient was asymptomatic
throughout his hospital course, denying any shortness of
breath or syncopal symptoms while out of bed.
Given his history of atrial fibrillation, he was monitored
closely on telemetry and demonstrated no arrhythmias.
CONDITION AT DISCHARGE: Condition on discharge was stable
and improved.
DISCHARGE DIAGNOSES:
1. Atrial fibrillation, status post radiofrequency ablation.
2. Cardiac tamponade.
3. Hypertension.
4. Hyperlipidemia.
5. Gout.
6. Asthma.
7. Remote history of peptic ulcer disease.
MEDICATIONS ON DISCHARGE:
1. Atenolol 50 mg p.o. q.d.
2. Lipitor 10 mg p.o. q.d.
3. Probenecid 500 mg p.o. b.i.d.
4. Rythmol 225 mg p.o. b.i.d.
5. Protonix 40 mg p.o. q.d.
6. Prednisone taper 50/50, 40/40, 30/30, 20/20, [**11-11**], [**6-6**].
The patient was to discontinue Losartan until follow-up
appointment. The patient was to discontinue aspirin for the
next 30 days.
DISCHARGE FOLLOWUP:
1. The patient was scheduled for a transthoracic
echocardiogram on [**2106-9-7**] at 11 a.m.
2. The patient was to schedule a follow-up appointment with
Dr. [**Last Name (STitle) **] in two to four weeks after discharge.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], M.D. [**MD Number(1) 9615**]
Dictated By:[**Last Name (NamePattern1) 6240**]
MEDQUIST36
D: [**2106-8-25**] 17:54
T: [**2106-8-31**] 09:16
JOB#: [**Job Number 102493**]
|
[
"427.31",
"493.90",
"401.9",
"423.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.21",
"37.0"
] |
icd9pcs
|
[
[
[]
]
] |
5765, 5955
|
5981, 6338
|
2001, 2331
|
4619, 5680
|
2354, 2464
|
5695, 5744
|
6358, 6861
|
160, 1741
|
1763, 1974
|
2481, 4601
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,827
| 128,160
|
15615
|
Discharge summary
|
report
|
Admission Date: [**2104-11-1**] Discharge Date: [**2104-12-4**]
Date of Birth: [**2038-4-1**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4583**]
Chief Complaint:
Bilateral leg weakness
Major Surgical or Invasive Procedure:
Lumbar puncture
IVC filter placement
Open right frontal brain biopsy
History of Present Illness:
Patient is a 66 year-old right-handed man with past medical
history of back injury 36years ago, coronary artery disease
status post CABG four years ago who presented to [**Hospital1 18**] ED on
[**2104-11-1**] with bilateral leg weakness and backache, with onset ten
days prior to admission and worsening over the three days
leading up to admission. He was in his usual state of health
until ten days prior to admission, when patient twisted his
lower back when he was standing in the bus, when it turned. He
noticed sharp shooting pain thru his legs bilaterally. Paint was
transient at that time and was followed by numbness. The
symptoms got worse three days prior to admission with bilateral
leg numbness, pain, weakness, and difficulty with ambulation.
Patient stayed in the bed. Noted difficulty with urination two
days prior to admission and no bowel movement for three days.
Patient has had chronic backaches and occasional/transient
numbness at legs for past 36 years since he injured his lower
back by slipping and falling when he carried bananas back in
[**Country 3594**]. Approximately twenty years ago, patient was diagnosed
with "spine compression" while in [**Country 3594**]. He was later
followed at [**Hospital1 112**] since about 10 years ago for his back pain and
occasional numbness.
On review of systems, reports no fever, headache, neckache,
diarrhea, vomiting, recent travel, tick bites, other traumatic
episodes.
Past Medical History:
Inflammatory disease of the spinal cord
Right frontal lobe lesion
Abnormal visual evoked potentials
Status post brain biopsy of right frontal lobe lesion
Pulmonary embolus
Status post IVC filter placement
Asthma
Coronary artery disease
Status post liver surgery for liver laceration following stab
wound
Chronic back pain
Vitiligo
Social History:
Patient lives alone and is divorced. Has 3 healthy children.
Retired due to back pain, used to work as [**Doctor Last Name 9808**] driver.
Family History:
No stroke, aneurysm, no seizure, no AAA.
Physical Exam:
Vitals: T-98.9 BP-120/85 HR-106, reg RR-20 SaO2 97% on room air
Gen: Awake, alert, no distress.
HEENT: Clear ears, conjunctivas, oral membrane, no neck bruit,
no goiter.
Chest: Vesicular sound, symmetrical, symmetrical chest.
Heart: S1, S2 nl, no murmur.
Abd: Soft nt/nd, no hepatosplenomegaly.
Skin: No lesions, skin stigmata.
Exts: No clubbing, cyanosis, or edema.
NEURO:
Mental status: Awake and alert, cooperative with exam, normal
affect. Oriented to person, place, and date. Attentive; able to
name of the days of week backwards smoothly. Speech is fluent
with normal comprehension and repetition. No dysarthria. [**Location (un) **]
intact. Registers [**4-11**], recalls [**3-14**] in 10 minutes. No right-left
confusion. No evidence of apraxia or neglect.
Cranial nerves: Visual acuity 20/200 w/o glasses, 20/25 w/
glasses bilaterally. Fundi with clear margins with normal color
of disc. No red desaturation. Visual fields full, both at mono-,
binocular testings).Pupils round, equal, and reactive to light,
4mm to 3mm. Symmetrical facial sensation and appearance. Palate
and uvula midline. Tongue full strength.
Motor: Upper extremity strength is full throughout with normal
tone. In the lower extremities, there is a flaccid paralysis.
Reflexes: Absent at patella and achilles bilaterally. Planters
mute. Upper extremity reflexes are present and symmetric.
Sensory: Sensory level to pin to ~T8 anteriorly. No vibratory,
position sense, or ability to appreciate light touch from pelvis
down.
Coordination: Normal on finger-nose-finger with no
dysdiadochokinesia. Heel shin unable to perform.
Gait: Unable to assess.
Pertinent Results:
Labs on admission:
-WBC-8.4 RBC-5.57# HGB-18.4*# HCT-51.1# MCV-92 MCH-33.1*
MCHC-36.1* RDW-14.2 PLT COUNT-167 with diff NEUTS-76.8*
LYMPHS-14.5* MONOS-6.6 EOS-1.9 BASOS-0.1.
-GLUCOSE-101 UREA N-16 CREAT-1.0 SODIUM-144 POTASSIUM-4.2
CHLORIDE-108 TOTAL CO2-21* ANION GAP-19
-CRP-11.0* TSH-0.73
-CHOLEST-147 TRIGLYCER-101 HDL CHOL-41 CHOL/HDL-3.6 LDL(CALC)-86
-IRON-79 calTIBC-316 VIT B12-668 FOLATE-13.2 FERRITIN-118
TRF-243
ALBUMIN-4.1
-----
Lumbar puncture with 32 wbc with 89% lymphocytes and 12%
monocytes, protein of 82 and glucose of 75. CSF culture
negative.
-----
Flow cytometry CSF [**11-3**]: No monotypic B-cell population
identified; most lymphocytes in the specimen are represent by
CD4 positive T-cells.
-----
Cytology CSF [**11-3**]: NEGATIVE FOR MALIGNANT CELLS. Lymphocytes
with reactive changes and monocytes.
-----
IMAGING:
[**11-1**] MRI T spine: Increased signal in the distal spinal cord
indicating cord edema. Subtle irregularity suspicious for flow
voids on the surface of the cord and this finding could indicate
arteriovenous fistula or AVM. No intrinsic hemorrhage is seen
within the spinal cord. Further evaluation with gadolinium
enhanced MRI of the thoracic spine is recommended. Findings were
conveyed to the neurology resident taking care of the patient at
the time of interpretation of this study.
[**11-1**] MRI L spine: Mild multilevel degenerative changes without
spinal stenosis or disc herniation. There are no MRI findings to
explain patient's lower extremity paralysis. Please also see the
thoracic spine MRI of the same day for further evaluation.
[**11-1**] Abd US: No evidence of abdominal aortic aneurysm.
[**11-1**] MRI T spine w/contrast: The increased signal in the distal
spinal cord is confirmed on T2 axial images. However, no
evidence of abnormal vascular enhancement seen along the surface
of the cord or to suggest arteriovenous malformation. MRA of the
spine or spinal angiogram would help for further assessment as
clinically indicated.
[**11-2**] CXR: no cardiopulmonary process
[**11-2**] MRI Head w/&w/o contrast: Multiple T2 signal white matter
abnormalities, some of which enhance. These findings may be the
same process that is occurring within the distal thoracic spinal
cord described on the [**2104-11-1**] examination. The differential
includes an inflammatory versus an infectious process. This
could include a demyelinating process such as multiple
sclerosis, or an infectious process such as Lyme disease.
Vasculitis is also a consideration.
[**11-4**] ECHO: The left atrium is elongated. No atrial septal defect
or patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. There is mild symmetric left
ventricular hypertrophy. There is moderate to severe global left
ventricular hypokinesis (ejection fraction 30 percent). 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 root is moderately
dilated. The ascending aorta is mildly dilated. The aortic arch
is mildly dilated. There are focal calcifications in the aortic
arch. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Trivial mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
[**11-4**] Chest CT w/contrast:
1. No evidence of sarcoidosis.
2. Incidental finding of pulmonary embolus involving the left
lower branch of the pulmonary artery and left lower lobe
segmental branches. There is Also thrombus in the right upper
lobe branch of the pulmonary artery.
3. Calcification of the aortic valve as described above.
4. Gallstone.
[**11-4**] C spine w/contrast: Extensive changes of cervical
spondylosis seen, most significantly at C4-C5, C5-C6 and C6-C7
levels resulting in exit neural foraminal stenosis.
Superimposed left paracentral and foraminal herniation is
identified at C6-C7 level encroaching over the left exiting C7
nerve root. No cord compression is seen.
[**11-5**] Bilateral LENIs: 1. Acute to subacute deep venous
thrombosis from the proximal left superficial femoral vein
extending into the left popliteal vein.
2. Acute thrombus within the right peroneal vein.
[**11-12**] MRA T spine: FINDINGS: The study reveals the distal
aspect of the anterior spinal artery extending from
approximately the mid thoracic region to the level of the conus
tip. The fact that the vessel is visible is not necessarily of
pathologic consequence. Nevertheless, if there remains clinical
suspicion for a spinal vascular malformation, this test is not
to be construed as the optimum examination to exclude this type
of pathology. For this purpose, conventional catheter spinal
angiography is the definitive diagnostic modality. There are no
other vascular abnormalities identified.
CONCLUSION: Visibility of the distal aspect of the anterior
spinal artery, a finding of dubious pathological significance.
See above report.
[**11-17**] MRI Head w/&w/o contrast: Resolution of the previously
seen areas of enhancement along the cerebral white matter since
the previous exam of [**2104-11-2**]. The findings raise the
suggestion of an inflammatory condition such as demyelinating
disease. Other infectious etiologies cannot be totally excluded
and were discussed on the prior MRI report. No
abnormal-enhancing lesions are seen on the current exam. There
are several scattered T2-hyperintense lesions within the
cerebral white matter in a similar distribution to the previous
exam. Further followup is suggested based on clinical grounds.
[**12-2**] Visual evoked potentials: After stimulation of either eye
there
were evoked potential peaks recorded. The peak after left eye
stimulation was 113 ms, near the upper limit of normal for this
laboratory (114 ms). The peak after right eye stimulation
occurred at
118 ms and was a very broad peak. Though the difference is
relatively
small, the peak after rightsided stimulation is delayed and
suggests a
defect in the optic conducting system anterior to the chiasm on
the
right.
Brief Hospital Course:
Briefly, patient is a 66 year-old male with remote history of
back injury, coronary artery disease, asthma who presented to
[**Hospital1 18**] ED with bilateral leg weakness and backache. Exam
progressed over day of admission to point of flaccid paraplegia
with ~T8 sensory level. Initial differential diagnosis included
infectious versus inflammatory disease like multiple sclerosis
versus post infectious process like acute disseminated
encephalomyelisits versus vascular cause like dural
arteriovenous malformation.
1. Neurology: Patient had MRI spine with gadolinium which
showed evidence of spinal cord edema in the nlower thoracic
cord. There was no inflammation in the cervical cord.
Additionally, MRI of the brain showed multiple T2 signal
abnormalities in the subcortical white matter as well as within
the right frontal lobe. Three of these areas enhanced with the
administration of gadolinium, specifically within the right
pons, within the right frontal lobe adjacent to the anterior
[**Doctor Last Name 534**] of the lateral ventricle, and within the left frontal lobe
within the corona radiata. Lumbar puncture showed pleocytosis
with 32 WBC (differential 89L 12M), elevated protein 82 and
glucose 75. Patient initially recieved 2 days of Decadron which
was then discontinued given WBCs in CSF until cultures were
negative. He was then placed on IV Solumedrol 1g QD. Please see
below for infectious workup. In terms of the inflammatory work
up, serum ACE level [**11-7**] was negative and serum protein was low.
SPEP/UPEP were negative, less suggestive of an neoplasm
producing paraproteins. Flow cytometry of CSF did not identify
a monotypic B-cell population; however, most lymphocytes in the
specimen are represented by CD4 positive T-cells. Cytology was
negative for malignant cells and there were no CSF peptides. On
[**11-8**], patient was started on mannitol 50mg q6 for cord edema
with minimal effect and was weaned off by [**11-12**]. An MRI/MRA
spine to evaluate for dural AVM was negative. Initial multiple
sclerosis profile and NMO antibody for neuromyelitis
optica/Devics were both negative. CSF had no oligoclonal bands.
Patient was unable to receive IVIG given coagulopathy or
plasmapheresis given his cardiac issues (EF 30%). After
receiving a full 2 week course of IV steroids, on [**11-22**], patient
was switched from IV Solumedrol to Prednisone 60mg [**11-22**].
Tizanidine 4 TID and Neurontin 600 QID were added for
neuropathic abdominal pain and doses titrated to pain control.
Visual evoked potentials ultimately showed evidence conduction
delay and suggest a defect in the optic conducting system
anterior to the chiasm on the right. This makes it most likely
that his underlying diagnosis is multiple sclerosis or an MS
variant. To exclude other possible inflammatory diseases which
may have altered long term therapy, he underwent biopsy of his
right frontal lesion on Tuesday [**11-25**]. Final patholgy was still
pending at time of discharge but preliminary results just showed
gliotic and reactive changes. Sadly, he did not improve with
standard treatment with high dose steroids and remains with a
flaccid paralysis of the lower extremties and T8 sensory level.
He will be followed in the general neurology and MS clinics as
an outpatient.
.
Please note: the sutures from his right frontal biopsy site
should be removed on [**2104-12-5**].
.
2. ID: Differential diagnosis included viral infection including
HTLV-1 which causes spastic paraparesis. CSF studies were
negative for HSV 1 and 2, EBV, HTLV-1, CMV, TB PCR and VZV.
Crytococcal antigen was negative. Oligoclonal bands and IgG
index were unrevealing. CSF bacterial, viral and fungal cultures
were negative. In the serum, testing for HIV, HBV, HCV, VZV,
CMV, HTLV, HSV, EBV were all negative. RPR was non-reactive.
Serum crytococcal antigen was negative. Serum antibodies for
Lyme and toxoplasmosis were negative. SPEP and UPEP were
unrevealing. PPD was placed [**11-3**] and was negative. Urine viral
cx prelim no growth.
.
Of note, patient had a urinary tract infection on [**11-21**]
associated with foley and completed a 7 day course of
Ciprofloxacin (last 2 days on Ceftazidime). Pansensitive
Pseudamonas aeruginosa grew from urine culture. Foley was
discontinued and patient was instructed on how to
self-catheterize approximately every 6 hours but was unable to
do so due to prostatism and lack of sensation. He will remain
with indwelling foley, but suprapubic catheterization should be
considered in the future.
On [**11-26**], patient was presistently tachycardic and hyptotensive.
He was given stress dose steroids and started on broad spectrum
antibiotics (ceftazidime, vancomycin) given concern for
developing pneumonia (+productive cough and bronchitis seen on
last CXR). Ultimately, he stabilized simply with volume
resuscitation and cultures were negative. He is on a slow oral
steroid taper given his previous issues with blood pressure.
.
3. Hematology: He was found to have a large DVT and asymptomatic
pulmonary embolus. This was likely due to immobility and statis.
Anti Phospholipid screen negative. He was started on warfarin
after bridging with heparin. Goal INR is 2.0-3.0. Ultimately, we
decided not to proceed with plasmapheresis or IVIG for treatment
of his inflammatory spinal cord disease given risk of heart
failure with the former and hypercoagulability with the latter
with questionable benefit. Had IVC filter placed under IR on
[**11-24**].
.
4. Cardiovascular: Echocardiogram showed no PFO, ASD, or VSD. He
has an ejection fraction of 30%. Has been relatively hypotensive
at times, but asymptomatic with systolic blood pressure in low
100s.
.
5. GI: Given his paraplegia and spinal cord inflammation,
constipation has been an issue. He will need to be maintained on
an aggressive bowel regimen to prevent obstruction or impaction.
He responds well to daily Lactulose and prn Golytely.
.
6. Social: Social work was consulted as patient lives alone and
is estranged from family. Has relatives in [**Location (un) 686**]. Getting
OOB to wheelchair. While a patient here, social work and
physician filled out paperwork to initiate getting handicap
accessible housing for the patient. He will need extensive
social supports in place in order to transfer from rehab to
independent or assistive living.
Medications on Admission:
1. Oxycodone/APAP 5/325mg po prn
2. Lisinopril 10 mg QD
3. Singulair 10 mg QD
4. Toprol XL 50 mg QD
5. Omeprazole 20 mg QD
6. Lipitor 20mg QD
7. Advair diskus 500/50 QD
Discharge Medications:
1. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
6. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
7. Simethicone 80 mg Tablet, Chewable Sig: 1.5 Tablet, Chewables
PO TID (3 times a day).
8. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
50-500 mcg Disk with Devices Inhalation [**Hospital1 **] (2 times a day).
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
10. Tizanidine 2 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
11. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
12. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO TID (3
times a day).
13. Insulin Regular Human 100 unit/mL Solution Sig: variable
units Injection ASDIR (AS DIRECTED): per sliding scale while on
steroid taper.
14. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
15. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed.
16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed.
17. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
[**Hospital1 **] (2 times a day) as needed.
18. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
19. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
20. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime): Please follow INR. Goal is 2.0-3.0.
21. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 1 days: Thereafter, taper by 10 mg every 5 days
until off. Needs slow taper please!.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Inflammatory disease of the spinal cord
Right frontal lobe lesion
Abnormal visual evoked potentials
Status post brain biopsy of right frontal lobe lesion
Pulmonary embolus
Status post IVC filter placement
Asthma
Coronary artery disease
Status post liver surgery for liver laceration following stab
wound
Chronic back pain
Vitiligo
Discharge Condition:
Patient continues to have a flaccid paraplegia of both lower
extremities. He is incontinent of bowel and bladder. He has a
sensory level at ~T8 anteriorly.
Discharge Instructions:
Please call your outpatient Neurologist or return to the nearest
Emergency Room if you experience any increased weakness, sensory
changes, visual changes, fevers, chills, or any other worrisome
symptoms.
Please keep all of your follow up appointments.
Followup Instructions:
The following appointments have already been scheduled:
1. Provider: [**Name Initial (NameIs) 43**]/[**Doctor Last Name **] Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2105-1-29**] 4:00
2. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7598**], MD Phone:[**Telephone/Fax (1) 5434**]
Date/Time:[**2105-2-17**] 10:30
|
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55,104
| 163,447
|
53704
|
Discharge summary
|
report
|
Admission Date: [**2167-4-13**] Discharge Date: [**2167-4-20**]
Date of Birth: [**2086-11-9**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor First Name 3290**]
Chief Complaint:
Delerium
Major Surgical or Invasive Procedure:
IR Guided Abscess Aspiration
History of Present Illness:
Mr. [**Known lastname 42484**] is an 80 y/o man with PMHx CVA with residual L
hemi-neglect and cognitive deficits and Crohn's disease s/p
recent laparotomy/end ileostomy ([**2167-3-12**]) for SBO as well as
ongoing steroid taper and Abx for intraabdominal abscess who was
brought to the ED due to confusion and decreased level of
alertness. At the time of most recent d/c ([**2167-4-10**]), pt was sent
home on IV Cipro/Flagyl for multiple intraabdominal abscesses
which were not amenable to IR guided drainage. He subsequently
presented to the ED on [**4-11**] with AMS and RUE swelling. RUE
ultrasound at that time showed brachial vein thrombus. His PICC
was pulled, antibiotics were changed to PO Cipro/Flagyl and the
pt was started on Lovenox and sent back to rehab. On the morning
of [**4-13**], his daughter visited him and noted he was altered - not
speaking, not interactive from a baseline of A/Ox3, interactive
with occasional confusion and inapproproate responses to
questions. For this, he was sent to the ED for evaluation.
.
In the ED, initial VS were:
T 97.9, pulse 68, BP 125/71, O2 99% RA.
Labs notable for WBC 17.4 (94% PMN, no bands), lacate 3.1 and
HCT 33.5 (baselione 20s). He received IV Vanc/Zosyn. He also
received 2L NS for his elevated lactate. Head CT showed 12-mm
left subdural collection with heterogeneous attenuation,
suggesting a subacute or chronic component with foci of
hyperdensity which may represent acute blood. Additionally a
large right parieto-temporal CSF density structure of
indeterminate etiology, thought to represent a large arachnoid
cyst, was observed. CT Abd/Pelvis showed stable to minimally
decreased size of air-containing left lower quadrant/pelvic
fluid collection. Neurosurgery was consulted and felt there was
no need for urgent neurosurgical intervention. Given initial
elevated lactate and WBC count, patient was admitted to the MICU
given concern for early sepsis. On arrival to the MICU, lactate
was rechecked: 1.9. Given his response to IVF and absence of a
pressor requirement, pt was called out to medicine [**2167-4-14**].
.
On arrival to the floor, initial VS were:
T 97.5 BP 105/68 HR 75 rr 18 O2 Sat 99% RA
Pt denies CP/SOB/N/V/HA. No complaints at this time. He is
A/Ox3, appropriate and interactive.
.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
Past Medical History:
Past Medical/Sirgical History:
Crohn's Disease
CVA
DVT/PE
IVC filter
COPD
Iileocecectomy ~30 years ago
Ileocectomy and take down of duodenal fistula as above [**2167-3-12**]
Social History:
The patient lives at home with his wife. [**Name (NI) **] quit smoking 18
years ago. He drinks ~1 glass of wine per night. Used to drink
atleast 4 cocktails per night. He worked in real estate.
Family History:
NC
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: Tmax: 36.8 ??????C (98.2 ??????F)
Tcurrent: 36.8 ??????C (98.2 ??????F)
HR: 66 (63 - 73) bpm
BP: 137/78(90) {136/72(87) - 149/87(101)} mmHg
RR: 12 (12 - 17) insp/min
SpO2: 96%
Heart rhythm: SR (Sinus Rhythm)
General: Alert, oriented, elderly gentleman in no acute distress
HEENT: MMM, left eye lateral deviation (baseline); right eye
with cornea and impaired vision; very dry MM
Neck: supple, no JVD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: decreased breath sounds at the bases but otherwise clear
to auscultation bilaterally, no wheezes, rales, rhonchi
Abdomen: midline scar well-healed; ostomy in place draining
yellow liquid; abdomen is not firm; no masses palpable and no
tenderness to deep palpation
GU: foley in place
Ext: warm; 2+ DP pulses; 2+ edema to the knees bilaterally;
upper extremities edematous and weeping with generalized
erythema and ecchymoses but no well-circumscribed area of
erythema
Neuro: face symmetric, uvula and tongue midline, left eye
deviation is chronic, [**4-18**] foot dorsi + plantar flexion; 4+/4
biceps bilarerally; cerebellar exam intact
.
Discahrge Exam:
Pertinent Results:
Admission Labs
[**2167-4-13**] 01:20AM BLOOD WBC-17.4*# RBC-3.44* Hgb-10.5* Hct-33.5*
MCV-97 MCH-30.4 MCHC-31.3 RDW-15.6* Plt Ct-294
[**2167-4-13**] 01:20AM BLOOD Neuts-94.2* Lymphs-3.5* Monos-2.0 Eos-0.1
Baso-0.2
[**2167-4-13**] 01:55AM BLOOD PT-13.0* PTT-35.5 INR(PT)-1.2*
[**2167-4-13**] 01:20AM BLOOD Glucose-151* UreaN-10 Creat-0.7 Na-131*
K-4.2 Cl-99 HCO3-24 AnGap-12
[**2167-4-13**] 01:20AM BLOOD ALT-15 AST-20 AlkPhos-109 TotBili-0.4
[**2167-4-13**] 01:20AM BLOOD Albumin-2.5*
[**2167-4-13**] 01:57AM BLOOD Lactate-3.1*
.
MICRO DATA:
[**2167-4-13**] 03:38AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.014
[**2167-4-13**] 03:38AM URINE Blood-TR Nitrite-NEG Protein-TR
Glucose-150 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM
[**2167-4-13**] 03:38AM URINE RBC-5* WBC-13* Bacteri-FEW Yeast-NONE
Epi-0
.
[**2167-4-13**] URINE URINE CULTURE-PENDING EMERGENCY [**Hospital1 **]
[**2167-4-13**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]
[**2167-4-13**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]
Imaging
CXR [**2167-4-13**]
Bilateral pleural effusions with bibasilar atelectasis, similar
compared to prior exam.
.
[**2167-4-13**] CT HEAD W/O CONTRAST
1. 12-mm left subdural collection with heterogeneous
attenuation, suggesting a subacute or chronic component. Foci of
hyperdensity may represent acute blood and/or crossing blood
vessels.
2. Large right parieto-temporal CSF density structure of
indeterminate etiology, possible representing a large arachnoid
cyst. Correlation with prior exams, if available, is recommended
to determine chronicity and stability.
.
[**2167-4-13**] CT ABDOMEN/PELVIS W/ CONTRAST [prelim report]
1. Stable to minimally decreased size of air-containing left
lower
quadrant/pelvic fluid collection.
2. Round hyperdensities in the ostomy bag, possibly representing
pills.
3. Anasarca, as seen previously, with moderate bilateral pleural
effusions
Brief Hospital Course:
Primary Reason for Admission: Mr. [**Known lastname 42484**] is an 80 y/o
gentleman with Crohn's Disease s/p laparotomy/end ileostomy
([**2167-3-12**]) for SBO c/b multiple intraabdominal abscess on steroid
taper and IV antibiotics, recent RUE thrombus at PICC site as
well as subacute SDH admitted to the MICU for elevated lactate
concerning for sepsis.
.
# Delerium/Encephalopathy: His altered mental status was ikely
multifactorial; contributing factors include delerium and
toxic/metabolic encephalopahy. His mental status waxed and waned
initially, but had normalized by the time of d/c. Given his
multiple recent hospitalizations and poor neurologic substrate,
delerium risk is very high. The precipitating factor for his
acute mental status change was most likey his intra-abdominal
infections given his AMS started in the setting of PICC
associated thrombus, which may have affected systemic delivery
of IV antibiotics. His AMS worsened when placed on PO
antibiotics, which is not unexpected given his extensive bowel
resection and evidence of undigested pills in his ostomy on CT
scan. He was initially started on Vanc/Zosyn in the MICU.
Antibiotics were narrowed to IV Cipro/Flagyl on arrival to the
floor and his mental status normalized, but once VSE and
presumptive strep bovis grew, we put him on vancomycin. He
occasionally refused to speak with staff and family, though this
was due to frustration with his multiple medical problems and
not due to an organic problem, and was resolving by discharge. .
.
# Abscesses/Leukocytosis: Pt was initially admitted to the MICU
with leukocytosis and elevated lactate concerning for early
sepsis. Broad spectum antimicrobial coverage was started with
Vanc/Zosyn. Repeat lactate was WNL after fluid recussitation
with 2L NS. He never required pressors and was called out to the
floor. On arrival to the floor, antibiotics were narrowed to
Cipro/Flagyl and his WBC normalized. On [**2167-4-17**] he underwent IR
guided drainage of his LLQ abscess without complication. On [**4-17**]
there was 70cc of drainage, on [**4-18**] and [**4-19**] 0cc drainage, and on
[**4-20**] 10cc drainage. Cultures grew enterococcus sensitive to vanc,
resistant to ampicillin, so vancomycin was started and he will
receive 10 days of this. He was never bacteremic. Culture also
grew presumptive strep bovis, which should also be covered by
vanc. The drain will stay in place at discharge and plan is for
Surgery to reassess and likely pull drain out (he has f/u with
Surgery on [**5-1**]). They may do a study for leakage first. Of
note, NO PICC line should be placed, given recent PICC
associated thrombus. Also of note, abscess is not thought to be
[**1-15**] active Crohn's disease, so we are tapering steroids off
slowly (per Crohn's section below).
.
# Subdural Hematoma: Subacute given CT head findings; most likey
spontaneous bleed in the setting of Lovenox given no falls or
trauma. Repeat CT head showed no interval change. Neurosurgery
was consulted and recommended holding anticoagulation for his
known R Brachial Vein thrombus given risk for expansion of SDH.
He was placed on Heparin SQ [**Hospital1 **] for DVT ppx. Serial neuro exams
were negative for new deficits, though he does have residual L
hemi-neglect from a prior CVA and esotropia, which has been
present since birth.
.
# Right Brachial Vein Thrombosis: PICC associated. He has a h/o
PE in the past and has IVC filter in place. RUE ultrasound to
asses for resolution of thrombus was performed, but the study
was incomplete, as the pt was non compliant. He was on Heaprin
SQ [**Hospital1 **] during his hospitaliztion for DVT ppx, as he cannot be
systemically anticoagulated due to his spontaneous SDH.
.
# Ostomy Output: Pt report, pt has had high output from his
ostomy. This may have been antibiotic related, as his ostomy
output normalized on arrival to the floor and C Diff was
negative. Normal ostomy output for an ileostomy is 500-1200cc of
applesauce consistency stool. At the time of discharge, he was
making <600cc of stool per day. He was placed on a high fiber
diet and Metamucil wafer supplementation once a day, as well as
loperamide. GI was involved in his care and recommended tapering
steroids and continuing Mesalamine. Also recommended low-sugar,
lactose free diet. There was no evidence of a chrons flare on
this admission. He will f/u with GI
.
# Anasarca: Albumin was 2.3 on arrival to the floor, so
suspicion for low albumin state causing low oncotic pressure.
TTE on [**4-14**] showed symmetric LVH, no valvular abnormalties,
preserved EF. His anasarca improved with increased PO intake and
[**Month/Day (4) **].
.
# Crohn's Disease: Persistent intraabdominal abscess thought to
be infectious and not related to Crohn's. Prednisone is being
tapered, he will be on 5mg PO for 10 more days after discharge,
then stop. If he becomes hypotensive at all low threshold to
stress dose. Continued mesalamine. Will f/u with GI
.
# Anemia: at baseline during this admission, though MCV is a bit
up (101). With h/o ileal resection, we sent a B12 level, but was
not back at time of d/c. B12 supplement empirically started as
well.
.
# Hyponatremia: Resolved. Likely hypovolemic hyponatremia.
Copious ostomy output at home
.
# Urinary retention: secondary to previous chronic Foley
catheter usage. Terazosin started this admission. Will need
straight cath q8h for now.
.
==================================================
TRANSITIONAL ISSUES
- Avoid sedating medications. Avoid unnecessary lines and
tethers.
- Continued need for intra-abdominal abscess drain will be
re-assessed by surgery on [**5-1**]
- prednisone continues to be tapered. Being d/c'ed on 5mg for 10
days, then stop. Should have f/u with PCP, [**Name10 (NameIs) **] ongoing
assessment for adrenal insufficiency.
- Pt should not be systemically anticoagulated for any reason.
If he were to have a pulmonary embolus, neurosurgery would need
to be involved in his care prior to anticoagulating.
- Will complete 10 more days of vancomycin for VSE and strep
bovis growing in abscess, and cipro for gram negative coverage
- At LTAC, should consult ostomy nurse [**First Name (Titles) **] [**Last Name (Titles) **]. If ostomy
output remains high (>1500cc/24 hours), should consult GI. Also,
probiotics should be started at LTAC (whatever is on formulary)
- assess urinary retention issue, and how terazosin is working.
[**Month (only) 116**] need to be uptitrated, though it was only started [**4-19**]
- f/u B12 level, adjust B12 supplementation as needed
Medications on Admission:
1. prednisone 20 mg Tablet Sig: One (1) Tablet PO daily () for 7
days.
2. prednisone 5 mg Tablet Sig: Three (3) Tablet PO daily () for
7 days.
3. prednisone 10 mg Tablet Sig: One (1) Tablet PO daily () for 7
days.
4. prednisone 5 mg Tablet Sig: One (1) Tablet PO daily () for *
days.
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Three
(3) Tablet, Delayed Release (E.C.) PO TID (3 times a day).
7. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
11. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
12. ciprofloxacin in D5W 400 mg/200 mL Piggyback Sig: Two
Hundred (200) mL Intravenous Q12H (every 12 hours) for 11 days.
13. metronidazole in NaCl (iso-os) 500 mg/100 mL Piggyback Sig:
One Hundred (100) mL Intravenous Q8H (every 8 hours) for 11
days.
14. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
15. sodium chloride 0.9 % 0.9 % Parenteral Solution Sig: Three
(3) ML Intravenous Q8H (every 8 hours) as needed for line flush.
16. loperamide 2 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
Discharge Medications:
1. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
4. mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Three
(3) Tablet, Delayed Release (E.C.) PO TID (3 times a day).
5. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. ferrous sulfate 300 mg (60 mg iron)/5 mL Liquid Sig: One (1)
PO DAILY (Daily).
8. terazosin 2 mg Capsule Sig: One (1) Capsule PO at bedtime.
9. psyllium 1.7 g Wafer Sig: One (1) Wafer PO TID (3 times a
day).
10. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours) for 10 days.
11. prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day for
10 days.
12. loperamide 2 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for loose ostomy output, with 24 hr output <
1500cc/24hours .
13. cyanocobalamin (vitamin B-12) 1,000 mcg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
14. psyllium 1.7 g Wafer Sig: Two (2) PO TID (3 times a day).
15. ciprofloxacin 400 mg/40 mL Solution Sig: One (1)
Intravenous Q12H (every 12 hours) for 9 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital for Continuing Medical Care - [**Location (un) 1121**]
([**Hospital3 1122**] Center)
Discharge Diagnosis:
Delerium/Toxic Metabolic Encephalopathy
Intraabdominal abscess with vancomycin-sensitive enterococcus
growing
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr [**Known lastname 42484**],
It was a pleasure caring for you at the [**Hospital1 827**]. You were admitted for confusion. We performed a
CT scan of your head, which showed a small bleed surrounding
part of your brain. This was likely due to the blood thinners
you were taking. Neurosurgeons evaluated you and felt you did
not need surgery, but recommended we stop your blood thinners.
We think your confusion was also due to worsening of your
infection in your abdomen. For this, we performed a procedure to
drain your abscess and gave you IV antibiotics. Your mental
status improved, and we feel you are now safe to return to
rehab.
During this admission, we made the following changes to your
medications:
** DECREASE prednisone [steroid] to 5mg daily, take for 10 days,
then stop
** DECREASE heparin [blood thinner] to 5000 units subcutaneously
twice a day
** STOP lovenox [blood thinner]
** STOP flagyl [oral antibiotic]
** START ciprofloxacin [IV antibiotic], take for 9 more days
** START vancomycin [IV antibiotic], take for 10 more days
** START terazosin [helps with urine retension]
** START psyllium [fiber supplement]
** START vitamin b12 supplement
** START loperamide as needed for loose ostomy output
**
Thank you for allowing us to participate in your care.
Followup Instructions:
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: TUESDAY [**2167-4-28**] at 1:45 PM
With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: SURGICAL SPECIALTIES
When: FRIDAY [**2167-5-1**] at 9:40 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 14117**], NP [**Telephone/Fax (1) 274**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2167-5-6**] at 1 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: SURGICAL SPECIALTIES
When: THURSDAY [**2167-5-14**] at 11:30 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 11714**], MD [**Telephone/Fax (1) 160**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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"276.1",
"496",
"V12.55",
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"263.9",
"453.82",
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icd9cm
|
[
[
[]
]
] |
[
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
15949, 16085
|
6512, 13054
|
315, 345
|
16239, 16239
|
4529, 6489
|
17732, 19049
|
3324, 3328
|
14598, 15926
|
16106, 16218
|
13080, 14575
|
16424, 17709
|
3343, 4510
|
266, 277
|
373, 2898
|
16254, 16400
|
2920, 3096
|
3112, 3308
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,696
| 140,480
|
17921
|
Discharge summary
|
report
|
Admission Date: [**2124-5-8**] Discharge Date: [**2124-5-16**]
Date of Birth: [**2067-11-6**] Sex: M
Service: GENERAL SURGERY/PURPLE
HISTORY OF PRESENT ILLNESS: The patient is a 56 year old
male who was referred to Dr. [**Last Name (STitle) **] for evaluation and
management of a recently diagnosed carcinoma in the
esophagogastric junction. He is from the State of [**State 1727**].
The patient was doing well until [**Month (only) 1096**] when he first noted
more heartburn and some more difficulty of swallowing and
decreased appetite. When the symptoms continued to worsen
and he lost about thirty pounds, but he was also on a weight
loss program, he was seen by his primary care physician who
found him to have a guaiac positive stool although the
patient denied any history of bleeding or melena. He has no
other complaints. Subsequently, he underwent an upper
gastrointestinal endoscopy which showed a partially
obstructing esophageal tumor with significant gastric
distention. The esophageal tumor extended down into the body
of the stomach and he is sent to [**Location (un) 86**] for further
evaluation. He was seen by oncology service who recommended
that he should undergo a surgical resection before possible
chemotherapy or radiation therapy.
PAST MEDICAL HISTORY: Significant for melanoma on the left
arm and testicular cancer on the left testis in [**2091**]. He is
status post radiation therapy.
Other medical problems include diabetes mellitus,
cardiovascular disease, status post coronary artery bypass
graft.
The patient denied history of allergies to medications.
MEDICATIONS ON ADMISSION:
1. Metoprolol 100 mg p.o. once daily.
2. Lisinopril 10 mg p.o. once daily.
3. Ribeprazole 20 mg p.o. once daily.
4. Metformin one gram once daily.
5. Simvastatin 20 mg p.o. once daily.
6. Cilostazol 200 mg p.o. once daily.
7. Aspirin one once daily.
PHYSICAL EXAMINATION: On admission, physical examination
showed a middle age male in no acute distress, afebrile,
blood pressure 120/70, pulse between 70 to 80, oxygen
saturation 99% in room air. The pupils are equal, round, and
reactive to light and accommodation. Extraocular motor
movements are intact. Nasal oropharyngeal membranes are
clear, no lesions, moist and pink. The neck is supple. The
heart is regular. The chest is clear to auscultation
bilaterally. The abdomen is soft, nontender, nondistended.
No hepatosplenomegaly. No surgical scar. Positive bowel
sounds. No inguinal hernia. Extremities have no edema.
HOSPITAL COURSE: The patient was taken to the operating room
on [**2124-5-8**], for a scheduled [**First Name9 (NamePattern2) 12351**] [**Doctor Last Name **] esophageal
gastrectomy and a feeding jejunostomy and feeding tube
placement. He tolerated the procedure well. The operation
went without complications. The estimated blood loss was
approximately 900cc and the patient received six liters of
crystalloid and made 330cc of urine intraoperatively. The
patient is transferred to the Post Anesthesia Care Unit in
stable condition. Pain control was obtained with epidural
catheter placement and also Dilaudid PCA. He was given one
gram of Kefzol perioperatively and he was subsequently
transferred to the Surgical Intensive Care Unit on
postoperative day one in stable condition for management of
fluid status and because of the amount of blood loss in the
operation. His Surgical Intensive Care Unit stay was
essentially unremarkable. He received two units of packed
red blood cells on postoperative day number two. He
continued to make good amount of urine and the oxygen
requirement was weaned off successfully. He was subsequently
transferred to the floor [**2124-5-10**], postoperative day number
two where he is starting to receive tube feeds at a low rate
of 10cc and received aggressive chest physical therapy for
pulmonary toilet. He tolerated these well. The epidural
catheter was discontinued on postoperative day number four.
He complained of some fullness. An upper gastrointestinal
series was obtained and showed some mild ileus and there was
no anastomotic leak. He was later started again on the tube
feeds and also started on p.o. intake. Postoperative day
number six, the chest tube was discontinued after putting on
water seal for more than 24 hours and putting out minimal
amount of fluid. His medication was switched to p.o. form
for which he tolerated fine. On postoperative day number
seven, his tube feeds have been increased to 80cc per hour
and he complained of some loose stool which seems to be
passage of barium contrast from prior upper gastrointestinal
series. A KUB was obtained for evaluation for possible
obstruction. The abdominal x-ray showed emptied left colon
and some remaining stool and barium in the right colon.
There was no dilated loop. He was then advanced to regular
food and the tube feeds were discontinued. He tolerated all
these very well. On postoperative day number eight, he is
tolerating completely house diet, making a good amount of
urine, pain control is adequate, and he is ambulating three
to four times a day. The loose stool has subsided. He is
discharged to home in stable condition with instruction to
follow-up with Dr. [**Last Name (STitle) **] in two weeks and he has also
been instructed to restart his home medication.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSIS: Esophagogastric cancer, status post
[**First Name9 (NamePattern2) 12351**] [**Doctor Last Name **] esophagectomy and gastrectomy and status post
jejunostomy for feeding tube placement.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 6066**]
Dictated By:[**Last Name (STitle) 46794**]
MEDQUIST36
D: [**2124-5-16**] 08:39
T: [**2124-5-16**] 19:36
JOB#: [**Job Number 49644**]
|
[
"414.00",
"E849.7",
"250.00",
"151.0",
"560.1",
"196.2",
"997.4",
"530.3",
"E878.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.39",
"96.6",
"43.99"
] |
icd9pcs
|
[
[
[]
]
] |
5434, 5889
|
1641, 1899
|
2552, 5349
|
1922, 2534
|
179, 1282
|
1305, 1615
|
5374, 5412
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,963
| 170,393
|
20393
|
Discharge summary
|
report
|
Admission Date: [**2106-2-16**] Discharge Date: [**2106-3-11**]
Date of Birth: [**2052-5-13**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Bactrim / Ciprofloxacin Hcl
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Transfer from OSH for further care of dehydration and cirrhosis.
Major Surgical or Invasive Procedure:
Placement of nasoduodenal tube by interventional radiology on
[**2106-2-24**].
History of Present Illness:
The pt. is a 53 year-old female with a history of cirrhosis
secondary to hepatitis C virus infection (diagnosed in [**2101**])
complicated by multiple admissions for acute renal failure,
sepsis and hepatic encephalopathy who was transferred from
[**Hospital 7188**] Hospital for further care. The pt. originally presented
to the [**Hospital 7188**] Hospital on [**2106-2-8**] after she sustained an
unwitnessed fall in her kitchen. She denied loss of
consciousness or injury at the time, she stated that she simply
fell. She was concerned enough, however, to go to the [**Hospital 7188**]
Hospital where she was found to be dehydrated and generally
weak. She was admitted for fluid resuscitation and subsequently
remained for eight days during which she underwent physical
therapy. The pt. was transferred to the [**Hospital1 18**] for further
treatment.
On arrival, the pt. complained only of "feeling tired." She
also admitted to one episode of "dry heaves" on the ambulance
ride over from [**Doctor Last Name **]. She denied recent fever, chills,
nausea, abdominal pain, vomiting (note dry heaves above),
diarrhea, melena, hematochezia or hematemesis, changes in bowel
or bladder habits. She feels she is "thinking clearly." She is
in no pain.
Past Medical History:
-cirrhosis secondary to hepatitis C virus infection(genotype 1),
originally diagnosed on routine labs in [**2101**], liver biopsy in
[**2103**] demonstrated cirrhosis; course has been complicated by
episodes of SBP, ARF, sepsis, hepatic encephalopathy; S/P
peg-interferon/ribavirin treatment, ending [**2-5**] (nonresponder);
currently awaiting liver transplant
-NIDDM
-HTN
-chronic LE cellulitis
-S/P appendectomy
-S/P dilatation and curretage
Social History:
The pt. is recently widowed and lives by herself. She has a
daughter who lives nearby. She denied use of tobacco, alcohol
or illicit drugs.
Family History:
Noncontributory.
Physical Exam:
Vitals: T: 97.4F P: 84 R: 24 BP: 131/76 SaO2: 100%RA
General: Awake, alert, NAD.
HEENT: NC/AT, PERRL, EOMI without nystagmus, + scleral icterus
noted, MM dry, no lesions noted in OP
Neck: supple, no JVD or carotid bruits appreciated
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, nontender, distended, normoactive bowel sounds,
+fluid wave
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. No asterixis noted.
-sensory: Anesthesia to light touch on feet bilaterally up to
ankles.
-cerebellar: No nystagmus, dysarthria, intention or action
tremor, dysdiadochokinesia noted. FNF and HKS WNL bilaterally.
-DTRs: 2+ biceps, triceps, brachioradialis, patellar and ankle
jerks bilaterally. Plantar response was flexor bilaterally.
Pertinent Results:
Labs on admission:
[**2106-2-16**] 09:30PM WBC-7.1 RBC-3.02* HGB-11.1* HCT-33.0*
MCV-110* MCH-36.9* MCHC-33.7 RDW-16.5*
[**2106-2-16**] 09:30PM PLT COUNT-66*
[**2106-2-16**] 09:30PM PT-18.0* PTT-36.4* INR(PT)-2.0
[**2106-2-16**] 09:30PM GLUCOSE-226* UREA N-42* CREAT-2.3* SODIUM-135
POTASSIUM-6.0* CHLORIDE-116* TOTAL CO2-10* ANION GAP-15
[**2106-2-16**] 09:30PM ALBUMIN-2.8* CALCIUM-8.6 PHOSPHATE-4.2
MAGNESIUM-1.6
[**2106-2-16**] 09:30PM ALT(SGPT)-56* AST(SGOT)-83* LD(LDH)-261* ALK
PHOS-152* TOT BILI-3.3*
[**2106-2-16**] 09:30PM AMMONIA-75*
Labs on discharge:
Renal U/S:
FINDINGS: The right kidney is located in the pelvis as seen on
the previous CT scan. It is not clearly visualized by
ultrasound, and hydronephrosis cannot be excluded. The left
kidney is normally positioned. It measures 10.5 cm. There is no
hydronephrosis or stones. There is a 1.6 x 1 cm cyst in the mid
left kidney. The bladder is partially distended and it appears
unremarkable.
IMPRESSION:
1) No left hydronephrosis.
2) Suboptimal visualization of the pelvic right kidney.
Hydronephrosis cannot be excluded.
MRI of the head
FINDINGS: There is increased T2 and FLAIR signal within the
periventricular white matter consistent with chronic
microvascular ischemia. There is also increased T2 signal in the
splenium of the corpus callosum. There is no evidence of an
acute infarct on diffusion imaging. There is no shift of midline
structures or hydrocephalus. There are normal vascular flow
voids. The osseous structures and sinuses appear normal. There
are no parenchymal masses.
IMPRESSION: No acute infarct. Findings consistent with chronic
small vessel ischemia.
Abdominal U/S:
LIVER ULTRASOUND WITH COLOR DOPPLER: [**Doctor Last Name **] scale images again
show a shrunken and nodular liver, consistent with patient's
history of cirrhosis. No focal liver lesions are identified. A
small amount of ascites is present, decreased from the previous
exam.
Color Doppler images of the liver were also obtained. The main,
right and left portal veins are patent, with flow in the
appropriate direction. There is, however, a small segment of
nonocclusive thrombus within the proximal portion of the left
portal vein, not seen on the previous exam. The hepatic veins
are patent, with flow in the appropriate direction. The main,
right and left hepatic arteries demonstrate normal-appearing
waveforms. The IVC and splenic vein are unremarkable. Noted is a
patent paraumbilical vein. The spleen is enlarged, measuring up
to 18 cm.
IMPRESSION:
1) Liver cirrhosis and portal hypertension.
2) Patent hepatic vasculature, as discussed above. Findings are
suggestive of a short segment of nonocclusive thrombus within
the left portal vein.
3) Small amount of abdominal ascites, decreased from the exam of
[**2106-1-6**]. An isolated pocket of fluid could not be identified for
safe bedside aspiration.
Brief Hospital Course:
1. HCV cirrhosis: The pt. was maintained on lactulose and
pantoprazole. Her MELD score peaked to 33 on hospital day seven
however the pt. It subsequently fell as her creatinine and
albumin improved. She was started on intravenous albumin on
hospital day seven and a nasoduodenal tube was inserted on
hospital day 8 for tube feeds. On [**3-1**] a diagnostic paracentesis
was performed. Prophylactic cipro was given. On [**3-2**] increased
encephalopathy was noted and lactulose was increased. A repeat
liver dedicated MRI was recommended to clarify previous MRI
findings of liver foci concerning for HCC. On [**2106-3-3**] patient
received a orthotopic cadaveric liver transplant. Intraop course
significant for episodes of hypotension requiring epinephrine.
She received 2 units PRBC preoperatively and intraoperatively
she received 10 liters of cyrstalloid, 9 units of PRBC, 14 units
of FFP, 5 units of platelets, 5 units of cryoglobulin and 5500
cellsaver. Please see operative note for further details. She
received induction immunosuppression that included simulect,
solumedrol, cellcept and prophylactic fluconazole and valcyte.
She was transferred to the SICU intubated, sedated and
paralyzed. Vital signs were stable. She was started on neoral IV
in addition to cellcept and solumedrol on tapering schedule. She
did well postoperatively and was extubated on POD 2. Hepatic
transaminases decreased. She was transfered to the transplant
unit on POD 2 with 2 JPs and 1 T tube draining bile. Foley was
draining qs .
urine output. On POD 3 she received a second dose of simulect
20mg IV. On POD 5, a T tube study was done to assess the bile
duct patency. This revealed The patient was placed supine on the
angiography table. Initial fluoroscopic imaging demonstrated a
right-sided transhepatic biliary drainage catheter along with
the right [**Location (un) 1661**]-[**Location (un) 1662**] drain. Under fluoroscopic guidance, the
biliary drainage catheter was then allowed to fill slowly with
contrast via gravity. There was progressive flow of contrast via
the biliary tree into the bowel. Retrograde filling of small,
non-dilated intrahepatic biliary ducts was seen. There is no
evidence of biliary leak or stricture.
CONTRAST: 20 cc of Optiray 320.
IMPRESSION: Tube cholangiography demonstrating progressive flow
of contrast through the existing T-tube into the bowel without
evidence of leak or stricture. Given these results, the T-tube
was capped. Cyclosporin level increased to 1172 after capping of
the T-tube. Cyclosporine was decreased to 200mg po bid.
Cyclosporin level decreased to 698 and the neoral level was
increased to 250mg [**Hospital1 **]. Goal range is [**9-15**].
PT worked with [**Known firstname 2127**] [**Last Name (NamePattern1) **]. [**Known firstname 2127**] demonstrated commitment to
progresing her mobility and endurance, but it was suggested that
given the patients function below baseline independence, she
would benefit by rehab to maximize her functional recovery.
The [**Last Name (un) **] endocrinologist was consulted to assist with insulin
adjustment as glucoses were elevated secondary to the solumedrol
She was managed on an insulin drip initially then glargine with
sliding scale insulin was started. Glucoses tended down to the
78mg/dl range and the insulin drip was discontinued. Solumedrol
was tapered down and stopped on POD 4 when prednisone taper
started. She is currently on prednisone 20mg qd. This will taper
down every ten day by 2.5mg per the transplant team's order.
Insulin needs are expected to decrease with this taper.
She has done well postoperatively. She is afebrile. HR 80, BP
150/88-123/73. RR 18. O2 sat on room air is 97%. Weight is 79.4.
Urine output averages ~ 2300ml/day. She is comfortable. JP was
removed on [**2106-3-10**] and incision is well approximated with clips.
No redness or drainage noted.
2. Acute renal failure: The pt's creatinine was elevated above
baseline on admission. It was initially felt that as the pt.
was dehydrated, a prerenal etiology of renal failure was likely.
Her FE Na, however, was 1.25%, arguing against a prerenal
cause. Her creatinine continued to steadily rise over the
course of the first five hospital days. A renal consult was
obtained. As the pt. had eosinophils in her urine, it was
thought that she may be suffering from acute interstitial
nephritis. Accordingly, bactrim and ciprofloxacin were
discontinued as they were felt to be possible inciting agents.
This resulted in a slow decrease in her serum creatinine. After
transplantation, her creatinine decreased to 1.1 on [**Date Range **] day
1. The creatinine did increase to 1.7-1.9. On [**3-10**] creatinine was
1.9 with bun 74.
Labs on [**3-10**]: wbc 9.2, hct 32.5, sodium 142, potassium 3.6,
chloride 105, bicarb 26, BUN 74, Creatinine 1.9, calcium 8.6,
phosphorus 2.8, magnesium 2.8, ast 32, alt 70, alk phos 81, t.
bili 1.8 and albumin 2.8. INR was 1.2 on [**2106-3-6**].
3. Urinary tract infection: The pt. was noted to have a urinary
tract infection on urinalysis. Subsequent culture grew E. Coli
sensitive only to bactrim, imipenem and zosyn. As the pt. is
allergic to penicillin, zosyn was not an option. Further, there
is a 40% cross-reactivity between the monobactams and
penicillin, therefore meropenem was not used. Bactrim was not
given as the pt. developed AIN on this [**Doctor Last Name 360**] as above. An
infectious disease consult was obtained. They recommended
giving the pt. one dose of fosfomycin. Subsequent urine
cultures were noted:
[**2106-2-20**] 9:20 pm URINE
**FINAL REPORT [**2106-2-24**]**
URINE CULTURE (Final [**2106-2-24**]):
ESCHERICHIA COLI.
>100,000 ORGANISMS/ML. OF TWO COLONIAL MORPHOLOGIES.
PRESUMPTIVE IDENTIFICATION.
Trimethoprim/sulfa sensitivity confirmed by
[**Doctor Last Name 3077**]-[**Doctor Last Name 3060**].
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 E. coli and Klebsiella species.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- R
CEFTRIAXONE----------- =>64 R
CEFUROXIME------------ =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN---------- =>128 R
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
Subsequent urine cultures on [**4-18**] and [**2-28**] were
consistently negative as below
**FINAL REPORT [**2106-3-1**]**
URINE CULTURE (Final [**2106-3-1**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
4. ?Transient ischemic attack: The pt. was noted to have
neurologic findings on exam on hospital day three which were
suggestive of a left cerebellar or right pontine lesion. An
emergent head CT was performed and was negative for intracranial
hemorrhage. Subsequently, an MRI of the head was performed
which was normal.
The neurology service was consulted and did not appreciate the
deficits previously noted on their examination roughly four
hours later. She had no further neurologic events for the
remainder of the hospital stay. Mental status improved steadily
post liver transplant. She is alert and oriented.
5. Insulin-dependent diabetes mellitus: The pt. was noted to
have poor control of blood sugar early in the course of
admission. Her glargine dose and humalog sliding scale were
titrated accordingly. She will need qid accuchecks at rehab. A
sliding scale insulin will be used in addition to glargine. She
is eating better.
6. Disposition: [**Hospital **] rehab with follow by Transplant
surgeons at [**Hospital1 18**].
Medications on Admission:
-aldactone 100mg po daily
-flagyl 500mg po q12h
-bactrim DS 1 tab po daily
-protonix 40mg po daily
-seroquel 20mg po daily
-lantus 25 units sc qpm
-lactulose 30cc po 5X/day
-tylenol 325mg po q8h prn pain
-proventil INH 2puffs q4h prn
-nadolol 20mg po daily
Discharge Medications:
Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24
hours).
Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Boost Liquid Sig: One (1) PO TID (3 times a day).
Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
follow taper 2.5mg every 10 days per transplant surgeon.
Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection four times a day: see sliding scale.
Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Cyclosporine Modified 100 mg Capsule Sig: Two (2) Capsule PO
Q12H (every 12 hours): take with 25mg cap for total dose of
225mg twice a day.
Neoral 25 mg Capsule Sig: One (1) Capsule PO twice a day: take
with two 100mg caps for total dose of 225mg twice a day.
Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO once a day.
Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day: check with
MD for dose.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
-cirrhosis secondary to hepatitis C infection
-acute renal failure
-urinary tract infection with E. Coli
-type II diabetes mellitus
-h/o hypertension
-Orthotopic liver transplant [**2105-3-3**]
Discharge Condition:
Stable.
Discharge Instructions:
Call if any fevers, chills, nausea, vomiting, inability to eat
or take medications, jaundice, elevated liver function tests,
decreased urine output or abdominal pain.
Labs every Monday & Thursday for cbc, chem 10, ast, alt, alk
phos, t.bili, albumin, and trough cyclosporin level. Fax results
immediately to [**Hospital1 18**] transplant office [**Telephone/Fax (1) 18623**]
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) **]: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2106-3-17**] 11:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) **]: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2106-3-24**] 11:20
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) **]: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2106-3-31**] 11:20
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2106-3-10**]
|
[
"572.2",
"263.9",
"572.3",
"401.9",
"789.5",
"250.00",
"070.54",
"584.9",
"571.5",
"276.5",
"599.0",
"285.9",
"041.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"50.59",
"96.6",
"96.08",
"99.15",
"99.04",
"54.91",
"00.93",
"87.54"
] |
icd9pcs
|
[
[
[]
]
] |
16273, 16352
|
6460, 14785
|
365, 446
|
16589, 16598
|
3550, 3555
|
17021, 17827
|
2376, 2394
|
15094, 16250
|
16373, 16568
|
14811, 15070
|
16622, 16998
|
3101, 3531
|
2409, 3004
|
261, 327
|
4131, 6437
|
474, 1732
|
3570, 4111
|
3019, 3084
|
1754, 2200
|
2216, 2360
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,413
| 129,479
|
45364
|
Discharge summary
|
report
|
Admission Date: [**2169-8-17**] Discharge Date: [**2169-8-25**]
Service:
CHIEF COMPLAINT: Shortness of breath.
HISTORY OF PRESENT ILLNESS: This is an 82-year-old man with
a history of CAD, CHF, and AFib who presents with increased
shortness of breath and a cough over the last week. At
baseline, he has shortness of breath with minimal exertion;
just walking to the bathroom. In the last week his shortness
of breath has increased even at rest with positive orthopnea.
He has had a nearly constant cough with productive white
nonpurulent sputum. He notes increased edema in his lower
extremities bilaterally. He complains of mild chest
discomfort only with coughing; nonradiating and very
difficult from his prior anginal/MI pain. The patient [**Year (4 digits) **]
any palpitations, fevers, chills, nausea, vomiting, or
diarrhea. No dysuria but has had increased frequency of
urination on Lasix. He [**Year (4 digits) **] any dietary indiscretion
including increased salt or water intake.
PAST MEDICAL HISTORY:
1. CAD; status post RCA stent in [**2167-7-27**].
2. CHF with an ejection fraction of 20%, 1+ AR, 2+ MR from a
[**2168-7-26**] echocardiogram.
3. AFib; status post pacemaker placement in [**2168-7-26**]; off
Coumadin secondary to GI bleed.
4. Chronic renal insufficiency (with a baseline creatinine of
2.0 to 2.5).
5. GI bleed; status post NICU course in [**2168-9-26**] due
to NSAID-induced gastritis.
6. PVD; status post femoral-to-popliteal bypass.
7. Hypertension.
8. Hypercholesterolemia.
9. Renal artery stenosis.
10. Hypothyroidism.
11. Carotid artery stenosis; status post CEA in [**2163**].
12. Gout.
13. History of Bell palsy.
14. Pulmonary hypertension.
MEDICATIONS ON ADMISSION: Allopurinol 200 mg p.o. daily,
Lipitor 10 mg p.o. daily, gemfibrozil 600 mg p.o. daily,
Protonix 40 mg p.o. daily, levothyroxine 25 mcg p.o. daily,
Toprol 25 mg p.o. daily, amiodarone 200 mg p.o. daily,
nortriptyline 10 mg p.o. daily, Imdur 30 mg p.o. daily,
hydralazine 10 mg p.o. q.i.d., iron 325 mg p.o. daily,
multivitamin, Lasix 20 mg p.o. daily, Colace, and Procrit
10,000 units 2 times a week.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: He lives at home with his wife. [**Name (NI) **] walks
with a walker. He has a nurse [**First Name (Titles) 1023**] [**Last Name (Titles) 2176**] him [**Hospital3 **]-
weekly for laboratory draws. He is a former smoker with a 50-
pack-year history. Occasional alcohol. No drug use.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION ON ADMISSION: Temperature of 97.3,
blood pressure of 139/54, heart rate of 75, respiratory rate
of 14, and O2 saturation of 97% on room air. In general, the
patient was lying in bed in no apparent distress. Alert and
oriented. HEENT revealed PERRLA, EOMI, moist mucous
membranes. Chest revealed bilateral crackles halfway up the
base. No wheezes. A 13-cm JVP. Heart exam revealed a regular
rate and rhythm. S1 and S2. A soft [**1-31**] to 2/6 systolic
ejection murmur. The abdomen was soft, obese, nontender, with
normal active bowel sounds. No hepatosplenomegaly or masses.
The extremities revealed 3+ edema bilaterally in the lower
extremities up to the knees. No erythema or warmth.
LABORATORY DATA ON ADMISSION: Notable for a white count of
5.0, a hematocrit of 33.0, an INR of 1.1, a BUN of 48, a
creatinine of 2.4, a CK of 22.
STUDIES: An echocardiogram from [**2168-7-26**] with an EF of
20%.
A catheterization from [**2167-7-27**] shows 1-VD, status post
RCA stent, severe pulmonary artery hypertension.
A chest x-ray from [**2169-8-17**] shows vascular
redistribution in the upper zones consistent with edema; and
no effusion.
EKG reveals AFib, V paced at 75 beats per minute, no
concordance or ST elevations over 5 mm.
HOSPITAL COURSE: In short, this is an 82-year-old man with a
past medical history of CAD, CHF, AFib, and chronic renal
insufficiency who presents with worsening heart failure.
1. CONGESTIVE HEART FAILURE: The patient ruled out for a
myocardial infarction and did not have any significant EKG
changes, although he was V paced. The patient was seen by
the CHF consult. The patient was believed to be a [**State 531**]
Heart Failure class 4 given his shortness of breath at
rest. The patient's dose of Lasix was titrated up, but the
patient only responded minimally. In addition, his
hydralazine dose was titrated up with the Imdur. The
patient was thought to be a candidate for the revived
trial involving levosimendan for decompensated chronic
heart failure. The patient was transferred to the CTU for
induction of this trial. The patient tolerated the trial
well with a stable QTC and subjective improvement of his
symptoms. He diuresed 1.5 to 2 liters a day. Also, his
Lasix was increased up to 40 mg IV b.i.d. A repeat
echocardiogram was performed which showed an EF of 30% and
an increased TR gradient up to 60; representing worsened
pulmonary artery hypertension. The patient continued to
diurese well, although his creatinine started to climb up.
Creatinine stabilized at 2.8. The patient's Lasix was
converted to a p.o. regimen. Also, he was started on
Aldactone for class 4 heart failure. Over the next several
days, his creatinine increased to 3.2. Lasix was held and
nesiritide was begun. The patient diuresed well and
creatinine stabilized at 3.1. The patient was restarted on
Lasix.
1. CORONARY ARTERY DISEASE: The patient ruled out for a MI
and had no significant EKG changes.
1. ATRIAL FIBRILLATION: The patient was continued on
amiodarone. He was not felt to be a candidate Coumadin
given his past history of GI bleeds.
1. CHRONIC RENAL INSUFFICIENCY: The patient stabilized his
creatinine at 3.1.
1. URINARY TRACT INFECTION: The patient was found to have a
Klebsiella UTI. He completed a 7-day course of
levofloxacin.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: Discharged to home with the following
diagnoses.
DISCHARGE DIAGNOSES: Congestive heart failure, coronary
artery disease, atrial fibrillation, chronic renal
insufficiency, hypertension, hyperlipidemia, hypothyroidism,
gout, pulmonary hypertension.
MEDICATIONS ON DISCHARGE:
1. Allopurinol 100 mg p.o. every other day.
2. Lipitor 10 mg p.o. daily.
3. Gemfibrozil 600 mg p.o. daily.
4. Toprol 50 mg p.o. daily
5. Levothyroxine 25 mcg p.o. daily.
6. Amiodarone 200 mg p.o. daily.
7. Nortriptyline 10 mg p.o. at bedtime.
8. Ferrous sulfate 325 mg p.o. daily.
9. Multivitamin.
10. Tylenol p.r.n.
11. Imdur 90 mg p.o. daily.
12. Lasix 40 mg p.o. daily.
13. Hydralazine 50 mg p.o. q.6h.
14. Protonix 40 mg p.o. daily.
DISCHARGE FOLLOWUP: The patient was to follow up with Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], Dr. [**Last Name (STitle) **], and Dr. [**Last Name (STitle) 284**]; all planned
for [**2169-8-27**].
[**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 6648**]
Dictated By:[**Last Name (NamePattern1) 96859**]
MEDQUIST36
D: [**2170-6-29**] 10:27:23
T: [**2170-6-29**] 15:22:46
Job#: [**Job Number 96860**]
|
[
"416.8",
"414.01",
"428.0",
"424.0",
"414.8",
"V45.82",
"599.0",
"427.31",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.13"
] |
icd9pcs
|
[
[
[]
]
] |
2515, 2554
|
6049, 6227
|
6253, 6718
|
1758, 2198
|
3810, 5926
|
102, 124
|
6739, 7183
|
153, 1005
|
3273, 3792
|
1027, 1731
|
2215, 2498
|
5951, 6027
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,267
| 120,568
|
6595
|
Discharge summary
|
report
|
Admission Date: [**2132-9-25**] Discharge Date: [**2132-10-2**]
Date of Birth: [**2064-1-9**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
right carotid stenosis, progressive,asymptomatic
Major Surgical or Invasive Procedure:
right carotid endartectomy [**2132-9-26**]
History of Present Illness:
Patient with known carotid disease. Serial carotid ultrasounds
done now with progressive stenosis. asymptomatic. admit for
elective rt. carotid endartectomy.
Past Medical History:
histroy of hypertension
histroy of dyslipdemia
histroy of DM2
histroy of carotid disease s/p Left CEA
histroy of dysrythmia AF,PAF, anticoagulated
histroyof coronary artery disease .s/p CABG's Lima-LAD,SVG-OM,
s/p PTCA RCA xa '[**29**] myoview 112/07 fixed apical defect with
possible focal ischemia of inferior wall. EF 60%
history of arthritis s/p rt. hip prothesis
history of obesity
history of obstructive sleep apnea/CPAP
Social History:
married and lves with spouse
Family History:
unknown
Physical Exam:
Vital signs:P-77 B/P 159/84 O2 sat 98%
HEENT: right carotid bruit
Lungs: clear to auscultation
Heart: regular irregular
ABd: bengin
Neuro: nonfocal exam
Pertinent Results:
[**2132-9-25**] 11:14AM freeCa-1.18
[**2132-9-25**] 11:14AM HGB-13.3* calcHCT-40
[**2132-9-25**] 11:14AM TYPE-ART PO2-224* PCO2-43 PH-7.36 TOTAL
CO2-25 BASE XS--1 INTUBATED-INTUBATED VENT-CONTROLLED
[**2132-9-25**] 06:21PM PTT-41.6*
[**2132-9-25**] 08:56PM PT-14.6* PTT-38.7* INR(PT)-1.3*
[**2132-9-25**] 08:56PM PLT COUNT-150
[**2132-9-25**] 08:56PM GLUCOSE-168* UREA N-18 CREAT-0.8 SODIUM-134
POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-22 ANION GAP-13
[**2132-9-25**] 09:07PM freeCa-1.12
[**2132-9-25**] 09:07PM GLUCOSE-160* LACTATE-1.7 K+-3.8
[**2132-9-25**] 09:07PM TYPE-ART PO2-147* PCO2-37 PH-7.39 TOTAL
CO2-23 BASE XS--1 INTUBATED-NOT INTUBA
Brief Hospital Course:
[**2132-9-25**] DOS: right [**Hospital 25204**] to PACU stable and
neurologically intact.@ 1800 c/p frontal headache-given tylenol.
1830 no change in heache 0.5mg IV diludid given At this time
increasing left upper extremity weakness with loss of left hand
grasp. CT head obtained during this time developed hypertension
while in scanner wich was controlled with Iv hydralazine.
Continued neuro changes with progressive upper extremity wakness
and left facial droop and left sided neglect. Iv heparin rate
increased. Develope hypotension and was fluid
resustated.Transfered to ICU. Neuro stoke consulted. MRI/MRA
obtained. inital read multiple small embollic foci and aberrant
rt. PCA comming from MCA which likely lead to minute thalmic
infracts as well.
[**2132-9-26**] POD#1 remains in ICU insulin gtt started for hyper
glycemia.Transfered to VICU @1600.[**Last Name (un) **] consulted for glycemic
mangment.po hypooglycemic [**Doctor Last Name 360**] resarted with addition of
metformin.
[**2132-9-27**] POD#2 stable neurologically intermittent AF . remains on
IV heparin.Dilt drip started Cardology consulted for AF with
RVR. diltdrip weaned after starting diltizem po.ERvaluated by PT
will need home Pt at discharge.Also evaluated by OT.
[**2132-9-29**] POD#4 tropinins not elevated AF well controlled.heparin
coumadin conversion in progress.TSH 0.8 TEE: RA6.0/LA 6.1 EF 50%
mild MR. [**Name13 (STitle) **] require out patient cardion version once
anticoagulated if still in AF in 4 weeks.Will also require an
outpatient stress.
[**2132-9-30**] POD# 5 cardology recommending d/c diltizem. and continue
lopressor with increasing dose 150mgm [**Hospital1 **].
[**2132-10-10**] POD# 6 INr 1.4
[**2132-10-2**] POD# 7 INR 1.7 d/c to home on 7.5mgm coumadin daily with
INR on [**10-6**] to be call to Dr.[**Name (NI) 1392**] office.
Patient should followup with Dr. [**Last Name (STitle) 25205**] his cardologist for
evaluation for cardioversion if still in AF 4 weeks.He should
also followup for stress test with his cardologist. Patient
instructed to arrange for appointment with cardologist upon
discharge. neck wound cliped and steri strips applied. Wound
without hematoma.
followup with Dr. [**Last Name (STitle) **] as directed.
Medications on Admission:
atenolol 50mgm [**Hospital1 **]
glyset 25mgm tid
plavix 75mgm daily
gabapentin 300mgm tid
asa 81mgm daily
mirapex 0.125mgm daily
vicodan 5/500 daily
slo niacin 100mgm daily
cardura 4mgm daily
liptor 40mgm daily
lisinoprinl 10mgm daily
imdur 60mgm daily
cosopt gtts OS [**Hospital1 **]
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
6. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
7. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
8. Pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO QHS PRN
().
9. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
10. Miglitol 25 mg Tablet Sig: One (1) Tablet PO with meals ().
11. Outpatient [**Name (NI) **] Work
PT/INR [**10-6**]
call results to Dr.[**Name (NI) 1392**] office [**Telephone/Fax (1) 1393**]
12. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
13. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
Disp:*180 Tablet(s)* Refills:*2*
14. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO DAYS
([**Doctor First Name **],MO,TU,WE,TH,FR,SA).
Disp:*90 Tablet(s)* Refills:*2*
15. [**Male First Name (un) **] niacin 100mgm daily
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Discharge Worksheet-Discharge Diagnosis-Finalized:[**Last Name (LF) **],[**First Name3 (LF) **],
PA on [**2132-10-2**] @ 0807
carotid stenosis, asymptomatic
histroy of a.fib/flutter,anticoagulated
histroy of coronary artery disease. Stressmyoview:[**12-28**] fixed
apical defect with possible focal inferior wall ischemia,s/p
CABG"S [**7-26**] Lima-LAD,[**Name (NI) 25206**], PTCA RCA x2
history of dyslipdemia
histroy of hypertension
history of arthritis, s/ p Rt. hip prothesis
histroy of DM2
histroy of obesity
postoperative embolic stroke.
postoperative hyper glycemia requiring IV insulin gtt, treated
Discharge Condition:
stable
Discharge Instructions:
asa 325mgm started
coumadin 5mgm daily began, changed [**10-1**] 7.5mgm daily
atenolol changed to lopressor 150mgm [**Hospital1 **]
plavix d/c'd
imdur d/c'd
metformin has been added to your Dm medications for improve
glycemic control.
please have a HgAC1 in 3 months
please have an INR drawn [**10-6**] and results called to Dr. [**Name (NI) 4436**] office @ [**Telephone/Fax (1) 1393**]
Followup Instructions:
followup with your cardiac provider to arrange for cardioversion
if still in AF and stress test
goal INR 2-3.0
will need outpatient cardioversion once anticoagulated. if still
in AF. Will need out patient stress after d/c to home
Completed by:[**2132-10-2**]
|
[
"434.91",
"433.10",
"250.00",
"V45.81",
"997.02",
"401.9",
"327.23",
"427.31",
"414.00",
"427.32"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.12",
"00.40"
] |
icd9pcs
|
[
[
[]
]
] |
5885, 5968
|
1991, 4228
|
362, 407
|
6619, 6628
|
1304, 1968
|
7064, 7325
|
1107, 1116
|
4563, 5862
|
5989, 6598
|
4254, 4540
|
6652, 7041
|
1131, 1285
|
274, 324
|
435, 595
|
617, 1045
|
1061, 1091
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,726
| 112,949
|
54683
|
Discharge summary
|
report
|
Admission Date: [**2171-9-23**] Discharge Date: [**2171-10-2**]
Date of Birth: [**2102-11-12**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor Last Name 19844**]
Chief Complaint:
s/p Pedestrian struck by auto
Major Surgical or Invasive Procedure:
[**2171-9-30**]
1. Open reduction internal fixation pelvic ring fracture
left and right side with cannulated 7.3 mm screws.
2. Open reduction internal fixation left ankle with medial
shear antiglide plating.
History of Present Illness:
68 year old male with unknown past
medical history who has been transferred from [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Hospital who presents with spinal and pelvic fractures
status post pedestrian struck.
He reportedly was struck by a motor vehicle traveling
approximately 30-35 miles per hour. There was significant
front end damage to the vehicle. The patient was thrown
approximately 15-20 feet and had a loss of consciousness
during the accident. EMS arrived on scene and found the
patient to be conscious but confused and complaining of hip
and leg pain.
He was taken by EMS to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] hospital, where
he was found to have spinal and pelvic fractures by CT
imaging. His pelvis was stabilized, and he was transported
to [**Hospital1 18**] for further surgical evaluation. The patient did
not receive any pain medication or sedation, and complains
now of 1 out of 10 pelvic pain.
Past Medical History:
EtOH abuse, HTN, anxiety
Social History:
+EtOH
Family History:
Noncontributory
Physical Exam:
Upon presentation to [**Hospital1 18**]:
HR: 85 BP: 130/ O(2)Sat: 98 Normal
Constitutional: GCS 15
HEENT: Left anterior scalp laceration. Small occipital
laceration, Pupils equal, round and reactive to light,
Extraocular muscles intact
Cervical collar in place. No hemotympanum. No bloode in the
nares.
Chest: Airway patent. Clear breath sounds bilaterally.
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nondistended
Pelvic: Pelvis wrapped with sheet
GU/Flank: Foley in place, + hematuria
Extr/Back: 2+ radial and DP pulses bilaterally.
Skin: Skin abrasions over knees, bilaterally
Neuro: 5/5 strength throughout the lower extremities,
bilaterally.
Pertinent Results:
[**2171-9-23**] 01:33PM HCT-31.4*
[**2171-9-23**] 06:37AM CK(CPK)-1810*
[**2171-9-23**] 06:37AM CK-MB-31* MB INDX-1.7 cTropnT-<0.01
[**2171-9-23**] 01:37AM PH-7.28* COMMENTS-TRAUMA,GRE
[**2171-9-28**] 01:08AM BLOOD WBC-9.0 RBC-2.72* Hgb-9.0* Hct-26.8*
MCV-98 MCH-33.2* MCHC-33.8 RDW-14.7 Plt Ct-206
[**2171-9-30**] 05:51AM BLOOD WBC-9.8 RBC-2.89* Hgb-9.5* Hct-28.4*
MCV-98 MCH-32.9* MCHC-33.5 RDW-14.3 Plt Ct-330#
[**2171-9-30**] 07:40PM BLOOD WBC-11.4* RBC-2.90* Hgb-9.7* Hct-28.6*
MCV-99* MCH-33.4* MCHC-33.9 RDW-14.2 Plt Ct-381
[**2171-10-1**] 06:00AM BLOOD WBC-9.1 RBC-2.72* Hgb-9.0* Hct-26.6*
MCV-98 MCH-32.9* MCHC-33.6 RDW-14.2 Plt Ct-335
[**2171-9-28**] 01:08AM BLOOD Glucose-132* UreaN-15 Creat-0.7 Na-140
K-3.6 Cl-105 HCO3-29 AnGap-10
[**2171-9-29**] 06:12AM BLOOD Glucose-153* UreaN-17 Creat-0.8 Na-139
K-3.6 Cl-104 HCO3-26 AnGap-13
[**2171-9-30**] 07:40PM BLOOD Glucose-146* UreaN-18 Creat-0.9 Na-138
K-4.5 Cl-104 HCO3-25 AnGap-14
[**2171-10-1**] 06:00AM BLOOD Glucose-115* UreaN-17 Creat-0.6 Na-137
K-4.1 Cl-103 HCO3-25 AnGap-13
CT head, C-spine(OSH)[**2171-9-23**]: no acute bleed/fracture
TIB/FIB (AP & LAT) LEFT([**2171-9-23**]): There are acute fractures
through the medial and lateral malleoli and proximal fibula, all
nondisplaced. No knee joint effusion.
KNEE 2 VIEW PORTABLE LEFT([**2171-9-23**]): There are acute fractures
through the medial and lateral malleoli and proximal fibula, all
nondisplaced. No knee joint effusion.
HAND (AP, LAT & OBLIQUE) RIGHT([**2171-9-23**]): No fracture.
WRIST, AP & LAT VIEWS RIGHT([**2171-9-23**]): Radius and ulna and elbow
joint are normal. There are no carpal bone, metacarpo- or
phalangeal fractures. The scaphoid appears intact. No fracture.
ELBOW (AP, LAT & OBLIQUE) RIGHT([**2171-9-23**]): There is no evidence
right glenohumeral or elbow joint dislocation. There is
no acute fracture. No AC joint separation.
SHOULDER 1 VIEW RIGHT([**2171-9-23**]): There is no evidence right
glenohumeral or elbow joint dislocation. There is
no acute fracture. No AC joint separation.
RIGHT HUMERUS (AP & LAT) ([**2171-9-23**]): There is no evidence right
glenohumeral or elbow joint dislocation. There is
no acute fracture. No AC joint separation.
RIGHT FOREARM (AP & LAT) ([**2171-9-23**]): Radius and ulna and elbow
joint are normal. No fracture.
[**9-26**] CT cystogram ([**Last Name (un) **]): filling defect on the CT cystogram.
given its appearance and comparing it to the CT from 4 days
earlier, differential would be clot versus tumor. given that the
foley is expanding pressure upon it, clot is more likely. no
evidence of extrav from the bladder. complex pelvic fx.
[**9-27**] CXR: There are persistent low lung volumes. Cardiomegaly
is accentuated by the low
lung volumes. Minimal bibasilar opacities, likely atelectasis,
have increased on the left. There is no pneumothorax or pleural
effusion. Dobbhoff tube tip is in the stomach.
Brief Hospital Course:
He was admitted to the acute care/trauma surgery service and
transferred to the trauma ICU for close monitoring.
His hospital course as follows by systems:
N: He was initially alert and responsive. However, his mental
status quickly deteriorated secondary to alcohol withdrawal and
he became confused and agitated. He was placed on a CIWA regimen
with Ativan and Valium. He was given thiamine for 7 days and a
clonidine patch to help with his withdrawal. His mental status
eventually cleared over the next few days. At time of transfer
from the ICU to the floor he had no requirements for Ativan or
Valium. His mental status on day of discharge was alert and
oriented x2 without agitation.
CV: He was hypertensive initially felt likely secondary to
withdrawal and he was given metoprolol and labetalol as well as
clonidine. He was also given hydralazine. Eventually as his
withdrawal symptoms subsided his blood pressure normalized at
and time of discharge his blood pressure was 128/80 with a heart
rate of 97. He is being discharged on Lopressor and Clonidine
patch. The Clonidine patch can be tapered over the next week if
his mental status continues to improve and his blood pressure
and heart rate are stable on the beta blockers.
Pulm: He had multiple rib fractures and his pain was controlled.
He was saturating well on face tent initially and then nasal
cannula. Serial chest xrays were followed showing low lung
volumes with some atelectasis. He was started on nebulizers and
the oxygen was weaned - his saturations are ranging in the high
90's range at time of discharge.
GI: He was kept NPO and on IVF while actively withdrawing. A
Dobbhoff tube was placed on [**9-26**] and tube feeds started. Once
his mental status improved, speech and swallow evaluated him and
he was then given a mechanical soft diet.
GU: There was concern for a hematoma near the bladder and
urology consult was placed. Urology recommended continuing Foley
for 7 days with gentle irrigation for clots. The Foley was
removed on HD# 9.
Heme: His hematocrits were stable ranging in the mid to high
20's. He is receiving daily Lovenox for DVT prophylaxis.
MSK: For his lower extremity and pelvic fractures Orthopedics
was consulted and once able to obtain consent he was taken to
the operating room for open reduction internal fixation pelvic
ring fracture left and right side with cannulated 7.3 mm screws
and open reduction internal fixation left ankle with medial
shear antiglide plating. He is non weight bearing on both lower
extremities.
Dispo: He was evaluated by Physical and Occupational therapy and
is being recommended for rehab after his acute hospital stay.
Medications on Admission:
Denies
Discharge Medications:
1. Enoxaparin Sodium 40 mg SC DAILY
2. Clonidine Patch 0.2 mg/24 hr 1 PTCH TD 1X/WEEK (MO)
3. Docusate Sodium 100 mg PO BID
4. Bisacodyl 10 mg PO/PR DAILY:PRN no BM
5. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze
6. Metoprolol Tartrate 50 mg PO TID
Hold for HR < 60, SBP < 100
7. Senna 1 TAB PO BID:PRN constipation
8. Acetaminophen 325-650 mg PO Q6H:PRN pain
9. Multivitamins 1 TAB PO DAILY
10. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Rehabilitation & Skilled Nursing Center - [**Location (un) 1456**]
Discharge Diagnosis:
s/p Pedestrian struck by auto
Injuries:
Right sacral fracture
Right inferior/superior pubic rami fractures with displacement
Right 2,4,6 rib fractures
T12 compression fracture subacute
Left medial maleolus fracture
Proximal left fibula fracture
Secondary Diagnosis:
Acute alcohol withdrawal
Delirium
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:
You were admitted to the hopsital after being struck by an auto
where you suatined multiple injuries including rib fractures and
broken bones in your pelvis, left leg and ankle. Your ankle
fracture required an operation to repair this injury. You should
avoid bearing any weight on your left ankle for at least the
next 4-6 weeks and possibly longer per recommendation of the
Orthopedic surgeon.
You were also found to have an old compresion fracture of one of
the spine bone located near your mid to lower back region. You
were seen by the Spine specialists who did not recommend any
acute treatments for this.
You were seen by the Physical therapists and being recommended
for discharge to a rehabilitation facility.
Followup Instructions:
*
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: THURSDAY [**2171-10-24**] at 3:15 PM
With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
*You will need a chest x-ray prior to this appointment. Please
go to [**Hospital1 7768**], [**Hospital Ward Name 517**] Clinical Center, [**Location (un) **]
Radiology 30 minutes prior to your appointment.
Department: ORTHOPEDICS
When: TUESDAY [**2171-10-29**] at 8:40 AM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: TUESDAY [**2171-10-29**] at 9:00 AM
With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2171-10-2**]
|
[
"E814.7",
"518.0",
"824.6",
"808.2",
"291.0",
"881.00",
"807.03",
"300.00",
"401.9",
"805.6",
"303.01",
"805.4",
"458.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.39",
"79.36",
"96.6",
"94.62"
] |
icd9pcs
|
[
[
[]
]
] |
8525, 8634
|
5326, 7987
|
335, 553
|
8980, 8980
|
2393, 5303
|
9903, 11025
|
1641, 1658
|
8044, 8502
|
8655, 8901
|
8013, 8021
|
9158, 9880
|
1673, 2374
|
266, 297
|
581, 1554
|
8922, 8959
|
8995, 9134
|
1576, 1602
|
1618, 1625
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,523
| 142,963
|
23406
|
Discharge summary
|
report
|
Admission Date: [**2127-5-29**] Discharge Date: [**2127-6-2**]
Date of Birth: [**2091-11-13**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor First Name 6716**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
35 yo female 1 week post partum, elective C-Section last week
POD #6 with a history of palpitations and questionable history
of MVP presents with dyspnea, palpitations, and lower extremity
swelling since yesterday. Her SOB is worse with lying flat and
improved with sitting up and was associated with increased lower
extremity swelling. She has intermittent chest pain R> L,
pleuritic in nature. She denies fevers, chills, nausea, or
vomiting. She denies increased/decreased urine output. Further
denies a foul smell to her urine.
The patient has a history of palpitations and reported MVP. She
has been followed by cardiologist Dr. [**First Name (STitle) 437**] since 5/[**2126**]. She
had a KOH event monitor in [**5-3**] which showed sinus rhythm/sinus
tachycardia at rates 74 to 142 BPM with 1 isolated APB. She had
an echo which showed no MVP in 5/[**2126**]. She had previously taken
metoprolol for the palpitations, but this was discontinued
during her pregnancy per recommendation by her obstetrician in
[**Country 3587**]. After discontinuing metoprolol, her palpitations
increased in frequency, particularly at night.
In the ED, initial vs were T 97.8 P 65 BP 128/77 RR 16 O2 sat:
100%. Echo was performed revealing moderate MR, TR, MVP, and
TVP, which are new from [**5-3**]. There was no evidence of right
heart strain. LENIs did not demonstrate DVT. CXRay was
unremarkable. Pt was seen by cardiology and postpartum OB/GYN.
There was concern for PE, but CTA could not be conducted because
of creatinine elevation to 2.4, baseline is 0.6. The patient
was placed on heparin without a bolus. Troponin x1 was
negative, but BNP was elevated to 6000s. EKG demonstrated sinus
brady @ 55, NA/NI, no ST changes. Cardiology was consulted and
felt presentation was unlikely to represent past partum
cardiomyopathy. She recieved 20 mg IV lasix and subsequently
produced 500 mL of urine. Vitals prior to transfer: 98, HR 68,
RR 24, BP 136/89, 100% on 2L
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies constipation, abdominal pain, diarrhea, dark
or bloody stools. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
OB Hx: G1P1
- [**2127-5-23**] pLTCS elective, uncomplicated. two 1cm L paratubal
cysts
fulgurated. 3535g, [**Doctor Last Name **].
Med Hx:
- Hx MVP and palpitations, [**2127-4-30**] ECHO done in third trimester
showed EF 55%, no MVP, nl LV size and function, nl pulmonary
artery systolic pressure. Holter at the time showed sinus
rhythm with tach 74-142 during events of palpitations.
[**Doctor First Name **] Hx:
- C/S as above
Social History:
Denies T/E/D, general surgeon in [**Country 3587**]. Husband at
bedside supportive.
Family History:
non-contributory
Physical Exam:
ADMISSION EXAM
General: Alert, oriented, no acute distress
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: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
BACK: + TTP of the R flank
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, 1+ edema R > L
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
Pertinent Results:
ADMISSION LABS
[**2127-5-29**] 11:25AM BLOOD WBC-11.6* RBC-3.28* Hgb-10.7* Hct-30.9*
MCV-94 MCH-32.7* MCHC-34.7 RDW-13.6 Plt Ct-437#
[**2127-5-29**] 11:25AM BLOOD Neuts-87.0* Lymphs-7.8* Monos-3.9 Eos-1.1
Baso-0.2
[**2127-5-29**] 11:25AM BLOOD PT-9.6 PTT-26.9 INR(PT)-0.9
[**2127-5-29**] 11:25AM BLOOD Glucose-80 UreaN-34* Creat-2.4*# Na-138
K-4.7 Cl-103 HCO3-22 AnGap-18
[**2127-5-29**] 11:25AM BLOOD ALT-50* AST-66* AlkPhos-151* TotBili-0.3
[**2127-5-29**] 11:25AM BLOOD Lipase-22
[**2127-5-29**] 11:25AM BLOOD proBNP-6348*
[**2127-5-29**] 11:25AM BLOOD cTropnT-<0.01
[**2127-5-29**] 11:25AM BLOOD UricAcd-7.3*
[**2127-5-29**] 05:20PM BLOOD TSH-2.0
.
URINE STUDIES
[**2127-5-29**] 11:25AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.005
[**2127-5-29**] 11:25AM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM
[**2127-5-29**] 11:25AM URINE RBC-2 WBC-12* Bacteri-FEW Yeast-NONE
Epi-7 TransE-1
[**2127-5-29**] 01:30PM URINE Hours-RANDOM Creat-39 Na-30 K-16 Cl-22
TotProt-18 Prot/Cr-0.5*
[**2127-5-31**] 02:00AM URINE 24Creat-1215 24Prot-540
.
MICROBIOLOGY
URINE CX- XXXX
.
IMAGING
TTE [**2127-5-28**]
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF 65%). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve leaflets are
mildly thickened. There is mild posterior leaflet mitral valve
prolapse. Moderate (2+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. Tricuspid valve
prolapse is present. Moderate [2+] tricuspid regurgitation is
seen. There is borderline pulmonary artery systolic
hypertension. Significant pulmonic regurgitation is seen. There
is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2127-4-30**], mitral valve prolapse and tricuspid valve
prolapse are now present, with moderate mitral regurgitation and
moderate tricuspid regurgitation.
.
CXR [**2127-5-29**]
Interval increase in size of the heart, likely related to recent
pregnancy.
No pulmonary edema or focal consolidation to suggest pneumonia.
Minimal right basilar atelectasis
.
LENIs [**2127-5-29**]
IMPRESSION: No findings of deep vein thrombosis in either the
right or left lower extremity.
.
Renal US [**2127-5-29**]
IMPRESSION: No evidence of hydronephrosis, stones, or masses.
Small left
pleural effusion.
.
PELVIC US [**2127-5-29**]
1. Enlarged postpartum uterus with a fibroid. Fluid within the
canal.
2. Unremarkable left ovary, right ovary not clearly visualized.
3. Small amount of complex free fluid within the cul-de-sac.
.
V/Q Scan [**2127-5-30**]
IMPRESSION: Low probability of PE.
.
RENAL US with Doppler [**2127-5-30**]
IMPRESSION: Normal study without evidence of renal vein
thrombus.
.
MRA Kidney [**2127-5-30**] (wet read)
No evidence of renal arterial or venous thrombosis, renal
infarction,
hydronephrosis or pyelonephritis. Heterogeneous perfusion of the
liver is
likely physiologic.
Brief Hospital Course:
35yo G1P1 POD#6 s/p uncomplicated primary LTCS, now with
sudden onset dyspnea, pleuritic R chest pain, and new R>L pedal
edema, and also found to have acute kidney injury of unclear
etiology.
1)SOB/Dyspnea/Swelling: On presentation patient appeared volume
overloaded on exam, but heart function is not compromised on
echo. Per cardiology presentation unlikely to represent a post
partum cardiomyopathy despite elevated BNP. CXR was without
consolidation suggestive of PNA. Given risk of clotting in the
post partum period presentation was concerning for PE,
especially in the setting of pleuritic chest pain. She is not a
candidate for CTA given elevated Cr. Therefore she was
empirically started on a heparin gtt. Given her complicated
clinical picture she was admitted to the ICU for overnight
monitoring. Lower extremity dopplers were negative for DVT. A
V/Q scan was negative for PE and heparin was discontinued.
Shortness of breath improved with diuresis and she was called
out to the floor. Once she arrived to the floor her symptoms
continued to improve and then resolve.
# [**Last Name (un) 13160**] Unclear etiology. Picture was consistent with prerenal
as pt endoreses good PO intake and FeNA was 2.5%. Renal US was
without hydronephrosis to suggest obstruction. She did have a
recent surgey however it is unlikely there was urteteral injury
during this procedure. She also reports NSAID use however
through this may have exacerbated renal disease it is unlikely
to be the etiology. 24 hour urine protein was normal making
neprhrotic syndrome/ a pre-eclampsia like picture unlikely. A
renal US with dopplers was done to r/o renal vein thrombosis
(higher risk in the post partum period) which was normal. Given
her severe flank pain a MRA was done to r/o thrombosis or
infarction and was also normal. Nephrology was consulted and fno
clear etiology could be idenitifed. We continued to follow her
clinically and with daily labs. Her creatinine peaked at 2.6 but
began to trend down and was 1.6 on the day of discharge.
# Dispo: After initial 1 day ICU stay she was called out to the
post-partum floor. Her clinical status continued to improve as
above. By hospital day 5 her shortness of breath had resolved,
she had diuresed and her edema was improved, and her kidney
function was trending back towards normal. She continued to
tolerate a regular diet, ambulate, void spontaneously and
control her pain with oral pain medications. She was discharged
from the hospital on hospital day 5 in good condition with
follow-up.
Medications on Admission:
- Motrin and Percocet PRN postop, no more than prescribed
- Colace PRN
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
2. 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*
3. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
4. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
Disp:*24 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
s/p acute kidney injury, recovering
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
NO ibuprofen/Motrin/Advil, NO naproxen/Aleve
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 60048**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 15653**]
Date/Time:[**2127-7-8**] 2:00
You do not need to come back for an OB-GYN appt before [**2127-6-28**]
Please call ([**Telephone/Fax (1) 10135**] for appt with Renal Medicine (kidney
doctor)
Please call ([**Telephone/Fax (1) 2037**] for appt with Cardiology (heart
doctor)
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 6721**]
Completed by:[**2127-6-6**]
|
[
"424.0",
"786.52",
"674.54",
"397.0",
"276.69",
"786.09",
"648.94",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10295, 10301
|
7149, 9691
|
338, 344
|
10381, 10381
|
3938, 7126
|
10601, 11163
|
3247, 3265
|
9812, 10272
|
10322, 10360
|
9717, 9789
|
10532, 10578
|
3280, 3919
|
2358, 2673
|
279, 300
|
372, 2339
|
10396, 10508
|
2695, 3130
|
3146, 3231
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,550
| 182,689
|
47271
|
Discharge summary
|
report
|
Admission Date: [**2167-6-25**] Discharge Date: [**2167-6-28**]
Date of Birth: [**2085-2-26**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2344**]
Chief Complaint:
Weakness, Slurred speech, RUE swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 12163**] is an 82 yo woman w/ h/o PE/DVT [**2164**] anticoagulated
on Coumadin, Alzheimer's dementia, breast ca, hyperlipidemia, RA
and colon ca s/p resection who p/w weakness, dysarthria, and a R
swollen arm. The family states that she first showed signs of
fatigue on [**6-22**], which they then attributed to her having
"stayed out late" over the weekend. Her daughter reports that
the pt also had a nosebleed around that time (last weekend).
When the fatigue/lethargy did not improve, they took her to her
PCP's office on [**6-23**], where she was started on Bactrim for ?UTI
(pos U/A with abundant wbc and nitrite pos, urine cx neg to
date). Yesterday in the evening before admission, she developed
dysarthria without language difficulty and was also noticed to
have bruising and swelling of her R arm, without history of
fall. This morning, her daughter noticed that she had a very
swollen tongue. On the way to the doctor's office, the daughter
had the impression that the patient was having difficulty
breathing and called an ambulance.
Upon arrival in the ED, her temp was 97.4, HR 72, BP 137/82, RR
18, O(2)Sat 98% on RA. She remained afebrile with stable vital
signs. She was started on 2L O2 within an hour of her arrival
but did not develop respiratory distress in the ED. Her most
notable lab was an INR of 20 (with hct 36). She received
Benadryl, famotidine, solumedrol 125, and Vitamin K 10 mg for
tongue swelling that ED staff thought was due to antibiotic
allergy. She received 1.5 L NS through her 2 peripheral IVs. She
was also seen by Neuro, who deemed her to have no clear language
deficits or weakness. Head CT/Neck showed no evidence of
intracranial bleed. RUE U/S showed no sign of clot.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain, recent change in diet. Denies headache, sinus tenderness,
rhinorrhea or congestion. Denies cough, shortness of breath.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
-Alzheimer's dementia (f/u at Cognitive Neurology, on namenda,
excelon. baseline she is not oriented to time, fluent, walks,
can get
dressed)
-breast ca in [**2148**] s/p lumpectomy and radiation
-hyperlipidimia
-RA
-glaucoma
-PE/ DVT in [**2164**] (per OMR but notes or imaging from that time
not available)
-PVD: carotid study ([**3-/2157**]) < 40% stenosis bilaterally. Left leg
claudication
-h/o rheumatic fever
-lumbar DJD
-stress incontinence s/p bladder suspension
-osteopenia
-h/o atrial tachycardia
-s/p hysterectomy
-s/p colon ca with low ant resection
-OSA w/ periodic limb movements of sleep
-constipation
Social History:
She is a widow and lives at home with her daughter [**Name (NI) **]. [**Name2 (NI) **]
other daughter [**Name (NI) 100066**] is her health care proxy. She also has a
third daughter and son.
Family History:
noncontributory
Physical Exam:
VS: T:98.3 HR:58, BP:118/59, RR:18 O2:100% RA.
Gen: pleasantly demented elderly woman lying in bed
HEENT: purple/black sublingual swelling causing slight upward
displacement of tongue. Pt able to breathe without difficulty.
Anisocoria (R~1mm, L~3mm)
CV: RRR, no M/R/G
Pulm: clear anteriorly
Ext: well perfused with 2+ pulses, large ecchymotic
discoloration of medial RUE
Pertinent Results:
Admission labs:
[**2167-6-25**] 10:00AM BLOOD WBC-14.3*# RBC-3.90* Hgb-12.2 Hct-36.0
MCV-92 MCH-31.3 MCHC-33.9 RDW-14.4 Plt Ct-252
[**2167-6-25**] 10:00AM BLOOD Neuts-88.6* Lymphs-8.0* Monos-3.1 Eos-0.1
Baso-0.2
[**2167-6-25**] 10:00AM BLOOD PT-150* PTT-127.8* INR(PT)-20.2*
[**2167-6-25**] 10:00AM BLOOD Plt Ct-252
[**2167-6-25**] 10:00AM BLOOD Glucose-181* UreaN-28* Creat-1.3* Na-134
K-5.7* Cl-102 HCO3-21* AnGap-17
[**2167-6-25**] 10:00AM BLOOD CK(CPK)-171
[**2167-6-25**] 10:00AM BLOOD Calcium-9.2 Phos-3.3 Mg-2.0
[**2167-6-25**] CT neck
1. No mass lesions seen within the nasopharynx or tongue. No
hematoma or fluid collection identified.
2. Heterogeneous multinodular thyroid. Correlation with thyroid
function
tests and, if clinically indicated, further evaluation with
ultrasound may be performed.
[**2167-6-25**] CT head
No evidence of acute intracranial process. Unchanged meningioma
adjacent to the left temporal lobe. If clinical concern for
acute ischemia
remains, MRI may be performed.
[**2167-6-25**] R UE U/S
1. Small amount of non-occlusive eccentrically located thrombus
within one of the distal right brachial veins, likely chronic.
2. Remaining right upper extremity veins are patent.
Brief Hospital Course:
Ms. [**Known lastname 12163**] is an 82 yo woman with a h/o Coumadin
anticoagulation and Alzheimer's who presented with weakness,
slurred speech, and RUE swelling and was found to have an INR
20, sublingual hematoma, and RUE hematoma.
# Increased INR: Her supratherapeutic INR was most likely due to
receiving 7.5mg instead of 2.5mg daily of Coumadin, per family
interview about home dosing of coumadin. It remained unclear for
how long the wrong dosing had been occurring. It was also
possible that interaction with Bactrim or other medication
(memantidine most recently new) or changes in diet may have
further complicated her coagulopathy. Interaction with Bactrim
seemed unlikely given time course of elevated INR (INR 2 wks ago
was supratherapeutic at 3.5.) In anticipation of the need for a
transfusion, she was typed and crossed for 2 units PRBCs on
admission. 4 units of FFP were given on arrival to the ICU, and
she had also received 10mg IV Vit K in ED. After these
therapies, her INR came down to 1.3. She was tranfered out of
the ICU on the day after admission, and she was restarted on her
home dose of coumadin. On hospital day 3 ([**2167-6-27**]), her INR had
increased to 2.2, which was greater than had been expected for a
single administration. It was decided that resuming coumadin
therapy should be addressed by her PCP on an outpatient basis.
On the day of discharge, her INR was 3.3. She recieved vitamin K
prior to discharge.
# Sublingual hematoma: She most likely had a tongue bite in the
setting of an INR of 20, leading to a bleed that turned into an
obstructive hematoma causing dysarthria. Her PO meds and
nutrition were held initially but then on morning after
admission, her hematoma had decreased significantly. Speech and
swallow consult was obtained and pureed foods and thin liquids
were advised. Her Hct initially fell from 36 to 24.5 on the day
of admission and remained stable throughout her hospitalization.
On day of discharge, her hct was 25.5.
.
# RUE hematoma: She had no sign of DVT, and his hematoma likely
resulted from a spontaneous bleed. Chronic nonocclusive clot on
U/S unlikely to be part of symptoms. This was monitored in the
ICU and she was advised to elevate her arm as she was able.
# h/o UTI: She was started on Bactrim [**6-23**]. ABX were held on
admission pending repeat u/a and urine culture. Urine culture
grew out E. Coli susceptible to Bactrim which was restarted for
a 7 day course on discharge.
.
# h/o atrial tachycardia: Initially continued 5 IV metoprolol Q
4 instead of home PO atenolol given NPO status. On transfer out
of the ICU, PO medication was resumed, and home regimen was
recommend on discharge.
.
# hyperlipidemia- All home PO meds initially held. Resumed
atorvastatin on transfer out of ICU and upon discharge
.
# glaucoma- continued home timolol eye drops.
.
# Alzheimer's dementia- Initially held namenda given NPO status.
All dementia medication resumed on discharge.
.
# Prophylaxis: supratherapeutic INR
# Access: peripherals
# Code: Full (discussed with patient's HCP)
Medications on Admission:
ALENDRONATE-VITAMIN D3 70 mg-2,800 weekly
AMOXICILLIN -2gm prior to dental work.
ATENOLOL 25 mg Q am and 12.5 Qpm.
ATORVASTATIN 10 mg daily
FOLIC ACID - 1 mg daily
MEMANTINE [NAMENDA] - 10 mg [**Hospital1 **]
RIVASTIGMINE [EXELON] - 9.5 mg/24 hour Patch 24 hr
SULFAMETHOXAZOLE-TRIMETHOPRIM - 800 mg-160 mg [**Hospital1 **] x10 days
TIMOLOL 0.5 % Drops daily
TRAZODONE 25-50 mg QHS prn sleep
WARFARIN 2.5 mg 6 days per week and 5mg once per week.
OMEPRAZOLE - 20 mg daily prn
Discharge Medications:
1. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
2. Exelon 9.5 mg/24 hour Patch 24 hr Sig: One (1) Transdermal
once a day.
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for sleep.
6. Atenolol 25 mg Tablet Sig: One (1) Tablet PO QAM (once a day
(in the morning)).
7. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO QPM (once a day (in
the evening)).
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. Namenda 10 mg Tablet Sig: One (1) Tablet PO twice a day.
10. Alendronate-Vitamin D3 70-2,800 mg-unit Tablet Sig: One (1)
Tablet PO once a week.
11. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 7 days.
Disp:*13 Tablet(s)* Refills:*0*
12. Amoxicillin 500 mg Tablet Sig: Four (4) Tablet PO prior to
dental work.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Sublingual Hematoma
Coagulaopathy
UTI
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital with a bleed under you tongue
that altered your speech and threatened your breathing. It was
determined that you were taking too much warfarin, which caused
a bleed under your tongue and in your right arm. Your warfarin
overdose was corrected in the intensive care unit and you were
carefully monitored as your bleeds resolved. You should take
your home medications as written in this discharge document and
keep your outpatient appointments.
.
We made the following changes to your medications:
STOPPED coumadin, Do not take this medication again until you
have discussed it with your PCP.
[**Name10 (NameIs) **] Bactrim for 7 days for a urinary tract infection. Main
side effect is potential allergic reactions with rash.
.
Please call Dr. [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) 2472**] at [**Telephone/Fax (1) 133**] on Tuesday
[**2167-6-30**] to make an appointment for follow-up within the
next week.
Followup Instructions:
Please call Dr. [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) 2472**] [**Telephone/Fax (1) 133**] on Tuesday [**6-30**] [**2166**] to make an appointment.
You will have a visiting nurse come to your house twice a week
to check your anticoagulation level. You will also get home
physical therapy.
|
[
"714.0",
"427.31",
"443.9",
"564.00",
"V12.51",
"272.4",
"E934.2",
"E928.3",
"784.51",
"V10.3",
"V10.05",
"285.1",
"331.0",
"294.10",
"365.9",
"920",
"327.23",
"041.4",
"599.0",
"729.92",
"721.3"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9764, 9821
|
5128, 8189
|
354, 361
|
9902, 9902
|
3893, 3893
|
11077, 11397
|
3469, 3487
|
8715, 9741
|
9842, 9881
|
8215, 8692
|
10087, 10588
|
3502, 3874
|
10617, 11054
|
2145, 2603
|
276, 316
|
389, 2126
|
3910, 5105
|
9917, 10063
|
2625, 3245
|
3261, 3453
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,413
| 140,215
|
11382
|
Discharge summary
|
report
|
Admission Date: [**2173-3-9**] Discharge Date: [**2173-3-17**]
Date of Birth: [**2117-3-1**] Sex: M
Service: GEN [**Doctor First Name 147**]
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 36427**] is a 55 year old
gentleman with a complicated past medical history, who
initially presented to this hospital with obstructive
jaundice and escalating diabetes mellitus in the Fall of
[**2172**]. He was operated on and underwent a pancreatic
duodenectomy which was complicated by a disruption of the
portal vein needing portal vein reconstruction with a Dacron
graft. T-tube was placed in his biliary tract at that time.
He is now admitted for an elective hepaticojejunostomy
reconstruction. He has been transferred to the hospital from
the rehabilitation facility.
PAST MEDICAL HISTORY:
1. Diabetes mellitus.
2. Hypertension.
3. Postoperative atrial fibrillation.
4. Postoperative pulmonary embolism status post IVC Filter.
5. Coronary artery disease status post percutaneous
transluminal coronary angioplasty with stent to left anterior
descending.
PAST SURGICAL HISTORY:
1. Whipple.
2. Percutaneous transluminal coronary angioplasty with stent
to left anterior descending.
ALLERGIES: None known.
MEDICATIONS ON ADMISSION:
1. Plavix discontinued on [**2173-3-3**].
2. Paxil 20 mg q. day.
3. Prevacid 30 mg p.o. q. day.
4. Multivitamins q. day.
5. Insulin sliding scale.
6. Enteric coated aspirin 325 mg p.o. q. day.
7. Protonix 40 mg q. day.
8. Megace 800 mg q. day.
9. Sodium chloride 1 gram twice a day.
10. Ativan p.r.n.
11. Percocet p.r.n.
12. Reglan 10 mg three times a day.
13. Tube feeds.
14. Trazodone 100 mg q. h.s.
15. Citracal.
16. Enalapril 5 mg twice a day discontinued on [**2173-3-8**].
17. Lopressor 25 mg twice a day held for systolic less than
100.
HOSPITAL COURSE: The patient was electively admitted as a
transfer from a rehabilitation facility for elective surgery
on [**2173-3-10**]. A preoperative Cardiology consultation was
obtained at the time, which noted a Persantine thallium study
of [**2173-1-29**], with an ejection fraction of 44%, severe fixed
inferior defect, reversible lateral apical defect.
Recommendation was to hold his Enalapril due to his relative
hypotension, beta blocker perioperatively.
The patient underwent a hepaticojejunostomy on [**2173-3-10**],
with extensive lysis of adhesions. He tolerated the
procedure reasonably well with no hemodynamic or pulmonary
complications. He was admitted to the Intensive Care Unit
for postoperative monitoring. In the Intensive Care Unit, he
was slightly hypotensive. He was treated with volume and a
Neo-Synephrine infusion. He continued to be followed by
Cardiology who agreed with the volume repletion. The
Neo-Synephrine was weaned off by postoperative day one. He
had an epidural for analgesia which was switched over to a
PCA on postoperative day two. He also received transfusion
of two units of packed cells. At this point, his blood sugar
was high and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consultation was obtained.
Per their recommendation, insulin Glargine was started q.
h.s. He continued to be stable and was transferred out to
the regular floor on postoperative day two. He was started
on p.o. sips on postoperative day three which he tolerated
well. His subsequently postoperative course was routine and
he was advanced to a regular diet as he tolerated. His blood
sugars were well controlled. He underwent EP Study on
[**2173-3-16**], which showed a patent hepaticojejunostomy with no
leak, and it was freely emptying.
He was also seen by Physical Therapy. He is now ready for
discharge, having tolerated a regular diet and being able to
ambulate with support. He is going home with his T-tube and
his J-tube, with [**Hospital6 407**] services for home
care.
DISCHARGE INSTRUCTIONS:
1. Follow-up with Dr. [**Last Name (STitle) 468**] on [**3-26**].
2. [**Hospital6 407**] services for T-tube checks and
wound checks q. day.
MEDICATIONS ON DISCHARGE:
1. Insulin Glargine, 8 units h.s.
2. Lisinopril 5 mg p.o. q. day.
3. Reglan 10 mg p.o. three times a day.
4. Lopressor 12.5 mg p.o. twice a day.
5. Multivitamins one capsule q. day.
6. Protonix 40 mg p.o. q. day.
7. Trazodone 100 mg p.o. h.s.
8. Dilaudid 2 to 4 mg p.o. q. three to four hours p.r.n.
9. Ativan 0.5 mg p.o. h.s.
10. Tylenol 650 p.o. p.r.n.
11. Paxil 20 mg p.o. q. day.
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 4984**]
Dictated By:[**Last Name (NamePattern1) 2209**]
MEDQUIST36
D: [**2173-3-17**] 13:24
T: [**2173-3-17**] 14:31
JOB#: [**Job Number 36428**]
|
[
"401.9",
"414.01",
"576.2",
"V55.4",
"568.0",
"250.00",
"458.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.91",
"54.59",
"51.37"
] |
icd9pcs
|
[
[
[]
]
] |
4047, 4701
|
1258, 1812
|
1830, 3853
|
3877, 4021
|
1101, 1232
|
187, 787
|
809, 1078
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,052
| 181,391
|
18035
|
Discharge summary
|
report
|
Admission Date: [**2190-10-6**] Discharge Date: [**2190-11-1**]
Date of Birth: [**2157-7-10**] Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Fever, body aches
Major Surgical or Invasive Procedure:
Bronchoscopy [**2190-10-8**]
History of Present Illness:
33-year-old female with a history of end-stage renal disease
secondary to
DM, severe gastroparesis and autonomic neuropathy, status post
living unrelated renal transplant in [**11/2189**], and status post
pancreas transplant on [**2190-9-26**] with reoperation for
intraabdominal hemorrhage. She was doing well at home until
[**2190-10-5**] when she experienced increased fatigue with chills and
fever to 102 on [**2190-10-6**]. She denied any increased nausea/vomit
(patient usually
vomits on a daily basis secondary to gastroparesis) or any
changes in her appetite.
Past Medical History:
Status post Pancreas transplant [**2190-9-26**]
Status post Living unrelated renal transplant [**11/2189**]
End-stage renal disease secondary to Type 1 diabetes mellitus
Gastroparesis
Autonomic neuropathy
Diabetic retinopathy and peripheral neuropathy
Osteopenia
Depression
Social History:
Married, no children, denies alcohol, IVDU and tobacco
Family History:
Non-contributory
Physical Exam:
VS: 101, 120, 120/80
Card: Tachy
Lungs: CTA bilaterally
Abd: Soft, NT, mildly distended, incision clean, staples in
place, no drainage
Extr: Warm
Pertinent Results:
[**2190-10-6**] 08:25PM GLUCOSE-107* UREA N-31* CREAT-1.3* SODIUM-138
POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-27 ANION GAP-14
ALT(SGPT)-23 AST(SGOT)-25 ALK PHOS-79 AMYLASE-34 TOT BILI-0.3
LIPASE-29 ALBUMIN-3.1*
WBC-15.1*# RBC-3.28* HGB-9.7* HCT-29.2* MCV-89 MCH-29.4
MCHC-33.0 RDW-16.1*
NEUTS-98.4* BANDS-0 LYMPHS-0.6* MONOS-0.5* EOS-0.4 BASOS-0.1
HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-NORMAL
MICROCYT-NORMAL POLYCHROM-NORMAL PLT SMR-NORMAL PLT COUNT-388#
PT-16.8* PTT-39.3* INR(PT)-1.5*
URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010
BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG RBC-[**2-7**]* WBC-1
BACTERIA-RARE YEAST-NONE EPI-1
On Discharge:
[**2190-11-1**] 07:00AM BLOOD WBC-14.2* RBC-3.33* Hgb-9.9* Hct-29.0*
MCV-87 MCH-29.9 MCHC-34.2 RDW-16.5* Plt Ct-501*
Glucose-85 UreaN-26* Creat-1.3* Na-140 K-3.2 Cl-103 HCO3-27
AnGap-13
ALT-11 AST-15 AlkPhos-85 Amylase-83 repeat 60 Lipase- 132,
repeat 71 TotBili-0.3
Brief Hospital Course:
33 y/o female s/p PAK on [**2190-9-23**] doing well at home but now
presents with fever to 102 on day of admission. Had chills the
previous day and decreased energy. Patient was started on broad
spectrum antibiotics. Chest xray on [**10-6**] shaowed no acute
cardiopulmonary process. CTA on [**10-7**] shows transplant pancreas
in right iliac fossa with mild surrounding edema. There is
external compression of donor splenic/portal vein, which remains
patent, and thrombus in the distal SMV. Patent arterial Y graft
with some thrombus in the distal donor SMA that appears beyond
branches that supply the pancreas, though this is uncertain.
Transplant kidney in left iliac fossa with mild calyectasis.
On [**10-9**] patient had fever to 104 and was having a worsening
respiratory status with hypoxemia. Patient was transferred to
the ICU where she underwent a bronchoscopy and elective
intubation. Chest xray on that day post intubation showed
worsened diffuse confluent opacities consistent with worsened
pulmonary edema, most likely with an infectious component(but
could be pulmonary hemorrhage or infection). Bronchoalveolar
lavage cultures were negative for Legionella, p carinii. Fungal
elements negative by KOH and acid fast bacilli (by smear,
culture remains pending)
Blood cultures taken throughout the hospitalization remained
negative. Patient also tested for cryptococcal antibodies,
toxoplasmosis, CMV which were all negative.
She did have diarrhea intermittently throughout the course, C
diff negative x 4, as well as stool culture which was negative
for pathogens.
7 urine cultures were performed throughout the hospitalization
which were all negative. Patient did have some urinary retention
but did not wish to have Foley catheter. Encouraged to urinate
on a scheduled basis.
Patients' temperature ranged from 100.8-104.1 with some element
of fever up until 3 days prior to discharge when it was Tmax of
98.9. Patient was switched from IV antibiotics, Vanco (20 days)
and Meropenem (10 days) to PO Fluconazole and Augmentin on [**10-25**], which will be continued for one week post hospitalization.
Patient had a mild bump in amylase/lipase on [**11-1**], however
repeat labwork later in the day was much improved. Blood sugars
77-144 throughout the entire hospitalization.
U/S of pancreas on [**11-1**] showed that the pancreas was well seen
on ultrasound and shows no evidence of edema. No fluid or
collections around the pancreas are seen.
There is normal arterial and venous blood flow identified in all
areas.
Patient to discharge home with labwork on [**11-4**] and followup
visit with Dr [**Last Name (STitle) 816**] next Monday [**11-8**].
Medications on Admission:
MMF 1", FK 2", [**Male First Name (un) **] 450", lopressor 12.5", domperidone 20",
prozac 60, desipramine 100, KCl 40, nystatin s&s"", neurontin
300", ASA 81, lasix 20
Discharge Medications:
1. Normal Saline
Normal Saline 0.9%
1000 cc bag
Please infuse up to 3 bags daily via portacath as needed for
fluid management.
Disp # 30
Refills: 2
2. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1)
ML Intravenous DAILY (Daily) as needed: for portacath.
Disp:*30 syringes* Refills:*2*
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
6. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*0*
7. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
8. Fluoxetine 20 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
10. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
11. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 1 weeks.
Disp:*7 Tablet(s)* Refills:*0*
12. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO TID (3 times a day) for 1 weeks.
Disp:*21 Tablet(s)* Refills:*0*
13. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
14. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day).
15. Outpatient Lab Work
Labs every week for cbc, chem 7, calcium, phos, ast, t.bili,
albumin, amylase, lipase, and trough prograf level. fax to
[**Telephone/Fax (1) 697**] attn: [**Name6 (MD) 5036**] [**Name8 (MD) 5039**], RN
Discharge Disposition:
Home With Service
Facility:
[**Hospital 5065**] Healthcare
Discharge Diagnosis:
Fever of unknown origin s/p pancreas transplant [**2190-9-26**]
pneumonia
Discharge Condition:
Good
Discharge Instructions:
Please take your medications as directed. Please call/return to
[**Hospital1 18**] if you experience persistent fevers (Temp>101), chills,
nausea/vomiting,inability to keep medications down, abdominal
pain,glucoses 200 or greater, or dizziness
Labs every Monday & Thursday for cbc, chem 7, calcium, phos,
ast, t.bili, albumin, amylase, lipase, and trough prograf level.
fax to [**Telephone/Fax (1) 697**] attn: [**Name6 (MD) 5036**] [**Name8 (MD) 5039**], RN
Continue one more week of augmentin and fluconazole
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2190-11-8**]
8:30
Completed by:[**2190-11-1**]
|
[
"250.61",
"V42.0",
"288.60",
"724.2",
"V58.65",
"733.90",
"799.02",
"787.91",
"780.6",
"536.3",
"486",
"V42.83"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.71",
"99.04",
"96.04",
"33.24",
"38.93",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
7097, 7158
|
2543, 5209
|
297, 328
|
7276, 7283
|
1513, 2237
|
7844, 8028
|
1314, 1332
|
5428, 7074
|
7179, 7255
|
5235, 5405
|
7307, 7821
|
1347, 1494
|
2251, 2520
|
240, 259
|
356, 928
|
950, 1226
|
1242, 1298
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,112
| 120,967
|
35563
|
Discharge summary
|
report
|
Admission Date: [**2154-5-23**] Discharge Date: [**2154-6-12**]
Date of Birth: [**2075-11-14**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Vicodin
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
Aortic Valve replacement(25mm porcine) & coronary artery bypass
grafts x2(LIMA-LAD,Basilic vein-OM)
History of Present Illness:
This 78 year-old female with critical aortic stenosis([**Location (un) 109**] 0.7,
peak gradient 42mm)and 3 vessel coronary disease is awaiting
surgucal intervention.She was discharged [**2154-5-9**] to rehab with
a wound vac on her right transmetatarsal site and vancomycin PO
for C. difficile. At rehab her initial weight was 203lbs. On
[**5-13**] she was noted to be orthostatic, was given a fluid bolus
and lasix was stopped. At that time her creatinine was also
noted to be rising (1.8 to 2.2). She has been of of Lasix since
that time. Given her poor oral intake and diarrhea she was
started on maintenance fluids on [**5-20**]. The morning of admission
she was found to be hypotensive (SBP 60s; baseline 90-110s) with
bibasilar crackles. She was given 1250cc fluid over 3 hours. As
BP was not fluid responsive she was started on dopamine and
transferred to [**Hospital1 18**].
On arrival to [**Hospital1 18**] she reported wheezing for 1-2 days and
denied nocyurnal dyspnea. She admitted to orthopnea, reports a
nonproductive cough, denies fever, chills.
Past Medical History:
chronic systolic heart failure
Critical Aortic stenosis
coronary artery disease
hypothyroidism
chronic renal insufficiency
peripheral [**Hospital1 1106**] disease
hyperlipidemia
MRSA & VRE carrier
Insulin dependent diabetes mellitus
Depression
s/p Right tramsmetatarsal amputation and revisions
s/p left femoral-popliteal bypass
s/p right femoral-popliteal bypass
s/p thyroidectomy
s/p ablation therapy for supraventricular tachycardia
anemia of chronic disease
prior C. difficile
Social History:
Quit smoking 40 years ago. Smoked 2 PPD for 20 years.
Denies alcohol or illicit drug use.
Prior to recent hospitalizations/rehab stays, lived alone. Was
independent with all activities.
Former cafeteria worker, now retired.
Family History:
Daughter with MI at age 45. Both parents passed with cancer,
unknown type.
Physical Exam:
Admission:
97.5; 105/63; 109; 19; 92 -> 97%RA
General - Resting comfortably in bed, no acute distress
HEENT - Sclera anicteric, pupils equal, MMM, oropharynx with
white exudate
Neck - Supple, JVP elevated to angle of mandible when HOB 30
degrees
Pulm - Diffuse expiratory wheezes; coarse breath sounds upper
lung fields, bibasilar crackles (few)
CV - RRR, III/VI holosystolic murmur heard at all auscultation
sites with radiation to carotids, no S2 appreciated
Abdomen - Obese, normo-active bowel sounds; soft, non-tender
Ext - Warm, trace lower extremity edema to knees bilaterally;
bilateral distal metatarsal amputations, right with new skin
dressing; right thigh with skin graft site; radial pulses 2+
Neuro - AOx3; EOMI
Pertinent Results:
[**2154-6-12**] 06:38AM BLOOD WBC-6.6 RBC-3.40* Hgb-10.4* Hct-31.1*
MCV-92 MCH-30.5 MCHC-33.3 RDW-17.1* Plt Ct-251
[**2154-5-23**] 02:30PM BLOOD WBC-5.4 RBC-3.49* Hgb-10.9* Hct-34.3*
MCV-98 MCH-31.1 MCHC-31.7 RDW-15.7* Plt Ct-297
[**2154-6-12**] 06:38AM BLOOD Plt Ct-251
[**2154-5-23**] 02:30PM BLOOD Plt Ct-297
[**2154-5-23**] 02:30PM BLOOD PT-16.4* PTT-30.4 INR(PT)-1.5*
[**2154-6-5**] 03:56PM BLOOD Fibrino-101*
[**2154-6-12**] 06:38AM BLOOD Glucose-121* UreaN-12 Creat-0.8 Na-139
K-4.3 Cl-98 HCO3-36* AnGap-9
[**2154-5-23**] 02:30PM BLOOD Glucose-146* UreaN-36* Creat-2.2* Na-139
K-4.0 Cl-103 HCO3-23 AnGap-17
[**2154-6-9**] 01:33PM BLOOD ALT-36 AST-51* LD(LDH)-309* AlkPhos-55
Amylase-15 TotBili-1.0
[**2154-5-23**] 02:30PM BLOOD CK(CPK)-22*
[**2154-6-9**] 01:33PM BLOOD Lipase-19
[**2154-5-29**] 09:25AM BLOOD proBNP-[**Numeric Identifier 80953**]*
[**2154-5-24**] 06:29AM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2154-6-12**] 06:38AM BLOOD Calcium-8.4 Phos-3.0 Mg-1.7
[**2154-6-10**] 12:58PM BLOOD TSH-18*
[**2154-6-10**] 12:58PM BLOOD T4-5.3 T3-48* calcTBG-0.95 TUptake-1.05
T4Index-5.6 Free T4-1.3
[**2154-6-10**] 06:05AM BLOOD Cortsol-35.7*
[**2154-6-12**] 10:54AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.006
[**2154-6-12**] 10:54AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname 10588**] [**Hospital1 18**] [**Numeric Identifier 80950**]Portable TTE
(Complete) Done [**2154-6-10**] at 3:40:54 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**] C.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2075-11-14**]
Age (years): 78 F Hgt (in): 67
BP (mm Hg): 94/58 Wgt (lb): 200
HR (bpm): 94 BSA (m2): 2.02 m2
Indication: AVR. Coronary artery disease. Left ventricular
function.
ICD-9 Codes: 414.8, 424.1, 424.0, 424.2
Test Information
Date/Time: [**2154-6-10**] at 15:40 Interpret MD: [**Name6 (MD) **] [**Name8 (MD) 4082**], MD
Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**First Name4 (NamePattern1) 1022**] [**Last Name (NamePattern1) **],
RDCS
Doppler: Full Doppler and color Doppler Test Location: [**Location 13333**]/[**Hospital Ward Name 121**] 6
Contrast: None Tech Quality: Suboptimal
Tape #: 2009W016-0:59 Machine: Vivid [**7-3**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 3.0 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *6.2 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *5.7 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.6 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 4.7 cm
Left Ventricle - Fractional Shortening: *0.16 >= 0.29
Left Ventricle - Ejection Fraction: 25% >= 55%
Left Ventricle - Lateral Peak E': 0.09 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.02 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': *20 < 15
Aorta - Sinus Level: 3.1 cm <= 3.6 cm
Aorta - Ascending: 3.0 cm <= 3.4 cm
Aorta - Descending Thoracic: 1.9 cm <= 2.5 cm
Aortic Valve - Peak Velocity: 1.9 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: 15 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 9 mm Hg
Mitral Valve - E Wave: 1.1 m/sec
Mitral Valve - A Wave: 0.9 m/sec
Mitral Valve - E/A ratio: 1.22
Mitral Valve - E Wave deceleration time: 165 ms 140-250 ms
Findings
This study was compared to the prior study of [**2154-3-4**].
LEFT ATRIUM: Elongated LA.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size.
Moderate-severe global left ventricular hypokinesis. No LV
mass/thrombus. TDI E/e' >15, suggesting PCWP>18mmHg. No resting
LVOT gradient.
RIGHT VENTRICLE: Mildly dilated RV cavity. Moderate global RV
free wall hypokinesis.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Normal descending aorta diameter.
AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). AVR
well seated, normal leaflet/disc motion and transvalvular
gradients. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
mitral annular calcification. Mild thickening of mitral valve
chordae. Calcified tips of papillary muscles. Mild (1+) MR. [Due
to acoustic shadowing, the severity of MR may be significantly
UNDERestimated.]
TRICUSPID VALVE: Indeterminate PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor parasternal
views. Suboptimal image quality - poor subcostal views.
Conclusions
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is
moderate to severe global left ventricular hypokinesis (LVEF =
25 %). No masses or thrombi are seen in the left ventricle.
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP>18mmHg). The right ventricular cavity is
mildly dilated with moderate global free wall hypokinesis. A
bioprosthetic aortic valve prosthesis is present. The aortic
valve prosthesis appears well seated, with normal leaflet motion
and transvalvular gradients. No 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.]
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2154-3-4**], the
aortic valve has been replaced with a well functioning
bioprosthesis. Left ventricular systolic function is similar.
CLINICAL IMPLICATIONS:
Based on [**2151**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis IS recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
Electronically signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2154-6-10**] 19:36
Brief Hospital Course:
Following admission she was diuresed and a fluid restriction was
instituted. Her heart failure and renal failure was
stabilized. Her hemodynamics improved and she was weaned off
pressors. She continued to improve and was ready for surgery on
[**2154-6-5**]. She was taken to the operating room and underwent
aortic valve replacement and coronary artery bypass graft
surgery. See operative note for details. She received
vancomycin for perioperative anitbiotics due to being in
hospital prior to surgery. She was transferred to the intensive
care unit for hemodynamic management on multiple pressors and
inotropes. She was slowly weaned off her drips and post
operative day one she was extubated. Beta blockers and digoxin
were started for rate control. Transferred to the floor on post
operative day 3, and physical therapy worked with him on
strength and mobility. Gynecology was consulted and ruled out
current recto-vaginal fistula, and pessary was removed, cleaned
and replaced. She was restarted on home diabetic medications and
had episode of hypoglycemia without any mental status changes
and treated with intravenous dextrose including drip and oral
agents and insulin stopped [**First Name8 (NamePattern2) **] [**Last Name (un) **] recommendations. [**Last Name (un) **]
surgery saw her for foot wound that continued with VAC dressing
and cleared her to weight bear on foot as tolerated. She
continued to progress and was ready for discharge to rehab ([**Hospital1 **]) on post operative day 7.
Sternal incision healing no drainage no erythema mammary support
on
Left upper arm with ecchymosis resolving no drainage no
erythema, staples intact
Right foot with VAC dressing intact
weight discharge 93.8 kg admission 88 kg
Edema trace
Medications on Admission:
MEDICATIONS AT REHAB FACILITY:
[**Hospital1 **] 81 mg po qd
Celexa 10 mg po qd
[**Hospital1 **] 75mg po qd
Fenofibrate microniyeld 48 mg po qd
FeSO4 325 mg po qd
Pepcid 20 mg po bid
MVI po qd
Simvastatin 80 mg po qd
Levothyroxine 150 mg po qd
Heparin 5000 units sc tid
Colon health two tabs po bid
Metoprolol 12.5 mg po bid, held last two doses
Lactobacillus 2 pks po bid
Humalog SSI
Januvia 50 mg po qd
Zofran 4 mg iv q6h prn n/v
Lopressor iv q4h prn hr>120
Trazodone 25 mg po qhs prn sleep
Colace 100 mg po bid prn const
Senna 2 tabs po qhs prn const.
Tylenol 650 mg po q6h prn pain
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Fenofibrate Micronized 48 mg Tablet Sig: One (1) Tablet PO
daily ().
6. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. Furosemide 80 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for sleep.
11. Acetaminophen-Codeine 300-30 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
12. Pioglitazone 15 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
14. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
17. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO AC .
18. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
19. Outpatient Lab Work
Please check SMA7 with magnesium [**Hospital1 **] weekly
Digoxin level in 1 week
20. EKG
Please obtain EKG in 1 week - monitor rhythm
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] TCU - [**Location (un) 701**]
Discharge Diagnosis:
acute on chronic systolic heart failure
Aortic stenosis s/p AVR
coronary artery disease s/p cabg
hypothyroidism
chronic renal insufficiency
peripheral [**Location (un) 1106**] disease
hyperlipidemia
MRSA carrier
diabetes mellitus
Depression
s/p Right tramsmetatarsal amputation and revisions
s/p left femoral-popliteal bypass
s/p right femoral-popliteal bypass
s/p thyroidectomy
s/p ablation therapy for supraventricular tachycardia
anemia of chronic disease
Discharge Condition:
good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Right foot wound - VAC dressing change every three days and
follow up with [**Telephone/Fax (1) 1106**] surgery Dr [**Last Name (STitle) 3407**]
Followup Instructions:
Please call to schedule all appointments
Dr. [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 12550**])
Dr. [**First Name (STitle) 80954**] B. Dharamporiya after discharge from rehab
([**Telephone/Fax (1) 80955**])
Dr. [**Last Name (STitle) 911**] in 2 weeks
Dr. [**Last Name (STitle) **] in 3 weeks
Please follow up with outpatient GYN in [**2-27**] months for cleaning
and
replacement of Pessary
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2154-7-2**] 11:00
Completed by:[**2154-6-12**]
|
[
"414.2",
"V02.9",
"V12.04",
"311",
"414.01",
"787.91",
"112.0",
"285.29",
"585.9",
"V02.54",
"V49.72",
"V15.82",
"424.1",
"707.15",
"440.4",
"428.0",
"250.80",
"272.4",
"428.23",
"584.9",
"440.23",
"244.0",
"V58.67"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"35.21",
"39.61",
"36.11",
"93.57",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
13486, 13562
|
9480, 11237
|
294, 396
|
14065, 14072
|
3090, 9020
|
14728, 15322
|
2254, 2330
|
11873, 13463
|
13583, 14044
|
11263, 11850
|
14096, 14705
|
2345, 3071
|
9043, 9457
|
235, 256
|
424, 1493
|
1515, 1997
|
2013, 2238
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,768
| 123,438
|
33437
|
Discharge summary
|
report
|
Admission Date: [**2160-2-3**] [**Month/Day/Year **] Date: [**2160-2-6**]
Date of Birth: [**2115-12-22**] Sex: M
Service: SURGERY
Allergies:
Caffeine
Attending:[**First Name3 (LF) 974**]
Chief Complaint:
status post assault
Major Surgical or Invasive Procedure:
Chest tube placement [**2-3**]
ORIF right ankle [**2-4**]
History of Present Illness:
This is a 46 year old male status post assault, with multiple
posterior stab wounds to back and flanks, lacerations to hands
and an ankle fracture. His injuries as identified upon
presentation to the emergency department are:
Past Medical History:
prior right elbow surgery
Social History:
alcohol use, h/o alcohol abuse, prior recreational drug use
Family History:
NC
Physical Exam:
Exam on Admission:
Tc 99.1 HR 85 BP 138/71 RR 16 Sats 100% NRB
GEN: A&0x3, appears intoxicated
HEENT: PERRLA, EOMI, no step offs or deformities CTLS spine
CV: RRR
Resp: R lung fields CTA, L lung with crackles L base, otherwise
clear
Chest: palpable sq emphysema L axilla/chest wall.
Back: Multiple (>4) puncture/laceration wounds c/w stab wounds.
Most significant appear to be 2 above R iliac crest, 2 above L
iliac crest and in the L axillary line approximately t12 level.
each are 1-2cm in length.
Abd/Pelvis: stable. nontender, nondistended
GU: nl. good rectal tone, no gross blood.
Extremities: Multiple lacerations to the dorsal (and volar)
bilateral hands and fingers, appearing superficial, with normal
neurovascular and tendon function. There is a R ankle deformity
c/w fracture, palpaple distal radial and dorsalis pedis pulses
bilaterally.
Neuro: GCS 15, following commands, moving all 4 extremities.
Exam on [**Month/Year (2) **]:
Tc 98.3 HR 79 BP 117/70 RR 18 Sats 97% RA
GEN: A&0X3, NAD
HEENT- normal
CV: RRR
Resp: Lungs CTAB all fields
Torso: wounds as noted above are hemostatic and well-healing
without evidence of infection. The chest-tube site is covered
with an occlusive dressing and the dressing is clean, dry and
intact.
Extremities: the wounds are sutured. The R ankle is in a
post-operative boot.
Neuro: normal
Pertinent Results:
IMAGING:
[**2160-2-2**] Initial CXR: Left subcutaneous emphysema and
pneumomediastinum. The previously noted pneumothorax of the left
lung apex is not visualized on this radiograph. The study is
somewhat limited by the trauma board.
.
[**2160-2-2**] CXR post chest tube: Interval placement of the left
chest tube with tip at apex. The remainder of the findings
appears unchanged compared to the study performed 20 minutes
ago.
.
[**2160-2-2**] CT Head: No acute intracranial pathology, including no
ICH.
.
[**2160-2-2**] CT CSpine: No fracture or malalignment is noted.
Pneumomediastinum and subcutaneous emphysema extend along the
neck soft tissue spaces towards the skull base.
.
[**2160-2-3**] CT Abd/Pelvis:
1. Splenic laceration in the lower pole, with no evidence
for perisplenic hematoma. Subcutaneous emphysema in the lateral
aspect of the left upper quadrant as well as in the lateral
aspect of the left lower hemithorax, with no evidence for
pneumothorax on the provided images.
2. Retroperitoneal hematoma posterolateral to the right
psoas muscle associated with retroperitoneal air. No evidence
for renal injury.
3. Trace of free fluid within the pelvis. The colon appears
intact.
.
[**2160-2-3**] CT abd/pelvis: Rectal contrast is evident within the
entire colon, which appears intact with no evidence of contrast
spillage into the abdomen to suggest colonic injury. There is no
evidence of free air. There is no significant change compared to
previous study from three hours ago.
.
[**2160-2-3**] R Ankle: Comminuted fractures of the distal fibula and
tibia with involvement of the tibial plafond. There is a
suspected talar fracture. Further characterization with CT is
suggested. It is unclear if there is mid foot involvement, as
fine osseous detail is obscured by overlying splint.
.
[**2160-2-3**] Bilat Hand XR:1. Laceration to bilateral hands as
described above. No radiopaque foreign body in the left hand. No
fractures. 2. 1 mm radiopaque foreign body at the distal dorsal
tip of the third right digit.
.
[**2160-2-4**] CXR: The tip of the left-sided chest tube is slightly
more caudal than before. There is clear regression of the air
collection in the left-sided soft tissues. At the very apex of
the left hemithorax, a subtle pneumothorax of 2 to 3 mm in width
can be seen. No signs of tension. Otherwise, no relevant
radiographic change.
.
[**2160-2-5**] CXR 4 hours s/p chest tube to water seal: 1. Tiny
residual left apical pneumothorax. 2. Stable left chest
drainage catheter. 3.Minimal bilateral pleural effusion
.
[**2160-2-5**] CXR 4 hours s/p Chest Tube Removal: Minimal residual
apical pneumothorax without signs of tension in the left
hemithorax. Minimal residual soft tissue air collection after
chest tube removal.
[**2160-2-3**] 06:07PM HCT-29.4*
[**2160-2-3**] 10:52AM WBC-8.4 RBC-3.41* HGB-11.3* HCT-33.1* MCV-97
MCH-33.3* MCHC-34.3 RDW-12.7
[**2160-2-3**] 10:52AM NEUTS-88.0* BANDS-0 LYMPHS-7.5* MONOS-3.7
EOS-0.7 BASOS-0.1
[**2160-2-3**] 10:52AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2160-2-3**] 10:52AM PLT SMR-NORMAL PLT COUNT-188
[**2160-2-3**] 05:42AM HCT-31.6*
[**2160-2-3**] 02:55AM GLUCOSE-87 UREA N-9 CREAT-0.9 SODIUM-140
POTASSIUM-3.8 CHLORIDE-106 TOTAL CO2-24 ANION GAP-14
[**2160-2-3**] 02:55AM CALCIUM-7.5* PHOSPHATE-3.0 MAGNESIUM-1.6
[**2160-2-3**] 02:55AM HCT-31.9*
[**2160-2-3**] 12:10AM URINE HOURS-RANDOM
[**2160-2-3**] 12:10AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2160-2-3**] 12:10AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.033
[**2160-2-3**] 12:10AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2160-2-3**] 12:10AM URINE RBC-1 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-1
[**2160-2-3**] 12:10AM URINE GRANULAR-1*
[**2160-2-2**] 11:21PM GLUCOSE-84 LACTATE-4.0* NA+-142 K+-3.8
CL--101 TCO2-24
[**2160-2-2**] 11:10PM UREA N-10 CREAT-1.0
[**2160-2-2**] 11:10PM estGFR-Using this
[**2160-2-2**] 11:10PM AMYLASE-77
[**2160-2-2**] 11:10PM ASA-NEG ETHANOL-304* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2160-2-2**] 11:10PM WBC-14.7* RBC-3.74* HGB-12.6* HCT-36.4*
MCV-97 MCH-33.7* MCHC-34.6 RDW-12.9
[**2160-2-2**] 11:10PM PLT COUNT-209
[**2160-2-2**] 11:10PM PT-10.1* PTT-22.7 INR(PT)-0.8*
[**2160-2-2**] 11:10PM FIBRINOGE-236
Brief Hospital Course:
This is a 44 year old male brought in by EMS who presented
with multiple injuries after a reported assault, as described in
the history and initial history physical exam above. On HD #1
([**2160-2-3**]), the pt was initially evaluated and treated in the
emergency department. A chest tube was placed based on the
clinical and radiographic findings consistent with pneumothorax.
His ankle fracture was reduced and splinted in the emergency
department. The patient was found to have a splenic lac on his
CT scan as noted above. The patient remained hemodynamically
stable with normal vital signs during his emergency department
course. Due to the patient's splenic laceration, his
pneumothorax and his multiple stab wounds, the patient was
admitted to the trauma SICU for close monitoring. The hand
surgery service was consulted for evaluation and repair of his
hand lacerations.
On HD#2 the pt remained hemodynamically stable and also had
a stable respiratory status with the chest tube in good
position. He went to the OR with the orthopedics service for
ORIF of his ankle fracture. At post-operative check, the
patient was stable and had voided. The patient's vital signs
remained normal and his pain was under good control with oral
pain medication. In the evening of HD#2, the pt was "triggered"
on the floor for chest pain. His respiratory and cardiac status
was evaluated and was stable; the pt had a stable chest x-ray
and a normal EKG. The pain was localized to his chest tube site
and the pain was thought due to his chest tube. The pt improved
with further pain medication.
On HD#3 the pt's chest tube was put to water seal, and then
pulled, with interval chest x-rays showing a stable tiny
pneumothorax. The patient's respiratory status and vital signs
remained stable throughout. The patient was able to work with
physical therapy and practice using crutches as he is NWB on his
RLE per the orthopedics service.
On HD#4 the pt's pain was under good control, he was
ambulating well with crutches, tolerating a regular diet,
continued to have normal vital signs, and met all [**Month/Day/Year **]
criteria. He was discharged to home in good condition with the
follow-up instructions and return precautions as listed.
Medications on Admission:
none
[**Month/Day/Year **] Medications:
1. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation: take while taking narcotic pain
medication.
Disp:*60 Capsule(s)* Refills:*0*
3. Lovenox 40 mg/0.4 mL Syringe Sig: One (1) injection
Subcutaneous once a day for 28 days: 40mg sc daily for 4 weeks,
or until otherwise instructed by your surgeons.
Disp:*qs * Refills:*0*
[**Month/Day/Year **] Disposition:
Home
[**Month/Day/Year **] Diagnosis:
s/p stabbing
splenic laceration
left apical pneumothorax
left pleural effusion
right ankle fracture
bilateral hand lacerations
[**Month/Day/Year **] Condition:
Good
[**Month/Day/Year **] Instructions:
Please call your physician or go to the emergency room if you
develop ANY new chest pain, shortness of breath,
lightheadedness, fever greater than 101.5, foul smelling or
colorful drainage from your incisions, worsening pain at your
incision sites, redness or swelling, severe abdominal pain or
distention, persistent nausea or vomiting, diarrhea, inability
to eat or drink, or any other symptoms which are concerning to
you.
.
Dressings: Please leave the dressing under your left arm over
your chest tube site in place for another 2 days until friday
morning [**2-8**]. After that time, you may remove the dressing and
keep the area clean and dry. There may be a small amount of
drainage from that site. You may use band-aids and
over-the-counter local wound care supplies and over the counter
antibiotic ointment as needed for local wound care of your
wounds and lacerations. The sutures on your hands will need to
be removed in approximately one week. Please make and keep your
follow-up appointments as listed below.
.
Activity: You may resume activity as tolerated. Please use your
crutches to walk as discussed with the physical therapists. Do
not bear weight on your injured leg, as discussed with your
orthopedic surgeon. Wear your boot as instructed.
.
Diet: You may resume your usual diet.
.
Medications: Resume your usual home medications. Take any new
medications as prescribed. Inject your lovenox daily as
instructed. You should take a stool softener with your pain
medication. Your pain medication may make you drowsy, so please
do not drive while taking pain medicine.
It is VERY important that you continue to cough and deep breath
at least 10x every hour to optimize lung expansion. This is very
important to do in order to prevent pneumonia, which is a
complication associated with chest injuries.
Follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **].
Followup Instructions:
Please call ([**Telephone/Fax (1) 376**] to schedule a follow up appointment
with trauma surgery, Dr. [**Last Name (STitle) **] in [**11-21**] weeks.
Please call ([**Telephone/Fax (1) 2007**] to schedule a follow up appointment
with orthopedics, Dr. [**Last Name (STitle) 1005**] or his PA [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in 2
weeks.
Please call ([**Telephone/Fax (1) 32269**] to schedule a follow-up appointment
in approximately one week in hand surgery clinic on [**2-15**] for
suture removal and re-evaluation of your hand wounds.
|
[
"865.00",
"883.1",
"824.8",
"824.4",
"868.04",
"511.9",
"882.0",
"860.4",
"E968.9",
"958.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.36",
"34.04",
"86.59"
] |
icd9pcs
|
[
[
[]
]
] |
6611, 8857
|
298, 358
|
2132, 2576
|
11616, 12187
|
757, 761
|
8883, 11593
|
776, 781
|
239, 260
|
386, 615
|
2585, 6583
|
795, 2113
|
637, 664
|
680, 741
|
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