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9,104
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4401
|
Discharge summary
|
report
|
Admission Date: [**2129-3-17**] Discharge Date: [**2129-3-30**]
Date of Birth: [**2061-7-15**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
CABG
History of Present Illness:
The patient is a 67 year old male with a history of DMII, ESRD
on HD and transplant list, CAD s/p stent in [**2123**] who presented
to [**Hospital3 **] ED on [**3-15**] with complaints of chest pain
while at dialysis. His EKG on arrival was unremarkable. He was
treated with sublingual nitroglycerin and morphine and admitted
to the CCU for further management. His trop came back at 22 (cpk
366 then 278 then 241, mb 36.2 then 29.6 then 26.4 and trop I
20.34 then 22.50 then 22.13) and he ruled in for an +NSTEMI. The
patient says he was in USOH until sat. when he had non-radiating
substernal cp. Pain lasted 6 hours and reduced with nitro. Pain
returned next day at rest and went away with 3 sl nitro. He went
to hospital tuesday for fistualogram and had pain again [**7-17**]
substernal, non-radiating pressure. Not associated with N, V,
Sob or diaphoresis. He was sent to ED and treated as per above.
Transferred to [**Hospital1 **] for cath
.
On floor still some cp, no n, v, ha, sob, diaphoresis, abd pain,
diarrhea or dysuria
Past Medical History:
- DMII -diagnosed in [**2106**] with retinopathy, neuropathy and ESRD
on HD
- CAD-?stent in [**2123**]
- CHF, EF 50%
- ESRD on HD (on transplant list), Cr 6.5 at baseline. Dialysis
since [**2123**]
- PM for symptomatic bradycardia? ([**2129-1-7**])
- h/o colon cancer s/p resection
- Secondary hyperparathyroidism
- HTN
- The patient recounts he had a dobutamine stress test in
[**2127-11-8**], which showed a fixed inferolateral defect and
an ejection fraction of 50%.
- left foot charcot join
Social History:
He continues to work periodically as a distributor for trophies.
He smoked three packs a day for 20 years and quit in [**2097**]. He
has never used IV drugs and denies use of alcohol. He is
divorced and has 3 children
Family History:
his father of [**Name (NI) 2481**] disease at 87. He lost a brother to an
MI at age 49.
Physical Exam:
vs: T: 98.0, bp: 139/76, hr 78, rr 18, 97% RA
Gen - nad, lying in bed, pleasant male
HEENT - right pinpoint, left surgical, eomi, mmm, no oral
lesions
Heart - rrr no m/r/g
Lungs - cta anterior
Abdomen - s/nt/nd nabs
Ext - pitting edema 1+ bilateral, av fistula in right forearm
Neuro - cn intact, aaox3, non-focal. neuropathy up to shins
bilateral.
pulses: right doppler, left faint pt and dp pulses
groin: no bruit, soft, no hematoma
Pertinent Results:
results:
cath [**3-17**]: 1. Selective coronary angiography of this co-dominant
system
demonstrated a three vessel CAD. The LMCA had mild disease.
The LAD
was diffusely diseased with a 90% mid vessel stenosis. The LCx
had an
80% mid vessel stenosis. The RCA had an 80% mid vessel stenosis
with a
possibel thrombus, as well as a distal 80% stenosis.
2. Resting hemodynamics revealed a moderate systemic arterial
systolic
hypertension with an SBP of 141 mm Hg.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
.
[**3-19**] echo:
Conclusions:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
to moderate regional left ventricular systolic dysfunction with
focal severe hypokinesis of the inferior and inferolateral walls
and distal septum. The remaining left ventricular segments
contract normally. Right ventricular chamber size is normal with
? focal hypokinesis of the apical free wall (clip #[**Clip Number (Radiology) **]). The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are structurally normal. There is no
mitral valve prolapse. Moderate (2+) mitral regurgitation is
seen. The estimated pulmonary artery systolic pressure is top
normal. There is a trivial/physiologic pericardial effusion.
.
labs:
[**2129-3-29**] 07:40AM BLOOD WBC-7.1 RBC-2.76* Hgb-9.1* Hct-27.3*
MCV-99* MCH-33.0* MCHC-33.4 RDW-16.5* Plt Ct-153
[**2129-3-29**] 07:40AM BLOOD PT-14.2* PTT-32.0 INR(PT)-1.3*
[**2129-3-29**] 07:40AM BLOOD Glucose-142* UreaN-42* Creat-9.8*# Na-139
K-4.9 Cl-98 HCO3-29 AnGap-17
Brief Hospital Course:
On [**3-23**] he was taken to the operating room where he underwent a
CABG x 5 (LIMA->LAD, SVG->OM1-OM2, SVG->PDA->PLV). He was
transferred to the ICU in critical but stable condition on
epinephrine and neosynephrine. He was extubated and weaned from
his epi by POD #1. He was weaned from his neo and transferred to
the floor on POD #2. He was seen by renal and dialyzed as prior
to surgery. He did well postoperatively. He was seen by Physical
therapy and was ready for discharge to rehab on POD #7.
Medications on Admission:
Medications at Home:
aspirin 81
fosrenol 1000 units tid
Toprol-XL 50 daily
NPH insulin 25 qam
Nephrocaps one daily
colace 100 [**Hospital1 **]
.
Medications on Transfer:
.
Heparin gtt
Lasix 80 on non-dialysis
Toprol
ASA
Renagel 3 tabs daily
Nitropaste
600mg plavix
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty
Five (25) units Subcutaneous 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. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed.
7. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) **]
Discharge Diagnosis:
CAD s/p CABGx5(LIMA-LAD,SVG-OM1-OM2, SVG-PDA-PLV)[**3-23**]
PMH: HTN,^chol,DM(neuropathy-retinopathy),ESRD/HD,Colon CA s/p
resection,colitis,vertigo,hyperparathyroidism,Charcot
feet,CCY,PPM(bradycardia
Discharge Condition:
Good.
Discharge Instructions:
keep wounds clean and dry. OK to shower, no bathing or swimming.
Take all medication as prescribed.
Call for any fever redness or drainage from wounds.
No lifting more than 10 pounds or driving until follow up with
surgeon.
Followup Instructions:
Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3646**] in [**4-10**] weeks
Dr [**Last Name (STitle) 17315**] 2 weeks
Dr [**Last Name (STitle) 914**] in 4 weeks
Previously scheduled appointments:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2129-4-21**] 1:20
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2129-4-21**]
2:30
Completed by:[**2129-3-30**]
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|
1938, 2159
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,800
| 128,294
|
8673
|
Discharge summary
|
report
|
Admission Date: [**2138-7-23**] Discharge Date: [**2138-7-27**]
Date of Birth: [**2091-1-15**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Erythromycin Base / Amoxicillin
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
neck tightening
Major Surgical or Invasive Procedure:
Coronary artery disease s/p coronary artery bypass graftx4
History of Present Illness:
47 yo male, known to our service (see
H&P from [**6-18**]), who reported neck and throat tightening to his
cardiologist during routine follow up. The patient then had an
abnormal stress test and was referred for cardiac
catheterization. Cath revealed three vessel coronary disease and
was referred for surgical revascularization.
Past Medical History:
Gastroesophageal reflux disease, Hyperlipidemia, Prostatitis,
Anxiety/depression, ? Mitochondrial myopathy
PSH: Tonsillectomy, Vasectomy, Rt shoulder surgery, Rt knee
arthroscopic surgery
Social History:
Occupation: Engineer
Last Dental Exam:couple of weeks ago
Lives with: wife, has 2 children
Race:Caucasian
Tobacco:quit 25 yrs ago, 15-20 cigs/day x 10 yrs
ETOH: [**2-5**] drinks/month
Family History:
Family History: (parents/children/siblings CAD < 55 y/o)Both
parents with stents in their 60s.
Physical Exam:
Physical Exam
Vitals: See anesthesia note
Height: 5'[**38**]" Weight: 192 lbs
General:Alert & oriented x 3
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] No Murmur or gallops
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:+2 Left:+2
DP Right:+2 Left:+2
PT [**Name (NI) 167**]:+2 Left:+2
Radial Right:+2 Left:+2
Carotid Bruit Right:None Left:None
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 30385**], [**Known firstname **] H [**Hospital1 18**] [**Numeric Identifier 30386**] (Complete)
Done [**2138-7-25**] at 8:49:28 AM PRELIMINARY
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
[**Hospital1 18**], Division of Cardiothorac
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2091-1-15**]
Age (years): 47 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Intraop CABG
ICD-9 Codes: 440.0, 424.0
Test Information
Date/Time: [**2138-7-25**] at 08:49 Interpret MD: [**Known firstname **] [**Last Name (NamePattern1) **], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2009AW1-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Peak Pulm Vein S: 0.4 m/s
Left Atrium - Peak Pulm Vein D: 0.3 m/s
Left Atrium - Peak Pulm Vein A: 0.1 m/s < 0.4 m/s
Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.8 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 55% to 65% >= 55%
Left Ventricle - Lateral Peak E': *0.02 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': *25 < 15
Mitral Valve - Peak Velocity: 0.5 m/sec
Mitral Valve - E Wave: 0.5 m/sec
Mitral Valve - A Wave: 0.4 m/sec
Mitral Valve - E/A ratio: 1.25
Mitral Valve - E Wave deceleration time: *103 ms 140-250 ms
Findings
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal
interatrial septum. No ASD or PFO by 2D, color Doppler or saline
contrast with maneuvers.
LEFT VENTRICLE: Normal LV wall thickness, cavity size, and
global systolic function (LVEF>55%). Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Simple atheroma in aortic arch. Normal
descending aorta diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MS. The
MR vena contracta is <0.3cm. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
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. No TEE related complications.
Conclusions
Pre bypass: The left atrium is normal in size. No atrial septal
defect or patent foramen ovale is seen by 2D, color Doppler or
saline contrast with maneuvers. Left ventricular wall thickness,
cavity size, and global systolic function are normal (LVEF>55%).
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. There is no pericardial effusion.
Post bypass: Preserved biventricular function, LVEF>55%. Cardiac
output 7.8 by TEE post chest closure. MR [**First Name (Titles) **] [**Last Name (Titles) 1506**]. Aortic
contours intact. Remaining exam is [**Last Name (Titles) 1506**]. All findings
discussed with surgeons at the time of the exam.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Interpretation assigned to [**Known firstname **] [**Last Name (NamePattern1) **], MD, Interpreting
physician
Brief Hospital Course:
Mr. [**Known lastname **] was admitted and taken to the OR for coronary artery
bypass graft x4 (LIMA-LAD, SVG to Diag, SVG to OM, SVg to PDA)
on [**2138-7-23**]. see operative note for details. Admitted to the
CVICU intubated and sedated on neo gtt for hemodynamic support.
Pressor and ventilator were weaned and Mr. [**Known lastname **] was extubated
the eve of POD 0. His chest tubes and temporary pacing wires
were d/c'd per protocol. On POD#1 he was started on betablocker,
diuresis and statin therapy. On POD#2 he was transferred to the
floor. His betablocker was titrated as tolerated. He was
evaluated and treated by physical therapy and cleared for
discharge to home on POD#4.
Medications on Admission:
Fioricet([**Medical Record Number 3668**]) 1-2 Tabs/PRN- no more than six per day
Cyclobenzaprine 10-20mg/prn-muscle spasm, Combivent 2p q4/PRN
Lorazepam .5-1.0 [**Hospital1 **]/prn, Niaspan 2000mg at bedtime 30 minutes
after ASA, Omeprazole 20", Pravastatin 20', Vitamin C 500", ASA
81',
Coenzyme Q10 200QAM/100QPM, MVI 1', Omega-3 Fatty Acids 5000',
Vitamin E 400", Plavix-last dose:[**2138-6-18**]
Discharge Medications:
1. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**12-6**]
Puffs Inhalation Q6H (every 6 hours) as needed for wheezes.
7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
10. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO BID (2 times a
day) as needed for anxiety.
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours) for 7 days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Coronary artery disease s/p coronary artery bypass graftx4
Gastroesophageal reflux disease, Hyperlipidemia, Prostatitis,
Anxiety/depression, ? Mitochondrial myopathy
PSH: Tonsillectomy, Vasectomy, Rt shoulder surgery, Rt knee
arthroscopic surgery
Discharge Condition:
good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month, and while taking
narcotics
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 4775**] in 1 week
Dr. [**Last Name (STitle) 5025**] [**Name (STitle) **] in [**1-7**] weeks
Please call for appointments
wound check as scheduled by [**Hospital Ward Name 121**] 6 nurses [**Telephone/Fax (1) 3071**]
Completed by:[**2138-7-27**]
|
[
"311",
"414.01",
"530.81",
"414.2",
"300.00",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
8351, 8409
|
5982, 6670
|
314, 375
|
8700, 8707
|
1939, 5959
|
9247, 9657
|
1182, 1263
|
7122, 8328
|
8430, 8679
|
6696, 7099
|
8731, 9224
|
1278, 1920
|
259, 276
|
404, 736
|
758, 948
|
964, 1150
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,015
| 124,114
|
6038+55722
|
Discharge summary
|
report+addendum
|
Admission Date: [**2178-1-15**] Discharge Date: [**2178-1-23**]
Date of Birth: [**2133-11-4**] Sex: M
Service: TRANS [**Doctor First Name 147**]
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 16471**] is a 44 year old
gentleman with a past history significant for coronary artery
disease, diabetes mellitus type 1 and end-stage renal
disease. He is status post living related renal transplant
in [**2175**] and now presents preoperatively for a pancreas
transplant. He states that his blood sugars have most
recently been between 150 and 200.
He denies any chest pain, shortness of breath, dyspnea on
exertion, paroxysmal nocturnal dyspnea, nausea, vomiting,
diarrhea or dizziness.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post myocardial
infarction; status post coronary artery bypass graft of three
vessels in [**2175**].
2. Diabetes mellitus, type 1 with retinopathy.
3. End-stage renal disease status post living related renal
transplant in [**2175**].
4. Gastroparesis.
5. Gastroesophageal reflux disease.
6. Peripheral vascular disease.
MEDICATIONS: On admission
1. Prednisone 5 once a day.
2. Prograf 3 twice a day.
3. Cellcept [**Pager number **] mg p.o. q. day.
4. Lopressor 100 g p.o. twice a day.
5. Humalog sliding scale.
6. Lantus 40 units q. p.m.
7. Zantac 150 mg p.o. twice a day.
8. Bactrim one single strength tablet p.o. q. day.
9. Aspirin 81 mg p.o. q. day.
10. Norvasc 10 gm p.o. twice a day.
11. Reglan 10 mg four times a day.
12. Lipitor 20 mg p.o. q. day.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: On admission, this is a 44 year old
gentleman appearing consistent with stated age. He was
afebrile with a temperature of 97.6 F.; his pulse is 80; his
blood pressure is 118/78. He was alert and oriented in no
distress. His pupils are equal, round and reactive to light
with all extraocular muscles intact. His neck is supple with
no jugular venous distention, no carotid bruits. His heart
is regular without murmurs, rubs or gallops. His lungs were
clear to auscultation bilaterally. His abdomen was soft,
nontender, nondistended, with a well healed transplant scar.
The extremities were warm and well perfused without edema.
SUMMARY OF HOSPITAL COURSE BY ORGAN SYSTEM:
1. On [**2178-1-16**], Mr. [**Known firstname **] [**Known lastname 16471**] underwent a
cadaveric pancreas transplant. The procedure was performed
by Dr. [**Last Name (STitle) **] and assisted by Dr. [**Last Name (STitle) **]. The patient tolerated
the procedure well and without complications. Please see
previously dictated operative note for more details.
After the operation, the patient was transferred to the
Intensive Care Unit where he did well on his fingersticks and
he was controlled on an insulin drip. The patient was
transferred out of the Intensive Care Unit on postoperative
day number one.
The remainder of Mr. [**Known lastname **] hospital course was
uncomplicated. The patient was passing gas by postoperative
day number two and by postoperative day number four his
nasogastric tube was removed without incident. The
[**Location (un) 1661**]-[**Location (un) 1662**] drain was removed on postoperative day number
five.
He experienced some mild nausea which was treated
successfully with his home dose Reglan and the initiation of
solid foods.
Mr. [**Known lastname 16471**] received the prescribed five doses of gamma
globulin on postoperative days zero through four. He was
also receiving Cellcept [**Pager number **] mg p.o. twice a day throughout
the duration of his hospital stay. In addition, he was
brought to a therapeutic level on his Prograf.
By postoperative day number seven, the patient was ambulating
without problem, tolerating p.o. and was stable in all his
immunosuppression.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSES: Status post cadaveric pancreas after
kidney transplant.
DISCHARGE MEDICATIONS:
1. Cellcept [**Pager number **] mg p.o. twice a day.
2. FK506 1 mg p.o. twice a day.
3. Prednisone 5 mg p.o. q. day.
4. Ganciclovir 450 mg p.o. q. day.
5. Bactrim 1 tablet p.o. q. day.
6. Fluconazole 400 mg p.o. q. day for the duration of one
month total.
7. Aspirin 81 mg p.o. q. day.
8. Lopressor 100 mg p.o. twice a day.
9. Protonix 40 mg p.o. q. day.
10. Insulin sliding scale.
11. Reglan 10 mg p.o. q. day.
12. Colace 100 mg p.o. twice a day.
13. Percocet p.r.n.
DISCHARGE INSTRUCTIONS:
1. Mr. [**Known lastname 16471**] has been discharged with his sliding scale
insulin.
2. He has also been given an appointment to follow-up with
the Transplant Center.
[**Name6 (MD) 1344**] [**Name8 (MD) 1345**], M.D. [**MD Number(1) 1346**]
Dictated By:[**Last Name (NamePattern1) 6355**]
MEDQUIST36
D: [**2178-1-23**] 14:53
T: [**2178-1-23**] 23:22
JOB#: [**Job Number 23718**]
Name: [**Known lastname 2760**], [**Known firstname **] Unit No: [**Numeric Identifier 4042**]
Admission Date: [**2178-1-15**] Discharge Date: [**2178-1-17**]
Date of Birth: [**2133-11-4**] Sex: M
Service: Transplant Surgery
HISTORY OF PRESENT ILLNESS: This is a 56 year old gentleman
well known to the Transplant Service who is status post
cadaveric renal transplant
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4043**]
Dictated By:[**Last Name (NamePattern1) 2383**]
MEDQUIST36
D: [**2178-1-17**] 14:17
T: [**2178-1-17**] 14:49
JOB#: [**Job Number 4044**]
|
[
"272.0",
"V45.81",
"250.63",
"250.53",
"401.9",
"536.3",
"530.81",
"362.01",
"V42.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"52.82"
] |
icd9pcs
|
[
[
[]
]
] |
3870, 3927
|
3950, 4428
|
4452, 5141
|
1605, 3812
|
5170, 5527
|
734, 1581
|
3838, 3847
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,559
| 127,407
|
44969
|
Discharge summary
|
report
|
Admission Date: [**2106-8-6**] Discharge Date: [**2106-8-11**]
Date of Birth: [**2027-3-19**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Shellfish / Morphine
Attending:[**Doctor Last Name 10493**]
Chief Complaint:
bright red blood per rectum
Major Surgical or Invasive Procedure:
Colonscopy
Tagged RBC scan
Mesenteric angiography
History of Present Illness:
CC:[**CC Contact Info 18195**].
.78 year old woman with h/o atrial fibrillation,
hypercholesterolemia, RA on prednisone, ? ocular stroke, and CAD
s/p RCA stent placement x2 in [**2103**] p/w BRBPR. She reports
several episodes of painless diarrhea on Wednesday and Thursday
of last week w/ BRBPR starting on Wednesday afternoon (enough to
fill the toilet).
On morning of admission, pt was noted was lightheaded and fell
on her right hip when getting up from the toilet. She denies any
LOC during the fall and denies trauma to the head. She was
brought in by EMS.
She denies any prior episodes of BRBPR. She usually has normal
stools. She did not eat any unusual foods and denies any recent
travels.
.
In the ED: initial VS: 98.9, 79, 132/104, 16, 99RA
She was given IVF, T&C for 4u of pRBCs. ECG is reportedly
unchanged (baseline LBBBB). She denies recent illnesses, f/c.
She denies any chest pain or SOB. No n/v, no abd pain, no
urinary symptoms. Pt was transferred to MICU for monitoring and
transfusion. In the MICU pt was given 2 units pRBCS and
remained stable with stable Hcts for 24 hours before, and was
transferred to the floor on [**2106-8-7**].
Pt only briefly on the floor, the evening of transfer at 11 pm
had another episode of BRBPR, for a total of 4 times, about
500-700cc in total. at that time her vitals were stable, SBP
160. Transfused 1 pRBCs, a second PIV was placed, and 2 more
units of blood were transfused. She was taken for a tagged RBC
scan scan, which showed active bleeding during the first 5
minutes on the left side. She was taken directly to the IR suite
for a mesenteric angiogram. An SMA injection showed no acute
bleed in the small bowel. [**Female First Name (un) 899**] was not visualzed at usual branch
point and had vessel branching posterior to aorta that is likely
[**Female First Name (un) 899**], which was severely stenosed. Contrast was unable to be
injected to visualize vascular distribution of colon. No
intervention was taken. Patient has known diverticular disease.
After this repeated episode pt has been stable. Pt has been
without BRBPR for 36-48 hours and had normal BP per the ICU
team. BPs have been stable and patient has been feeling well.
.
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2912**], cardiologist ([**Telephone/Fax (1) 89685**]
Dr. [**Last Name (STitle) 96155**] PCP
Allergies: pcn, shellfish, morphine, mtx
Past Medical History:
-Coronary artery disease, s/p PCI in [**2103**] pre-op with DES to
-RCA, also known diffuse 50% lesion in LAD (non-flow limiting)
and LCx had a 50% ostial OM stenosis and otherwise mild
irregularities.
-[**2103**] echo nl EF mild MR
[**Name13 (STitle) 73210**] fibrillation on flecainide, not on other anticoagulation
-Hypercholesterolemia
-s/p L hip replacement
-nephrolithiasis
-s/p recent L fibular fracture
-RA on pred.
-sigmoidoscopy in [**2100**]- benign findings
-GERD
-CHF [**First Name8 (NamePattern2) **] [**Location (un) 620**] records (admitted for SOB)- however, no recent
echo
Social History:
She lives alone. Able to do most ADL's but dependent on
daughters for tasks such as doing groceries. Recently retired
from work as a secretary. Former "heavy" tobacco smoker (quit >
20 years ago); no alcohol use.
Family History:
Father died of aneurysm, Mother reportedly had angina, also
colon ca (died from this).
Physical Exam:
99.2 BP 131/51, P 78, RR 15 O2 100 on RA
Gen: appears comfortable, no distress. pale.
HEENT: pale conjunctiva, MMM, no jvd
Cor: no JVD, RRR, III/VI SEM at RUSB
Chest: CTAB
Abd: obese abdomen, NT/ND normoactive bs
Ext: no edema in LE, good distal pulses bilaterally
right hip/buttock slightly TP, no bruising.
.
ECG: LBBB, rate 69, no sttw changes.
.
Pertinent Results:
[**2106-8-6**] 09:20PM HCT-24.2*
[**2106-8-6**] 04:50PM WBC-9.0 RBC-2.65* HGB-7.7* HCT-23.9* MCV-90
MCH-29.1 MCHC-32.3 RDW-15.9*
[**2106-8-6**] 04:50PM PLT COUNT-322
[**2106-8-6**] 01:40PM GLUCOSE-120* UREA N-29* CREAT-0.7 SODIUM-138
POTASSIUM-4.7 CHLORIDE-102 TOTAL CO2-25 ANION GAP-16
[**2106-8-6**] 01:40PM CALCIUM-9.3 PHOSPHATE-3.2 MAGNESIUM-1.9
.
[**2106-8-8**] GI bleeding study - IMPRESSION: Intermittent brisk GI
bleeding.
.
[**2106-8-6**] EKG Sinus rhythm. Consider left atrial abnormality. Left
axis deviation. Intraventricular conduction delay. Consider
inferior myocardial infarction. Since the previous tracing of
[**2105-9-20**] the axis is more leftward, ventricular premature beat is
not seen and QRS width is not as wide
.
Echo ([**2103**]) - The left atrium is moderately dilated. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. The aortic valve leaflets are mildly
thickened. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
Brief Hospital Course:
Assessment and Plan: 79 yo F w/ htn, a.fib (not on coumadin), RA
on prednisone p/w BRBPR s/p MICU admission. Pt currently with
stable Hct and > 36 without bloody bowel movement. Vitals
stable, monitoring crits serially.
.
# BRBPR: Likely with a LGIB most likely from bleeding
diverticuli.
- q8 hct now stable
- has received multiple units of packed RBCs in the setting of
GI bleed, now crit appears stable
- on admission, held asa, bblocker, and ticlid (anti-platelet)
in the setting of GI bleed, now has been stable, will be d/c as
per Dr. [**Last Name (STitle) 2912**] on 81 mg PO aspirin (previously on 325 mg
daily), will d/c Ticlid and will continue outpatient carvedilol
as previously prescribed.
- postive repeat tagged RBC scan for bleeding however had
angiography where no intervention was performed
- had colonscopy which demonstrated multiple non-bleeding
diverticuli in the colon
- s/p multiple RBCs transfusion and right IJ catheter placement
and removal
.
# CAD: s/p 2 stents on ticlid, asa, carvedilol, statin
- restarted b-blocker and ASA 81 on discharge, will not restart
ticlid at this time as per Dr. [**Last Name (STitle) 2912**]
.
# CHF: diagnosed during last [**Location (un) 620**] admission, pt. was SOB on
presentation and improved with lasix. Did not get an echo there.
[**Month (only) 116**] benefit from repeat echo as outpatient.
- d/c home on carvedilol
.
# Atrial fibrillation: currently in sinus rhythmn
- continue flecanide, currently not on anticoagulation likely
secondary to fall risk
- CHADS score = +1 HTN, +1 age, ? CHF +1
.
# Rheumatoid arthritis: continue prednisone
.
# Hypertension: HTN meds originally held, restarted avapro
today, and carvedilol once stable.
.
# Hyperlipidemia: atorvastatin.
.
# anxiety: continue ativan 1mg q6hrs prn
.
# Fen: low cholesterol diet, will d/c on outpatient vitamins and
mineral supplementation
.
# ppx: subQ heparin, can restart bowel regime
.
# code status: full code, confirmed with pt.
.
Full up scheduled with Dr. [**Last Name (STitle) 2912**] and PCP.
Medications on Admission:
Aspirin 325mg PO DAILY
Escitalopram 10mg PO DAILY
Ticlopidine 250mg PO BID
Atorvastatin 40mg PO DAILY
Folic Acid 1 mg PO DAILY
Ascorbic Acid 500mg PO DAILY
Flecainide 100mg PO Q12H
prednisone 10mg qdaily
iron 65mg [**Hospital1 **]
centrum silver
vitamin D 1000u qdaily
prevacid 30mg qdaily
avapro 300mg qdaily
lasix 20mg qdaily
carvedilol 6.25mg qdaily
benadryl prn
ativan 1mg q6hrs prn
ibuprofen prn
Ezetimibe 10mg PO DAILY
Discharge Medications:
1. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Flecainide 50 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12
hours).
3. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Irbesartan 150 mg Tablet Sig: One (1) Tablet PO daily ().
6. Lorazepam 2 mg/mL Syringe Sig: One (1) Injection Q6H (every
6 hours) as needed for anxiety.
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO once a
day.
9. Iron 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO twice
a day.
10. Vitamin D 1,000 unit Capsule Sig: One (1) Capsule PO once a
day.
11. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
12. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
13. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO once a day.
14. Aspirin 81 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: Lower GI Bleed
Secondary diagnosis: atrial fibrillation (not anticoagulated),
hypertension, rheumatoid arthritis
Discharge Condition:
Stable.
Discharge Instructions:
You were admitted with Lower GI bleeding. The source of the
bleeding was felt to be from diverticuli in the colon. The
bleeding stopped on its own without intervention. You were
transfused red blood cells in the ICU and are being discharged
with a stable hematocrit. You should follow-up with your
cardiologist Dr. [**Last Name (STitle) 2912**] and your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16258**] as
scheduled below. You should contact your PCP if you experience
and new bleeding per rectum, dizziness, worsening constipation,
low blood pressure or if you passout. You should also contact
PCP with any chest pain, shortness of breath, or abdominal pain.
You are being discharged on your home medications, however you
no longer need the Ticlid. Also, your aspirin is being changed
to 81 mg PO daily instead of 325. There is a prescription for
you to fill below.
Followup Instructions:
Dr. [**Last Name (STitle) 2912**] [**8-23**] at 2 pm
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16258**] Tuesday [**8-24**] at 2 pm
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**] MD, [**MD Number(3) 10495**]
Completed by:[**2106-8-11**]
|
[
"714.0",
"414.01",
"562.12",
"300.00",
"272.4",
"V43.64",
"455.3",
"401.9",
"557.1",
"427.31",
"V15.82",
"V45.82",
"428.0",
"455.0",
"V14.0",
"530.81",
"428.32"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.47",
"88.42",
"45.23",
"99.05",
"38.93",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
9025, 9031
|
5463, 7501
|
323, 375
|
9207, 9217
|
4152, 5440
|
10200, 10517
|
3676, 3764
|
7976, 9002
|
9052, 9052
|
7527, 7953
|
9241, 10177
|
3780, 4133
|
256, 285
|
403, 2811
|
9107, 9186
|
9071, 9086
|
2833, 3429
|
3446, 3660
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,078
| 172,724
|
41407
|
Discharge summary
|
report
|
Admission Date: [**2123-4-4**] Discharge Date: [**2123-5-4**]
Date of Birth: [**2098-5-6**] Sex: F
Service: MEDICINE
Allergies:
Haldol / Fluphenazine / Chlorpromazine / Clozapine / Risperidone
/ Zyprexa / Reglan / Promethazine / Flagyl / Trileptal /
Clindamycin / Cefazolin / Erythromycin Base / Amoxicillin
Attending:[**First Name3 (LF) 832**]
Chief Complaint:
Abdominal pain, nausea, vomiting, diarrhea
Major Surgical or Invasive Procedure:
Intubation/Sedation to allow medical care early in hospital
course
History of Present Illness:
Ms. [**Known lastname 90100**] is a 24 year-old woman with recent diagnosis of SLE
vs possible Crohn's on steroid taper and pervasive development
disorder (resides in a group home) who presents with worsening
abdominal pain, nausea, vomiting, and diarrhea. She was noted
to be vomiting starting last night. She has been having
diarrhea, no BRBPR or melena. The mother feels that she is in
pain as she brings her knees up to her chest. She was doing very
well since [**Month (only) 404**] until 2 weeks ago when she developed
nausea/vomiting thought to be from Plaquenil. This was changed
to Azathioprine a few days ago at 25mg. Her Prednisone was
increased to 10mg. Her symptoms began this weekend as above.
Howevever, her symptoms are different than in [**Month (only) 404**], given her
emesis is clear and she is having watery diarrhea. Per her
mother, there is no reported fever/chills, CP/SOP/ cough, or
rash. She also denies recent sick contacts.
She was seen at Health Alliance this morning at 3 AM. CT showed
no obstruction but diffuse colitis. Pt received zofran, reglan
(with benadryl), and hydrocortisone 100mg prior to transfer.
In the ED, initial VS were: 98 106 122/90 14 99%. Exam was
notable for soft abdomen, guaiac negative. Labs were notable
for WBC 8.5. ESR, CRP pending. GI was consulted. Currently she
is doing well with no clear abdominal pain.
Past Medical History:
- SLE vs Crohns Disease, followed by Dr. [**First Name (STitle) 679**] and Dr. [**Last Name (STitle) 1667**].
Admitted [**12-29**] for colitis/SBO. Improved on steroids. Imuran
also started.
- Pervasive developmental disorder
- OCD
- Bipolar disorder
- Question of seizure disorder
Social History:
She is single, lives in a group home in [**Location (un) 16843**], with
visitations from the family on weekends. She does not smoke,
does not drink.
Family History:
There is a family history of colitis, Crohn's, ADHD, Tourette's
and Asperger's in the family.
Physical Exam:
VS: T 98.2, BP 104/75, HR 111, RR 16, 100%RA
Gen: well appearing, smiling, NAD
HEENT: anicteric sclera, MMM, OP clear
Neck: supple no LAD
Heart: Tachy, regular, no m/r/g
Lung: CTAB though exam limited by cooperation
Abd: soft NT/ND +BS no rebound or guarding
Skin: no obvious rashes though exam limited by cooperation
Ext: no pitting edema, warm
Neuro: alert, non-verbal, smiles and reactive. Would no
cooperate with rest of exam.
Pertinent Results:
LABS:
C3: 94
C4: 8
Anti dsDNA: negative
Beta-2-Glycoprotein Ab: IgM elevated; IgG and IgA normal
C. diff PCR: Negative
Sputum [**2123-4-8**]: +MSSA, +EColi
Blood Cx [**2123-4-8**]: +Coagulase negative staph aureus
Urine Cx [**2123-4-8**]: +EColi
CT ABD & PELVIS WITH CONTRAST [**2123-4-7**]:
1. Diffuse colitis, infectious, inflammatory, or vasculitis
etiologies should be considered. There is associated abdominal
ascites, and small bowel dilatation.
2. Small bowel acute on chronic inflammatory change with dilated
loops and
wall edema. Favor inflammatory vs. vasculitis, though findings
are not
specific for either. No small bowel transition point is seen to
suggest a
mechanical bowel obstruction, and any component of partial
obstruction is
likely to be functional as the result of inflammation.
3. No CT signs of vasculitis of the abdominal vessels and no
arterial or
venous occlusion.
4. Small right pleural effusion.
SIGMOIDOSCOPY [**2123-4-8**]:
- Moderately severe colitis with likely pseudomembrane in the
sigmoid and descending colon (biopsy, biopsy)
- Loss of vascularity in the rectum
- Internal hemorrhoids
- Otherwise normal sigmoidoscopy to splenic flexure
RECS: Await pathology report. Likely C.diff colitis, but cannot
rule-out Crohn's disease based on endoscopic appearance alone.
Send stool studies for C.diff toxin/PCR, and would initiate
empiric therapy for C.diff colitis with PO/PR Vancomycin. Would
recommend against increasing steroid therapy for now given the
concern and high likelihood for C.diff colitis, unless
histologic evaluation appears otherwise.
SIGMOID AND DESCENDING COLON BIOPSIES:
- Colonic mucosa with abundant surface mucin (highlighted by
mucicarmine stain).
- No pseudomembranes, vasculitis, or cryptitis seen (additional
levels were examined).
PORTABLE ABDOMEN [**2123-4-12**]:
Unchanged prominent loops of small bowel with some contrast seen
in the
ascending as well as descending colon likely representing
essentially
unchanged partial small bowel obstruction
Brief Hospital Course:
24 year-old woman with SLE, pervasive developmental disorder,
who presented with nausea and vomiting feculant material [**1-20**]
recurrent ileus vs. partial SBO associated with a probable
vasculitis-induced colitis. Management is complicated by
behavioral issues (pulling out all lines), requiring sedation
and intubation to enable medical management. Decompression with
[**Last Name (un) **]-gastric tube was performed. CT demonstrated bowel wall
thickening suggestive of colitis. C.diff toxin and C.diff PCR
were negative. Given patient's h/o lupus, there was concern for
a possible vasculitic process. Patient was started on a course
1000 mg Methylprednisolone x3d followed by a taper. Of note,
azathioprine, which she had been on for lupus treatment, was
transiently held. Flex [**Last Name (un) 65**] was performed to determine the
etiology of colitis. Biopsies were non-dagnostic and did not
demonstrate signs of vasculitis, cryptitis or psuedomembranes.
Nonetheless, it was the opinion of the rheumatology consult
service that this likely represent vasculitis-associated colitis
and her symptoms improved with ongoing prednisone and restarted
azathioprine use. The patient will continue on 30mg daily of
prednisone and 75mg daily of azathioprine with calcium, vitamin
d, atovaquone prophylaxis with weekly blood draws for
azathioprine toxicity monitoring. She will follow-up with
rheumatology in approximately 1 week. Symptomatically the
patient had significant improvement with apparent improvement in
abdominal pain and distention.
He hospital course was complicated by pneumonia, with sputum
growing out GI flora consistent with aspiration PNA, as well as
UTI with EColi. She was treated with Meropenem for 8 days
([**Date range (1) **]). Treatment with Vancomycin was planned for 14 days
([**Date range (1) 90101**]), but the patient pulled out her IV access and was
converted to PO Linezolid. The patient will reufse PO meds
sometimes, so because of clinical stability and difficulty with
administering IV or PO meds, treatment for Coag-neg staph was
stopped at 12 days (stopped [**4-21**]).
Ms. [**Known lastname 90100**] was followed by Psychiatry during her admission for
behavioral issues and developmental disorder. In addition to her
Klonopin she received PRN Valium.
On [**4-23**], she was noted to have increased agitation and stated she
had abdominal pain. She was also unable to void. Foley catheter
was placed which found the bladder to be retaining 900cc urine.
She was given a voiding trial on [**4-25**] and failed, so Foley
catheter was replaced. Subsequently the patient pulled her foley
catheter and repeat post-void residual measurement revealed
<100cc residual on multiple repeat measurements. It appears that
the patient's urinary retention resolved. She has no signs of
ongoing urinary difficulty. For recurrent abdominal complaints
or changes in urinary patterns, this issue should be
re-investigated.
The patient had signs of a significant fungal infection of the
perineum and intercrural region. Attempts were made at treating
this with antifungal powder however the patient intermittently
refused this therapy and she did not show clinical response. She
was therefore started on a 2 week course of oral fluconazole.
She requires ongoing attempts at keeping the area clean and dry
to allow adequate healing.
Medications on Admission:
Azathioprine 25 mg daily
Clonazepam 0.5mg [**Hospital1 **]
Benadryl 25 mg daily
Prednisone 10 mg daily
Prevacid 30 mg [**Hospital1 **]
CaCO3 500 mg [**Hospital1 **]
Vitamin B12
Colace 100 mg [**Hospital1 **]
Vitamin D
Folate 1gm qAM
MVI
Miralax
Discharge Medications:
1. azathioprine 75 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. clonazepam 0.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times
a day).
3. diphenhydramine HCl 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO once
a day as needed for acute agitation.
4. prednisone 10 mg Tablet [**Hospital1 **]: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
5. Prevacid SoluTab 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] twice a day.
6. calcium carbonate 500 mg calcium (1,250 mg) Tablet [**Last Name (STitle) **]: One
(1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
7. cholecalciferol (vitamin D3) 400 unit Tablet [**Last Name (STitle) **]: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. folic acid 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
9. diazepam 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
10. acetaminophen 325 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain fever.
11. atovaquone 750 mg/5 mL Suspension [**Last Name (STitle) **]: Two (2) PO DAILY
(Daily).
Disp:*60 doses* Refills:*3*
12. fluconazole 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q24H (every
24 hours) for 2 weeks.
Disp:*12 Tablet(s)* Refills:*0*
13. Outpatient Lab Work
Weekly blood tests on Monday: CBC, LFT's and chem 7. Discuss the
results with your physician.
Discharge Disposition:
Extended Care
Facility:
group home
Discharge Diagnosis:
- Pancolitis, possibly from lupus
- Systemic lupus erythematosus
- Pneumonia, right upper lung, with MSSA and E. Coli from
aspiration
- Bacteremia, coagulase-negative staph aureus
- Urinary tract infection, E. Coli
- Urinary retention, resolved
- Developmental delay
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with nausea and vomitting from colitis that we
think is related to your lupus. You were treated with
decompression with an NG tube and steroids and you gradually
improved. During the admission, you were also found to have a
pneumonia, urinary infection and bacteremia, all of which were
treated with antibiotics.
Treatment for lupus was given; initially with steroids and then
Azathioprine was added. You should continue to take these
medications along with atovaquone and calcium with vitamin d.
You should also follow-up with your rheumatologist for ongoing
care of this issue. Have weekly blood testing while on
azathioprine.
You were also noted to have urinary retention and a Foley
catheter was placed. This seems to have resolved. You have an
appointment on [**5-6**] with [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 90102**] and she will
arrange for you to follow-up with a urologist if necessary.
You also have a severe fungal infection of the thighs. Please
use the anti-fungal cream as prescribed as well as fluconazole
for 2 weeks.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] M.
Location: Meeting House Family Practice
Address: [**Last Name (un) 90103**], [**Location (un) **],[**Numeric Identifier 90104**]
Phone: [**Telephone/Fax (1) 90105**]
Appointment: Thursday [**5-6**] at 10:45AM
**Please speak with your PCP at this appointment about the need
to see a Urologist. They will arrange for this appointment if
necessary.**
Department: RHEUMATOLOGY
When: TUESDAY [**2123-5-11**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 4900**], MD [**Telephone/Fax (1) 2226**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"790.7",
"560.89",
"299.90",
"584.9",
"V49.87",
"599.0",
"276.8",
"788.20",
"511.9",
"780.39",
"710.0",
"507.0",
"276.0",
"482.82",
"300.3",
"482.41",
"110.8",
"780.09",
"307.9",
"556.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.25",
"99.15",
"96.04",
"38.93",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
10273, 10310
|
5046, 8402
|
479, 547
|
10620, 10620
|
3006, 5023
|
11877, 12627
|
2444, 2539
|
8697, 10250
|
10331, 10599
|
8428, 8674
|
10770, 11854
|
2554, 2987
|
397, 441
|
575, 1955
|
10635, 10746
|
1977, 2262
|
2278, 2428
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,913
| 156,867
|
30572
|
Discharge summary
|
report
|
Admission Date: [**2126-5-14**] Discharge Date: [**2126-5-17**]
Date of Birth: [**2066-8-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 465**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
colonoscopy
History of Present Illness:
59 yo man with no significant prior medical history transferred
to [**Hospital1 18**] from [**Hospital3 13313**] with GI bleed. Pt initially
presented to [**Hospital3 13313**] on [**5-11**] after 4-5 episodes of
bloody diarrhea earlier that day. He estimates about 4 ounces
of BRB during each episode. He denies any lightheadedness, SOB,
CP, fever, chills, nausea, vomiting, or abdominal pain. Of
note, the patient had a prostate biopsy on [**5-6**] but denies any
complications after the procedure.
.
At [**Hospital3 13313**], he received 5 units of PRBC (patient is
O negative). EGD showed small hiatal hernia, a non-bleeding
erosion at the pylorus, and a non-bleeding erosion at the
duodenal bulb. Patient also had a flex sig and colonoscopy
significant for diverticulosis of the sigmoid and descending
[**Hospital3 499**] and non-bleeding internal hemorrhoids. Quality of flex
sig was poor; quality of colonoscopy was fair. H. pylori IGG
was negative. Per report, his hospitalization was complicated
by minor alcohol withdrawal. He was discharged to home on [**5-13**]
with HCT = 27.7 after bleeding spontaneously stopped, where he
felt well for several hours before he began having bloody
diarrhea again. He noted clots at this time. He returned to
[**Hospital3 13313**] and was given an additional 2 units of PRBC
for HCT = 25. He was transferred from the [**Hospital1 10478**] ICU to
the [**Hospital1 18**] ICU. Last episode of bloody diarrhea before transfer
to [**Hospital1 18**] was at 3am.
Past Medical History:
prostate biopsy on [**2126-5-6**] for increasing PSA; follow-up biopsy
scheduled in 6 months. Per patient report, biopsy results
showed no evidence for cancer
Social History:
electrical engineer; lives with his wife and daughter in [**Name (NI) **],
MA. 3 alcoholic drinks daily, usually red wine. Last drink was
[**5-10**]. 35 year history of smoking a pipe; no cigarettes; denies
IVDA.
Family History:
mother with [**Name2 (NI) 499**] cancer in her 60s
Physical Exam:
T 99.2 HR 96 BP 141/68 RR 12 99% O2 sat on RA
Gen: well-appearing; NAD
HEENT: atraumatic; normocephalic; pupils 3->2 bilaterally
Neck: supple; no cervical LAD
CV: RRR; nl S1, S2; no M/R/G; no JVD
Lungs; CTAB
Abd: soft, non-distended; +BS; non-tender to palpation; no
organomegaly
Extrem: no c/c/e; 2+ DP pulses bilaterally
Skin: warm, dry, intact
Neuro: CN grossly intact; full strength and sensation throughout
Pertinent Results:
[**2126-5-14**] 02:45PM FIBRINOGE-213
[**2126-5-14**] 02:45PM PT-11.6 PTT-26.6 INR(PT)-1.0
[**2126-5-14**] 02:45PM PLT COUNT-148*
[**2126-5-14**] 02:45PM ANISOCYT-1+
[**2126-5-14**] 02:45PM NEUTS-77.6* LYMPHS-17.1* MONOS-4.7 EOS-0.5
BASOS-0.1
[**2126-5-14**] 02:45PM WBC-7.0 RBC-3.05* HGB-9.6* HCT-27.2* MCV-89
MCH-31.5 MCHC-35.4* RDW-16.5*
[**2126-5-14**] 02:45PM ETHANOL-NEG
[**2126-5-14**] 02:45PM TSH-4.4*
[**2126-5-14**] 02:45PM ALBUMIN-2.8* CALCIUM-7.2* PHOSPHATE-2.6*
MAGNESIUM-1.8
[**2126-5-14**] 02:45PM LIPASE-31
[**2126-5-14**] 02:45PM ALT(SGPT)-41* AST(SGOT)-39 LD(LDH)-131 ALK
PHOS-33* TOT BILI-0.5
[**2126-5-14**] 02:45PM estGFR-Using this
[**2126-5-14**] 02:45PM GLUCOSE-115* UREA N-5* CREAT-0.6 SODIUM-134
POTASSIUM-3.2* CHLORIDE-96 TOTAL CO2-21* ANION GAP-20
[**2126-5-14**] 06:25PM HCT-25.5*
[**2126-5-14**] 08:48PM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
[**2126-5-14**] 08:48PM URINE BLOOD-LGE NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2126-5-14**] 08:48PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.012
[**2126-5-14**] 11:53PM HCT-27.1*
[**2126-5-15**] 04:21AM BLOOD WBC-5.9 RBC-2.67* Hgb-8.5* Hct-23.8*
MCV-89 MCH-31.9 MCHC-35.9* RDW-16.4* Plt Ct-174
[**2126-5-16**] 05:30AM BLOOD WBC-5.2 RBC-3.28* Hgb-10.5* Hct-29.1*
MCV-89 MCH-32.0 MCHC-36.1* RDW-17.3* Plt Ct-238
[**2126-5-17**] 12:45AM BLOOD WBC-5.4 RBC-3.04* Hgb-9.8* Hct-27.1*
MCV-89 MCH-32.2* MCHC-36.0* RDW-17.4* Plt Ct-288
[**2126-5-17**] 08:05AM BLOOD WBC-6.6 RBC-3.77* Hgb-12.0* Hct-32.8*
MCV-87 MCH-31.7 MCHC-36.4* RDW-17.5* Plt Ct-306
[**2126-5-15**] 04:21AM BLOOD Plt Ct-174
[**2126-5-17**] 12:45AM BLOOD Plt Ct-288
[**2126-5-17**] 08:05AM BLOOD Plt Ct-306
.
.
STUDIES:
COLONOSCOPY [**2126-5-15**] - Red spot along a vessel in the rectum
compatible with old biopsy site. Endoclip was placed. Polyp in
the rectum. Diverticulosis of the sigmoid [**Month/Day/Year 499**].
Brief Hospital Course:
1. GI bleed - pt's bleeding was felt to be [**3-15**] bleeding form
site of his recent prostate biopsy. he remained hemodynamically
stable throughout his ICU course. Initial HCT on arrival was
27.2. He was given 40 mg pantoprazole IV twice daily. The
patient was evaluated by GI and prepped for colonoscopy
overnight. Initial stools were mostly liquid with bright red
blood. After completing the prep, the patient was passing clear
yellow liquid without blood. Early morning HCT on [**5-15**] was 23.8.
A repeat HCT was drawn on [**5-15**] just before transfusion of 1 unit
PRBC, which was 26.8. HCT after transfusion of 1 unit PRBC was
29.9. He underwent colonoscopy on [**5-15**].
.
colonscopy showed site of bleeding at site of prostate biopsy,
clips were applied. HCT was stable x 12 hours, thus pt was
called out to floor. on the medical floor pt received 1.5L IVF
given some tachcyardia, however, his HCT remained stable, thus
he was discharged home with instructions to f/u with his PCP and
to avoid NSAIDs.
.
.
2. EtOH withdrawal - Per report from [**Hospital3 13313**], the
patient had mild alcohol withdrawal during his prior
hospitalization from [**5-11**] to [**5-13**]. The patient denied any
alcohol use since [**5-10**]. Serum EtOH level on admission was
negative. The patient had no symptoms of alcohol withdrawal
during his ICU course. He was seen by social work for support.
.
3. Hematuria - Large amount of blood was noted on urine
dipstick with no RBCs. CK was 127. The patient was instructed
to follow-up with his PCP.
Medications on Admission:
aspirin 81 mg daily
Discharge Disposition:
Home
Discharge Diagnosis:
primary:
lower gi bleeding
dehydration
alcohol withdrawal
Discharge Condition:
stable, HR 80s, HCT=32.
Discharge Instructions:
you were admitted to the hospital because of bleeding from your
rectum. a colonscopy was performed and revealed a source at the
site of a recent prostate biopsy. this site was clipped to stop
the bleeding.
.
you were discharged home with instructions to discontinue
aspirin use until instructed to restart by your PCP.
.
you were not started on any new medications.
.
if you develop recurrent symptoms of light headedness, being
pale, bleeding from your rectum, bloody diarrhea, fevers,
chills, shortness of breath, or other worrisome symptoms please
contact your primary care physician or the emergency department.
Followup Instructions:
please follow-up with your PCP [**Name Initial (PRE) 176**] 4-6 weeks. specifically,
you were found to have a sessile polyp at the time of
colonscopy, this should be followed with routine screening.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
|
[
"E878.8",
"285.1",
"276.1",
"276.51",
"569.0",
"998.11",
"600.00",
"291.81",
"305.01",
"562.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.43"
] |
icd9pcs
|
[
[
[]
]
] |
6439, 6445
|
4808, 6369
|
323, 336
|
6547, 6573
|
2815, 4785
|
7240, 7564
|
2312, 2364
|
6466, 6526
|
6395, 6416
|
6597, 7217
|
2379, 2796
|
275, 285
|
364, 1880
|
1902, 2063
|
2079, 2296
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,339
| 155,417
|
37498
|
Discharge summary
|
report
|
Admission Date: [**2133-12-9**] Discharge Date: [**2134-1-9**]
Date of Birth: [**2071-2-21**] Sex: M
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 4611**]
Chief Complaint:
Right Parietal Occipital Brain Mass
Major Surgical or Invasive Procedure:
Craniotomy with resection of supratentorial metastases
Rhinoscopy
History of Present Illness:
62M w/ hx of ETOH abuse, A-fib, cardiomyopathy who was found to
be confused and shaking on [**12-9**]. He was brought to [**Hospital 6138**]
Hospital, where a non-contrast CT-head showed 3.5x 4.2cm right
parietooccipital mass. He was tranferred to [**Hospital1 18**] for definitive
intervention.
Past Medical History:
A-fib, ETOH abuse, cardiomyopathy
Social History:
+ETOH abuse, otherwise unknown
Family History:
unknown
Physical Exam:
On Admission:
Gen: WD/WN, comfortable, NAD.
HEENT:Atraumatic Pupils: 6->4mm EOMs full
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 6 to 4
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-12**] throughout. L pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Toes downgoing bilaterally
On Discharge:
XXXXXXXXXXXXXX
Pertinent Results:
Labs on Admission:
[**2133-12-9**] 05:20PM BLOOD WBC-13.5* RBC-4.01* Hgb-12.5* Hct-37.1*
MCV-92 MCH-31.2 MCHC-33.7 RDW-16.3* Plt Ct-258
[**2133-12-9**] 05:20PM BLOOD Neuts-94.3* Lymphs-3.1* Monos-1.1*
Eos-0.9 Baso-0.7
[**2133-12-9**] 05:20PM BLOOD PT-13.3 PTT-25.1 INR(PT)-1.1
[**2133-12-9**] 05:20PM BLOOD Glucose-103 UreaN-26* Creat-1.1 Na-141
K-3.3 Cl-99 HCO3-28 AnGap-17
[**2133-12-9**] 05:20PM BLOOD CK(CPK)-57
[**2133-12-9**] 05:20PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2133-12-10**] 01:20AM BLOOD Phenyto-9.1*
[**2133-12-10**] 01:20AM BLOOD Digoxin-1.4
[**2133-12-9**] 05:20PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
Labs on Discharge:
XXXXXXXXXXXXXXXX
MICRO:
-[**12-10**] Urine culture: PROBABLE ENTEROCOCCUS. ~1000/ML.
IMAGING:
-[**12-21**] CT Neck:
1. Extensive nodular mass present throughout the neck, with
lymphadenopathy present bilaterally and the largest conglomerate
of masses seen on the right as detailed above.
2. Heterogeneous bulky appearance to the right side of the
glottis and
supraglottic region which needs evaluation with direct
exmaination and MR [**First Name (Titles) **] [**Last Name (Titles) 31186**] [**Last Name (un) 78953**] without and with contrast
for better assessment of extension and exclude neoplasm in this
location.
3. Heterogeneous mass close to the right palatine tonsil
extending into
parapharyngeal space and carotid space- ? nodal mass or mass in
the
tonsillar/peritonsillar region. Correlation with ENT examination
and MR [**First Name (Titles) **] [**Last Name (Titles) 31186**] [**Last Name (un) 78953**] can be helpful to assess the extent
-[**12-17**] MRI Brain:
1. Status post craniotomy and resection of the previously seen
tumor centered in the calvarium, with supratentorial and
infratentorial extension. There may be a small focus of residual
nodular enhancement in the infratentorium which may represent
residual disease versus post-surgical changes. In the
supratentorial compartment, there is smooth pachymeningeal
enhancement, without nodularity to suggest residual neoplasm.
2. Large bulky mass in the right aspect of the neck as well as
a necrotic node of Rouviere. The findings may represent a
conglomerate of metastatic lymph nodes, but the appearance given
the relationship to the pyriform sinus raises the possibility of
a primary neoplasm of the head and neck. Dedicated CT of the
neck is recommended for further evaluation.
[**12-17**] CT Head:
1. Expected postoperative change at the site of right parietal
craniectomy
for tumor resection.
2. Combination of edema and encephalomalacia in right parietal,
temporal, and occipital lobes.
3. No unexpected large hemorrhage.
[**12-11**] CTA Head: 1. Segment of non-opacification within the right
transverse sinus, consistent with likely chronic occlusion. The
remainder of the dural sinuses in addition to the visualized
right internal jugular vein remain patent.
2. Large mass centered in the right parietal bone, better
assessed on recent MRI of the head.
[**12-10**] MRI Head
Diffusely enhancing mass centered in the right parietal bone,
extending into the subcutaneous tissues as well as involving the
leptomeninges with mass effect on the adjacent right parietal
and temporal lobes and probable invasion of the transverse and
sigmoid sinuses. Differential considerations include metastatic
disease as well as a plasmacytoma.
Meningioma and a chronic infection are less likely but still
considerations.
CT Torso [**12-10**]:
IMPRESSION:
1. Findings of metastatic disease without a definite primary
lesion
identified.
2. Bilateral supraclavicular, right paratracheal, retrocrural,
mesenteric,
and retroperitoneal lymphadenopathy.
3. Numerous hepatic masses consistent with metastases.
4. 5mm left upper lobe pulmonary nodule.
5. Small right pleural effusion with underlying atelectasis.
6. Destructive lesion of the right ischium.
7. Right posterior sixth rib fracture without callus formation
which
therefore may be pathologic.
PATHOLOGY:
-[**12-11**] Lymph node biopsy: A. Lymph node, site not specified:
Poorly differentiated non-small carcinoma. B. Lymph node, site
not specified: Poorly differentiated non-small cell carcinoma.
Immunophenotyping:
A limited panel was attempted to exclude a B-cell non-Hodgkin
lymphoma, however was non-diagnostic due to insufficient numbers
of B cells for analysis. Correlation with clinical findings and
morphology (see separate report) is recommended. Flow cytometry
immunophenotyping may not detect all lymphomas as due to
topography, sampling or artifacts of sample preparation.
-[**12-17**] Surgical Pathology:
1. Muscle, mastoid, right (A-E): Metastatic carcinoma with
focal squamous cell differentiation.
2. Bone, temporal, right (F-G): Metastatic carcinoma with
squamous cell differentiation.
3. "Temporal tumor" right (H-O): Metastatic carcinoma with
squamous cell differentiation
Brief Hospital Course:
Patient was admitted to [**Hospital1 18**] dept of neurosurgery after having
an episode of confusion and shaking. He was then taken to an
OSH, where CT head imaging revealed a right sided
parietal-occipital mass. He was admitted to the intensive care
unit for frequent neurlogical monitoring and managment. MRI of
the head, as well as CT of the Torso were obtained which
revealed significant, likely metastatic disease. In this
setting, Craniotomy for resection was deferred pending further
work up. A Lymph node biopsy was obtained which revealed
metastatic carcinoma. Further differentiation was not able to be
done from the biopsy. The patient underwent a
craniectomy/craniotomy for resection of the skull mass and
supratentorial lesion on [**2133-12-17**]. He also had a cranioplasty
with mesh as the bone was not able to be replaced due to the
infiltration of the mass.
The patient went directly to CT scan from the OR and the scan
showed no hemorrhage and confirmed resection of the
supratentorial portion of the mass. The patient the went to the
ICU and remained intubated overnight. He was extubated the
following day and later transferred to the neurosurgery floor.
The patient's steroids were weaned to 2 mg [**Hospital1 **]. His neuro exam
remained stable and he was ambulating without difficulty.
He was transferred to the OMED service on [**2133-12-22**] for
initiation of chemotherapy.
*****************
The patient started chemotherapy with cisplatin and
5-fluorouracil on [**12-25**]. On [**2134-1-9**] he expired. His OMED course
involved the following issues:
.
# Squamous cell Carcinoma: The patient's pathology revealed
metastatic carcinoma with squamous cell differentiation. CT
scans and rhinoscopic visualization performed by ENT suggested
that a soft [**Date Range 31186**] mass in the right neck was the primary
cancer. Vascular surgery was consulted, given the proximity of
the mass to the patients carotid artery, and they said they
would be available for assistance, in the event that the neck
mass would be resected. As above, the patient underwent his
first cycle of cisplatin/5FU on [**12-25**]. His chemotherapy was
complicated by tumor lysis syndrome and neutropenia (pleae see
below).
# Tumor lysis syndrome/[**Last Name (un) **]: Following his first cycle of
chemotherapy, the patient developed signs of tumor lysis,
including acute kidney injury, hyperphosphatemia, hypocalcemia,
hyperuricemia (in the setting of a high baseline uric acid
level), and an LDH level that rose into the 5000s. He did not,
however, develop hyperkalemia. His creatinine rose from a
baseline of 0.9 to 1.8. He was treated with aggressive IV
hydration, at 200 cc/hour continuously, for several straight
days. Both normal saline and D5W with NaHCO3 were used, aiming
to keep the patient from becoming acidotic, but also to avoid
over-alkalinization and subsequent exacerbation of calcium
phosphate precipitation in the renal tubules. He had excellent
urine output during this time. Renal was consulted, and
attributed the [**Last Name (un) **] to cisplatin nephrotoxicity. IV fluid rates
were subsequently decreased. As of [**1-3**], creatinine had
improved back to 1.4. Urinalysis was sent, revealing hyaline
casts. The aggressive hydration caused severe generalized
edema. However, because the pt's BPs remained in the low 90's
he was not diuresed. He was maintained on his home lasix 40 mg
PO and his IVF were stopped. His Is and Os remained even to
slightly negative and his edema improved.
.
# Nuetropenia: Over the course of his hospitlaization the
patient's cell counts decreased and on C1D#12 after the
cisplatin/5FU he became neutropenic. It was thought that his
nuetropenia was likely due to the chemotherapy. His Hct stayed
around 30 and his platelets around 40 - 60. However, it was
possible that his dilantin was contributing to decreased
production in the BM so this medication was stopped. The
patient was switched to Keppra 500 mg [**Hospital1 **] which is less toxic to
the bone marrow. This medication was to be weaned slowly over
time and eventually discontinued. The patient remained afebrile
and was treated with supportive care. Overnight on [**2134-1-9**] he
became hypotensive, unresponsive to fluids. Then after having
3.5 liters of fluid (BP still in 60s), he developed resp
distress. The next AM he was mentating with BP in 60s, then
throughout the day became more unresponsive. ABG showed a mixed
metabolic and respiratory acidosis with an elevated lactate. No
EKG changes, and pt was warm, so unlikely cardiogenic shock. He
was afebrile, but given empiric vanco and zosyn. His WBC had
been improving. However, he stopped making urine and appeared by
labs to have ATN. Lasix was given to help with his breathing,
but had no effect despite large doses. Family was there and
confirmed that he was DNI/DNR and they did not want an ICU
transfer or escalated care. That afternoon he was placed on a
morphine gtt, about 1 hour later he passed.
.
# Acute kidney injury: The patient initially presented with a
creatinine of 1.1. After the chemotherapy it bumped to 1.6
where it remained. Renal was consulted and felt that the [**Last Name (un) **]
was from cisplatin toxicity. The day of [**2134-1-9**] the patient's
creatinine was 3.1 (see above) and he appeared to be in ATN.
.
# abdominal discomfort: The patient complained of increasing
abdominal discomfort and gas with increased appetite, but nausea
and pain after PO intake. He continued to pass flatus and
multiple loose BMs several times a day. C. diff was negative x
2. On [**1-6**] a KUB was obtained to rule out SBO which was also
negative. Digital disempaction was unable to be performed
secondary to the patient's nuetropenia. He was encouraged to
ambulate and get OOB and was kept on bowel regimen.
.
# Head trauma: On [**1-3**], the patient fell forward from sitting
on the edge of his bed. He quickly developed a hematoma over his
right forehead. STAT head CT revealed a extracranial hematoma,
and (likely chronic) pooling of CSF at the site of the surgery.
As the patient was thrombocytopenic to 60K that morning, he was
transfused platelets, with a post-transfusion plt level of 89K.
Given the relative proximity to the patient's craniotomy site,
neurosurgery was asked to come see the patient; they recommended
no further intervention, other than the platelet transfusion and
regular neuro checks. The patient continued to have a non-focal
neurologic exam as the hematoma resolved.
.
# BRBPR/Diarrhea: On the night of [**1-1**], the patient had a
single episode of BRBPR, with no major change in Hct or
hemodynamic instability. Following that episode, the patient had
frequent episodes of watery diarrhea, with no further blood. C.
Diff was negative x 2, and the patient was started on PRN
imodium. He has never had a colonoscopy, and outpatient
screening colonoscopy was recommended.
.
# Atrial fibrillation w/RVR: The patient was generally well rate
controlled with dilitazem 30 QID and lopressor 50 TID. These
medications were frequently held, because of hypotension.
Digoxin was also continued and levels were generally found to be
therapeutic. The patient was kept on telemetry, which altered
between runs of tachycardia and occasional bradycardia with
asymptomatic pauses of ~2 seconds. Anticoagulation was held,
given chemo and expected drop in cell counts, BRBPR (see above),
and recent neurosurgery.
.
# Cardiomyopathy/CHF - The patient was found to have an EF of
50-55% as seen on [**12-10**] TTE. In spite of aggressive IV fluid
hydration for tumor lysis (see above), the patient did not
experience any dyspnea or hypoxemia suggestive of pleural
effusions. He did experience significant symmetric edema of his
lower extremities, and gained upwards of 30 lbs. His beta
blocker, CCB, digoxin and lasix were all continued as above. He
was kept on a low sodium diet. His fluids were tapered and he
was not aggressively diuresed (as above) and his edema resolved.
.
# Anemia - The patient maintained a Hct around 30. He was
transfused 1 unit of RBCs on [**2134-1-2**]. Hct remained stable
after BRBPR.
.
# Thrombocytopenia: The patient maintained platelet levels
stably low ~60K. Other coag studies were normal, including
fibrinogen. The patient had significant ecchymoses at sites of
subcutaneous injections. His subcutaneous heparin was
discontinued and he was placed on pneumoboots and ambulation for
DVT prophylaxis.
.
# Hearing loss: The patient complained of worsening hearing out
of both ears, in the days following his cisplatin/5FU regimen.
.
# Code: The patient was confirmed DNR/DNI on [**12-17**]
Medications on Admission:
Ranitidine 150', Klor-Con 10mEq, Metoprolol 25', Lasix 40mg',
Diltiazem 60mg", Digoxin 125mcg'
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
|
[
"348.5",
"276.4",
"285.9",
"E884.4",
"787.91",
"790.6",
"198.4",
"389.9",
"275.3",
"198.3",
"V12.71",
"274.9",
"277.88",
"197.7",
"599.0",
"287.5",
"E933.1",
"427.31",
"288.60",
"041.04",
"196.8",
"428.0",
"293.0",
"733.19",
"303.90",
"198.5",
"195.0",
"275.41",
"920",
"197.0",
"197.3",
"528.01",
"288.03",
"569.3",
"425.4",
"584.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.25",
"02.12",
"01.59",
"38.93",
"86.07",
"40.11"
] |
icd9pcs
|
[
[
[]
]
] |
15712, 15721
|
6922, 15567
|
304, 372
|
15772, 15782
|
1990, 1995
|
819, 828
|
15742, 15751
|
15593, 15689
|
843, 843
|
1954, 1971
|
229, 266
|
2657, 4432
|
400, 697
|
1238, 1940
|
4441, 6899
|
2009, 2638
|
1001, 1222
|
719, 755
|
771, 803
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,688
| 175,731
|
47915
|
Discharge summary
|
report
|
Admission Date: [**2147-12-4**] Discharge Date: [**2147-12-17**]
Date of Birth: [**2085-10-10**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
dyspnea on exertion
Major Surgical or Invasive Procedure:
preop for MVR-case aborted
History of Present Illness:
62 y/o male with severe CAD, s/p CABG [**2124**], s/p CABG [**2132**]
(LIMA-LAD, SVG-RCA, SVG-Diag, SVG-OM), s/p PTCA and BMS to
SVG-OM on [**2147-11-8**] at [**Hospital1 18**], dilated cardiomyopathy, severe MR,
moderate PA HTN, and chronic AF on coumadin. He was planned to
undergo MVR by Dr. [**Last Name (STitle) 1290**] [**12-11**] but after intubation patient
crashed, PA line with PA pressures equal to systemic pressures.
He had insertion & removal of ECMO femoral cannulas with closure
of R femoral [**Month/Year (2) **] with perclose device [**12-11**] Dr. [**Name (NI) **]
didn't want to do right thoracotomy and one lung ventilation
with high pulmonary pressures. The surgeons considered doing an
from mediansterotomy, but if doesn't go well then they wanted a
back-up out strategy of ? LVAD +/- ? heart transplant. The
patient refused this option and now is being medically managed
for his heart failure.
.
ON transfer to the CCU he was complaining of no CP or SOB. He
can lie flat in bed without SOB. Denies swelling in legs. Does
endorse feeling lightheaded when standing or walking. Few weeks
ago he had black stools for ~1wk. UGI and LGI scoping in last
1.5 years with only benign polyps. He was told to avoid ASA at
the time.
Past Medical History:
CAD-CABG '[**22**]/'[**31**],PCI '[**46**]
Cardiomyopathy
Sev MR
Afib
^chol
CVA after 2nd CABG
CCY
Appy
Tonsillectomy
Social History:
Lives with wife. retired
denies tobacco or etoh
Family History:
father MI @63yo
Physical Exam:
BP 117/54 (MAP 70), HR 73, O2 sat 100% on 2L NC
General: lying in bed in NAD; very pleasant male.
HEENT: PERRL, EOMI, MMM, anicteric sclera, non-injected
conjunctiva, OP mild erythema but no exudate. No cervical or
supraclavicular LAD. RIJ in place.
CV: irreg irreg, 3/6 systolic murmur heard best at apex but
throughout precordium.
Lungs: CTAB no w/r/r
Abdomen: +BS, soft, NTND
Ext: trace bilateral lower extremity edema. No clubbing or
cyanosis. R groin dressing c/d/i. no hematoma or bruit. DP
pulses 1+ BLE.
Neuro: CNII-XII in tact, strength 5/5 in right UE, [**1-22**] in left
UE distally. [**3-23**] in bilateral LE
Pertinent Results:
Hemo: Systemic pressures 110/50, PA 83/30 mean 50, PCW 30, CO 5.
PVR = 442, [**Doctor Last Name **] units = 5.5 on Milrinone 0.25
Milrinone 0.5 --> [**Doctor Last Name **] units 2.7, milrione 0.75 --> 4.0 [**Doctor Last Name **]
units
.
.
133 102 10
-------------<
-- 24 0.6
Ca: 9.4 Mg: 2.2 P: 3.9
.
91
6.0 8.9 139
>-------<
24.8
.
PT: 13.3 PTT: 56.1 INR: 1.2
.
[**2147-12-13**] ECHO:
Conclusions:
1. The left atrium is moderately dilated.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is severely depressed. 20% given the severity
of valvular regurgitation.] Global hypokinesis with inferior
wall akinesis.
3.The mitral valve leaflets are mildly thickened. Severe (4+)
mitral
regurgitation is seen. The left ventricular inflow pattern
suggests a restrictive filling abnormality, with elevated left
atrial pressure.
4.There is moderate pulmonary [**Month/Day/Year **] systolic hypertension.
5. The RV function is deverely reduced.
Compared with the findings of the prior study (images reviewed)
of [**2147-12-8**], the MR [**First Name (Titles) **] [**Last Name (Titles) **] are slightly less while the EF is
slightly reduced. However the MR is worse relative to the study
of [**2147-12-11**].
Brief Hospital Course:
A/P: 62 yo M with severe MR transferred to CCU for medical
management of his heart failure. As described in the HPI, he
was admitted to the surgery team for MVR. He was hospitalized
for about a week before the surgery, and he was planned to
undergo MVR by Dr. [**Last Name (STitle) 1290**] [**12-11**]. DUring induction, he
crashed. A PA line was placed and showed PA pressures equal to
systemic pressures. He had insertion & removal of ECMO femoral
cannulas with closure of R femoral [**Month/Year (2) **] with perclose device
[**12-11**]. He quickly stablized after this event and was transferred
to the CCU for medical management as the patient did not want
surgery with if the risk was LVAT and transplant. He wanted to
improve his CHF at least to allow him to walk across a room. The
rest of his hospital course is described below.
.
#cardiac:
.
PUMP: LVEF of 20% and severe MR 4+ on latest ECHO. Patient does
not want surgery if there is possibility of LVAD or transpant
needed if surgery fails. He prefers medical management. He was
euvolemic by exam. He was briefly tried on a milrinone drip;
but it became clear that he did not want to go home on an IV
infusion although the milrinone did help his [**Doctor Last Name **] units
improve. This was discontinued and his Swan line was pulled.
He was kept on lisinopril 10, coreg 3.125 [**Hospital1 **], lasix 20 daily.
He walked with nurses prior to leaving and was asymptomatic.
.
ISCHEMIA: s/p CABG x2 years ago and PCI in [**10-24**] with stent to
SVG to OM. He was continued on plavix and aspirin as well as a
beta blocker and ACEI.
.
RHYTHM: He remained in rate controlled afib throughout his
hospitalization.
He was kept on a heparin gtt during the hospitalization, and
then transitioned to warfarin 4 prior to discharge. He will
follow up with his PCP for INR check.
.
#anemia: normocytic anemia. HCT decreased likely secondary to
blood draws and surgical procedure. He had recent c-scope and
UGI in last 1.5 years with only benign polyps seen. He was told
to avoid ASA at that time. He was started on low dose ASA and
maintained on a PPI for GI ppx. He was transfused 1 Unit of
pRBCs for a low HCT of 24.8. His hct was stable prior to
discharge.
.
#FEN: heart healthy, low sodium diet. Replete lytes prn. Fluid
restriction
.
#PPX: coumadin for afib. PPI for GI ppx given possible h/o of GI
bleeding
.
#code: full code
Medications on Admission:
ASA 325'
Lisinopril 20'
Plavix 75'
Aldactone 25'
Crestor 20' Celexa 20'
Coreg 3.125"
Lasix 40"
Digoxin 0.125'
KCL 20'
Warfarin 4'
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
7. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
CHF, severe MR
[**First Name (Titles) **] [**Last Name (Titles) **] disease
atrial fibrillation
Discharge Condition:
fair
BP 90/50, HR 70, 95% RA
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
.
Please continue to take all medications as prescribed. You
should seek medical attention if you have worsening shortness of
breath, fatigue, light headedness, palpitations, or for any
other concern.
.
You will need to see you primary care doctor for an INR check
within the week as well.
Followup Instructions:
please make a follow-up appointment with your cardiologist and
PCP [**Name Initial (PRE) 176**] 1 week
[**Last Name (LF) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 101099**]
[**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 975**] [**Telephone/Fax (1) 4451**]
Dr. [**Last Name (STitle) 101100**], your cardiologist in NH
Completed by:[**2147-12-18**]
|
[
"427.31",
"428.0",
"458.29",
"V64.1",
"414.01",
"428.23",
"416.8",
"424.0",
"425.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"00.40",
"38.93",
"39.59"
] |
icd9pcs
|
[
[
[]
]
] |
7278, 7284
|
3854, 6248
|
345, 373
|
7424, 7455
|
2544, 3831
|
7895, 8288
|
1869, 1886
|
6428, 7255
|
7305, 7403
|
6274, 6405
|
7479, 7872
|
1901, 2525
|
286, 307
|
401, 1647
|
1669, 1788
|
1804, 1853
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,581
| 101,552
|
6084
|
Discharge summary
|
report
|
Admission Date: [**2173-4-22**] Discharge Date: [**2173-5-10**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 87 year old
man with a history of end stage renal disease from systemic
lupus erythematosus (SLE) who was found to spike a
temperature of 104 degrees at the end of his hemodialysis
session on [**2173-4-23**]. He had been started on Vancomycin
the day prior, that for a positive wound culture from a right
Hickman's which was taken on [**4-15**], and was positive on [**4-18**]
and grew Coagulase positive Staphylococcus which was
sensitive to Oxacillin. He also did get a dose of Vancomycin
of 500 mg at hemodialysis. The port site did appear
erythematous and given his temperature of 104 degrees he was
taken to the Emergency Room for further evaluation. En route
to the Emergency Room the blood pressure was 110/58 with a
heartrate of 106, and respirations were 20, however, in the
Emergency Room his systolic blood pressure decreased to the
low 80s; however, he was asymptomatic, maintaining well and
had good urine output. He was given 1 liter of normal saline
as well as started on a Dopamine drip. Systolic blood
pressures remained in the 80s on this and he was therefore
admitted to the Medicine Intensive Care Unit. The line was
pulled by Interventional Radiology Service in the Emergency
Room. The patient's white blood cell count was increased to
17 down to 7 from prior laboratory data, and he was also
started on Levofloxacin and Flagyl in the Emergency Room.
PAST MEDICAL HISTORY: 1. End stage renal disease secondary
to systemic lupus erythematosus on hemodialysis since [**2167**];
2. Dementia; 3. Hypertension; 4. Anemia; 5. Depression;
6. Hyperthyroidism; 7. Coronary artery disease, status post
myocardial infarction in [**2168**] and catheterization in [**2168**]
showed three vessel disease with percutaneous transluminal
coronary angioplasty stent to the left anterior descending.
7. Status post cerebrovascular accident. 8. Status post
deep vein thrombosis. 9. Ejection fraction of 30% on
echocardiogram in [**2168**]. 10. Osteoarthritis.
ALLERGIES: The patient is allergic to non-steroidal
anti-inflammatory drugs, Aspirin, magnesium, laxatives and
Plaquenil.
MEDICATIONS ON ADMISSION: 1. Levoxyl 150 mcg q.d.; 2.
Nephrocaps one tablet p.o. q.d.; 3. TUMS 650 mg t.i.d.; 4.
Coumadin 5 mg q.d.; 5. Aricept 10 mg p.o. q.h.s.; 6.
Atenolol 25 mg p.o. q.h.s.; 7. Tylenol prn; 8. Calcitonin
spray one q.d. alternating nostrils; 9. Colace; 10. Effexor
75 mg q.h.s.; 11. Lisinopril 5 mg q.d.; 12. Sorbitol 70% 30
mg q.i.d. prn; 13. Ensure supplements.
SOCIAL HISTORY: The patient has baseline dementia with
intermittent hallucinations, however, is otherwise functional
and those are at baseline. He has a very involved son,
[**Name (NI) **] [**Name (NI) 23847**], home #[**Telephone/Fax (1) 23848**], work #[**Telephone/Fax (1) 23849**].
PHYSICAL EXAMINATION: The patient's temperature initially
was 101.7, decreased to 99.2, heartrate 58, blood pressure
83/28, respiratory rate 14, oxygenation at 100%. In general
he was a cachectic appearing elderly man in no acute
distress. He was mentating, alert and oriented to time and
place. His pupils equal, round and reactive. Extraocular
movements intact. His oropharynx showed mild erythema and
was dry. His neck was supple with no lymphadenopathy and no
bruits and flat jugulovenous pressure. His lungs were clear
to auscultation bilaterally. His heart was regular rate and
rhythm with normal S1 and S2. Chest, chest wall had a
dressing at the site of the removal of the old catheter. His
abdomen was soft, nontender, nondistended with active bowel
sounds. His extremities were cool with no cyanosis, clubbing
or edema and distal pulses bilaterally and neurological
examination was nonfocal.
LABORATORY DATA: The patient's initial white blood cell
count was 17 with a hematocrit of 34.1 and platelets 109.
Differential showed 59% polys, 15% bands, 33% lymphocytes, 2%
monocytes, and 1 metamyelocyte when the initial white blood
cell count of 7 and changed to a differential of 93 polys, 0%
bands when the white blood cell count was 17. Chem-7 showed
a sodium 135, potassium 4, chloride 198, bicarbonate 24, BUN
17, creatinine 1.6, glucose 112, INR was 2.1. Chest x-ray
showed no evidence of congestive heart failure or pneumonia.
Heart size was upper limits of normal. Electrocardiogram
showed normal sinus rhythm with Q waves in III and T wave
inversion in V2, V3, V4 which were old as well as a biphasic
T wave inversion in V5 and V6 all of which were old. The
patient's blood cultures drawn at hemodialysis as well as
after hemodialysis by Oncology on [**4-15**] from the Hickman
Porta-cath site had grown Coagulase positive Staphylococcus
which was sensitive to Oxacillin, Levofloxacin and Gentamicin
and Erythromycin and Clindamycin.
HOSPITAL COURSE: The patient was initially admitted to
Medical Intensive Care Unit for monitoring of blood pressure
as well as therapy for his infections. Blood cultures drawn
on [**2173-4-22**] grew Escherichia coli which was sensitive to
Ampicillin, Cefuroxime, ................., Gentamicin and
Bactrim. The patient had initially been started on
Vancomycin, however, once the cultures grew positive for
Escherichia coli, this was switched to Ampicillin with a plan
for a two week course. The patient did otherwise well on the
Medical Intensive Care Unit and he had a temporary
hemodialysis line placed with plans to arrange for a new
line, originally planned for [**2173-4-26**]. The patient
improved and was called off of the floor on [**2173-4-25**].
However, on [**2173-4-26**], the patient was sitting up in bed
to have breakfast and slid out of bed with a result of
hitting his head as well as his hip. A head computerized
tomography scan done at the time was negative for any
intracranial hemorrhage. The patient had a bruise over his
right eye but no evidence of fracture. A right hip film
showed a probable right neck femoral fracture which was
recommended to be followed up by an magnetic resonance
imaging scan. The hip magnetic resonance imaging scan showed
a right subcapital femoral neck fracture with varus
angulation as well as adjacent edema and a subacute L4
compression fracture. The patient was called out to the
Medicine Floor with plans to schedule him for orthopedic
surgery. He was also scheduled for a new line placement on
[**2173-4-26**]. However, at about one hour before going to the
Operating Room he had a temperature of 101 degrees. Given
this, the procedure was cancelled and rescheduled for a later
date. The patient otherwise was doing well. His hematocrit
remained stable. He had no mental status changes and his
distal leg showed no evidence of vascular compromise. The
patient Coumadin had been held during the initial Medicine
Intensive Care Unit admission in anticipation for the
Operating Room as the INR was 1.0 on the day of transfer to
the Medical Floor. The following is the hospital course on
the Medical Floor by issues:
1. Infectious disease - The patient was continued on
Ampicillin for Escherichia coli bacteremia, multiple cultures
were drawn following the initial positive blood cultures.
The catheter tip culture remained negative, all follow up
blood cultures remained negative as well as several urine
cultures done on the floor. After discussion with the Renal
Service as well as Orthopedic Service, it was decided the
patient should be continued for at least a total of two week
course of Ampicillin and following the initially positive
blood cultures, he was continued on intravenous Ampicillin
throughout the hospitalization and this will be discontinued
on the date of discharge as follow up cultures following the
Orthopedic Surgery have remained negative throughout
hospitalization. Likewise a right femoral head culture taken
at the time of surgery showed polymorphonuclear leukocytes,
however, no micro-organisms and no thick cultures or tissue
as well as anaerobic cultures showed no growth.
2. Renal - The patient had been undergoing hemodialysis
through a temporary femoral line. As this was in the right
groin, goal was to replace this prior to orthopedic surgery.
Given that the patient remained afebrile after the initial
spike on [**2173-4-26**] and that all cultures remained
negative, he was taken to the Operating Room for a Perma-cath
placement on the left side on [**2173-4-30**]. However, when
the patient returned to the floor it was noted that the
Perma-cath had likely been lost or not been placed in the
Operating Room. The Renal Service was felt unable to use the
hemodialysis line for concerns of infection and it was
revised on [**2173-5-2**]. This Perma-cath line was then
successfully used for hemodialysis throughout the rest of the
hospitalization and the temporary line was removed.
3. Orthopedics - The patient did go to the Operating Room
for a right hemiarthroplasty on [**2173-5-4**]. He tolerated
the procedure well and had no postoperative complications.
At the date of discharge, he was able to ambulate slowly with
physical therapy and per Orthopedics was able to do full
weightbearing as tolerated. Physical therapy should be
continued at rehabilitation. The staples will come out two
weeks following discharge when he follows up with Dr. [**First Name (STitle) 1022**] as
an outpatient.
4. Hematology - For postop the patient's Coumadin had been
held on admission. Discussion was held between the
Orthopedic Service and the Renal Service as well as the
medical team for anticoagulation prophylaxis following both
the hip fracture as well as following the hip surgery.
Pneuma boots were placed on the patient. Lovenox was
considered to be not of use in the setting of hemodialysis.
The patient was started on intravenous heparin and maintained
until the surgery. He did have repeated hematocrit drop in
this setting with no source of bleeding ever identified and
guaiac negative stools throughout. He received 2 units of
blood at hemodialysis. His hematocrit dropped to 24.8 on [**2173-5-7**]. He received another unit of blood with increase to
27.8 and 30.9 on the day of discharge. After further
discussion the heparin was held on [**2173-5-7**] in the
setting of the more dramatic drop, and the hematocrit
remained stable for 48 hours thereafter. His Coumadin had
been restarted at a lower dose, 3 mg q.h.s. At the time of
discharge his INR goal will be 1.5 to 2.0, it is 1.5 on the
day of discharge, this should be adjusted as the patient
tolerates.
5. Cardiovascular - The patient had baseline history of
hypertension, and he is on Lisinopril as well as Atenolol.
The Atenolol was initially held and then slowly restarted as
Lopressor 12.5 mg b.i.d. This should be titrated up as
tolerated with the goal to be returned to the 25 mg q.d. if
the patient needs it. The patient's Lisinopril was also
held, given the patient's eosinophilia and hypotension. It
should be restarted as the patient's blood pressure
tolerates.
6. Psychiatric - The patient had a baseline dementia but was
oriented and interactive throughout the hospitalization. He
did have intermittent hallucinations and was initially placed
on sitter, however, he did not require a sitter and the
sitter was discontinued. He remained oriented to time and
place as well as recent history throughout, except that he
occasionally stated that he was in a different place,
however, he corrected himself to the correct location. He
appeared to have a slightly more severe episode of this on
[**2173-5-8**], so urine culture and chest x-ray were checked
and urine culture was negative and chest x-ray was unchanged.
The patient was otherwise tardy at baseline. The patient
overall improved throughout the hospitalization and will be
discharged to rehabilitation on [**2173-5-10**].
DISCHARGE STATUS: Do-Not-Resuscitate, Do-Not-Intubate.
CONDITION ON DISCHARGE: Good.
DISCHARGE MEDICATIONS:
1. Nephrocaps one capsule p.o. q.d.
2. Levoxyl 150 mcg p.o. q.d.
3. Calcium carbonate 500 mg p.o. b.i.d.
4. Coumadin 3 mg q.h.s., to be adjusted for INR 1.5 to 2 mg
5. Donepizil 10 mg p.o. q.h.s.
6. Lopressor 12.5 mg p.o. b.i.d.
7. Venlafaxine standard release 75 mg one capsule p.o.
q.h.s.
8. Tylenol prn
9. Colace 100 mg p.o. b.i.d.
10. Dulcolax p.r. q.h.s. prn
11. Calcitonin spray, one nasal spray q.d. alternating
nostrils
DISCHARGE DIAGNOSIS:
1. Hemodialysis line sepsis with Escherichia coli
2. Placement of new hemodialysis line
3. Right hip fracture, status post hemiarthroplasty
4. See past medical history
[**Name6 (MD) **] [**Name8 (MD) 16134**], M.D. [**MD Number(1) 16135**]
Dictated By:[**Last Name (NamePattern1) 423**]
MEDQUIST36
D: [**2173-5-9**] 15:32
T: [**2173-5-9**] 16:35
JOB#: [**Job Number 23850**]
|
[
"294.8",
"403.91",
"276.2",
"710.0",
"820.09",
"242.90",
"V58.61",
"038.42",
"996.62"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"86.07",
"81.52",
"39.95",
"38.91",
"38.95"
] |
icd9pcs
|
[
[
[]
]
] |
11997, 12435
|
12456, 12874
|
2268, 2632
|
4907, 11942
|
2944, 4889
|
113, 1512
|
1535, 2241
|
2649, 2921
|
11967, 11974
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,445
| 139,977
|
12520+56372+56373
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2116-12-17**] Discharge Date: [**2116-12-29**]
Service: NEURO
HISTORY OF PRESENT ILLNESS: This is an 80-year-old man with
a past medical history significant for polymyalgia
rheumatica, temporal arteritis, CAD status post MI,
orthostatic hypotension, possible seizures, dementia, and a
history of recurrent C. difficile who presents after episode
of "garbled speech" and confusion ("unable to understand how
to get into the car") on [**2116-12-17**]. Head CT on admission
showed no hemorrhage, and MRI was negative for stroke. Exam
was felt to be consistent with nonconvulsive status
epilepticus on admission, and the patient was sent to the
Intensive Care Unit.
In the ICU EEGs were consistent with periodic lateralized
epileptiform discharges in left temporal and left parietal
regions but no electrographical seizures were recorded.
Clinically, there were witnesses to a couple of episodes of
left arm shaking. He was initially continued on his Tegretol
then started on Depakote (question allergy to Dilantin) but
more recently changed to Keppra. He has had no further
witnessed seizures. His hospital course has, however, been
complicated by pneumonia (gram negative rods and sputum) for
which he is currently covered with Levofloxacin and
Vancomycin. Blood cultures and C. diff. samples have so far
been negative. He has been stabilized in the ICU and sent
out to the floor, afebrile, but still with altered mental
status.
PAST MEDICAL HISTORY:
1. Hypertension.
2. CAD status post MI and RCA stent in 08/[**2114**].
3. Polymyalgia rheumatica
4. Temporal arteritis.
5. Benign prostatic hypertrophy.
6. History of orthostatic hypotension.
7. History of question seizure disorder.
8. Anemia.
10. Recurrent C. diff.
11. Status post lumbar spinal fusion.
12. 12 months of progressive dementia.
ALLERGIES: Question to phenytoin.
OUTPATIENT MEDICATIONS:
1. Iron.
2. Atenolol.
3. Lisinopril.
4. Remeron.
5. Risperdal.
6. Aspirin.
7. Florinef.
8. Tegretol.
9. Lactobacillus.
10. Diclofenac XR.
11. Protonix.
12. Calcium carbonate.
13. Lipitor.
SOCIAL HISTORY: Lives in a nursing home. Baseline is
conversant and mobile. Had an MVC two years and required
rehab and has had progressive dementia for the past 12
months.
PHYSICAL EXAMINATION: Afebrile, blood pressure 104/72.
General medical exam: Unremarkable. Neurologic: Awakens
with stimulation, and he is alert and follows some commands,
such as "open your eyes" and "squeeze my hand then let go."
Does not show two fingers or protrude tongue. Answers simple
questions, names. Says he is from [**Hospital1 392**]. Relates that he
is married. When asked where he is, he says, "I am somewhere
down South," and perseverates. Cranial nerves: Pupils
equal, round, reactive to light. Extraocular eye muscles
intact. Able to fix and follow. Facial movements symmetric.
Blinks to threat bilaterally and corneals intact
bilaterally. Motor normal. Bulk tone normal on right but
slightly spastic in the left lower extremity. Spontaneous
movements of all extremities but more so on the right. Does
lift legs to command. Reflexes symmetric except slightly
brisker in the left lower extremity. Toe downgoing on right,
upgoing on left. Sensation: Localizes to pain in all
extremities, though right upper extremity more than left
upper extremity and withdraws all extremities briskly to
noxious stimuli.
LABORATORY DATA: White count 11.9, hematocrit 37.7,
platelets 224, INR 1.1, UA negative. Cerebrospinal fluid on
[**2114-12-18**] showed 0 white cells, 60 red cells. Chem-10 is
normal. Ruled out for myocardial infarction by enzymes.
Triglycerides 90, HDL 50, LDL 109, ammonia 19, TSH 0.91.
Tegretol level on [**2116-12-25**] was 6.7. Total protein in CSF
35, glucose in CSF 83. C. diff.: Three were negative.
Fecal cultures also negative. Urine cultures negative.
Blood cultures negative. Methicillin-resistant
Staphylococcus aureus screen negative twice.
Vancomycin-resistant enterococcus screen negative. Sputum
grew some gram negative rods on [**2116-12-19**].
Heparin-dependent antibodies negative. HSV negative in the
CSF.
MRI showed no evidence of acute infarction or intracranial
hemorrhage. No parenchymal mass lesion noted on post
contrast images. Symmetric appearance of the hippocampi and
temporal lobes without evidence of acute encephalitis.
The patient's chest x-ray: Serial chest x-ray showed
clearing of bilateral infiltrate and atelectasis of the lung
bases.
Cytology was negative for malignant cells of the CSF.
He showed abnormal portable EEG to the persistent left
temporal and left hemisphere sharp waves and due to slow
background, first abnormality signifies focal lesion with
epileptogenic potential, but the discharges were less frequent
and far less rhythmic than on several earlier recordings. No
electrographic seizures. Slow background indicates widespread
encephalopathy.
The patient's LFTs on [**2116-12-27**]: ALT 69, AST 28, LD 194,
alkaline phosphatase 81.
HOSPITAL COURSE: The patient was admitted to the Neurology
service, initially admitted to the Intensive Care Unit
because he was thought to be in nonconvulsive status
epilepticus. EEGs were negative for this. The patient did
develop pneumonia during the hospital course but was covered
with antibiotics and is now on Levaquin for the pneumonia.
He continued to improve and required less and less oxygen and
now is on nasal cannula on the day of discharge.
He initially was obtunded on admission. He does have a
history of having episodes of lost consciousness, which has
been worked up thoroughly in the past, and the patient was on
Tegretol on admission. However, this did not seem to be one
of those episodes, and it remains unclear exactly what caused
the patient's initial presentation. There is a question as
to whether it was caused by HSV encephalitis due to the PLEDs
on the EEG, although the HSV PCR did return negative. Also,
there was no evidence of HSV on MRI. The patient was,
however, started on a course of Acyclovir.
The patient began to become more alert and awake after he was
called out of the ICU and went on the floor. He continues
daily to be more and more conversant, able to answer simple
questions, and follow simple commands. He passed the swallow
evaluation well, and on [**2116-12-28**] was able to start a
regular diet. He seems to be getting closer and closer to
his baseline and able to go back to his nursing home. He
will go home on a full 21-day course of Acyclovir.
He was also initially started on Depakote. However, during
the first couple days of admission his LFTs bumped slightly,
and his Lipitor was also stopped, and since then his LFTs
have decreased nicely and are now normal except for a
slightly elevated ALT. There is no history of alcoholism
that was known. The patient steadily continues to improve.
DISCHARGE CONDITION: Good.
DISCHARGE MEDICATIONS:
1. Miconazole powder 2%, one application t.p. q.i.d. p.r.n.
2. Famotidine 20 mg p.o. b.i.d.
3. Tegretol 200 mg q. a.m., 400 mg at noon, and 200 mg q.
p.m.
4. Heparin subq. q. 12 hours.
5. Keppra 1000 mg p.o. b.i.d.
6. Atenolol 37.5 mg p.o. q.d.
7. Levofloxacin 500 mg p.o. q.d.
8. Albuterol nebulizer q. six hours p.r.n.
9. Acyclovir 350 mg intravenous q. eight hours to complete a
21-day course.
10. Florinef 0.1 mg p.o. three times per week.
11. Lisinopril 5 mg p.o. q.d.
12. Tylenol p.r.n.
13. Insulin sliding scale.
14. Aspirin 325 mg p.o. q.d.
DISCHARGE INSTRUCTIONS: The patient's follow-up appointment
is to be scheduled.
If any further addendum to the discharge summary will be
dictated by Dr. [**First Name (STitle) **] [**Name (STitle) **].
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**], M.D. [**MD Number(1) 4269**]
Dictated By:[**Last Name (NamePattern1) 10034**]
MEDQUIST36
D: [**2116-12-28**] 19:31
T: [**2116-12-29**] 10:43
JOB#: [**Job Number 38819**]
Name: [**Known lastname 6940**], [**Known firstname **] Unit No: [**Numeric Identifier 6941**]
Admission Date: [**2116-12-17**] Discharge Date: [**2116-12-29**]
Date of Birth: [**2035-12-30**] Sex: M
Service: NEURO
ADDENDUM:
This is an addendum just to state that the patient was
transitioned off of intravenous Acyclovir and will be given
p.o. valacyclovir 1g p.o. [**Hospital1 **] for 3 days after discharge, for a
total of a two week course of treatment for a possible HSV
encephalitis, although the HSV PCR has been negative. This is
really being done because of a dramatic improvement after
initiation of this medication.
DISCHARGE MEDICATIONS: His discharge medicines thus include:
1. Keppra one gram p.o. twice a day.
2. Tegretol 200 mg p.o. twice a day.
3. Heparin subcutaneously 5000 units q. 12 hours.
4. Tegretol 400 mg p.o. at noon every day.
5. Miconazole Powder 2%, one application to the effected
areas four times a day p.r.n.
6. Famotidine 20 mg p.o. twice a day.
7. Atenolol 37.5 mg p.o. q. day.
8. Lisinopril 5 mg p.o. q. day.
9. Fluticasone 0.1 mg p.o. three times a week on Monday,
Wednesday and Saturday.
10. Valacyclovir 1 gram po bid for 3 days after
discharge.
DISCHARGE INSTRUCTIONS:
1. The patient is to follow-up with his primary care
physician at the [**Hospital3 7005**] Group.
2. He also will follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in the
[**Hospital 2996**] Clinic and phone number at that Clinic is
[**Telephone/Fax (1) 7006**]. Someone will be calling with a follow-up
appointment time.
[**First Name8 (NamePattern2) 77**] [**First Name8 (NamePattern2) **] [**Name8 (MD) 904**], M.D. [**MD Number(1) **]
Dictated By:[**Name8 (MD) 74**]
MEDQUIST36
D: [**2116-12-29**] 15:33
T: [**2116-12-29**] 16:26
JOB#: [**Job Number 7007**]
Name: [**Known lastname 6940**], [**Known firstname **] Unit No: [**Numeric Identifier 6941**]
Admission Date: [**2116-12-17**] Discharge Date: [**2116-12-30**]
Date of Birth: [**2035-12-30**] Sex: M
Service: NEUROLOGY
ADDENDUM:
MEDICATIONS ON DISCHARGE CORRECTED:
1. Aspirin 325 mg p.o. once daily.
2. Acetaminophen 325 to 650 mg p.o. q4-6hours p.r.n. fever
or pain.
3. Keppra 1000 mg p.o. twice a day.
4. Tegretol 200 mg p.o. twice a day and an additional 400 mg
p.o. q.noon.
5. Miconazole Powder.
6. Famotidine 20 mg p.o. twice a day.
7. Atenolol 37.5 mg p.o. once daily.
8. Lisinopril 5 mg p.o. once daily.
9. Fludrocortisone 0.1 mg p.o. three times a week on Monday,
Wednesday and Saturday.
10. Heparin subcutaneously 5000 units q12hours.
11. Valacyclovir one gram p.o. twice a day for three days.
HOSPITAL COURSE: After discussion, it was determined that
the patient did receive a full eleven day course of
intravenous Acyclovir for presumed HSV encephalitis. There
have been conflicting reports about the actual duration
needed for effective treatment for the HSV encephalitis. It
is indicated that ten days appears to be a full course,
however, with other sources indicating fourteen to twenty-one
days of being a more usual duration of antiviral treatment,
we decided to finish his course of antiviral treatment with
three days of Valacyclovir p.o. at one gram p.o. twice a day.
Although we suspect that he most likely did not actually have
HSV encphalitis, we cannot be sure and opted to complete the
treatment as above. The patient is to follow-up with his
neurologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], on [**2117-1-6**], as well as Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] and Dr. [**First Name8 (NamePattern2) 7008**] [**Last Name (NamePattern1) **] in the [**Hospital 2996**] Clinic on
[**2117-4-8**], at 1:00 p.m.
[**First Name8 (NamePattern2) 77**] [**First Name8 (NamePattern2) **] [**Name8 (MD) 904**], M.D. [**MD Number(1) **]
Dictated By:[**Name8 (MD) 74**]
MEDQUIST36
D: [**2116-12-30**] 16:29
T: [**2116-12-30**] 18:43
JOB#: [**Job Number 7009**]
|
[
"599.0",
"507.0",
"725",
"287.5",
"112.0",
"446.5",
"412",
"345.3",
"054.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
6923, 6930
|
8676, 9221
|
10752, 12108
|
9245, 10734
|
1900, 2098
|
2298, 2740
|
120, 1465
|
2757, 5033
|
1487, 1876
|
2115, 2275
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,665
| 186,634
|
19103+57017
|
Discharge summary
|
report+addendum
|
Admission Date: [**2185-7-26**] Discharge Date: [**2185-9-14**]
Date of Birth: [**2113-3-10**] Sex: M
Service: SURGERY
Allergies:
Penicillins / Hayfever
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
heel ulcer r
osteo left
Major Surgical or Invasive Procedure:
none
History of Present Illness:
CC:[**CC Contact Info 52141**]
Past Medical History:
- IDDM
- PVD
- CAD (no MI)
- hyperlipid
- Hypertension
- CRI (baseline Cr 1.5-1.7)
- s/p L AK [**Doctor Last Name **]-DP spliced [**Doctor Last Name 5703**] BPG ([**2-4**])
- s/p LRKT ('[**79**])
- s/p CABG/Mech.[**Year (2 digits) 1291**]('[**77**])
- s/p Excise L metatarsal head
- s/p L AV fistula ('[**79**])
- s/p Excise colon polyp ('[**77**])
Social History:
non-contrib
Family History:
non-contrib
Physical Exam:
a/o
nad
rrr
cta
abd - benign
left palp graft / fem
left palp dp
right palp fem
dop pt / dp
Pertinent Results:
[**2185-7-28**] 09:00AM BLOOD
WBC-6.2 RBC-3.24* Hgb-9.5* Hct-26.6* MCV-82 MCH-29.4 MCHC-35.7*
RDW-15.8* Plt Ct-177
[**2185-7-28**] 09:00AM BLOOD
PT-22.4* PTT-33.2 INR(PT)-2.2*
[**2185-7-28**] 09:00AM BLOOD
Calcium-8.6 Phos-4.1 Mg-2.7*
[**2185-7-26**] 07:30PM BLOOD
%HbA1c-9.0*
RENAL TRANSPLANT U.S.
Reason: eval for incr Cr, please eval transplanted kidney only,
plea
HISTORY: 72-year-old man with end-stage renal disease and
transplanted kidney in [**2179**] with rising baseline creatinine.
DOPPLER ULTRASOUND EXAMINATION: The transplanted kidney is in
the right lower quadrant. No renal stones or hydronephrosis is
seen. It measures 12.2 cm in length. No renal masses are seen. A
small 6 mm cyst is seen in its interpolar region.
The resistive indices in the upper pole are 0.81, and in the
lower pole are 0.81 as well. Increased resistance is
demonstrated in the mid pole arterials with low to no diastolic
flow. The main renal artery and [**Year (4 digits) 5703**] in the renal hilum are
patent. Images of the bladder are limited as the bladder is not
fully distended.
IMPRESSION: Increased resistance to flow demonstrated in the mid
pole arterioles of the transplant kidney as described above
FOOT AP,LAT & OBL LEFT [**2185-7-26**] 7:00 PM
HISTORY: 72-year-old man with transmetatarsal amputation and
sinus wound.
FINDINGS: Comparison is made to previous study from [**2184-2-11**].
The patient is status post transmetatarsal amputation. There is
a prominent ulcer along the stump of the fifth metatarsal, which
appears to extend to the cortical surface. The underlying bones
demonstrate some lucency and osteomyelitis is suspected.
[**Year (4 digits) **] calcifications as well as [**Year (4 digits) 1106**] clips are seen.
Brief Hospital Course:
pt admitted for angio
increase creat / renal transplant consulted
DC avapro
sacrolimus level stable
c/w lasix
follow-up with Dr [**Last Name (STitle) 52142**] as outpt
angio canceled
high blood sugars / [**Last Name (un) 387**] consult
started on insulin drip
[**Last Name (un) 387**] increases lantus to 30 from 18
bs stable on DC
ulcers on right foot
accuzyme ointment
osteo left met head / probe to bone
confirmed by x-rays
f/u as out pt with Dr [**Last Name (STitle) **] / need removal bone
cx's taken left foot ulcer
pseudomonas
home on renal dose levo
sensitivities pending
Medications on Admission:
[**Last Name (un) 1724**]: lantus 18 units qhs, rapamune 3, prednisone 5, omeprazol
20, metoprolol 50 "', zyvox 600 [**Hospital1 **], lasix 120 am / 80 qpm,
metolaone 2.5, myfortic 720 ", pravochol 20, avapro 300,
coumadin 5, norvasc 10 (noon),fosamaxx 35 weekly, gemfibrizole
600 "
Discharge Medications:
1. Sirolimus 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily).
2. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
5. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
8. Alendronate 70 mg Tablet Sig: 0.5 Tablet PO QTHUR (every
Thursday).
9. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 14 days.
Disp:*14 Tablet(s)* Refills:*0*
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
11. Mycophenolate Sodium 180 mg Tablet, Delayed Release (E.C.)
Sig: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a
day).
12. insulin
take as directed by your PCP
13. Papain-Urea 1,100,000-100 unit-mg/g Ointment Sig: One (1)
Appl Topical [**Hospital1 **] (2 times a day) for 3 weeks: until wound is
debrided right heel.
Disp:*1 Papain-Urea (Topical) 1,100,000-100 unit-mg/g Ointment*
Refills:*1*
14. glargine
take 30 units at night / if you are on SS please take as
directed by your PCP
15. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
have your INR followed. you must get this done early next week.
16. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 169**]
Discharge Diagnosis:
b/l Gangrenous foot / pad
left 5th met head osteo
increase creat 2.9 - transplant kidney
hypercoagable on admission
hyperglycemic on admission
PVD
DM Type 2
ESRD - transplant
CAD
Hyperlipidemia
HTN
Discharge Condition:
good
Discharge Instructions:
WOUND CARE:
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
Redness in or drainage from your wound(s).
New pain, numbness or discoloration of your lower or upper
extremities (notably on the side of the incision).
Watch for signs and symptoms of infection. These are: a fever
greater than 101 degrees, chills, increased redness, or pus
draining from the incision site. If you experience any of these
or bleeding at the incision site, CALL THE DOCTOR.
GENERAL:
DIABETIC FOOT CARE:
Diabetes is a disease in which high blood glucose levels over
time can damage the nerves, kidneys, eyes, and blood vessels.
Diabetes can also lead to decreases in the body's ability to
fight infection. When diabetes is not well controlled, damage to
the organs and impairment of the immune system is likely. Foot
problems can develop and quickly become serious.
With damage to the nervous system, a person with diabetes may
not be able to feel his or her feet properly. Normal sweat
secretion and oil production that lubricates the skin of the
foot is impaired. These factors together can lead to abnormal
pressure on the skin, bones, and joints of the foot during
walking and can lead to breakdown of the skin of the foot. Sores
may develop.
Damage to blood vessels and impairment of the immune system from
diabetes makes it difficult to heal these wounds. Bacterial
infection of the skin, connective tissues, muscles, and bones
can then occur. These infections can develop into gangrene. The
ultimate result may be the amputation of the foot or leg. If the
infection spreads to the bloodstream, this process can be life
threatening.
People with diabetes must be fully aware of how to prevent foot
problems before they occur, to recognize problems early, and to
seek the right treatment when problems do occur. Although
treatment for diabetic foot problems has improved, prevention,
including good control over blood sugar, remains the best way to
prevent problems.
Diabetics should learn how to examine their own feet and how to
recognize the early signs and symptoms of diabetic foot
problems.
They should also learn what is reasonable to do at home as far
as routine foot care, how to recognize when to call the doctor,
and how to recognize when a problem has become serious enough to
seek emergency treatment.
RISK FACTORS:
These risk factors increase your chances of developing foot
problems and diabetic infections in your legs and feet if you
are diabetic.
Footwear:
Poorly fitting shoes are a common cause of diabetic foot
problems.
If you have red spots, sore spots, blisters, corns, calluses, or
consistent pain associated with wearing your shoes, you need to
get new, properly fitting footwear as soon as possible.
If you have common foot abnormalities such as flat feet,
bunions, or hammertoes, you may need prescription shoes or shoe
inserts.
Nerve damage:
People with long-standing or poorly controlled diabetes are at
risk for having damage to the nerves in their feet. The medical
term for this is peripheral neuropathy.
Because of the nerve damage, you may be unable to feel your feet
normally. Also you may be unable to sense the position of your
feet and toes while walking and balancing. With normal nerves,
you can usually sense if your shoes are rubbing on your feet or
if one part of your foot is becoming strained while walking.
The diabetic may not properly perceive minor injuries (such as
cuts, scrapes, blisters), signs of abnormal wear and tear (that
turn into calluses and corns), and foot strain. Normally, people
can feel if there is a stone in their shoe and remove it
immediately. A diabetic may not be able to perceive a stone. Its
constant rubbing can easily create a sore.
Poor circulation:
Diabetes, especially when poorly controlled, can lead to
accelerated hardening of the arteries or atherosclerosis.
Trauma to the foot:
Any trauma to your foot can be a risk factor for a more serious
problem to develop.
Infections:
Athlete's foot can lead to more serious bacterial infections and
should be treated promptly.
Ingrown toenails should be handled right away by a foot
specialist. Toenail fungus should also be treated.
Smoking:
Smoking any form of tobacco causes damage to the small blood
vessels in the feet and legs. This damage can disrupt the
healing process and is a major risk factor for infections and
amputations.
SIGNS AND SYMPTOMS:
Persistent pain can be a symptom of sprain, strain, bruise,
overuse, improperly fitting shoes, or underlying infection.
Redness can be a sign of infection, especially when surrounding
a wound, or of abnormal rubbing of shoes or socks.
Swelling of the feet or legs can be a sign of underlying
inflammation or infection, improperly fitting shoes, or poor
venous circulation.
Other signs of poor circulation:
Pain in your legs or buttocks that increases with walking and
improves with rest (the medical term is claudication)
Hair no longer growing on the lower legs and feet
Hard shiny skin on the legs
Localized warmth can be a sign of infection or inflammation,
perhaps from wounds that won't heal or are slow to heal.
Any break in the skin is serious and can be from abnormal wear
and tear, injury, or infection. Calluses and corns may be a sign
of chronic trauma to your foot. Toenail fungus, athlete's foot,
and ingrown toenails may lead to more serious bacterial
infections.
Drainage of pus from a wound is usually a sign of infection.
Persistent bloody drainage is also a sign of a potentially
serious [**Last Name 4241**] problem.
A limp or difficulty walking can be sign of joint problems,
serious infection, or improperly fitting shoes.
Fever or chills in association with a wound on the foot can be a
sign of a limb- or life-threatening infection.
Red streaking away from or redness spreading out from a wound is
a sign of a progressively worsening infection.
New or lasting numbness in your feet or legs can be a sign of
nerve damage from diabetes and increases your risk for leg and
foot problems.
HOME CARE:
Foot examination:
Examine your feet daily and also after any trauma, no matter how
minor, to your feet. Report any abnormalities to your physician.
[**Name10 (NameIs) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4242**] moisturizer to prevent dry skin and cracking.
Wear cotton or wool socks. Avoid elastic socks and hosiery
because they may impair circulation.
Eliminate obstacles:
Move or remove any items you are likely to trip over or bump
your feet on. Keep clutter on the floor picked up. Light the
pathways used at night??????indoors and outdoors.
Toenail trimming:
Always cut your nails with a safety clipper, never a scissors.
Cut them straight across and leave plenty of room out from the
nailbed or quick. If you have difficulty with your vision or
using your hands, let your doctor do it for you or train a
family member how to do it safely.
Footwear:
Wear sturdy, comfortable shoes whenever feasible to protect your
feet. To be sure your shoes fit properly, see a podiatrist (foot
doctor) for fitting recommendations or shop at shoe stores
specializing in fitting diabetics. Your endocrinologist
(diabetes specialist) can provide you with a referral for a
podiatrist or orthopedist who may also be an excellent resource
for finding local shoe stores. If you have flat feet, bunions,
or hammertoes, you may need prescription shoes or shoe inserts.
EXERCISE:
Regular exercise will improve bone and joint health in your feet
and legs, improve circulation to your legs, and will also help
to stabilize your blood sugar levels. Consult your physician
prior to beginning any exercise program.
SMOKING:
If you smoke any form of tobacco, quitting can be one of the
best things you can do to prevent problems with your feet.
Smoking accelerates damage to blood vessels, especially small
blood vessels leading to poor circulation, which is a major risk
factor for foot infections and ultimately amputations.
DIABETES CONTROL:
Following a reasonable diet, taking your medications, checking
your blood sugar regularly, exercising regularly, and
maintaining good communication with your physician are essential
in keeping your diabetes under control. Consistent long-term
blood sugar control to near normal levels can greatly lower the
risk of damage to your nerves, kidneys, eyes, and blood vessels.
WHEN TO CALL THE DOCTOR:
Write down your symptoms and be prepared to talk about them on
the phone with your doctor. Following is a list of common
reasons to call your doctor if you have a diabetic foot or leg
problem. For most of these problems, a doctor visit within about
72 hours is appropriate.
Any significant trauma to your feet or legs, no matter how
minor, needs medical attention. Even minor injuries can result
in serious infections.
Persistent mild-to-moderate pain in your feet or legs is a
signal that something is wrong. Constant pain is never normal.
Any new blister, wound, or ulcer less than 1 inch across can
become a more serious problem. [**Name (NI) **] will need to develop a plan
with your doctor on how to treat these wounds.
Any new areas of warmth, redness, or swelling on your feet or
legs are frequently early signs of infection or inflammation.
Addressing them early may prevent more serious problems.
Pain, redness, or swelling around a toenail could mean you have
an ingrown toenail??????a leading cause of diabetic foot infections
and amputations. Prompt and early treatment is essential.
New or constant numbness in your feet or legs can be a sign of
diabetic nerve damage (neuropathy) or of impaired circulation in
your legs. Both conditions put you at risk for serious problems
such as infections and amputations.
Difficulty walking can result from diabetic arthritis (Charcot's
joints), often a sign of abnormal strain or pressure on the foot
or of poorly fitting shoes. Early intervention is key to
preventing more serious problems including falls as well as
lower extremity skin breakdown and infections.
Constant itching in the feet can be a sign of fungal infection
or dry skin, both of which can lead to infection.
Calluses or corns developing on the feet should be
professionally removed. Home removal is not recommended.
Fever, defined as a temperature greater than 98.6??????F, in
association with any other symptoms or even fever alone should
prompt an immediate call to your doctor. The degree of fever
does not always correlate with the seriousness of infection. You
could have no fever or a very low fever and still have a serious
infection. People with diabetes need to be especially cautious
of fever.
WHEN TO GO TO THE HOSPITAL:
If time and your condition permit, write down your symptoms, a
list of your medications, allergies to medicines, and your
doctor's name and phone number prior to coming to the hospital's
Emergency Department. This information will greatly assist the
emergency physician in the evaluation and treatment of your
problem.
Following are some common reasons to seek immediate medical
attention for diabetic foot and leg problems.
Severe pain in your feet or legs is often a sign of acute loss
of circulation to the leg, serious infection, or may be due to
severe nerve damage (neuropathy).
Any cut to your feet or legs that bleeds significantly and goes
all the way through the skin needs proper cleaning and repair to
aid healing.
Any significant puncture wounds to your feet (for example,
stepping on a nail or being bitten by a dog or cat) carry a high
risk of becoming infected.
Wounds or ulcers that are more than about 1 inch across on your
feet or legs are frequently associated with limb-threatening
infections.
Redness or red streaks spreading away from a wound or ulcer on
your feet or legs are a sign of infection spreading through the
tissues.
Fever higher than 101.5??????F in association with redness, swelling,
warmth, or any wound or ulcer on your legs may be a sign of a
limb or life-threatening infection. If you have diabetes and you
simply have a fever more than 101.5?????? F, and no other symptoms,
seek immediate emergency care to determine a source and
treatment plan. Because the degree of fever does not always
correlate with the seriousness of the illness, people with
diabetes should take even low-grade fevers (less than 101.5??????F)
very seriously and seek medical attention.
Alteration in mental status (confusion) may be a sign of
life-threatening infection that could lead to loss of a leg or
foot, when associated with a leg wound or foot ulcer. It may
also be a sign of either very high or very low blood sugars,
which are more common when there is infection present.
PREVENTION:
Prevention of diabetic foot problems involves a combination of
factors.
Good diabetes control
Regular leg and foot self-examinations
Knowledge on how to recognize problems
Choosing proper footwear
Regular exercise, if able
Avoiding injury by keeping footpaths clear
FOLLOW-UP
Read any instructions from the doctor while you are still in the
Emergency Department or doctor's office. Ask questions about any
instructions you don't understand. Follow all of your doctor's
or nurse's instructions. Let your doctor know if your condition
is not improving within a reasonable time.
OTHER INFO:
Less pain, swelling, redness, warmth, or drainage are generally
all signs of improvement in an infected wound. Shrinkage of the
wound or ulcer is a good sign. Absence of fever is also
generally a good sign. Generally, some improvement should occur
within the first 2-3 days. Let your doctor know if you are not
improving as expected.
Be especially vigilant about your diabetes care while you are
healing a foot or leg infection. Good glycemic control is not
only good for healing an ulcer you already have, it is good for
preventing future ulcers. Check your blood sugar regularly and
let your doctor know of any pattern of lows or highs.
Followup Instructions:
[**Last Name (LF) 4784**],[**First Name3 (LF) 488**] J [**Telephone/Fax (1) 52143**]. make an appointment aand see him
immediatly after DC.
Please call your renal doctor. Have him follow your creatinine.
You have a transplanted kidney.
Call Yopu cardiologist and have your INR followed. On Dc your
INR is 2.1. Take your coumadin tonight
Call Dr[**Name (NI) 1720**] office and schedule an appointment for two
weeks. His number is [**Telephone/Fax (1) 1241**].
You were seen by Dr [**Last Name (STitle) **], the Podiatrist. You should follow
up with him in at the same time you see Dr [**Last Name (STitle) **]. His office
number is [**Telephone/Fax (1) 543**].
Completed by:[**2185-7-28**] Name: [**Known lastname 9699**],[**Known firstname **] Unit No: [**Numeric Identifier 9700**]
Admission Date: [**2185-7-26**] Discharge Date: [**2185-9-14**]
Date of Birth: [**2113-3-10**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Hayfever
Attending:[**First Name3 (LF) 2670**]
Addendum:
.
Chief Complaint:
osteomyelitis of L foot
Major Surgical or Invasive Procedure:
[**8-1**]
left tibiallis anterior tendon lengthing,extensor hallucis
longus tendonotomoy,left ulcer excision,fifth met head
resection. [**2185-8-1**]
.
[**9-9**]
Resection of infected osteomyelitis and
debridement of nonviable tissues.
History of Present Illness:
72 year-old male with diastolic CHF, mechanical AVR, DM2,
lipids, HTN, PVD s/p L [**Doctor Last Name **]-DP bypass and L TMA initially
admitted to the vascular service for debridement of L foot after
pt presented to ED [**7-26**] with worsening L foot pain and
ulceration at prior TMA op site. Pt taken to OR [**8-1**] where he had
wound debridement/TMA revision of L foot.
.
[**Name (NI) 9701**], pt remained in-house waiting to become therapeutic on
coumadin. By [**8-1**] cr down from 3.2 to 1.5, which is his baseline.
The improvement occured in the setting of holding pt's home
avapro and decreasing standing diuretics for known heart
failure. However, over the next few days cr rose. By [**8-7**] cr up
to 3.2. Given renal failure pt transferred to [**Doctor Last Name **] [**Hospital 2300**]
medical service.
.
While on medical service pt developed new oxygen requirement
around [**8-8**]. Pt stable on [**5-5**] L until this AM. Pt de-satted to
high 80s requiring increase in oxygen to 6L. Pt's sats
transiently recovered. Pt again de-satted to high 80s and
recovered with NRB. MICU team consulted. Pt eval'd. On exam
breathing to high 20s, satting low 90s on nrb. Crackles 1/2 up
b/l. On discussion with renal team, urgent dialysis planned on
transfer to the MICU.
Past Medical History:
- IDDM
- PVD- CHF (EF 40-50% by [**8-9**] echo)
- CAD s/p CABG + AVR ('[**77**])
- hyperlipidemia
- Hypertension
- CRI (baseline Cr 1.5-1.7)
- s/p L [**Doctor Last Name **]-DP bypass followed by L TMA [**2-5**] with revision [**5-6**]
- s/p LRKT ('[**79**])
- s/p CABG/Mech.AVR('[**77**])
- s/p Excise L metatarsal head
- s/p L AV fistula ('[**79**])
- s/p Excise colon polyp ('[**77**])
Social History:
Married, but lives with daughter in [**Name (NI) 9702**]. Has never
smoked. Denies etoh/illicits.
Family History:
non-contrib
Physical Exam:
Temp 98.5
BP 91/51 (baseline systolics 90s to low 100s)
Pulse 70
Resp 30
O2 sat 93% nrb
Gen - Alert, speaking in full sentences, NAD, cachectic
HEENT - PERRL, extraocular motions intact, anicteric, mucous
membranes sl. dry
Neck - no JVD, no cervical lymphadenopathy
Chest - diminished at bases, crackles 1/2 up b/l (R>L)
CV - Normal S1/S2, RRR, no murmurs appreciated
Abd - Soft, nontender, nondistended, with normoactive bowel
sounds
Extr - [**2-1**]+ pitting edema in LE's. L foot with TMA and lateral
dime-sized area of necrosis with small amount of purulent
material expressable. R heel with ischemic lateral decubitus
ulcer.
Neuro - Alert and oriented x 3, mild intentional tremor
Skin - scattered ecchymoses, no rash
Pertinent Results:
ADMISISON LABS [**2185-7-26**]
CBC:
WBC-7.5 RBC-3.76* Hgb-10.8* Hct-30.7* MCV-82 MCH-28.6 MCHC-35.0
RDW-15.8* Plt Ct-239
.
COAGS:
PT-27.2* PTT-36.0* INR(PT)-2.8*
.
CHEM:
Glucose-343* UreaN-96* Creat-3.2*# Na-135 K-4.1 Cl-93* HCO3-26
AnGap-20
Calcium-8.6 Phos-4.1 Mg-2.7*
.
%HbA1c-9.0*
.
cxr: worsening b/l pulm edema, R sided effusion
.
ekg: nsr @76 bpm, LBBB, unchanged from prior
.
DISCHARGE LABS [**2185-9-14**]
CBC
WBC-5.5 RBC-3.45* Hgb-9.3* Hct-29.6* MCV-86 MCH-26.9* MCHC-31.3
RDW-18.7* Plt Ct-432
.
COAGS:
PT-30.9* PTT-41.7* INR(PT)-3.3*
.
CHEM:
Glucose-79 UreaN-29* Creat-2.0* Na-142 K-4.6 Cl-111* HCO3-21*
AnGap-15 Calcium-7.2* Phos-3.6 Mg-2.2
.
STUDIES
FOOT AP,LAT & OBL LEFT [**2185-7-26**]
The patient is status post transmetatarsal amputation. There is
a prominent ulcer along the stump of the fifth metatarsal, which
appears to extend to the cortical surface. The underlying bones
demonstrate some lucency and osteomyelitis is suspected.
Vascular calcifications as well as vascular clips are seen.
.
OR PATHOLOGY [**2185-8-1**]
SPECIMEN SUBMITTED: 5TH METATARSAL LEFT.
Procedure date Tissue received Report Date Diagnosed
by
[**2185-8-1**] [**2185-8-2**] [**2185-8-12**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 588**]/kg
Previous biopsies: [**Numeric Identifier 9703**] REVISION LT TMA.
[**Numeric Identifier 9704**] LT. TMA TISSUE.
[**Numeric Identifier 9705**] LT TMA.
[**Numeric Identifier 9706**] BONE 5TH METATARSAL.
(and more)
DIAGNOSIS:
Metatarsal, left fifth:
1. Focal acute osteomyelitis
2. Fragments of bone with degenerative change, hyaline
cartilage, and fibrous tissue.
.
PTA PERIPHEREAL ARTERY [**2185-8-24**] 9:25 AM
IMPRESSION: Successful balloon angioplasty of a tight stenosis
at the brachial artery/venous anastomosis of the left AV
fistula.
.
MR FOOT W/O CONTRAST LEFT [**2185-8-31**]
IMPRESSION:
1) Findings highly concerning for osteomyelitis involving the
remnant fifth metatarsal.
2) Reactive marrow edema versus early osteomyelitis involving
the fourth remnant metatarsal and distal cuboid.
3) Probable reactive marrow edema involving the remainder of the
tarsals.
4) Nondisplaced fracture of the cuboid.
.
MR FOOT W/O CONTRAST RIGHT [**2185-9-2**]
IMPRESSION:
1. No evidence of osteomyelitis.
2. Sinus tarsi and plantar muscle compartment edema. Appearance
is nonspecific and may be due to myositis.
.
FOOT AP,LAT & OBL LEFT [**2185-9-9**]
FINDINGS: Comparison is made to the MRI from [**2185-8-31**].
Patient is status post debridement of the fifth metatarsal
remnant and resection. There is a surgical drain seen within the
lateral soft tissues. Soft tissue swelling is present. The
patient is status post transmetatarsal amputation.
Brief Hospital Course:
72 year-old male with MMP including mechanical Aortic Valve
Repair, diastolic CHF, lipids, HTN, and longstanding DM2 c/b
ESRD s/p renal transplant. This gentleman also has a
vasculopathic history including peripheral vascular disease s/p
multiple vascular surgeries including L [**Doctor Last Name **]-DP bypass and L
transmetaarsal amputation (TMA) in [**2184**]. He was was initially
admitted to the surgical service for debridement (which occured
on [**8-1**]) of L TMA ulcer and osteo of L 5th metatarsal. His
post-op course was c/b C. Diff (s/p Flagyl x 2 weeks)and by
hypoxic respiratory distress requiring MICU stay and treated
with emergent HD and lasix drip. Much improved after volume
correction and transferred to medical floor for continued care.
Did well initially, with improved renal function and no
desaturations on room air, but had began to have intermittent
fevers on [**8-26**]. Temporary HD line was pulled, tip culture was
negative. Other infectious workup was extensive and revealed L
foot wound with serratia M. and Hemophilus paraflu. Also a urine
culture grew cipro-resistant pseudomonas. A repeat urine sent
[**8-28**] also grew VRE. He was switched from cipro to ceftazidime,
which was subsequently changed to cefepime on [**9-1**]. The VRE was
not felt to be an infection as patient had no dysuria, and so
was not treated with daptomycin. He has been afebrile on
cefepime since [**2185-9-3**]. Despite being asymptomatic, he was
restarted on Flagyl as C. Diff prophylaxis while on cefepime. He
had a recent UCx from [**9-7**] which was entirely negative. Had an
MRI L foot [**2185-8-31**], showed findings again highly concerning for
osteomyelitis. R foot MRI [**2185-9-2**] negative for osteo. Underwent
repeat podiatric debridement [**9-9**] with removal of infected bone
and tissue from L foot. Post-op, has been successfully bridged
back to coumadin for artifical valve phophylaxis and has
remained afebrile.
.
Currently, his renal trasplant function is as good as it has
been during his long hospitalization. His immunosuppression has
been tailored to prednisone and mycopheylate, with
discontinuation of Rapamure given its notable effects on the
inhibition of would healing. He did have an Left AV-graft
angioplasty during this admission, which will mature in roughly
1 month, however there is no plan for placing pt on regular HD
at this time as his renal function is optimized and he urinates
regularly.
.
In terms of his Diabetes Mellitus and coronary artery disease,
he was followed by [**Last Name (un) 616**], put on glargine/ISS, and continued
asa/statin. His glargine dose on discharge was 13 untis qHS.
Higher doses made him mildly hypoglycemic.
.
In terms of his aortic valve, his goal INR is 2.5-3.5. His
coumadin dose at home was 5/7.5 alternating days, however this
will need to be substantially reduced given the many interacting
medicines he is on. He is being discharged on 2.5 mg qHS but
will need close INR follow-up and titration of coumadin.
.
He has follow-up with several [**Hospital1 **] teams,
including podiatric surgery, renal transplant medicine,
pulmonary medicine, amd infectious disease.
Medications on Admission:
Acetaminophen 325-650 mg PO Q6H:PRN
Albuterol 0.083% Neb Soln 1 NEB IH Q6H
Metoclopramide 10 mg PO QIDACHS
Aspirin 81 mg PO DAILY
MetRONIDAZOLE (FLagyl) 500 mg PO TID
day 1 = [**8-7**]
Carvedilol 25 mg PO BID
Myfortic *NF* 360 mg Oral [**Hospital1 **]
Ondansetron 4 mg IV Q8H:PRN nausea
Oxycodone-Acetaminophen [**2-1**] TAB PO Q6H:PRN pain
Ciprofloxacin HCl 500 mg PO Q24H started [**8-6**]
Pantoprazole 40 mg PO Q24H
Epoetin Alfa 10,000 UNIT SC QM-W-F
Papain-Urea Ointment 1 Appl TP [**Hospital1 **]
Eplerenone 25 mg PO DAILY
PredniSONE 5 mg PO DAILY
Pravastatin 20 mg PO DAILY
Sevelamer 800 mg PO TID
ISS
glargine 24 units qhs
Discharge Medications:
1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
4. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Mycophenolate Sodium 180 mg Tablet, Delayed Release (E.C.)
Sig: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a
day).
6. insulin
take as directed by your PCP
7. glargine
take 13 units at night / if you are on SS please take as
directed by your PCP
8. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO at bedtime:
have your INR followed. you must get this done beginning
tomorrow. Tablet(s)
9. Cefepime 1 g Recon Soln Sig: One (1) Recon Soln Intravenous
Q24H (every 24 hours) for 5 weeks: last dose 9/18.
10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 5 weeks: last dose 9/18.
11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. Eplerenone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
16. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
17. Papain-Urea 830,000-10 unit/g-% Ointment Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day).
18. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
19. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
20. Mycophenolate Sodium 180 mg Tablet, Delayed Release (E.C.)
Sig: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a
day).
21. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
22. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
23. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) mL
Injection QM-W-F ().
24. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
25. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4
times a day) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1353**]
Discharge Diagnosis:
Primary: osteomyelitis of L foot
.
Secondary:
peripheral vascular disease
dry gangrene of R heel
chronic renal insufficiency
transplanted kidney
Peripheral vascular disease
Diabetes Mellitus Type 2
Coronary artery disease
diastolic heart failure
aortic valve replacement
Hyperlipidemia
Hypertension
Discharge Condition:
good, afebrile, much improved
Discharge Instructions:
You were admitted to the hospital for surgery on your infected
Left foot. You had a long stay and your course was complicated
by many problems, including repeat infections, respiratory
distress, mild kidney failure, and recurrence of L foot
infection requiring repeat surgery.
.
All of your problems have now been successfully treated and you
are stable for discharge to rehabilitation. You have follow-up
scheduled with many different doctors. Please keep all of these
appointments. They are listed below.
.
Please take all your medicines as prescribed. Please notify a
physician if you notice any of the following problems:
# Redness in or drainage from your wound(s).
# New pain, numbness or discoloration of your lower extremities
(notably on the side of the incision).
# Watch for signs and symptoms of infection. These are: a fever
greater than 101 degrees, chills, increased redness, or pus
draining from the incision site. If you experience any of these
or bleeding at the incision site, please call the doctor.
Followup Instructions:
Primary care doctor:
[**Last Name (LF) 9707**],[**First Name3 (LF) **] J [**Telephone/Fax (1) 9708**]. Please call to make an appointment
for within the next 2-3 weeks.
.
Kidney Doctor:
[**Name6 (MD) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 242**] Date/Time:[**2185-10-10**]
1:00PM
.
Podiatrist (Foot Doctor)
Dr. [**Last Name (STitle) 9709**]
Your appointment is [**9-22**] at 8:40AM ([**Telephone/Fax (1) 456**])
.
Pulmonary (lung) Doctor:
Dr. [**First Name (STitle) **] and Dr. [**Last Name (STitle) **] [**10-17**]. Please arrive at 3PM for your
appointment. You must call the office at any time prior to your
appointment to register with them.
.
Infectious Disease Doctor:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9710**], MD Phone:[**Telephone/Fax (1) 496**] Date/Time:[**2185-10-10**] 10:00 AM
[**First Name4 (NamePattern1) 460**] [**Last Name (NamePattern1) 461**] MD [**MD Number(1) 2671**]
Completed by:[**2185-9-14**]
|
[
"996.73",
"285.21",
"250.62",
"996.81",
"403.91",
"518.81",
"997.69",
"440.24",
"730.07",
"428.0",
"357.2",
"585.6",
"008.45",
"428.30",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.4",
"38.95",
"83.13",
"00.40",
"83.85",
"39.50",
"38.93",
"39.95",
"77.88"
] |
icd9pcs
|
[
[
[]
]
] |
32282, 32333
|
26255, 29409
|
20647, 20885
|
32676, 32708
|
23507, 26232
|
33777, 34771
|
22734, 22748
|
30089, 32259
|
32354, 32655
|
29435, 30066
|
32732, 33754
|
22763, 23488
|
20584, 20609
|
5573, 19490
|
20913, 22190
|
22212, 22603
|
22619, 22718
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,849
| 182,695
|
37583
|
Discharge summary
|
report
|
Admission Date: [**2184-10-28**] Discharge Date: [**2184-11-4**]
Date of Birth: [**2125-7-19**] Sex: M
Service: NEUROSURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 3227**]
Chief Complaint:
Right sided hemiparesis
Major Surgical or Invasive Procedure:
[**2184-10-28**] s/p left craniotomy for evacuation of subdural hematoma
with Dr. [**First Name (STitle) **]
History of Present Illness:
59M accompanied by brother who has noted 3 days of
progressive R side weakness with difficulty with ambulation and
forgetfullness. Has not gotten out of bed in 36 hrs. Pt does
remember slipping in shower 3 d ago but does not recall bumping
head. He is however a martial artist and states he has hit head
on concrete blocks multiple occasions in past. he also endorses
heavy EToH use - 1pint blackberry brandy and at least [**4-21**] beer
per day.
Past Medical History:
fx finger as child
Social History:
lives with brother, +smoker, retired, recently lost father and
wife recently left him. Recently retired. + ETOH abuse- 1 pint
blackberry brandy and at least [**4-21**] beer per day.
Family History:
Non-contributory
Physical Exam:
Upon Admission:
PHYSICAL EXAM:
O: T:98.3 BP: 151/113 HR:99 R 16 O2Sats 100RA
Gen: WD/WN, comfortable, NAD.follows all commands but somewhat
slowed
HEENT: Pupils: EOMs full
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person only.
Language: Speech fluent.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4to3
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-20**] throughout. + pronator drift on
right.
Sensation: Intact to light touch bilaterally.
Toes downgoing bilaterally
** Upon Discharge **
xxxxxxxxxxxx
Pertinent Results:
CT Head [**2184-10-28**]:
IMPRESSION:
1. Minimally enlarged or grossly stable large heterogeneous
extra-axial
collection, mostly in the left frontal cranial fossa, likely
representing a subdural hematoma Areas of hyperdense attenuation
likely represent a component of acute-on-chronic hemorrhage.
Clinical correlation is recommended.
2. mass effect and left sided cerebral edema with 1.5 cm right
[**Hospital1 **] shift and subfalcine herniation and mild medial
displacement of the uncus with possible mild herniation.
MRI [**2184-10-29**]:
IMPRESSION: Stable post-surgical changes with persistent
subdural air-fluid collection at the left frontoparietal
convexity and residual subdural collection on the right as
described above. Areas of restricted diffusion are adjacent to
the subdural collection on the right. There is no evidence of
restricted diffusion in the brain parenchyma to suggest acute
ischemic changes. Persistent effacement of the sulci at the left
parietal convexity and midline shifting, approximately 7.2 mm of
deviation towards the right is demonstrated with mild left uncal
herniation.
CT Head [**2184-11-1**]:
Interval removal of the left subdral drain. Near-complete
resolution
resolution of the left pneumocephalus. Deceased left fluid
collection and
mass effect. No new foci of enhancement. Decreased SQ soft tisse
gas in left temporal region.
Brief Hospital Course:
[**Known firstname **] [**Known lastname 84340**] was admitted to [**Hospital1 18**] on [**2184-10-28**] for a large left
sided chronic subdural hematoma. He was plegic on the right
urgently taking to the OR for a craniotomy and SDH evacuation.
The patient had several episodes of mental status change post-op
prompting multiple CTs and an MRI. No new lesions were found.
The mental status changes were ultimately attributed to the CIWA
protocal for alcohol withdraw prophylaxis.
The patient's Subdural drain was removed on [**10-31**]. On [**11-1**] head
CT was repeated. This showed resolving pneumocephalus and left
subdural fluid collection. There was improvement in rightward
shift of midline structures. Prior to discharge, the patient
regained full strength of his RUE and RLE. He was discharged to
[**Hospital 84341**] [**Hospital **] Hospital based on PT evaluation.
Medications on Admission:
None reported
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain,fever.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
6. Levetiracetam 500 mg/5 mL Solution Sig: One (1) Intravenous
[**Hospital1 **] (2 times a day).
Disp:*60 * Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
Large left sided chronic subdural hematoma
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:
General Instructions
??????Take your pain medicine as prescribed.
??????Exercise should be limited to walking; no lifting, straining,
or excessive bending.
??????Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
??????Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
??????If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin prior to your injury, do not
resume this medication until you receive clearance from Dr. [**First Name (STitle) **]
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Your sutures are dissolveable, they do not need to be removed.
Please keep dry for 7 days post-op
Followup Instructions:
Your sutures are dissoleveable, they do not need to be removed.
You should follow up with Dr [**First Name (STitle) **] in 1 month with a head CT
Completed by:[**2184-11-4**]
|
[
"852.29",
"348.4",
"291.81",
"780.09",
"E929.3",
"305.1",
"303.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"94.62",
"01.31"
] |
icd9pcs
|
[
[
[]
]
] |
5270, 5343
|
3706, 4586
|
301, 412
|
5430, 5430
|
2307, 3683
|
6885, 7062
|
1150, 1168
|
4650, 5247
|
5364, 5409
|
4612, 4627
|
5607, 6862
|
1214, 1432
|
238, 263
|
440, 892
|
1581, 2288
|
1199, 1199
|
5444, 5583
|
914, 934
|
950, 1134
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,518
| 111,118
|
4293
|
Discharge summary
|
report
|
Admission Date: [**2200-8-25**] Discharge Date: [**2200-8-31**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1631**]
Chief Complaint:
Abdominal distension and fevers
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] year old Cantonese-only speaking female with past medical
history significant for dementia, psychosis, and hypertension
who presents with pseudoobstruction. Per her son, her appetite
has been extremely poor and has had to try and force things down
in order to maintain proper nutrition. He has also noticed that
her belly has gotten bigger over the past few days and has not
been able to fit into her usual diapers or pants. Last BM [**2-24**]
days ago prior to admission. Son also reports of low grade
fevers ~100 over the past few days.
.
In the ED her initial vitals were T 99.9 BP 188/97 AR 124 RR 16
O2 sat 95% RA. BPs as high as 243/117. Received 2L NS. She
received Hydralazine 10mg IV x2, Ativan 1mg IV, Ceftriaxone 1gm
IV, and Flagyl 500mg IV x1.
.
This is a [**Age over 90 **] year old Cantonese speaking female with history of
dementia with psychosis, depression, and HTN who presented to
the ED 2 days ago with pseudoobstruction of the large bowel.
According to her son, he began to note increasing abdominal
distention 3 days ago in the setting of no BMs for 3-5 days. She
was also having difficulty fitting into her usual pants and
diapers and was having low grade fevers to 100F along with a dry
cough, for which he gave her pseudoephedrine and codeine. On the
day of admission, he noticed a rash along her R groin which had
not been there previously. The pt was also complaining of slight
headache and dizziness.
.
In the ED her initial vitals were T 99.9 BP 188/97 AR 124 RR 16
O2 sat 95% RA. BPs as high as 243/117. Received 2L NS. She
received Hydralazine 10mg IV x2, Ativan 1mg IV, Ceftriaxone 1gm
IV, and Flagyl 500mg IV x1. A KUB was significant for dilated
loops of large bowel c/w ileus and CT abd/pelvis showed
pseudoobstruction without any definitive transition point. She
was admitted to the MICU given hypertensive urgency and
pseudoobstruction. Her BPs were controlled with metoprolol 10 mg
IV tid and hydralazine 10 mg IV q6h for SBP > 150. Dermatology
was consulted for the R groin rash and thought this was most
consistent with zoster, for which she was started on valcyte. GI
was also consulted for pseudoobstruction who recommended
conservative mgmt for now with serial KUBs. The pt is now being
transferred to the floor for further care.
Past Medical History:
)Dementia with psychosis
2)Hearing loss
3)Depression
4)Hypertension
5)Osteoarthritis
6)Cholelithiasis s/p cholecystectomy and hepatojejunostomy in
[**2190**]
7)Constipation
8)Hypercholesteremia
9)s/p subdural hematoma and seizures
10)Urinary incontinence
Social History:
Lives with son, who is her primary caretaker. [**Name (NI) **] current
tobacco, alcohol, or intravenous drug use.
Family History:
Non-contributory
Physical Exam:
Physical Exam:
vitals T 97.7 BP 179/74 AR 115 RR 21 O2 sat 94% RA
Gen: Patient difficult to arouse, responsive to tactile stimuli
HEENT:Unable to visualize oral cavity
Heart: Sinus tachycardia, no audible m,r,g
Lungs:CTAB, no crackles
Abdomen: firm, distended, decreased bowel sounds
Extremities: No edema, 2+ DP/PT pulses bilaterally
Skin: Erythematous rash along right groin into vaginal area with
evidence of blisters/vesicles
Rectal: Guaiac negative in ED
Pertinent Results:
CHEST (PA & LAT)
Reason: eval acute process, free air.
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **] year old woman with cough, low grade temps, abd distension
REASON FOR THIS EXAMINATION:
eval acute process, free air.
INDICATION: [**Age over 90 **]-year-old woman with cough, low-grade temperature,
abdominal distention.
PA AND LATERAL CHEST RADIOGRAPH: Comparison was made with the
prior chest radiograph dated [**2199-5-27**]. The heart is top normal
in size allowing the technique. Again note is made of markedly
elongated and tortuous aorta. Lung volumes are low, probably due
to low inspiratory level. There is faint opacity at the lung
bases, probably representing atelectasis. No evidence of CHF or
other consolidation is noted. Degenerative changes of
thoracolumbar spine is noted. No evidence of free air below the
diaphragm. The lateral view is limited due to overlying soft
tissue.
IMPRESSION: Somewhat limited study. Probable bibasilar
atelectasis. Tortuous aorta.
CT PELVIS W/CONTRAST [**2200-8-25**] 1:59 AM
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
Reason: eval obstruction.
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **] year old woman with distension, no BM, h/o surgeries,
dementia
REASON FOR THIS EXAMINATION:
eval obstruction.
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: [**Age over 90 **]-year-old woman with distension, no bowel
movement, history of surgeries and dementia.
TECHNIQUE: Contiguous axial CT images of the abdomen and pelvis
were obtained with administration of intravenous contrast [**Doctor Last Name 360**].
Multiplanar reformation images are reconstructed.
There is no prior CT study for comparison. Ultrasound dated
[**2195-3-30**] was referred.
FINDINGS: The evaluation of the bowel loops is limited due to
poor oral prep, in this patient who did not tolerate enough oral
contrast. The patient is status post cholecystectomy and
hepaticojejunostomy, with extensive intrahepatic ductal
dilatation with pneumobilia, probably due to surgery. The
intrahepatic duct in the right lobe measures up to 1 cm, and the
left lobe measures up to 1.4 cm. CBD is also dilated, measuring
up to 1.5 cm. There is no focal liver lesion identified on this
single-phase study. Spleen is unremarkable. In the body of the
pancreas, there is 7 mm hypodense lesion, which appears to be
connected from the main pancreatic duct. The rest of the
pancreas enhances homogeneously and is unremarkable. Adrenal
glands and kidneys are unremarkable without evidence of
hydronephrosis. Again note is made of diffusely distended large
bowel with feces material in the ascending colon. There is
focally dilated loop of small bowel in the right upper quadrant
measuring up to 5.1 cm, however, there is no definitive
transition point. The oral contrast is present both proximal and
distal to this dilated loop of small bowel. There is no ascites
or significant lymphadenopathy.
PELVIS: Rectum is dilated with air-fluid level. Feces material
is seen in distal ileum, however, no definitive transition point
is noted.
In the visualized portion of the lung bases, there is
peribronchial thickening with basilar atelectasis. There are
cystic changes at the right lung base, of uncertain clinical
significance. There is dilated esophagus filled with contrast.
There is compression fracture of L1 vertebral body. There are
degenerative changes of the thoracolumbar spine.
IMPRESSION:
1. Status post hepaticojejunostomy and cholecystectomy, with
marked intrahepatic and extrahepatic ductal dilatation with
pneumobilia.
2. Diffusely distended large bowel loops and focally dilated
proximal small bowel loop as described above, without transition
point. Feces material in the ascending colon, as well as in
distal ileum, however, again there is no transition point.
3. Peribronchial thickening with atelectasis at the lung bases.
Dilated esophagus. Nonspecific cystic changes of the lung.
4. Compression fracture of L1, chronicity uncertain.
5. 7 mm hypodense lesion in the pancreas. Differential diagnosis
include cyst or segmental IPMT. Evaluation is limited on this
single phase study.
The wet read was provided to ED dashboard.
ABDOMEN (SUPINE & ERECT)
Reason: eval stool, volvulus.
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **] year old woman with distension, constipation
REASON FOR THIS EXAMINATION:
eval stool, volvulus.
INDICATION: [**Age over 90 **]-year-old woman with distention and constipation.
SUPINE AND UPRIGHT ABDOMINAL RADIOGRAPH: Comparison was made
with the prior abdominal radiograph dated [**2198-1-14**].
Diffusely distended bowel gas is seen throughout the abdomen,
involving both large and small bowel, however, the gas is seen
down to the rectum. No evidence of free air is identified on
this radiograph. Residual stool in the ascending colon.
Degenerative changes of thoracolumbar spine is again noted.
Bibasilar opacities are again noted, probably representing
atelectasis.
IMPRESSION: Diffusely distended bowel gas with rectal gas
present, probably representing ileus, however, clinical
correlation is recommended.
[**2200-8-24**] 10:30PM PT-11.9 PTT-28.6 INR(PT)-1.0
[**2200-8-24**] 10:30PM PLT COUNT-331#
[**2200-8-24**] 10:30PM NEUTS-78.8* LYMPHS-13.9* MONOS-6.2 EOS-0.3
BASOS-0.7
[**2200-8-24**] 10:30PM WBC-10.0# RBC-4.41 HGB-12.9 HCT-40.1 MCV-91
MCH-29.4 MCHC-32.3 RDW-15.2
[**2200-8-24**] 10:30PM ALBUMIN-3.8 CALCIUM-9.6 PHOSPHATE-3.7
MAGNESIUM-2.4
[**2200-8-24**] 10:30PM ALT(SGPT)-43* AST(SGOT)-43* ALK PHOS-116
AMYLASE-62 TOT BILI-0.3
[**2200-8-24**] 10:30PM estGFR-Using this
[**2200-8-24**] 10:30PM GLUCOSE-155* UREA N-29* CREAT-0.7 SODIUM-145
POTASSIUM-3.8 CHLORIDE-107 TOTAL CO2-26 ANION GAP-16
[**2200-8-24**] 10:42PM LACTATE-1.3
[**2200-8-25**] 09:48AM TSH-0.86
[**2200-8-25**] 11:45AM PLT COUNT-303
[**2200-8-25**] 11:45AM WBC-12.2* RBC-4.22 HGB-12.2 HCT-37.4 MCV-89
MCH-28.9 MCHC-32.6 RDW-15.0
[**2200-8-25**] 11:45AM CALCIUM-8.2* PHOSPHATE-3.0 MAGNESIUM-2.1
[**2200-8-25**] 11:45AM GLUCOSE-149* UREA N-20 CREAT-0.6 SODIUM-143
POTASSIUM-4.0 CHLORIDE-110* TOTAL CO2-23 ANION GAP-14
Brief Hospital Course:
Ms. [**Known lastname **] is a [**Age over 90 **] year old female with past medical history as
listed above who presents with increasing abdominal distention,
found to have pseudo-obstruction on CT scan.
.
1)Pseudoobstruction: Patient presented with worsening nausea,
abdominal distention, and no bowel movements over past few days.
A CT scan did not show any inflammation, ischemia, or evidence
of significant adhesions. She has a history of abdominal surgery
but in [**2190**], and no recent procedures. Her abdominal exam
remained benign, and she has no history of inflammatory bowel
disease. It was thought that her zoster was likely to be playing
a role in delaying her gut motility.
- Patient was initially kept NPO, and [**First Name8 (NamePattern2) **] [**Last Name (un) **]-gastric tube was
placed for decompression. After she had a bowel movement and her
abdomen was much less distended, she was started on clears and
her diet was advanced as tolerated.
- GI and surgery were consulted and recommend a rectal tube
which was placed to help with decompression. Serial x-rays of
her abdomen were followed to assess the amount of dilation of
her bowel, which showed some improvement over time.
- At the time of discharge, her abdominal exam had returned to
baseline--it was soft, non-tender, and not distended. She was
tolerating her diet and passing flatus without any problems or
pain. An aggressive bowel regimen was continued.
.
2) Hypertension: Patient presented with systolic [**Last Name (un) **] pressures
as high has 230's in the ED. Per son, her [**Name2 (NI) **] pressure and
heart rate are elevated in the setting of psychosis, and she had
received pseudoephedrine at home for a cold. In the ED, she
received Hydralazine with little effect. Per OMR, her BP has
been well controlled as an outpatient, and per family and OMR,
she was not on any medications at home.
- She was initially kept on intravenous agents, then
transitioned to Metoprolol 12.5 mg TID, with goal systolic
[**Name2 (NI) **] pressure 120-140s, to avoid risk of hypotension.
.
3)Right sided groin rash: Patient found to have erythematous
rash with blister like lesions on right groin. Per son, this is
new for her. Dermatology was consulted and testing revealed that
the rash was consistent with zoster, DFR was negative for HSV 1
and 2, while direct antigen test was VZV positive. The rash was
confined primarily to the L2 dermatome on the right side, and
improved daily, with crusting and less erythema of the lesions.
- Patient was initially treated with intravenous Acyclovir since
she was being kept NPO, then trasitioned to valacyclovir per
dermatology recommendations.
- Patient denied any pain from the rash.
.
4) Dementia with psychosis: Patient has longstanding history of
severe psychosis which is triggered by insomnia. She is followed
closely by geriatrics and also has an upcoming appointment in
psychiatry. Aside from her urinary frequency which led to the
patient frequently trying to get out of bed unassisted, she had
little symptoms during this stay. A 1:1 sitter was kept for
patient when needed.
- Once patient was able to take oral medications, we continued
her outpatient regimen of Risperidone, Ativan, and Trazadone.
.
5) Urinary frequency: Patient denied any dysuria, but it was
noted that she was having to urinate frequently, about once an
hour, and a bladder scan revealed large amounts of urine in the
bladder. An urinalysis was sent off which was not very
impressive for urinary tract infection (moderate LE, [**2-24**] WBC),
however urine culture grew pseudomonas and gram positive
bacteria 10-100 thousand colonies, which was thought to be a
contaminant since foley was in place. Patient may also have had
a component of neurogenic bladder secondary to zoster
involvement. Per family, has never had any difficulties with
retention. Patient was not taking any medications that would
cause retention either.
- Several voiding trials were given to patient with foley
removed, however she had the urge to urinate, but would only
pass small amounts with large amount of urine (700-800cc)
remaining in bladder. Due to difficulty placing foley catheter
by nursing and medical team, urology was consulted to [**Month/Day (1) **]
with placement. It was decided that due to the patient's
retention on several occasions, she would leave with foley in
place and, as her zoster was treated, follow up with urology for
another voiding trial and removal of foley.
- Follow up urology appointment was made for week after
discharge.
.
6) Code status: Patient was DNR/DNI during this hospitalization
per discussions with patient and son.
.
Medications on Admission:
Actigall 300mg PO BID
Amoxacillin prior to dental procedures
Aspirin 81mg PO daily
Glucosamine-Chondroitin
Ativan 0.5mg PO daily PRN
Risperdal 0.25mg PO daily
Trazodone 25mg PO QHS
Vitamin D
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): For [**Month/Day (1) **] pressure.
Disp:*30 Tablet(s)* Refills:*2*
3. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for PRN.
4. Risperidone 0.25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): To prevent constipation.
Disp:*60 Capsule(s)* Refills:*2*
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): To prevent constipation.
Disp:*60 Tablet(s)* Refills:*2*
8. Valacyclovir 500 mg Tablet Sig: Two (2) Tablet PO daily ()
for 5 days: For zoster (shingles) rash.
Disp:*10 Tablet(s)* Refills:*0*
9. Actigall 300 mg Capsule Sig: One (1) Capsule PO twice a day.
10. Continue taking Amoxicillin prior to dental procedures.
Continue glucosamine-chondroitin and Vitamin D as you were prior
to admission.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnosis:
- Pseudo-obstruction
Secondary Diagnoses:
- Urinary Retention
- Zoster
- HTN
- Diabetes
- Dementia with psychosis
- Depression
- Hearing loss
- Cholelithiasis
- Urinary incontinence
Discharge Condition:
Stable.
Vital Signs:
Temperature 98.1
Heart Rate 92
Respiratory rate 16, Saturating 95% on room air.
Discharge Instructions:
You were admitted due to concern for an obstruction in your
intestines and for very elevated [**Hospital **] pressure. A number of
tests were completed and no clear cause for your abdominal pain
and distention was found, although it was likely it was due to
pain medications and zoster activation (shingles rash). You
should continue to eat as tolerated.
.
While hospitalized, your [**Hospital **] pressure was very high. A
medication called metoprolol was added to help control this. You
should continue taking this medication unless directed by Dr.
[**Last Name (STitle) 713**].
.
It was also discovered that you had a rash in your groin that
was found to be zoster (shingles). Others should avoid
contacting this rash until it resolves further. You should take
the medication valacyclovir for another 5 days to help clear the
rash. A visiting nurse [**First Name (Titles) **] [**Last Name (Titles) **] with caring for your rash and
dressings.
.
During your stay, you developed difficulty urinating and urine
retention. A foley catheter was placed to help with these
symptoms. You will need to follow up with urology within one
week for further care of the foley and urinary retention. A
visiting nurse [**First Name (Titles) **] [**Last Name (Titles) **] with the care of your foley.
.
Please return to your primary care doctor or the Emergency Room
if you experience any abdominal pain, chest pain, headache,
visual changes, shortness of breath, difficulty urinating,
worsening abdominal distention, fever, chills, worsening rash,
or other concerning symptoms.
Followup Instructions:
Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 713**],
within one week. The number for the office is ([**Telephone/Fax (1) 6846**].
.
You will also need to follow up with urology for further care of
your Foley catheter and urinary retention. Please follow up
within one week as well. The number for urology clinic is ([**Telephone/Fax (1) 18591**].
.
Your son will be called tomorrow morning after we try to set up
these appointments for you.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1636**]
|
[
"401.0",
"290.0",
"298.9",
"272.0",
"564.89",
"053.9",
"788.20"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
15676, 15734
|
9719, 14362
|
294, 300
|
15979, 16082
|
3563, 3620
|
17695, 18322
|
3048, 3066
|
14604, 15653
|
7849, 7913
|
15755, 15755
|
14388, 14581
|
16106, 17672
|
3096, 3544
|
15816, 15958
|
223, 256
|
7942, 9696
|
328, 2622
|
15774, 15795
|
2644, 2901
|
2917, 3032
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,607
| 187,399
|
49362+59172
|
Discharge summary
|
report+addendum
|
Admission Date: [**2200-10-28**] Discharge Date: [**2200-11-8**]
Date of Birth: [**2124-8-24**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Codeine / Scopolamine
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
CABGx4(LIMA->LAD< SVG->[**Last Name (LF) **], [**First Name3 (LF) **], PDA) [**2200-11-3**]
History of Present Illness:
76 year old female presented to OSH emergency room with
complaints of chest discomfort. Chest pain started initially
while walking briskly on a treadmill and relieved at rest. She
had an episode of chest pain at rest on the day of admission.
She had a positive stress test at the OSH on [**2200-10-27**] that was
(+) for ischemia, 2-[**Street Address(2) 2051**] depression in V4-V6 associated with
chest pain. She had a single episode of rest pain during the
admission that resolved with sl. Nitroglycerin and was
transferred to [**Hospital1 18**] for a cardiac catheterization.
Past Medical History:
coronary artery disease, s/p CABG [**2200-11-3**]
Migraines
tooth abscess
Mitral valve prolapse- asymptomatic
Dyslipidemia
thyroid nodule- biopsy with ultrasound every year and stable
Social History:
Lives with:alone, supportive daughter
Occupation:[**Name2 (NI) 103390**] for elementary school [**Location (un) 1131**] and math
Tobacco:denies
ETOH: 1 glass 2-3x/week
Family History:
Mother MI at age of 90, Father MI at age of 80
Physical Exam:
ADMISSION:
VS: 98.7 137/69 72 16 97%RA
GENERAL: NAD, AOx3, Comfortable
HEENT: PERRL, EOMI, MMM, No xanthalesma.
NECK: Supple, no JVD noted
CARDIAC: RRR, nlS1/S2. No m/r/g. No S3/S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No abdominial bruits.
EXTREMITIES: No c/c/e. R femoral cath site c/d/i, small
hematoma, no bruit.
SKIN: No stasis dermatitis, ulcers.
PULSES:
Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Pertinent Results:
Intra-op TEE
PREBYPASS
No atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thicknesses and cavity size are normal.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) are mildly thickened. Mild to moderate ([**11-30**]+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Physiologic mitral regurgitation is seen
(within normal limits).
POSTBYPASS
There is preserved biventricular systolic function. The study is
otherwise unchanged from prebypass.
[**2200-11-3**] 01:32PM BLOOD PT-14.3* PTT-32.9 INR(PT)-1.2*
[**2200-11-7**] 04:40AM BLOOD Glucose-96 UreaN-20 Creat-0.9 Na-140
K-4.5 Cl-103 HCO3-32 AnGap-10
[**2200-11-7**] 09:05AM BLOOD Hct-25.3*
[**Known lastname **],[**Known firstname **] S [**Medical Record Number 103391**] F 76 [**2124-8-24**]
Radiology Report CHEST (PA & LAT) Study Date of [**2200-11-6**] 4:41 PM
[**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG FA6A [**2200-11-6**] 4:41 PM
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 103392**]
Reason: eval left ptx
[**Hospital 93**] MEDICAL CONDITION:
76 year old woman s/p small apical ptx
REASON FOR THIS EXAMINATION:
eval ptx
Final Report
TYPE OF EXAMINATION: Chest PA and lateral.
INDICATION: 76-year-old female patient with small apical
pneumothorax on left
side. Evaluate.
FINDINGS: PA and lateral chest views were obtained with patient
in upright
position. Available for comparison is the next preceding
portable AP single
chest view of [**2200-11-5**]. The previously identified tiny
left-sided
pneumothorax residual after tube removal cannot be identified
anymore.
Comparison is now made with the preoperative chest examination
of [**2200-10-29**]. Moderate postoperative enlargement of the
cardiac silhouette is noted, status post sternotomy with
unremarkable position of wires and multiple surgical clips in
left anterior mediastinum, all consistent with bypass surgery.
The pulmonary vasculature is not congested. Remaining densities
in the left lower lobe posteriorly consistent with residual
postoperative atelectasis. There remains mild blunting of both
lateral pleural and posterior pleural sinuses consistent with
small amounts of postoperative pleural effusions. No other new
abnormalities are identified.
IMPRESSION: Pneumothorax has been absorbed. Postoperative
changes include
small pleural effusions and posterior segment atelectasis in
left lower lobe.
A followup examination is recommended.
DR. [**First Name (STitle) **] [**Initials (NamePattern5) 3250**] [**Last Name (NamePattern5) 3251**]
[**2200-11-8**] 06:05AM BLOOD WBC-7.9 RBC-3.45*# Hgb-10.4*# Hct-30.9*
MCV-90 MCH-30.2 MCHC-33.7 RDW-15.0 Plt Ct-245
[**2200-11-7**] 04:40AM BLOOD Glucose-96 UreaN-20 Creat-0.9 Na-140
K-4.5 Cl-103 HCO3-32 AnGap-10
[**2200-11-7**] 04:40AM BLOOD TotBili-0.4
[**2200-10-28**] 07:32PM BLOOD %HbA1c-5.3 eAG-105
Brief Hospital Course:
76yo F w PMHx HLD, MVP with OSH admission [**2200-10-26**] for LSSS CP
+exertional +radiation to L breast, w +ETT w 2-[**Street Address(2) 2051**]
depression in V4-V6 and chest pain, single episode of CP with
rest, admitted for cardiac catheterization, found to have 3VD..
The patient was brought to the operating room on [**2200-11-3**] where
the patient underwent CABG x 4 with Dr. [**Last Name (STitle) **]. See operative
note for further details. Overall the patient tolerated the
procedure well and post-operatively was transferred to the CVICU
in stable condition for recovery and invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. Beta blocker was initiated and the patient
was gently diuresed toward the preoperative weight. The patient
was transferred to the telemetry floor for further recovery.
Chest tubes and pacing wires were discontinued without
complication. The patient was evaluated by the physical therapy
service for assistance with strength and mobility.
on [**11-7**] her hct was 22.9 and she was transfused 2UPRBC. Repeat
hct was 30.9.
On POD#5 the pt. was discharged to [**Location (un) **] House in stable
condition.All f/u appts were advised.
Medications on Admission:
ASA 81 mg daily
Multivitamin 1 tab daily
Naprosyn 1 tab daily for pain as needed
Calcium + VitD
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 weeks.
4. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever, pain.
6. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
7. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
8. furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
9. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 7 days.
10. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] Nursing & Rehabilitation Center - [**Location (un) **]
Discharge Diagnosis:
coronary artery disease, s/p CABG
PMH:
Migraines
tooth abscess
Mitral valve prolapse- asymptomatic
Dyslipidemia
thyroid nodule- biopsy with ultrasound every year and stable
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
You are scheduled for the following appointments:
Surgeon Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**],Date/Time:[**2200-12-4**] 1:45
Cardiologist Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] A. [**Telephone/Fax (1) 88876**] [**2200-12-8**] @ 2PM
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 28262**] in [**3-3**] weeks
Completed by:[**2200-11-8**] Name: [**Known lastname 16734**],[**Known firstname **] S Unit No: [**Numeric Identifier 16735**]
Admission Date: [**2200-10-28**] Discharge Date: [**2200-11-8**]
Date of Birth: [**2124-8-24**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Codeine / Scopolamine
Attending:[**First Name3 (LF) 741**]
Addendum:
Small area of blancing sternal erythema noted at distal pole of
incision due to friction from bra. Patient was discharged to
[**Location (un) **] House prior to recieving first dose of kefelx. Rehab
called and order given to begin keflex 500mg po qid x 7days and
to follow up on friday [**11-14**] with [**Name8 (MD) 16736**] NP/PA for wound check.
Spoke to nurse [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 16737**] [**Telephone/Fax (1) 16738**].
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 weeks.
4. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever, pain.
6. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
7. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
8. furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
9. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 7 days.
10. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
11. keflex 500mg po QID x7days
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 12660**] Nursing & Rehabilitation Center - [**Location (un) 12660**]
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2200-11-8**]
|
[
"411.1",
"V70.7",
"E879.0",
"414.01",
"733.90",
"458.29",
"272.4",
"424.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"36.13",
"37.22",
"39.61",
"88.56",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
11254, 11489
|
5128, 6469
|
300, 394
|
7911, 8067
|
2016, 3284
|
8939, 10223
|
1414, 1463
|
10246, 11231
|
3324, 3363
|
7715, 7890
|
6495, 6592
|
8091, 8916
|
1478, 1997
|
250, 262
|
3395, 5105
|
422, 1004
|
1026, 1212
|
1228, 1398
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,299
| 168,827
|
6285
|
Discharge summary
|
report
|
Admission Date: [**2133-11-11**] Discharge Date: [**2133-11-20**]
Date of Birth: [**2091-10-12**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Confusion.
Major Surgical or Invasive Procedure:
[**11-12**]: Bilateral bur hole evacuation (four burr holes).
History of Present Illness:
Pt is a 41 yo male w/ PMhx sig for DM II, hypertension,
hypercholesterolemia admitted to [**Hospital1 18**] in [**8-17**] for worst HA of
his life with negative work-up now presents with bilateral
subdural hematomas. The patient has been taking ibuprofen every
4 hrs for the last 3-4 days prior to admission for chronic neck
pain. On [**11-11**], he was stopped by police while driving because
of swerving in the road. He was found to be confused and
brought to an OSH where head CT showed chronic bilateral
subdural hematomas. He was transferred to [**Hospital1 18**] for definitive
care.
Past Medical History:
DMII
HTN
Hypercholesterolemia
Chronic low back pain
Eczema
Social History:
-Tob: none
-EtOH: Occasional
-Illicits: None
-Living situation: monogamous with wife, lives with her and 4,
13 and 15 year-olds
-Occupation: maitr'd restaurant
Family History:
Non Contributory
Physical Exam:
On Admission:
Vitals: T 99.2; BP 140/91; P 67; RR 14; O2 sat 97% RA
General: lying in bed NAD
Neck: supple
Pulmonary: CTA b/l
Cardiac: regular rate and rhythm, with no m/r/g
Abdomen: soft, nontender, non distended, normal bowel sounds
Extremities: no c/c/e.
Neurological Exam:
Mental status: awake, slightly lethargic, year [**2122**], month [**Month (only) **],
president elect - [**Last Name (un) 2753**]. Unable to say MOYB. Fluent speech
with
no paraphasic or phonemic errors. Adequate comprehension.
Follows all commands. Repetition intact (no ifs, ands or buts).
Able to name low and high frequency objects.
Cranial Nerves:
I: Not tested
II: PERRL, 4-->2mm with light.
III, IV, VI: EOMI.
V, VII: facial sensation intact, facial strength
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: SCM [**4-13**]
XII: Tongue midline without fasciculations.
Motor: Normal bulk. Normal tone. b/l pronator drift. Full
strength.
Sensation: intact to light touch.
Reflexes: 2+ symmetric.
Toes downgoing bilaterally.
Coordination: FNF intact.
On Discharge:
Pt A&Ox3, PERRL, follows commands, MAE. Ambulates without
difficulty.
Pertinent Results:
Labs On Admission:
[**2133-11-11**] 06:58PM BLOOD WBC-8.0 RBC-4.90 Hgb-15.1 Hct-42.5 MCV-87
MCH-30.9 MCHC-35.6* RDW-13.5 Plt Ct-241
[**2133-11-11**] 06:58PM BLOOD Neuts-67.0 Lymphs-27.6 Monos-3.3 Eos-1.4
Baso-0.7
[**2133-11-12**] 03:27PM BLOOD PT-13.6* PTT-26.3 INR(PT)-1.2*
[**2133-11-11**] 06:58PM BLOOD Glucose-168* UreaN-11 Creat-0.8 Na-137
K-3.8 Cl-99 HCO3-29 AnGap-13
[**2133-11-11**] 06:58PM BLOOD CK(CPK)-85
[**2133-11-12**] 06:05AM BLOOD ALT-35 AST-20 AlkPhos-78 TotBili-1.2
[**2133-11-11**] 06:58PM BLOOD Calcium-9.9 Phos-3.6 Mg-2.0
[**2133-11-12**] 06:05AM BLOOD %HbA1c-7.1*
[**2133-11-12**] 06:05AM BLOOD Phenyto-13.6
[**2133-11-11**] 06:58PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**11-18**] Na 139 K 3.3 Bun 9 Creat 0.7 Glu 107
[**11-18**] WBC 6.2 Hgb 12.2 Hct 32.4 Plts 261
Imaging:
CTA of Head [**11-11**]:
COMPARISON: CT head without contrast on [**2133-9-3**].
FINDINGS:
HEAD CT: There are moderate-sized bilateral subdural hematomas,
mildly
hyperdense suggesting a subacute nature. The maximum thickness
measures 13mm on the left and 16mm on the right. There is a 4-mm
leftward shift of midline structures . There is effacement of
quadrigeminal and suprasellar cistern, consistent with
descending transtentorial herniation. There is no evidence of
tonsillar herniation. No fractures are identified.
HEAD AND NECK CTA: The carotid and vertebral arteries and their
major
branches are patent without evidence of stenosis. The diamter of
distal
cervical internal carotid artery measures 4 mm on the right and
4 mm on the left. There is no evidence of aneurysm formation or
other vascular
abnormality.
IMPRESSION:
1. Moderate-sized subacute bilateral subdural hematoma, with
4-mm leftward
shift of midline structures. Evidence of descending
transtentorial
herniation. No evidence of tonsillar herniation.
2. No evidence of aneurysm or stenosis.
CT Head 12/4(7:16am)
FINDINGS:
There are bilateral subdural hematomas, the left measuring 10 mm
compared to 13 mm in prior, and the right measuring 18 mm
compared to 16 mm on the prior. Again noted is 4mm leftward
shift of midline structures, unchanged compared to prior. There
is persistent effacement of the basal cisterns, consistent with
descending transtentorial herniation. There is no evidence of
tonsillar herniation. There is no evidence of fracture.
CONCLUSION:
Unchanged moderate bilateral subdural hematomas. Mass effect on
leftward
shift and transtentorial herniation and effacement of basal
cisterns.
CT Head [**11-12**] (5:40pm)-Post-op
FINDINGS: Two parietal burr holes are identified bilaterally and
patient is status post surgical evacuation of bilateral large
subdural hematomas. The subdural collections now consist of
nondependent air with predominantly hypodense fluid layering
posteriorly with more hyperdense fluid in the most dependent
portions of the subdural cavity. The greatest axial dimension of
the subdural fluid on the right approaches 11 mm and on the
left, 13 mm. The persistent leftward shift of midline structures
is small, measuring approximately 3 mm. Effacement of the
basilar cisterns persists, suggesting persistent descending
transtentorial herniation. Once again, there is no evidence for
tonsillar herniation. The imaged portions of the paranasal
sinuses are well aerated.
IMPRESSION: Air and mixed density, bilateral subdural
collections status post surgical evacuation with persistent mild
leftward shift of normally midline structures. Effacement of
basilar cisterns and transtentorial
(central) herniation persists.
CT Head [**11-15**] IMPRESSION:
1. Unchanged bilateral subdural hematomas and unchanged mass
effect compared
to prior study on [**2133-11-14**].
2. No evidence of aneurysm or intracranial vascular
malformation.
3. New air-fluid level at the left maxillary sinus. Interval
decrease of
pneumocephalus.
Brief Hospital Course:
Mr. [**Known lastname **] is a 41M who was previously hospitalized under the
medicine service in [**8-17**] after presenting with "worst headache
of life". This hospitalization was negative for definitive
identification of causation and he was discharged to home. On
[**11-11**], the was found to be driving erratically and pulled
over by a police officer. He was found to be confused and
subsequently brought to an outside hospital. OSH identified
bilateral, significantly sized subdural hematomas, and he was
transferred to [**Hospital1 18**] for definitve neurosurgical intervention.
As his neurological examination was quite good on admission, he
was admitted to the neurosurgical step-down unit. On the morning
neurosurgical rounds on [**11-12**], he was found markedly more
lethargic/somolent. An emergent head CT was done, and identified
worsening of bilateral SDH. He was urgently taken to the
operating room for bilateral burr hole evacuation(two holes each
side). For details of the surgical procedure, please review
separately dictated operative note by Dr. [**Last Name (STitle) **].
Patient was monitored routinely in the PACU and subsequently
transferred to the neurosurgical step down unit. On [**11-13**] am he
was persistantly agitated, and pulling on IV lines, so he was
started on 2.5mg of zyprexa in the interim. On [**11-14**] he was
transferred to the ICU due to lethargy and intubated. He was
then started on Mannitol and his mental status resolved. He was
extubated on [**11-16**] and passed S&S. He had a CTA which was
negative for malformation. He then tolerated reg. diet and
worked with PT who cleared him for home.
Medications on Admission:
1. Metformin
2. Glipizide
3. Vytorin
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Glipizide 5 mg Tab,Sust Rel Osmotic Push 24hr Sig: Two (2)
Tab,Sust Rel Osmotic Push 24hr PO DAILY (Daily).
3. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed: Please do not drink or drive while taking this
medication.
Disp:*60 Tablet(s)* Refills:*0*
5. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Bilateral Subdural Hematomas(chronic)
Discharge Condition:
Neurologically stable
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures have been removed.
If your wound closure uses dissolvable sutures, you must keep
that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
If you haven been discharged on Keppra (Levetiracetam), you
will not require blood work monitoring.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office in 7 days for removal of your
sutures.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast.
??????You will not need an MRI of the brain.
Completed by:[**2133-11-24**]
|
[
"401.9",
"518.81",
"250.00",
"432.1",
"272.0",
"724.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.72",
"01.24",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
8713, 8719
|
6388, 8036
|
333, 397
|
8801, 8825
|
2496, 2501
|
10492, 10871
|
1297, 1315
|
8124, 8690
|
8740, 8780
|
8062, 8101
|
8849, 10469
|
1330, 1330
|
2406, 2477
|
1609, 1609
|
283, 295
|
425, 1021
|
1968, 2392
|
3432, 6365
|
2515, 3423
|
1624, 1952
|
1043, 1103
|
1119, 1281
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,472
| 103,785
|
11079
|
Discharge summary
|
report
|
Admission Date: [**2183-7-18**] Discharge Date: [**2183-8-11**]
Date of Birth: [**2109-8-31**] Sex: M
Service:
CHIEF COMPLAINT: Dyspnea on exertion.
HISTORY OF PRESENT ILLNESS: This is a 73 year old male with
a history of aortic valve replacement in [**2180**], abdominal
aortic aneurysm, hypertension who was transferred from an
outside hospital with one week of dyspnea on exertion,
shortness of breath, fever and violent chills. The patient
denied a history of recent travel, sick exposure, cough,
sputum production, nasal congestion, abdominal pain or skin
infection.
On admission the patient's temperature was 100.8. Three
blood cultures were drawn and he was started on Vancomycin
and Gentamicin. The initial chest x-ray showed negative
pleural effusions or evidence of congestive heart failure.
Transesophageal echocardiogram showed an left ventricular
ejection fraction of 65% with thickened mitral valve with
mild regurgitation, large echodense objects, suggestion of
vegetation, and tricuspid regurgitation. The initial
transesophageal echocardiogram done at [**Hospital6 649**] showed dehiscence of the porcine arteriovenous
graft and a positive abscess. He was admitted for evaluation
and consideration for surgery.
PAST MEDICAL HISTORY: Significant for aortic valve
replacement with porcine valve. The patient unclear reason
for aortic valve replacement, abdominal aortic aneurysm and
hypertension. Hypercholesterolemia, chronic anemia,
infrarenal abdominal aortic aneurysm, and chronic renal
insufficiency.
PAST SURGICAL HISTORY: Aortic valve replacement with porcine
valve.
MEDICATIONS:
1. Lipitor 10 mg p.o. b.i.d.
2. Vitamin B12
3. Lopressor 25 mg b.i.d.
4. Vancomycin started at outside hospital
5. Gentamicin started at the outside hospital
PHYSICAL EXAMINATION: Temperature was 98.4, heartrate 64,
blood pressure 120/70, respiratory rate 20 and saturations
97% on room air. General: He was alert, awake and in no
acute distress, resting comfortably. Head, eyes, ears, nose
and throat: Pupils are equal, round, and reactive to light,
extraocular muscles intact, no lymphadenopathy. Neck was
supple, negative left axis deviation, negative masses,
jugulovenous distension of 14 cm, negative bruits. Trachea
aortic murmur, 2 to 3 tricuspid murmur. Pulmonary clear to
auscultation bilaterally. Abdomen was soft, nontender,
nondistended, positive bowel sounds. Abdominal had no bruits
and no hepatosplenomegaly. Extremities: +2 dorsalis pedis
pulses bilaterally, negative edema. Skin was negative for
dermatitis, ecchymosis, negative splinter hemorrhages or
axillary nodes.
LABORATORY DATA: Initial labs included a white blood cell
count of 6, hemoglobin 11, hematocrit 34.8 and platelets 168.
Chem-7 included sodium 131, potassium 3.3, chloride 102,
carbon dioxide 21, BUN 14, creatinine 1.4, and 98% glucose.
Calcium was 8.6, phosphate was 3.9 and magnesium was 1.8. He
showed dehiscence of the AV.
ALLERGIES: No known drug allergies
HOSPITAL COURSE: After admission the patient was continued
on intravenous Vancomycin and Gentamicin. Infectious Disease
was also consulted. The patient was transferred to the
Coronary Care Unit.
On [**7-21**], the patient was taken to the Operating Room for
an indication of infected aortic valve replacement and
endocarditis. Procedure was a redo sternotomy aortic valve
replacement with homograft 29 mm. The patient tolerated the
procedure well and was sent to the Coronary Intensive Care
Unit. On [**7-22**], Neurology was consulted for an altered
mental status. Their impression was that decreased alertness
could be due to several factors including culture-negative
endocarditis, recent Propofol use and Morphine. [**7-22**],
Infectious Disease reassessed the situation and decided to
continue the intravenous Ceftriaxone, Vancomycin and
Rifampin. On [**7-25**], Renal was consulted for acute renal
failure in which their assessment of the situation was acute
renal failure but there was no indication for dialysis and
that they would follow. The patient continued to course in
the Intensive Care Unit with close monitoring and broad
spectrum antibiotics, including Ceftriaxone, Vancomycin, and
Rifampin. During the course of the Intensive Care Unit stay
Cardiology had recommended placement of a pacemaker. On [**8-1**], the patient was brought back to the Operating Room for
placement of a [**Company 1543**] lead pacemaker. The patient
tolerated the procedure well. Neurology was consulted and
the patient was started on Dilaudid 200 mg. There were no
complications. The patient continued his stay in the
Intensive Care Unit until [**8-5**], at which time he was
transferred to the floor. During the Intensive Care Unit stay
the patient had signs and symptoms of what possibly could
have been a seizure.
On [**8-6**], the patient was assessed for placement of a
percutaneous endoscopic gastrostomy tube due to a 24 hour
caloric count well below [**2182**] calories. On [**8-8**], the
patient was brought back to the Operating Room with placement
of the percutaneous endoscopic gastrostomy tube. The patient
tolerated the procedure well and was discharged back to the
Surgical Floor. Also on [**8-8**], the patient was assessed
for rehabilitation placement.
On [**8-10**], the patient was doing well and tolerating tube
feeds without abdominal pain, nausea or vomiting.
The discharge physical showed vital signs 98.6 temperature,
60 heartrate, 130/70, blood pressure was 105/58, 18
respiratory rate, and 96% on 2 liters. General: He was
alert and oriented in no acute distress. Cardiovascularly,
he was regular rate and rhythm with no murmurs or rubs.
Respiratory rate was clear to auscultation bilaterally.
Abdomen was soft, nontender, nondistended with positive bowel
sounds, positive percutaneous endoscopic gastrostomy
placement. Extremities, negative peripheral edema. Incision
was intact. Physical therapy level was 1 out of 5.
Complications and significant events included acute renal
failure treated without dialysis, pacemaker placement and
percutaneous endoscopic gastrostomy placement.
Discharge laboratory data included a white blood cell count
of 4.7, hemoglobin 10.1, hematocrit 30 on [**8-8**] and a
sodium of 141, potassium 4.0, chloride 109, carbon dioxide of
22, BUN 19 and creatinine of 1.9 and glucose of 94. Dilantin
was 3.5 with a free Dilantin of 1.1 on [**8-9**].
DISCHARGE MEDICATIONS:
1. Hydralazine 50 mg p.o. q. 4 hours
2. Rifampin 600 mg p.o. q.d.
3. Ceftriaxone 2 mg intravenously q. 24
4. Vancomycin 1 gm intravenously q.d.
5. Dilantin 250 mg b.i.d., hold to repeat 30 minutes prior
and 30 minutes after administration of Dilantin
6. Docusate 100 mg p.o. b.i.d.
7. Heparin 5000 units subcutaneous b.i.d.
8. Vitamin C 500 mg p.o. b.i.d.
9. ZnSO4 220 mg p.o. q.d.
10. Amiodarone 400 mg p.o. q.d.
11. Norvasc 10 mg p.o. q.d.
12. Nephrocaps times one p.o. q.d.
13. Nystatin powder to the groin b.i.d. prn
14. UltraCal 80 cc/hr, hold 30 minutes prior and after
administration or administration of Dilantin
15. Ibuprofen 400-600 mg p.o. q. 6 hours
16. Milk of Magnesia 30 ml p.o. prn
17. Tylenol 650 mg p.o. q. 4 hours
PRIMARY DISCHARGE DIAGNOSIS:
1. Status post redo sternotomy and aortic valve replacement
with homograft
SECONDARY DIAGNOSIS:
1. Chronic renal insufficiency
2. Hypertension
3. Hypercholesterolemia
4. Chronic anemia
5. Infrarenal abdominal aortic aneurysm
DISPOSITION: [**Hospital **] hospital, [**Hospital3 672**]
Hospital & Rehabilitation Center. #[**Telephone/Fax (1) 35784**], Fax
[**Telephone/Fax (1) 35785**].
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] R. 02-358
Dictated By:[**Last Name (NamePattern4) 959**]
MEDQUIST36
D: [**2183-8-10**] 19:49
T: [**2183-8-10**] 21:24
JOB#: [**Job Number 35786**]
|
[
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icd9cm
|
[
[
[]
]
] |
[
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"43.11",
"38.91",
"37.72",
"42.23",
"39.61",
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] |
icd9pcs
|
[
[
[]
]
] |
6462, 7213
|
7234, 7311
|
3029, 6439
|
1579, 1802
|
1825, 3011
|
149, 171
|
200, 1258
|
7332, 7867
|
1281, 1555
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,033
| 196,709
|
43040
|
Discharge summary
|
report
|
Admission Date: [**2187-2-18**] Discharge Date: [**2187-2-21**]
Date of Birth: [**2148-4-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Abdominal pain, nausea, vomiting
Major Surgical or Invasive Procedure:
hemodialysis
History of Present Illness:
38yo man w/ DMI c/b gastroparesis, CAD s/p STEMI w/ BMS [**2186-12-17**],
ESRD on HD who presents w/ N/V, diffuse abd pain that began last
night. Pain is described as simillar to his usuall
presentations. Pain persisted throughout night and patient
developed nausea and vomiting in AM at which point he called
EMS. Pt was recently discharged from [**Hospital1 18**] on [**2187-2-15**] after a
MICU stay w/ HTN urgency. Pt reports doing well after dc until
the night prior to readmission. Denies CP, diaphoresis,
lightheadedness/dizziness. + SOB, + palpitations (not new).
Reports compliance w/ his meds (including [**Date Range 4532**], which he
reportedly took yesterday afternoon).
.
Past Medical History:
DMI complicated by gastroparesis
CAD s/p STEMI on [**2186-12-17**] in setting of cocaine use with bare
metal stent placement to the LAD
ESRD on HD since [**2-/2184**]
Line sepsis, coag negative staph most recently [**2187-1-10**], prior
klebsiella/enterobacteremia
Autonomic dysfunction wtih hypertensive emergency and
orthostatic hypotension
History of substance abuse (cocaine and marijuana)
History of esophageal erosion, [**Doctor First Name **]-[**Doctor Last Name **] tear
History of AV fistula clot
CVA?
Social History:
Patient has a prior history of tobacco and marijauna use, but
he does not currently smoke. He has a prior history of alcohol
abuse and has been sober for 9 years. He has a past history of
cocaine use. He currently denies illicit drugs.
Family History:
Father deceased of ESRD and DM. Mother aged 50's with
hypertension. 2 sisters, one with diabetes. 6 brother, one with
diabetes. There is no family history of premature coronary
artery disease or sudden death.
Physical Exam:
VS: 97.3 89 195/125 -> 116/114 15 100% RA (wearing 2L)
Gen: middle aged male in NAD, resp or otherwise. Oriented x3.
Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctival pallor
no cyanosis of the oral mucosa.
Neck: Supple
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. +S4, no S3. [**4-19**] HSM at LSB.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi.
RUQ tunneled HD line dressing c/d/i.
Abd: soft, ND, No HSM. No abdominial bruits. diffuse minimal
tenderness to palpation, no rebound, gaurding.
Ext: No c/c. trace B LE edema. No femoral bruits left or right.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Brief Hospital Course:
38 M h/o DM c/b gastroparesis, HTN, CAD s/p MI [**12-21**] with
persistent STE since [**12-21**] who presents with usual syndrome of
n/v/abd pain noted to have persistent STE with ?new STE in V1-2,
no CP/sob. On arrival to [**Hospital1 18**], VS=98.5 110 234/156 18 100%RA,
pt vomiting. EKG showed new ST elevations in V1/V2 with
otherwise diffuse ST elevations that are unchanged from prior.
Pt was given Dilaudid 5mg iv & ativan 6mg iv for his abdominal
pain and nausea. He was initially given labetolol IV for bp
control to which he did not respond, followed by nitro gtt which
caused precipitous drop in bp to 108/75. Cardiology was
consulted and felt it was unclear if new ST elevations were due
to new ischemic event. Patient was admitted to CCU for
observation and possible cardiac cath in AM. Patient had recent
STEMI in [**12-21**] that presented with L-sided chest tightness
radiating to L arm with associated diaphoresis. During that
admission he was found to have occlusion of LAD distal to D1
with BMS placement.
# CAD/Ischemia: Denies CP or SOB. However may be absent in
setting of DM/neuropathy. Did have L-sided chest tightness on
presentation of initial MI in [**12-21**]. Prior stent to LAD. RCA was
not visualized on prior cath. New ST elevations in V1, V2 with
persistent elevation V3-4. Territory concerning for ongoing LAD
ischemia vs aneurysm, none seen on TTE [**1-20**]. Doubt to be
ischemic event as CE negative (trop positive however in the
setting of renal failure and stable. could be mild form
pericarditis (small effusion on ECHO) or mild demand ischemia in
the setting of hypertensive urgency. We continued ASA, [**Month/Year (2) **],
Lisinopril and BB, with good blood pressure control during the
hospital course.
.
# Pump: chronic systolic CHF. EF 45% [**2187-2-2**] TTE. stable
without signs of decompensation. Continued Lisinopril 40mg po
qdaily, as well as Labatalol.
.
# HTN: pt hypertensive episodes most likely due medication
non-absorption in the setting of nausea and vomiting, due to
gastroparesis. Nausea and vomiting also further trigger for
increase of BP. Once pt's nausea and vomiting well controled
through IV medication, and blood sugar controled with insulin,
patient becomes asymptomatic and BP is much easier to control on
home regiment. Upon discharge arrangements have been made to set
patient up with VNA for medication assistance.
.
# DM: Remained less of an issue and was stable and well
controlled on home regiment of Lantus, and SSI.
.
# ABD PAIN/n/v - similar to prior episodes consistent with
chronic gastroparesis. currently having 3 loose BMs/day, no
recent abx, afebrile. Advanced diet to diabetic diet as
tolerated and prn ativan 1 mg PO/IV Q4H:PRN, dilaudid 1-2 mg IV
Q3H:PRN, reglan prior to each meal.
.
# ESRD: Creatinine 8.9, Pt on HD tue/[**Last Name (un) **]/sat schedule. Pt
continues to make urine, and was diuresed without complication
through his hospital course.
Medications on Admission:
1. Aspirin 325 mg Tablet PO DAILY
2. Clopidogrel 75 mg Tablet PO DAILY
3. Reglan 10 mg po tid.
4. Compazine 10 mg Tablet Sig: One (1) Tablet PO every six prn
n/v.
5. Lanthanum 500 mg Tablet TID W/MEALS
6. Clonidine 0.2 Patch QTEUSDAY
7. Clonidine 0.1 mg PO BID
8. Insulin Glargine 100 unit/mL Solution Sig: Twelve (12) units
Subcutaneous once a day.
9. Pantoprazole 40 mg po qdaily
10. Lidocaine 5 %(700 mg/patch) qdaily
11. Atorvastatin 80 mg po qdaily.
12. Lisinopril 40 mg PO once a day.
13. Ativan 2 mg po tid prn pain.
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 tabs* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
Disp:*30 Tablet(s)* Refills:*0*
4. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QTUES (every Tuesday).
5. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical QDAILY ().
7. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
8. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
12. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
13. Insulin Glargine 100 unit/mL Cartridge Sig: Twelve (12)
units Subcutaneous at bedtime.
14. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)): VERY IMPORTANT TO
TAKE THIS MEDICATION 30 MINUTES BEFORE EACH MEAL.
15. Labetalol 300 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*30 Tablet(s)* Refills:*2*
16. Lanthanum 500 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
17. Lorazepam 1 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for nausea.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Hypertensive urgency
DMI complicated by gastroparesis
CAD s/p STEMI on [**2186-12-17**] in setting of cocaine use with bare
metal stent placement to the LAD
ESRD on HD since [**2-/2184**]
Line sepsis, coag negative staph most recently [**2187-1-10**], prior
klebsiella/enterobacteremia
Autonomic dysfunction wtih hypertensive emergency and
orthostatic hypotension
History of substance abuse (cocaine and marijuana)
History of esophageal erosion, [**Doctor First Name **]-[**Doctor Last Name **] tear
History of AV fistula clot
Discharge Condition:
Good
Discharge Instructions:
You were admitted with nausea, vomiting and hypertension. You
were treated with your normal medications and got better in a
couple of days.
.
Call your PCP or come to the ED if you develop any worrisome
symptoms such as fevers or abdominal pain.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 31804**] [**Last Name (NamePattern1) 31805**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2187-2-22**] 3:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9546**], MD Phone:[**Telephone/Fax (1) 1047**]
Date/Time:[**2187-3-13**] 10:00
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] TRANSPLANT SOCIAL WORK
Date/Time:[**2187-4-9**] 2:00
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
[
"414.01",
"403.01",
"V45.82",
"585.6",
"428.0",
"428.22",
"285.21",
"412",
"536.3",
"250.63",
"337.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
8371, 8377
|
3053, 5998
|
347, 362
|
8948, 8955
|
9250, 9793
|
1883, 2095
|
6574, 8348
|
8398, 8927
|
6024, 6551
|
8979, 9227
|
2110, 3029
|
275, 309
|
390, 1078
|
1100, 1613
|
1629, 1867
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,329
| 163,816
|
45172
|
Discharge summary
|
report
|
Admission Date: [**2143-12-13**] Discharge Date: [**2143-12-17**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2344**]
Chief Complaint:
Lethargic
Major Surgical or Invasive Procedure:
Central line placement
Arterial line placement
History of Present Illness:
Pt is a 83 yo female with h/o DM2, CAD s/p CABG, carotid
stenosis s/p stent to L ICA, ASD, TIA, CRI, seizure d/o presents
to the ED with lethargy and non-specific complaints. The
symptoms had been increasing and were accompanied by decreased
PO intake per the patient's family. In addition, she had
developed N/V/D and, more recently, abdominal pain.
In the [**Name (NI) **] pt was found to be anemic to 28, with a Creat of 3.8
(Baseline 1.6-2.1), K of 6.5, Lactate 2.2 --> 0.89. UA was c/w
infection and a low grade temp to 100.2. Pt was hypotensive to
60's and 70's. She received IVF without resolution, and was
entered into the sepsis protocol (R IJ was placed, total of 4L
IVF given, dopamine started, and vanc/levo/flagyl were started).
Pt also reported to have been hypoxic with sats in low 80's and
put on NRB.
Dopamine was weaned off in MICU.
Past Medical History:
1. DM type 2
2. CAD s/p 2 vessel CABG and pci to lima-lad in '[**23**]
3. Carotid stenosis s/p stent to left ica in '[**36**]
4. Atrial septal defect
5. TIA/CVA
6. Chronic Kidney Disease
7. Stroke Induced Seizures
8. HTN
9. Hyperlipidemia
10.Cervical Spondylosis
11.Lumbar Radiculopathy
12. S/p cataract repair
13. s/p LUE fx repair
14. Depression
Social History:
Retired math professor [**First Name (Titles) **] [**Last Name (Titles) **], married, husband is health care
proxy. [**Name (NI) **] EtoH.
Family History:
Non- contributory
Physical Exam:
Vitals: 74, 112/45 (art BP), Oxygen sats 95% on 2L NC
Gen: arousable, and will follow very simple commands. Appears
pale.
HEENT: PERRL, OP clear, MMM, No LAD
CV: RRR, II/VI systolic murmur at LSB.
Lungs: Clear
Abd: soft, mild tenderness, +BS. Protruberant, but no fluid wave
ext: trace edema, +left surgical scar and mild erythema at shin
Neuro: CN II-XII intact grossly - no droop, MAE
Pertinent Results:
Labs on admission:
[**2143-12-12**] 09:30PM BLOOD WBC-18.0*# RBC-3.38* Hgb-9.4* Hct-28.6*
MCV-85 MCH-27.9 MCHC-33.0 RDW-14.5 Plt Ct-291
[**2143-12-12**] 09:30PM BLOOD Neuts-89.6* Bands-0 Lymphs-7.5* Monos-2.7
Eos-0.1 Baso-0.1
[**2143-12-12**] 11:00PM BLOOD PT-13.0 PTT-21.8* INR(PT)-1.1
[**2143-12-12**] 09:30PM BLOOD Glucose-75 UreaN-117* Creat-3.8*# Na-136
K-6.5* Cl-99 HCO3-20* AnGap-24*
[**2143-12-12**] 09:30PM BLOOD AST-17 CK(CPK)-106 AlkPhos-75
Amylase-104* TotBili-0.2
[**2143-12-13**] 12:10AM BLOOD Calcium-7.4* Phos-3.9 Mg-1.5*
[**2143-12-13**] 12:21AM BLOOD Type-[**Last Name (un) **] pO2-133* pCO2-43 pH-7.23*
calHCO3-19* Base XS--9
[**2143-12-12**] 09:35PM BLOOD Lactate-2.2* K-6.6*
_______________________
Other Labs:
[**2143-12-12**] 09:30PM BLOOD CK-MB-4 cTropnT-0.07*
[**2143-12-13**] 12:10AM BLOOD CK-MB-4 cTropnT-0.04*
[**2143-12-13**] 09:30AM BLOOD CK-MB-7 cTropnT-0.08*
[**2143-12-12**] 09:30PM BLOOD AST-17 CK(CPK)-106 AlkPhos-75
Amylase-104* TotBili-0.2
[**2143-12-13**] 12:10AM BLOOD CK(CPK)-103
[**2143-12-13**] 09:30AM BLOOD CK(CPK)-129
[**2143-12-13**] 11:34AM BLOOD calTIBC-252* Ferritn-92 TRF-194*
[**2143-12-13**] 08:15AM BLOOD Cortsol-20.1*
[**2143-12-13**] 09:00AM BLOOD Cortsol-38.7*
[**2143-12-13**] 09:30AM BLOOD Cortsol-43.7*
[**2143-12-13**] 12:10AM BLOOD CRP-130.3*
[**2143-12-12**] 09:30PM BLOOD Valproa-20*
_______________________
Labs on discharge:
[**2143-12-17**] 06:00AM BLOOD Glucose-96 UreaN-28* Creat-1.1 Na-142
K-3.8 Cl-109* HCO3-24 AnGap-13
[**2143-12-17**] 06:00AM BLOOD Calcium-8.5 Phos-2.4* Mg-1.7
_______________________
Radiology:
[**2143-12-12**]- CXR AP- IMPRESSION: No free intraperitoneal air or
evidence of pneumonia is identified.
Brief Hospital Course:
83 yo female admitted to MICU from ED under sepsis protocol.
Found to be in urosepsis.
1. [**Name (NI) 15305**] Pt was septic and entered sepsis protocol. She was on
dopamine for BP support in the MICU overnight and started on
vancomycin, Levaquin, and Flagyl. Initially urine grew GNR, and
blood had 2/4 bottles of staph coag negative. Additionally, CT
scan showed ? minimal diverticulitis and thus all those things
were being covered. The staph was likely contaminant as it grew
out four different species. Additionally, urine grew e. coli
pansensitive and pt was started on amoxicillin. Vancomycin,
Levaquin, and Flagyl were then d/cd. Pt was then hemodynamically
stable and did well.
2. [**Name (NI) 3674**] Pt with Hct that had decreased to 24 on admission,
with a normal Hct in low 30s and here with guaiac positive
stool, requiring two units of pRBC. Also appeared to have anemia
of chronic disease on iron studies (low iron, low TIBC, high
ferritin). An active T&S was kept at all times as well as 2
large bore IVs. PPI was changed to [**Hospital1 **]. Hct after transfusions
remained stable.
3. CV-
a. Ischemia- EKG showed inferolateral TWI and ST depressions.
Cardiac enzymes x 3 were done. Troponins were up to 0.08 but CKs
and MBs flat; this was thought to [**1-16**] demand, a low pressure
state, and increased HR. We continued ASA, beta blocker, Statin,
and ACE inhibitor.
b. Pump- Echo [**2141**] with EF 20%. Pt was euvolemic on exam.
Initially we held her Lasix as she was auto diuresing and did
not take in a lot of PO except for when her husband was present.
Lasix was restarted on discharge. Continued beta blocker, ACE as
above.
c. Rhythm- Normal sinus.
4. Metabolic acidosis- Pt had a non gap hypochloremic metabolic
acidosis initially. It was likely [**1-16**] renal failure as well as
normal saline. This resolved.
5. ARF- Baseline creatinine 1.6-2.1, 3.8 on admission. It was
from a prerenal etiology, low blood pressure and decreased
forward flow. This resolved during hospitalization.
6. DM- Gets 14 units 70/30 at home. Continued home insulin,
slightly decreased as pt was taking poor POs. She was also on a
RISS.
7. Seizure disorder- Continued valproate per outpatient dosages.
8. Psych- continued Zyprexa per home dosages.
9. F/E/N- cardiac low salt diet. Electrolytes were checked and
repleted.
10. PPx- subcutaneous heparin, bowel regimen, PPI. Refused to
work with physical therapy.
11. Code status- Code status was Full Code.
12. Access- IJ CVL, arterial line while in MICU. 2 PIVs on
floor.
Medications on Admission:
Aspirin 81 mg daily
Atorvastatin 20 mg daily
Gabapentin 300 mg TID
Isosorbide Mononitrate 30 mg qd
Lansoprazole 30 mg Capsule once daily
Atenolol 50 mg Tablet daily
Glyburide 5 mg Tablet daily.
Zyprexa 2.5 mg Tablet at bedtime.
Zyprexa 2.5 mg Tablet [**Hospital1 **] PRN
RISS - Check FSG qidachs
Lisinopril 5 mg Tablet daily
Lasix 20 mg Tablet po daily
70/30 Humulin 14 units qam
Depakote 150 mg [**Hospital1 **]
Discharge Medications:
1. Amoxicillin 500 mg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours) for 6 days.
Disp:*12 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed.
6. Divalproex 125 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
7. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
9. Glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day.
10. insulin
per outpatient dose. 14 units 70/30 humulin qam
11. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
12. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day. Capsule, Delayed
Release(E.C.)(s)
Discharge Disposition:
Home With Service
Facility:
CareGroup
Discharge Diagnosis:
Primary Diagnosis:
Urosepsis
Anemia
Acute Renal Failure
Secondary Diagnosis:
Coronary Artery Disease
Diabettes Mellitus
Seizure Disorder
Hypertension
Hyperlipidemia
Discharge Condition:
Hemodynamically stable. She is refusing Physical therapy.
Discharge Instructions:
Please call your doctor or go to the ED immediately if you have
fever, chills, feel dizzy, lightheaded, shortness of breath,
breathing problems or any other health concern.
Take your medications as prescribed. You are on a new medication
called Amoxicillin which is an antibiotic.
Your stool tested positive for blood here a few times. You
should follow up with Dr. [**Last Name (STitle) 2204**]. You may need an outpatient
colonoscopy if you have not had one recently.
Followup Instructions:
Please call Dr. [**Last Name (STitle) 2204**] [**Telephone/Fax (1) 2936**] for follow up in the next
week.
|
[
"272.4",
"585.9",
"038.9",
"599.0",
"414.01",
"584.9",
"276.2",
"250.00",
"285.29",
"995.92",
"780.39",
"041.4",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"99.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
7924, 7964
|
3908, 6450
|
274, 323
|
8174, 8234
|
2192, 2197
|
8754, 8864
|
1749, 1768
|
6913, 7901
|
7985, 7985
|
6476, 6890
|
8258, 8731
|
1783, 2173
|
225, 236
|
3582, 3885
|
351, 1205
|
8063, 8153
|
8004, 8042
|
2211, 2912
|
1227, 1576
|
1592, 1733
|
2924, 3563
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,126
| 105,515
|
1059
|
Discharge summary
|
report
|
Admission Date: [**2112-5-7**] Discharge Date: [**2112-7-7**]
Service: GENERAL SURGERY
HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **] year old man
with a history of coronary artery disease status post
coronary artery bypass graft times three in [**2104-2-26**], hypertension, aortic insufficiency, and hiatal hernia,
who presented with postprandial epigastric pain followed by
nausea and vomiting. The patient denied any shortness of
breath, diaphoresis, palpitations. He states that this pain
is different from the pain that he had when he had his
myocardial infarction. When seen in the Emergency Room, the
patient was given aspirin, morphine, heparin, and he was
admitted to rule out myocardial infarction. The patient's
amylase and lipase were found to be elevated consistent with
pancreatitis.
PAST MEDICAL HISTORY:
1. Coronary artery bypass graft in [**2104**].
2. Hypertension.
3. Aortic insufficiency.
4. Hiatal hernia.
5. Echocardiogram with an ejection fraction of 44 to 48%.
MEDICATIONS:
1. Lopressor.
2. Aspirin.
ALLERGIES: No known drug allergies.
HOSPITAL COURSE: The patient was admitted to the Medical
Service in which care I did not partake in during that time.
The patient was seen by General Surgery for a consultation of
abdominal pain. The rest of his labs included ALT 15, AST
21, alkaline phosphatase 99, total bilirubin 0.7, amylase
111, lipase 164, albumin 3.
The patient underwent an extensive work-up which eventually
revealed that he had an obstructing lesion at the fourth part
of the duodenum and proximal jejunum at the area of the
ligament of Treitz, and therefore was taken for an
exploratory laparotomy on [**2112-5-20**]. The patient had a
exploratory laparotomy and lysis of adhesions, takedown of
splenic flexures, biopsy of peritoneal metastases,
duodenal-jejunal bypass, placement of feeding jejunostomy
tube. Please see Operative Note for further detail.
Postoperatively, the patient was admitted to the Surgical
Intensive Care Unit for a week for close cardiac monitoring.
The patient, afterwards, continued to have nausea and
vomiting. The patient had a prolonged ileus and gastroparesis
which became evident postop and likely stemmed from
longstanding duodenal obstruction as well as his age, and
physical status, which required TPN use. The patient
tolerated tube feeds well. Once TPN was discontinued the
[**Hospital 228**] hospital stay was thus characterized as slowly
progressing nutrition, p.o. and then there would be episodes
of nausea and vomiting, then the patient would start over with
tube feeds, p.o. and his feedings were slowly advanced.
UGI study showed that the contrast passed through the native
duodenum as well as the bypasss loop and upper endoscopy
showed that the duodenojejunostomy was widely patent. Thus
he was treated with reglan and erythromycin for gastroparesis
with slow improvement clinically.
His cultures while in the hospital: He had transient episode
of urinary sepsis and urine cultures at that time showed
Pseudomonas treated with IV antibiotics and then
Ciprofloxacin; a swab on [**5-30**] of a small separation and
wound infection in the upper portion of his abdominal wound
was growing out Methicillin resistant Staphylococcus aureus
and he was treated with vancomycin. The recent KUB on [**7-4**] showed no obstruction. There was plenty of stool in the
rectum. The patient's diet was slowly advanced and tolerated
a regular diet, also tolerating tube feeds well in hospital,
with Physical Therapy. The patient and his family were told of
his diagnosis and oncology consult and evaluation was
recommended. However, the patient adamantly refused. His
daughter will therefore make arrangements for follow-up by his
PCP.
DISCHARGE MEDICATIONS:
1. Heparin 5000 units subcutaneously twice a day.
2. Megace 600 mg p.o. q. day for appetite.
3. Protonix 40 mg p.o. q. day.
4. Reglan 5 mg p.o. q. six.
5. Erythromycin 250 mg p.o. q. six.
6. Colace 100 mg p.o. twice a day.
7. Ciprofloxacin 500 mg p.o. q. day times five more days.
8. Flagyl 500 mg p.o. three times a day times five more
days.
9. Tube feeds, ProMod with fiber, 90 cc for 18 hours.
DISPOSITION: The patient is being sent to rehabilitation
for Physical Therapy, caloric counts, p.o. monitoring.
The patient will follow-up with Dr. [**Last Name (STitle) **] in 1 week and will
follow-up with his PCP as well.
[**First Name11 (Name Pattern1) 4952**] [**Last Name (NamePattern1) 4953**], M.D. [**MD Number(1) 4954**]
Dictated By:[**Name8 (MD) 6908**]
MEDQUIST36
D: [**2112-7-7**] 08:28
T: [**2112-7-7**] 09:36
JOB#: [**Job Number 6909**]
|
[
"997.4",
"412",
"424.1",
"199.1",
"599.0",
"560.1",
"197.4",
"426.12",
"577.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"37.72",
"46.39",
"45.91",
"37.26",
"54.11",
"54.23",
"54.59",
"37.83"
] |
icd9pcs
|
[
[
[]
]
] |
3788, 4690
|
1126, 3765
|
128, 834
|
856, 1108
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,605
| 196,706
|
54257
|
Discharge summary
|
report
|
Admission Date: [**2105-1-9**] Discharge Date: [**2105-1-24**]
Date of Birth: [**2063-9-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
transferred from OSH for thrombocytosis, leukocytosis, hypoxic
resp failure
Major Surgical or Invasive Procedure:
plasmapheresis
History of Present Illness:
41yo man with h/o PCV, vWF def, PSA, who p/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8**] Hosp 5d
PTA with c/o LUQ pain s/p falling down stairs, found to have
ruptured spleen, went to OR for splenectomy, then ICU post-op
2/2 blood loss, where his plt count rose to 2,019,000 and WBC to
118,000 on Post-Op Day #4. Pt also noted to be in withdrawal
from etoh, was maintained on ativan CIWA scale and esmolol gtt
from HR control. He had a fever to 103 on Post-Op Day #2, was
started on Zosyn and Vanc empirically, blood cultures negative
to date. He was kept NPO with NGT on suction post-op "to protect
the vascular lines of the short gastrics," according to OSH d/c
summary. He was having diarrhea, C Diff toxin was negative, but
he was started empirically on IV Flagyl as well. The patient
was in moderate hypoxic respiratory failure presumably since his
surgery, requiring 50% FiO2 on non-rebreather to maintain his
sats in the 95% range. The patient was transferred to [**Hospital1 18**] for
platelet plasmapheresis at the suggestion of the Hematology
consultants at the OSH.
Past Medical History:
PCV
vWF Def
Etoh abuse/dependence
Polysubstance abuse
MI x 2, [**3-17**] PCV, with stenting x 2 done 3y PTA
No previous surgery.
Social History:
etoh: active abuser, unknown quantities
tob: active smoker
drugs: active abuser, unknown drugs or quantities
Family History:
Unremarkable (per OSH)
Brief Hospital Course:
41yo man with h/o PCV, vWF def, PSA, who p/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8**] Hosp 5d
PTA with c/o LUQ pain s/p falling down stairs, found to have
ruptured spleen, underwent splenectomy, post-op plt count rose
to 2,019,000 and WBC to 118,000 on Post-Op Day #4. Also found
to have mod hypoxic resp distress, AMS, etoh w/d, fever to 103,
diarrhea. Transferred to [**Hospital1 18**] for platelet plasmapheresis,
further w/u.
1. Thrombocytosis: Peak at 2813 k. Etiology attributed to
previous PV, exacerbated by reactive thrombocytosis s/p
traumatic splenectomy. Pt had L femoral pharesis line placed by
surgery and underwent total of 6 large volume phareses.
Mr.[**Known lastname 111152**] did complain of headache early in the course of his
hospitalization that subsided when his platelet count was
consistently less than 1.5 million. He did not manifest other
s/s of hyperviscosity (i.e. tinnitus, erythromelalgia, visual
changes). He did develop bluish discoloration and numbness of
his R forefinger that was attributed to a thrombotic event. He
was maintained on aspirin 81 mg po QD to prevent further
thromboses. Hematology was consulted and recommeneded
increasing his dose of hydroxyurea to 5g/D and also initiated
IFN-alpha tr-weekly shots. He has tolerated these therapies
well with occasional flushing associated with IFN. Initially,
the doubling time of Mr.[**Known lastname 111153**] platelet count was 12 hours,
requiring plt pharesis every other day. Mr. [**Known lastname 111153**] platelt
count is now decreasing daily, currently at 1115k, just on
interferon. Hydroxyurea was discontinued when his WBC dropped
precipitously to 7K.
2. Leukocytosis: Peaked at 62k. Etiology thought to be [**3-17**]
combination C.diff leukocytosis, s/p splenectomy and possible
myeloproliferative disorder. No signs/symptoms of leukostasis.
Leukocytosis improved much quicker than thrombocytosis, possibly
due to greater contribution from C.diff colitis (being treated
for). Unlikely blast crisis given lack of blasts seen on
peripheral smear, but will need formal bone marrow biopsy to
address this problem. Mr.[**Known lastname 111153**] white count decreased from
16-->7, so his hydrea was held.
3. Hypoxic Resp Failure: Pt admit ABG: 7.49/33/48, CXR
revealed multilobar pneumonia and CTA was negative for pulmonary
embolism. Pt's hypoxia improved quickly and on HD#3 was 100% on
RA. Repeat CXR revealed resolution of multilobar infiltrates.
No definite organism was obtained. Pt finished a 14 day course
of antibiotics for this problem. HIV negative this admission.
4. AMS: Pt was admitted with change in mental status from OSH.
His baseline mental status was not familiar to anyone and the pt
appeared agitated and had visual hallucinations. Head CT
negative. These visions and anxiousness improved and dissapeared
with resolution of plt count. In-depth social history revealed
occasional alcohol use, roughly 7-8 beers once a week.
Therefore, the patient's AMS was not [**3-17**] alcohol withdrawl. He
eventually related he has been diagnosed with schizotypal d/o,
but he was not seeing a psychiatrist. Psychiatry was consulted
and agreed Mr.[**Known lastname 111153**] mental status/ behavior was consistent
with schizotypal personality disorder. No antipsychotics
recommended.
5. Diarrhea: C.diff positive from OSH. Completed a 14 day
course of PO flagyl. No longer C.diff positive or having
diarrhea.
6. CAD: no acute events- pt switched from diltiazem, which he
was taking as outpt, to metoprolol for optimal cardioprotection.
Continued aspirin, statin held due to LFT abnormalities- to be
followed as outpt.
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
3. Interferon Alfa-2A 3,000,000 unit/0.5 mL Kit Sig: Three (3)
million units Subcutaneous MWF.
Disp:*qs * Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Polycythemia [**Doctor First Name **] with thrombocytosis
Multilobar Pneumonia
C.diff Colitis
schizotypal personality disorder
Discharge Condition:
Stable
Discharge Instructions:
If you have these symptoms, please call your doctor or go to the
ED:
1. headache
2. shortness of breath
3. fever
4. chest pain
5. abnormal bleeding
6. bluish/purplish discoloration of your fingers/toes
7. cough
Followup Instructions:
1. Meet Dr.[**Last Name (STitle) 8494**] (covering for Dr.[**Last Name (STitle) 13972**], Hematology) at
[**Hospital1 **]Hospital on Monday, [**1-26**] at 11:am. Labs will be
drawn at this time.
2. Meet Dr.[**Last Name (STitle) 13972**] at 9:30 AM on Tuesday [**1-27**].
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2105-1-24**]
|
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"276.5",
"286.4",
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"301.22"
] |
icd9cm
|
[
[
[]
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[
"38.93",
"99.71",
"99.04"
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icd9pcs
|
[
[
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|
1872, 5547
|
389, 405
|
6126, 6134
|
6402, 6829
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5570, 5926
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5976, 6105
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6158, 6379
|
274, 351
|
433, 1530
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1552, 1683
|
1699, 1809
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,128
| 104,705
|
43332
|
Discharge summary
|
report
|
Admission Date: [**2146-5-9**] Discharge Date: [**2146-5-15**]
Date of Birth: [**2062-12-7**] Sex: F
Service: MEDICINE
Allergies:
Ciprofloxacin
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
Transfer from outside hosptial after ventricular fibrillation
arrest in setting of bradycardia
Major Surgical or Invasive Procedure:
Cardiac catheterization, Pacemaker placement
History of Present Illness:
Patient is an 83 year old female with coronary artery disease
status post bare metal stent to LCx on [**2146-3-8**], severe MR, COPD,
CHF EF 35-40%, [**Hospital **] transferred from [**Hospital3 **] with recurrent
ventricular fibrillation arrest.
Pt admitted [**Hospital1 18**] [**3-8**] from [**Hospital3 **] (where stress thalium
showed ant/lat ischemia, TTE showed [**1-25**]+MR) for increasing
shortness of breath, had CCath [**3-8**] revealed patent LMCA, mod
diagonal LAD stenosis, 90% proximal lesion in LCx intervened on
with BMS. Pt noted to have severe MR [**1-25**]+, but bc of her PVD,
her age, calcified aorta, MVR felt to be too risky. Pt
discharged to rehab.
Pt admitted mid-[**Month (only) 116**], per report and DC summary, for heart
failure, initiated on Bumex gtt, discharged to rehab (these
records not available to me).
Pt was readmitted to [**Hospital3 **] for "weakness and confusion"
on [**5-3**]. She was treated with ctx for unknown reason and
diuresed. Due to Afib with rapid heart rate, iv dig loaded
[**5-5**], [**5-6**], and [**5-8**] (total 1.125mg). On [**5-8**] pm, 1 episode of
vtach with spontaneous conversion, then 1 episode of v-fib
requiring DC cardioversion, prompting iv amio load and gtt and
then lidocaine (unknown time of start). In AM [**5-9**], 8 episodes
of vfib requiring defibrillation(7:20am - 8:20am), intubated,
reverted to sinus rhythm. HR dropped to mid-30s with BP in 80s,
given atropine and dopamine gtt, both amio and and lidocaine
discontinued. Pt given two doses of digibind for dig toxicity
concern. Pt trasnferred to [**Hospital1 18**] for EP consult and possible
cardiac cath in AM for LCx disease causing ischemia-related
arrythmia.
ROS unable to be obtained at this time due to patient
sedation and mechanical ventilation.
Past Medical History:
- Hip fracture with ORIF in [**1-28**] c/b postop PAF and CHF. Placed
on amiodarone and Lasix
- h/o PAF
- moderate to severe MR (grade [**1-25**] several months ago at NEBH)
- mod pulm HTN
- Left carotid endarterectomy on [**2135-9-24**].
- Coronary artery disease. Angina and chest pain. She gets this
once a month usually resolved after one dose of sublingual
Nitroglycerin
- Congestive heart failure; EF 35-40% in [**2136**]
- Chronic obstructive pulmonary disease
- Hypertension
- Hypercholesterolemia
- h/o R MCA infarct [**2136**]
- PVD
- s/p hysterectomy and appendectomy
- h/o breast CA treated with lumpectomy and tamoxifen
Cardiac Risk Factors: Dyslipidemia, Hypertension
Social History:
The patient lives with her husband and grandson. She is retired
from a factory. The patient has a [**11-24**] pack smoking history of
forty years and quite in [**2136**] s/p CVA. She rarely drinks a glass
of wine with dinner. She has [**Location (un) 86**] VNA services in her home,
along with weekly housekeeping. She has been a rehabilitation
since her last admission.
Family History:
The patient's father died of cancer. The patient's mother died
of coronary artery disease and diabetes mellitus in the [**2117**].
Physical Exam:
On admission:
VS: T 98, BP 120/48, HR 54, RR 12, ac tv 500 f12 98% FiO2 0.40
Gen - elderly female, NAD, responsive to command. answers
questions but not fully appropriately, can repeat her name.
unsure of where she is. Pleasant. Multiple ecchymotic lesions
on upper torso and upper extremities.
HEENT - sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. Temporal wasting.
Neck: Supple with JVP unappreciable.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3. Tender to exam at L 3rd ic
space.
Lungs - minimal crackles at bases, wheeze, rhonchi.
Abd - obese, soft, NTND, No HSM or tenderness. No abdominial
bruits. R breast with 2cm by 2cm nodule on underside of breast.
Ext: No c/c/e. No femoral bruits. MSK [**1-26**] bil LE, could not
lift legs off of bed bil symmetric.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP
Pertinent Results:
EKG - tele strips available from OSH - periods of polymorphic
vtach and monomorphic vtach.
[**2146-3-9**] - NSR, bl 1st degree av block, prwp
[**2146-5-3**] - tele, irregular, likely afib, hr 110s with exertion
[**2146-5-3**] - aflutter, +lvh by aVL criteria, rate 90
[**2146-5-4**] - afib, vent rate 105, nl axis, st depressions v5-v6
[**2146-5-5**] - nsr, early transition, nl axis, nl intervals
[**2146-5-8**] - nsr, with regular PVC? following each sinus qrs
[**2146-5-8**] - polymorphic VT
[**2146-5-9**] - pvc --> polymorphic vt
[**2146-5-9**] - 'junctional escape' with bradycardia to 41, LAD
TELE here - idioventricular rhythm, no identifiable p-waves.
sinus bradycardia
Cardiac Cath [**2146-5-10**]
COMMENTS:
1. Coronary angiography of this left dominant system
demonstrated no
angiographically apparent flow-limiting coronary artery disease.
The
LMCA had mild luminal irregularities. The LAD had a small
diagonal
branch that had a 70% stenosis. The LCx had mild in-stent
restenosis.
Radi pressure wire was performed across this stenosis and showed
an FFR
of 0.97 after maximal hyperemia with IV adenosine. The RCA was
small
and non-dominant.
2. Limited resting hemodynamics revealed mild systemic arterial
systolic
hypertension at 155/64 mmHg.
3. Successful femoral artery closure with Angioseal VIP.
FINAL DIAGNOSIS:
1. Single vessel coronary artery disease.
2. Mild systemic arterial systolic hypertension.
Echocardiogram [**2146-5-10**]
The left atrium is mildly dilated. The left atrial volume is
markedly increased (>32ml/m2). Left ventricular wall thicknesses
are normal. The left ventricular cavity is mildly dilated. There
is severe global left ventricular hypokinesis (LVEF = 25 %).
[Intrinsic left ventricular systolic function is likely more
depressed given the severity of valvular regurgitation.]
Transmitral Doppler and tissue velocity imaging are consistent
with Grade II (moderate) LV diastolic dysfunction. Right
ventricular chamber size is normal. with mild global free wall
hypokinesis. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. The mitral valve leaflets
are mildly thickened. There is moderate thickening of the mitral
valve chordae. Moderate to severe (3+) mitral regurgitation is
seen. [Due to acoustic shadowing, the severity of mitral
regurgitation may be significantly UNDERestimated.] The
tricuspid valve leaflets are mildly thickened. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2137-6-24**], the
left ventricle is more dilated with worsened systolic function.
The findings of mildly depressed right ventricular function,
moderate to severe mitral regurigtation are similar.
Brief Hospital Course:
Patient is an 83 year old female with history of paroxysmal
atrial fibrilation, hypertension, hyperlipidemia, severe mitral
regurgitation, and coronary artery disease, who was transferred
from [**Hospital6 2910**] after polymorphic ventricular
tachycarida and fibrillation arrest in setting of bradycardia
and prolonged QTc, status post multiple defibrillations.
.
CARDIOVASCULAR:
# Coronary artery disease: Patient had underwent catherization
on [**2146-3-8**] which showed patent LMCA, moderate diagonal LAD
stenosis, and a 90% proximal lesion in LCx, to which a bare
metal stent was placed. At outside hosptial, her CKs were not
elevated. On admission, repeat cardiac enzymes were negative.
Given concern that ischemia could be contributing to her
arrhythmia and worsening of her mitral regurgitation, she
underwent cardiac catherization on [**2146-5-10**]. There were no
signs of new coronary occlusions, with a stable LCx stented
lesion. Patient was initially treated with ASA 325 mg, however
this was changed to 81 mg enteric coated once she was noted to
have guaiac positive stool. She was also treated with plavix 75
mg, and a statin (on fluvastatin 40 mg as an outpatient,
tolerated atorvastatin 80 mg as in patient). She did not
initially tolerate a beta-blocker (developing bradycardia after
once dose of 12.5 mg), but was restarted on metoprolol at 12.5
mg twice daily following pacer placement. She received 3 days
of antibiotics for procedure prophylaxis, and was monitored on
telemetry during entire admission.
.
# Congestive heart failure, mitral regurgitation: Patient was
admitted with chronic systolic heart failure. Her last echo at
[**Hospital1 18**] was in [**2136**], which demonstrated an ejection fraction of
40%, with other reports demonstrating ECHO 60% more recently. A
repeat transthoracic echocardiogram on [**2146-5-10**] demonstrated an
ejection fraction of 25%, suggestive of interval myocardial
infarction versus variable estimate of mitral regurgitation
leading to variable calculated EF. Patient had been on
significant dose of lasix (80 mg twice daily) as outpt, and
recently treated for congestive heart failure with bumex drip in
setting of severe mitral regurgitation. Was kept on PRN Lasix
boluses and maintained good O2 sats. CXR showed stable L pleural
effusion, stable cardiomegaly. She will require repeat Echo at
3 months.
.
# Rhythm - Pt had had a number of arrhythmias in the week prior
to admission - afib with tachy-brady syndrome upon presentation
to [**Hospital3 **], phase of polymorphic vtach [**5-8**] with reported
vfib arrest s/p defibrillations x10, presented to [**Hospital1 18**] with
idioventricular, narrow complex rhythm with bradycardic rate in
40s, now in sinus rhythm 60s. Of note, pt was on amiodorone on
[**5-3**] to [**5-8**] at [**Hospital3 **], then amio IV loaded on [**5-8**], with
addition of lidocaine. Also, dig loaded over past 4 days. On
dopamine [**2054-5-7**] for positive chronotropy. BB initiated [**5-9**],
but held for bradycardia lasting approx. 30 minutes. It was
thought that bradycardia could represent digoxin toxicity vs.
structural/ischemic heart disease. Pacermaker placed [**5-12**].
Coumadin reinitiated for A-fib. Follow-up appointment on [**5-20**] at 9 am in the device clinic. She will need ongoing
monitoring of her INR for goal 2.0 to 3.0.
.
# HTN - Pt is hypertensive at baseline, initially normotensive
here on low dose dopamine-->SBP in 90s off dopa. Previously
had been on large doses of dilt at rehab and at [**Hospital3 **]. BB
reinitiated for pressure control s/p pacemaker.
.
# HCT drop: From 38-->31 on [**5-10**] to [**5-11**]. Thereafter, daily
HCTs 31-->31-->29-->29 Had diarrhea that was guaiac positive,
non-melenous, C.diff neg x 2. Given PPI [**Hospital1 **], changed ASA to 81
mg EC.
.
# Access - 1 midline, 1 PIV.
.
# Leukocytosis - had wbc 10k at OSH-->12 at [**Hospital1 18**], 85% PMNs,
afebrile, now normalized Did have + UA at OSH with unknown
duration of ctx then. UA with 2 WBCs, no bacteria. UCx neg, BCx
NGTD.
.
# Vaginal Bleeding - in setting of Tamoxifen for Breast CA.
Appointment on [**6-9**] at 4:30 pm with gynecologist, Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], on [**Hospital Ward Name 23**] 8.
.
# R breast lump - underside of R breast, 2cm by 2cm. Hx of
breast CA. Also vaginal bleeding. On tamoxifen. Arranged for
ONC f/u as outpt
.
# ARF - unsure of pt's baseline cr/renal dysfunction, if any.
Cr 1.4-->1.2
.
# Hypothyroidism - continued levothyroxine. Noted to have TSH
0.09 on last admission, unsure if dose changed. TSH normal.
.
# Hyperlipidemia - continue fluvastatin 80mg qd.
.
# Prophylaxis - INR 1.1 currently, pneumoboots, asa, plavix,
ranitidine.
.
# Code - full, discussed with son.
Medications on Admission:
1. Aspirin 325 mg
2. Clopidogrel 75 mg qd
3. Levothyroxine 100 mcg qd
4. Acetaminophen 500 mg q6
5. Diltiazem HCl 360 qd
6. Furosemide 80mg [**Hospital1 **]
7. Tamoxifen 20mg qd
8. Lescol XL 80 mg qd
9. Warfarin 2 mg qd
10. Alprazolam 0.25 mg qhs prn
11. Spironolactone 25 mg qd
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Primary: Cardiac arrest, Atrial fibrillation,
tachycardia-bradycardia syndrome.
.
Secondary: Hypertension, coronary artery disease
Discharge Condition:
Stable.
Discharge Instructions:
You were admitted due to a heart arrhythmia and respiratory
distress after being transferred from another hospital. You were
given medications and monitored closely for further arrhythmias.
You underwent cardiac catherization to evaluate for any
ischemia. Due to persistently slow heart rhythm, you had a
pacemaker placed.
.
Please contact Dr. [**Last Name (STitle) **] or go to the emergency room if you
experience any chest pain, difficulty breathing, palpitations,
inability to keep down food or drink, fevers, bleeding, or other
concerning symptoms. It has been a pleasure caring for you.
.
The following medication changes have been made:
- Metoprolol 12.5 mg twice a day was started.
- Diltiazem 360 mg daily was STOPPED.
- Spironolactone 25 mg daily was STOPPED.
- Aspirin was decreased to 81 mg daily due to bleeding.
- Alprazolam was STOPPED.
.
You have a follow-up appointment on [**5-20**] at 9 am in the
device clinic to check your pacemaker, in the [**Hospital Ward Name 23**] Building,
[**Location (un) 436**], [**Hospital1 18**] [**Hospital Ward Name 516**]. The office can be reached at
([**Telephone/Fax (1) 2361**].
.
You have an appointment on [**6-9**] at 4:30 pm with a
gynecologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], to evaluate your vaginal
bleeding. The office is located at [**Hospital1 18**] [**Hospital Ward Name 516**], [**Hospital Ward Name 23**]
Building, [**Location (un) **], phone number is ([**Telephone/Fax (1) 93312**].
.
Please follow up with your oncologist, to evaluate a right-sided
breast mass noted during your stay that may be new. An
appointment has been made for you [**5-30**] at 11:30 AM at his
office. The number for his office is ([**Telephone/Fax (1) 33521**].
.
Please follow up with your cardiologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], in the
next 2-4 weeks. Please call his office to arrange follow up upon
discharge from rehabilitation.
Followup Instructions:
You have a follow-up appointment on [**5-20**] at 9 am in the
device clinic in the [**Hospital Ward Name 23**] Building, [**Location (un) 436**], [**Hospital1 18**] [**Hospital Ward Name 5074**]. The office can be reached at ([**Telephone/Fax (1) 2361**].
.
You have a follow-up appointment on [**6-9**] at 4:30 pm with a
gynecologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], to evaluate your vaginal
bleeding. The office is located at [**Hospital1 18**] [**Hospital Ward Name 516**], [**Hospital Ward Name 23**]
Building, [**Location (un) **], phone number is ([**Telephone/Fax (1) 93312**].
|
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78,701
| 198,275
|
34453
|
Discharge summary
|
report
|
Admission Date: [**2189-3-15**] Discharge Date: [**2189-4-17**]
Date of Birth: [**2123-3-1**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3561**]
Chief Complaint:
Dizziness
Major Surgical or Invasive Procedure:
Angiogram with aneurysm coil [**2189-3-20**]
Intubation
History of Present Illness:
66 year old female who reports dizziness since [**Month (only) 1096**]. She was
scheduled for a MRI today by her Primary Care physician to
further diagnose her dizziness and was found to have a large
vertebral artery aneurysm. She presented today to the ED for
further workup and management. She reports seeing floaters in
her visual fields for the past few months and states that her
legs feel "heavier" or "weaker", but denies any recent falls,
use of cane or walker,or her legs giving out on her. She denies
bowel and bladder incontinence, numbness or tingling sensation,
other visual disturbance, nausea, vomiting, headache. She
reports a chronic productive cough.
Past Medical History:
Left proximal PICA aneurysm w/mass effect on brainstem s/p
coiling
Emphysema
Hypertension
Hyperlipidemia
Cholecystectomy
Peripheral vascular disease, mild celiac stenosis and
moderate-to-severe SMA stenosis s/p stent [**8-15**] with known [**Female First Name (un) 899**]
occlusion.
S/P left ankle fracture
Tobacco abuse
Appendectomy
Depression
Social History:
She is married with four living children. Tobacco - quit in
[**8-15**](prior 1 pack per day x 56 years. She works as bookkeeper
for her husband [**Name (NI) **]
Family History:
Her mother and father both had cancer (unclear which type)
Physical Exam:
Vitals: T99.9 BP 103/92 HR 94 RR 33 100% 40% FIO2
Gen: intubated, awake and alert, following commands, no acute
distress
Neck: supple, no JVD
CV: RRR, nl s1/s2, no appreciable murmur
Resp: vented breath sounds, decreased BS at bases, no wheezing
Abd: soft, NT/ND, normoactive bowel sounds, no rebound or
guarding
Ext: warm, no edema
Pertinent Results:
CTA Head and Neck:
1. 3.2 cm extra-axial mass centered in the cerebello-pontine
cistern on the left avidly enhances following contrast
administration, and may originate from the proximal portion of
the left PICA (though not from the origin). Most likely, this
represents a giant aneurysm. However, given that it enhances
slightly less than blood pool, unusual appearance of a mass
lesion such as meningioma or other extra-axial neoplasm should
also be considered. MRI and angiography may be helpful for
further evaluation.
2. Emphysema.
ECHO:
The left atrium is normal in size. The estimated right atrial
pressure is 0-10mmHg. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is mild
functional mitral stenosis (mean gradient 4 mmHg) due to mitral
annular calcification. The tricuspid valve leaflets are mildly
thickened. The pulmonary artery systolic pressure could not be
determined. There is a trivial/physiologic pericardial effusion.
CT CHEST/ABDOMEN/PELVIS:
IMPRESSION:
1. Left upper pole homogeneously enhancing kidney lesion may
represent a
complicated cyst; however, further characterization of this cyst
with MRI is recommended to exclude cystic renal cell carcinoma.
2. Indeterminate left adrenal lesion likely represents adenoma.
This could be confirmed at the time of MRI.
3. Dilation of the hepatic ducts may be related to ampullary
stenosis or
reflect postsurgical change. MRI would be helpful to further
exclude a
malignancy.
4. Moderate emphysema.
5. Right lower quadrant lymph node and associated stranding are
nonspecific. They may relate to infectious process or recent
procedure. Clinical correlation is recommended.
[**2189-3-31**] MRI Abdomen:
1) Limited study due to limited breath-holding capacity and lack
of
intravenous gadolinium.
2) Left adrenal adenoma.
3) Left renal cyst in question appears completely simple, but
can be re-
assessed at the time of MRCP with intravenous gadolinium.
4) Mild bilie duct dilatation with the suggestion of some debris
within the common duct. Dedicated MRCP is recommended for
further assessment when the patient is able and an IV can be
placed.
5) Bibasilar consolidation and effusions, new compared to the CT
of [**2189-3-17**], likely secondary to aspiration.
Labs on Discharge:
[**2189-4-16**] 04:35AM BLOOD WBC-10.2 RBC-2.74* Hgb-7.6* Hct-22.8*
MCV-83 MCH-27.6 MCHC-33.1 RDW-18.0* Plt Ct-494*
[**2189-4-16**] 04:35AM BLOOD Plt Ct-494*
[**2189-4-16**] 04:35AM BLOOD Glucose-118* UreaN-18 Creat-0.5 Na-134
K-4.6 Cl-95* HCO3-31 AnGap-13
[**2189-4-11**] 04:15AM BLOOD LD(LDH)-166 TotBili-0.2
[**2189-4-16**] 04:35AM BLOOD Calcium-8.9 Phos-4.7* Mg-2.0
[**2189-4-16**] 04:35AM BLOOD TSH-7.1*
[**2189-4-16**] 04:35AM BLOOD Free T4-1.2
[**2189-4-9**] 04:32PM BLOOD Type-ART pO2-59* pCO2-60* pH-7.38
calTCO2-37* Base XS-7
Brief Hospital Course:
Hospital Course:
Mrs. [**Known lastname 79193**] is a 66y/o F with a PMH of PVD s/p SMA stenting,
HTN, hyperlipidemia initially presenting on [**3-15**] after being
found to have an incidental unruptured 3X3X 2.5 cm left PICA
aneurysm identified on oupatient MRI for workup of dizziness.
She reported seeing floaters in her visual fields and leg
heaviness over the past few months. Denies falls, incontinence,
visual disturbance. CT Head and Neck demonstrated a 3.2 cm
extra-axial mass centered in the cerebello-pontine cistern on
the left, consistent with a giant aneurysm. HCT dropped to 21.6
on [**3-17**], med consult obtained and she was transfused 2U PRBC. CT
torso demonstrated several indeterminate lesions (L adrenal, L
kidney). ECHO: EF >55%. She underwent coiling of the anuerysm
on [**3-20**]. She was placed on a heparin drip following the
procedure. She had an episode of desaturation immediately after
extubation and received a bolus of Glycopyrrolate, and
Neostigmine for suspected residual paralysis. She developed a
slight worsening left sided weakness on [**3-21**] w/ right sided
sensory deficit, per nsurg c/w Wallenberg syndrome (lateral
medullary infarct). Also developed a femoral hematoma, but
follow-up US without evidence of aneurysm or fistula. CT head
stable on [**3-22**]. Sputum was obtained on [**3-22**] given worsening
hypoxemia and thick secretions, grew Moraxella and ceftriaxone
was started.
During her first stay in the MICU, it was suspected that she was
having aspiration events. Passed bedside swallow eval, but due
to high suspicion for aspiration a barium swallow was performed
with aspiration of barium into the lungs. Antibiotics were
switched to Vanc/Zosyn and she required intubation for worsening
respiratory distress. A BAL was performed with washout of the
barium. She was extubated and transferred to floor on [**2189-3-29**].
On floor, she continued to be tenuous for a respiratory
perspective with high oxygen requirements. This was believed to
be multi-factorial from VAP, repeated aspiration events, poor
cough and baseline lung disease. A repeat speech and swallow
evaluation showed evidence of aspiration with deficits
consistent with neurological deficit and it was decided to
proceed with PEG tube placement on [**3-31**]. Following PEG
placement, she had an episode of acute desaturation on the floor
to 60% on NRB. She was reintubated and retransferred to the
ICU. Hypoxemia was most likely [**2-9**] mucous plugging given that
it resolved following ET suctioning. She was extubated the
following morning however continued to require chest pt,
pulmonary toilet and significant supplemental O2. She did have
several episodes of acute desaturation due to mucous plugging
which resolved with chest pt and suctioning.
Problem [**Name (NI) **]:
#Hypoxic Respiratory Failure/Aspiration Pneumonia: [**2-9**]
aspiration of barium, with persistent thick secretions. She has
had recurrant difficulties due to mucous plugging exacerbated by
generalized weakness and overall deconditioning. At the time of
transfer to rehab she is
-continue with chest PT every 4-8 hours
-continue standing guaifensin for thinning of secretions
-physical therapy and ambulation
-incentive spirometry
-albuterol/ipratropium nebs
-acapella device
-oxygen by 4-6L NC or 40%-50% humidified face mask
.
#Dysphagia, left sided weakness - likely [**2-9**] giant PICA
aneurysm. Stable throughout admission with no change on serial
head CT. She is s/p PEG placement for dysphagia and aspiration.
-discharge to PT for rehab
-would benefit from repeat swallow study once strenght improved
to determine if dysphagia resolves.
#Urinary Retention - she has had foley catheter throughout the
majority of her admission. It was removed at one point however
replaced due to persistent retention. On [**4-16**] her foley was
discontinued and she was straight cathed q shift for urinary
retention.
-continue to straight cath q4-6 hours. If her urinary retention
does not resolve in [**1-9**] days she will likely require replacement
of her foley catheter with outpatient urology follow up. She
had a urinalysis sent on [**4-16**] which did not show any evidence of
UTI.
#. Severe iron deficiency/Acute Blood Loss anemia: Her baseline
hematocrit is mid 20's with a ferritin of 6. Outside hospital
records were obtained for EGD and colonscopy in [**6-15**] which
showed only ischemic colonic ulcer. She was continued on PO iron
supplementation after receiving 8 days of IV iron repletion. She
had this discontinued secondary to constipation and will
continue on ferrous sulfate. She should receive a colonoscopy to
evaluate the iron deficiency anemia. EGD performed during PEG
placement revealed duodenitis for which she was placed on
lansoprazole through the PEG tube.
.
#. Left kidney cysts and left adrenal incidentaloma: These were
identified on Abdominal CT with concern for malignancy. An
abdominal MRI was attempted, but she was unable to tolerate this
due to difficulty holding breath for extended periods of time.
She will need an outpatient MRI for further characterization
sometime in near future once her respiratory status is stable
enough to tolerate lying flat.
.
#. PVD: Had evidence of ischemic colitis in [**2188-6-8**] and a BMS
was placed in SMA on [**8-15**]. She was continued on plavix and ASA,
these were discontinued for placement of PEG tube and restarted
following this procedure.
.
#.Anxiety/Depression ?????? On xanex 0.5mg [**Hospital1 **] at home. Pt has PMHx
of depression but not currently on medications. Significant
nursing and family concern for depression during this admission.
Citalopram was started empirically. She will need outpatient
psychiatry follow-up. Psychiatry evaluated patient and would
recommend adding mirtazipine once she is stable from a pulmonary
standpoint given risk of sedation and possible aspiration with
this medication. She was given an occasional one time extra
dose of alprazolam for her anxiety. A TSH was checked which was
elevated at 7.1 with normal FT4 likely due to either sick
euthyroid or subclinical hypothyroidism. She will need repeat
TSH to determine cause and whether treatment is needed.
Code status is Full
Medications on Admission:
Plavix 75 mg
Diltiazem 120mg qd
Lipitor 40 mg qd
Xanax 0.5 mg qd
ASA 325 po qd
Discharge Medications:
1. Simvastatin 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
2. Alprazolam 0.25 mg Tablet [**Hospital1 **]: Two (2) Tablet PO BID (2 times
a day).
3. Acetaminophen 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q6H (every
6 hours) as needed.
4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) nebulizer Inhalation Q2H (every 2
hours) as needed.
5. Aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
7. Citalopram 20 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily).
8. Clopidogrel 75 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
9. Diltiazem HCl 60 mg Tablet [**Hospital1 **]: One (1) Tablet PO QID (4
times a day).
10. Docusate Sodium 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO twice a
day.
11. Guaifenesin 100 mg/5 mL Syrup [**Hospital1 **]: Thirty (30) ML PO TID (3
times a day).
12. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: 5000 (5000)
units Injection TID (3 times a day).
13. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation
Q6H (every 6 hours) as needed.
14. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
15. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical QID
(4 times a day) as needed.
16. Senna 8.6 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO BID (2 times a
day).
17. Polyethylene Glycol 3350 100 % Powder [**Last Name (STitle) **]: One (1) PO DAILY
(Daily) as needed for constipation.
18. Ferrous Sulfate 325 mg (65 mg Iron) Tablet [**Last Name (STitle) **]: One (1)
Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Aspiration pneumonia
Mucous plugging
3 cm giant left PICA artery aneurysm
Emphysema
Left adrenal mass
left kidney cyst
Iron deficiency anemia, severe
Horner's syndrome
Low-density lesion in the thyroid.
Dyphagia s/p PEG placement
Discharge Condition:
Hemodynamically stable and afebrile. Tolerating PO's. Improving
neurologically. Requiring 4-6L NC or 40-50% humidified face
mask. She has slight left sided weakness and dysphagia from her
cerebral aneurysm. She has thick secretions and requires
assistance with chest PT and suctioning to clear secretions. If
acutely desaturates, most likely due to mucous plugging.
Discharge Instructions:
You were admitted to the hospital with an aneurysm in your brain
that was embolized. After the procedure you had difficulty
swallowing and aspirated into your lungs which caused difficulty
breathing requiring intubation. You developed a pneumonia that
was treated with antibiotics and aggressive lung rehab.
Please inform you doctor or return to ED if you experience loss
of vision, blurring, double vision, half vision, slurring of
speech or difficulty finding correct words to use, severe
headache or worsening headache not controlled by pain
medication, sudden change in the ability to move or use your arm
or leg or the ability to feel your arm or leg, trouble
swallowing, breathing, or talking, numbness, coldness or pain in
lower extremities, temperature greater than 101.5F for 24 hours.
Followup Instructions:
Please call your primary care doctor as your CT scan of the
chest this hospital admission indicates emphysema. You also had
some abnormal findings on your CT scan that requires follow-up
with an abdominal MRI. Please arrange this with your outpatient
provider once stable.
Please follow up with Dr. [**First Name (STitle) **] of Neurosurgery in one month.
The number to call and schedule this appointment is
[**Telephone/Fax (1) **].
If you continue to have difficulty urinating you will need to
follow up in [**Hospital 159**] clinic. The number for this clinic is ([**Telephone/Fax (1) 18591**].
|
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icd9cm
|
[
[
[]
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[
"33.24",
"38.93",
"88.41",
"43.11",
"96.72",
"96.6",
"39.72",
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] |
icd9pcs
|
[
[
[]
]
] |
13471, 13543
|
5229, 5229
|
324, 382
|
13817, 14188
|
2075, 4649
|
15034, 15638
|
1645, 1706
|
11587, 13448
|
13564, 13796
|
11484, 11564
|
5247, 11458
|
14212, 15011
|
1721, 2056
|
275, 286
|
4669, 5206
|
410, 1082
|
1104, 1450
|
1466, 1629
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,924
| 113,884
|
3198
|
Discharge summary
|
report
|
Admission Date: [**2195-5-14**] Discharge Date: [**2195-5-16**]
Service: MEDICINE
Allergies:
Amoxicillin / Sulfonamides / Penicillins
Attending:[**First Name3 (LF) 710**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
none
History of Present Illness:
88 y.o woman with metastatic [**First Name3 (LF) 499**] cancer to the liver, possible
primary pancreatic cancer, recent dx of UTI on cipro, who
presented to the hospital after developing acute shortness of
breath at home. The patient was at home at her [**Hospital3 **]
when her aide noticed her to be in acute respiratory distress.
The aid called her son in law, who is a physician, [**Name10 (NameIs) **] because
the hospice agency was unable to come to evaluate, he decided to
bring her to the hospital.
.
Of note, the patient had recently been admitted to the hospital
on [**4-7**] for tachycardia, cough, found to have a bandemia and was
treated for pneumonia. During that admission, after extensive
consultations with palliative care and given the patient's
underlying oncologic disease, she was discharged with PO
antibiotics and was placed in hospice care the day after.
According to his chart in OMR, the family has been actively
involved in the decision to place her in hospice as the patient
herself has not wanted to know anything about her diagnosis.
.
In the ED, initial vs were: T 97.9 P 113 BP 170/90 R 23 O2 sat
99% on NRB. Patient was given Vancomycin 1 gram IV x1 and Ativan
2 mg IV x1. Zosyn was ordered but not given in the ED. She was
also given 40mg IV lasix enroute by EMS. The patient was
hypoxic, and was placed on Bipap 40%, [**9-15**], drawing a tidal
volume of 400cc with minute ventilation of 16. Vitals on
transfer were HR 110, BP 135/87, RR 40 O2 sat of 100%.
Past Medical History:
- Biopsy proven [**Month/Day (1) 499**] ca, possible pancreatic cancer, and
possible liver mets (not Bx proven). The family knows, however,
the patient does not and apparently the PCP has been in
discussion with the family, and the patient has told the PCP she
does not want to know her diagnosis. They feel she will be
anxious and depressed and do not want her to know.
-HTN
-glaucoma
-OA
-?Rheum dx
-LBP
-gait disorder
-stage I pressure ulcer on kyphotic area of spine, noted [**2-18**]
-GERD
-Depression
-Extensive bilateral DVT's seen on u/s [**2-18**] with IVC filter in
place
-pulmonary artery hypertension
Social History:
"The patient lives in [**Hospital3 **] with a home health aide to
whom she is dearly attatched. She has two daughters, one lives
in [**Name (NI) 531**] and one in [**Location (un) 86**]. The patient went to teachers
college and worked in an engineering office. Her social supports
include her family. She does do physical therapy, but she says
that she does not do much of the activities because she gets
tired. Denies alcohol, smoking. Says that she sometimes eats 50%
of the meals; she tries to drink Boost in between. She has been
doing physical therapy, which is continuing, and apparently, she
has made progress. In terms of sleep, she says that some nights
are good and some nights are not, but she denies any pain while
sleeping or that wakes her up from sleep. She feels otherwise
safe at home."
Family History:
No history of [**Location (un) 499**] cancer, IBD, breast cancer, CAD, diabetes,
rheumatic diseases, asthma.
Physical Exam:
Vitals: T: 98.5 BP: 102/47 P: 100 R: 22 O2: 97% on Bipap
General: responsive to voice, in moderate distress
HEENT: BiPAP mask on
Neck: supple, JVP not elevated, no LAD
Lungs: Bilateral crackles and rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, palpable cords, 2+
bilateral LE edema
Skin: diffuse ecchymoses
Pertinent Results:
CXR:
IMPRESSION: Extensive opacification in the right middle lobe
with air bronchograms. Although the significant rotation
severely limits evaluation of this region, there is a likely
underlying infiltrate.
Brief Hospital Course:
Patient admitted to the MICU service with respiratory distress.
Thought to most likely be secondary to her known pneumonia. She
received vancomycin in the ED and was started on cefepime and
ciprofloxacin IV as empiric coverage for HAP. She was placed on
BiPAP overnight and then a facemask in the morning. She seemed
comfortable. Family meeting held on [**5-15**] regarding goals of
care. At this point, family preferred CMO with morphine gtt.
Patient called out to floor on [**2195-5-15**] and expired [**2195-5-16**].
Medications on Admission:
Acetaminophen 500 mg Tablet Two (2) Tablet by mouth three times
a day.
Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray One (1)
spray Nasal DAILY (Daily).
Calcium Carbonate 500 mg Tablet, Chewable One (1) Tablet,
Chewable by mouth four times a day.
Ciprofloxacin 500mg [**Hospital1 **]
Cholecalciferol (Vitamin D3)400 unit Tablet Two (2) Tablet by
mouth DAILY (Daily).
Docusate Sodium 100 mg Capsule One (1) Capsule by mouth twice a
day
Duloxetine 20 mg Capsule, Delayed Release(E.C.) Two (2) Capsule,
Delayed Release(E.C.) by mouth DAILY (Daily).
Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**12-14**]
Adhesive Patch, Medicateds Topical DAILY (Daily) as needed for
pain.
Lorazepam 0.5 mg Tablet One (1) Tablet by mouth every four (4)
hours as needed for anxiety.
Magnesium Hydroxide 400 mg/5 mL Suspension Thirty (30) ML by
mouth every six (6) hours as needed for constipation.
Metoprolol XL 50 mg Tablet One (1) Tablet by mouth once a day.
Mirtazapine 30 mg Tablet One (1) Tablet by mouth HS (at
bedtime).
Oxycodone 10 mg Tablet Sustained Release 12 hr One (1) Tablet
Sustained Release 12 hr by mouth every twelve (12) hours.
Oxycodone 5 mg Tablet One (1) Tablet by mouth every four (4)
hours as needed for pain.
Polysaccharide Iron Complex 150 mg Capsule One (1) Capsule by
mouth DAILY (Daily).
Prednisone 5 mg Tablet One (1) Tablet by mouth DAILY (Daily).
Sennosides [Senna] 8.6 mg Tablet Two (2) Tablet by mouth HS (at
bedtime).
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
N/A
Discharge Condition:
expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
Completed by:[**2195-5-18**]
|
[
"V12.51",
"530.81",
"401.9",
"197.7",
"157.9",
"486",
"365.9",
"715.90",
"518.81",
"416.8",
"707.21",
"V66.7",
"707.09",
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] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6186, 6195
|
4132, 4658
|
251, 257
|
6242, 6251
|
3901, 4109
|
6303, 6337
|
3251, 3361
|
6158, 6163
|
6216, 6221
|
4684, 6135
|
6275, 6280
|
3376, 3882
|
208, 213
|
285, 1778
|
1800, 2414
|
2430, 3235
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,267
| 160,017
|
51355
|
Discharge summary
|
report
|
Admission Date: [**2169-4-11**] Discharge Date: [**2169-4-22**]
Date of Birth: [**2118-4-16**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Fever of 102 with chills.
Major Surgical or Invasive Procedure:
Redo sternotomy, mediastinal washout and exploration with
remocal of sternal wires [**2169-4-12**].
History of Present Illness:
This 50 y/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4746**] is s/p AVR/asc. aorta replacement [**2169-4-3**] and had
fever and chills to 102.5 for 2 nights. He was admitted for
fever workup.
Past Medical History:
bicuspid AV
AS
parox. atrial tachycardia
dilated asc. aorta
s/p AVR/asc. aorta replacement [**2169-4-3**]
Social History:
works as electrician
occasional ETOH
never used tobacco
married, lives with wife
no IVDA
Family History:
non-contrib.
Physical Exam:
WDWNWM, ill appearing
Temp 103 SBP 90
HEENT: NC/AT, PERLA, EOMI, oropharynx benign
Neck: supple, FROM, no lymphadenopathy or thyromegaly, carotids
2+= bilat. without bruits.
Lungs: Clear to A+P
CV: RRR without R/G/M
Abd: +BS, soft, nontender, without masses or hepatosplenomegaly
Wnds: C/D/I, sternum stable.
Ext: without C/C/E
Neuro: nonfocal
Pertinent Results:
[**2169-4-21**] 07:05AM BLOOD WBC-13.3* RBC-3.72* Hgb-10.3* Hct-30.0*
MCV-81* MCH-27.5 MCHC-34.2 RDW-15.2 Plt Ct-773*
[**2169-4-21**] 07:05AM BLOOD PT-16.2* PTT-24.6 INR(PT)-1.5*
[**2169-4-21**] 07:05AM BLOOD Glucose-84 UreaN-15 Creat-1.0 Na-138
K-3.9 Cl-103 HCO3-23 AnGap-16
CHEST (PA & LAT) [**2169-4-20**] 9:57 AM
CHEST (PA & LAT)
Reason: evaluate for pleural effusions
[**Hospital 93**] MEDICAL CONDITION:
50 year old man s/p AVR/asc. aorta replacement w/ sternal wnd.
inf. and reexploration.
REASON FOR THIS EXAMINATION:
evaluate for pleural effusions
REASON FOR EXAMINATION: Followup of a patient after
reexploration of sternal wound after aortic valve and ascending
aorta replacement.
PA and lateral upright chest radiograph compared to [**2169-4-19**].
The heart size is mildly enlarged but stable. The mediastinal
contours are unchanged. The sternal wires appear in unchanged
position and have unchanged appearance. There is improved
aeration of the lungs especially in the lower lobes with still
present bilateral small pleural effusion. No pneumothorax is
identified.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
DR. [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Brief Hospital Course:
The patient was admitted and seen by ID. He was fully cultured
and started on Vanco and Gent. He had a negative chest CT. The
night of admission he had a large amount of purulent sternal
discharge. He was taken to the OR the following morning for
redo sternotomy and washout with sternal wire removal. He was
transferred to the CSRU intubated and paralyzed with an open
chest. His blood cultures and wound cultures grew MSSA. He
continued to have positive blood cultures after the debridement
and was changed from Nafcillin to Vanco for 4 days. He had his
sternum closed on [**4-14**]. He was extubated the day after and was
slow to improve. He was transferred to the floor on POD#4. He
went into rapid AF and converted on Amio. He continued to
improve and was discharged to home on Nafcillin on POD#9. He
will remain on Nafcillin until [**5-15**] and will be followed by
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] from ID.
Medications on Admission:
Colace 100 mg PO BID
Zantac 150 mg PO BID
ASA 81 mg PO daily
Dilaudid 2 mg PO q 4-6 hours PRN
Captopril 12.5 mg PO TID
Norvasc 5 mg PO daily
Lopressor 100 mg PO TID
Lasix for 5 days
KCl for 5 days
Discharge Medications:
1. Nafcillin 2 g Recon Soln Sig: One (1) Intravenous every four
(4) hours: Plan for course to complete [**5-15**].
Disp:*144 units* Refills:*0*
2. IV therapy
PICC line care per NEHT protocol
3. Outpatient [**Month/Year (2) **] Work
CBC w/ diff, LFT, BUN, creat ESR, CRP qThrus (first [**4-27**])
Call results to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]/Dr [**First Name (STitle) **] : Fax: [**Telephone/Fax (1) **],
(P)[**Telephone/Fax (1) **]
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 7 days: Decrease dose to 200 mg PO daily after [**Hospital1 **]
dose finished.
Disp:*35 Tablet(s)* Refills:*0*
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
8. Nafcillin 2 gm IV Q4H
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
10. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
please take 2.5mg [**4-22**] and [**4-23**] - and have INR checked [**4-24**] Dr
[**First Name (STitle) **] for further dosing .
Disp:*30 Tablet(s)* Refills:*0*
11. Ferrous Gluconate 324 (38) mg Tablet Sig: One (1) Tablet PO
once a day.
Disp:*30 Tablet(s)* Refills:*0*
12. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*0*
13. Outpatient [**Name (NI) **] Work
PT/INR as needed first draw [**4-24**] with results to Dr [**First Name (STitle) **]
[**Telephone/Fax (1) 19327**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Sternal wound infection, s/p AVR/ascending aortic replacement
Discharge Condition:
Good.
Discharge Instructions:
Follow medications on discharge instructions.
Do not drive for 3 weeks.
Do not lift more that 10 lbs. for 2 months.
Shower daily, let water flow over wounds, pat dry with a towel.
call our office for temp>101.5, sternal drainage.
Followup Instructions:
Make an appointment with Dr. [**Last Name (STitle) 1290**] for 2-3 weeks.Provider:
[**First Name8 (NamePattern2) 870**] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 9486**] Date/Time:[**2169-5-4**] 9:20
Make an appointment with Dr. [**First Name8 (NamePattern2) **] [**Telephone/Fax (1) 106499**] for
[**2159-5-16**]
Completed by:[**2169-4-24**]
|
[
"401.9",
"E878.2",
"041.11",
"519.2",
"998.59",
"427.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.79",
"77.61"
] |
icd9pcs
|
[
[
[]
]
] |
5714, 5772
|
2696, 3657
|
348, 450
|
5878, 5886
|
1335, 1712
|
6164, 6559
|
940, 954
|
3904, 5691
|
1749, 1836
|
5793, 5857
|
3683, 3881
|
5910, 6141
|
969, 1316
|
282, 310
|
1865, 2673
|
478, 688
|
710, 817
|
833, 924
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,588
| 152,696
|
43984
|
Discharge summary
|
report
|
Admission Date: [**2117-2-25**] Discharge Date: [**2117-3-1**]
Date of Birth: [**2073-1-19**] Sex: M
Service: MEDICINE
Allergies:
lorazepam
Attending:[**First Name3 (LF) 896**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
intubation, mechanical ventilation
History of Present Illness:
44 yo male with history of DM1, adrenal insufficiency, Hepatitis
C, alpha-1-antitrypsin deficiency, COPD on home O2, and h/o
recent MRSA pneumonia presents from rehab for shortness of
breath. At rehab, the patient was noted to be suddenly hypoxic
with sats in the high 80s, somewhat lethargic, and with pinpoint
pupils. He was given 1mg naloxone and he became more alert. He
then became more agitated and complained of SOB so sent in to
the ED. Per rehab facility, patient has been complaining of back
pain and chest pain for the past few days. He has also been a
slight nonproductive cough and wheezing. He had a CXR at rehab
that was negative. He did not have any fevers. Per rehab, he is
full code.
In the ED, initial VS were: 96.6 120 151/98 24 99% 10L
Non-Rebreather. He was anxious, complaining of SOB. He was
switched to 4L NC and desatted to 70s. CXR showed questionable
LUL infiltrate. He was wheezing on exam, intubated. Labs were
notable for WBC 16, ALT 97, AST 79, Alk Phos 204. ABG post
intubation was 7.34/81/436/46/13.
He was given vanc, levo, cefepime for HCAP. and hyrdocortisone
for his adrenal insufficiency. Vitals on transfer notable for BP
95/50 80s-90s FiO2 40% PEEP of 5.
.
On arrival to the MICU, patient intubated, sedated.
.
Review of systems:
Per HPI, unable to obtain additional information as patient is
intubated.
Past Medical History:
# Alpha-1 antitrypsin deficiency on [**First Name3 (LF) **] for 8 years
(followed by Dr [**Last Name (STitle) 6174**] at [**Hospital1 112**]); portocath for [**Hospital1 **]
infusions
-reports not receiving [**Hospital1 **] for one month while at rehab
-denied for transplantation
# COPD on home O2 (3L at rest, 4L with activity)
# Diabetes Mellitus Type 1 since [**2091**]
# Adrenal insufficiency
# HCV Infection -Dr [**Last Name (STitle) **] at [**Hospital1 112**]
-never been treated
-reportedly has cirrhosis on liver biopsy at [**Hospital1 112**]
-no ascites on CT [**2117-2-12**]
# Chronic back pain secondary to compression fractures
# Methadone therapy for chronic pain
# Hypogonadism
# Osteoporosis
# Polysubstance abuse history
# Anxiety/depression
# Distal fibula fracture
# Hypothyroidism
Social History:
# Tobacco: Prior 25-pack-year smoking history. Denies current
use.
# Alcohol: Prior alcohol abuse.
# Drugs: Prior IVDU.
# Work: Currently on disability.
# Residence: [**Hospital 169**] Center. Previously lived in
[**Location 2312**] with roommate/mother's boyfriend.
Family History:
Mother: Mother with DN died in [**4-14**], patient unsure of cause.
Father: Died at age 46 from throat/mouth cancer.
Physical Exam:
Admission physical:
Vitals: T: BP: 89/63 P:99 O2: 99%
GENERAL - intubated, sedated, unresponsive
[**Date Range 4459**] - sclerae anicteric, MMM
NECK - Supple, no elevated JVP
HEART - RRR, nl S1-S2, no MRG
LUNGS - Diffuse bilateral rhonchi, very poor air movement
ABDOMEN - +BS, soft, diffusely tender to palpation, moderate
distension, no rebound or guarding
EXTREMITIES - WWP, no c/c, 1+ pitting edema bilaterally, no
erythema
NEURO - unresponsive
Pertinent Results:
Admission Labs:
[**2117-2-25**] 06:40PM GLUCOSE-194* UREA N-29* CREAT-1.0 SODIUM-140
POTASSIUM-4.3 CHLORIDE-97 TOTAL CO2-40* ANION GAP-7*
[**2117-2-25**] 06:40PM CALCIUM-7.8* PHOSPHATE-3.1 MAGNESIUM-1.8
[**2117-2-25**] 06:40PM %HbA1c-11.2* eAG-275*
[**2117-2-25**] 06:40PM URINE HOURS-RANDOM CREAT-210 SODIUM-10
POTASSIUM-83 CHLORIDE-LESS THAN
[**2117-2-25**] 06:40PM WBC-6.9# RBC-3.80* HGB-12.1* HCT-35.9* MCV-95
MCH-31.9 MCHC-33.8 RDW-13.7
[**2117-2-25**] 06:40PM PLT COUNT-131*
[**2117-2-25**] 11:34AM LACTATE-1.3
[**2117-2-25**] 11:34AM freeCa-1.12
Discharge Labs:
micro:
Blood culture pending
Urine culture pending
Imaging:
CXR [**2117-2-25**]: IMPRESSION: 1. Appropriate ET tube positioning. 2.
Prominent cardiac contour and increased left greater than right
upper lung
opacification, likely representing cardiac decompensation and
asymmetric
edema. 3. Can't exclude supervening infection in the upper
lungs. Consider reevaluation following treatment for pulmonary
edema. Improving right lower lobe consolidation. 4. Severe
emphysema, basal predominant, in keeping with known Alpha-1
antitrypsin deficiency.
CXR [**2117-2-26**]: IMPRESSION: 1. Heterogeneous opacities in the upper
lungs, left greater than right, not significantly changed since
[**2117-2-28**] exam. Retrocardiac opacity is new since prior. Above
findings may represent asymmetric pulmonary edema or multifocal
infection
2. Moderate emphysema with basal predominance, compatible with
patient's
given history of alpha-1 antitrypsin deficiency.
CXR [**2117-2-27**]: Compared with [**2117-2-26**] at 2:22 a.m., multiple lines
and tubes have been removed. A left subclavian indwelling
catheter tip is unchanged, overlying the SVC/RA junction.
Otherwise, no significant change is detected. Again seen is
hyperinflation and parenchymal scarring. Relative lucency at
both apices is stable and may reflect bullous change.
Brief Hospital Course:
1. Hypoxic hypercarbic respiratory failure: Most likely
multifactorial in etiology with possible contribution from
anxiety, respiratory depression from narcotics and possible
aspiration. Patient with alpha 1 antitrypsin deficiency and
severe COPD in 3-4L O2 at baseline. He was recently admitted for
a pneumonia 1 month ago and has completed a course of
ceftriaxone and azithromycin. CXR on admission shows a possible
LUL opacity and he had an elevated WBC count of 16 though no
fever. He was intubated in the ED and started on broad-spectrum
antibiotics with vanc, cefepime and levofloxacin, which were
discontinued on day 2 due to low suspicion for true infection.
Patient was extubated on day 2 and was satting well on NC.
Oxygen was weaned on the medicine floor and patient was satting
well on RA
2. Diabetes mellitus type I: Poorly-controlled with most recent
A1c 11.9, and resent, with result of 11.2 . He was maintained on
outpatient Lantus 35 units daily and insulin SS.
3. LE Edema: On Bumex for diuresis. Was treated with 80mg IV
lasix x2 and then restarted on home bumex with good effect. He
currently does not appear significantly volume overloaded. He
needs outpatient follow up for his cirrhosis.
4. Cirrhosis (HCV and A1AT): Hep C has not been treated. He has
not followed up with liver in a while. He was recently
discharged on lactulose and bumex and instructed to follow up
with liver as outpatient
5. Adrenal Insufficiency: He was given hydrocortisone in the ED.
Continued on prednisone taper down to home dose of 10mg daily
6. Hypothyroidism: Originally placed on IV levothyroxine while
intubate and switched to PO home levothyroxine.
7. Chronic Back Pain: Placed on fentanyl while in the ICU.
Switched to home dose methadone and oral morphine when
extubated. On transfer to floor, morphine was held for
oversedation with adequate control with home methadone
8. Anxiety / Depression: Restarted clonazepam and home
mirtazapine
Goals of Care: Though previous d/c summaries state pt is
DNR/DNI, code status was clarified with family who confirm he is
full code. Palliative care followed him during this hospital
stay.
Medications on Admission:
1. clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times
a day).
2. pravastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
3. insulin glargine 100 unit/mL Solution Sig: Thirty Five (35)
units Subcutaneous once a day.
4. gabapentin 600 mg Tablet Sig: One (1) Tablet PO three times a
day.
5. methadone 40 mg Tablet, Soluble Sig: One (1) Tablet, Soluble
PO at bedtime.
6. methadone 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
7. oxycodone 15 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for breakthrough pain.
8. bumetanide 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q2H (every 2 hours) as
needed for dyspnea, wheeze.
11. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed
for constipation.
12. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
13. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
14. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO once a week.
15. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
16. clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
17. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
18. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
capful PO once a day.
19. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
20. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
21. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
22. Fleet Enema 19-7 gram/118 mL Enema Sig: One (1) enema Rectal
DAILY (Daily) as needed for constipation.
23. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
24. mirtazapine 30 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
25. levothyroxine 150 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily): For total dose of 163mg daily.
26. levothyroxine 13 mcg Capsule Sig: One (1) Capsule PO once a
day: For total daily dose of 163mg.
27. testosterone cypionate 200 mg/mL Oil Sig: Two (2) ML
Intramuscular EVERY WEEK ().
28. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
29. insulin aspart 100 unit/mL Solution Sig: as directed units
Subcutaneous four times a day: Per sliding scale.
Discharge Medications:
1. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
2. pravastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. insulin glargine 100 unit/mL Cartridge Sig: Thirty Five (35)
units Subcutaneous once a day.
4. clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for anxiety.
5. gabapentin 600 mg Tablet Sig: One (1) Tablet PO three times a
day.
6. methadone 10 mg Tablet Sig: Four (4) Tablet PO [**Hospital1 **] (once a
day (at bedtime)) as needed for pain.
7. methadone 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day) as needed for pain.
8. bumetanide 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Inhalation twice a day.
10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as
needed for wheezing.
11. bisacodyl 5 mg Tablet Sig: Two (2) Tablet, Delayed Release
(E.C.) PO DAILY (Daily) as needed for constipation.
12. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO twice a day.
13. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO once a day.
14. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO once a week.
15. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
16. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily).
17. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
19. magnesium hydroxide 400 mg/5 mL Suspension Sig: One (1) PO
every six (6) hours as needed for constipation.
20. Fleet Enema 19-7 gram/118 mL Enema Sig: One (1) Rectal once
a day as needed for constipation.
21. mirtazapine 30 mg Tablet Sig: Two (2) Tablet PO at bedtime.
22. insulin aspart 100 unit/mL Solution Sig: as directed
Subcutaneous per SS.
23. levothyroxine 150 mcg Capsule Sig: One (1) Capsule PO once a
day.
24. levothyroxine 13 mcg Capsule Sig: One (1) Capsule PO once a
day.
25. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
26. testosterone cypionate 200 mg/mL Oil Sig: Two (2) ml
Intramuscular once a week.
27. prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] LivingCenter - Heathwood - [**Location (un) 55**]
Discharge Diagnosis:
hypoxic respiratory failure
antitrypsin 1 alpha deficiency
COPD
anxiety
back pain
constipation
DM type I
Discharge Condition:
Activity Status: Ambulatory - Independent.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Dear Mr. [**Known lastname 12226**],
You were admitted to the [**Hospital1 69**]
for respiratory distress. You became very confused and had a
low oxygen saturation which required intubation and mechanical
ventilation. You were originally admitted to the intensive care
unit, but as your symptoms improved you were able to be
transferred to the medicine floor. Your respiratory symptoms
resolved and you were able to come off supplemental oxygen
completely
.
We have made the following changes to your medications:
# CHANGE prendisone to 10mg daily by mouth
# STOP oxycodone, continue methadone as needed for pain
Please continue all of your other medications as previously
prescribed
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **]
Location: [**Hospital3 249**]
[**Hospital1 **]/EAST
Address: [**Location (un) **], E/CC-6, [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 250**]
**Please discuss with the staff at the facility the need for a
follow up appointment with your PCP when you are ready for
discharge.**
**As of [**3-8**] the new phone number to [**Company 191**] will be
[**Telephone/Fax (1) 2010**].**
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: CENTER FOR CHEST DISEASE AT [**Hospital1 112**]
Address: [**Doctor First Name **], [**Location (un) **],[**Numeric Identifier 6425**]
Phone: [**Telephone/Fax (1) 23428**]
Appointment: [**Telephone/Fax (1) **] [**3-15**] AT 11:30AM
|
[
"518.81",
"338.29",
"273.4",
"250.01",
"V46.2",
"V58.67",
"496",
"070.70",
"255.41",
"244.9",
"304.01",
"733.00",
"V15.82",
"257.2",
"311",
"300.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
12648, 12740
|
5364, 7510
|
289, 325
|
12888, 12931
|
3433, 3433
|
13751, 14584
|
2827, 2946
|
10274, 12625
|
12761, 12867
|
7536, 10251
|
13038, 13527
|
4019, 5341
|
2961, 3414
|
13556, 13728
|
1626, 1702
|
229, 251
|
353, 1607
|
3449, 4002
|
12946, 13014
|
1724, 2527
|
2543, 2811
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,595
| 164,084
|
34596
|
Discharge summary
|
report
|
Admission Date: [**2184-8-25**] Discharge Date: [**2184-9-6**]
Date of Birth: [**2152-5-3**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
hanging
Major Surgical or Invasive Procedure:
bronchoscopy
History of Present Illness:
Pt is a 32F who was 6 weeks post partum who was found in her
home having hung herself. EMS responded and cut her down. She
was initially apenic without vital signs, but after several
minutes of CPR, she regained a pulse. She was intubated and
brought to [**Hospital1 18**].
Past Medical History:
depression
Social History:
lives with husband who is a graduate student. family speaks only
Japanese
Family History:
non contributatory
Physical Exam:
discharge: patient passed away
Brief Hospital Course:
The patient was admitted to the trauma surgery service in the
trauma ICU. She was intubated with a GCS of 4. Her head CT was
concerning for anoxic brain injury. Over the next week her
neurologic status did not improve. At times she had spastic
movement of her extremities and multiple EEGs were performed.
The neurology consult service did not feel these movements were
consistent with seizures.
With time she developed ventillator associated pneumonia which
was treated with bronchoscopy and antibiotics. Nutrition was
provided via a daubhoff tube.
Multiple family meetings were help with the patient's husband
and mother, social work, interpreters, the trauma team, and the
neurology team. Her neurologic status did not improve.
Ultimately the decision was made to make the patient CMO. She
was extubated and started on a morphine drip. She died on
[**2184-9-6**].
Medications on Admission:
none
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
anoxic brain injury
ventillator associated pneumonia
Discharge Condition:
deceased
Discharge Instructions:
.
Followup Instructions:
.
|
[
"994.7",
"311",
"348.1",
"648.44",
"E849.0",
"780.39",
"780.01",
"999.9",
"E953.0",
"485"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.6",
"33.24",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
1830, 1839
|
871, 1746
|
320, 334
|
1935, 1945
|
1995, 1999
|
781, 801
|
1801, 1807
|
1860, 1914
|
1772, 1778
|
1969, 1972
|
816, 848
|
273, 282
|
362, 640
|
662, 674
|
690, 765
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,150
| 131,301
|
52174
|
Discharge summary
|
report
|
Admission Date: [**2167-5-12**] Discharge Date: [**2167-5-18**]
Date of Birth: [**2092-2-13**] Sex: M
Service: [**Location (un) 259**]
CHIEF COMPLAINT: Weakness.
HISTORY OF PRESENT ILLNESS: The patient is a 75 year old man
whose past medical history includes renal cell cancer, status
post partial right nephrectomy, prostate cancer, coronary
artery disease, type 2 diabetes mellitus requiring insulin,
hypertension, Methicillin resistant Staphylococcus aureus
sputum, and Clostridium difficile colitis, status post
ileostomy. The patient was discharged from [**Hospital1 346**] on [**2167-4-18**], for dehydration (?
gastritis ?) and subsequently was transferred to
rehabilitation. He was discharged from [**Hospital **]
Rehabilitation on [**2167-5-8**]. He started an ace inhibitor at
about this time.
The patient was in his usual state of health until [**2167-5-12**],
approximately four hours prior to his admission, when the
patient attempted to get out of bed and fell due to weakness.
The patient did not suffer any injuries or loss of
consciousness from his fall. The patient was subsequently
taken to the [**Hospital1 69**] Emergency
Department, where the patient's electrocardiogram revealed
tall, peaked T waves and a widened QRS complex. His
potassium was subsequently checked and found to be 10.1. The
patient was then given two grams of Calcium Gluconate,
intravenous insulin, amp of D50 and normal saline with two
ampules of bicarbonate. A dialysis line was then placed in
the right femoral artery, and the patient was subsequently
transferred to the Medical Intensive Care Unit.
At the time of admission, the patient noted that he had
recently been started on an ace inhibitor approximately at
the time of his discharge from [**Hospital6 3953**]. In addition, the patient noted that he had
chronically elevated potassium in the past, and that he has
required bicarbonate, that he has been on Sodium Bicarbonate
and Kayexalate. At the time of his presentation, the patient
admitted some left groin/left hip pain, which he thought to
be musculoskeletal in origin. The patient denied other
complaints including fever, chills, nausea, vomiting,
diarrhea and constipation. The patient denies chest pain,
shortness of breath, palpitations. The patient denies
light-headedness or other focal neurological symptoms. The
patient denies urinary symptoms, including dysuria, pyuria,
hematuria. The patient denies melena or bright red blood per
rectum.
PAST MEDICAL HISTORY:
1. Renal cell carcinoma, status post partial nephrectomy
([**12-22**]).
2. Perioperative inferolateral myocardial infarction
([**12-22**]).
3. Fulminate Clostridium difficile colitis ([**1-23**]),
requiring total colectomy.
4. History of pneumonia with Methicillin resistant
Staphylococcus aureus positive sputum ([**12-22**]).
5. Type 2 diabetes mellitus, requiring insulin.
6. Hypertension.
7. Diabetic nephropathy.
8. Prostate cancer, status post radiation therapy.
9. Hypercholesterolemia.
10. History of submandibular abscess in [**2161**].
MEDICATIONS ON ADMISSION:
1. Aspirin 81 mg p.o. once daily.
2. Neurontin 300 mg p.o. four times a day.
3. Lantus 56 units subcutaneous q.h.s.
4. Prevacid 30 mg p.o. q.a.m.
5. Lisinopril 5 mg p.o. twice a day.
6. Reglan 10 mg p.o. twice a day with meals.
7. Metoprolol 12.5 mg p.o. twice a day.
8. Paxil 20 mg p.o. q.h.s.
9. Zocor 20 mg p.o. q.h.s.
10. Ambien 10 mg p.o. q.h.s.
11. Imodium 2 mg p.o. four times a day p.r.n.
ALLERGIES: Adverse reactions - This patient states that he
is allergic to Penicillin and Cephalosporins. In addition,
the patient appears to develop hyperkalemia on ace inhibitors
and ARBS.
SOCIAL HISTORY: Since the time of his discharge from
[**Hospital6 310**] on [**2167-5-8**], the patient has
been living at home with a caretaker. The patient's sister
lives in [**Name (NI) **], [**State 350**] and is the [**Hospital 228**] health
care proxy. The patient's primary care physician is [**Last Name (NamePattern4) **].
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1728**]. The patient denies any history of tobacco,
alcohol or illicit or intravenous drug use.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: As above. The patient denies headache,
head trauma, dizziness. The patient complains of discharge
and pruritus of the eyes bilaterally, and he notes that he
has recently been started on topical Erythromycin for
presumed conjunctivitis. The patient denies other visual
changes. The patient denies any recent history of cough or
sputum production. The patient denies shortness of breath,
dyspnea on exertion, orthopnea, hemoptysis, wheezing. The
patient denies paroxysmal nocturnal dyspnea, edema or any
history of heart murmurs. The patient denies any history of
hot or cold intolerance or preexisting muscle or joint pain.
The patient denies any recent lymphadenopathy or any changes
in sensation or strength. The patient denies recent travel
or changes in diet.
PHYSICAL EXAMINATION: Upon admission, temperature is 97.2,
heart rate 40s, blood pressure 133/50, respiratory rate 18,
oxygen saturation 98% in room air. In general, the patient
is a well developed, well nourished male appearing pale and
looking his stated age, in no acute distress. Head, eyes,
ears, nose and throat - normocephalic and atraumatic. The
sclerae were clear and anicteric, no proptosis. Conjunctiva
were injected, erythematous and there was discharge
bilaterally from the eyes. The oropharynx was clear without
erythema, injection, sores, lesions, exudate. Moist mucous
membranes. Neck - trachea midline. The neck was supple
without lymphadenopathy, thyromegaly or thyroid nodules.
Carotid pulses with normal upstrokes without audible bruit
bilaterally. Thorax and lungs - thorax symmetrical, no
increased AP diameter or use of accessory muscles. Bibasilar
crackles. Lungs otherwise clear to auscultation and resonant
to percussion bilaterally with normal diaphragmatic
excursions and I:E ratio. Cardiac - jugular venous pressure
less than five centimeters. Bradycardic. Normal S1 and
physiologically split S2, no S3, S4, ejection or midsystolic
clicks. No murmurs, rubs or gallops appreciated. Abdomen -
positive bowel sounds, colostomy in right lower quadrant, bag
intact with moderate volume brown stool. Abdomen otherwise
soft, nontender, nondistended. No hepatosplenomegaly
appreciated. No palpable abdominal aortic aneurysm or
audible bruits. Genitourinary - No costovertebral angle
tenderness. Extremities - No cyanosis, clubbing or edema.
1+ pedal pulses bilaterally. Musculoskeletal - Tenderness
with hip compression bilaterally. Skin - No rashes,
pigmentation changes. Neurologically, awake, alert and
oriented times three. Cranial nerves II through XII are
grossly intact. Motor normal bulk, symmetry and tone.
Sensation intact to light touch throughout. No focal
deficits.
LABORATORY DATA: Upon admission, complete blood count
revealed white blood cell count 11.6, hemoglobin 15.3,
hematocrit 46.1, platelet count 288,000. Differential
revealed 65% neutrophils, 24% lymphocytes, 4% monocytes, 6%
eosinophils, 1% basophils. Basic coagulation studies showed
prothrombin time 12.4, partial thromboplastin time 19.1, INR
1.0. Chemistries revealed sodium 134, potassium greater than
10, chloride 113, bicarbonate 15, blood urea nitrogen 44,
creatinine 1.7, glucose 242. Repeat potassium 10.1. Total
protein 7.8, albumin 3.9, globulin 3.9, calcium 9.8,
phosphate 3.1, magnesium 2.5. Cardiac - CPK 45, CK MB not
performed because CK less than 100, troponin C less than 0.3.
Arterial blood gases - pO2 60, pCO2 37, pH 7.29, total CO2
19, base excess negative 7. Free calcium 1.37. Urinalysis
revealed specific gravity 1.009, trace blood, negative
nitrites, protein, glucose, ketone, bilirubin, urobilinogen,
leukocytes. Microscopic urine examination - 0-2 red blood
cells, 0-2 white blood cells, occasional bacteria, no yeast,
0-2 epithelial cells. Urine chemistry - Creatinine 29,
sodium 72, potassium 50, chloride 105, total protein 9,
protein to creatinine ratio 0.3.
Microbiology: Urine culture no growth.
IMAGING ON ADMISSION: Left hip radiograph - no fracture or
dislocation detected involving the left hip. Mild
degenerative spurring is present. AP pelvis - no fracture or
dislocation is detected about the pelvis. There are multiple
radiation seeds overlying the prostate as well as surgical
sutures and a right lower quadrant ostomy.
Electrocardiogram - sinus bradycardia at a rate of 44 beats
per minute, first degree AV block, right bundle branch block,
left anterior fascicular block, wide QRS complex and peaked T
waves, consistent with hyperkalemia.
HOSPITAL COURSE:
1. FEN - Hyperkalemia - In the Emergency Department, the
patient was administered Calcium Gluconate, insulin, an
ampule of D50, intravenous normal saline with two ampules of
Sodium Bicarbonate. A renal consultation was then called,
and a double lumen Quinton catheter was then placed in the
patient's right groin in anticipation of hemodialysis to
dialyze off the patient's elevated potassium. The patient
was then admitted to the Medical Intensive Care Unit and
subsequently underwent hemodialysis on [**2167-5-12**]. Following
dialysis, the patient's potassium trended back toward his
baseline of approximately 5.0. Throughout the remainder of
the patient's admission, his potassium remained between 4.4
and 5.4. With the patient's potassium stable, the patient's
Quinton catheter was removed on [**2167-5-13**]. The etiology of
the patient's hyperkalemia was felt to be multifactorial,
including a combination of baseline elevated potassium,
noncompliance with outpatient Kayexalate, diet at home, and
medication induced with recent prescription of ace inhibitors
at the outside hospital. Other traditional causes of
hyperkalemia include advanced renal failure, marked volume
depletion and hypoaldosteronism. The patient's clinical and
laboratory examination provided little evidence for either
advanced renal failure or marked volume depletion, raising
the question of hypoaldosteronism in its etiology. With
these thoughts in mind, the patient subsequently had an
aldosterone level drawn, and he was started empirically on
Fludrocortisone, for presumed hyporeninemic
hypoaldosteronism, a condition that typically affects
patients 50 to 70 years of age with diabetic nephropathy or
chronic interstitial nephritis with mild to moderate renal
insufficiency. In addition, it was noted that the patient
may have been on Heparin while at the outside hospital, and
that Heparin has been known to have a direct toxic effect on
the adrenal zonaglomerulosa cells. The patient's course in
the Medical Intensive Care Unit with respect to his
hyperkalemia upon admission was otherwise uncomplicated, and
he was subsequently transferred from the Medical Intensive
Care Unit to the floor on [**2167-5-14**]. At the time of his
transfer from the Medical Intensive Care Unit on [**2167-5-14**],
the patient's renal medications included Furosemide 20 mg
p.o. once daily, Fludrocortisone Acetate 0.1 mg p.o. once
daily, and Sodium Bicarbonate 1300 mg p.o. twice a day. In
order to reduce the patient's potassium to a desire range of
between 4.0 and 4.5, the patient's dose of Fludrocortisone
was increased from 0.1 mg p.o. once daily to 0.1 mg p.o.
twice a day. At the time of his discharge on [**2167-5-18**], the
patient had a potassium of 4.4. On the morning of the
patient's discharge, the patient's previous aldosterone level
came back from the laboratory. The patient's aldosterone was
found to be 13.0 with a reference range of 1.0-16.0 for a
patient when supine. At discharge, the patient was continued
on his Fludrocortisone at a dose of 0.1 mg p.o. twice a day
with instructions to follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in the
[**Hospital 2793**] Clinic at [**Hospital1 69**].
Hypercalcemia - At the time of his admission, the patient's
free calcium was noted to be 1.37. The elevated calcium
occurring in the context of hyperkalemia raised the question
of multiple myeloma, and the patient subsequently had an SPEP
and UPEP sent. These tests revealed no specific
abnormalities, and there was no monoclonal immunoglobulin
seen. The patient's calcium at the time of discharge was
9.4.
2. Endocrine - The patient has a history of type 2 diabetes
mellitus requiring insulin. During the time of his admission,
the patient was maintained on a regimen of Glargine 54 units
q.h.s. with a Humalog sliding scale.
Hypoaldosteronism - As mentioned previously, the patient's
presentation with hyperkalemia raised the question of
hypoaldosteronism in its etiology. Given the patient's
history of type IV RTA, it was thought that the patient's
hypoaldosteronism might be due to hyporeninemic
hypoaldosteronism, a condition that typically affects
patients in their 50s to 70s with diabetic nephropathy or
chronic interstitial nephritis with mild to moderate renal
insufficiency. As mentioned above, at the time of his
discharge, the patient's aldosterone returned at a level of
13.0, which was within normal limits of 1.0-16.0. While the
patient was continued on his Fludrocortisone at admission, he
was scheduled to follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of
nephrology in the [**Hospital 2793**] Clinic as an outpatient.
3. Renal - After the patient's one episode of hemodialysis
on [**2167-5-12**], the patient's right Quinton catheter was
subsequently pulled and he required no further episodes of
hemodialysis. During the remainder of his admission, the
patient's creatinine remained between 1.0 and 1.5. As
mentioned above, given the patient's presumed type IV RTA and
hyporeninemic hypoaldosteronism, the patient was continued on
his Fludrocortisone, initially at 0.1 mg p.o. once daily and
subsequently on 0.1 mg p.o. twice a day. In addition, as
has been noted in prior discharge summaries, it was again
emphasized that the patient should avoid treatment with ace
inhibitors and ARBS.
4. Cardiovascular - Coronary artery disease - From the time
of his Emergency Department presentation on [**2167-5-12**], the
patient was ruled out for a myocardial infarction with three
sets of cardiac enzymes, all of which were negative. The
patient was continued on his Aspirin, Lopressor and statin.
5. Infectious disease - Conjunctivitis - The patient was
continued on his Erythromycin strips for bilateral
conjunctivitis.
6. Musculoskeletal - Hip/groin pain - The patient's
radiographs at the time of presentation in the Emergency
Department provided no evidence of either hip or pelvic
fracture or dislocation. While the patient continued to
complain of some right groin pain, this pain was treated to
good effect with heat packs and Acetaminophen.
Weakness - While the patient's weakness precipitating his
fall on [**2167-5-12**], might have been attributed to his
hyperkalemia, the patient was also ruled out for
hypothyroidism. The patient's TSH was 1.2 and his free T4
was 1.5, both within normal limits. In addition, the patient
was seen by physical therapy, who felt that much of his
weakness was due to deconditioning. Following several
sessions with the patient, physical therapy felt that the
patient was safe to be discharged home with 24 hour
supervision.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: Discharged to home with services.
DISCHARGE DIAGNOSES:
1. Hyperkalemia.
2. Type 2 diabetes mellitus requiring insulin.
3. Coronary artery disease, status post myocardial
infarction.
4. Hypertension.
5. Peripheral nephropathy.
6. Renal call cancer.
7. Prostate cancer.
8. History of Clostridium difficile colitis.
MEDICATIONS ON DISCHARGE:
1. Glargine insulin 54 units q.h.s.
2. Humalog insulin sliding scale.
3. Gabapentin 300 mg p.o. four times a day.
4. Furosemide 20 mg p.o. once daily.
5. Erythromycin Ophthalmic Ointment one strip O.U. six times
per day.
6. Fludrocortisone 0.1 mg p.o. twice a day.
7. Lopressor 12.5 mg p.o. twice a day.
8. Sodium Bicarbonate 1300 mg p.o. twice a day.
9. Aspirin 81 mg p.o. once daily.
10. Loperamide 2 mg p.o. four times a day p.r.n.
11. Reglan 10 mg p.o. q6hours.
12. Zocor 20 mg p.o. once daily.
13. Paxil 10 mg p.o. once daily.
DISCHARGE INSTRUCTIONS: The patient is to follow-up with his
primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1728**]. In addition, the
patient is to schedule an outpatient appointment with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] at the [**Hospital1 69**]
[**Hospital 10701**] Clinic.
[**First Name11 (Name Pattern1) 312**] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 314**]
Dictated By:[**Name8 (MD) 30463**]
MEDQUIST36
D: [**2167-5-20**] 16:53
T: [**2167-5-20**] 18:50
JOB#: [**Job Number 107943**]
|
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30,536
| 137,068
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32051
|
Discharge summary
|
report
|
Admission Date: [**2110-10-25**] Discharge Date: [**2110-10-29**]
Service: MEDICINE
Allergies:
Codeine / Ivp Dye, Iodine Containing
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Reason for transfer: GI evaluation
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
HPI: 85 year old male with PUD s/p Billroth II and vagotomy
presenting with recurrent hematemesis. The patient initially
presented 2.5 weeks ago to an OSH with UGIB and melena. He
underwent EGD at that time which demonstrated several AVMs, some
with active bleeding--including at the GD anastamotic site--and
underwent APC coagulation and hemoclip placement. EGD also
revealed Candidal esophagitis and he was treated with diflucan.
He also had a colonoscopy which demonstrated sigmoid
diverticulosis and a nonbleeding cecal AVM. His coumadin was
discontinued. He was discharged home with a stable hematocrit.
Follow up labs demonstrated HCT 24 (from 29) and he was
transfused an additional 2 units of blood about 10 days after
discharge.
.
The patient re-presented to the OSH with 1 episode coffee ground
emesis on [**2110-10-23**], HCT 31. He was guaiac positive in the ED. He
was treated with PPI gtt and admitted to the medical floor. He
subsequently had three episodes (50 mL) bright red
blood/hemetemesis and became hypotensive to 90/50 and was
transferred to the ICU. He was continued on the PPI gtt and
octreotide gtt was added, and he had a positive NG lavage. His
hypotension corrected with IV fluid and blood transfusion. He
had no further episodes of hematemesis but passed several
melanotic stools. He underwent repeat EGD on [**2110-10-23**] which
failed to identify a bleeding source (old clot through gastric
remnant therefore cardia and gastric remnant could not be
viewed, cautery of red areas with a heater probe was performed,
but none of the areas were throught to be causing the bleeding).
Given multiple endoscopies without source of bleeding, he was
transferred to [**Hospital1 18**] for further evaluation. [**Name8 (MD) **] RN report (not
documented in d/c sum) patient hypotensive to 70s/30s today but
responded to a 250 cc bolus. He had a single melanotic stool at
5 pm on day of transfer.
Past Medical History:
PMH:
1. PUD s/p billroth II and vagotomy--[**2063**]
2. PE s/p IVC filter [**9-23**]
3. CHF
4. Atrial fibrillation
5. Hypertension
6. Hypercholesterolemia
7. CAD s/p MI
8. history of colon polyps
9. Open AAA repair
Social History:
SH: married, 2 children, 1 ppd X 60 years quit [**2093**], 2 drinks
3-4 times per week, no IVDU, retired [**Company 2318**] mechanic.
Family History:
-mother: ALS
-father: [**Month (only) **] at 51 from MI
-brother: ESRD on HD
Physical Exam:
PE:
vitals: 96, 142/50, 52, 16, 100% RA
general: well appearing elderly male, HOH, no distress, pleasant
heent: OP clear, PERRL, EOMI, MMM
neck: JVP at 8 cm H2O
car: Irreg rhythm, rate controlled, no murmur
resp: insp crackles 1/2 up bilaterally
Abd: s/nt/nd/nabs, several well healed incisions
ext: no edema
Pertinent Results:
[**2110-10-25**] 08:00PM GLUCOSE-110* UREA N-28* CREAT-1.6* SODIUM-134
POTASSIUM-3.8 CHLORIDE-97 TOTAL CO2-30 ANION GAP-11
[**2110-10-25**] 08:00PM estGFR-Using this
[**2110-10-25**] 08:00PM CALCIUM-8.9 PHOSPHATE-3.7 MAGNESIUM-2.0
[**2110-10-25**] 08:00PM WBC-5.8 RBC-3.93* HGB-10.8* HCT-32.3* MCV-82
MCH-27.5 MCHC-33.5 RDW-19.7*
[**2110-10-25**] 08:00PM NEUTS-67 BANDS-0 LYMPHS-16* MONOS-7 EOS-2
BASOS-0 ATYPS-8* METAS-0 MYELOS-0
[**2110-10-25**] 08:00PM PLT COUNT-210
[**2110-10-25**] 08:00PM PT-14.2* PTT-28.4 INR(PT)-1.2*
.
Studies (OSH):
1. CXR ([**10-23**]): in comparison, some clearing on right, persistent
infiltrate on left.
2. CXR ([**10-25**]): improved mild vascular congestion, cannot r/o left
lower lobe infiltrate.
.
EGD ([**10-27**]): Ulceration without visible vessel and an edematous
fold adjacent to the enterostomy consitent with previous
cautery. No blood in stomach or bleeding sites seen. Small
hiatal hernia with probable tongue of Barrett's esophagus with
an isolated squamous mucosal patch. GI Bleeding
Otherwise normal EGD to second part of the duodenum
.
Echo ([**10-27**]): The left atrium is mildly dilated. No left atrial
mass/thrombus seen. There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is mild regional left
ventricular systolic dysfunction with focal severe hypo/akinesis
of the basal half of the inferior and inferolateral walls. The
remaining segments contract normally (LVEF = 40 %). 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. Mild (1+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. The pulmonic valve leaflets are thickened. There
is no pericardial effusion.
.
MRA Abdomen ([**10-29**]):
1. No evidence of aortoenteric fistula. Unremarkable
appearance of the
infrarenal abdominal aorta status post surgical repair.
2. High-grade stenoses involving the ostia of the superior
mesenteric artery, proximal right renal artery, and origins of
both common iliac arteries. Moderate grade stenoses involving
the origin of the left external iliac artery and mid right
common iliac artery.
3. Aneurysmal dilatation of the left common iliac artery.
4. Multiple bilateral simple renal cysts. Subcentimeter right
renal cyst
containing hemorrhagic or proteinaceous debris, without
suspicious features.
Brief Hospital Course:
A/P: 85 yom with PUD s/p Billroth II p/w recurrent UGIB from
unclear source.
.
1. UGIB: Patient's HCT remained stable and no additional
episodes of bleeding were noted. IV octreotide was stopped. He
was started on IV PPI and then transitioned to po Protonix as an
outpatient. He tolerated a normal diet without further evidence
of continued bleeding. He underwent upper endoscopy which did
not see any actively bleeding areas. They recommended potential
capsule study of the small intestine as an outpatient. Also GI
recommended an MRA of the abdomen (CT w/ contrast
contraindicated given constrast/iodine allergy) to r/o
aorto-enteric fistula given hx AAA repair which showed no
evidence of this, but did reveal extensive PVD in abdominal
vasculature. He will get a follow-up CBC and see his PCP within
the week. Coumadin was held given GIB - he does not wish to
restart this medication in the future and will continue this
conversation with his primary care provider.
2. Hypertension: Patient was hypotensive on day of transfer, and
he responded to fluids. On regimen of captopril, toprol xl,
nitro-[**Hospital1 **] and lasix on transfer. His antihypertensives were
initially held. However, he had no further episodes of
hypotension and all home medications were restarted.
.
3. CAD: On beta blocker, statin, nitro-[**Hospital1 **] and ace on transfer.
Aspirin was held.
Medications on Admission:
All: Contrast dye, Codeine
.
Medications on transfer:
Octreotide gtt
Nexium gtt
Zofran 4 mg IV q6
Tylenol 650 mg po q4 prn
Captopril 25 mg po q8
Diflucan 100 mg IV X 5 days (last dose 9/11)
Toprol XL 12.5 mg po daily
Zoloft 50 gm po daily
Zocor 80 mg qhs
Nitro-[**Hospital1 **] 6.5 mg daily
Lasix 40 mg daily
Discharge Medications:
1. Lipitor 10 mg Tablet Sig: One (1) Tablet PO once a day.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*14 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: 0.5
Tablet Sustained Release 24 hr PO once a day.
6. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
7. Sertraline 25 mg Tablet Sig: One (1) Tablet PO once a day.
8. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
9. Outpatient Lab Work
Please check CBC - fax results to Dr. [**Last Name (STitle) 1057**] at # ([**Telephone/Fax (1) 75055**]
To be done by Monday [**11-3**].
10. Nitroglycerin 6.5 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1.) Upper gastrointestinal bleed
2.) Peptic ulcer disease s/p Bilroth II procedure and vagotomy
Secondary:
1.) History of abdominal aortic aneurysm repair
2.) Atrial fibrillation
3.) Hypertension
Discharge Condition:
afebrile, displaying normal vital signs and tolerating a regular
diet
Discharge Instructions:
You were admitted to the hospital because of bleeding in your
gastrointestinal tract. You were treated with a short stay in
the intensive care unit and underwent upper endoscopy to look in
your stomach which showed no active bleeding. Your blood count
was followed and remained stable at the time of discharge. A
new medication called Protonix was started for your stomach
which should be taken daily, in the morning with a glass of
water. You should also take many small meals daily and avoid
eating at night or before lying down to prevent stomach upset.
You have a followup appointment as well in the [**Hospital **] clinic here at
[**Hospital1 **]. You should also have blood work done on
Friday ([**10-31**]) or Monday ([**11-3**]) to check your blood
count before going to your appointment with Dr. [**Last Name (STitle) 1057**] on [**11-4**].
Followup Instructions:
You have a follow-up appointment with Dr. [**First Name4 (NamePattern1) 636**] [**Last Name (NamePattern1) 1407**] in
gastroenterology on Tues. [**11-11**] at 1pm - the GI suite is
located on the [**Location (un) 448**] of the [**Hospital Unit Name **] on the [**Hospital1 18**]
[**Hospital Ward Name **].
.
You also have a follow-up appointment with your primary care
provider [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1057**] on Tuesday [**11-4**] at 3pm.
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 21795**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2110-11-11**] 1:00
|
[
"V45.3",
"584.9",
"534.90",
"440.1",
"285.1",
"593.2",
"414.01",
"442.2",
"447.1",
"427.31",
"578.1",
"458.9",
"V43.4",
"530.85",
"578.0",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
8421, 8427
|
5610, 6989
|
281, 287
|
8676, 8748
|
3074, 5587
|
9650, 10279
|
2651, 2729
|
7348, 8398
|
8448, 8655
|
7015, 7044
|
8772, 9627
|
2744, 3055
|
206, 243
|
315, 2244
|
7069, 7325
|
2266, 2483
|
2499, 2635
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,990
| 102,865
|
49188
|
Discharge summary
|
report
|
Admission Date: [**2173-8-16**] Discharge Date: [**2173-8-27**]
Date of Birth: [**2098-6-13**] Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
pseudoaneurysm of LUE AVF
Major Surgical or Invasive Procedure:
[**2173-8-16**] excision of LUE AVF pseudoaneurysm
History of Present Illness:
Ms. [**Known lastname 103090**] is a 75 year-old Creole-speaking woman with history
of DM 2, ESRD on
HD, HTN, stroke with vascular dementia, and CHF who presented
with a spontaneous rupture of an aneurysm involving an AV
fistula. Patient is a poor historian, french creole speaking,
spoken to with french speaking ER staff. She was at dialysis
two days
prior without incident. She awoke with bleeding at her AV
fistula site of the LUE. She arrived via EMT with gross
saturation of her bandage.
On arrival she had an approximately 5 mm bleeding ulceration at
the midpoint of a large 5 cm by 3 cm aneurysm. This was
controlled with pressure dressing by ED staff.
Past Medical History:
ESRD on HD TThSat - left AV fistual s/p thrombectomy and
revision
-Type 2 diabetes c/b triopathy
-Hypertension
-CVA with vascular dementia
-Anemia
-Congestive heart failure withejection fraction of 55%. Echo
[**2170**].
-Osteoarthritis
-Cataracts
-insertion Left groin permcath [**2172-12-23**]
Social History:
SH: no tobacco, ETOH, illicit drug use, lives at [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **]
Daughter involved in care
Family History:
noncontributory
Physical Exam:
98.6 HR 84 BP: 215/120 RR: 20 O2SAT: 93% 2LNC
EXAM: Awake, alert, MAE, agitated
EXAM per ER staff WNL
LUE bleeding AV fistula pseudo aneurysm.
Pertinent Results:
[**2173-8-16**] 07:50AM PT-13.7* PTT-30.0 INR(PT)-1.2*
[**2173-8-16**] 07:50AM PLT COUNT-250
[**2173-8-16**] 07:50AM WBC-13.9*# RBC-3.15* HGB-10.6* HCT-31.2*
MCV-99* MCH-33.6* MCHC-33.9 RDW-14.1
[**2173-8-16**] 07:50AM CALCIUM-9.9 PHOSPHATE-4.8* MAGNESIUM-2.0
[**2173-8-16**] 07:50AM GLUCOSE-185* UREA N-43* CREAT-7.8* SODIUM-138
POTASSIUM-4.7 CHLORIDE-96 TOTAL CO2-27 ANION GAP-20
[**2173-8-27**] 06:55AM BLOOD WBC-11.1* RBC-2.95* Hgb-9.7* Hct-31.0*
MCV-105* MCH-32.9* MCHC-31.3 RDW-16.3* Plt Ct-416
[**2173-8-27**] 06:55AM BLOOD Plt Ct-416
[**2173-8-16**] 11:28AM BLOOD PT-14.5* PTT-32.6 INR(PT)-1.3*
[**2173-8-27**] 06:55AM BLOOD Glucose-389* UreaN-30* Creat-5.5*# Na-142
K-3.8 Cl-104 HCO3-25 AnGap-17
[**2173-8-27**] 06:55AM BLOOD Calcium-10.2 Phos-2.6* Mg-2.1
Brief Hospital Course:
On [**2173-8-16**] Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] performed an exploration of the
left upper arm
arteriovenous fistula, with excision of an aneurysm and
interposition graft placement for spontaneous rupture of an
arteriovenous fistula aneurysm. At the end of the case, she
became hypotensive to the 50 systolic range. This was
treated with multiple vasopressors with poor response. BP was
unreadable for ~ 8 min. Am intraoperative TEE was performed
which demonstrated a poor right ventricular flow consistent with
a possible pulmonary embolus. The patient was eventually
stabilized with epinephrine and taken to the PACU". A chest CT
was done and was negative for PE. In the PACU, she became
hypertensive with systolics in 200s. She was transferred to the
SICU intubated where she received a nitro drip and remained
sedated on a propofol drip while intubated. She spiked a
temperature to 101.4. Blood cultures and a sputum culture were
sent. She was dialyzed via a temporary hemodiaysis line. A unit
of PRBC was transfused for a hct of 24.4.
On [**8-17**] she had successful placement of an 19 cm tip to cuff 15.5
French tunneled
hemodialysis catheter through the right subclavian vein.
Occlusion of the lower right internal jugular vein.
Sedation was weaned and she was extubated, but she remained
unresponsive and was not breathing on her own. She was
reintubated. A CT scan of the head was done showing no bleed or
major vascular infarct. Sedatives were held. An EEG was done
showing mild to moderate
encephalopathy of toxic, metabolic, or anoxic etiology. No
evidence of
ongoing or potential epileptogenesis was seen. A neuro consult
was obtained. Recommendations included holding sedatives,
continuing antibiotics and keeping sbp greater than 140. An LP
was performed. This was negative. IV vanco, ceftriaxone and
acyclovir were given. All blood and urine cultures remained
negative. Neuro felt that her mental status was consisten with
watershed hypoperfusion of the MC and ACA territories
bilaterally related to the intraop hypotension. An MRI was
recommended. This was done and showed the following:
"No evidence of acute infarction. Stenosis of left A1,
multiple
areas of irregular narrowing in the MCA bilaterally, as well as
the posterior
circulation vessels. The left A1 segment stenosis may be worse,
when compared
to the prior study of [**2170-7-29**]."
She was extubated, but did experience some stridor requiring
re-intubation. A pulmonary consult was obtained and
recommendations included treating with dexamethasone. She had
good response to this and was successfully extubated by
bronchoscopy assistance by Dr. [**First Name (STitle) **] [**Name (STitle) **]. There was no
evidence of airway obstruction, edema, or compromise up to the
level of the vocal cords.
A postpyloric feeding tube was placed and she received tube
feedings until the tube was self-removed by the patient on [**8-26**].
The feeding tube was replaced on [**8-17**] and again this was removed
by the patient. A speech and swallow eval was obtained given
concerns for aspiration. Recommendations included PO diet:
pureed solids, nectar thick liquids. If meds to be given PO,
crushed in puree with f/u sips of nectar thick liquid to clear.
1:1 assist with all POs to maintain standard aspiration
precautions and to monitor for signs of aspiration. Please
alternate each bite of puree with a sip of nectar thick liquid.
Mental status gradually improved to baseline per daughter who
visited and spoke to the patient in Creole. She was transferred
out of the SICU and was safe to go back to [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] where
she resides. Dialysis was last done on [**8-26**]. She remained alert
and oriented to herself only. She was able to answer simple
questions. Vital signs remained stable. (afeb, hr ranged in mid
70s, BP 121/50s and O2 stats in mid 90s on room air. rr was 18).
The right chest tunnelled hemodialyis line site remained clean,
dry and intact. The Left upper arm incision line was clean, dry
and intact.
Of note, namenda, risperdal and celexa were held during this
hospitalization. This will need to be re-addressed by her PCP at
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **].
Medications on Admission:
phoslo 1334mg tid with meals on HD days, celexa 10mg qd,
amlodipine 10mg po at 5pm, hold for sbp <100 or HR <60, renal
caps 1 qd, colace 100mg [**Hospital1 **], labetalol 100mg [**Hospital1 **], hold for sbp
<100 or HR <60, simvastatin 40mg qd, diovan 40mg qd, procrit
10,000 units 3xwk at HD, novolin sliding scale, lisinopril 5mg
qd, hold for sbp <100, namenda 5mg at HS, risperdal 0.25mg at
HS, dulcolax 10mg pr prn nitorquick 0.3mg sl prn for chest pain,
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Lisinopril 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Labetalol 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
6. Insulin Regular Human 100 unit/mL Solution Sig: follow
sliding scale Injection four times a day.
7. PhosLo 667 mg Capsule Sig: Two (2) Capsule PO three times a
day: with meals.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **]
Discharge Diagnosis:
pseudoaneurysm of LUE AVF
ESRD
Dementia
Discharge Condition:
good
Discharge Instructions:
Please call Dr.[**Name (NI) 670**] Office [**Telephone/Fax (1) 673**] if fever, chills,
malfunction of right tunnelled Hemodialysis line or if LUE AVF
incision red/draining
Followup Instructions:
Call Dr.[**Name (NI) 670**] office [**Telephone/Fax (1) 673**] to schedule follow up
Completed by:[**2173-8-27**]
|
[
"294.8",
"996.73",
"250.70",
"E879.8",
"997.2",
"458.29",
"585.6",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"39.95",
"38.43",
"33.23",
"03.31",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
7937, 8033
|
2554, 6854
|
296, 349
|
8117, 8124
|
1754, 2531
|
8346, 8462
|
1544, 1561
|
7364, 7914
|
8054, 8096
|
6880, 7341
|
8148, 8323
|
1576, 1735
|
231, 258
|
377, 1045
|
1067, 1364
|
1380, 1528
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,321
| 161,196
|
2042
|
Discharge summary
|
report
|
Admission Date: [**2115-7-30**] Discharge Date: [**2115-8-4**]
Date of Birth: [**2056-12-15**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
ABDOMENAL PAIN AND NAUSEA
Major Surgical or Invasive Procedure:
SMALL BOWEL RESECTION
History of Present Illness:
58 YEAR-OLD FEMALE S/P GASTRIC BYPASS [**3-14**] WITHOUT COMPLICATIONS
POST-OPERATIVELY, NOW PRESENTS WITH ABOMENAL AND AND ASCOCIATED
NAUSEA SINCE THE NIGHT BEFORE ADMISSION. PAIN IS DIFFUSED, [**6-18**]
OUT OF 10 IN INTENSITY, AND HAS NOT IMPROVED OVERNIGHT. NO
FLATUS X 1 DAY.
Past Medical History:
OBESITY
HYPERTENSION
GERD
HYPERLIPIDEMIA
APPENDECTOMY
OVARIAN CYST
Physical Exam:
AFEBRILE, PULSE 70-80'S, VITAL STABLE AND WITHIN NORMAL LIMITS
GENERAL: ALERT, ANICTERUS,
OROPHARYNX CLEAR
NO LYMPHANOPATHY
LUNGS CLEAR TO ASCULTATION
HEART REGULAR RATE RHYTHM
ABDOMEN SOFT, NON-DISTENDED, DIFFUSE TENDERNESS, NO PERITOMEAL
SIGNS
EXTREMITIES NO EDEMA
Pertinent Results:
CT PELVIS ([**7-30**])An abnormal loop of slightly dilated small bowel
with fecalization and possible bowel wall thickening. A clear
transit point is not visualized. This small bowel obstruction is
likely secondary to closed loop obstruction. This could be due
to internal hernia or could be stricture related. Other
differential includes ischemia. Infectious etiology is less
likely due to the focal nature of the involvement.
Brief Hospital Course:
UPON PRESENTATION TO THE HOSPITAL AND INTIAL WORK-UP, THE
PATIENT WAS IMMEDIATELY TAKEN TO THE OPERATING ROOM FOR AN
EXPLORATORY LAPORATOMY. INTRAOPERATIVELY, THE PATIENT WAS FOUND
TO HAVE SMALL BOWEL OBSTRUCTION WITH ISCHEMIC SMALL BOWEL.
PORTIONS OF THE SMALL BOWEL WERE RESECTED. SHE TOLERATED THE
PROCEDURE AND WAS ADMITTED TO THE INTENSIVE CARE UNIT. SHE DID
WELL IN THE ICU AND WAS [**Hospital 11166**] TRANSFERED TO THE FLOOR.
SHE HAS BEEN AFEBRILE POST-OPERATIVELY, MAKING GOOD URINE,
AMBULATING, EATING A REGULAR DIET WITHOUT ANY COMPLICATIONS.
SHE WILL BE DISCHARGED IN GOOD CONDITION.
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
2. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Discharge Disposition:
Home
Discharge Diagnosis:
SMALL BOWEL OBSTRUCTION
ISCHEMIC SMALL BOWEL
Discharge Condition:
GOOD
Discharge Instructions:
PLEASE TAKE MEDICATIONS AS PRESCRIBED AND READ WARNING LABELS
CAREFULLY. IF SIGNS AND SYMPTOMS OF WOUND INFECTION, SUCH AS
SUDDEN FEVER, INCREASED PAIN, NAUSEA/VOMITING, PURULENT
DISCHARGE, PLEASE GO TO THE EMERGENCY ROOM OR CALL. [**Month (only) **] SHOWER,
NO BATHS. PAD DRY--DO NOT SCRUB WOUND.
Followup Instructions:
PLEASE CALL DR.[**Doctor Last Name 11167**] OFFICE([**Telephone/Fax (1) 2047**] FOR A FOLLOW-UP
APPOINTMENT IN [**1-13**] WEEKS.
Completed by:[**2115-8-4**]
|
[
"V64.41",
"401.9",
"560.2",
"530.81",
"272.4",
"557.0",
"V45.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.62"
] |
icd9pcs
|
[
[
[]
]
] |
2378, 2384
|
1522, 2121
|
340, 364
|
2473, 2479
|
1069, 1499
|
2827, 2987
|
2144, 2355
|
2405, 2452
|
2503, 2804
|
780, 1050
|
275, 302
|
392, 675
|
697, 765
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,205
| 160,529
|
43838
|
Discharge summary
|
report
|
Admission Date: [**2109-9-10**] Discharge Date: [**2109-9-15**]
Date of Birth: [**2029-11-30**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 4659**]
Chief Complaint:
Sigmoid colon cancer and facial
cyst.
Major Surgical or Invasive Procedure:
Open sigmoid colectomy with laproscopic takedown of splenic
flexure
History of Present Illness:
The patient is 79-year-old woman referred to me
for colon cancer. She became constipated which she relates to
her knee surgery in [**2109-4-13**] and had to be disimpacted but
has not been right since then. It was finally so bad that she
ended up in the emergency room on [**2109-8-10**] for suprapubic
abdominal pain and cramping at the [**Hospital 9464**] Hospital in
[**Location (un) 5450**], [**Location (un) 3844**]. CT scan showed a normal liver,
gallstones, normal small bowel, some perineural fat stranding
adjacent to the mid descending colon. Review of the CT scan
shows an annular lesion in the mid sigmoid colon with near
obstruction. Her CEA was 3.1. Her LFTs were normal. She had a
colonoscopy which revealed a near obstructing tumor at 30 cm
from the anal verge with ulceration. It was tattooed. The
scope could not be passed beyond it. Biopsies reveal invasive
adenocarcinoma of the sigmoid colon.
She cannot be further colonoscoped because of the near
obstructing nature of this lesion and we plan to do an
additional colonoscopy when she recovers postoperatively. The
barium enema was discussed with her gastroenterologist who
felt that the barium was simply impacted proximal to the
lesion if it got there. She has been on a liquid diet.
In addition, the patient had a right facial cyst that she
wishes to have removed. It is on the right jaw line 1.2 cm in
size.
Past Medical History:
NIDDM, OA
Social History:
Social History: She is from [**Country 2559**], has been in US for over 40
years. She is widowed, has two grown children, one living in New
[**Location (un) **]. She is a housewife. Quit smoking in [**2077**]. No
alcohol use. No drug use.
Family History:
.
Family Medical History: Positive for lung cancer and throat
cancer. No family history of diabetes, hypertension, or heart
disease.
Physical Exam:
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time.
Pertinent Results:
Pathology: Tumor configuration: Ulcerating.
Tumor Size
Greatest dimension: 3 cm. Additional dimensions: 2 cm x
0.7 cm.
Histologic Type: Adenocarcinoma.
Histologic Grade: Low-grade (well or moderately
differentiated).
Primary Tumor: pT3: Tumor invades through the muscularis
propria into the subserosa or the nonperitonealized pericolic or
perirectal soft tissues.
Regional Lymph Nodes: pN1: Metastasis in 1 to 3 lymph nodes.
Lymph Nodes
Number examined: 18.
Number involved: 3.
[**2109-9-10**] 07:22PM HCT-31.9*
Brief Hospital Course:
[**2109-9-10**]: PT admitted to the surgical service. PT kept NPO, IVF
post operatively. She has at baseline central apnea that was
exacerbated by narcotic administration post operatively which
necessitated overnight respiratory monitoring in the ICU for
appropriate and safe pain control. PCa discontined.
[**9-11**]: Acute pain service was consulted regarding possibility of
epidural placement. Pt refused. Pain was treated with Morphine
sulfate with monitoring. No further apneic events. PT remained
NPO.
[**9-12**]: Pt tranferred to the floor in the evening. Pt advanced to
sips.
[**9-13**]: Pt advanced to sips. Foley dcd
[**9-14**]: PT evaluated and worked wth patient. PT advanced to clears.
[**9-15**]: PT discharged home tolerating PO diet, pain well controlled
with PO pain medication, ambulating.
Medications on Admission:
fosamax, lipitor 20mg', glipizide 5mg in am, 7.5 mg in pm,
metformin 500 x2 qday
Discharge Medications:
1. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
Disp:*qs qs* Refills:*0*
2. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet
PO Q4-6H () as needed for pain: Do not exceed 8 tablets in 24
hours. Do not take tylenol while on this medication. .
Disp:*40 Tablet(s)* Refills:*0*
3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
4. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
5. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. Glipizide 5 mg Tablet Sig: One (1) Tablet PO twice a day:
takew 5 mg in the a.m. and 7.5 mg in the p.m.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Colon cancer, Apnea
Secondary: Diabetes type II
Discharge Condition:
VSS, ambulating, tolerating DM diet, pain well controlled with
PO pain medication.
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
Incision Care:
-Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
PLease call Dr[**Doctor Last Name **] office to schedule follow up
appointment in 1 - 2 week : [**Telephone/Fax (1) 8792**]
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **] MD, [**MD Number(3) 4661**]
Completed by:[**2109-9-16**]
|
[
"E935.2",
"706.2",
"216.3",
"799.02",
"E849.7",
"250.00",
"733.00",
"153.3",
"278.00",
"196.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.3",
"40.3",
"45.76"
] |
icd9pcs
|
[
[
[]
]
] |
4962, 4968
|
3322, 4137
|
362, 432
|
5069, 5154
|
2758, 3299
|
6685, 6982
|
2156, 2291
|
4268, 4939
|
4989, 5048
|
4163, 4245
|
5178, 6324
|
6339, 6662
|
2306, 2739
|
284, 324
|
460, 1848
|
1870, 1881
|
1913, 2140
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,155
| 141,034
|
44004
|
Discharge summary
|
report
|
Admission Date: [**2112-12-15**] Discharge Date: [**2112-12-22**]
Service: MEDICINE
Allergies:
Levaquin
Attending:[**First Name3 (LF) 1674**]
Chief Complaint:
CC:[**CC Contact Info **]
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Age over 90 **] y/o female brought in by her daughter who reports several
months of worsening mental status, described as delerium,
agitation, and repetative movements including hand banging and
picking at things, which has been worse over the last several
days. Her daughter has been treating her with ativan and haldol
with some improvement. Her lasix had been decreased from 40 mg
TID to 40 mg [**Hospital1 **] because of a rising creatinine, but more
recently daughter reported using up to 120mg daily for apparent
sob.
.
In the ED, T 97.3 HR 100 BP 163/94 (up to 236/130) RR 20 SAT
96%RA. She was treated with 10 mg IV lasix, 10 mg IV labetolol x
2, and 0.5 mg ativan. After continued hypertension, she was
started on one inch of nitropaste and later on a nitro drip up
to max of 20ml/hr.
Past Medical History:
1.Chronic diastolic congestive heart failure - The patient is
followed in Heart Failure Clinic by Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] and nurse
practitioner [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. She has chronic congestive heart
failure which is diastolic in nature. Her most recent
echocardiogram was on [**2112-5-30**]. Her left and right atrium as
were dilated. There was mild symmetric left ventricular
hypertrophy. Her LVEF was greater than 55%.
2.Hypertension
3.Status post left-sided CVA - [**2091**]
4.Status post left breast cancer - [**2095**] The patient was treated
with lumpectomy and radiation therapy.
5.Peripheral vascular disease - The patient underwent stenting
in the subsequent atherectomy of the right superficial femoral
artery when she was found to have stent restenosis in 04/[**2111**].
She is on aspirin and Plavix at this time.
6.Chronic renal insufficiency - The patient is followed in
nephrology clinic by Dr. [**Last Name (STitle) **]. She would not wish to have
hemodialysis in the future if her renal function worsens.
However, she is open to having Aranesp if needed.
7.Chronic artery disease
8.Narrow angle glaucoma
9.Gastroesophageal reflux disease
10.Gastritis
11.COPD
12.Pulmonary hypertension
13.Insomnia
14.Osteoporosis
15.Left carotid bruits
16.Status post herpes zoster - [**2108**]
17.Dementia - The patient was seen in Memory Clinic by Dr. [**Last Name (STitle) **]
on [**2111-11-9**].
18.Depression
19.Pneumonia [**1-/2111**]
20.Anemia - This was felt to be secondary to chronic disease and
iron deficiency.
21.Weight loss
22.Status post right arm fracture
23.Restless leg syndrome.
24.Valvular heart disease - The patient had 2+ MR, [**12-21**]+ TR and
her echocardiogram from 06/[**2111**].
25.Chronic atrial fibrillation - The patient is not on
anticoagulation for this.
26.Hypotensive episode - The patient has had no further
symptomatic hypotensive episodes since she was seen in clinic on
[**2112-9-14**]. She is trying to have an increase fluid intake.
Social History:
Her daughter has been living with her full time since [**Month (only) 956**]
[**2111**]. She has aids during the day while her daughter is at work.
Has been in home hospice ([**Hospital 2255**] Hospice) since [**Month (only) **]
[**2111**].
Family History:
Noncontributory
Physical Exam:
GENERAL: Pleasant elederly female in no distress.
VITALS: T 98.9, 110/60, 83, 20, 96% 2L
HEENT: Sclera anicteric, mouth dry, edentulous
NECK: No JVP elevation
CHEST: Decreased breath sounds at bases. No wheezing.
HEART: Regular rhythm. Systolic murmur throughout precordium. No
distolic murmurs audible.
ABD: Nondistended, soft, good bowel sounds, nontender, wihtout
paplable mass.
EXT: No edema. Good femeral pulses. Weak [**Doctor Last Name **] and DP pulses. Feet
warm to touch with good capillary refill.
NEURO: Oriented to person, place, and month/year. Follows
commands. Left pupil 2mm and right pupil 3mm and reactive. EOMI.
Cranial nerves intact. Strength 5/5 in major muscle groups and
equal bilaterally
Brief Hospital Course:
# Hypertension, urgent: BP well controlled since titration of BP
meds and addition of amlodopine, continued carvedilol, nitrates,
hydralazine.
.
# Delirium: Multifactorial due to UTI, hyponatremia,
anti-psychotic medications, and acute CHF. Resolved with
treatment of all.
.
# Bacterial UTI: Vanco sensitive enterococcos, received
vancomycin for total of 7 days.
.
# Acute on Chronic systolic CHF: Improvement with increase to
Lasix 40 mg po bid and strict control of blood pressure. O2 sat
stable, better air movement, breathing without increased work.
Continued ASA, plavix, carvedilol, hydralazine and nitrates.
.
# CKD stage 5: Stable; Avoid nephrotoxins
.
#Anemia: Stable. Further work up deferred, discussed with PCP.
.
# Hyponatremia - Resolved, was likely due to overdiuresis with
lasix (pt's daughter stating lasix 120 mg daily at home prior to
admit). Monitor for recurrance in setitng of increasing lasix
dose.
.
####Patient was discharged to [**Hospital 13684**] Hospice, a switch from
[**Hospital 2255**] Hospice which daughter had been unhappy with. Midline
placed at request of hospice team in order that acute pulm edema
could be treated at home for comfort with morphine and lasix.
At this point, hospice team and daughter will attempt to treat
at home to prevent requiring hospitalization. However, daughter
has NOT committed to "do not hospitalize" plan.
Medications on Admission:
Aspirin 325 mg daily
Docusate Sodium 100 mg [**Hospital1 **]
Furosemide 40 mg [**Hospital1 **]
Trazodone 50 mg QHS
Fluticasone-Salmeterol 250-50 mcg [**Hospital1 **]
Citalopram 10 mg QHS
Clopidogrel 75 mg daily
Pantoprazole 40 mg [**Hospital1 **]
Tiotropium Bromide 18 mcg daily
Calcium Carbonate 500 mg TID
Acetaminophen 325 mg prn
Isosorbide Mononitrate 30 mg QHS
Hydralazine 37.5 mg TID
Carvedilol 12.5 mg [**Hospital1 **]
Ativan 0.5 mg prn
morphine sulfate 1 mL prn
atrovent, albuterol prn
acetominophen 500 mg prn
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
5. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
8. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
9. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
10. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*4*
11. Hydralazine 25 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
Disp:*180 Tablet(s)* Refills:*4*
12. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*4*
13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*4*
14. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two
(2) Tablet Sustained Release PO once a day.
15. Morphine 10 mg/mL Solution Sig: 1-10 mg Intravenous every
six (6) hours as needed for shortness of breath or wheezing.
Disp:*qs qs* Refills:*2*
16. lasix Sig: 10-40 mg Intravenous every six (6) hours as
needed for shortness of breath or wheezing.
Disp:*qs qs* Refills:*2*
17. Please provide midline care per Evercare protocol
18. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
treatment Inhalation Q4H (every 4 hours).
19. Atrovent HFA 17 mcg/Actuation Aerosol Sig: One (1) treatment
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
20. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tabs
Sublingual Q5min: max 3 pills, if still w/sob/pain call hospice.
21. Calcium and vitaminD
TID with meals
22. Compazine 5 mg Tablet Sig: One (1) Tablet PO three times a
day.
23. Morphine Concentrate 5 mg/0.25 mL Solution Sig: 0.5-1 cc PO
every six (6) hours as needed for shortness of breath or
wheezing.
Disp:*qs qs* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 13684**] Hospice
Discharge Diagnosis:
congestive heart failure, acute on chronic diastolic
hypertension
Chronic kidney disease
Discharge Condition:
stable
Discharge Instructions:
The hospice nurses will come to the house regularly to evaluate
patients breathing status and comfort. She should continue her
standing doses of blood pressure medication and lasix
(furosemide). On the occasion that pt has changes in breathing
and comfort, hospice nursing may change medication, and may give
medication acutely, such as lasix and morphine for worsening
difficulty breathing and agitation. If patient short of breath
or confused, call hospice nursing team.
Followup Instructions:
Please follow up with hospice team.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**]
Completed by:[**2112-12-29**]
|
[
"041.04",
"V15.82",
"414.01",
"584.9",
"311",
"386.11",
"427.31",
"294.8",
"585.5",
"276.1",
"285.21",
"276.2",
"V45.89",
"V10.3",
"443.9",
"280.9",
"V12.54",
"437.0",
"733.00",
"V66.7",
"496",
"416.8",
"290.43",
"428.0",
"397.0",
"428.33",
"365.20",
"V09.80",
"E944.4",
"333.94",
"530.81",
"424.0",
"599.0",
"403.01"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8586, 8645
|
4221, 5600
|
244, 251
|
8778, 8787
|
9310, 9500
|
3451, 3468
|
6170, 8563
|
8666, 8757
|
5626, 6147
|
8811, 9287
|
3483, 4198
|
179, 206
|
279, 1078
|
1100, 3174
|
3190, 3435
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,034
| 104,726
|
49428
|
Discharge summary
|
report
|
Admission Date: [**2150-11-17**] Discharge Date: [**2150-11-20**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5119**]
Chief Complaint:
Hypoxia at [**Hospital1 1501**]
Major Surgical or Invasive Procedure:
None
History of Present Illness:
History and physical is as per ICU team.
.
[**Age over 90 **]-year-old woman from [**Hospital6 459**] with h/o dementia,
aortic stenosis, iron def anemia presented with acute hypoxia.
[**Hospital 100**] Rehab staff noted that patient desated to 79% on room air
with T 98, HR 131, BP 160/84. Her O2 sat improved to 95% on 7L
NC. On exam, had bilateral rales and mottled skin. (Labs from
[**11-5**] revealed WBC 6.1, Hgb 9, BUN 32, Cr 0.8.) She was given
one nebulized treatment and sent to [**Hospital1 18**] for evaluation. EMS
gave her furosemide 40 mg IV x 1--patient has no history of CHF.
.
On arrival to the ED, T 97.7, HR 112, BP 118/58, RR 40, 100% on
NRB. WBC 12.1 with 91%N, 6.5%L, no bands. Hct 25.8 with MCV 94
(?baseline high 20s). INR 1.2. BUN 36 and Cr 1.0. Lactate 3.1.
U/A was negative. CXR revealed RLL/RML infiltrate. She received
levoflox, vancomycin, with metronidazole hanging on transfer to
ICU. Patient's nurse then reported that patient had two "large"
melenotic stools. Rectal exam revealed dark brown
guaiac-positive stool. NG [**Hospital1 103468**] was negative. GI was made
aware, planning to see her in the morning.
.
ROS: not obtained due to patient's dementia
.
Past Medical History:
dementia
aortic stenosis
iron deficiency anemia
Social History:
Lives in [**Hospital1 1501**]. Otherwise, pt unable to give history
Family History:
Non-contributory
Physical Exam:
On ICU admission:
GEN: Elderly woman, tired-looking but in no acute distress, on
NC, conversant comfortably
HEENT: EOMI, PERRL, sclera anicteric, poor dentition
NECK: flat JVP, carotid pulses brisk, no bruits, no cervical
lymphadenopathy
COR: reg rate, [**3-26**] pansystolic murmur best heard throughout
PULM: Bibasilar crackles
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords, DP/PT [**Name (NI) 103469**]
NEURO: oriented to person only. Moves all 4 extremities.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
On admission:
[**2150-11-16**] 11:00PM BLOOD WBC-12.1* RBC-2.74* Hgb-7.9*# Hct-25.8*
MCV-94 MCH-28.7 MCHC-30.5* RDW-15.0 Plt Ct-208
[**2150-11-16**] 11:00PM BLOOD Neuts-90.6* Lymphs-6.5* Monos-2.5 Eos-0.3
Baso-0.2
[**2150-11-16**] 11:00PM BLOOD PT-14.1* PTT-31.8 INR(PT)-1.2*
[**2150-11-16**] 11:00PM BLOOD Glucose-223* UreaN-36* Creat-1.0 Na-142
K-3.9 Cl-105 HCO3-23 AnGap-18
[**2150-11-16**] 11:00PM BLOOD CK(CPK)-70
[**2150-11-17**] 04:33AM BLOOD Calcium-9.0 Phos-2.9 Mg-2.0
[**2150-11-16**] 11:00PM BLOOD Iron-26*
[**2150-11-16**] 11:00PM BLOOD calTIBC-295 VitB12-340 Folate-GREATER TH
Ferritn-21 TRF-227
[**11-16**] CXR: Small bilateral pleural effusions, with increased
opacity in the right lung base, may reflect atelectasis.
However, developing consolidation cannot be excluded.
[**11-17**] TTE: The left atrium is normal in size. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
There is mild regional left ventricular systolic dysfunction
with focal hypokinesis of the mid to distal septum, distal
anterior wall and apex. Overall left ventricular systolic
function is mildly depressed (LVEF= 45-50 %). The remaining left
ventricular segments contract normally. Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets are severely thickened/deformed. There is severe aortic
valve stenosis (area 0.5 cm2). Moderate (2+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is mild functional mitral stenosis (mean
gradient 4 mmHg) due to mitral annular calcification. Mild (1+)
mitral regurgitation is seen. [Due to acoustic shadowing, the
severity of mitral regurgitation may be significantly
UNDERestimated.] The tricuspid valve leaflets are mildly
thickened. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Severe aortic stenosis. Moderate aortic
regurgitation. Mild functional mitral stenosis from annular
calcification. Mild regional left ventricular systolic
dysfunction consistent with mid LAD disease. Moderate pulmonary
hypertension.
Brief Hospital Course:
Pt is a [**Age over 90 **]-year-old woman with h/o dementia, aortic stenosis,
iron def anemia presented with acute hypoxia, found to have
RLL/RML pneumonia.
.
1. Healthcare associated pneumonia: Likely cause of the
hypoxia. Pt was initially covered with zosyn and vanco. Pt was
initially given gentle IVF hydration. Urine legionella was
negative. Urine culture was negative. Blood cultures were
negative. A PICC line was placed and she will complete her
antibiotic course at [**Hospital **] rehab.
.
2. Anemia: reported to have 2 "large" melenotic stools by ED
nurse. [**First Name (Titles) **] [**Last Name (Titles) 103468**] negative for blood. Hct was 23.9 at admission
and dipped down to 19 after IVF. Patient was transfused 2 units
PRBCs in the ICU. For the rest of the patients hospitalization
her Hct remained stable in the mid 20s. Pt does carry a history
of Fe deficieny anemia. Iron supplements were continued. B12
and folate were within normal limits. The patient is DNR/DNI
and the family does not [**Last Name (un) 21405**] to pursue aggresive interventions
such as EGD/colonoscopy at this time.
.
3. Dementia: Continued memantine, seroquel, exelon and
paroxetine.
.
4. Code: DNR/DNI
.
5. Dispo: The patient will be transferred back to [**Hospital 100**] rehab
in stable condition for further care.
Medications on Admission:
ASA 81 mg qday
Fe gluconate 324 mg qday
folate 1 mg qday
memantine 5 mg qday
paroxetine 20 mg qday
quetiapine 25 mg [**Hospital1 **]
rivastigmine 4.5 mg [**Hospital1 **]
Discharge Medications:
1. Vancomycin 500 mg Recon Soln Sig: One (1) gm Intravenous
every twelve (12) hours for 6 days.
2. Memantine 5 mg Tablet Sig: One (1) Tablet PO qday ().
3. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Rivastigmine 1.5 mg Capsule Sig: Three (3) Capsule PO bid ().
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every four
(4) hours as needed for pain or fever.
7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: 1-2 Tablets
PO DAILY (Daily).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
9. Zosyn 2.25 gram Recon Soln Sig: One (1) dose Intravenous
every six (6) hours for 6 days.
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Healtchcare associated pneumonia.
Anemia.
Discharge Condition:
Good
Discharge Instructions:
-Continue Vancomycin and Zosyn for 6 more days.
-Continue all other meds as prescribed.
-Wean oxygen as tolerated.
-Monitor Hct preiodically as per rehab physician.
[**Name10 (NameIs) **] electrolytes and give free water or D5W if patient has
worsening hypernatremia.
-Return to ED if you experience worsening shortness of breath,
chest pain, fever/chills or other worrisome signs/symptoms.
Followup Instructions:
Patient to be followed at [**Hospital **] rehab.
[**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**]
Completed by:[**2150-11-20**]
|
[
"280.9",
"E884.4",
"486",
"E849.7",
"518.81",
"276.52",
"578.9",
"331.0",
"424.1",
"294.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6816, 6882
|
4439, 5765
|
296, 302
|
6968, 6975
|
2309, 2309
|
7414, 7637
|
1698, 1716
|
5986, 6793
|
6903, 6947
|
5791, 5963
|
6999, 7391
|
1731, 2290
|
225, 258
|
330, 1525
|
2323, 4416
|
1547, 1597
|
1613, 1682
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,598
| 122,024
|
44121
|
Discharge summary
|
report
|
Admission Date: [**2185-4-15**] Discharge Date: [**2185-4-20**]
Service: MEDICINE
Allergies:
Iodine / Fosamax / Gadolinium-Containing Agents /
Hydrochlorothiazide / Vasotec / Etodolac
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
wound drainage
Major Surgical or Invasive Procedure:
unsuccessful thoracentesis
History of Present Illness:
[**Age over 90 **] y.o woman with hx of CAD s/p MI, CHF, h/o breast CA with XRT
c/b chronic osteo of the sterum, CRI, presents with 5 days of
worsening left chest wall discomfort, skin tenderness,
increasing and purulent drainage without fevres, chills, night
sweats. She has also had worsening left arm swelling and pain
with movement of the left shoulder, however L arm swelling is
chronic.
.
Pt was recently on Cipro 500mg [**Hospital1 **] for wound infection by her
doctor after obtaining a wound swab. However there was no
increase in tenderness, foul odor, or increased discharge at
that time. Three months ago she had bleeding and clots from her
sternal wound, surgery was recommended at that time, but patient
refused. Bleeding stopped on its own.
.
.
In the ED, initial VS were: 98.8 96 117/52 12 97. A CT chest was
done showeing worsening sternum, manubrium and medial clavicle
osteomyelitis, RUL consolidation, and left small to mod sized
empyema. Thoracic Surgery was consulted. Patient continued to
refuse surgical interventions. A thoracentesis was not
considered urgent given appearence. She was treated with
Solumedrol, Benadryl, Vancomycin, ceftriaxone, and Zosyn. Prior
to transfer, VS: 98.8 89 140/63 16 95/RA.
.
.
On the floor, she continues to be in pain from her chest and
shoulder. No overnight events.
.
Review of systems:
(+) Per HPI, left knee pain X 5 months prohibiting her from
walking, dysphagia to solids, no history of aspiration, and
chronic left ear pain for 2 months.
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, cough, shortness of breath. Denied chest
pain or tightness, palpitations. Denied nausea, vomiting,
diarrhea, constipation or abdominal pain. No recent change in
bowel or bladder habits. No dysuria.
Past Medical History:
Past Medical History:
(ONC)
- Breast cancer - bilateral mastectomy, XRT [**2144**]
- Skin cancer
- Anemia
- Squamous cell cancer - followed by Dr. [**First Name (STitle) **] of ENT who
recommended a CT of left temporal bone, which has not been done
yet.
(CARDS)
- 3V Coronary artery disease s/p MI, c/b re-stenosis of bare
metal stents, last cath [**4-23**] with 3VD, moderated diastolic
ventricular dysfunction, s/p PCI of the LMCA/LAD/LCX with
kissing drug-eluting stents.
- congestive heart failure (EF 40-45%)
- Aortic stenosis (4 m/s peak; moderate to severe [**5-26**] echo)
- Aortic regurgitation (mild-moderate [**5-26**] echo)
- Mitral regurgitation (mild-moderate [**5-26**] echo)
- Atrial septal defect (left-to-right flow, small; [**2182**] echo)
- Secundum ASD (L -> R), 2+AR, [**11-20**]+MR
- Paroxysmal atrial fibrillation ([**3-25**])
- SVT [**1-19**]
- Carotid stenoses - 40% bilateral ([**11-22**])
- Hypertension
- Hypercholesterolemia
- Multiple mechanical falls leading to subarachnoid hemorrhage-
felt not to be a warfarin candidate
- Hysterectomy ([**2137**])
- Colonic polyps (adenoma [**4-24**])
(ID)
- Chronic sternal infection with actinomyces - followed for
this by ID, [**Doctor Last Name 1352**] at [**Hospital1 112**].
(OTHER)
- Hypothyroid
- Depression
([**Doctor First Name 147**])
- s/p Appendectomy
- s/p TAH
(GI)
- GIB secondary to peptic ulcer/angioectasia ([**3-23**])
- colon polyps (adenoma) [**4-24**]
- Colitis NOS
(RENAL)
- CRI baseline Cr 1.4-1.8
(PULM)
- h/o bilateral pleural effusions thought [**12-21**] CHF
.
Social History:
Pt lives alone with a [**Hospital 2241**] home health aides. She requires
assistance with dressing, walking (unsteady on a [**Hospital **]),
preparing meals. Able to feed herself. She previously worked
in the development office of [**Hospital **] Hospital for 47 years. No
tobacco or EtOH. NOK: Eldest daughter - [**Name (NI) **] [**Name (NI) **] -
[**Telephone/Fax (1) 94693**], daughter from [**Location (un) 5131**]
- [**Telephone/Fax (1) 94694**].
Family History:
nc
Physical Exam:
Vitals: T98.2 142/86 96 20 96RA
General: Alert, oriented, sitting upright, complaining of
sternal pain
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Good air movement bilaterally, reduced breath sounds and
rales at bases, no wheezes
CV: Regular rate and rhythm, multiple murmurs. holosystolic
murmur at axilla, crescendo/decreascendo murmur at LUSB.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: both shoulders with reduced range of passive and active
mostion, Left worse than right. Left shouulder appears more
swollen. Tenderness at AC joint to palpation, though moves
without too much pain. No other edema, erythema.
Skin: chronic radiation changes that are erythemetous around
all aspections of wound. Faint blanching erythema and
tnederness on the left lateral aspect of the wound. No petechia
lesions. open skin wound over sternum with granulation tissue
underneath and bloody discharge.
Pertinent Results:
CT TORSO ([**2185-4-15**]):
POST-CONTRAST NECK CT: There is no abscess, fluid collection, or
soft tissue abnormality within the neck. Dental work is noted.
Multilevel degenerative changes of the spine are seen. The
submandibular glands and imaged oropharynx are unremarkable. The
major cervical vessels are patent. Thyroid gland is
unremarkable.
.
POST-CONTRAST CHEST CT: There is new, 19 x 17 mm, air-fluid
collection superior to the manubrium concerning for abscess at
the sternoclavicular
junction (2:26). There is adjacent significant soft tissue
swelling. There is increased destruction, fragmentation, and
sclerosis of the manubrium,
clavicles, and sternum compatible with worsening chronic
osteomyelitis. There is also increased osteolysis and bone
destruction at the upper-mid sternum as compared to prior study
(2:37) where an oblique sternal fracture was present; the
fractured fragments appear more distracted as well. No
subcutaneous tissue is seen overlying the area of osseous
destruction within the upper and mid sternum and to the left of
midline, with an overlying bandage again seen, unchanged from
prior.
Severe atherosclerotic calcifications of the aorta and coronary
arteries are seen. The heart is enlarged. There is trace
pericardial effusion. There is no mediastinal, hilar or axillary
lymphadenopathy by size criteria. The esophagus is severely and
diffusely dilated and contains fluid, placing the patient at
high risk for aspiration.
There is peripherally enhancing fluid collection in the left
lower lung
concerning for empyema. There is a small right pleural effusion
with adjacent atelectasis.
Paramediastinal radiation fibrosis is redemonstrated with
multifocal
bronchiectasis. Focal area of ground-glass opacity in the right
upper lobe
with adjacent nodular opacities are nonspecific and concerning
for
infectious/inflammatory etiologies. There is no pneumothorax.
Airways are
grossly patent.
The patient has undergone left radical mastectomy. Imaged upper
abdominal
organs are grossly unremarkable.
Degenerative changes of the spine are noted.
.
IMPRESSION:
1. Increased bone destruction, osteolysis and bone fragmentation
of the
sternum and manubrium with a 19-mm air and fluid collection at
the
sternoclavicular junction. Findings are compatible with
cellulitis, worsening chronic osteomyelitis and focal abscess
formation.
2. Left lower lobe peripheral enhancing pleural effusion
concerning for
empyema.
3. Right upper lobe area of ground-glass opacity, most
compatible with
pneumonia or an inflammatory process.
4. Unchanged marked and diffuse dilatation of the esophagus.
.
.
LEFT UPPER EXTREMITY U/S:
FINDINGS: Grayscale and Doppler evaluation of left internal
jugular,
axillary, brachial, basilic, cephalic vein demonstrates normal
compressibility, flow, response to augmentation wherever
applicable. The left subclavian vein on the other hand
demonstrates wall thickening and occlusive thrombus. Moderate
edema is noted in the left arm.
IMPRESSION:
1. Left subclavian vein thrombosis.
2. Moderate edema is noted in the left arm subcutaneous tissues.
.
.
LEFT SHOULDER PLAIN FILM:
There is severe osteoarthritis of the glenohumeral joint with
joint space
narrowing, subchondral sclerosis, and osteophyte formation. No
fracture is
identified. The acromion is somewhat dysplastic in morphology.
Unclear if
this pertains to congenital or developmental etiology.
.
.
[**2185-4-15**] 04:30PM NEUTS-88.0* LYMPHS-8.8* MONOS-2.8 EOS-0.2
BASOS-0.2
[**2185-4-15**] 04:30PM WBC-12.2* RBC-4.06* HGB-10.3* HCT-33.5*
MCV-83 MCH-25.5* MCHC-30.9* RDW-15.5
[**2185-4-15**] 04:30PM CK(CPK)-21*
[**2185-4-15**] 04:30PM GLUCOSE-182* UREA N-36* CREAT-1.5* SODIUM-138
POTASSIUM-4.6 CHLORIDE-103 TOTAL CO2-27 ANION GAP-13
Brief Hospital Course:
[**Age over 90 **] F with CAD, AS, CRI, chronic sternal wound from radiation,
multiple other problems, presenting with worsening sternal wound
discharge, empyema.
.
# STERNAL OSTEOMYELITIS: She was admitted to the medicine floor
and started on broad spectrum IV antibiotics pending wound
culture results for the sternal osteomyelitis and abscess.
Consistent with previous decisions, the patient declined
invasive measures including surgical debridement. The infectious
disease team evaluated the patient. She was changed from IV
antibiotics to oral moxifloxacin with plans to continue for a
prolonged course. She will follow up with Dr. [**Last Name (STitle) **] in infectious
disease on [**2185-5-18**].
.
#EMPYEMA: She was found to have a possible empyema on chest
imaging. Thoracentesis was attempted by interventional
pulmonology for culture data but was not successful. She
tolerated this well. Thoracic surgery was consulted but the
patient declined more invasive measures to obtain a fluid
sample, which is appropriate given her high risk. She was startd
on moxifloxacin with plan for a prolonged course.
.
#SUBCLAVIAN DVT: She reported left upper extremity swelling. An
ultrasound showed subclavian DVT. She was started on a heparin
drip at 900/hr for goal PTT 60-80. In coordination with her
primary care physician, [**Name10 (NameIs) **] plan is to start her on coumadin
2.5mg daily for a goal INR of [**12-22**]. We are starting at a lower
dose out of concern for interaction with moxifloxacin, which is
expected to raise her INR. Also given that she has a history of
subarachnoid hemorrhage, her INR will have to be monitored very
closely as the appropriate dose is determined. She will be kept
on a heparin drip until her INR is therapeutic and then heparin
can be discontinued.
.
#SHOULDER PAIN: This was evaluated with an Xray which showed no
fracture. Pain was thought to be due to cellulitis or extension
of her osteomyelitis. It improved during the course of her
hosptialization.
.
# DYSPHAGIA: She was evaluated by bedside speech and swallow.
The recommended diet was to continue with regular PO diet of
solids and thin liquids.
.
# HOARSENESS: The patient was started on cepacol lozenges.
.
# CAD: pt with hx of 3VD, s/p multiple stents. Given she
presented with shoulder pain she was initially ruled out for MI.
She was continued on statin and aspirin.
.
# CHRONIC DIASTOLIC CHF: She was felt to be euvolemic on exam
and was continued on lasix. Her lasix was held on [**2185-4-18**] as her
creatinine was slightly elevated at 1.8 up from a baseline of
1.3-1.6. Her creatinine came down the next day and lasix 60mg
daily was re-started.
.
# Hypothyroidism: She was continue synthroid.
.
# Anemia: She was continued on iron supplements. She also takes
aranesp as an outpatient, which she receives at clinic.
.
# Code status: After discussing with the patient, PCP and
daughter code status was no chest compressions, no prolonged
intubation but trial of intubation ok for reversible causes,
defibrillation ok
.
# Contact: daughter. [**Name2 (NI) **] [**Name2 (NI) **] ([**Telephone/Fax (1) 94693**])
Medications on Admission:
Lasix 80mg qod, 60mg on alternate days
Lactinex tablet [**Hospital1 **]
Levothyroxine 100mcg on Sunday, Tuesday, Thursday, Saturday,
125mcg MWF
Lipitor 80mg
Protonix 40mg daily
Vitamin D 1000IU daily
ASA 325
Carvedilol 6.25mg [**Hospital1 **]
Citalopram 60mg daily
Digoxin 0.125mg, half tab MWF, one tab Sun/Tue/Th/Sat
Iron 325 [**Hospital1 **]
Folic acid 4mg daily
ARANESP - 60 mcg/0.3 mL Syringe - inject s/c every 14 days to
receive in H/O clinic
Discharge Medications:
1. Atorvastatin 80 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at
bedtime).
2. Moxifloxacin 400 mg Tablet [**Hospital1 **]: One (1) Tablet PO daily ():
Day [**4-19**].
3. Menthol-Cetylpyridinium 3 mg Lozenge [**Year (4 digits) **]: One (1) Lozenge
Mucous membrane PRN (as needed) as needed for sore throat .
4. Ferrous Sulfate 300 mg (60 mg Iron) Tablet [**Year (4 digits) **]: One (1)
Tablet PO DAILY (Daily).
5. Digoxin 125 mcg Tablet [**Year (4 digits) **]: One (1) Tablet PO 4X/WEEK
([**Doctor First Name **],TU,TH,SA).
6. Digoxin 125 mcg Tablet [**Doctor First Name **]: [**11-20**] tablet Tablet PO 3X/WEEK
(MO,WE,FR).
7. Carvedilol 3.125 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO BID (2
times a day).
8. Folic Acid 1 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily).
9. Ammonium Lactate 12 % Lotion [**Month/Day (2) **]: One (1) Appl Topical [**Hospital1 **] (2
times a day).
10. Acetaminophen 500 mg Tablet [**Hospital1 **]: Two (2) Tablet PO TID (3
times a day).
11. Citalopram 20 mg Tablet [**Hospital1 **]: Three (3) Tablet PO DAILY
(Daily).
12. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
13. Docusate Sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID
(2 times a day): hold if loose stools, patient may refuse.
14. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at bedtime):
hold if loose stools, patient may refuse .
15. Levothyroxine 100 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
16. Oxycodone 5 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO every eight (8)
hours as needed for pain: hold if RR<12.
17. Trazodone 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
18. Aspirin 81 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
19. Aranesp (Polysorbate) 60 mcg/0.3 mL Syringe [**Last Name (STitle) **]: One (1)
Injection every 14 days: given in clinic.
20. Vitamin D 1,000 unit Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a
day.
21. Lasix 40 mg Tablet [**Last Name (STitle) **]: 1.5 tablets Tablets PO once a day.
22. Heparin IV per weight based guidelines for PTT 60-80
23. Coumadin 2.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Sternal osteomyelitis
Abscess
Possible empyema
Shoulder pain
Subclavian vein thrombosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid ([**Hospital6 **]
or cane).
Discharge Instructions:
It was a pleasure to be involved in your care. You were admitted
with worsening chest wall drainage likely due to worsening of
your chronic osteomyelitis. You were evaluated by the infectious
disease service. You were initially started on IV antibiotics,
which were switched to oral antibiotics. Also you were found to
have a fluid collection in the lung. The interventional
pulmonary service attempted to biopsy this fluid but were not
successful. You decided not to pursue further invasive
evalution including debridement or surgery.
You were also found to have left arm swelling. An ultrasound
showed a [**Hospital6 **] clot in one of the veins leading from the arm
(subclavian vein thrombosis). You will be started on a
medication called coumadin to eliminated the clot, which you
will need to continue for at least the next three months. You
will need to have your [**Hospital6 **] levels monitored very closely while
on this medication. Please have your [**Hospital6 **] work checked on
Friday.
Please continue your home medications with the following
changes.
1. Start taking moxifloxacin for the wound infection
2. Start taking coumadin for the [**Hospital6 **] clot
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
1. Department: CARDIAC SERVICES
When: THURSDAY [**2185-4-28**] at 10:20 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
2. Department: Infectious disease
With: Dr. [**Last Name (STitle) **]
When: Wednesday [**5-18**] at 10:30AM
Location: 110 [**Doctor First Name **], [**Hospital Ward Name **] in basement suite G
Phone: [**Telephone/Fax (1) **]
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
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[
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77,070
| 163,560
|
16899
|
Discharge summary
|
report
|
Admission Date: [**2158-5-23**] Discharge Date: [**2158-6-2**]
Date of Birth: [**2097-3-2**] Sex: F
Service: SURGERY
Allergies:
Morphine / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) /
aspirin
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
abdominal pain, pneumoperitoneum
Major Surgical or Invasive Procedure:
[**2158-5-23**]
1. Exploratory laparotomy.
2. Enterotomy repair, distal ileum.
3. Adhesiolysis.
4. Closure of duodenal ulcer with [**Location (un) **] patch, omentum.
History of Present Illness:
61F transferred from an outside hospital with free air and
abdominal fluid. She had undergone a previous gastric bypass 10
years earlier, which was subsequently complicated by perforated
ulcer. She had recovered from that was advised to not take
nonsteroidals antiinflammatory medications; however, after a
knee surgery she resumed nonsteroidals, and by her report, has
had chronic abdominal pain for at least 1 month. She presented
this admission with acute worsening abdominal pain and CT
findings consistent with recurrent perforated peptic ulcer.
Past Medical History:
PMH: HTN, MV Prolapse, OA, DJD, Venostasis
PSH: Hysterectomy '[**47**], Tonsillectomy, Lap Appy '[**51**], Arthroscopy
'[**47**], repair of perforated peptic ulcer '[**53**], RYGB and CCY '[**49**],
Social History:
She quit smoking in [**2142**] and uses alcohol occasionally.
Family History:
Non-contributory
Physical Exam:
98.9 98.7 89 129/60 18 97%RA
GEN: NAD, A&Ox3
CV: RRR
PULM: CTAB
ABD: soft, appropriately tender, non-distended
EXT: warm and well-perfused
Incision: c/d/i, prior drain sites with no evidence of infection
Neuro: grossly intact
Pertinent Results:
[**2158-5-26**] 01:57AM BLOOD WBC-0.8* RBC-2.77* Hgb-7.6* Hct-25.4*
MCV-92 MCH-27.6 MCHC-30.1* RDW-15.8* Plt Ct-114*
[**2158-6-2**] 05:35AM BLOOD WBC-6.1 RBC-2.72* Hgb-7.2* Hct-24.1*
MCV-88 MCH-26.5* MCHC-30.0* RDW-16.6* Plt Ct-316
[**2158-6-2**] 05:35AM BLOOD Glucose-97 UreaN-16 Creat-0.6 Na-136
K-3.9 Cl-106 HCO3-22 AnGap-12
[**2158-6-1**] 05:06AM BLOOD ALT-265* AST-366* LD(LDH)-407*
AlkPhos-455* TotBili-1.9* DirBili-1.3* IndBili-0.6
[**2158-6-2**] 05:35AM BLOOD ALT-189* AST-148* AlkPhos-422*
TotBili-1.1 DirBili-0.6* IndBili-0.5
Brief Hospital Course:
The patient was admitted for surgical repair of a likely
perforated peptic ulcer. She tolerated the procedure well;
please see the separately-dictated operative note for details.
Following the procedure, she was transferred to the TICU for
close monitoring, and transferred to the floor on POD#3.
NEURO/PAIN: The patient was taken to the TICU postoperatively,
and was sedated and intubated; sedation was weaned as she was
extubated POD#1. The patient was maintained on IV pain
medication in the immediate post-operative period and later
transitioned to PO narcotic medication with adequate pain
control. A social work consult was called for assistance with
coping. The patient was also noted at times to appear confused
and distractable; she was indeed maintained on her home
antidepressant, and a psychiatry consult was eventually
requested. It was thought that her mental status changes were
due to resolving delirium, and indeed by the day of discharge,
her mental status was reassuring.
CARDIOVASCULAR: The patient was hemodynamically stable. Her
vitals signs were monitored. Initially, in the TICU, she was
mildly tachycardic, thought to be secondary to hypovolemia. She
was maintained on IV fluids until tolerating sufficient PO
intake.
RESPIRATORY: The patient was transferred postoperatively to the
TICU, intubated. She was extubated the next day, without event.
She was stable room air.
GASTROINTESTINAL: Following the procedure, the patient was NPO.
She was started on TPN on POD#1, and this was continued to
POD#8, when she demonstrated sufficient tolerance of a bariatric
stage 3 diet. Her tolerance of the diet was halting at first,
secondary to occasional nausea and emesis, but these issues
appeared to resolve with minimization of her narcotic pain
medication. On POD#8, her LFTs were noted to have risen, and
these were trending downward after discontinuation of the TPN.
She had 3 abdominal drains in place after the procedure, and
these were discontinued sequentially prior to discharge
beginning on POD#6. A nasogastric tube was discontinued on
POD#3. By the day of discharge, the patient was passing flatus
and having bowel movements.
GENITOURINARY: The patient's urine output was closely monitored
in the immediate post-operative period. A Foley catheter was
placed intra-operatively and removed on POD#5, and she was able
to void. The patient's intake and output was closely monitored.
The patient's creatinine was 0.6 on the day of discharge.
HEME: In the postoperative period, the patient was noted to be
pancytopenic. A hematology consult was obtained, and it was
thought that this was likely due to bone marrow suppression in
the setting of her infection. She was initially placed on
neutropenic precautions; over the remainder of her course, her
cell counts trended upward and the neutropenic precautions were
discontinued on POD#6.
ID: The patient was initially on vancomycin and cefepime due to
concerns about polymicrobial infection in the setting of
intestinal perforation. After consultation with infectious
disease, and per the organisms' sensitivities, her antibiotics
were changed to ciprofloxacin, and this was discontinued on
POD#6; she showed no signs of infection after this.
ENDOCRINE: The patient remained stable from an endocrine
standpoint.
PROPHYLAXIS: The patient was maintained on subcutaneous heparin
and compression boots. She was encouraged to ambulate and she
worked with physical therapy. Incentive spirometry was
encouraged. She was on a PPI.
On the day of discharge, she was sent home in stable condition,
tolerating a bariatric stage 3 diet, ambulating, with bowel
function, and pain well-controlled. She was encouraged to call
or return to the ED if she had any concerning symptoms.
Medications on Admission:
prozac 40', modafinil 200', iron 65 SR', MVI w/ minerals'',
ibuprofen PRN
Discharge Medications:
1. fluoxetine 20 mg/5 mL Solution Sig: Ten (10) ML PO DAILY
(Daily).
Disp:*600 ML* Refills:*2*
2. oxycodone 5 mg/5 mL Solution Sig: 2.5 - 5 ML PO Q8H (every 8
hours) as needed for Pain: No alcohol or driving.
Disp:*100 ML* Refills:*0*
3. omeprazole 2 mg/mL Suspension for Reconstitution Sig: Forty
(40) mg PO twice a day.
Disp:*QS for 1 month * Refills:*1*
4. modafinil Oral
5. multivitamin Liquid Sig: One (1) PO once a day.
Discharge Disposition:
Home With Service
Facility:
Bayada Nurses Inc.
Discharge Diagnosis:
perforation of peptic ulcer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for surgical repair of a perforation of part
of your intestine. You have recovered from this and are ready to
go home to finish your recovery. During your hospitalization,
you were followed by hematology for a brief period of low blood
cell counts, and you were seen by psychiatry, too. You were
evaluated by physical therapy, and they recommended continued
physical therapy as an outpatient.
You are tolerating a bariatric stage 3 diet. Please continue
this diet until your follow-up with Dr [**Last Name (STitle) 15645**] clinic.
* Do NOT take non-steroidal anti-inflammatory medications
(including but not limited to ibuprofen, naproxen, and aspirin)
Please call your doctor or go to the emergency department if:
* You experience new chest pain, pressure, squeezing or
tightness.
* You develop new or worsening cough, shortness of breath, or
wheezing.
* You are vomiting and cannot keep down fluids, or your
medications.
* If you are getting dehydrated due to continued vomiting,
diarrhea, or other reasons. Signs of dehydration include: dry
mouth, rapid heartbeat, or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit, or have a
bowel movement.
* You experience burning when you urinate, have blood in your
urine, or experience an unusual discharge.
* Your pain is not improving within 12 hours or is not under
control within 24 hours.
* Your pain worsens or changes location.
* You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
* You develop any other concerning symptoms.
General Discharge Instructions:
* Please resume all regular home medications, unless
specifically advised not to take a particular medication (for
example, do not take ibuprofen, naproxen, or aspirin).
* Please take any new medications as prescribed.
* Please take the prescribed analgesic medications only as
needed. You may not drive or operate heavy machinery while
taking narcotic analgesic medications. You may also take
acetaminophen (Tylenol) as directed, but do not exceed 4000 mg
in one day.
* Please get plenty of rest, continue to walk several times per
day, and drink adequate amounts of fluids.
* Avoid strenuous physical activity and refrain from heavy
lifting greater than 10 lbs., until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
* Please also follow-up with your primary care physician.
Incision Care:
* Please call your surgeon or go to the emergency department if
you have increased pain, swelling, redness, or drainage from the
incision site.
* Avoid swimming and baths until cleared by your surgeon.
* You may shower and wash incisions with a mild soap and warm
water. Gently pat the area dry.
* If you have staples, they will be removed at your follow-up
appointment.
* If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
Followup Instructions:
Please call Dr [**Last Name (STitle) 15645**] office to confirm your follow-up
appointments for [**6-14**]. You will see Dr [**Last Name (STitle) **] at 1130am, and
then a bariatric dietician at 1230pm. Call [**Telephone/Fax (1) 2723**].
Please call your PCP to make [**Name Initial (PRE) **] follow-up appointment.
Completed by:[**2158-6-2**]
|
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|
6672, 6702
|
6046, 6122
|
6874, 8461
|
9336, 9829
|
1457, 1690
|
8494, 9320
|
284, 318
|
553, 1105
|
6738, 6850
|
1127, 1328
|
1344, 1408
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,956
| 154,628
|
31583
|
Discharge summary
|
report
|
Admission Date: [**2158-4-28**] Discharge Date: [**2158-5-2**]
Date of Birth: [**2102-1-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
56 yo M admitted overnight to MICU after presenging to ED with
fever, cough and need for NRB. Treated for HAP now stable for
transfer to medical floor. PMH of recurrent aspiration PNA, s/p
transhiatal esophagectomy/pyloroplasty/hiatal herniorrohapy for
high grade esophageal dysplasia in [**9-18**].
Patient initially presented to ED with 1 week of productive
cough and low grade fevers and DOE. In the ED, patient was
febrile to 101.7 and was 83% on RA----->98% on NRB. He had a
leukocytosis to 13.7 with left shift, elevated lactate to 2.2
and a LLL infiltrated of [**Date Range **]. He was recently admitted late [**Month (only) **]-
early [**Month (only) 958**] for recurrent multifocal aspiration PNA. Has had
numerous similar admission following his surgery. In ICU, was
treated with Vanc/Zosyn overnight and solumedrol for presumed
COPD flare. He was stable for floor transfer.
Of note, patient has been evaluated by S&S, who felt that
aspiration was due to GERD over silent aspiration. Pt was
evaluated by thoracic surgery in [**5-19**] and recommended a
Roux-en-Y.
Patient was evaluated in the ICU. He currently feels comfortable
on nasal cannula, no SOB. Denies CP, HA, change in vision,
change in bowel habits, nausea or vomiting, dizziness or
lightheadedness.
Past Medical History:
-Esophageal ca s/p transhiatal esophagectomy/pyloroplasty/hiatal
herniorrohapy in [**2156**], no XRT or chemo, currently stable
-Hx of recurrent aspiration pneumonia, MRSA in BAL from [**1-/2157**]
-Diabetes II
-COPD, intermittently on home O2 by NC when he feels short of
breath
-OSA, refusing home CPAP
-GERD
-Hyperlipidemia
-Chronic back pain s/p back fusion for slipped discs. No
hardware per patient.
-Diverticulosis
-TB exposure at a young age, never treated. PPD positive per his
report. Exposures include grandparents from [**Country 4754**] and
backpacking in Europe in the 70s. He was ruled out for active TB
with 3 neg AFBs in [**2-20**].
Social History:
The patient is married, has 2 daughters. Former [**Name2 (NI) 1818**]
(40pack-years), quit spring [**2156**]. Used to be a heavy drinker in
the 70s but no longer drinks. On disability for back issues.
Previously worked for family construction supplier business.
Family History:
Mother died of head/neck ca. Father died of pulmonary issues
related to copd/asbestosis/polio.
Physical Exam:
On Transfer to floor:
VS: 98.3 149/82 96 18 97% on 3L nc
GEN: NAD, comfortable
HEENT: EOMI, PERRL, no OP lesions, MMM
CV: Regular no mrg
PULM: decreased breath sounds throughout with scattered rhonchi
and wheezing
ABD: Obese, +bs, soft, NTND
EXT: no [**Location (un) **], warm 2+ DP pulses B
NEURO: a/o x3
PSYCH: appropriate
Pertinent Results:
Admission [**Location (un) **]:
A suggestion of somewhat vague ill-defined opacity involving the
left lower lobe, although this is compromised somewhat by AP
portable
technique and body habitus and may reflect an element of soft
tissue
attenuation. If further imaging is desired to help management,
consider PA
and lateral views in the radiology suite for more sensitive
evaluation.
DISCHARGE LABS:
- WBC-6.1 RBC-3.84* Hgb-11.4* Hct-33.8* MCV-88 MCH-29.8
MCHC-33.9 RDW-13.6 Plt Ct-269
- Glucose-169* UreaN-11 Creat-0.6 Na-142 K-3.7 Cl-103 HCO3-30
AnGap-13
Brief Hospital Course:
56 yo M with recurrent aspiration pneumonia after esophageal
resection who presents with pneumonia initially required NRB,
stabilized in ICU and transferred to floor. Treated for
health-care associated PNA with 8 days of IV vancomycin and
zosyn. Discharged [**Last Name (un) **] off of oxygen with visiting nurse [**First Name (Titles) **] [**Last Name (Titles) 74253**]s teaching.
#. Healthcare-associated pneumonia: Thought to be [**2-13**] aspiration
given multiple prior aspiration-associated PNA. Treated as HCAP
given recent hospitalization (discharged on [**2158-3-14**]). To
complete 8 days of iv vancomycin and zosyn, last dose on
[**2158-5-6**]. Also discharged on Guaifenesin prn. Patient's
sulfacrate was stopped and PPI was decreased as they were
thought to increase risk of PNA by altering stomach acid.
Additionally, patient has been seen multiple times by speech and
swallow at previous admission and has been instructed on
specifics to reduced risk of aspiration. Spoke with CT surgeon
Dr. [**First Name (STitle) 4667**] [**Doctor Last Name **] who said there was not a surgical role.
#. Hemoptysis: Had on admission, but only one episode. Possibly
[**2-13**] bronchiectasis due to recurrent pneumonias though not [**Month/Day (2) 65**].
on recent CT chest. Pt has been ruled out for TB by neg. AFB x3,
latest sample from [**2158-3-13**]. Did not have repeated episodes.
#. COPD Exacerbation. Treated with short prednisone burst og 60
mg for 6 days, last dose [**2158-5-4**]. Should have outpatient follow
up with [**Hospital **] Clinic for repeat spirometry given recurrent
pneumonias.
#. Diarrhea: Resolved prior to discharge. Likely viral as family
members have it as well. C. diff was not checked as patient did
not have stool.
#. DM2: Held home metformin and covered with SSI. Restarted
home metformin upon discharge.
#. Hyperlipidemia: Continued home statin.
#. Chronic Back Pain: Pain was well controlled on home regimen
of vicodin, lidocaine patches, celebrex, Duloxetine, Doxepin.
Medications on Admission:
1. Hydrocodone-Acetaminophen 5-500 mg PO Q6H as needed for pain.
2. Metoclopramide 10 mg PO QIDACHS
3. Montelukast 10 mg PO DAILY
4. Duloxetine 60 mg PO DAILY
5. Diazepam 10 mg PO Q12H as needed for anxiety.
6. Oxycodone 40 mg Tablet Sustained Release 12 hr PO Q12H
7. Doxepin 300 mg PO HS
8. Butalbital-Acetaminophen-Caff 50-325-40 mg PO Q6H as needed
for headache.
9. Fluticasone-Salmeterol 100-50 mcg/Dose Disk Inhalation [**Hospital1 **]
10. Multivitamin PO DAILY
11. Lidocaine 5 %(700 mg/patch) Adhesive Patch
12. Celebrex 200 mg Capsule PO daily
13. Metformin 500 mg PO twice a day.
14. Sucralfate 1 gram PO QID
15. Omeprazole 40 mg PO twice a day.
16. Simvastatin 80 mg PO once a day.
Discharge Medications:
1. Hydrocodone-Acetaminophen 5-500 mg Tablet [**Hospital1 **]: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
2. Metoclopramide 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
3. Montelukast 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
4. Duloxetine 30 mg Capsule, Delayed Release(E.C.) [**Hospital1 **]: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Diazepam 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q12H (every 12
hours) as needed for anxiety.
6. Oxycodone 40 mg Tablet Sustained Release 12 hr [**Hospital1 **]: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
7. Doxepin 150 mg Capsule [**Hospital1 **]: Two (2) Capsule PO at bedtime.
8. Fioricet 50-325-40 mg Tablet [**Hospital1 **]: One (1) Tablet PO every six
(6) hours as needed for headache.
9. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device [**Hospital1 **]:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
10. Multivitamin Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
11. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital1 **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
12. Celecoxib 200 mg Capsule [**Hospital1 **]: One (1) Capsule PO daily ().
13. Metformin 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO twice a day.
14. Simvastatin 80 mg Tablet [**Hospital1 **]: One (1) Tablet PO at bedtime.
15. Omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Hospital1 **]: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
16. Colace 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
17. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*60 Tablet(s)* Refills:*2*
18. Guaifenesin 100 mg/5 mL Syrup [**Hospital1 **]: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
Disp:*500 ML(s)* Refills:*0*
19. Prednisone 20 mg Tablet [**Hospital1 **]: Three (3) Tablet PO once a day
for 2 days.
Disp:*6 Tablet(s)* Refills:*0*
20. Heparin, Porcine (PF) 10 unit/mL Syringe [**Hospital1 **]: Ten (10) ML
Intravenous PRN (as needed) as needed for line flush.
Disp:*30 flushes* Refills:*0*
21. Vancomycin in Dextrose 1 gram/200 mL Piggyback [**Hospital1 **]: One (1)
gram Intravenous Q 12H (Every 12 Hours) for 5 days.
Disp:*10 gram* Refills:*0*
22. Piperacillin-Tazobactam 4.5 gram Recon Soln [**Hospital1 **]: 4.5 gm
Intravenous every eight (8) hours for 5 days.
Disp:*68 grams* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 511**] Home Therapies
Discharge Diagnosis:
Primary Diagnosis:
1. Aspiration Pneumonia
Secondary Diagnosis:
1. Chronic Obstructuve Pulmonary Disease
2. Diarrhea
3. Type 2 Diabetes Mellitus
4. Hyperlipidemia
5. Chronic Back Pain
Discharge Condition:
Vitals stable. Ambulating without difficulty or pain.
Discharge Instructions:
You were admitted with aspiration pneumonia. You were given IV
antibiotics and improved with these medications. You are being
discharged on iv antibiotics which you will receive until
[**2158-5-6**].
Please continue to take all your medications as prescribed. The
following changes have been made:
ADDED:
* Zosyn iv until [**5-6**] for pneumonia
* Vancomycin iv until [**5-6**] for pneumonia
* Prednisone 60mg for 2 days for COPD exacerbation
* Colace and Senna to soften stools
* Cough medicine as needed
CHANGED:
* Omeprazole was decreased to 20mg once day (down from 40mg).
STOPPED:
* Sulfacrate - you should stop taking this
Please adhere to the follow recommendations for eating:
1. PO diet of thin liquids and regular solid consistencies.
2. Pills may be taken whole with puree.
3. Aspiration Precautions:
A. Chin tucked to chest for SMALL cup sips of thin liquids.
B. Repeat swallow after sips of liquids with chin still
tucked to chest.
C. No straws.
D. Cough intermittently when drinking liquids.
E. Follow reflux precautions (stay upright after meals, wait
2-3 hours after meal before going to bed, keep head of bed
elevated above 30 degrees).
If you have any of the following symptoms, please call your
doctor or go to the nearest ED: fever > 101, chest pain,
shortness of breath, abdominal pain, or any other concerning
symptoms.
It was a pleasure meeting you and participating in your care.
Followup Instructions:
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD (ALLERGY) Phone:[**Telephone/Fax (1) 9316**] Date/Time:[**2158-5-9**]
4:45
|
[
"327.23",
"786.3",
"496",
"272.4",
"V10.03",
"507.0",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9027, 9096
|
3640, 5667
|
320, 328
|
9325, 9381
|
3059, 3443
|
10877, 11011
|
2602, 2698
|
6409, 9004
|
9117, 9117
|
5693, 6386
|
9405, 10854
|
3459, 3617
|
2713, 3040
|
273, 282
|
356, 1632
|
9182, 9304
|
9136, 9161
|
1654, 2305
|
2321, 2586
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,301
| 178,238
|
21256
|
Discharge summary
|
report
|
Admission Date: [**2138-3-9**] Discharge Date: [**2138-3-15**]
Date of Birth: [**2056-6-15**] Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
lethargy, decreased right sided movement
Major Surgical or Invasive Procedure:
none
History of Present Illness:
81yo woman with PMH significant for recent R MCA and
bilateral ACA strokes, atrial fibrillation, and other vascular
risk factors, presents from rehab with one week of lethargy,
absence of speech, and right hemiparesis. She is known to the
neurology service, where she was admitted [**Date range (1) 16572**] with these
infarcts. She initially presented with left hemiparesis and was
found to have R MCA infarct, which was treated with IV tPA. She
did well initially with improvement in her left sided movement,
and was noted in angio to have had revascularization of the MCA
without IA tPA or MERCI retrieval. The next day she was noted to
be moving the left side better than the right, specifically in
the leg. Repeat scan showedd bilateral ACA infarcts, with both
ACAs deriving from the right circulation. She was abulic,
nonverval, with RLE plegia and decreased spontaneous movement
throughout. She was discharged to [**Hospital 38**] Rehab on [**2-25**].
At rehab, she was seen by neurology and was started on coumadin
on [**2-26**]. Per her daughter, her examination began to improve, to
the point on [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1017**] that she was able to answer questions
about her family (where her sister-in-law lived, for example)
and
make a family joke. That night she became very tired, and
lethargy continued into Monday. She no longer spoke and stopped
moving the right side. This continued throughout the course of
the week, attributed to waxing/[**Doctor Last Name 688**] post-infarct, until she
appeared dehydrated and was brought in to [**Hospital1 18**] for further
evaluation.
Of note, INRs were 8.6 on [**3-6**].5 on [**3-7**], and 2.3 on [**3-9**].
Past Medical History:
-Afib dx 1 month ago-declined coumadin because of frequent blood
draws
-HTN (not well controlled per daughter)
-CABG stent x5 (20 y ago)
-CAD
patient had 3 stents placed. One stent was placed in [**2132**] and
another stent was placed in [**2135**]
-breast mass diagnosed in [**2137-7-10**]
[**2137-8-10**]- breast cancer was resected (lumpectomy) with
negative, clear margins
No chemo or radiation
-Bilateral CEA
Social History:
Married, has 2 daughters, one of whom died in her 50s of an
aneurysm bleed
daughter Ms. [**Last Name (Titles) 56256**], [**Telephone/Fax (1) 56257**](C), [**Telephone/Fax (1) 56258**](H),
[**Telephone/Fax (1) 56259**](W)
Family History:
Had daughter who died of brain aneurysm
Physical Exam:
PE: VS: T 98, BP 164/48 on arrival, to 84/48 at time of exam on
propofol, HR 67, RR 14, SaO2 100%/vent
Genl: intubated, sedated, taken off just briefly before
examination
HEENT: NCAT, MMM, ETT in place
CV: unable to appreciate over vented BS
Chest: vented BS, sound clear to auscultation
Abd: soft, NTND, PEG in place
Ext: warm and dry
Neurologic examination:
MS: moves to noxious, no eye opening, does not follow commands
CN: pupils small and irregular, asymmetric, but reactive b/l,
unable to appreciate OCR, corneals R>L, no response to nasal
tickle, +cough
Motor: extends BUE to noxious, triple flexes BLE to noxious,
tone
decreased throughout
Sensory: responds to noxious throughout
DTRs: 2+ in RUE, 2 in LUE, unable to elicit in BLE, toes upgoing
bilaterally
Pertinent Results:
128 93 23
-----------< 114
5.0 25 0.8
estGFR: 69 / >75 (click for details)
CK: 101 MB: 5 Trop-T: 0.03
Ca: 9.5 Mg: 2.1 P: 3.6
9.6 > 35.4 < 503
N:74.0 L:17.3 M:6.6 E:1.8 Bas:0.2
PT: 24.1 PTT: 24.3 INR: 2.3
Imaging: HCT: "Large intraparenchymal hemorrhage consistent with
hemorrhagic transformation in the known area of left anterior
cerebral artery infarct with intraventricular extension, and
surrounding edema causing rightward subfalcine herniation." ICH
appears to be 6cm x 6cm x 3cm, with 9mm MLS
Brief Hospital Course:
81yo woman with PMH significant for recent R MCA and bilateral
ACA strokes (both her ACAs oriinate from R ICA), in the context
of recent dx of atrial fibrillation not on Coumadin, and other
vascular risk factors, presents from rehab with one week of
lethargy. She was found to have large hemorrhagic transformation
into her L frontal infarct, likely in the setting of
supratherapeutic INR. Her ICH scale is at least 3, likely 4, for
volume, age, and poor GCS score.
She was initially admitted to the Neuro ICU, intubated, and
given prophylene to reverse her INR, as well as started on
Mannitol. After discussion with the family and in light of her
extremely poor prognosis, they decided to make her CMO status.
She was started on a Scopolamine patch, Morphine gtt and PRN
Ativan. She had a very irregular breathing pattern with
occasional apneic episodes during the ensuing few days while on
the [**Hospital1 **] but seemed comfortable. She died around noontime on
[**2138-3-15**].
Medications on Admission:
Meds:
amantadine 50mg daily
ASA 81mg daily
cholestyramine
famotidine 20mg daily
MgOxide 400mg daily
metoprolol 50mg q8hrs
miconazole topical [**Hospital1 **]
MVI 5ml daily
simvastatin 80mg daily
coumadin 3mg qhs
prns:
tylenol 650mg q6h
bisacodyl 10mg daily
colace 100mg [**Hospital1 **]
sorbitol 30ml daily
All: PCN, sulfa
Discharge Medications:
patient died
Discharge Disposition:
Expired
Discharge Diagnosis:
hemorrhagic conversion of L frontal infarct
Discharge Condition:
patient was made CMO and died on [**3-15**]/8
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2138-3-24**]
|
[
"V45.89",
"438.9",
"790.92",
"432.9",
"E934.2",
"V10.3",
"V45.82",
"V45.81",
"518.81",
"438.20",
"427.31",
"V44.1",
"414.01",
"799.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
5565, 5574
|
4168, 5153
|
335, 341
|
5661, 5829
|
3633, 4145
|
2789, 2831
|
5528, 5542
|
5595, 5640
|
5179, 5505
|
2846, 3183
|
255, 297
|
369, 2079
|
3207, 3614
|
2101, 2533
|
2549, 2773
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,590
| 179,179
|
22867
|
Discharge summary
|
report
|
Admission Date: [**2118-8-31**] Discharge Date: [**2118-9-6**]
Date of Birth: [**2042-9-29**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2118-9-2**] Three Vessel Coronary Artery Bypass Grafting utilizing
the left internal mammary artery to LAD, and vein grafts to
Ramus and PDA.
History of Present Illness:
Mr. [**Known lastname 6339**] is a 75 year old male with known coronary disease.
During evaluation for myelodysplastic anemia, he noted
significant shortness of breath and worsening fatiuge. He
subsequently underwent cardiac cathterization which revealed 50%
left main lesion and severe three vessel coronary artery
disease. He was urgently transferred to the [**Hospital1 18**] for further
evaluation and treatment.
Past Medical History:
Coronary Artery Disease, s/p PCI with [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] [**2114**]
History of Myocardial Infarction
Type II Diabetes Mellitus
COPD, Pulmonary Hypertension
Chronic Renal Insufficiency
Anemia, Myelodysplastic Disease
History of Atrial Fibrillation/Flutter
Sick Sinus Syndrome, s/p Pacemaker Implantation
Osteoarthritis
History of Renal Calculi - s/p Lithotripsy
History of Skin Cancer - s/p removal
Bladder Cancer - s/p Prostatectomy, TURP
Prior Knee Surgery
Social History:
Retired engineer. 75 pack year history of tobacco. Admits to [**12-8**]
glasses of wine per day.
Family History:
Father, MI at age 61. Sister with atrial fibrillation.
Physical Exam:
Admit PE:
vitals - bp 138-149/70-74, hr 64
general - elderly male in no acute distress
skin - multiple nevi
heent - oropharynx benign, PERRL, sclera anicteric
neck - supple, no JVD, no carotid bruits
chest - lungs clear bilaterally
heart - regular rate and rhythm, normal s1s2, no murmur
abd - benign
ext - warm, no edema
neuro - nonfocal
pulses - 2+ distally bilaterally
Pertinent Results:
[**2118-9-1**] TTE:
The left atrium is mildly dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is mild regional left
ventricular systolic dysfunction with distal septal hypokinesis.
The remaining segments contract normally (LVEF = 50%). Right
ventricular chamber size and free wall motion are normal. There
is a minimally increased gradient consistent with minimal aortic
valve stenosis. The mitral valve leaflets are mildly thickened.
There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. Moderate [2+] tricuspid regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is no pericardial effusion.
[**2118-9-1**] Carotid:
Mild calcified plaques in the common and internal carotid
arteries bilaterally with less than 40% stenosis on both sides.
[**2118-9-2**] Intraop TEE:
PREBYPASS
1. The left atrium is moderately dilated. Mild spontaneous echo
contrast is seen in the body of the left atrium. No thrombus is
seen in the left atrial appendage. No atrial septal defect of
PFO is seen by 2D or color Doppler.
2. Left ventricular wall thicknesses and cavity size are normal.
There is mild regional left ventricular systolic dysfunction
with hypokinesis seen in inferioseptal and septal walls.
3. The aortic arch is mildly dilated. There are simple atheroma
in the aortic arch. The descending thoracic aorta is mildly
dilated. There are complex (>4mm) atheroma in the descending
thoracic aorta.
4. The aortic valve leaflets (3) are mildly thickened. There is
mild aortic valve stenosis (area 1.2-1.9cm2).
5. The mitral valve leaflets are mildly thickened. Mild to
moderate ([**12-8**]+) mitral regurgitation is seen.
POSTBYPASS
1. Patient is on phenylephrine and epinephrine infusions
2. Left ventricular function is improved. EF 55%. Inferioseptal
and septal walls are improved but patient is on inotropes.
3. Right ventricular functions is improved, although on inotrope
infusion.
4. Aortic contour is smooth after decannulation.
CAROTID U/S
IMPRESSION: Mild calcified plaques in the common and internal
carotid
arteries bilaterally with less than 40% stenosis on both sides.
This is a
baseline examination at the [**Hospital1 18**].
[**2118-9-5**] 05:27AM BLOOD WBC-9.6 RBC-2.62* Hgb-8.9* Hct-25.9*
MCV-99* MCH-33.9* MCHC-34.2 RDW-15.8* Plt Ct-183
[**2118-9-6**] 05:45AM BLOOD PT-13.9* INR(PT)-1.2*
[**2118-9-5**] 05:27AM BLOOD Plt Ct-183
[**2118-8-31**] 05:17PM BLOOD WBC-7.6 RBC-3.47* Hgb-11.5* Hct-34.5*
MCV-100*# MCH-33.0* MCHC-33.2 RDW-15.3 Plt Ct-239
[**2118-8-31**] 05:17PM BLOOD Plt Ct-239
[**2118-8-31**] 05:17PM BLOOD PT-15.8* PTT-26.3 INR(PT)-1.4*
[**2118-9-5**] 05:27AM BLOOD Glucose-137* UreaN-33* Creat-1.2 Na-135
K-3.6 Cl-101 HCO3-25 AnGap-13
[**2118-8-31**] 05:17PM BLOOD Glucose-156* UreaN-33* Creat-1.1 Na-139
K-4.0 Cl-97 HCO3-33* AnGap-13
[**2118-8-31**] 05:17PM BLOOD ALT-18 AST-24 CK(CPK)-24* AlkPhos-81
Amylase-51 TotBili-0.5
[**2118-8-31**] 05:17PM BLOOD Lipase-25
[**2118-9-5**] 05:27AM BLOOD Calcium-9.2 Phos-3.1 Mg-2.1
[**2118-8-31**] 05:17PM BLOOD %HbA1c-5.9
Brief Hospital Course:
Mr. [**Known lastname 6339**] was admitted to the cardiac surgical service and
underwent routine preoperative testing which included carotid
ultrasound, and echocardiogram - see result section. He remained
stable on intravenous Heparin. Workup was unremarkable and he
was cleared for surgery. On [**9-2**], Dr. [**Last Name (STitle) **]
performed coronary artery bypass grafting surgery. For surgical
details, please see operative report. Following the operation,
he was brought to the CVICU for invasive monitoring. Within 24
hours, he awoke neurologically intact and was extubated without
incident. Low dose beta blockade, lasix, Plavix and Warfarin
were resumed. He maintained stable hemodynamics and transferred
to the SDU on postoperative day one. Physical therapy worked
with him on strength and mobility. He was ready for discharge
home with VNA and physical therapy post operative day 4.
Medications on Admission:
Warfarin - stopped [**8-27**], Digoxin 0.25 qd, Plavix - stopped [**8-30**],
Atenolol 75 [**Hospital1 **], Avalide 150/12.5 qd, Mg Oxide 400 [**Hospital1 **],
Allopurinol 300 qd, Lupron injection, Lipitor 10 qd, Lasix 40
MWF and 20 TuThSat, KCL 20 MWF, Aspirin 81 qd, Spiriva daily,
Folate 1 qd, Nitro patch, Zithromax
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
[**Hospital1 **]:*60 Capsule(s)* Refills:*0*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
[**Hospital1 **]:*30 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
[**Hospital1 **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
[**Hospital1 **]:*60 Tablet(s)* Refills:*0*
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Hospital1 **]:*30 Tablet(s)* Refills:*0*
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Hospital1 **]:*30 Tablet(s)* Refills:*0*
7. Warfarin 2.5 mg Tablet Sig: INR goal 2.0-2.5 Tablets PO once
a day: 2.5mg wednesday with lab draw [**9-8**] results to MWHC
coumadin clinic for further dosing.
[**Month/Day (2) **]:*90 Tablet(s)* Refills:*0*
8. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day.
[**Month/Day (2) **]:*30 Tablet(s)* Refills:*0*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
if increased edema or weight please contact physician.
[**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*0*
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*0*
11. Irbesartan 150 mg Tablet Sig: One (1) Tablet PO once a day.
[**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*0*
12. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
[**Name Initial (NameIs) **]:*qs Cap(s)* Refills:*0*
13. Atenolol 50 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
[**Name Initial (NameIs) **]:*90 Tablet(s)* Refills:*0*
14. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
[**Name Initial (NameIs) **]:*50 Tablet(s)* Refills:*0*
15. MagOx 400 mg Tablet Sig: One (1) Tablet PO once a day.
[**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA, [**Hospital1 1559**]
Discharge Diagnosis:
Coronary Artery Disease - s/p CABG
Type II Diabetes Mellitus
Aortic stenosis
COPD, Pulmonary Hypertension
Chronic Renal Insufficiency
Renal Calculi
Osteoarthritis
Neuropathy
Anemia, Myelodysplastic Disease
Atrial Fibrillation/Flutter
Sick Sinus Syndrome, s/p Pacemaker Implantation
Discharge Condition:
Good
Discharge Instructions:
1)Please shower daily. Wash incisions with soap and water. Do
not apply creams, lotions or ointments to surgical incisions.
2)No driving for at least one month.
3)No lifting more than 10 lbs for at least 10 weeks from
surgical date.
4)Please contact cardiac [**Name2 (NI) 5059**] if you develop fevers and/or
any signs of wound infection (redness, drainage), [**Telephone/Fax (1) 170**].
Followup Instructions:
Please call to schedule appointments
Dr. [**Last Name (STitle) **] in 4 weeks
Dr. [**Last Name (STitle) 59121**] in 1 week
Dr. [**Last Name (STitle) 1655**] or Young in [**1-9**] weeks
Wound check - please schedule with RN [**Telephone/Fax (1) 3071**]
PT/INR for atrial fibrillation goal INR 2.0-2.5 - results to
coumadin clinic at [**Hospital1 **] heart center [**Telephone/Fax (2) **]
First draw thrusday [**9-8**]
Completed by:[**2118-9-6**]
|
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icd9cm
|
[
[
[]
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[
"36.12",
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"37.12",
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icd9pcs
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[
[
[]
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8504, 8577
|
5152, 6051
|
297, 444
|
8903, 8910
|
2004, 5129
|
9346, 9793
|
1541, 1597
|
6420, 8481
|
8598, 8882
|
6077, 6397
|
8934, 9323
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1612, 1985
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238, 259
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472, 890
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912, 1411
|
1427, 1525
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,806
| 147,447
|
23089
|
Discharge summary
|
report
|
Admission Date: [**2134-12-2**] Discharge Date: [**2134-12-2**]
Date of Birth: [**2064-3-12**] Sex: F
Service: [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: The patient is an unfortunate 70
year old woman that underwent a coronary artery bypass graft
times two by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**2134-11-15**]. She did
remarkably well and was eventually discharged home about one
week later postoperatively. Once at home, she developed
diarrhea and abdominal pain. For this problem, she presented
to [**Hospital3 1280**] Hospital where she was initially treated for a
question of Clostridium difficile infection. Unfortunately,
she became progressively ill and continued to deteriorate.
Subsequently she was found to have a pulmonary embolism and
she was initially treated with intravenous Heparin. The
patient became thrombocytopenic and she was diagnosed with
HIT clinically but no antibodies were checked. Subsequently,
she was anticoagulated with Hirudin but unfortunately
developed a massive upper gastrointestinal bleed with
significant hemodynamic instability. She was intubated and
transferred to the Medical Intensive Care Unit at [**Hospital3 1280**]
Hospital where over the course of the next week developed
worsening renal failure as well as liver failure with a
creatinine of 3.0, almost no urine output, and liver function
tests in the 7,000s. She was also coagulopathic with an INR
of 8.0. She remained significantly acidotic with a lactate
of 20. The medical team had made arrangements to transfer
this patient to the [**Hospital1 69**] but
her hemodynamic instability precluded this from happening.
Finally on [**2134-12-2**], she was stable enough transiently and
off her Levophed and vasopressin that she was transferred to
the [**Hospital1 69**] for further
management.
HOSPITAL COURSE: Upon arriving to the Intensive Care Unit at
the [**Hospital1 69**], she was back on the
Levophed and vasopressin and her systolic blood pressure
measured by cuff was in the 80s. An A line, Swan catheter
and a dialysis catheter were immediately placed in a joint
effort with the Intensive Care Unit team and the surgical
team that was admitting the patient. Her initial gas upon
arrival was severely acidotic with a pH of 7.04, pCO2 52, pO2
110, bicarbonate 50 and base excess of minus 17 and a lactate
of 24. She was bolused and resuscitated with two liters of
intravenous crystalloid and fresh frozen plasma was ordered.
A duplex ultrasound was obtained and demonstrated flow from
both hepatic arteries and veins as well as a patent portal
vein as it was a major concern that she might have thrombosed
either her hepatic arteries or veins. Kidneys were also
within normal limits in this limited ultrasound study. An
electrocardiogram demonstrated partial intermittent blocks
and cardiology was consulted for a potential pacing wire.
This was decided since the patient was placed on Dopamine and
her heart rate was still in the 50s. Renal was also
consulted in an effort to correct her acidosis and
potentially remove some volume as she had an initial wedge of
26 with pulmonary artery pressures of 50/25 and cardiac
output of 3.0 and an index of 1.7. These numbers were the
opening pressures when the Swan catheter was placed. Despite
the pressors and Dopamine, her pressure remained low. Her
initial hematocrit was 27.0 but subsequently dropped to 24.0
and later to 21.0. She was transfused two units of packed
red blood cells and six units of fresh frozen plasma in an
effort to correct her coagulopathy and to further resuscitate
her with partial and transient improvement of her
hemodynamics. A new arterial blood gas was obtained
revealing persistent acidosis and a new hematocrit of 12.0.
Given her recent coronary artery bypass graft, liver failure,
renal failure, as well as her severe coagulopathy and
acidosis, the family was informed of the severity of this
patient's condition and they requested to make her comfort
measures only. Postmortem was offered to the family and they
agreed for that. Shortly after pressor support was
withdrawn, the patient expired and was pronounced dead at
6:32 p.m. on [**2134-12-2**]. Dr. [**First Name (STitle) **], Dr. [**Last Name (STitle) **] and the
family were informed of the event and the medical examiner
waived the case.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**]
Dictated By:[**Last Name (NamePattern1) 26130**]
MEDQUIST36
D: [**2134-12-3**] 19:08:01
T: [**2134-12-4**] 10:21:16
Job#: [**Job Number 59470**]
cc:[**Last Name (NamePattern1) 26130**]
|
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icd9cm
|
[
[
[]
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[
"38.91",
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icd9pcs
|
[
[
[]
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1888, 4686
|
183, 1870
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,292
| 108,644
|
8805
|
Discharge summary
|
report
|
Admission Date: [**2136-1-24**] Discharge Date: [**2136-1-28**]
Date of Birth: [**2078-7-2**] Sex: M
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
Admit for elective portal venogram/thrombectomy and attempted
TIPS procedure.
Major Surgical or Invasive Procedure:
Transcutaneous Intrahepatic Porto-Systemic Shunt Placement
1) Portal venogram
2) Attempted TIPS procedure
History of Present Illness:
57 y/o M with hx EtOH cirrhosis, portal hypertension and
gastroesophageal varices who presents for evaluation of portal
vein thrombectomy or TIPS placement. The patient has had a 14-15
yr history of liver disease in the setting of heavy drinking
(8-9 beers daily) since teenage. He has been completely
abstinent of EtOH since his diagnosis (14-15 years). He has had
a 5 yr hx of ascites, and reports recent acceleration of ascites
accumulation, with SOB being a prominent symptom of the
accumulated ascites. His SOB resolves upon a therapeutic
paracentesis; most recent paracentesis performed at [**Hospital1 **] [**12-2**] removed 4L fluid. On CT [**2135-12-14**] his known main
portal vein thrombus x 10 years was found to have extended into
L portal and splenic veins. He also has gastroesophageal varices
with hx of bleeding which presented as dehydration and
lightheadedness with no melena/hematochezia/hematemesis; last
major bleed in [**2125**] with ICU admission but no recent bleeding
episodes, last banded by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 15532**] ([**Hospital3 **])
summer [**2134**].
ROS: Denies any jaundice, confusion or mental status changes,
myoclonus, melena, hematochezia, hematemesis, dysuria,
hematuria. Reports one episode of emesis and lightheadedness
this morning due to "anxiety" before leaving for the hospital.
Past Medical History:
1. Cirrhosis, EtOH related.
2. Portal hypertension gastropathy with gastroesophageal
varices.
3. Question acute renal failure with previous admission.
4. Borderline diabetes mellitus 2, diet control only.
5. Hypertension, on medication.
6. Silent MI discovered on chemical stress test at [**Hospital1 2519**]
7. Rheumatoid arthritis, previously on Remicade stopped 1 month
ago
8. C. diff enterocolitis.
9. Chronic anemia.
10. Anxiety.
11. Bipolar disorder.
12. Asthma.
Past Surgical History:
1. ORIF, left femur 9/[**2134**].
2. Total hip replacement bilaterally.
3. Total knee replacement bilaterally, [**2118**], [**2120**].
Social History:
Patient states that he quit smoking approximately seven weeks
ago, previously 3ppd hx for 45 years. He denies any alcohol for
the past 14 years. He also denies any recreational drug use.
Physical Exam:
Exam on initial admission post-portal venogram, [**2136-1-24**]:
VS: T 98.9, BP 106/74, HR 79, RR 16, O2 Sat 100% RA.
GEN: Pleasant, talkative middle-aged male lying in bed in NAD
without tachypnea.
NEURO: A+O X 3, appropriate, no asterixis or confusion.
SKIN: Spider angiomata on face, [**12-27**] erythematous scaly lesions
on scalp, no jaundice, no palmar erythema.
HEENT: PERRL (4->3mm bilat), EOMI, sclerae anicteric. MMM, OP
clear, tongue midline.
NECK: Supple, no JVD.
CV: RRR, no M/R/G.
PULM: fine end-inspiratory crackles LLL, otherwise clear.
ABD: distended with caput medusae, somewhat tense, +BS,
+splenomegaly, 3x IR entry sites on R flank clean and dry.
EXT: no edema, poor perfusion in feet but +dopplers bilaterally
in PACU.
Exam on ICU Admission:
GEN: Intubated, sedated
SKIN: Spider angiomata on face, [**12-27**] erythematous scaly lesions
on scalp, no jaundice, no palmar erythema.
HEENT: sclerae anicteric. MMM, OP clear, ET tube inplace
NECK: Supple, no JVD.
CV: RRR, no M/R/G.
PULM: upper airway sounds
ABD: distended with caput medusae, soft +BS, +splenomegaly, 3x
IR entry sites on R flank clean and dry.
EXT: no edema, palp pulses
Pertinent Results:
LABS:
[**2136-1-24**]:
139 | 101 | 28
---------------< 153
3.9 | 34 | 1.3
8.7
4.5 >-----< 83
25.9
PT 14.1, PTT 21.9, INR 2.1
Albumin 3.2, Ca 8.6 Phos 3.6 Mg 2.1
Lab results post TIPS, [**2136-1-26**]:
139 | 106 | 27
---------------< 167
4.1 | 27 | 1.1
10.8
9.1 >-----< 115
30.3
PT 13.6, PTT 22.4, INR 1.2
Retic count 1.6%, Fibrinogen 487
[**2136-1-24**] Portal Venogram Prelim report:
Portal venogram demonstrated the portal vein was completely
occluded with a collateral vein connecting the splenic vein to
the right and the left portal veins. This collateral vein is in
good size and with no pressure gradient drop from the splenic
vein to the collateral and further to the left and right portal
veins. No clots were visualized inside the collateral vein a
highpressure was measured inside the collateral vein, which was
36mmHg. A TIPS procedure should be evaluated for the patient.
[**2136-1-26**] TIPS procedure Preliminary provisional report:
1. Unsuccessful TIPS procedure. The patient's systolic blood
pressure
dropped into the mid 70s and due to two capsular perforations
and this being an elective case, the procedure was terminated.
2. 3 liters of bloody ascites fluid removed.
[**2136-1-26**] Abd/Pelvis CT:
1. Ascites, slightly increased in comparison to [**2135-12-14**], with
contrast layering dependently related to attempted TIPS
placement. 2. No active extravasation seen on post-contrast
imaging. 3. Unchanged cirrhosis and portal hypertension. 4.
Extrahepatic and probable intrahepatic locules of gas associated
with the posterior segment of the right lobe of the liver. 5.
Splenic, superior mesenteric and portal venous thrombosis is
better evaluated on the previous CT.
Brief Hospital Course:
57 y/o M with hx EtOH cirrhosis, portal hypertension and
gastroesophageal varices s/p portal venogram with unsuccessful
thrombectomy [**2136-1-24**], s/p attempted TIPS complicated by bleeding
and hypotension [**2136-1-26**].
.
Patient was initially admitted after elective portal venogram
and evaluation for thrombectomy of portal vein thrombus on [**1-24**].
This was unsuccessful, however, 1.7L ascites was removed.
Patient was then admitted for observation awaiting elective TIPS
eval and procedure on [**1-26**].
.
On [**1-25**], his hematocrit was found to drop from a preop baseline
of 30 to a low of 22; he remained asymptomatic without
lightheadedness, tachycardia or significant hypotension. He then
received 2U PRBCs [**1-25**] pm, which increased his Hct to 29-30 the
next day.
.
On [**1-26**], he was taken by Interventional Radiology for a elective
TIPS eval/placement. For detailed report by IR see Pertinent
Results. Roughly 3 L of bloody ascites was removed prior to the
procedure. Briefly, during the procedure contrast was observed
to extravasate along the track/tract made during the prior
procedure on [**1-25**]; up to 5 passes were made in an attempt to
place TIPS device, but this was complicated by repeated bouts of
hypotension to SBP of 90s and finally 70s. At this point the
procedure was aborted; the patient was started on a low
continuous dose of neosynephrine and transferred to the MICU for
observation and management. Surgery was consulted. CT [**2136-1-26**]
did not show evidence of a active bleed around the liver or in
the abdomen.
.
Per the IR team notes online, contrast injection revealed
extrahepatic pooling lateral to liver likely from transhepatic
access. In addition, the IR team speculates that there is likely
a second capsular perforation inferiorly from one of today's
passes. RA pressure were noted to be 16 mmHg without an IVC
gradient.
MICU Course:
[**2136-1-26**]: The patient developed SBPs to the 70s during failed TIPS
procedure. He was given 2 units of PRBCs prior during the
procedure and in the PACU, intubated, and placed on
neosynephrine. After intubation and on proprofol drip, SBPs were
in 100s on low dose neo. In the ICU, Propofol/neo were weaned.
Antihypertensives and diuretics were held and hematocrit was
monitored closely. His Hct stabilized at 30, and remained stable
throughout HD2. As propofol was weaned, the patient awoke and
self-extubated overnight. His respiratory status was stable
throughout the day post-extubation. His pressures improved
overnight in the ICU and were stable with SBPs 110-120s upon
discharge to the floor. Per IR recommendations, the patient was
given prophylactic ceftriaxone.
On [**2136-1-28**], patient was called out to the floor from the MICU. As
above, BP improved overnight and Hct was stable. On the floor,
his BP was stable (100s - 120s) although lower than his usual
baseline (130s) hence his BP meds were held. He was instructed
not to restart his diltiazem and metoprolol until he speaks to
his PCP. [**Name10 (NameIs) **] Hct continued to be stable at 29-30 with no sign or
symptom of cardiovascular instability or GI bleed; he was
discharged with instructions for followup in the next 2 weeks
with Dr. [**Last Name (STitle) **] and his PCP.
Medications on Admission:
1. Advair 1 puff daily
2. Spironolactone 50mg daily
3. Colace 100mg daily
4. Diltiazem 180mg daily
5. Folate
6. Lasix 40mg [**11-25**] daily
7. Metoprolol XL 25mg daily
8. Prednisone 5mg [**Hospital1 **]
9. Pantoprazole 40mg [**Hospital1 **]
10. Trazodone 100mg QHS
11. Vicodin 5/500 Q6H PRN
12. Lithium 300mg daily
13. Vitamin D2 50,000U qFriday
14. Lexapro 20mg daily
15. "IV iron" likely ferrelecit
* Remicade for RA stopped 1 month ago for liver intervention.
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Tablet(s)
2. Prednisone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
[**11-25**] Disk with Devices Inhalation [**Hospital1 **] (2 times a day).
5. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 6 days: Please continue to take this medication until it is
finished.
Disp:*12 Tablet(s)* Refills:*0*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
7. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO QFRIDAY ().
8. Docusate Sodium 50 mg/5 mL Liquid Sig: Two (2) PO once a
day.
9. Spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a
day.
10. Lasix 40 mg Tablet Sig: 1-2 Tablets PO once a day.
11. Trazodone 100 mg Tablet Sig: One (1) Tablet PO at bedtime.
12. Vicodin 5-500 mg Tablet Sig: 1-2 Tablets PO Q6H:PRN as
needed for pain.
13. Lithium Carbonate 300 mg Capsule Sig: One (1) Capsule PO
once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
1) Liver cirrhosis secondary to alcohol.
2) Portal gastropathy
3) Portal hypertension
Discharge Condition:
Afebrile, ambulating, blood pressures stable, no
lightheadedness, dizziness, tachycardia, no abdominal pain at
rest.
Discharge Instructions:
You were admitted for an evaluation for a procedure called TIPS,
which was aimed at reducing the likelihood of bleeding from the
distended veins in your stomach and esophagus, as well as
reducing the fluid in your abdomen. However, the procedure could
not be successfully performed due to intraoperative
complications where there was a small amount of bleeding around
your liver with a drop in your blood pressure. You were given 4
units of blood during your stay due to low blood counts.
IMPORTANT: Due to your current low blood pressure, we have
stopped the following medications. PLEASE DO NOT TAKE THESE
MEDICATIONS:
1) Diltiazem (Cardizem)
2) Metoprolol (Toprol)
You should see your PCP or other doctor in [**12-27**] days after
discharge for an evaluation before restarting both these
medications.
Please continue to take all your other medications as prescribed
previously. We have also added a new medication called
cefpodoxime which is an antibiotic that you have to take twice a
day for 6 days. Please finish the entire course of this
medication.
If you experience any dizziness, lightheadedness, fainting
spells, increase in your abdominal pain, nausea/vomiting or find
blood in your stool, urine or vomit, notice black tarry stools
or feel unwell, please seek medical help as soon as possible.
Please call the liver center for an appointment with Dr. [**Last Name (STitle) **]
(see below)
Followup Instructions:
It is very important that you follow up with these providers:
1) Dr. [**First Name (STitle) **] [**Name (STitle) **], your liver doctor here at [**Hospital1 18**] within 2
weeks. Call ([**Telephone/Fax (1) 1582**] to schedule an appointment.
2) Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 18323**] during the next
week about your blood pressure medications.
3) Please follow up with your liver doctors [**First Name (Titles) **] [**Hospital3 4107**]
as soon as possible.
Completed by:[**2136-1-28**]
|
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"458.29",
"V43.65",
"V43.64",
"296.80",
"571.2",
"E878.8",
"300.00",
"998.2",
"790.29",
"789.59",
"999.9",
"572.3",
"412",
"714.0",
"456.8",
"493.90",
"V12.51",
"E870.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.64",
"99.04",
"38.93",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
10584, 10590
|
5666, 8926
|
346, 454
|
10720, 10839
|
3906, 5643
|
12292, 12837
|
9440, 10561
|
10611, 10699
|
8952, 9417
|
10863, 12269
|
2372, 2508
|
2728, 3887
|
229, 308
|
482, 1857
|
1879, 2349
|
2524, 2713
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,242
| 174,308
|
42211+58507
|
Discharge summary
|
report+addendum
|
Admission Date: [**2106-9-25**] Discharge Date: [**2106-10-11**]
Date of Birth: [**2028-9-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
morphine
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
[**2106-9-25**] emergency repl. ascending and arch aorta
[**2106-9-27**] chest closure
History of Present Illness:
78 year old retired urologist
presented to OSH complaining of 40 minutes of chest pain that
radiated to his back and throat. Per report from OSH, ECG
notable for inferior and lateral ST changes concerning for
ischemia and pt not currently in AFib. CTA done at OSH revealed
type A Aortic dissection. He was medflighted into [**Hospital1 18**]. Dr.[**Last Name (STitle) **]
reviewed the CTA and Mr.[**Known lastname **] was taken emergently to the
operating room.
Past Medical History:
Chronic AFib->on Pradaxa, HTN,
? hx of
cardiac dz per OSH HPI, prostate cancer.
Social History:
has family in vicinity
? girlfriend
Physical Exam:
pt was seen emergently-VS noted
Pulse: 64 Resp: O2 sat:
B/P 104/65
Height: 74" Weight: ? 90 kg
Five Meter Walk Test #1_______ #2 _________ #3_________
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI []
Neck: Supple [x] Full ROM []
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [] non-distended [] non-tender [] bowel sounds +
[]
Extremities: Warm [x], well-perfused [] Edema [] _____
Varicosities: None []
Neuro: Grossly intact [x]
Pulses:
Femoral Right: Left:
DP Right:2+ Left:2+ bounding DP pulses(B)
PT [**Name (NI) 167**]: Left:
Radial Right: Left:
Carotid Bruit Right: Left:
Pertinent Results:
Pe-Bypass:
No spontaneous echo contrast is seen in the left atrial
appendage.
Overall left ventricular systolic function is low normal (LVEF
50-55%).
Right ventricular chamber size and free wall motion are normal.
The ascending aorta is severely dilated. The descending thoracic
aorta is mildly dilated. A mobile density is seen in the
ascending and descending aorta, and across the arch, consistent
with an intimal flap/aortic dissection. The aortic valve
leaflets (3) are mildly thickened. There is no aortic valve
stenosis. Mild aortic regurgitation is seen. The flap overlies
the aortic valve enough that the short axis window is poor, and
coronary flow cannot be determined. The STJ looks intact.
Trivial mitral regurgitation is seen.
There is no pericardial effusion.
Post-CPB:
The patient is paced, on no inotropes.
Preserved biventricular systolic fxn.
There is a tube graft in the ascending aorta. 1+ AI.
Descending aorta unchanged. Other parameters as pre-bypass.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2106-10-7**] 13:18
Brief Hospital Course:
Mr.[**Known lastname **] was Medflighted in from [**Hospital3 **] and taken emergently
to OR for Type A dissection repair with Dr. [**Last Name (STitle) **]. He underwent
Resection of ascending aortic dissection with hemi-arch
replacement under circulatory arrest. Cross clamp time: 99
minutes.Pump time:170 minutes.Circulatory arrest time:26
minutes. He had been on Pradaxa at home and had significant
coagulopathy postoperatively requiring his chest to be left
open. On [**2106-9-27**] his bleeding has stopped, and he was brought
back to the operating room for closure of the sternum. Please
refer to operative reports for further surgical details.
Mr.[**Known lastname **] [**Last Name (Titles) 8337**] the operations well and was transferred back
to the CVICU intubated and sedated in stable condition on
titrated phenylephrine and propofol drips. Postoperatively, he
developed renal failure with creatinine peaking at 5.8. Renal
service was consulted. His creatnine trended down during
admission. Chest tubes and pacing wires removed per protocol. He
was gently diuresed toward his preop weight. He awoke
neurologically intact and was extubated on POD #4. He had
intermittent confusion over the next few days. His mental status
cleared and he was transferred to the step down unit on POD # 12
to begin increasing his activity level. Physical Therapy was
consulted for evaluation of strength and mobility. His chronic
atrial fibrillation was not well rate controlled on maximum dose
of Diltiazem and Rhythmol alone. Beta-blocker was added to his
regimen, as previously the patient deferred beta-blocker due to
his feeling lethargic after taking it. A Non-selective
beta-adrenoreceptor was initiated in lieu of Lopressor. His
anticoagulation was resumed with Coumadin. The remainder of his
postoperative course was essentially uneventful. His Creatnine
continued to trend down and he was cleared to [**Hospital1 **] [**Hospital3 **]
rehab on POD#15. All follow up appointments were advised.
(stopped [**10-10**])
Medications on Admission:
Nexium 40(1),lipitor 40 mg 3x/weekly.,
Propafenone HCL 150mg (4), Pradaxa 150 (2), Levitra prn
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Hospital3 **] ([**Hospital **]
Hospital of [**Location (un) **] and Islands)
Discharge Diagnosis:
acute Type A aortic dissection s/p repl. ascending and arch
aorta
acute renal failure
Chronic AFib->was on Pradaxa s/p ablation
hypertension
hx of cardiac dz per OSH HPI
prostate cancer
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal and R axillary - healing well, no erythema or drainage
Edema ................
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call 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 have been scheduled for the following appts:
Surgeon Dr. [**Last Name (STitle) **] Thursday [**11-11**] @ 1:15 pm [**Hospital Ward Name **] [**Hospital Unit Name **]
Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (cardiologist) [**Telephone/Fax (1) 19666**] [**10-25**] @ 11:00 AM
Please call to schedule appointments with your
Primary Care Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in 4 weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication A Fib
Goal INR 2.0-2.5
First draw day after discharge
*** please arrange for coumadin/INR f/u with PCP or cardiologist
prior to discharge from rehab***
Completed by:[**2106-10-10**] Name: [**Known lastname 14407**],[**Known firstname **] J Unit No: [**Numeric Identifier 14408**]
Admission Date: [**2106-9-25**] Discharge Date: [**2106-10-11**]
Date of Birth: [**2028-9-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
morphine
Attending:[**First Name3 (LF) 135**]
Addendum:
Dr. [**Known lastname **] remained inpatient for an additional twenty-four hours
to monitor his response to beta blockade. He tolerated this
well, and was discharged to [**Hospital1 **] of [**Location (un) 776**] and Islands on
POD 16. At the time of discharge he was alert and oriented x 3
without confusion. The wounds were healing and pain was
controlled with Tylenol.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
[**2106-9-25**] emergency repl. ascending and arch aorta
[**2106-9-27**] chest closure
Past Medical History:
Chronic AFib->on Pradaxa, HTN,
? hx of
cardiac dz per OSH HPI, prostate cancer.
Pertinent Results:
[**2106-10-11**] 06:47AM BLOOD PT-18.1* INR(PT)-1.6*
[**2106-10-10**] 04:40AM BLOOD PT-15.8* INR(PT)-1.4*
[**2106-10-9**] 07:17AM BLOOD PT-16.1* INR(PT)-1.4*
[**2106-10-8**] 06:05AM BLOOD PT-19.1* INR(PT)-1.7*
[**2106-10-7**] 02:49AM BLOOD PT-27.3* PTT-38.6* INR(PT)-2.6*
[**2106-10-6**] 01:59AM BLOOD PT-28.8* PTT-40.6* INR(PT)-2.8*
[**2106-10-5**] 03:20AM BLOOD PT-29.0* PTT-42.6* INR(PT)-2.8*
[**2106-10-4**] 02:00AM BLOOD PT-27.2* PTT-40.6* INR(PT)-2.6*
[**2106-10-3**] 02:22AM BLOOD PT-28.4* PTT-38.4* INR(PT)-2.7*
[**2106-10-2**] 04:24AM BLOOD PT-21.8* INR(PT)-2.0*
[**2106-10-1**] 04:40AM BLOOD PT-17.2* PTT-31.6 INR(PT)-1.5*
[**2106-9-30**] 03:13AM BLOOD PT-12.0 PTT-29.9 INR(PT)-1.0
[**2106-9-29**] 02:53AM BLOOD PT-11.5 PTT-30.9 INR(PT)-1.0
[**2106-9-27**] 09:47AM BLOOD PT-12.0 PTT-36.2* INR(PT)-1.0
[**2106-9-27**] 02:13AM BLOOD PT-12.1 PTT-34.6 INR(PT)-1.0
Discharge Medications:
1. propafenone 150 mg Tablet [**Month/Day/Year 1649**]: One (1) Tablet PO QID (4 times
a day).
2. aspirin 81 mg Tablet, Chewable [**Month/Day/Year 1649**]: One (1) Tablet, Chewable
PO DAILY (Daily).
3. docusate sodium 100 mg Capsule [**Month/Day/Year 1649**]: One (1) Capsule PO BID (2
times a day) for 2 weeks.
4. atorvastatin 20 mg Tablet [**Month/Day/Year 1649**]: One (1) Tablet PO DAILY
(Daily).
5. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) 1649**]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
6. warfarin 1 mg Tablet [**Last Name (STitle) 1649**]: MD to order daily dose Tablet PO
DAILY (Daily).
7. acetaminophen 325 mg Tablet [**Last Name (STitle) 1649**]: Two (2) Tablet PO Q4H (every
4 hours) as needed for temperature >38.0.
8. bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) 1649**]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
9. lactulose 10 gram/15 mL Syrup [**Last Name (STitle) 1649**]: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
10. diltiazem HCl 180 mg Capsule, Extended Release [**Last Name (STitle) 1649**]: Three
(3) Capsule, Extended Release PO DAILY (Daily).
11. hydralazine 25 mg Tablet [**Last Name (STitle) 1649**]: Two (2) Tablet PO Q6H (every 6
hours).
12. carvedilol 12.5 mg Tablet [**Last Name (STitle) 1649**]: One (1) Tablet PO BID (2
times a day).
13. furosemide 40 mg Tablet [**Last Name (STitle) 1649**]: One (1) Tablet PO once a day
for 1 weeks.
14. potassium chloride 20 mEq Tablet, ER Particles/Crystals [**Last Name (STitle) 1649**]:
One (1) Tablet, ER Particles/Crystals PO once a day for 1 weeks.
15. Outpatient Lab Work
Labs: PT/INR for Coumadin ?????? indication A Fib
Goal INR 2.0-2.5
First draw [**2106-10-12**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 41**] - [**Hospital3 709**] ([**Hospital **]
Hospital of [**Location (un) 776**] and Islands)
Discharge Diagnosis:
acute Type A aortic dissection s/p repl. ascending and arch
aorta
acute renal failure
Chronic AFib->was on Pradaxa s/p ablation
hypertension
hx of cardiac dz per OSH HPI
prostate cancer
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with assistance
Incisional pain managed with oral analgesics
Incisions:
Sternal and R axillary - healing well, no erythema or drainage
Edema 1+
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) 1477**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 1477**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You have been scheduled for the following appts:
Surgeon Dr. [**Last Name (STitle) **] Thursday [**11-11**] @ 1:15 pm [**Hospital Ward Name **] [**Hospital Unit Name **]
Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (cardiologist) [**Telephone/Fax (1) 14409**] [**10-25**] @ 11:00 AM
Please call to schedule appointments with your
Primary Care Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12223**] in 4 weeks
Recommended Renal follow up, please call to make an appointment
#[**Telephone/Fax (1) 13670**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 1477**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication A Fib
Goal INR 2.0-2.5
First draw [**2106-10-12**]
*** please arrange for coumadin/INR f/u with PCP or cardiologist
prior to discharge from rehab***
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 137**] MD [**MD Number(2) 138**]
Completed by:[**2106-10-11**]
|
[
"441.01",
"518.5",
"285.1",
"424.1",
"307.9",
"287.5",
"998.11",
"401.9",
"275.3",
"E934.2",
"427.31",
"276.69",
"298.9",
"584.5",
"E878.2",
"286.9",
"V10.46"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"78.41",
"38.45",
"96.72",
"38.93",
"96.6",
"35.11"
] |
icd9pcs
|
[
[
[]
]
] |
11257, 11390
|
3036, 5060
|
8328, 8417
|
11620, 11810
|
8540, 9411
|
12652, 13720
|
9434, 11234
|
11411, 11599
|
5086, 5183
|
11834, 12629
|
1040, 1748
|
8278, 8290
|
404, 868
|
8439, 8521
|
988, 1025
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,087
| 117,796
|
32674
|
Discharge summary
|
report
|
Admission Date: [**2182-1-28**] Discharge Date: [**2182-2-1**]
Date of Birth: [**2125-6-3**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
confusion
Major Surgical or Invasive Procedure:
none
History of Present Illness:
56 year old male with HCV cirrhosis (on transplant list), c/b
portal HTN, hepatic encephalopathy, peripheral edema, and
ascites, managed with diuretics and albumin infusions Q4wks,
transferred from OSH on [**1-28**] with altered mental status
requiring intubation for airway protection. He was admitted to
[**Hospital1 18**] SICU for further management.
.
Upon transfer to [**Hospital1 18**] ED, CT Head/Neck were without acute
process. In the SICU, the patient was treated with lactulose and
rifaximin for presumed hepatic encephalopathy. The patient was
extubated on [**1-29**] after improvement in his mental status. A
precipitant for his symptoms remains unclear as family indicated
strict compliance with medication regimen. Infectious work-up
was initiated, though all cultures have revealed no growth to
date. No diagnostic paracentesis was performed, though only
trace ascites was visualized in the abdomen.
.
The patient had a recent admission ([**Date range (1) 43171**]) for hepatic
encephalopathy. The day prior, he underwent an EGD for which he
was premedicated with fentanyl and versed, believed to have
caused his confusion. His mental status significantly improved
and his home meds were restarted at discharge.
Currently, the patient reports that his thinking is much more
clear. He cannot remember exaclty how he arrived to the hospital
or the circumstances leading up to this admission, but he does
recall being in an ambulance. Per his nurse, he has been
somewhat "off" this evening (still not always making sense), but
this is a significant improvement since admission. He is unsure
what may have precipitated this episode and reiterates that he
was taking his medications as prescribed.
.
On ROS, he denies pain other than his baseline MSK complaints.
He denies any recent fevers/chills or other localizing symptoms.
He does endorse some recent SOB, though this is not bothering
him now. He has no CP or palpitations. He would like his Foley
out; otherwise no urinary complaints. He reports recent [**3-3**] BM
at home with lactulose as is his goal. Sore throat and hoarse
voice since extubation. Otherwise ROS negative.
Past Medical History:
- HCV cirrhosis (VL [**7-/2180**] of 262,000), s/p IFN+ribavirin in
[**2175**], genotype 1
- grade II non-bleeding varices
- thrombocytopenia
- Cervical lumbar herniated discs on chronic narcotics
- Obstructive sleep apnea on home CPAP
- Hematuria status post recent cystoscopy
- Plantar fasciitis
- Meniscal tear status post repair [**2174**]
- Bilateral shoulder injuries
Social History:
He formerly worked for the Mass Water Resource in sewage and as
a painter; currently he is not working (disability paperwork has
just gone through per patient; he states this is more due to
shoulder issues than his liver disease). He lives with his
girlfriend. Denies history of tobacco abuse. He drank approx one
six-pack daily x 10 yrs, but has been sober since [**2158**] when he
was diagnosed with hepatitis C. H/o IV drug use in high school,
but has not used any illicit drugs since that time.
Family History:
His mother died at 82 from pancreatic cancer. Father died at age
78 with type 2 diabetes and colon cancer. The patient is one of
eight children. His sister died of melanoma. Two brothers with
diabetes. One brother with esophageal cancer. Nephew who died
suddenly from a blood clo
Physical Exam:
EXAM ON ADMISSION TO FLOOR
VS: Afebrile, HR 87, BP 136/63, O2 sat 97% on RA
GENERAL: Awake, cooperative with exam. Oriented to place [**Hospital1 18**],
day of week Tuesday, year [**2181**]. Some tangential speech noted and
some difficulty naming month/day. Vocal hoarseness noted.
HEENT: Sclera faintly icteric. PERRL (pupils large at baseline,
5-6mm but reactive), EOMI.
NECK: Supple with low JVP
CARDIAC: RRR, S1 S2 clear and of good quality without murmurs,
rubs or gallops. No S3 or S4 appreciated.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use, moving air fairly well
and symmetrically. CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, non-tender to palpation. No ascites/fluid wave by
exam. No HSM or tenderness.
EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. 2+
DP pulses bilaterally, trace edema (wearing pneumoboots).
.
DISCHARGE EXAM
VS: Tc-96.5 HR 59, BP 116/64, 20 O2 sat 98% on RA
GENERAL: Awake, sitting up in a chair, A+O x3, less confused .
HEENT: Sclera faintly icteric. PERRL (pupils large at baseline,
5-6mm but reactive), EOMI.
NECK: Supple with low JVP
CARDIAC: RRR, S1 S2 clear and of good quality without murmurs,
rubs or gallops.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, non-tender to palpation. No ascites/fluid wave by
exam. No HSM or tenderness.
EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. 2+
DP pulses bilaterally, trace pedal edema
Pertinent Results:
ADMISSION LABS
[**2182-1-28**] 07:15PM BLOOD WBC-4.9 RBC-4.04* Hgb-13.8* Hct-38.7*
MCV-96 MCH-34.1* MCHC-35.6* RDW-14.0 Plt Ct-37*
[**2182-1-28**] 07:15PM BLOOD Neuts-80* Bands-0 Lymphs-12* Monos-8
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2182-1-28**] 07:15PM BLOOD PT-16.6* PTT-31.9 INR(PT)-1.6*
[**2182-1-28**] 07:15PM BLOOD Glucose-127* UreaN-15 Creat-0.7 Na-138
K-4.1 Cl-112* HCO3-19* AnGap-11
[**2182-1-28**] 07:15PM BLOOD ALT-200* AST-155* AlkPhos-137*
TotBili-3.2*
[**2182-1-28**] 07:21PM BLOOD Type-ART pO2-207* pCO2-25* pH-7.48*
calTCO2-19* Base XS--2 Intubat-INTUBATED
[**2182-1-28**] 07:21PM BLOOD Lactate-1.9
[**2182-1-28**] 11:42PM BLOOD Lactate-2.2*
.
DISCHARGE LABS
[**2182-2-1**] 12:55PM BLOOD WBC-3.0* RBC-3.62* Hgb-12.6* Hct-35.5*
MCV-98 MCH-34.8* MCHC-35.5* RDW-13.6 Plt Ct-40*#
[**2182-2-1**] 06:20AM BLOOD PT-16.0* PTT-43.2* INR(PT)-1.5*
[**2182-2-1**] 06:20AM BLOOD Glucose-121* UreaN-16 Creat-0.7 Na-135
K-4.2 Cl-105 HCO3-25 AnGap-9
[**2182-1-31**] 06:40AM BLOOD ALT-160* AST-135* LD(LDH)-237 AlkPhos-77
TotBili-3.1*
.
URINE STUDIES
[**2182-1-28**] 07:15PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.025
[**2182-1-28**] 07:15PM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2182-1-28**] 07:15PM URINE RBC-5* WBC-1 Bacteri-NONE Yeast-NONE
Epi-<1
[**2182-1-28**] 07:15PM URINE CastHy-2*
[**2182-1-28**] 07:15PM URINE Mucous-MOD
[**2182-1-28**] 07:15PM URINE bnzodzp-POS barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
.
MICROBIOLOGY
URINE CULTURE (Final [**2182-1-30**]): NO GROWTH.
GRAM STAIN (Final [**2182-1-29**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS IN SHORT CHAINS.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI.
RESPIRATORY CULTURE (Final [**2182-2-1**]):
SPARSE GROWTH Commensal Respiratory Flora.
MORAXELLA CATARRHALIS. MODERATE GROWTH.
STREPTOCOCCUS PNEUMONIAE. MODERATE GROWTH.
PRESUMPTIVELY PENICILLIN SENSITIVE BY OXACILLIN SCREEN.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STREPTOCOCCUS PNEUMONIAE
|
PENICILLIN G---------- S
.
Blood culture- pending
.
STUDIES
EKG-Baseline artifact. Sinus tachycardia. Cannot rule out ST-T
wave
abnormalities but much of it may be artifact. Since the previous
tracing
of [**2181-7-12**] the rate has increased.
.
CXR
Single supine AP portable view of the chest was obtained.
Endotracheal tube is seen, terminating approximately 5.5 cm
above the level of the carina. There are low lung volumes.
Patchy right upper lobe opacity could relate to low lung volumes
and artifact, although an underlying consolidation can be
present. No additional consolidation is seen. The right
costophrenic angle is not included on the image. There is no
pleural effusion or pneumothorax. The cardiac and mediastinal
silhouettes are likely accentuated by supine, AP technique. No
overt pulmonary edema. Gaseous distention of the colon is
incidentally noted.
.
CT C-SPINE
No acute fracture or malalignment.
.
CT HEAD
No acute intracranial process
.
Abdominal US
IMPRESSION: Scant trace of ascites seen in the abdomen.
.
ECHO
The left atrium is mildly dilated. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%). Right ventricular chamber sizeand wall motion are
normal. The aortic arch is mildly dilated. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is borderline pulmonary artery systolic
hypertension. There is an anterior space which most likely
represents a prominent fat pad.
IMPRESSION: Biatrial enlargement. Normal left ventricular cavity
size and wall thickness with preserved global and regional
biventricular systolic function. No clinically significant
valvular disease. Normal pulmonary artery systolic pressure.
Some late bubbles are appreciated with Valsalva maneuver, but
given that this was after the third injection of saline contrast
it is unlikely that they represent clinically significant
pulmonary shunting.
Brief Hospital Course:
ASSESSMENT AND PLAN: 56M with HCV cirrhosis on the transplant
list who was admitted with an episode of confusion/altered
mental status which required intubation for airway protection.
He was initially admitted to the SICU. Mental status improved
significantly with aggressive lactulose.
.
ACTIVE ISSUES
.
# Altered Mental Status: Mental status changes likely due to
hepatic encephalopathy. As above he required intubation for
airway protection and admission to the SICU. He was started
lactulose and rifaximin with improvement in his mental status.
He was successful extubated and transferred to the floor.
Precipitant was initially unclear (as the patient had no
evidence of active infection or new metabolic derangement).
Blood and urine cultures were negative. The patient only had
minimal ascites making spontaneous bacterial peritonitis
unlikely. However, on further questioning of the patient's
girlfriend reported he has been having a productive cough a few
days prior to presentation. CXR did show a small area
concerning for consolidation and sputum culture grew S.
pneumonae and Moraxella Catarrhalis. He was started on
levofloxacin for a planned 5 day course. His home
cyclobenzaprine and gabapentin were also held. The patient's
mental status was at baseline at the time of discharge. Patient
was instructed to consider a vegetarian diet should instances of
encephalopathy continue.
.
# ? Pneumonia- As above sputum showing moraxella and s. pneumo.
Original CXR concerning for possible RUL infiltrate. Given
patient was having low grade temps, cough, and a positive sputum
cough he was started on levofloxacin for a 5 day course.
.
# Ear pain- Patient complained of R sided ear pain. Otoscopic
exam was unremarkable. It was felt pain might be reflective of
TMJ. Pain was controlled with Tylenol.
.
STABLE ISSUES
.
# HCV Cirrhosis: Patient is on the transplant list. Course has
been complicated by hepatic encephalopathy (on lactulose and
rifaximin), peripheral edema and ascites (managed with diuretics
and albumin infusions Q2wks) and grade varices II (on nadolol).
Patient was continued on his home diuretics, nadolol, lactulose
and rifaximin as above.
.
# Thrombocytopenia: This was felt to likely be due to liver
disease. Platelets remained stable throughout admission.
.
# Muscle Spasms: Patient has a history of muscle spasms for
which he receives infusions of 50 g of IV albumin every 2 weeks.
The patient received this infusion while hospitalized.
.
# Dyspnea- Patient was scheduled for an echo as an outpatient.
He was scheduled of an echo. Therefore study was performed
while the patient was in-house. Echo was notable only for
biatrial enlargement.
.
# OSA: On CPAP at home
.
# Back, shoulder pain: Patient has chronic pain on narcotics,
gabapentin and cyclobenzaprine at home. These medications were
initially held give confusion. His home oxycodone was restarted
with caution on discharge. The patient was instructed to
minimize use of narcotics. Gabapentin and cyclobenzaprine were
held at the time of discharge.
.
TRANSITIONAL ISSUES
- Blood cultures were pending at the time of discharge
- Patient will follow-up at the liver center
- Patient was full code throughout this hospitalization
Medications on Admission:
furosemide 20 mg PO DAILY
gabapentin 300 mg PO QHS.
lactulose 10 gram/15 mL Syrup 30 ML PO twice a day
nadolol 20 mg Tablet PO DAILY
omeprazole 20 mg Capsule daily
oxycodone 5 mg q6h
cyclobenzaprine 5 mg Tablet PO PRN
rifaximin 550 mg Tablet [**Hospital1 **]
spironolactone 200 mg PO DAILY
tolterodine 2 mg Tablet PO DAILY
zinc sulfate 220 mg PO DAILY
Calcium Citrate + D 315-200 mg-unit Tablet tabs Qam 1tab Qpm
multivit-min-FA-lycopen-lutein 0.4-2-250 mg-mg-mcg
magnesium 250 mg Tablet 4 Tablet PO once a day
ensure TID
albumin, human 25 % 1 infusion Intravenous q2 weeks
Discharge Medications:
1. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
3. nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO twice a
day.
5. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. spironolactone 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. oxycodone 5 mg Capsule Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
9. tolterodine 2 mg Tablet Sig: One (1) Tablet PO once a day.
10. zinc sulfate 220 mg Tablet Sig: One (1) Tablet PO once a
day.
11. Calcium Citrate + D 315-200 mg-unit Tablet Sig: One (1)
Tablet PO once a day.
12. multivit-min-FA-lycopen-lutein 0.4-2-250 mg-mg-mcg Tablet
Sig: Four (4) Tablet PO once a day.
13. albumin, human 25 % 25 % Parenteral Solution Sig: Fifty (50)
gram Intravenous q 2 weeks.
14. Ensure Liquid Sig: One (1) PO three times a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Hepatic encephalopathy
Community acquired pneumonia
Hepatitis C Cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 54184**],
It was a pleasure participating in your care while you were
admitted to [**Hospital1 69**]. As you know
you were admitted because you were having confusion. We feel
this was most likely caused by an infection in your lungs
resulting in hepatic encephalopathy. You were given increased
doses of lactulose which improved your mental status. You were
also given antibiotics for the infection in your lungs which you
will need to continue for 3 more days.
We made the following changes to your medications
1. Start levofloxaxin 750 mg daily for 3 more days
2. Stop cyclobenzaprine (flexeril)
3. Stop gabapentin
It is important that your take all other medications as
instructed. Please feel free to call with any questions or
concerns.
Followup Instructions:
Department: TRANSPLANT
When: THURSDAY [**2182-2-7**] at 11:20 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Name: [**Last Name (LF) **],[**First Name3 (LF) **] C
Location: [**Location (un) 2274**]-[**Location (un) **]
Address: 111 [**Doctor Last Name **] DR, [**Location (un) **],[**Numeric Identifier 17464**]
Phone: [**Telephone/Fax (1) 17465**]
***The office is working on an appt for you in the next [**12-31**]
weeks and will call you at home with an appt. If you dont hear
from them by Monday, please call them directly to book.
|
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8,579
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1301+1302
|
Discharge summary
|
report+report
|
Admission Date: [**2142-6-11**] Discharge Date: [**2142-6-15**]
Date of Birth: [**2064-9-22**] Sex: M
Service: MICU Green
CHIEF COMPLAINT: Hypoxia.
HISTORY OF PRESENT ILLNESS: The patient is a 77-year-old
gentleman with renal cell carcinoma originally diagnosed in
[**2134**]. The patient had bilateral partial nephrectomies at
that time for chromophobe oocytic component tumor (grade II
to III) with 4.5 cm skin size with capillary penetration but
negative margins.
Cancer was quiescent until two months ago when metastases
were noted in the patient's lungs. The patient presents with
progressive dyspnea on exertion over the past two weeks and
an oxygen saturation in the 80s on the day of admission at
his oncologist's office. Prior oxygen saturation in [**Month (only) **] had
been 99%. As noted, a chest x-ray in [**2142-3-29**] showed
hilar lymphadenopathy and a bronchoscopy with biopsy showed
metastatic renal cell carcinoma.
The patient denies fevers, chills, nausea, vomiting, chest
pain, and palpitations. The patient has had a chronic cough
for months which has been intermittently productive of yellow
and green sputum. The patient has complained of anorexia
over the past several weeks. The patient notes orthopnea
requiring him to sleep on two pillows, but no paroxysmal
nocturnal dyspnea.
The patient went to his oncologist on [**6-11**] for an
appointment and had low oxygen saturations to 83% and was
sent to the Emergency Department.
In the Emergency Department, the patient responded to 3
liters of oxygen with oxygen saturations coming up to 92% but
had an increasing oxygen requirement. The patient was seen
by the Primary Medicine team at 4 a.m. and was short of
breath on 100% nonrebreather but was mentating well. An
arterial blood gas at that time revealed pH was 7.56, PCO2
was 38, and PO2 was 38.
The patient was transferred to the Medical Intensive Care
Unit for further evaluation. The chest x-ray on admission
was consistent with congestive heart failure with small
bilateral pleural effusions. The patient's last dialysis had
been on [**2142-6-9**].
PAST MEDICAL HISTORY:
1. Renal cell carcinoma diagnosed in [**2134**] with bilateral
partial nephrectomies; chromophobe oocytic component tumor
(grade II to III); 4.5 cm; capillary penetration; and
negative margins. The patient has been on dialysis since
[**2135**].
2. Paroxysmal atrial fibrillation.
3. Hypertension.
4. Coronary artery disease with a myocardial infarction in
[**2108**] and a normal echocardiogram in [**2138**].
5. Seizure disorder (however the patient is no longer on
Dilantin).
6. History of transient ischemic attacks.
7. Vascular dementia.
8. Gout.
9. History of gastrointestinal bleed resulting in a
hemicolectomy.
10. Psoriasis.
11. Type 2 diabetes.
MEDICATIONS ON ADMISSION: (Medications on admission were as
follows)
1. Celexa 20 mg p.o. once per day.
2. Digoxin 0.125 mg p.o. once per day.
3. Metoprolol 75 mg p.o. once per day.
4. Isosorbide mononitrate 90 mg p.o. once per day.
5. Zantac 150 mg p.o. once per day.
6. Zestril 20 mg p.o. once per day.
7. Clarinex 5 mg p.o. once per day.
8. Ticlid 250 mg p.o. once per day.
9. Renagel 21 mg p.o. twice per day.
10. Phos-Lo 3 p.o. three times per day.
11. Nephrocaps one tablet p.o. once per day.
ALLERGIES: Allergy to ASPIRIN (which causes bleeding) and to
PENICILLIN (which causes a rash).
SOCIAL HISTORY: The patient was a building wrecker for about
20 to 30 years beginning in the [**2078**] and then a salesman.
The patient does not have a smoking history.
FAMILY HISTORY: Family history was noncontributory.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on admission revealed temperature was 96.3, heart rate was
76, blood pressure was 190/80, the respiratory rate was 21,
and the oxygen saturation was 80% to 92% on a 100%
nonrebreather mask. In general, the patient was in no acute
distress. Alert and oriented times three. Head, eyes, ears,
nose, and throat examination revealed pupils were equal,
round, and reactive to light. Extraocular movements were
intact. The neck was supple with no jugular venous
distention. Pulmonary examination revealed the patient's
lungs were clear to auscultation bilaterally/anteriorly.
Cardiovascular examination revealed a regular rate and
rhythm. No murmurs appreciated. The abdomen was soft,
nontender, and nondistended with positive bowel sounds.
Extremity examination revealed no edema. Dorsalis pedis
pulses were 2+ bilaterally. Neurologic examination revealed
no gross deficits. Skin examination revealed multiple
psoriatic plaques on the scalp.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories
on admission revealed white blood cell count was 8,
hematocrit was 38, and platelets were 280. Sodium was 139,
potassium was 3.9, chloride was 92, bicarbonate was increased
at 35, blood urea nitrogen was 34, creatinine was 7.2, and
blood glucose was 111. Arterial blood gas initially revealed
pH was 7.56, PCO2 was 38, and PO2 was 38. Arterial blood gas
then improved to a pH of 7.42, PCO2 of 43, and PO2 of 62;
this was on 100% nonrebreather mask.
PERTINENT RADIOLOGY/IMAGING: A chest x-ray from [**6-11**]
showed bulky lymphadenopathy with diffuse reticular nodular
pattern and bilateral pleural effusions; consistent with
congestive heart failure and metastatic disease.
Electrocardiogram was compared with [**2139-11-30**] with a
rate of 75, normal sinus, left axis deviation, and normal
intervals. Left ventricular hypertrophy with a flipped T
wave in leads V4, V5, and III (which were new).
Just noting a computed tomography scan from [**6-8**], prior to
admission, showed extensive mediastinal adenopathy with a
node as large as 3.3 cm X 2.9 cm (which has increased in
size). Also, small bilateral pleural effusions. Also with
new nodular densities and an increased size of metastases in
the left lobe with one nodule measuring 12 mm in diameter.
HOSPITAL COURSE BY ISSUE/SYSTEM:
1. HYPOXIA ISSUES: The patient was admitted with hypoxia
with an oxygen requirement, but his saturations improved on
100% nonrebreather mask to the 90s. He was breathing
comfortably. It seemed that the patient encountered sputum
that he could not clear. His saturations dropped, but when
he coughed his saturations would improve.
Of note, the patient came to the Intensive Care Unit on a
nitroglycerin drip and had been taking isosorbide
mononitrate, and this may have worsened his respiratory
status as it may have dilated pulmonary vasculature that was
contracting to try and keep his V/Q match. Also, the patient
had been anorexic over the past several weeks and had
probably lost wean by mask, though his dialysis was being
maintained at the same dry weight. When the patient was
dialyzed off 3 liters later in the morning on the day of
admission, the patient's respiratory status improved. The
patient will most likely require establishment of a new lower
dry weight.
There was an immediate suspicion for a pulmonary embolism on
admission; however, given the patient's metastatic status,
history of bleeds, and improving oxygen saturations, the
patient was not fully heparinized at that time. However, on
day two of admission the patient was sent for a computed
tomography angiogram to rule out a pulmonary embolism.
In the Medical Intensive Care Unit, the patient continued to
improve his oxygenation and was switched to 6 liters nasal
cannula and was breathing comfortably.
2. METABOLIC ALKALOSIS ISSUES: The patient was admitted
with a bicarbonate of 35. This may have enhanced his
respiratory distress as the patient is oliguric. This likely
was an iatrogenic elevated bicarbonate level due to either
over bicarbonated dialysis solution and/or his Phos-Lo and/or
Renagel. Those two medications were held in the Medical
Intensive Care Unit, and he was dialyzed again with a low
bicarbonate solution, and his bicarbonate resolved down to 27
after that. It seemed that this may no longer be an issue
for this patient.
3. HYPERTENSIVE ISSUES: The patient was hypertensive to
200/80s to 90s on admission to the Medical Intensive Care
Unit. The patient was initially placed on a labetalol drip
with good affect. This was after the nitroglycerin drip was
stopped. The next day we attempted to take the patient off
the labetalol drip and maintain him on his metoprolol 75 mg
p.o. twice per day; however, this was not sufficient
overnight, and the patient was placed on hydralazine 20 mg
intravenously every six hours for blood pressure maintenance
which worked well.
4. END-STAGE RENAL DISEASE ISSUES: The patient was last
dialyzed on [**6-9**]. He was dialyzed again on [**6-12**] with 3
liters removed. The patient seemed to have an improvement in
his respiratory status after this and had no signs of being
overly dried out by this dialysis. It was very likely that
due to the patient's recent anorexia he had lost dry weight
and needed to be dialyzed to a lower dry weight.
5. CORONARY ARTERY DISEASE ISSUES: The patient had a
distant history of a myocardial infarction. A recent
echocardiogram from [**2138**] showed a preserved ejection fraction
and left ventricular function.
The patient did have a small troponin leak by enzymes at
approximately 0.2, but his creatine kinase levels were flat
at around 50 to 60. We had a low suspicion that the patient
had a cardiac event and thought that this was more likely due
to his respiratory distress and his end-stage renal disease.
However, the patient received another echocardiogram with a
bubble study. This echocardiogram on [**6-12**] showed a small
right-to-left shunt across the atrium, left ventricular
function was preserved and normal size, normal ejection
fraction of greater than 55%, mild aortic regurgitation, and
mild mitral regurgitation. The patient did have moderate
pulmonary artery systolic hypertension. The patient was also
switched from Ticlid to Plavix for an anti-platelet [**Doctor Last Name 360**]
which the patient is presumably on in lieu of aspirin which
he is allergic to.
6. TYPE 2 DIABETES MELLITUS ISSUES: The patient was placed
on an insulin sliding-scale and a diabetic diet with
fingersticks four times per day.
7. RENAL CELL CARCINOMA ISSUES: The patient recently
learned that he had metastases to his lungs. His family and
outpatient oncologist were notified of this situation.
8. PROPHYLAXIS ISSUES: The patient was maintained on
subcutaneous heparin and ranitidine for gastrointestinal
prophylaxis.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8037**], M.D. [**MD Number(2) 8038**]
Dictated By:[**Last Name (NamePattern1) 6006**]
MEDQUIST36
D: [**2142-6-13**] 13:39
T: [**2142-6-20**] 10:55
JOB#: [**Job Number 8039**]
Admission Date: [**2142-6-11**] Discharge Date: [**2142-6-15**]
Date of Birth: [**2064-9-22**] Sex: M
Service: [**Hospital1 **]
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 8040**] is a 77-year-old male
with a medical history significant for coronary disease
status post myocardial infarction in [**2108**], multiple
transient ischemic attacks, hypertension, gastrointestinal
bleed, type 2 diabetes mellitus, renal cell carcinoma with
metastases to the lungs, status post partial left nephrectomy
and end stage renal disease on hemodialysis who presented
with progressive dyspnea on exertion for the past four weeks.
On the day of presentation, [**2142-6-11**], the patient was at
his [**Hospital **] Clinic appointment where he was found to be
dyspneic with just short walking and found to have an oxygen
saturation of 83% on room air. Of note, just one month prior
in clinic, the patient had an oxygen saturation of 99% on
room air. He denied history of orthopnea, or paroxysmal
nocturnal dyspnea and reported no chest pain at the time.
Mr. [**Known lastname 8040**] was subsequently transferred to the [**Hospital6 1760**] Emergency Department, where
his breathing became more labored requiring 100%
nonrebreather, which resulted in an oxygen saturation in the
low 90s. His initial vitals were as follows: Temperature of
98.1. Heart rate of 76. Blood pressure 160/80. Respiratory
rate of 14. His oxygen saturation was in the low 90s with
100% nonrebreather.
He had diffuse rhonchi and crackles on his lung exam and
evidence of volume overload on physical examination. His
chest x-ray demonstrated findings consistent with congestive
heart failure, bilateral pleural effusion, bibasilar
collapse, consolidation, and mediastinal hilar
lymphadenopathy with diffuse bilateral small nodules,
consistent with metastatic disease.
A repeat chest x-ray revealed worsening pulmonary edema
consistent with congestive heart failure. Patient's blood
pressure also rose to 230/120 requiring intravenous
nitroglycerin drip. Once the patient was stabilized, he was
transferred to the floor for further care and management.
PAST MEDICAL HISTORY:
1. Renal cell carcinoma. Renal cell carcinoma was
discovered during a work-up for abdominal pain in [**2135-5-30**], which revealed bilateral renal masses. CT and MI scan
revealed 3 cm mass in left upper pole and a 4 cm mass in
upper right pole and patient is now status post left partial
nephrectomy for cancer treatment as of [**2135-6-30**].
2. End stage renal disease. Patient's end stage renal
disease is likely secondary to type 2 diabetes mellitus, as
well as renal cell carcinoma status post left partial
nephrectomy. He is currently on hemodialysis treatment at
[**Location (un) 1468**] Dialysis Unit on a Tuesday, Thursday, Saturday
schedule.
3. Type 2 diabetes mellitus. Diabetes is currently
controlled with diet.
4. Coronary disease. Patient is status post myocardial
infarction in the [**2108**] and had recent chest pain in the past
which has been worked up.
5. Hypertension.
6. History of transient ischemic attack. First demonstrated
in [**2135-6-30**] postoperatively from nephrectomy, which was
partial on the left kidney. There has also been an episode
where he became unresponsive with straining and extension of
his right arm. MI and MRA of the head showed small vessel
disease and evidence for an old left-sided cerebral
infarction. This work-up was done on previous admissions.
7. Gout.
8. Sciatica.
9. Cataracts. Patient is status post bilateral cataract
surgery.
10. Benign prostatic hypertrophy. He is status post
suprapubic prostatectomy in [**2139-7-31**].
11. Paroxysmal atrial fibrillation.
12. Hypercholesterolemia.
13. Hemicolectomy for massive gastrointestinal bleed
secondary to CMV colitis exacerbated by aspirin.
ALLERGIES: Penicillin causes rashes. Aspirin exacerbates
gastrointestinal bleed.
MEDICATIONS: The patient on previous admissions was on:
1. Claritin 10 mg po q.d.
2. Digoxin 125 mcg po q.d.
3. Imdur 90 mg po q.d.
4. Isosorbide 60-90 mg po q.d.
5. Metoprolol 75 mg po b.i.d.
6. Nephrocaps 1 mg po q.d.
7. Nifedipine ER 60 mg po q.h.s.
8. Phos-Lo.
9. Ranitidine 75-250 mg po q.h.s.
10. Ticlid 250 mg po q.d.
11. Zestril 20 mg po q.d.
FAMILY HISTORY: Significant for renal cell carcinoma in both
father and brother.
SOCIAL HISTORY: Significant for no alcohol or tobacco abuse.
Patient also denies illicit drug use. He lives with his wife
of 55 years and is a War World II veteran.
PHYSICAL EXAMINATION: On initial physical examination in the
Emergency Department, the patient was breathing heavily in
mild distress in a bed. He appeared his stated age and
cachectic, otherwise, he was pleasant, alert and oriented
times three. His vitals were a temperature of 98.1. Heart
rate of 76. Blood pressure 160/80 with intermittent rise to
systolic blood pressure of 230 and a respiratory rate of 14.
His initial weight was approximately 73 kg. His head, eyes,
ears, nose and throat exam: Normocephalic, atraumatic.
Anicteric and noninjected sclera. No lesions in the
oropharynx and upper dentures were noted. Pupils are equal,
round, and reactive to light and accommodation. His
Extraocular muscles were intact. No rhinorrhea was
appreciated. Neck exam: Soft, trachea midline. Jugular
venous pressure was 8-9 cm and no thyromegaly was noted.
Pulmonary chest exam: Rhonchi on expiration bilaterally with
mild crackles, left greater than right. heart exam:
Regular, audible, but distant S1, S2, 1-2/6 systolic murmur
heard loudest at the base, no rubs or gallops were
appreciated. Abdominal exam: Nondistended, positive bowel
sounds, soft and nontender, no hepatosplenomegaly. Back
exam: No CVA tenderness bilaterally. Genitourinary exam:
Deferred. Rectal exam: Deferred. Pulses: 2+ radial pulses
and palpable, 1+ pedal pulses bilaterally. Extremity exam:
[**11-30**]+ pitting peripheral edema, especially in the lower
extremities. AV fistula noted in the left upper extremity
with good thrill. Neurological exam: Alert and oriented
times three. Cranial nerves II through XII tested and were
intact. Dermatology exam: Very mild psoriatic rash on
scalp, face and extensor surfaces. There is also some brown
discoloration of skin noted on anterior tibial aspect on the
right leg.
LABORATORY DATA: The patient's initial CBC showed white
blood cell count of 8.0, hematocrit 38.0, and a platelet
count of 280. His Chem-7 demonstrated sodium of 139,
potassium 3.9, chloride 92, bicarbonate 35, BUN of 34,
creatinine 7.2 and blood sugar of 111. His first CK enzyme
came back 65 which was within normal limits. His first
troponin T came back as 0.21. Second set was 0.27. Third
set was 0.27. Fourth set was 0.22 and a fifth set was 0.19.
His calcium level was 9.0, phosphate of 4.4 and magnesium of
1.9. His digoxin level was found to be 1.3. His blood gas
was shown to have PO2 of 38, pCO2 of 41, and a pH of 7.56.
His lactate level was 1.0.
His first chest x-ray revealed findings consistent with
previous heart failure with bilateral pleural effusions,
bibasilar collapsing consolidation in mediastinal hilar
lymphadenopathy with diffuse bilateral small nodules
consistent with metastases.
The patient also had an electrocardiogram done which showed
no acute changes from previous studies. There were still
signs of left ventricular hypertrophy strain, but otherwise,
no clear evidence for myocardial infarction.
An echocardiogram on [**6-12**] demonstrated left ventricular
ejection fraction of greater than 55% and a small right to
left intracardiac shunt, most likely consistent with atrial
septal defect. Pulmonary artery systolic hypertension was
noted, but there was preserved global and regional
biventricular systolic function. There was mild aortic
regurgitation and mild mitral regurgitation.
HOSPITAL COURSE:
1. Shortness of breath: The patient was transferred to the
floor on the day of admission for further care and
management, however, after a couple hours, he complained of
increased dyspnea on exertion and had an oxygen saturation of
approximately 80% on 100% nonrebreather with systolic blood
pressure in the 160s. He was subsequently transferred to the
Medical Intensive Care Unit for further treatment. At the
Medical Intensive Care Unit, Mr. [**Known lastname 8040**] was continued on
oxygen saturation with nonrebreather and face tent. At
admission, he was ruled out for PE with CT angiogram. He
received hemodialysis on [**2142-6-12**] under the care of Dr.
[**Last Name (STitle) 1860**] and had three liters of fluid removed with significant
improvement of his shortness of breath, but still complained
of productive green-yellow cough. Given his rapid
improvement, the patient was transferred to the floor on [**2142-6-13**] with further management. On [**6-14**], the patient
received another hemodialysis session with 2.6 kg of fluid
removed to a dry weight of 66 kg and Epogen administered.
However, three hours into the session, the patient
experienced a dull pressure type of chest pain with no
radiation, however, it resolved with oral nitroglycerin and
morphine. The chest pain only lasted a few minutes and there
was no recurrence of chest pain throughout the hospital
course.
His most recent echocardiogram was otherwise normal except
for a mild right to left shunt atrial septal defect and his
latest electrocardiogram indicated a possible new T wave
inversion, however, Cardiology Consult was requested and the
evaluation indicated no evidence of myocardial infarction or
acute myocardial ischemia process, instead, they felt the
electrocardiogram was consistent with left ventricular
hypertrophy strain patterns.
Patient's shortness of breath continued to improve to the
point where his oxygen saturation on room air was 92%. His
pulmonary function appeared to have returned to baseline and
he was seen by Physical Therapy. Physical Therapy walked the
patient around the hospital floor and found him to be in the
low 90s on room air with ambulation. They felt that he was
clear to go home with home Physical Therapy. Pulmonary also
evaluated the patient and felt that he did not need an
interventional pulmonary procedures done at this time as his
pulmonary function had returned to baseline and seemed to be
continually improving.
2. Coronary disease/Cardiovascular: Patient's blood
pressure on initial examination at the Emergency Department
was a systolic blood pressure as high at 230, however, a
nitroglycerin drip was able to control his blood pressure
throughout the Medical Intensive Care Unit course and his
medication was adjusted with increase in Lopressor and
hydralazine dosage throughout the Medical Intensive Care Unit
course helped keep his blood pressure in the 140s to 150s.
He did complain of a dull pressure like substernal chest pain
on the 17th after three hours of hemodialysis. He has had
episodes of chest pain in the past during hemodialysis as per
Dr.[**Name (NI) 129**] notes. He was seen by Cardiology Consult, Dr.
[**First Name (STitle) 2572**], and he was evaluated. His troponin and CKs were
within his baseline. His troponin T was in the low 0.20
range, however, this has been his consistent levels
throughout this hospital course with no acute rises
throughout this admission. He was continued on his current
cardiac regimen which included Lopressor, hydralazine and ACE
inhibitor. His electrocardiogram was consistent with a left
ventricular hypertrophy pattern, but showed no acute evidence
of acute myocardial infarction or process. He also had his
medications filtered through a PVO filter given his new
discovery of a right to left shunt on echocardiogram.
3. End stage renal disease: The patient most likely
presented due to volume overload secondary to end stage renal
disease. Hemodialysis sessions were done twice with total
removal of approximately 6.6 kg of fluid. It seems that he
may not have had sufficient fluid removal in the past,
therefore, we aggressively tested his lowest possible dry
weight as tolerated and it seems that he may need to have a
new setting for his optimal dry weight given his recent
weight loss secondary to his metastatic renal cell carcinoma.
However, he continued to improve and his volume status
improved and at the time of discharge he appeared to be
euvolemic.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: To home with services, primarily home
Physical Therapy.
DISCHARGE DIAGNOSES:
1. Dyspnea.
2. Hypoxia.
3. Chronic renal failure.
4. Congestive heart failure.
5. Metastatic renal cell carcinoma.
DISCHARGE MEDICATIONS:
1. Citalopram 20 mg q.d.
2. Ranitidine 150 mg q.h.s.
3. Nephrocaps 1 mg q.d.
4. Plavix 75 mg po q.d.
5. Lisinopril 40 mg po q.h.s.
6. Toprol XL 150 mg t.i.d.
7. Renagel 800 mg t.i.d. with meals.
8. Claritin 10 mg po q.d.
9. Digoxin 125 mcg q.d.
10. Imdur 90 mg q.d.
FOLLOW-UP PLANS: The patient's follow-up plans include:
Continuation of Dialysis schedule at [**Location (un) 1468**] Dialysis Unit on
[**6-16**] at 11:15 a.m. He will also follow-up with Dr. [**Last Name (STitle) 1860**]
as necessary. He will also contact his oncologist to
schedule a follow-up appointment. He will also call his
primary care physician or return to the hospital if he has
any new symptoms of shortness of breath or chest pain.
FOLLOW-UP APPOINTMENTS:
1. Follow-up in [**Hospital **] Clinic on Saturday, [**6-16**] at
11:15 a.m.
2. Primary care physician [**Name9 (PRE) 702**] within one week.
3. Follow-up appointment with oncologist.
[**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**]
Dictated By:[**First Name3 (LF) 8041**]
MEDQUIST36
D: [**2142-6-15**] 06:14
T: [**2142-6-22**] 20:28
JOB#: [**Job Number 8042**]
|
[
"403.91",
"416.0",
"518.0",
"276.3",
"E879.1",
"V45.1",
"428.0",
"518.82",
"197.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
15156, 15222
|
23384, 23505
|
23528, 23804
|
2844, 3435
|
18766, 23255
|
6029, 10997
|
24278, 24707
|
15413, 16923
|
23822, 24254
|
16943, 18748
|
157, 167
|
11026, 12999
|
13021, 15139
|
15239, 15390
|
23280, 23363
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,485
| 159,088
|
1171
|
Discharge summary
|
report
|
Admission Date: [**2123-3-20**] Discharge Date: [**2123-4-16**]
Date of Birth: [**2050-8-29**] Sex: M
Service: Intensive Care Unit
CHIEF COMPLAINT: Pneumonia.
HISTORY OF PRESENT ILLNESS: Patient is a 73-year-old man
with Parkinson's disease, who recently was admitted to [**Hospital1 **] the beginning of [**Month (only) 956**] and found at that
time to have a right lower lobe consolidation initially
treated with ceftaz and clindamycin. Speech and swallow
evaluation demonstrated impaired swallowing. Was discharged
on puree liquids.
He presents again with shortness of breath and fever from his
nursing home.
PAST MEDICAL HISTORY:
1. Parkinson's.
2. Dementia.
3. Anemia.
4. Benign prostatic hypertrophy.
5. Osteoarthritis.
6. Bradycardia status post pacemaker.
7. Anorexia.
8. Constipation.
ALLERGIES: Cephalosporins causes rash.
SOCIAL HISTORY: Patient resides at [**Hospital3 537**] Nursing
Home. He has a wife and three daughters.
PHYSICAL EXAM ON ADMISSION: Blood pressure 94/56, heart rate
84, respiratory rate 32, and O2 saturation 104% on 4 liters
nasal cannula. General: Diaphoretic, tachypneic. Eyes
closed. Moderate respiratory distress. HEENT: Oropharynx
is clear. Moist mucosal membranes. Neck is supple, no LAD.
Pulmonary: Coarse breath sounds anteriorly. Heart: Regular
rate and rhythm, normal S1, S2, no murmur. Abdomen is soft,
nontender, and nondistended, normoactive bowel sounds.
Extremities: 3+ pitting edema bilaterally in the ankles.
Neurologic: Alert and oriented times 0, per notes baseline.
LABORATORIES ON ADMISSION: Sodium 145, potassium 4.6,
chloride 107, bicarb 24, BUN 27, creatinine 0.9, glucose 182.
White count 27.8 with 15% bands, hematocrit 42.9, platelets
600. Lactate 3.6.
Chest x-ray demonstrated increased consolidation right middle
lobe, right lower lobe, and left lower lobe concerning for
pneumonia, question aspiration.
EKG: Wandering pacemaker at 90, normal limit axis/intervals,
no ST wave changes.
HOSPITAL COURSE: 1. Patient was initially admitted to the
medicine course and treated with ceftriaxone, vancomycin, and
Flagyl. On night of [**3-22**], patient was noted to have a
witnessed aspiration with O2 saturations of 84% on a
nonrebreather. Patient was intubated and transferred to the
Medical Intensive Care Unit.
Patient continued on antibiotic treatment and underwent
bronchoscopy with thick-yellow secretions in the right lower
lobe on [**3-24**]. On [**3-25**], patient was extubated, which he
initially tolerated well. However, failed again on [**3-26**]
secondary to inability to handle secretions.
Given patient's overall poor condition and repeated failed
extubations as well as history of recurrent aspiration
pneumonias with poor swallow, plan for tracheostomy was made.
Patient's family was unable to decide if patient would have
wanted this intervention to the end of [**Month (only) 956**] and beginning
of [**Month (only) 958**]. Eventually decision were to extubate and try and
involve patient and family discussion.
This occurred on [**2123-4-13**]. Patient has tolerated
extubation and remains on 50% face tent. He has poor cough
at this time. Family wishes to reintubate and proceed
immediately with tracheostomy if patient fails extubation
again.
2. Gastrointestinal: Patient developed severe C. diff
colitis confirmed on culture [**3-25**]. Patient's CT
demonstrated extensive ascites with marked bowel edema.
Patient was evaluated for surgical intervention. With the
patient's overall weakened condition, it was felt that he
would not tolerate surgery. Plan for medical management and
patient continued on antibiotics with IV Flagyl and p.o.
Vancomycin for a 19 and 14-day course respectively.
Patient was maintained on TPN for nutrition and restarted on
tube feeds [**4-8**] which he tolerated well. At the time of
discharge, the patient will be maintained on Dobbhoff
feeding. PEG could not be placed secondary to remaining
ascites.
3. Fungemia: Patient developed single blood culture positive
for yeast on [**3-22**], [**Female First Name (un) 564**] albicans. Patient had central
venous lines changed, his TPN stopped, began treatment
initially with caspofungin x1 day as well as three weeks of
fluconazole given presence in blood and sputum of yeast.
Patient completed this course on [**2123-4-16**]. Of note, given
patient's poor nutritional status, TPN was restarted and
subsequent blood cultures remained negative.
4. Renal failure: Patient experienced prerenal azotemia
during his C. diff colitis due to significant third spacing
of fluid. Patient ......... to approximately 36 liters of
fluid during his Intensive Care Unit stay. Continues to have
anasarca, which is slowly improving.
5. Neurologic: Patient was continued on his Sinemet and
ropinirole throughout hospitalization.
6. Anemia: Patient has anemia of chronic disease requiring
few transfusions of packed red blood cells during ICU stay.
7. Skin: Patient developed an erythematous rash, which was
biopsied and felt to be consistent with a hypersensitivity
reaction. Medication not clearly identified, although per
Dermatology felt likely to be cephalosporins patient was
initially treated with for his pneumonia.
Patient was maintained on subq Heparin prophylaxis as well as
proton-pump inhibitor, and H2 blocker throughout
hospitalization.
8. Access: Patient with a right IJ replaced for fungemia for
a left subclavian line as well as left A-line during ICU
stay.
9. Code status: Initially full code. Patient is currently
DNR, but would want to be reintubated with direct proceeding
to tracheostomy.
DISCHARGE CONDITION: Guarded.
DISCHARGED TO: Chronic pulmonary care facility.
MEDICATIONS ON DISCHARGE:
1. Sinemet 25/100 one tablet p.o. q.i.d.
2. Ropinirole 1 mg p.o. q.i.d.
3. Aspirin 325 mg per nasogastric q.d.
4. Paroxetine 40 mg per nasogastric q.d.
5. Albuterol nebulized inhaler q.6h. prn.
6. Tylenol 650 mg p.o. q.[**5-11**]. prn.
7. Oxycodone elixir [**6-14**] mL p.o. q.[**5-11**]. prn.
8. Heparin 5000 units subq q.12h.
9. Colace liquid 100 mg p.o. b.i.d.
10. Lansoprazole oral suspension 30 mg nasogastric q.d.
DISCHARGE DIAGNOSES:
1. Recurrent aspiration pneumonia.
2. Clostridium difficile colitis.
3. Sepsis.
4. Poor nutrition secondary to inability to swallow.
5. Fungemia.
6. Anemia of chronic disease.
7. Hypersensitivity dermatitis.
8. Anasarca.
9. Parkinson's disease.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**]
Dictated By:[**Last Name (NamePattern1) 7485**]
MEDQUIST36
D: [**2123-4-15**] 14:42
T: [**2123-4-15**] 14:41
JOB#: [**Job Number 7486**]
(cclist)
|
[
"112.5",
"008.45",
"286.7",
"789.5",
"518.82",
"276.6",
"038.9",
"584.9",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.93",
"86.11",
"33.24",
"96.04",
"99.15",
"96.72",
"38.91",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
5668, 5728
|
6196, 6724
|
5754, 6175
|
2021, 5646
|
170, 182
|
211, 640
|
1597, 2003
|
662, 864
|
881, 985
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,481
| 187,527
|
51855
|
Discharge summary
|
report
|
Admission Date: [**2102-2-4**] [**Month/Day/Year **] Date: [**2102-2-16**]
Date of Birth: [**2033-8-28**] Sex: F
Service: SURGERY
Allergies:
Codeine / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
lower abdominal pain, vomiting
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt is a 68 y/o F with complicated history beginning with a
repair
of ventral hernia with mesh and component separation that was
complicated by an EC fistula SIRS, ARF, line infections, UTI's.
She was most recently discharged on [**1-20**] after being
hospitalized
with a klebsiella UTI and staph bacteremia. Her PICC line at
that time was removed. She completed a 10 day course of
ceftriaxone and is currently on a prolonged course of vancomycin
for staph bacteremia in setting of LUE and LIJ venous
thromboses.
The patient returns to the hospital today with fever to 102 at
rehab associated with chills, hypotension to 90's in ER with
tachycardia to 130 (both responsive to fluid). She complains of
some vague lower abdominal pain. She vomitted this morning and
reports it to have been a yellow color although there is some
discrepancy about this. She has been passing flatus and has had
some loose stools. She otherwise reports tolerating her tube
feeds through her fistula. Her po intake has not been great but
is not worse. She is not currently nauseous. She denies chest
pain, shortness of breath, URI symptoms, BRBPR. She does
indicate that her fistula output may be a bit higher. Pt has
received zosyn in ER.
Past Medical History:
SBO s/p surgery complicated by ventral heria s/p repair c/b
wound infection and EC fistula; s/p hysterectomy, s/p lap chole,
s/p LOA, epilepsy, anxiety, tremors, depression, hypothyroid,
klebsiella UTI, Staph bacteremia, LIJ and LUE venous thrombus
Social History:
currently living at NE Siani since [**Month/Year (2) **]. no tobacco or EtOH
Family History:
Breast CA, CVA, HTN, CAD, depression
Physical Exam:
On Admission:
T: 101.9 P: 130 R: 20 BP: 92/40, O2Sat 99% 84% at rehab on RA
General: A/O x 3 although bit flat, NAD
HEENT: NCAT, No icterus, no jaundice
Lungs: CTAB, No crackles or wheezes
Heart: RRR, 2/6 systolic murmur
Abdom: midline 10 x 10cm wound with ostomy bag over top, and
J-tube entering the middle of wound. Bag with fistula output.
RUQ
tenderness with mild guarding. Guaiac neg
Extrem: PICC site no erythema or pus, no lower ext edema
Urine: tea colored
Pertinent Results:
[**2102-2-4**] 11:15AM BLOOD WBC-11.5* RBC-4.20# Hgb-11.3*# Hct-34.0*#
MCV-81* MCH-27.0 MCHC-33.3 RDW-14.3 Plt Ct-193
[**2102-2-4**] 06:30PM BLOOD WBC-22.1*# RBC-3.30* Hgb-9.2* Hct-26.7*
MCV-81* MCH-27.8 MCHC-34.4 RDW-14.7 Plt Ct-181
[**2102-2-5**] 02:07AM BLOOD WBC-16.1* RBC-2.97* Hgb-8.2* Hct-24.1*
MCV-81* MCH-27.7 MCHC-34.3 RDW-14.7 Plt Ct-174
[**2102-2-6**] 03:18AM BLOOD WBC-11.6* RBC-3.20* Hgb-8.6* Hct-25.7*
MCV-81* MCH-27.0 MCHC-33.5 RDW-14.8 Plt Ct-196
[**2102-2-7**] 12:08AM BLOOD WBC-13.2* RBC-3.49* Hgb-9.2* Hct-28.6*
MCV-82 MCH-26.5* MCHC-32.4 RDW-14.8 Plt Ct-238
[**2102-2-7**] 06:48PM BLOOD WBC-11.1* RBC-3.40* Hgb-9.0* Hct-27.7*
MCV-82 MCH-26.5* MCHC-32.5 RDW-15.0 Plt Ct-229
[**2102-2-8**] 06:37AM BLOOD WBC-9.9 RBC-3.43* Hgb-9.4* Hct-28.1*
MCV-82 MCH-27.5 MCHC-33.5 RDW-15.3 Plt Ct-253
[**2102-2-9**] 05:20AM BLOOD WBC-14.2* RBC-3.37* Hgb-9.3* Hct-27.6*
MCV-82 MCH-27.6 MCHC-33.7 RDW-15.3 Plt Ct-280
[**2102-2-10**] 05:00AM BLOOD WBC-14.4* RBC-3.45* Hgb-9.2* Hct-28.3*
MCV-82 MCH-26.6* MCHC-32.4 RDW-15.3 Plt Ct-385
[**2102-2-11**] 03:15AM BLOOD WBC-14.9* RBC-3.37* Hgb-9.1* Hct-27.6*
MCV-82 MCH-26.9* MCHC-32.9 RDW-15.6* Plt Ct-404
[**2102-2-12**] 03:54AM BLOOD WBC-13.8* RBC-3.28* Hgb-8.9* Hct-27.0*
MCV-82 MCH-27.1 MCHC-33.0 RDW-16.1* Plt Ct-375
[**2102-2-13**] 04:10AM BLOOD WBC-12.0* RBC-3.16* Hgb-8.4* Hct-26.0*
MCV-83 MCH-26.5* MCHC-32.2 RDW-16.2* Plt Ct-385
[**2102-2-14**] 04:19AM BLOOD WBC-14.4* RBC-3.14* Hgb-8.6* Hct-25.9*
MCV-83 MCH-27.4 MCHC-33.2 RDW-16.9* Plt Ct-390
[**2102-2-15**] 05:30AM BLOOD WBC-12.1* RBC-3.17* Hgb-8.5* Hct-26.4*
MCV-83 MCH-26.9* MCHC-32.2 RDW-16.7* Plt Ct-346
[**2102-2-16**] 05:37AM BLOOD WBC-12.3* RBC-3.01* Hgb-8.4* Hct-24.9*
MCV-83 MCH-27.8 MCHC-33.6 RDW-17.6* Plt Ct-311
[**2102-2-4**] 11:15AM BLOOD Neuts-91.8* Lymphs-5.0* Monos-2.0 Eos-1.0
Baso-0.1
[**2102-2-4**] 11:15AM BLOOD PT-23.8* PTT-25.8 INR(PT)-2.3*
[**2102-2-4**] 06:30PM BLOOD PT-21.9* PTT-30.5 INR(PT)-2.1*
[**2102-2-5**] 02:07AM BLOOD PT-25.9* PTT-35.6* INR(PT)-2.6*
[**2102-2-7**] 12:08AM BLOOD PT-36.9* INR(PT)-3.9*
[**2102-2-8**] 06:37AM BLOOD PT-38.1* PTT-41.3* INR(PT)-4.1*
[**2102-2-9**] 05:20AM BLOOD PT-36.4* PTT-38.1* INR(PT)-3.9*
[**2102-2-9**] 05:20AM BLOOD PT-36.4* PTT-38.1* INR(PT)-3.9*
[**2102-2-10**] 05:00AM BLOOD PT-35.5* PTT-38.2* INR(PT)-3.8*
[**2102-2-11**] 03:15AM BLOOD PT-32.9* PTT-36.5* INR(PT)-3.4*
[**2102-2-12**] 03:54AM BLOOD PT-32.8* PTT-35.3* INR(PT)-3.4*
[**2102-2-13**] 04:10AM BLOOD PT-26.7* INR(PT)-2.7*
[**2102-2-14**] 04:19AM BLOOD PT-25.9* INR(PT)-2.6*
[**2102-2-15**] 05:30AM BLOOD PT-26.0* PTT-30.6 INR(PT)-2.6*
[**2102-2-16**] 05:37AM BLOOD PT-28.4* INR(PT)-2.9*
[**2102-2-4**] 11:15AM BLOOD Glucose-111* UreaN-36* Creat-2.5*# Na-140
K-3.3 Cl-110* HCO3-17* AnGap-16
[**2102-2-4**] 06:30PM BLOOD Glucose-157* UreaN-34* Creat-2.6* Na-141
K-3.4 Cl-112* HCO3-17* AnGap-15
[**2102-2-5**] 02:07AM BLOOD Glucose-93 UreaN-36* Creat-2.9* Na-141
K-3.6 Cl-114* HCO3-17* AnGap-14
[**2102-2-6**] 03:18AM BLOOD Glucose-77 UreaN-38* Creat-3.5* Na-142
K-3.8 Cl-115* HCO3-16* AnGap-15
[**2102-2-7**] 12:08AM BLOOD Glucose-101 UreaN-40* Creat-4.1* Na-141
K-4.0 Cl-110* HCO3-20* AnGap-15
[**2102-2-7**] 06:48PM BLOOD Glucose-99 UreaN-40* Creat-4.4* Na-141
K-3.8 Cl-111* HCO3-20* AnGap-14
[**2102-2-8**] 06:37AM BLOOD Glucose-107* UreaN-42* Creat-4.5* Na-140
K-3.8 Cl-109* HCO3-21* AnGap-14
[**2102-2-9**] 05:20AM BLOOD Glucose-115* UreaN-44* Creat-4.7* Na-144
K-3.7 Cl-112* HCO3-22 AnGap-14
[**2102-2-10**] 05:00AM BLOOD Glucose-121* UreaN-44* Creat-4.6* Na-143
K-3.6 Cl-114* HCO3-19* AnGap-14
[**2102-2-11**] 03:15AM BLOOD Glucose-114* UreaN-42* Creat-4.1* Na-141
K-3.7 Cl-113* HCO3-19* AnGap-13
[**2102-2-9**] 05:20AM BLOOD Glucose-115* UreaN-44* Creat-4.7* Na-144
K-3.7 Cl-112* HCO3-22 AnGap-14
[**2102-2-10**] 05:00AM BLOOD Glucose-121* UreaN-44* Creat-4.6* Na-143
K-3.6 Cl-114* HCO3-19* AnGap-14
[**2102-2-11**] 03:15AM BLOOD Glucose-114* UreaN-42* Creat-4.1* Na-141
K-3.7 Cl-113* HCO3-19* AnGap-13
[**2102-2-12**] 03:54AM BLOOD Glucose-112* UreaN-42* Creat-4.2* Na-140
K-3.7 Cl-113* HCO3-18* AnGap-13
[**2102-2-13**] 04:10AM BLOOD Glucose-103 UreaN-40* Creat-3.7* Na-142
K-3.6 Cl-114* HCO3-18* AnGap-14
[**2102-2-14**] 04:19AM BLOOD Glucose-113* UreaN-37* Creat-3.2* Na-144
K-4.5 Cl-116* HCO3-18* AnGap-15
[**2102-2-15**] 05:30AM BLOOD Glucose-147* UreaN-33* Creat-2.9* Na-144
K-4.2 Cl-115* HCO3-19* AnGap-14
[**2102-2-16**] 05:37AM BLOOD Glucose-96 UreaN-32* Creat-2.5* Na-143
K-3.9 Cl-115* HCO3-20* AnGap-12
[**2102-2-4**] 11:15AM BLOOD ALT-25 AST-19 AlkPhos-170* Amylase-63
TotBili-0.4 DirBili-0.3 IndBili-0.1
[**2102-2-4**] 06:30PM BLOOD ALT-22 AST-16 CK(CPK)-35 AlkPhos-126*
TotBili-0.5
[**2102-2-5**] 02:07AM BLOOD ALT-19 AST-16 CK(CPK)-26 AlkPhos-104
TotBili-0.3
[**2102-2-5**] 10:45AM BLOOD CK(CPK)-24*
[**2102-2-6**] 03:18AM BLOOD ALT-17 AST-16
[**2102-2-7**] 12:08AM BLOOD CK(CPK)-32
[**2102-2-8**] 06:37AM BLOOD ALT-12 AST-10 AlkPhos-98 TotBili-0.4
[**2102-2-4**] 06:30PM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2102-2-5**] 02:07AM BLOOD CK-MB-2 cTropnT-0.05*
[**2102-2-5**] 10:45AM BLOOD CK-MB-NotDone cTropnT-0.06*
[**2102-2-6**] 07:45PM BLOOD CK-MB-2 cTropnT-0.06*
[**2102-2-7**] 12:08AM BLOOD CK-MB-NotDone cTropnT-0.05*
[**2102-2-7**] 10:35AM BLOOD CK-MB-3 cTropnT-0.05*
[**2102-2-4**] 06:30PM BLOOD Calcium-7.8* Phos-5.1* Mg-1.1*
[**2102-2-6**] 03:18AM BLOOD Calcium-8.4 Phos-6.2* Mg-2.2
[**2102-2-7**] 06:48PM BLOOD TotProt-6.6 Calcium-8.8 Phos-5.4* Mg-2.1
[**2102-2-9**] 05:20AM BLOOD Calcium-8.7 Phos-5.7* Mg-2.1
[**2102-2-11**] 03:15AM BLOOD Calcium-8.8 Phos-4.9* Mg-1.8
[**2102-2-13**] 04:10AM BLOOD Calcium-8.5 Phos-5.4* Mg-1.6
[**2102-2-15**] 05:30AM BLOOD Calcium-8.1* Phos-5.4* Mg-1.8
[**2102-2-16**] 05:37AM BLOOD Calcium-8.2* Phos-5.4* Mg-2.2
[**2102-2-12**] 10:46AM BLOOD calTIBC-198* Ferritn-GREATER TH TRF-152*
[**2102-2-10**] 05:00AM BLOOD calTIBC-190* Ferritn-1699* TRF-146*
[**2102-2-4**] 11:15AM BLOOD calTIBC-220* TRF-169*
[**2102-2-7**] 06:48PM BLOOD PTH-45
[**2102-2-9**] 05:20AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-NEGATIVE
[**2102-2-11**] 11:26AM BLOOD ANCA-NEGATIVE B
[**2102-2-12**] 10:46AM BLOOD ANCA-NEGATIVE B
[**2102-2-7**] 06:48PM BLOOD PEP-NO SPECIFI
[**2102-2-9**] 05:20AM BLOOD C3-104 C4-36
[**2102-2-4**] 06:30PM BLOOD Vanco-10.3
[**2102-2-10**] 05:00AM BLOOD Vanco-5.2*
[**2102-2-9**] 05:20AM BLOOD HCV Ab-NEGATIVE
[**2102-2-7**] 02:11PM BLOOD Type-ART pO2-90 pCO2-42 pH-7.28*
calTCO2-21 Base XS--6
[**2102-2-4**] 11:42AM BLOOD Glucose-104 Lactate-2.1* Na-144 K-3.5
Cl-110 calHCO3-18*
[**2102-2-4**] 11:42AM BLOOD Hgb-12.1 calcHCT-36
Other results:
[**2-4**] ECHO:
Left ventricular wall thicknesses are normal. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function is
moderately depressed (LVEF= 30-35 %). 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
masses or vegetations are seen on the aortic valve, but cannot
be fully excluded due to suboptimal image quality. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. An eccentric jet of Mild to moderate ([**11-25**]+) mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion. There is an anterior space which most
likely represents a fat pad. There are no echocardiographic
signs of tamponade. No right atrial diastolic collapse is seen.
Compared with the prior study (images reviewed) of [**2101-9-16**],
overall image quality is worse. Ejection fraction has decreased
significantly. The degrees of mitral and tricuspid regurgitation
and estimated PA systolic pressures have increased.
[**2-4**] ECG:
Sinus tachycardia. Possible left atrial enlargement. There is a
crista pattern
in leads VI-V2, a normal variant. Non-specific ST-T wave
abnormalities are
diffusely seen. Compared to the previous tracing of [**2102-1-11**] the
heart rate has
increased substantially. T wave inversions previously seen in
the precordial
leads are no longer apparent and have been replaced non-specific
ST-T wave
abnormalities. Clinical correlation and repeat tracing are
suggested.
[**2-4**] CT Abd/Pelvis:
1. No change in configuration of anterior abdominal wall defect
and
enterocutaneous fistula. The jejunum and ileum distal to the
drain are
collapsed and do not demonstrate intra-luminal contrast, whereas
on the prior
study the contrast did pass into jejunum and ileum.
2. No evidence of abscess, obstruction, or perforation.
3. Unchanged adrenal thickening bilaterally.
4. Unchanged right greater than the left bilateral pleural
effusions.
[**2-6**] CXR:
As compared to the previous examination, the pre-existing small
right-sided pleural effusion has substantially increased in
extent. As a
consequence, the right lung base has decreased in transparency.
Also
decreased in transparency have the left basal lung areas, mainly
as a
consequence of the newly occurred retrocardiac atelectasis.
Newly occurred
minimal left-sided pleural effusion. Right-sided central venous
access line in unchanged position.
[**2-6**] renal US:
No hydronephrosis or obstruction in both kidneys. Study is
somewhat limited due to overlying bowel gas.
[**2-9**] Bladder US:
No mass, stone or large hematoma is seen within the partially
distended urinary bladder. If there is concern for bladder wall
abnormality, direct visualization by cystoscopy would be
recommended.
[**2-10**] Urine Cytology:
NEGATIVE FOR MALIGNANT CELLS.
Reactive urothelial cells, present singly and in clusters,
consistent with instrumentation effect.
Mixed inflammatory cells and numerous fungal organisms
morphologically consistent with [**Female First Name (un) 564**] species.
Cultures:
[**2-4**] Blood Cx:
KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES.
WARNING! This isolate is an extended-spectrum
beta-lactamase
(ESBL) producer and should be considered resistant to
all
penicillins, cephalosporins, and aztreonam. Consider
Infectious
Disease consultation for serious infections caused by
ESBL-producing species.
SENSITIVITIES: MIC expressed in
MCG/ML
_______________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- R
CEFUROXIME------------ =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- <=1 S
[**2-4**] Blood Cx: NO GROWTH.
[**2-4**] Urine Cx: NO GROWTH.
[**2-4**] PICC Tip:
WOUND CULTURE (Final [**2102-2-7**]):
KLEBSIELLA PNEUMONIAE. >15 colonies.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- R
CEFUROXIME------------ =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- <=1 S
[**2-5**] Stool:
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
(Reference Range-Negative).
A positive result in a recently treated patient is of
uncertain
significance unless the patient is currently
symptomatic
(relapse).
[**2-5**] Blood cx: neg x2
[**2-6**] MRSA screen neg
[**2-10**] Blood cx neg x 2
Brief Hospital Course:
Patient received 4.5 mg Zosyn and 6 L NS prior to admission to
SICU on [**2-4**]. Pt received 2 units FFP and a right IJ central
line was placed and patient was started on levophed and
Vancomycin and Zosyn. The PICC was removed and cultured. CT
abdomen and pelvis on [**2-4**] showed no abdominal collection, and
unchaged R>L bl pleural effusions. An ECHO showed LVEF of
30-35%, MR [**11-25**]+, and moderate PA systolic hypertension.
Infectious disease was consulted for recommendations on
treatment of sepsis.
Sepsis: ID was consulted on [**2-4**] and sepsis was intiallly
thought to be due to PICC bloodstream infection or urosepsis.
They recommended Daptomycin, Cefepime, Metronidazole, and oral
vancomycin. The PICC tip and 1 of 2 blood cultures were
positive for klebsiella. Patient was started on meropenem and
daptomycin and cefepime were stopped. Meropenem was continued
until the day of [**Month/Year (2) **]. On [**2-6**] patient was transferred to
the floor, and restarted on a beta blocker, and diuresis was
started. Blood cultures 3/16 and [**2-10**] were negative.
Mental Status: After transfer to the floor on [**2-6**], she was
noted to be quite anxious, and received her home psych meds.
Afterward, became somnolent, though her vitals and labs were
generally unchanged. There was concern that her ativan might
not be cleared in the context of acute renal failure, so ativan
and seroquel were stopped until she became more alert. Her
seroquel was restarted, as was her ativan, though care was taken
to separate the timing of administration of the seroquel,
ativan, and narcotics.
Acute renal failure: Renal consult obtained on [**2-7**], and
thought that this was likely due to multiple episodes of ATN.
Thorough laboratory workup and examination of urine revealed no
other causes. Creatinine peaked at 4.7 on [**2-9**] and decreased to
2.5 at time of [**Month/Year (2) **]. She received intermittent lasix for
diuresis. The renal consultants initially recommended keeping
patient's fluid status slightly positive, but at time of
[**Month/Year (2) **] were recommending even ins & outs.
Heme: Patient's initial INR was 2.3. She became
supratherapeutic with a peak of 4.1 on [**2-8**], and her coumadin
was held. Daily INR checked and coumadin dosed to target range
of [**12-27**]. INR was 2.9 at time of [**Date Range **].
Hematuria: Patient noted to have hematuria on admission (>50
RBCs), which may have been present for several days/weeks prior
to admission. On [**2-9**], she was noted to have >1000 RBCs in the
UA. Urology consulted, labs as above. Urine cytology and
bladder ultrasound negative. Recommend outpatient cystoscopy.
Abdominal Pain: Patient had intermittent abdominal pain and
tenderness throughout her hospitalization, which was thought to
be at her baseline. She was started on oral morphine for pain
control, which decreased the nausea she had experienced with
dilaudid.
Clostridium Difficle: Patient continued on oral vancomycin, ID
recommendation for 2 weeks of PO vancomycin through [**2102-2-20**].
Nutrition: At time of [**Year (4 digits) **], patient was tolerating clear
diet, and tubefeeds of Novasource Renal Full strength at 35
mL/hr and 150 mL flushes water q4hours.
Medications on Admission:
Vancomycin 750 qod, Coumadin 3' (goal [**12-27**]), Tylenol,
Olanzapine 5', Citalopram 40', Quetiapine 200'', Primidone 50HS,
Levothyrox 200', Mirtazapine 15HS, Lopressor 100''', Keppra
500''
IV, Nexium 40', Fentanyl ptch 100q3d, MVI, Sevelamer 1600''',
RISS
[**Month/Day (3) **] Medications:
1. Olanzapine 5 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO DAILY (Daily).
2. Citalopram 20 mg Tablet [**Month/Day (3) **]: Two (2) Tablet PO DAILY (Daily).
3. Quetiapine 200 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO BID (2 times
a day).
4. Mirtazapine 15 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO HS (at
bedtime).
5. Primidone 50 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO HS (at
bedtime).
6. Levothyroxine 100 mcg Tablet [**Month/Day (3) **]: Two (2) Tablet PO DAILY
(Daily).
7. Famotidine 20 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO DAILY (Daily).
8. Sevelamer Carbonate 800 mg Tablet [**Month/Day (3) **]: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
9. Levetiracetam 250 mg Tablet [**Month/Day (3) **]: Two (2) Tablet PO BID (2
times a day).
10. Insulin Regular Human 100 unit/mL Solution [**Month/Day (3) **]: see attached
Injection ASDIR (AS DIRECTED).
11. Vancomycin 125 mg Capsule [**Month/Day (3) **]: One (1) Capsule PO Q6H (every
6 hours) for 4 days: please use liquid form. .
12. Warfarin 2 mg Tablet [**Month/Day (3) **]: 1-1.5 Tablets PO once a day: goal
INR [**12-27**].
13. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Month/Day (3) **]: One (1) neb Inhalation Q6H (every 6 hours) as
needed for wheezing.
14. Metoprolol Tartrate 50 mg Tablet [**Month/Day (3) **]: Two (2) Tablet PO TID
(3 times a day).
15. Morphine 15 mg Tablet [**Month/Day (3) **]: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
16. Lorazepam 0.5 mg Tablet [**Month/Day (3) **]: 0.5 Tablet PO BID (2 times a
day) as needed: hold when sedated. do not give within 2 hours
of morphine.
[**Month/Day (3) **] Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
[**Location (un) **] Diagnosis:
Primary:
1. Sepsis
2. Klebsiella bacteremia
3. Hematuria
4. Acute Renal Failure
5. Clostridium difficle
6. Abdominal pain
[**Location (un) **] Condition:
Stable. Tolerating tube feeds, pain controlled, afebrile.
[**Location (un) **] Instructions:
Call or return to the ED for any of the following:
-chest pain, shortness of breath
-temperature > 101.5
-abdominal pain
-persistent vomiting
-increased stool output
-any other new or concerning symptoms
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] in [**12-27**] weeks for reevaluation. Call
his office at [**Telephone/Fax (1) 600**] to schedule an appointment.
For the blood in your urine, urology recommended an outpatient
cystoscopy with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3748**], please call [**Telephone/Fax (1) 3752**] for
an appointment.
|
[
"584.5",
"781.0",
"V12.51",
"008.45",
"999.31",
"E879.8",
"244.9",
"300.4",
"716.90",
"569.81",
"038.49",
"791.0",
"511.9",
"789.00",
"599.70",
"585.9",
"995.91",
"345.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
14409, 15501
|
332, 339
|
2520, 14386
|
20262, 20641
|
1980, 2019
|
17688, 19750
|
2034, 2034
|
19782, 19905
|
262, 294
|
19937, 19998
|
20033, 20239
|
367, 1596
|
2048, 2501
|
15517, 17662
|
1618, 1869
|
1885, 1964
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,721
| 119,913
|
48487
|
Discharge summary
|
report
|
Admission Date: [**2164-7-26**] Discharge Date: [**2164-8-11**]
Date of Birth: [**2096-6-9**] Sex: F
Service: MEDICINE
Allergies:
Latex / Oxaliplatin / Iodine; Iodine Containing / Fluconazole /
Ace Inhibitors
Attending:[**First Name3 (LF) 4057**]
Chief Complaint:
hypotension/UTI/bacteremia
Major Surgical or Invasive Procedure:
Multilumen CVC placement and removal
A line placement and removal.
History of Present Illness:
The patient is a 68 year old female with history of stage IV
metastatic colon cancer complicated by an enterocutaneous
fistula and extensive spread of carcinoma into the osotomy bag.
The patient presents with gross hematuria. One month ago, she
began to have dysuria and chills. She was found to have a UTI,
a urinary catheter was placed, and she was given a ten day
course of IV Cipro. The catheter was left in place for about
three weeks and removed one week ago. 2 days prior to
admission, patient had dysuria and UA was positive for UTI. She
was started on Cipro pending sensitivities. On day of
admission, the patient had three episodes of hematuria and she
was told by her doctor to come to the ED. She has no abdominal
or back pain, but has complained of chills for "a long time".
She currently has no change in her appetite, increased weakness,
cough, SOB, chest pain, fevers. She does have blood out of her
colostomy, which is normal for her due to colon ca.
.
In the ED, initial vs were: T 98.7 HR 110, BP 101/55, O2Sat
95%RA. the patient underwent CT abdomen/pelvis, two units were
typed and screened, and recieved vancomycin and Unasyn. SBP
went to 85 in the ED and she got 3L IVNS with 40meq KCl with
improvement in her blood pressure to SBP 90-110.
.
On the floor, the patients vitals were: HR 105 BP 108/61 RR 18.
she has no complaints.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
.
Past Medical History:
Metastatic colon cancer to lung and peripancreatic mass.
0riginally diagnosed in [**3-/2156**] with a T3 N0 M0 ulcerating colon
adenocarcinoma of the ascending colon. [**9-14**]: developed
metastatic disease in porta hepatis
Pulmonary Embolism
Recurrent SBO
SVC syndrome
DM (patient denies, being treated for at [**Location (un) 582**])
PAST SURGICAL HISTORY: Per OMR
s/p Small bowel resection, resection of mass, lysis of
adhesions [**5-20**]
s/p right cataract [**1-21**] s/p port [**7-16**]
s/p repair of incarcerated incisional hernia w/mesh [**5-16**]
s/p ORIF right ankle distal fibular fracture with plate and
screws [**3-15**]
s/p right colectomy [**3-13**]
ONCOLOGIC HISTORY: Per OMR
Prior chemotherapy and history:
[**2158-2-12**] Oxaliplatin/xeloda- discontinued after 1 dose because of
allergic reaction to oxaliplatin
[**2158-3-18**] Ankle fracture (admitted to hospital)
[**2158-3-15**]- [**2158-11-22**] Irinotecan/Xeloda for 9 cycles. discontinued
because of rising CEA
[**2158-12-27**] Erbitux/Irinotecan weekly started, baseline CEA 45. She
received a total of 7 combined Erbitux/irinotecan treatments.
CEA fell to 7 ([**2159-3-14**])
[**2159-4-11**] Begin single [**Doctor Last Name 360**] Erbitux, baseline CEA [**2159-5-4**] Repair of surgical hernia
[**2159-6-6**]- [**2159-10-3**] Erbitux/irinotecan, discontinued
because of allergic reaction to Erbitux (see below)
[**2159-10-24**] Begin [**Month/Day/Year 49565**]/irinotecan, CEA rose to 43
[**2159-12-25**] Begin 5-FU/LCV/[**First Name9 (NamePattern2) 49565**]
[**2160-1-13**] Cyberknife treatment (radiation therapy)
[**2160-12-12**] Begin [**Year (4 digits) 102068**]
[**Date range (3) 102071**] Hospitalization for pneumococcal mastoiditis
and meningitis
[**2161-3-12**]- [**2161-5-12**] Begin 5-FU/Leucovorin/[**First Name9 (NamePattern2) 49565**]
[**2161-6-12**] Cyberknife (radiation treatment)
[**2161-9-12**] 5-FU/Leucovorin/[**Year/Month/Day 49565**]
[**Date range (1) 102073**]: 5FU/Leucovorin x 33cycles
Present: cycle 2 Vectibix
Social History:
Husband died of cancer recently on [**2163-9-22**]. She immigrated from
[**Country 5976**] in [**2127**]. lives alone now. has 3 sons (1 in ME, 1 in UT, 1
in [**Location (un) 86**]). Currently on disability secondary to cancer;
formerly worked housekeeping for [**Hospital3 1810**]. EtOH:
none. Tobacco: none
Family History:
Mother and father with unknown cancer.
Physical Exam:
Admission PE:
Vitals: T: BP:118/94 P:108 R:23 18 O2: 100%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: left colostomy in place with fungating mass protruding,
small amount of brown fecal material in bag, no erythema,
colostomy site c/d/i, abdomen soft, non-tender, non-distended,
bowel sounds present, no rebound tenderness or guarding, no
organomegaly
GU: foley catheter in place draining bright red blood
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2164-7-26**] 01:22PM BLOOD WBC-9.1 RBC-3.01*# Hgb-8.0*# Hct-24.9*#
MCV-83 MCH-26.5* MCHC-32.0 RDW-19.4* Plt Ct-411
[**2164-7-26**] 01:22PM BLOOD Glucose-115* UreaN-13 Creat-0.7 Na-139
K-2.5* Cl-107 HCO3-25 AnGap-10
[**2164-7-31**] 05:54AM BLOOD ALT-5 AST-11 LD(LDH)-151 AlkPhos-60
TotBili-0.3
[**2164-7-31**] 04:55PM BLOOD Cortsol-19.5
[**2164-7-31**] 05:54AM BLOOD Cortsol-6.7
[**2164-8-1**] 03:31AM BLOOD Type-ART Temp-37.1 pO2-77* pCO2-28*
pH-7.45 calTCO2-20* Base XS--2 Intubat-NOT INTUBA
[**2164-7-26**] 01:24PM BLOOD Lactate-1.4
Microbiology:
[**2164-7-26**] URINE URINE CULTURE-FINAL {ESCHERICHIA COLI}
INPATIENT
[**2164-7-26**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2164-7-26**] BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY [**Hospital1 **]
[**2164-7-26**] BLOOD CULTURE Blood Culture,
Routine-PRELIMINARY {ENTEROCOCCUS FAECALIS}; Anaerobic Bottle
Gram Stain-FINAL
Brief Hospital Course:
The patient is a 68 year old female with a history of metastatic
colon cancer with extensive local spread into ostomy bag and
enterocutaneous fistula who presents with dysuria and gross
hematuria; now in septic shock with vanc-sensitive enterococcus
bacteremia and cipro-resistant E. Coli
# Hypotension ?????? For the patient's hypotension, she was initially
placed on pressor support with Levophed; she also received
broad-spectrum antibiotics per ID recommendations. Her
antibiotic regimen was tapered to cover her enterococcus
bacteremia as well as cipro-resistant E. coli UTI with Unasyn.
Her indwelling PICC line was removed and a temporary CVC was
placed. Her pressure continued to be labile after appropriate
antibiotic therapy and she maintained clear mentation and good
Uop despite BPs in the 80s-90s/50s. Her pressors were weaned
off. She was continued on antibiotics on [**8-9**] (amp/sulbactam).
She has remained afebrile. her heart rate has been persistently
in the low 100s, apparently her baseline. She was weaned off of
pressors. She was transferred to the oncology service for
further management where her blood pressure remained stable.
#Fluid balance - The patient's fluid balance remained tenuous
with depleted intravascular volume [**2-14**] hypoalbuminemia. She had
worsening bilateral pleural effusions as well as increased UE
edema and the decision was made to begin a lasix drip. She
diuresed a portion of this fluid and her edema had improved
prior to transfer to the floor. While on the floor and after
discussion with patient, TPN was discontinued, and patient began
to take PO. She received intermittent fluids IV, however over
the past 24 hours, has not required further IVFs. After transfer
to the oncology service, she was able to tolerate PO. She was
started on TPN and was maintained on this regimen until the day
of discharge. We discussed discontinuing TPN and the patient
agreed to this.
#Rash: The patient developed an erythematous rash on her abdomen
and thorax around her ostomy bag. The rash appeared fungal and
she was given miconazole cream as well as micafungin, this was
completed on [**8-11**] (7 days of Micafungin).
#Coagulopathy: The patient had an elevated INR during her ICU
course. She was given PO Vitamin K to normalize her PT. The
coagulopathy was thought to be [**2-14**] to poor PO. She did have one
episode of bleeding from her ostomy site and the patient's
lovenox was discontinued. She was transfused 2U PRBC in
addition, last tranfusion on [**8-6**] 2 Units. Her hematocrit had
stabilized prior to transfer from the ICU with slow decline to
range of 23-26 over the last two days. Given high risk of DVT
and hx of PE, Lovenox was restarted at 60mg SC BID. She should
have a HCT checked within 3 days of admission to the facility.
#Nutrition: The patient had decreased PO during her ICU stay.
She was placed on TPN. She received nutritional supplements as
per her home regimen. See above for nutrition discussion.
.
#. Metastatic Colon Cancer: For the patient's colon cancer -
metastatic and locally invasive, oncology recs were followed.
Her ostomy was closely cared for and she was placed on
anti-diarrheals to decrease output. She was given IVF to keep up
with ongoing losses. She was placed on a fentanyl patch for
pain. Near the end of her ICU stay, the patient and her family
decided to change her code status to DNR/DNI and a morhpine drip
was added to help control the pain. No further interventions
were made. She was comfortable and pain free at time of
discharge.
# History of PE's - The patient received lovenox for her history
of PEs. This was discontinued, however, when she had increased
bleeding from her ostomy site. She was placed on pneumoboots for
DVT prophylaxis, however, as listed above, lovenox was restarted
give her high risk for VTE and stable hematocrit. She did have
RUE edema at site of picc, US was negative for DVT, PICC was
left in place due to difficult placement in IR and in case she
requires further IVF or transfusions.
# h/o depression: She was kept on her home medication
Mirtazapine.
# Hematuria ?????? The patient's hematuria early in her admission
resolved with antibiotic treatment of her UTI.
# Stoma care: fistula pouch was changed as needed. Her
peri-fistula skin remained intact but was red. The fungating
tumor continues to get larger and also
continues to bleed a significant during the cleansing of the
site. She was again pouched with Coloplast [**Month/Year (2) **]/fistula pouch.
[**Last Name (un) **] seals and surgical cement were added to the adhesive
surface of the pouch and cement was added to her skin and
allowedto dry for a few minutes prior to applying the pouch to
her. The
pouch's edges were taped using Pink Hy Tape. The cover of
thepouch was cemented on as well as taped in place. Both ports
of the Pouch were connected to gravity drainage.
Hospital order numbers for the items used:
Pouch # [**Numeric Identifier 102074**]
Cement # [**Numeric Identifier 102075**]
[**Last Name (un) **] seal # [**Numeric Identifier 89560**]
Stomahesive paste # [**Numeric Identifier 102076**]
Optional supplies:
Stomahesive powder # [**Numeric Identifier 102077**]
No Sting Barrier Wipe # [**Numeric Identifier **]
Code status: DNR/I.
Medications on Admission:
Ensure supplement TID
Neutraphos packet TID
Fluticasone 50 mcg 2 prays each nostril [**Hospital1 **]
Ferrous gluconate 324 mg [**Hospital1 **] with meals
Sodium Bicarb 650 mg tab 2 tabs by mouth TID
Vitamin C 500 mg [**Hospital1 **]
Omeprazole 20 mg [**Hospital1 **]
Rifaxamin 200 mg daily
Lovenox 60 mg q12h
Fentanyl 100 mcg patch q72h
Discharge Medications:
1. Fluticasone 50 mcg/Actuation Spray, Suspension [**Hospital1 **]: Two (2)
Spray Nasal [**Hospital1 **] (2 times a day).
2. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet [**Hospital1 **]: One (1)
Tablet PO TID (3 times a day).
3. Ascorbic Acid 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2
times a day).
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Hospital1 **]: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
5. Rifaximin 200 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a
day).
6. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Psyllium 1.7 g Wafer [**Hospital1 **]: One (1) Wafer PO TID (3 times a
day).
8. Mirtazapine 15 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at
bedtime).
9. Miconazole Nitrate 2 % Cream [**Hospital1 **]: One (1) Appl Topical [**Hospital1 **] (2
times a day): Please apply to affected area around ostomy site
and under left breast.
10. Miconazole Nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical [**Hospital1 **]
(2 times a day): Please apply to affected area around ostomy
site and under left breast.
.
11. Opium Tincture 10 mg/mL Tincture [**Hospital1 **]: Fifteen (15) Drop PO Q
12H (Every 12 Hours).
12. Loperamide 2 mg Capsule [**Hospital1 **]: One (1) Capsule PO Q4H (every 4
hours).
13. Fentanyl 100 mcg/hr Patch 72 hr [**Hospital1 **]: One [**Age over 90 **]y Five
(125) mcg Transdermal Q72H (every 72 hours).
14. Insulin Regular Human 100 unit/mL Solution [**Age over 90 **]: One (1) per
sliding scale Injection ASDIR (AS DIRECTED).
15. Acetaminophen 325 mg Tablet [**Age over 90 **]: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain, fever.
16. Morphine 100 mg Tablet Sustained Release [**Age over 90 **]: Two (2) Tablet
Sustained Release PO Q12H (every 12 hours).
17. Morphine 10 mg/5 mL Solution [**Age over 90 **]: One (1) mg PO Q2H (every 2
hours) as needed for pain.
18. Prochlorperazine Maleate 10 mg Tablet [**Age over 90 **]: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
19. Lovenox 60 mg/0.6 mL Syringe [**Age over 90 **]: One (1) Subcutaneous
twice a day.
20. Outpatient Lab Work
HCT Weekly to assess for Anemia.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] of [**Location (un) 583**]
Discharge Diagnosis:
Enterococcal sepsis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to [**Hospital1 18**] with infection on your blood. You
were treated with antibiotics and have restarted to take some
food by mouth. You TPN (supplemental IV nutrition) was
discontinued after discussion with you. Now that you infection
is controlled and you are taking some food by mouth, you are
being discharged to your facility.
Please take all medications as written.
Please follow up with your doctor at the nursing home.
Please call the office of Dr. [**First Name8 (NamePattern2) 2426**] [**Last Name (NamePattern1) 2427**], [**Telephone/Fax (1) 250**] to
confirm your follow up plans.
Followup Instructions:
Please follow up with you care giver at [**Hospital 24591**] nursing home.
Please call the office of Dr. [**First Name8 (NamePattern2) 2426**] [**Last Name (NamePattern1) 2427**], [**Telephone/Fax (1) 250**] to
confirm your follow up plans.
|
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52,389
| 127,115
|
42688
|
Discharge summary
|
report
|
Admission Date: [**2137-1-28**] Discharge Date: [**2137-2-2**]
Date of Birth: [**2074-8-14**] Sex: M
Service: MEDICINE
Allergies:
lisinopril / Penicillins
Attending:[**First Name3 (LF) 602**]
Chief Complaint:
nausea, vomiting, diffuse abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt is a 62 yo M transferred from [**Hospital3 **] Hospital for possible
necrotic pancreatitis. Pt was in his usual state of health until
2 days ago, when he developed [**9-23**] abdominal pain. Pt was
nauseated and had dry heaves. He also felt weak for a few days
prior. Pt usually drinks [**1-14**] pints of rum (Captain [**Doctor Last Name **])
daily, last drink 2d PTA. Pt tried taking pepto-bismol and
maalox, but these did not relieve pain. Also feels that his
abdomen is larger than normal. Denies any fevers, sweats,
reports mild chills. No cough, no shortness of breath, no chest
pain. No diarrhea or constipation, no urinary symptoms. No focal
numbness or weakness.
Pt initially presented to [**Hospital3 **] Hospital, where his vitals
were 152/87, HR 119, RR 28, Temp 100.9F, Sat 97% RA. He was
found to have a lipase of 3000, AP 35, and Tbili 1.6, AST 118,
ALT 117. Lactic acid 4.4, WBC 9.3, Hct 42, Plt 156. Troponin <
0.046. Potassium 2.7, Cr 1.05. He was given potassium repletion,
2L NS and had a CT abdomen w/ IV contrast, which showed an
edematous pancreas w/ "slightly decreased enhancement of the
tail, peripancreatic fat stranding, and small amount of
ascites." Question of possible early necrosis of the tail vs
decreased enhancement secondary to edema. Pt had difficult to
control pain. Pt was then transferred to [**Hospital1 18**] ED.
.
In the [**Hospital1 18**] ED inital vitals were, 99.3 126 149/87 18 96%. Pt
received K repletion and another 3L fluid bolus.
.
On arrival to the ICU, vitals were 99.6F, 119, 157/87, RR 23,
96% 2L nc. Pt reports having [**7-23**] generalized burning abdominal
pain that does not change with palpation.
.
Review of systems:
Per HPI
Past Medical History:
type 2 diabetes - oral meds
hypertension
alcohol abuse - no h/o DTs, no seizures
chronic bilateral hip pain
hepatitis C, cleared w/ treatment
hyperlipidemia
severe spinal stenosis w/ radiculopathy
hypogonadism
Past Surgical history:
-L hip replacement
Social History:
lives in [**Location 3615**], MA. Works as a security guard. Has a
long-term girlfriend.
- Tobacco: rare
- Alcohol: drinks [**1-14**] pints of rum daily for 20 years
- Illicits: prior heroin use. None in decades.
Family History:
DM in father's side. No cancer or heart disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 99.6F, 119, 157/87, RR 23, 96% 2L nc.
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx normal
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Distant heart sounds, tachycardic rate, normal rhythm,
normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, moderately distended / obese, moderate pain in
upper abdomen but not noticeably worse w/ palpation. No masses.
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Exam on day of transfer to [**Hospital3 **] Hospital:
Vitals: Tm 101 Tc 99.9 BP 110s-120s/80s HR 100s, RR 18-22,
95-98% on RA
General: Alert, oriented, no acute distress. He is pleasant and
speaks in full sentences
HEENT: Sclera anicteric, MMM, oropharynx normal
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Distant heart sounds, tachycardic rate, normal rhythm,
normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, moderately distended / obese, no pain with deep
palpation.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
LABS:
On admission:
[**2137-1-28**] 12:00PM BLOOD WBC-10.4 RBC-4.54* Hgb-14.5 Hct-40.7
MCV-90 MCH-31.9 MCHC-35.6* RDW-14.0 Plt Ct-142*
[**2137-1-28**] 12:00PM BLOOD Neuts-92.7* Lymphs-4.0* Monos-2.7 Eos-0.4
Baso-0.2
[**2137-1-28**] 12:00PM BLOOD PT-12.2 PTT-24.0* INR(PT)-1.1
[**2137-1-28**] 12:00PM BLOOD Glucose-240* UreaN-18 Creat-1.0 Na-132*
K-3.2* Cl-96 HCO3-24 AnGap-15
[**2137-1-28**] 12:00PM BLOOD ALT-104* AST-119* AlkPhos-40 Amylase-326*
TotBili-1.8*
[**2137-1-28**] 12:00PM BLOOD Lipase-830*
[**2137-1-28**] 05:16PM BLOOD Albumin-3.5 Calcium-7.5* Phos-1.1* Mg-1.7
[**2137-1-28**] 05:16PM BLOOD Triglyc-103
[**2137-1-28**] 12:34PM BLOOD Glucose-224* Lactate-2.4* Na-137 K-3.1*
Cl-98 calHCO3-26
[**2137-1-28**] 12:34PM BLOOD freeCa-0.99*
Notable studies:
Microbiology:
Blood cxs from [**1-28**], [**1-29**], and [**1-31**] all no growth to date
UCx [**1-28**]: >3 colonies c/w contamination
Radiology:
Read of CCH CT [**1-28**]: CT OF THE ABDOMEN AND PELVIS WITH IV
CONTRAST: This examination was performed at [**Hospital3 **] Hospital
and a second read was requested. The examination is performed
with intravenous contrast.
CT OF THE ABDOMEN WITH IV CONTRAST: There is mild atelectasis in
the lower
lobes as well as the lingula. There are no pleural effusions.
The liver
measures 56 Hounsfield units on this contrast enhanced scan
compared to the spleen which measures 101 Hounsfield units, this
is consistent with fatty deposition. The gallbladder is
unremarkable. No stones are seen. The spleen is normal in size,
there is a small amount of ascites is seen surrounding the
spleen. The pancreas is edematous. Enhancement of the pancreas
varies with an air in the uncinate process enhancing to only 25
Hounsfield units and an area in the body of the pancreas
enhances to 50 Hounsfield units. The pancreatic tail enhances to
30 Hounsfield units. There is extensive stranding surrounding
the pancreas with fluid along Gerota fascia bilaterally. The
portal vein is patent as is the splenic vein and SMV. The
adrenal glands are
normal. The kidneys are normal in size. There is no
retroperitoneal
lymphadenopathy. No hydronephrosis is identified. The small and
large bowel
loops are normal. There are some diverticula along the
descending colon.
CT OF THE PELVIS WITH IV CONTRAST: There is artifact from a left
total hip
prosthesis that obscures interpretation of the true pelvis. The
bladder is
filled and appears unremarkable. There is a small amount of free
fluid in the pelvis. Some diverticula seen along the sigmoid
colon. There is no pelvic lymphadenopathy. On bone windows,
there are degenerative changes involving the lumbar spine as
well as the right hip. No concerning osteolytic or
osteosclerotic lesions are seen.
IMPRESSION:
1. Acute pancreatitis. Small areas of necrosis may be present in
the
uncinate process and the tail of the pancreas.
2. Fatty infiltration of the liver.
3. Small amount of ascites
CXR [**1-31**]: FINDINGS: A small left pleural effusion is stable, and
likely represents
irritation from patient's known pancreatitis. Bibasilar
atelectasis is
unchanged and still persists on the right. There is no pleural
effusion on
the right. Lung volumes are larger than in the previous chest
x-ray, which
makes the cardiac silhouette appear more normal. There is no
definite
enlargement of the cardiac size in today's examination. There is
no
congestion or pulmonary edema. There is no pneumothorax.
IMPRESSION:
1. Stable small left pleural effusion.
2. Stable bibasilar atelectasis.
[**1-29**] RUQUS: IMPRESSION:
1. Technically limited scan with non-visualization of the
pancreas.
2. No intra- or extra-hepatic biliary dilation and no biliary
stones
identified.
3. Fluid adjacent to normal-appearing gallbladder
Discharge Labs:
[**2137-2-2**] 06:45AM BLOOD WBC-8.0 RBC-4.04* Hgb-12.8* Hct-37.3*
MCV-92 MCH-31.7 MCHC-34.4 RDW-14.4 Plt Ct-172
[**2137-2-1**] 06:25AM BLOOD Glucose-227* UreaN-6 Creat-0.9 Na-135
K-3.5 Cl-97 HCO3-27 AnGap-15
[**2137-2-2**] 06:55AM BLOOD ALT-46* AST-34 AlkPhos-48 TotBili-0.7
[**2137-2-1**] 06:25AM BLOOD Calcium-9.0 Phos-2.5* Mg-1.9
Brief Hospital Course:
62 yo M w/ PMH of chronic pain, alcohol abuse, and type 2
diabetes admitted from [**Hospital3 **] Hospital for necrotizing
pancreatitis. Course was notable for Pantoea bacteremia. Patient
was transferred back to [**Hospital3 **] Hospital clinically stable
after showing improvement with conservative management for
continued monitoring and to be closer to family.
#Acute necrotizing pancreatitis: This was felt to be due to
alcohol as there were no signs of gallstones on OSH CT.
Presented to OSH with increased LFTs, lipase, lactate. OSH CT
abdomen showed decreased contrast enhancement of pancreatitc
tail, which is compatible with potential early necrosis. On
admission found to be hypertensive, persistently tachycardic to
120s, in moderate pain. Pt was admitted to ICU for close
monitoring, per recommendation of the pancreatitis consult
service (consulted in the ED). Shortly after his arrival, his
blood cultures from the OSH turned positive for [**Last Name (LF) 77756**], [**First Name3 (LF) **] he was
started on zosyn. He was aggressively fluid resuscitated,
lactate normalized, and lipase trended down. He was made NPO
with strict bowel rest, and pain was controlled with frequent IV
dilaudid. RUQUS obtained to rule out gallstones and possible
cholangitic picture was negative. He remained hemodynamically
stable while in the ICU and had downtrending liver chemistries
and lipase. Prior to transfer to [**Hospital3 **] Hospital he was able
to tolerate a full liquid diet without problems. [**Name (NI) **] was
transferred to [**Hospital3 **] Hospital hemodynamically stable, taking
pos well, and amlodipine was added as he was not hypotensive.
His home HCTZ was not started as he had mild tachycardia to the
100s and was felt to still have mild inflammatory state. Patient
was given instructions to follow up in Gastroenterology and
Hepatology clinics either at [**Hospital1 18**] or closer to his home at [**Location (un) 28985**].
.
#Severe sepsis/Pantoea bacteremia: Patient met criteria for
severe sepsis on admission -- SIRS criteria + [**Location (un) 77756**] on OSH blood
culture + lactate 4.4. Suspected abdominal source, started
empirically on zosyn. CT and CXR also showed a LLL lung
opacity, however this looked more compatible with atelectasis
and effusion from pancreatitis than infiltrate, and he denied
pulmonary symptoms. He was therefore not treated for pneumonia.
UA was normal and UCx consistent with contamination. Blood
pressures remained stable (actually hypertensive) with
aggressive fluid rescuscitation, and he did not require
pressors. Pt was started on Zosyn on [**1-28**] for suspected GI
source. On [**1-29**], one of two blood culture bottles at [**Hospital3 **]
Hospital grew a Pantoea species, with the following
sensitivities on [**1-30**]: Intermediate to Cephazolin, cefo.
Resistant to Ampicillin and Amp-Sulbactam. Sensitive to Ceftaz,
CTX, Ertapenem, Gent, Bactrim, Levo, Cipro. His antibiotics were
changed to ceftriaxone/metronidazole on [**1-30**] after
discussion with infectious disease service given resistance to
Amp/sulbactam. Zosyn testing was added on to his OSH blood
cultures. On [**1-31**], [**Hospital3 **] Hospital reported that the
organism was sensistive to Zosyn. ID ultimately recommended
treating with iv ceftriaxone for 14 days without metronidazole.
(through [**2137-2-10**]). He had a midline placed in his right forearm
and received a dose of Ceftriaxone prior to transfer to CCH.
Patient will need home infusion services set up prior to
discharge if he is discharged home to continue his abx.
#Fever:
Patient had a temperature to 101 the day prior to transfer to
CCH. He was asymptomatic and it did not recur prior to transfer.
All blood cxs have remained negative. This should be followed
with further evaluation as indicated should his fevers return.
Given that the patient was asymptomatic this is most likely
related to either atelectasis or residual pancreatic
inflammation that continues to improve.
.
#Tachycardia: Initially persistently tachycardic to the 120s,
thought to be due to a combination of pain, dehydration, alcohol
withdrawl, and sympathetic activation from pancreatitis. Slowly
improved throughout his stay in the ICU with pain control and
benzodiazepines for alcohol withdrawal (see below). Pt was at
one point 13 L positive during and had voluminous urine output
starting [**1-30**]. IV fluids were stopped. Patient was close to
euvolemia on transfer to CCH.
# Alcohol abuse with withdrawal: Patient endorsed long-term
alcohol abuse with last drink 2 days prior to admission. Placed
on CIWA scale, required frequent ativan for anxiety initially
but did not require any benzodiazepines for 24 hours prior to
transfer to CCH. He was also started on thiamine and folate.
Social Work followed the patient.
# Delirium: He began to get more delirious and at times
agitated during his stay in the ICU, which improved with
treatment of infection, pain control, and alcohol withdrawal.
This was not an issue on transfer to CCH.
# Chronic pain: Patients home pain medications were held given
his treatment with IV dilaudid for pancreatitis, but upon
transfer to CCH he can likely be taken off IV dilaudid and
restarted on his home pain medications given that he can
tolerate a regular diet.
# Hypertension: Held home meds (amlodipine, hctz) while in the
ICU, given concern for developing hypotension. Amlodpine was
restarted. HCTZ was held on transfer and may be able to be
restarted closer to discharge from the hospital or at follow up
PCP [**Name Initial (PRE) **].
# Hypercholesterolemia: Held home statin given transaminitis.
[**Month (only) 116**] be restarted at outpatient PCP [**Last Name (NamePattern4) **].
# Diabetes mellitus type 2, controlled, without complications:
Patient was managed with an insulin sliding scale as well as
metformin.
# BPH: Initially held in the ICU, and restarted on day of
transfer out of the ICU given pt remained HD stable.
#Dispostion: Patient was transferred back to [**Hospital3 **] Hospital
where he initially came from per the patient's request. He will
need IV Ceftriaxone for a total of 2 weeks to end [**2137-2-10**] and
will need outpatient GI, Hepatology, and PCP follow up.
Medications on Admission:
simvastatin 10mg qhs
amlodipine 5mg daily
doxyzosin 2mg daily
metformin 1000mg [**Hospital1 **]
norco 10/325 1 tab tid
hydrochlorothiazide 25mg daily
Discharge Medications:
1. ceftriaxone in dextrose,iso-os 1 gram/50 mL Piggyback Sig:
One (1) GRAM Intravenous Q24H (every 24 hours).
2. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
3. doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
4. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
8. 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.
9. Ondansetron 4 mg IV Q8H:PRN nausea
10. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for upset stomach.
11. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
12. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for pain.
13. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
14. lorazepam 1 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for CIWA>10.
15. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day).
16. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
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. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
19. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
20. insulin regular human 100 unit/mL Solution Sig: as directed
units Injection ASDIR (AS DIRECTED): Please give at AC
FSG(mg/dL) Insulin
71-100mg/dL 0 units
101-150 2 Units 151-200 4 Units [**Telephone/Fax (2) 92280**]-300 8 Units 301-350 10 Units
351-400 12 Units 400 mg/dL Notify M.D. .
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Pancreatitis, acute, necrotizing
Alcohol abuse and withdrawal
Back pain, chronic
Fatty liver
Sepsis, Pantoea bacteremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted because of acute pancreatitis. You were
initially admitted to the ICU and were seen by the
Gastroenterology service. You were found to have necrotizing
pancreatitis but improved with conservative management. You were
also noted to have bacteria in your blood and are being treated
with IV antibiotics which you should continue for 2 weeks.
Please follow up with a Gastroenterologist and Hepatologist as
noted below as well as with your PCP.
Followup Instructions:
1) Please call the Digestive Disease Center Department at
[**Telephone/Fax (1) 87101**] located at E/[**Hospital Ward Name 1950**] 3 to set up a follow up
appointment at [**Hospital1 18**] for your pancreatitis in one month. You may
also see a Gastroeneterologist closer to your home at [**Location (un) **]
in one month for follow up.
2) Please call the Liver Center at [**Telephone/Fax (1) 2422**] located at
W/LMOB-8E and please schedule a follow up in one month for
follow up of your liver disease.
3) Please call your PCP and schedule [**Name Initial (PRE) **] follow up appointment in
[**1-14**] weeks following discharge from [**Hospital3 **] Hospital.
|
[
"577.0",
"276.51",
"995.92",
"250.00",
"401.1",
"511.9",
"038.49",
"600.00",
"291.81",
"303.91",
"272.4",
"518.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
16478, 16493
|
7984, 14223
|
325, 332
|
16657, 16657
|
3860, 3866
|
17292, 17959
|
2581, 2632
|
14424, 16455
|
16514, 16636
|
14249, 14401
|
16808, 17269
|
7626, 7961
|
2310, 2331
|
2672, 3841
|
2044, 2054
|
244, 287
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360, 2025
|
3880, 7610
|
16672, 16784
|
2076, 2287
|
2347, 2565
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,676
| 137,455
|
2018+55342
|
Discharge summary
|
report+addendum
|
Admission Date: [**2202-4-2**] Discharge Date: [**2202-4-6**]
Date of Birth: [**2138-2-22**] Sex: M
Service: SURGERY
Allergies:
Penicillins / Protonix / Codeine / Venomil Honey Bee Venom /
Vicodin
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Acute exacerbation of Left flank/back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
64M well-known to Dr. [**Last Name (STitle) **], w/ multiple medical issues who
has a known 5.5 cm AAA, last seen in clinic on [**3-25**] (at which
time was an increase by 4 mm since [**2201-7-27**]), now presents from
[**Hospital6 8972**] with acute exacerbation of lower back
pain and left flank pain. The patient has chronic lower back
pain (s/p lumbar spinal fusion) but this is an exacerbation at
rest and the patient states that this pain is markedly different
from his chronic back pain. The patient denies nausea/vomiting,
dizziness, chest pain, shortness of breath, or loss of
consciousness. He had a L CEA on [**2201-8-18**], was readmitted POD4
for neck hematoma and troponin leak. He is also s/p CABGx4 [**2199**]
but he has been stable from a cardiac standpoint since then.
There was a concern for AAA leak/rupture however, CTA abd/pel at
the OSH did not demonstrate any evidence for leak/rupture. He
was treated for his HTN but was stable overall and he was
transferred to [**Hospital1 18**] for further evaluation and treatment.
Past Medical History:
PMH:
- Abdominal aortic aneurysm (last assessed by US on [**2202-3-25**] at
which time, the aneurysm measured 5.5cm that had a 4 mm growth
compared to the prior study dated [**2201-7-27**]).
- Renal artery stenosis (right kidney atrophic, left renal
artery status post angioplasty and stenting)
- Bilateral carotid artery stenosis s/p L CEA
- Aortic ulcer - type A penetrating aortic ulcer, 8 x 8 mm
involving the junction of the ascending aorta and the aortic
arch, identified on CTA on [**2200-7-23**].
- Chronic kidney disease, stage 3-4, followed by Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] in nephrology. Single functioning L kidney with renal
artery stent; R atrophic kidney.
- Hypertension.
- Hyperlipidemia.
- PVD.
- Chronic left lower extremity swelling (thought to be related
to prior saphenous vein graft harvesting).
- Secondary hyperparathyroidism.
- Right radial nerve palsy.
- GERD, on omeprazole.
- Lumbar disc herniation at L4-L5.
- Spinal stenosis.
- Chronic back pain (on narcotics, [**Location (un) 86**] pain clinic).
- Restless legs syndrome (on ropinirole, but was previously on
pramipexole).
- Insomnia, on Ambien.
- PTSD.
- OSA.
- COPD; hypersensitivity pneumonitis.
- anisicoria (R 0.5 > L)
- ETOH abuse.
PSH:
- Left carotid endarterectomy and bovine pericardial patch
angioplasty [**2201-8-18**]
- Coronary artery disease status post CABG x4 on [**2200-2-27**]
(LIMA to LAD, SVG to OM2, SVG to distal RCA, SVG from OM vein
graft to D1)
- spinal stenosis s/p total laminectomy at L4 and discectomy
L4-L5 on [**2198-3-30**], s/p partial vertebrectomy of L4 and L5 and
fusion L4-S1 on [**2198-11-12**], s/p revision laminectomy of L4,
total laminectomy of L5, and fusion L4-S1 on [**2198-11-13**].
Social History:
Lives in [**Location (un) 8973**] with family. The patient is a retired
police officer (retired in [**2192**]). Tobacco smoking: half a pack
per day starting at age 15, smoking up to two packs per day,
currently on Chantix. Former heavy alcohol use between [**2159**] and
[**2192**]. Currently, he drinks one drink per week. No other drug
usage.
Family History:
Father died of an intracranial hemorrhage at the age of 35.
Paternal grandparents both had strokes. Maternal grandfather had
an AAA. Maternal grandmother had diabetes. A daughter has
breast cancer. Another daughter is healthy. Five grandsons are
healthy.
Physical Exam:
Tm/Tc: 98.8/97.3 HR: 54 BP: 117/72 RR: 16 SaO2: 94% 2L NC
Gen: AAOx3, NAD, sitting up in chair, tolerating PO
Heart: RRR
Lungs: CTAB
Abd: +BS, soft, NT, ND
Back: min L back pain on palpation
Extremities: no CCE
RLE Femoral: P. DP: P. PT: P.
LLE Femoral: P. DP: D. PT: P.
Pertinent Results:
[**2202-4-2**] 04:05AM:
Trop-T: 0.01
138 106 19 AGap=14
------------< 99
4.5 23 2.0
estGFR: 34/41
Ca: 8.2 Mg: 2.1 P: 3.0
5.3 \ 9.6 / 273
/ 28.5 \
N:71.8 L:17.3 M:6.0 E:4.0 Bas:0.9
PT: 14.3 PTT: 25.8 INR: 1.2
[**2202-4-2**] 05:50AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.015
BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG
[**2202-4-5**] 03:05a:
140 102 18 / 75 AGap=17
--------------
3.9 25 2.5 \
Ca: 8.5 Mg: 2.1 P: 4.4
5.3 \ 8.9 / 215
/ 27.1 \
IMAGING:
CTA abd/pel w/ recons [**2202-4-2**]:
1. Extensive atherosclerotic disease involving the thoracic and
abdominal aorta with calcified and noncalcified plaque
formation. Soft tissue penetrating ulcers in the thoracic aorta
are stable. No evidence of active abdominal aortic aneurysm
rupture.
2. Interval increase in the size of the abdominal aortic
aneurysm, now measuring 5.6 cm, previously measured 5.0 cm.
3. Extensive branch vessel narrowing and stenosis, including
SMA.
4. Centrilobular emphysema and borderline enlargement of the
mediastinal lymph nodes, unchanged.
Brief Hospital Course:
The patient was transferred from [**Hospital6 8972**] for
exacerbation of L flank/back pain in the setting of known
enlarging AAA. Inital concern for AAA leak/rupture but CTA
there did not demonstrate any evidence of an acute process.
On arrival, patient was admitted to the CVICU and was
aggressively treated with IV/PO antihypertensives to control his
BP (goal of SBP<120) and a repeat CTA abd/pel with
reconstructions was performed. This demonstrated: extensive
atherosclerotic disease involving the thoracic and abdominal
aorta with calcified and noncalcified plaque formation, stable
appearance of penetrating ulcers in thoracic aorta without
evidence of active AAA rupture but interval increase in size to
5.6 cm from 5.0cm.
He was treated with hydration/bicarb/mucomyst for renal
protection after the dye loads from the CTA. His pain was
controlled with IV/PO narcotics and his symptoms progressively
improved.
His imaging was extensively reviewed with Dr. [**Last Name (STitle) **] and the
entire [**Last Name (STitle) 1106**] service and the decision was made to continue
only conservative management given that the risks of operative
intervention greatly outweighed the potential benefits,
especially in the current setting where his symptoms were
improving and his was clinically stable. This was discussed
with the patient and his family.
The patient was eventually titrated off IV medications and was
stabilized with only PO medications. He was restarted on a
regular cardiac diet on HD 3 and continued to void well. His
creatinine was elevated from his baseline of 2.0 to 2.5 on HD4
but repeat Cr was 2.6. On HOD#5 his Creatinine was 2.7 and he
will follow-up with blood pressure and creatinine checks with
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (neprhologist). He has an outpatient
appointment later this week.
He was discharged to home in stable condition with new
adjustments in his PO anti-hypertensive medications and was
instructed to follow-up with Dr. [**Last Name (STitle) **] next week.
Medications on Admission:
lipitor 40 daily, diovan 40 daily, pramipexole 0.125 daily,
Chantix 1mg [**Hospital1 **], nortripyline 25 daily, ASA 81 daily, Niaspan
500 qHS, calcitriol 0.25 mcg daily, omeprazole 40mg daily,
sertraline 200 daily, oxycodone 5 prn, oxycodone ER 20mg [**Hospital1 **],
ferrous sulfate 325 daily, amlodipine 5 daily, labetolol 300
[**Hospital1 **], folic acid 1 daily
Discharge Medications:
1. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. nortriptyline 25 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. sertraline 50 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
8. labetalol 100 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
9. oxycodone 20 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q12H (every 12 hours).
10. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for breaktrhough pain.
Disp:*60 Tablet(s)* Refills:*0*
11. pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO daily ()
as needed for restless legs.
12. valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
14. ferrous sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO once a day.
15. Niaspan Extended-Release 500 mg Tablet Extended Release 24
hr Sig: One (1) Tablet Extended Release 24 hr PO at bedtime: Per
Dr. [**Last Name (STitle) **]: Please take two baby aspirins (162 mg) 30 minutes
before and after taking the Niaspan.
16. Chantix 1 mg Tablet Sig: One (1) Tablet PO twice a day.
17. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
18. Outpatient Lab Work
Creatinine level prior to Nephrology appointment on [**2202-4-8**] at
9:30AM
Discharge Disposition:
Home
Discharge Diagnosis:
Enlarged AAA without evidence of leak/rupture
Exacerbation of left flank and chronic back pain
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* Excruciating, or changing back pain
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* Continue to ambulate several times per day.
* No heavy ([**9-18**] lbs) until your follow up appointment
Followup Instructions:
Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2202-4-7**] 1:10
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 3736**]
Date/Time:[**2202-4-7**] 1:30
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2202-4-22**] 12:30
You have an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (nephrology) on
[**2202-4-8**] at 09:30AM for a creatinine check. Please take the
prescription for labs to be collected prior to your appointment.
Name: [**Known lastname **],[**Known firstname **] R Unit No: [**Numeric Identifier 1542**]
Admission Date: [**2202-4-2**] Discharge Date: [**2202-4-6**]
Date of Birth: [**2138-2-22**] Sex: M
Service: SURGERY
Allergies:
Penicillins / Protonix / Codeine / Venomil Honey Bee Venom /
Vicodin
Attending:[**First Name3 (LF) 1546**]
Addendum:
CLARIFICATION:
The patient had documented renal insufficiency and was noted to
have an acute creatinine elevation while hospitalized. The acute
renal failure was likely related to the constrast agents
received during CT imaging, although pre-contrast hydration with
bicarbonate and mucomyst was employed. The patient was scheduled
to follow-up with his nephrologist regarding his creatinine
elevation. His most recent creatinine was 2.4, which has
decreased since discharge.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1547**], MD
Discharge Disposition:
Home
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1548**] MD [**MD Number(1) 1549**]
Completed by:[**2202-4-28**]
|
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icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
13036, 13199
|
5356, 7410
|
369, 376
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9725, 9725
|
4183, 5333
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287, 331
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404, 1452
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9740, 9852
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1474, 3227
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3243, 3595
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,511
| 162,801
|
34431
|
Discharge summary
|
report
|
Admission Date: [**2172-6-26**] Discharge Date: [**2172-7-8**]
Date of Birth: [**2108-9-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1666**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
Pleurex catheter placement.
History of Present Illness:
Mr. [**Known lastname **] is a 63yo gentleman with h/o thoracic aortic
aneurysm and tobacco abuse admitted with shortness of breath.
Over the last 3 weeks, Mr. [**Known lastname **] has had worsening shortness
of breath, particularly at night. He wakes up repeatedly during
course of night unable to get his breath. Uses a fan to try to
relieve his sense of dyspnea and symptoms improve after 15-20
minutes. He describes DOE such that he has to stop to rest [**3-14**]
times when climbing 2 flights of stairs. +Chronic cough
productive of white sputum. +Weight loss of >30 pounds over 3
months. He sleeps with only one pillow.
Patient also describes chronic tightness around his chest
wrapping around his left side to his back at the bottom of his
rib cage ever since he had a repair of esophageal rupture about
5 years ago at [**Hospital1 112**]. Over the last 3 weeks, this chronic pain
has been more intense.
At [**Hospital3 3583**], he was given nebulizers with some
improvement in symptoms. CT chest showed stable aneurysm at
4.5cm but new 2.7x2.6cm non-calcified thrombus. He was also
found to have a large, loculated right pleural effusion with R
hilar and mediastinal adenopathy compressing his right middle
and lower lobe.
In the ED, his VS were: 97.5 143/100 86 16 97% 4L. He
was started on an esmolol gtt, but continued to have SBP in
150s-160s and pulse in 70s-80s. He also received morphine 4mg
IV for pain. CT surgery evaluated the patient and stated there
was no indication for surgery.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative except as noted above.
Cardiac review of systems is notable for absence ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
HTN
Thoracic Aortic Aneurysm
Esophageal rupture [**1-11**] emesis (Boerhaave's syndrome)
Chronic bronchitis
Rheumatoid Arthritis??
Denies h/o CAD but has stress test suggestive of prior ischemia
(described below)
ALLERGIES: NKDA
OUTPATIENT CARDIOLOGIST: in [**Hospital1 1562**], name unknown
PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] (?sp) of Born, Mass
Social History:
Social history is significant for the presence of current
tobacco use: [**12-11**] PPD since the age of 14, continues to smoke.
There is a history of alcohol abuse, though he stopped 10 years
ago. He also did coke up until 3-4 months ago; he denies ever
using IV drugs.
Family History:
There is a family history of premature coronary artery disease
or sudden death: his father d. of an MI at the age of 57. His
mother is alive at the age of 97. He has a brother who had a
stroke at about 60yo.
Physical Exam:
VS: T 97.2, BP 152/97, HR 72, RR 24, O2 97% on 4L
Gen: Thin gentleman who is mildly tachypneic and using his
accessory muscles to breath. Able to speak in full sentences.
Appears older than stated age. Oriented x3. Mood, affect
appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. +conjunctival
pallor.
Neck: Supple with JVP of 8 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis.
Decreased breath sounds at right base > left base. Poor air
movement with scattered crackles and wheezes audible.
Abd: +BS, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Pertinent Results:
EKGs: no prior for comparison
11:23 NSR with PACs, normal axis, slow R wave progression,
non-specific T wave changes (flat in inferior leads and I, aVL
and TWI in V6.
17:03 as above except T waves biphasic in V4 and TWI in V5-V6.
.
TELEMETRY demonstrated: NSR in the 60s.
.
Echo from [**Hospital1 1562**] [**2171-6-3**]: Mild concentric LVH with reduced
LV diastolic compliance.
.
2D-ECHOCARDIOGRAM [**2172-6-26**] (PRELIM):
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic root is moderately dilated at the sinus level. The
ascending aorta is mildly dilated. The number of aortic valve
leaflets cannot be determined. Mild (1+) aortic regurgitation is
seen. No mitral regurgitation is seen. There is no pericardial
effusion.
IMPRESSION: Suboptimal image quality. Left ventricular
hypertrophy with preserved biventricular systolic function.
Dilated ascending aorta with mild (1+) aortic regurgitation. If
number of aortic cusps needs to be determined, would recommend
full study by son[**Name (NI) 930**].
.
adenosine stress with nuclear imaging [**2171-6-3**]:
Poor exercise tolerance with normal HR and no chest pain.
Nonspecific STT changes, no arrhythmias. Nuclear imaging
suggestive of prior infarct with mild fixed defects in the
inferior and mid basal regions. Estimated EF 44%.
LABORATORY DATA:
Na/K 141/3.8
Cl/HCO3 106/26
BUN/Cr 19/0.9
Gluc 137
.
WBC 13.8
Hct 44
Plt 326
.
INR 1.1
.
CK 68
Trop 0.01
.
UA negative
.
CT Chest [**2171-4-12**]:
Thoracic aortic aneurysm, maximal diameter 4.5cm. No
dissection. No mediastinal or hilar adenopathy. Multiple
nodular appearing areas in both lungs (11mm in Left upper lung,
etc).
.
CT Chest w/ contrast [**2172-6-26**]:
Unchanged dilatation as compared with prior (max 4.5cm). Now
has large noncalcified irregular thrombus in distal aspect of
the proximal portion of the descending aorta (2.7 x 2.6 cm).
Left ventricle is hypertrophied; recommend echo to r/o thrombus.
Complex right pleural effusion with multiple loculations as well
as nodules and septations within the effusion. +Adenopathy in
right hilum and mediastinum with compression of the middle lobe
and RLL bronchus and significant atelectasis of the middle lobe.
Highly suspicious for malignancy.
---------
CT Abd/Pelvis:
IMPRESSION:
1. There is no definite evidence of metastatic disease beneath
the
hemidiaphragms. However, the left adrenal gland is bulky,
raising concern for neoplastic involvement. There is a sizable
right retrocrural node as well.
2. Abnormal soft tissue along the base of the right chest along
the superior aspect of the right hemidiaphragm, concerning for
neoplasm. There is also a multiloculated right pleural effusion
and abnormal densities within the right middle and right lower
lobes of the lungs, which are not fully characterized on this
study.
3. Two rounded hypodensities within the liver, which are not
fully
characterized. These could represent cysts.
4. Changes related to prior esophageal perforation.
--------
CXR S/P Pleurex Catheter Placement:
IMPRESSION:
1. Interval decrease in volume of right-sided pleural effusion
status post
drainage of 1.5 liters of fluid. No evidence for pneumothorax.
2. Continued right middle and lower lobe atelectasis.
--------
Cytology:
DIAGNOSIS: Pleural fluid:
POSITIVE FOR MALIGNANT CELLS,
consistent with malignant epithelioid neoplasm. (See note.)
Note: The differential diagnosis includes adenocarcinoma and
mesothelioma. The corresponding slide from the hematology
lab (933A) was reviewed and shows similar findings.
Immunostains of a cell block preparation are pending and
will be reported in an addendum.
Immunohistochemical studies
Pleural fluid, cell block (C08-[**Numeric Identifier 43548**]):
Malignant epithelioid neoplasm, consistent with
adenocarcinoma. (See note.)
Note: Immunohistochemical studies show strong positive
staining of the tumor cells with keratin AE1-3/CAM5.2, CK7,
[**Last Name (un) **]-31 and TTF-1. Some tumor cells show faint staining with
CK20 and calretinin. There is focal staining of the tumor with
Leu-M1 and B72.3. The tumor cells do not demonstrate nuclear
reactivity with WT-1. The findings favor metastatic
adenocarcinoma from the lung. Clinical correlation is needed.
-----------------
Brief Hospital Course:
# Pleural Effusion:
Patient describes chronic dyspnea that has been getting worse
over the last several weeks. He has significant weight loss,
+tobacco abuse, and CT chest with mediastinal adenopathy
impinging on his RML and RLL bronchi. Patient continued to have
episodes of tachypnea and subjective shortness of breath during
hospital stay, with no hypoxemia, not requiring oxygen, and
relieved by nebulizer treatment. CT and CXR revealed loculated
right pleural effusion which was drained. Cytology was positive
for malignant cells, immunostains most consistent with
adenocarcinoma of lung origin. A staging abdominal and pelvic CT
did not show any clear evidence of malignant spread beneath the
diaphragm, although the left adrenal gland was enlarged. In
either case, he diagnosed with Stage IV adenocarcinoma of likely
lung origin. A pleurex catheter was placed for drainage of
pleural fluid.
Dx: Adenocarcinoma of the Lung, Stage IV
Plan:
-To f/u as outpatient with Dr. [**Last Name (STitle) 20889**] for consideration of
palliative chemotherapy.
-Pleurex Catheter to be drained every 2-3 days as tolerated.
.
# Thoracic artery aneurysm:
Stable on imaging from OSH except for new thrombus. He has been
hemodynamically stable and has not c/o chest pain. Therapeutic
anticoagulation was decided against considering multiple
procedures while inpatient and risk for bleed and hemothorax.
Hematology was consulted regarding the need for long term
anticoagulation and recommended agatinst anticoagulating aortic
thrombus as thought [**1-11**] to local plaque build-up.
Dx: Thoracic Aortic Aneurysm with aortic thrombus
Plan:
-Medical management of blood pressure with goal SBP 100-120's
-no anticoagulation at this time.
.
# HTN: In the ICU, labetalol IV gtt for BP control. On the
floor, SBP ranging between 130s-160s, goal was below 130
considering thoracic aortic aneurysm. treated with atenolol,
lisinopril and amlodipine.
Dx: Hypertension
Plan:
[**Hospital **] medical management with goal pressures <130
.
# COPD: Patient with frequent episodes of wheezing in-house
requiring almost daily nebulizer therapy. Started on
fluticasone/salmeterol with PRN albuterol.
Dx: COPD
Plan:
- Advair, albuterol, atrovent
- Pleurex catheter mgmt.
.
# CAD: contined aspirin, beta blocker, ACR I and statin
.
# Concern for LV thrombus: there was initial concern at OSH for
LV thrombus, but ECHO showed no evidence of LV thrombus.
.
# Communication: with girlfriend [**Name (NI) 16883**] [**Name (NI) **] [**Telephone/Fax (1) 79149**]
.
Remainder of hospital stay was uneventful.
Medications on Admission:
Enalapril 20mg PO BID
HCTZ 25MG daily
Atenolol 50mg PO daily
Sulfazalazine 500mg PO BID
Hydroxychloroquine 200mg [**Hospital1 **]
Prozac 20MG daily
ASA 81mg daily
Protonix 40mg daily
Albuterol INH 1-2 puffs q6 PRN
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
6. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
10. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed for wheezing.
11. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
13. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
The Pavillion
Discharge Diagnosis:
Adenocarcinoma of the Lung
Malignant Pleural Effusion
Hypertensive Urgency
COPD
Hypertension
Thoracic Aortic Aneurysm
Aortic Thrombus
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital for evaluation of difficulty
breathing. It was found that your shortness of breath was due
to a large accumulation of fluid in your right lung. As you
know, this fluid is due to a lung cancer. You had a catheter
placed to allow you to drain off this fluid when needed.
.
Please stop smoking. Information was given to you on admission
regarding smoking cessation.
.
Followup Instructions:
Please follow-up with your primary care physician,
[**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Telephone/Fax (1) 62067**],
.
Please follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 20889**] ([**Telephone/Fax (1) 79150**], we have
contact[**Name (NI) **] their office and you will be contact[**Name (NI) **] with a new
patient appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1672**] MD, [**MD Number(3) 1673**]
|
[
"444.1",
"401.9",
"441.2",
"197.2",
"414.01",
"518.82",
"305.1",
"496",
"162.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
12768, 12808
|
8826, 11401
|
333, 363
|
12986, 12995
|
4259, 8803
|
13445, 13953
|
3101, 3313
|
11665, 12745
|
12829, 12965
|
11427, 11642
|
13019, 13422
|
3328, 4240
|
274, 295
|
391, 2393
|
2415, 2796
|
2812, 3085
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,039
| 130,003
|
10849
|
Discharge summary
|
report
|
Admission Date: [**2198-12-31**] Discharge Date: [**2199-1-7**]
Date of Birth: [**2120-7-15**] Sex: M
Service: MEDICINE
Allergies:
Celexa / Zestril
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
NSTEMI
Major Surgical or Invasive Procedure:
Dialysis Tunneled Catheter placement
Cardiac Catheterization
History of Present Illness:
EVENTS / HISTORY OF PRESENTING ILLNESS: 77 yo male with a
history of CAD s/p CABG in '[**81**] (lima to lad, svg to om, svg to
rca, svg to D1), redo one vessel CABG [**2191**] with an SVG to OM,
MIs in [**2191**] and [**2195**], multiple PCIs, 5 cm AAA, and ESRD on HD
TUES/THURS/SAT who presented to [**Hospital3 **] with refractory chest
pain on [**2198-12-29**]. His last cath at [**Hospital1 18**] in [**2195**] revealing severe
CAD (Occluded SVG-OM, SVG to DIAG and SVG to RCA, patent SVG to
OM) intervention was felt to be high-risk and the patient was
medically managed.
.
Vitals at OSH: 142/73, sat 99% on 2lnc, sinus 70's no ectopy,
Temp 99.3. EKG at [**Hospital3 417**] showed ST depressions in III,
II, AVF, V4-V6 per the referring cardiologist. Troponins were
0.01->0.7. He was transfused 1 unit PRBC's for Hct 24 (guaic
negative), bumped to 31.
.
He had multiple episodes of chest pain overnight-described as
vague discomfort that pt does not rate on pain scale-occurs with
activity such as trying to void, moving for CXR, all relieved
with Morphine 2mg.
.
Arrived to CCU after cath and currently chest pain free. Denies
feeling SOB, n, v, f, c. +constipation
.
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
currently, dyspnea on exertion, paroxysmal nocturnal dyspnea,
orthopnea, ankle edema, palpitations, syncope or presyncope.
Past Medical History:
PAST MEDICAL HISTORY:
- ESRD on hemodialysis Tues/Thurs/Sat [**Last Name (un) **] [**Hospital1 1474**] Kidney
ctr-Dr. [**Last Name (STitle) **], [**First Name3 (LF) **] fistula left arm does not work, has a right
sided hemodialysis catheter
-GERD
-Atrial Fibrillation s/p CABG redo [**6-18**]
-AAA: infrarenal, 5.2 x 5.1 cm in [**11-23**]
-TIA x 2
-Right cataract surgery
-Cholecystectomy [**12-19**]
-GI bleed [**12-19**], ASA and Coumadin stopped at that time, does not
get heparin during HD
-Bilateral renal artery stenosis on MRA [**2192-7-3**], cath [**2192-7-4**]
showed moderate right renal artery stenosis without functional
flow limitation.
-Neuropathy
.
Cardiac Risk Factors:
(+) Diabetes
(+) Dyslipidemia
(+) Hypertension
.
Cardiac History: CABG, in [**2181**] with LIMA -> LAD and SVG ->
diagonal, OM1, and PDA
-[**2192-7-6**]: Re-do off pump bypass x1; bypass from the ascending
thoracic aorta to the obtuse marginal with reverse saphenous
vein, c/b cholesterol emboli requiring HD and c/b post-op atrial
fibrillation
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse.
Family History:
His father had CAD in his 50's, and his sister died at age 64 of
CAD. He is a retired dairy farmer and cabinetmaker.
Physical Exam:
PHYSICAL EXAMINATION:
VS - 99.2, 127/57, 75, 18, 97% on 6L oxygen
Gen: WDWN elderly male in NAD. Oriented x3.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. 2/6 systolic murmur. No thrills, lifts. No S3
or S4.
Chest: Resp were unlabored, no accessory muscle use. CTAB, with
mild crackles at the bases. HD cath in place on right chest
wall.
Abd: Soft, NTND. No HSM or tenderness.
Ext: No c/c/e. bilateral femoral bruits
.
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:
MEDICAL DECISION MAKING
EKG demonstrated sinus rhythm, nl axis, STD in V4-6.
.
[**2198-12-31**] 05:30PM WBC-18.3*# RBC-3.92* HGB-12.2* HCT-36.3*
MCV-93 MCH-31.0 MCHC-33.5 RDW-17.7*
[**2198-12-31**] 05:30PM PLT COUNT-537*#
[**2198-12-31**] 05:30PM GLUCOSE-112* UREA N-29* CREAT-5.2*#
SODIUM-133 POTASSIUM-5.3* CHLORIDE-96 TOTAL CO2-26 ANION GAP-16
[**2198-12-31**] 09:15PM PT-14.5* PTT-35.0 INR(PT)-1.3*
[**2198-12-31**] 09:15PM WBC-14.0* RBC-3.62* HGB-10.9* HCT-32.8*
MCV-91 MCH-30.1 MCHC-33.2 RDW-16.8*
[**2198-12-31**] 09:15PM NEUTS-87.4* LYMPHS-6.6* MONOS-5.6 EOS-0.2
BASOS-0.2
[**2198-12-31**] 09:15PM PLT COUNT-377
[**2198-12-31**] 09:15PM GLUCOSE-101 UREA N-33* CREAT-5.4* SODIUM-133
POTASSIUM-5.5* CHLORIDE-97 TOTAL CO2-24 ANION GAP-18
[**2198-12-31**] 09:15PM CALCIUM-9.1 PHOSPHATE-4.7* MAGNESIUM-2.6
.
[**2198-12-31**] Cath
COMMENTS: 1. Coronary angiography in this right dominant
system
revealed three vessel coronary artery disease. The LMCA had
severe
diffuse disease up to 80%. The LAD was occluded proximally. The
LCx had
severe diffuse disease. The RCA was known occluded and was not
engaged.
2. Arterial conduit angiography revealed a patent LIMA-LAD. The
SVG-OM
was ectatic with moderate disease, TIMI 3 flow, not changed in
appearance from cath [**2195**]. The SVG-Diag and SVG-RCA were
occluded.
3. Resting hemodynamics revealed elevated left and right sided
filling
pressures with LVEDP of 28 mmHg and RVEDP of 11 mmHg. There was
moderate-severe pulmonary arterial hypertension with PASP of 53
mmHg.
The cardiac index was preserved at 2.1 L/min/m2. There was
systemic
systolic arterial hypertension with SBP 142 mmHg on
Nitroglycerine drip
at a max dose of 140 mcg/min.
4. Left ventriculography was not performed.
5. Left subclavian angiography revealed a moderate stenosis with
a
dissection cap. The pressure gradient with IV ntg 100 mcg was 7
mmHg.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Patent SVG-OM and LIMA-LAD.
3. Left ventricular diastolic dysfunction.
4. Moderate-severe pulmonary arterial hypertension.
5. Pressure gradient of left subclavian insignificant after IC
.
TTE [**2199-1-1**]
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is mildly
dilated. There is moderate regional left ventricular systolic
dysfunction with a basal inferior aneurysm/akinesis, as well as
akinesis of the septul, and hypokinesis of the inferolateral
wall (c/w multivessel CAD). There is mild hypokinesis of the
remaining segments (LVEF = 30%). No masses or thrombi are seen
in the left ventricle. The estimated cardiac index is borderline
low (2.0-2.5L/min/m2). There is no ventricular septal defect.
The right ventricular cavity is mildly dilated with mild global
free wall hypokinesis. There are three aortic valve leaflets.
The aortic valve leaflets are moderately thickened. There is no
aortic valve stenosis. Mild (1+) aortic regurgitation is seen.
An eccentric, posteriorly directed jet of moderate to severe
(3+) mitral regurgitation is seen. The tricuspid valve leaflets
are mildly thickened. Moderate to severe [3+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Dilated left ventricle with moderate regional left
ventricular systolic dysfunction, c/w multivessel CAD. Mild
right ventricular systolic dysfunction. Moderate-to-severe
mitral regurgitation. Moderate-to-severe tricuspid
regurgitation. Moderate pulmonary hypertension.
Brief Hospital Course:
# NSTEMI - On arrival to [**Hospital1 18**] the patient was taken to the cath
lab where angiography demonstrated three vessel coronary artery
disease. The LMCA had severe
diffuse disease up to 80%. The LAD was occluded proximally. The
LCx had
severe diffuse disease. The RCA was known occluded and was not
engaged. Arterial conduit angiography revealed a patent
LIMA-LAD. The SVG-OM was ectatic with moderate disease, not
changed in appearance from cath [**2195**]. The SVG-Diag and SVG-RCA
were occluded. There was systemic systolic arterial hypertension
with SBP 142 mmHg on Nitroglycerine drip at a max dose of 140
mcg/min. Nitro was weaned off overnight. Given the patient's
diffuse CAD he was continued on medical management. Post cath
the patient was noted to have bilateral femoral bruits,
ultrasound negative for pseudoaneurysm. The patient was
continued on aspirin, plavix, statin, zetia. His BP meds were
held initially secondary to hypotension however we restarted.
Continued on metoprolol and amlodipine. The patient was
receiving Imdur 120mg [**Hospital1 **] at home, recommended change to 180mg
daily to avoid tolerance.
.
# Pump - TTE demonstrated an EF of 30% and a basal inferior
aneurysm. The patient refused heparin products and
anticoagulation for this aneurysm due to prior GI bleed while
anticoagulated.
.
# Rhythm: The patient was in atrial fibrillation on admission,
also very volume overloaded prior to receiving dialysis. He was
continued on his home dose of amiodarone and metoprolol.
.
# Bacteremia - The patient was found to have a positive blood
culture from surveillence culture taken on [**1-1**] growing coag
negative staph. He was started on Vancomycin dosed with dialysis
on [**1-1**]. Repeat BC from the periphery and cultures drawn on [**1-4**]
also positive. His dialysis tunneled cath was replaced by IR.
Follow up cultures on [**1-5**] and [**1-6**] were no growth at the time
of discharge. After initiating vancomycin the patient remained
afebrile and hemodynamically stable. He was discharged home to
follow up in dialysis to receive antibiotics to complete a 2
week course.
.
# AAA- known 5cm AAA, not a surgical candidate.
.
# ESRD- Continued on HD Tue/Thurs/Sat schedule. R Dialysis cath
removed on [**1-4**] and replaced on [**1-5**] as above. The patient had a
small hematoma following the tunneled cath removal, was
evaluated by general surgery, no intervention needed. Hematoma
was clinically improving prior to DC.
.
# DM 2- The patient is diet controlled at home, he was
maintained on a SSI while inpatient.
.
# GERD: continued on PPI
.
The patient was discharged home in good condition with home PT.
Medications on Admission:
MEDICATIONS AT HOME:
Amlodipine 2.5 mg PO DAILY
Insulin SC (per Insulin Flowsheet)
Sliding Scale
Amiodarone 200 mg PO DAILY
Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
Aspirin 325 mg PO DAILY
Metoprolol 50 mg PO BID
hold for SBP<100 or HR<55
Nephrocaps 1 CAP PO DAILY
Bisacodyl 10 mg PO/PR DAILY:PRN
Omeprazole 40 mg PO Q24H
Docusate Sodium (Liquid) 100 mg PO BID
Vytorin 10/40mg daily
nitro prn
.
MEDICATIONS on TRANSFER:
ASA 325 mg
Plavix 75 mg
Aspirin 325 mg daily
amiodarone 200mg daily
nexium 40mg daily
zetia 10 daily-given last night
folic acid 1mg daily
SS insulin - has not required
imdur 120mg daily-on hold due to nitro
synthroid
senakot [**Hospital1 **]
nephrocaps
zocor 40 daily
lopressor 100mg daily-getting 50 [**Hospital1 **] now
isordil 60mg po q6hours in addition to nitro gtt ! last dose
given at 6am
norvasc 2.5mg daily
Nitro gtt at 130mcg/min
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO twice a
day.
6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2*
10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Amlodipine 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
12. Vancomycin 1,000 mg Recon Soln Sig: 1000 (1000) mg
Intravenous qHD for 11 days.
Disp:*QS * Refills:*0*
13. Vytorin 10-40 10-40 mg Tablet Sig: One (1) Tablet PO once a
day.
14. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tab
Sublingual every 3 minutes as needed for chest pain: Do not
exceed more than 3 tabs. If chest pain is not relieved, call
doctor or 911.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Primary: Non ST elevation myocardial infarction, Coagulase
negative staphylococcus bacteremia
Secondary: End Stage Renal disease
Discharge Condition:
Good, chest pain free, vital signs stable. Cleared for home by
physical therapy.
Discharge Instructions:
You were admitted to the hospital because of a heart attack. You
were treated with medications.
.
You were also noted to have an infection in your blood. This was
most likely due to bacteria in your tunneled line. This was
removed and a clean line was placed. You were started on an
antibiotic called Vancomycin to treat this infection.
Changes were made to your medications which include:
Imdur 180 mg daily
.
Please follow up with your cardiologist in [**1-20**] weeks.
Please follow up with yoru primary care doctor in [**2-19**] weeks.
.
Please call your doctor or return to the emergency room if you
develop any worrisome symptoms such as chest pain, shortness of
breath, palpitations (fluttering in your chest),
lightheadedness, bleeding, etc.
Followup Instructions:
Follow up with your cardiologist in [**1-20**] weeks.
Follow up with your primary care doctor in [**2-19**] weeks.
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
[
[
[]
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|
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|
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|
237, 245
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373, 2088
|
10753, 11196
|
2132, 3143
|
3159, 3269
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,571
| 137,086
|
14143
|
Discharge summary
|
report
|
Admission Date: [**2133-9-25**] Discharge Date: [**2133-9-25**]
Service: MEDICINE
Allergies:
Plavix
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
hemetemesis
Major Surgical or Invasive Procedure:
1. Upper GI Endoscopy
History of Present Illness:
[**Age over 90 **] y.o. W from [**Hospital 100**] Rehab with MMP including CAD with 3VD s/p
NSTEMI, ischemic cardiomyopathy, CHF, DM2, HTN, hyperlipidemia,
who presents with 1 episode of hemetemisis. On DOA pt c/o
abdominal pain and nausea, had a large brown bowel movement,
then vomitted what the staff at HR described as a large amount
of bright red blot with "tiny" clots.
.
In the ED, patient denied HA, CP, SOB, or any abdominal pain. VS
on arrival were: HR: 60, BP: 110/50; RR: 34; O2: 100 NC. She was
guiac + on rectal exam. An NG lavage did not clear after 300
cc's. Two large-bore PIV's were started and patient was given 40
mg of IV Protonix.
.
Of note, pt does not have capacity to make decisions. HCP is her
son [**Name (NI) 5279**] [**Known lastname 42104**].
Past Medical History:
1. CAD: 3VD, cath [**2128**] with 99% LAD, 90% LCx, 100% RCA stenoses.
Refused CABG. NSTEMI [**9-11**], hospitalization complicated by
cardiogenic shock requiring pressors and intubation and NSVT.
2. Ischemic cardiomyopathy: echo [**3-15**] EF 15-20%; severe global
LV HK, inferior AK, 1+ AR, [**4-11**]+ MR
3. CHF: Baseline 2 pillow orthopnea, chronic intermittent LE
edema. Numerous admissions for flash pulmonary edema. Most
recently discharged [**4-11**].
4. DM type II
4. HTN
5. Hyperlipidemia
Social History:
Lives at [**Hospital 100**] Rehab. She lost her husband almost 30 years
ago, and has 2 sons. [**Name (NI) **] [**Name (NI) 9464**] is a health care proxy. She
denies any history of smoking or alcohol use. No IVDU.
Family History:
non-contributory
Physical Exam:
VS: T: 97.2; P: 103 ; BP: 108/52; RR: 17; O2: 92% on RA
Gen: Elderly female laying in NAD
HEENT: PERRLA; sclera anicteric. OP clear with dry MM, neck
supple, JVD to 7 cm
CV: RRR II/VI systolic murmur at apex
Lungs: CTAB - no wheezes/rales/ronchi
Abd: Soft, NT, ND, + BS
Ext: + 4 pitting edema to knees bilaterally
Neuro: alert,
Pertinent Results:
[**2133-9-25**] 06:32AM HCT-28.1*
[**2133-9-25**] 04:00AM K+-4.7
[**2133-9-25**] 03:50AM GLUCOSE-133* UREA N-65* CREAT-1.2* SODIUM-139
POTASSIUM-5.6* CHLORIDE-101 TOTAL CO2-25 ANION GAP-19
[**2133-9-25**] 03:50AM CK(CPK)-44
[**2133-9-25**] 03:50AM CK-MB-NotDone cTropnT-<0.01
[**2133-9-25**] 03:50AM CK-MB-NotDone cTropnT-<0.01
[**2133-9-25**] 03:50AM WBC-9.7 RBC-3.57* HGB-10.1* HCT-30.5* MCV-85#
MCH-28.4# MCHC-33.2 RDW-16.4*
[**2133-9-25**] 03:50AM NEUTS-83.3* BANDS-0 LYMPHS-11.2* MONOS-3.2
EOS-1.4 BASOS-0.9
[**2133-9-25**] 03:50AM PLT COUNT-742*#
[**2133-9-25**] 03:50AM PT-14.7* PTT-26.6 INR(PT)-1.3*
CHEST (PORTABLE AP) [**2133-9-25**] 5:22 AM
COMPARISON: [**2133-3-10**].
AP PORTABLE CHEST: There has been interval placement of a
nasogastric tube which terminates in the stomach. Mild
cardiomegaly and the mediastinal contours are unchanged.
Multiple small bilateral nodular densities are noted which
appear to be new compared to [**2133-3-10**]. There is no
pleural effusion or pneumothorax. The bones are demineralized.
IMPRESSION: Multiple small nodular densities of both lungs. In a
patient with an esophageal mass, these may represent metastatic
foci. Alternatively, if the patient has infectious symptoms,
these could represent septic emboli or pseudomonal infection.
Brief Hospital Course:
A/P: 91 W with multiple medical problems including CAD with 3VD,
CHF with EF 15% and [**4-11**]+ MR, 1+ AR, HTN, anemia, dementia, who
presents with GI bleeding.
.
#GI bleed: Hct is at her baseline of 28-30. Patient was admitted
to ICU for EGD this AM, because of her active bleeding and
multiple co-morbidities and medications which increase her risk
of severe bleeding.
- 1 unit PRBC per GI request
- EGD revealed 8cm, diffusely bleeding mass of esophagus
concerning for squamous cell carcinoma. Pathology confirmed
squamous cell carcinoma. This seems to be only source of GI
bleed and is unfortunately not resectable or cauterizable.
#Esophageal mass: squamous cell carcinoma. [**Name (NI) 42108**], pt.
is not a candidate for chemotherapy. Discussed dx with son, who
has made pt DNR/DNI with the goal of her care being palliation.
Pt. will return to [**Hospital 100**] Rehab with palliative care to be
involved there.
#CAD- Stable. 1 set of enzymes in ED negative. No c/o chest pain
so will not cycle enzymes.
- Cont ASA, Ticlopidine, Carvedilol.
.
#CHF- Marked LE edema. CXR clear. Not on ACE [**3-12**] hyperkalemia.
- cont lasix at home dose
- cont BB
.
#HTN- Continue beta blocker
.
#DM2- mild, diet controlled - not on ISS at heb reb.
- cover with RISS while in ICU
.
#Chronic renal failure- Baseline creatinine 1.4-1.5.
.
#CODE - Full Code (per record)
.
#access: PIVs
Medications on Admission:
ASA EC 325 mg qday
Carvedilol 3.125 mg qday
Darbepoetin alpha 40 mcg qweek
Ferrous Sulfate 325 mg qday
Furosemide 60 mg qday
Lisinopril 5 mg qpm
MVI
Pantoprazole 40 mg qday
Senna 2 tablets [**Hospital1 **]
Simvastatin 40 mg qday
Ticlopidine 250 mg [**Hospital1 **]
Allergies:
Plavix
Discharge Medications:
ASA EC 325 mg qday
Carvedilol 3.125 mg qday
Darbepoetin alpha 40 mcg qweek
Ferrous Sulfate 325 mg qday
Furosemide 60 mg qday
Lisinopril 5 mg qpm
MVI
Pantoprazole 40 mg qday
Senna 2 tablets [**Hospital1 **]
Simvastatin 40 mg qday
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
Upper GI bleed
Esophageal mass, likely squamous cell carcinoma
Discharge Condition:
Stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:
Followup Instructions:
Please follow up with regular geriatrician at [**Hospital 100**] Rehab
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2133-9-25**]
|
[
"585.9",
"414.8",
"150.4",
"401.9",
"272.4",
"396.3",
"250.00",
"398.91",
"530.82",
"294.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"45.16"
] |
icd9pcs
|
[
[
[]
]
] |
5526, 5591
|
3551, 4939
|
233, 256
|
5698, 5707
|
2219, 3528
|
5874, 6112
|
1837, 1855
|
5273, 5503
|
5612, 5677
|
4965, 5250
|
5731, 5851
|
1870, 2200
|
182, 195
|
284, 1061
|
1083, 1586
|
1602, 1821
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,149
| 102,195
|
4150
|
Discharge summary
|
report
|
Admission Date: [**2158-2-12**] Discharge Date: [**2158-3-3**]
Date of Birth: [**2097-9-7**] Sex: M
Service: MEDICINE
Allergies:
Simvastatin / Tape [**12-18**]"X10YD / Hydrochlorothiazide /
Eptifibatide / CellCept
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
intubation
mechanical ventilation
arterial line placement
internal jugular venous line placement
ultrasound guided renal biopsy
bronchoscopy with bronchoalveolar lavage
History of Present Illness:
60 M w/ ESRD [**1-18**] Wegener's granulomatosis s/p kidney transplant
([**4-/2154**]) on tacro/cellcept, severe CAD s/p five-vessel CABG
with PFO closure [**12/2154**] and s/p multiple previous PCIs (most
recently in [**2-22**]), sCHF (EF=35%), COPD, PAF, HTN, HLD p/w cough
productive of whitish sputum, sinus tightness, and muscle pain.
He was recently discharged [**2158-1-15**] after a 3-day stay for
evaluation of dyspnea and productive cough when he was found to
have positive Influenza A DFA and was treated w/ 5 day course of
osetalmavir.
.
In the ED VS: , exam was notable for elevated JVD, tachypnea and
bibiasilar rales. He required 4L O2 and SaO2 was 93%. CXR
revealed a new retrocardiac opacity and labs were notable for a
leukocytosis to 15 and BNP of 30,000. O2 was increased to 6L and
pt was satting 93%. He had a BNP of 30,000 (double what it was
last month) and was given 20mg IV lasix with 500cc UOP. He was
empirically tx w/ vanc/levo for PNA per CXR. He was also found
to be in AF w/ rate in 100s, as high as 120s, so was given 25 mg
metoprolol. He was also given IV potassium for a K=2.9.
.
In the ED, initial VS: 100 110 118/76 20 93% 4L
.
In the ICU, pt states his breathing is very difficult, and feels
like when he had flu, except doesn't have the same
fatigue/myalgias he had at that time. Also endorses diarrhea
(nonbloody, nonmelenotic) 4x/day.
.
Denies CP, palpitations, lower extremity edema or orthopena. Has
not increased pillows (baseline 2). Denies dietary or medication
noncompliance.
.
ROS: Denies night sweats, vision changes, sore throat, chest
pain, abdominal pain, nausea, vomiting, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
- Major depression
- CHF EF%35-40%
- Paroxysmal Atrial fibrillation, not on coumadin
- ESRD s/p living donor (sister) renal transplant in [**5-/2154**]
- CAD: s/p CABG CABG x 5 [**2154-12-23**] (LIMA-->LAD, SVG-->D,
SVG-->OM,
SVG-->R-PL-->R-PLV) and PFO closure, (occluded OM and RCA
grafts)
- s/p acute MI [**2143**] with Palmaz LAD and RCA stents
- s/p rotablation and hepacoat stent to the D1 in [**6-/2149**],
treated with brachytherapy for instent restenosis in [**10/2149**]
- s/p Taxus stent in RPL in [**10/2151**]
- s/p two Cypher stents placed in the RCA [**10/2152**]
- cath in [**7-23**] with 60-70% ostial stenosis of LAD, moderate
diffuse disease of LCx, 60% proximal of RCA with in stent
restenosis with a 70% in the PL branch Taxus stent
- Denies h/o DM; however, sugars have been elevated in past
- Chronic angina
- Hypertension
- Hypercholesterolemia
- Wegener's granulomatosis (renal/pulmonary involvement)
diagnosed [**2143**] s/p cytoxan/prednisone x 1y initially, ANCA neg.
since (chronic proteinuria); now s/p renal transplant in [**5-/2154**]
- Idiopathic pericarditis [**2150**]
- GERD
- Anxiety
- Gout
- Umbilical hernia repair
- Restless leg syndrome
- basal cell carcinoma
Social History:
- married for 30+ years with very recent separation from spouse
- 3 adult children whith whom he is very close, and put them all
through college
- bachelor's degree in finance
- was a teacher for numerous years, which he loved and then used
to work in computer sales until his disease progressed
- on SS/SSDI
- loves to play music and write (except cannot motivate himself
to do so currently)
- remote history of smoking, quit 30 years ago, no alcohol or
ilicits.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Mother had CVA at 46. Sister with scleroderma
and another sister with [**Name (NI) 18109**].
Physical Exam:
Admission Physical Exam:
VS: AF, 97 109/65 28 SaO2 high 80s-low 90s on 100% face tent +
3L NC
GEN: Pleasant man, speaking full sentences w/o HEENT:
Normocephalic, atraumatic. No conjunctival pallor. No scleral
icterus. PERRLA/EOMI. MMM. OP clear, no throat erythema, no
sinus tenderness. Neck Supple, No LAD, No thyromegaly.
CV: Irregularly Irregular , faint. no rubs or gallops. JVP=10cm.
LUNGS: b/l bases with decreased BS, rhonchi, wheezes b/l. No
rales, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXT: Trace edema, 2+ dorsalis pedis/ posterior tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. [**12-18**]+ reflexes,
equal BL. Normal coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
.
Transfer Physical Exam:
Gen: NAD, very sleepy and difficult to arouse
HEENT: sclera anicteric, OP clear, MMM
CV: irregularly irregular
Lungs: clear anteriorly
Abd: soft, patient reports diffuse tenderness on palpation,
non-distended
Ext: no edema
Neuro: CN II-XII intact, full strength in all extremities
(although requires significant prompting to lift right lower
extremity), alert to person and place, odd affect
Pertinent Results:
ADMISSION LABS:
[**2158-2-12**] 12:10AM BLOOD WBC-15.2*# RBC-4.08* Hgb-11.6* Hct-34.6*
MCV-85 MCH-28.5 MCHC-33.6 RDW-15.0 Plt Ct-181
[**2158-2-12**] 12:10AM BLOOD Neuts-88.7* Lymphs-7.7* Monos-2.4 Eos-0.8
Baso-0.3
[**2158-2-12**] 07:54AM BLOOD PT-14.7* PTT-24.8 INR(PT)-1.3*
[**2158-2-12**] 12:10AM BLOOD Glucose-139* UreaN-37* Creat-2.4* Na-139
K-2.9* Cl-105 HCO3-19* AnGap-18
[**2158-2-12**] 07:54AM BLOOD ALT-20 AST-19 LD(LDH)-222 CK(CPK)-76
AlkPhos-73 TotBili-0.9
[**2158-2-12**] 07:54AM BLOOD Albumin-3.5 Calcium-7.9* Phos-3.7 Mg-1.2*
.
DISCHARGE LABS:
.
MICROBIOLOGY:
[**2158-2-17**] BAL: no bacterial growth, no [**Month/Day/Year 14616**], no PCP, [**Name10 (NameIs) **] AFB,
no CMV
**All blood, urine, and sputum cultures were negative**
.
IMAGING:
[**2158-2-13**] CT SINUS: Bilateral sphenoid sinus, frontal sinuses, and
ethmoidal air cell mucosal thickening. Bilateral mucus-retention
cysts or polyps in the maxillary sinuses.
.
[**2158-2-13**] CT CHEST: Progression of bibasilar consolidations and
pleural effusions concerning for progression of pneumonia.
Opacities previously noted in the right middle lobe, however,
have resolved. Cardiomegaly, but no evidence for CHF. Increased
mediastinal lymphadenopathy, likely reactive in the setting of a
progressive pneumonia. Distended gallbladder.
.
[**2158-2-13**] RENAL TXP US: No hydronephrosis. Resistive indices
ranging from 0.63 to 0.73, slightly increased as compared to the
previous study. Patent main renal artery and renal vein.
.
[**2158-2-20**] CT HEAD: Left middle cerebral artery distribution
infarction without evidence of mass effect or hemorrhage.
.
[**2158-2-21**] TTE: No atrial septal defect or patent foramen ovale is
seen by 2D, color Doppler or saline contrast with maneuvers. LV
systolic function appears depressed. The apex is akinetic. No
masses or thrombi are seen in the left ventricle (Definity
contrast [**Doctor Last Name 360**] used). The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Moderate (2+) mitral regurgitation is seen. There is
no pericardial effusion.
.
[**2158-2-22**] CAROTID US: No evidence of stenosis on the right. The
left system was not visualized due to presence of a central
line.
Brief Hospital Course:
60 M w/ ESRD [**1-18**] Wegener's granulomatosis s/p kidney transplant
[**4-/2154**] on tacro/cellcept, severe CAD s/p five-vessel CABG w/
PFO closure in [**2154-12-17**] and s/p multiple previous PCIs,(most
recently in [**2-22**]), sCHF (EF=30%), PAF, HTN/HLD gout, and
depression/anxiety p/w 3 weeks of productive cough and SOB.
.
# HYPOXIC RESPIRATORY DISTRESS: Mr. [**Known lastname 5850**] was admitted from
the ED in respiratory distress w/ increasing O2 requirement,
likely [**1-18**] post-infectious bacterial PNA given recent admission
for Influenza. He was covered broadly for HCAP with
Vanc/Zosyn/Levofloxacin. There was also likely a component of
volume overload that contributed to his respiratory dysfunction
given IVF and antibiotics given in ED in the setting of pt's
poor forward flow (CHF w/ EF~30%). Due to increasing work of
breathing, patient was intubated later on the admission day
[**2158-2-12**]. Chest CT on [**2158-2-13**] demonstrated bibasilar
consolidations and pleural effusions concerning
for progression of pneumonia. As ANCA returned moderately
positive (see below), patient underwent bedside bronchoscopy on
[**2158-2-17**] to rule out bronchial or alveolar hemorrhage.
Bronchoscopy revealed erythematous airways but no obvious
hemorrhages. BAL was negative for PCP, [**Name10 (NameIs) **], AFB, CMV,
fungus or micro-organisms. Patient's vent settings continued to
be weaned and he was extubated on [**2158-2-21**]. Unfortunately, during
a speech and swallow evaluation the following day, he had a
significant aspiration event, which shortly required
reintubation secondary to respiratory distress. He was liberated
from the ventilator on [**2158-2-24**] following the placement of a
large bore NG tube. He did well following extubation. He
completed a 7 day course of levofloxacin for aspiration
pneumonia. He was diuresed with lasix as needed and received
nebs/mucolytics as needed. He underwent another speech and
swallow evaluation and was able to tolerate POs He was stable
on room air at discharge. Recommend continuation of incentive
spirometry and ambulation with PT
.
# ACUTE ON CHRONIC RENAL INSUFFICIENCY: Mr. [**Known lastname 18118**] baseline
Cr was 2.4 as he is s/p renal transplant ([**2153**]) and his
creatinine slowly increased during his admission, with Cr peak
at 5.4. This was thought to be [**1-18**] ATN from poor perfusion due
to hypotension and hypoxemia. The renal transplant team followed
the patient closely during his hopsital course, monitoring his
renal function and immunosuppression with tacrolimus and
mycophenolate. Tacro levels were checked daily and adjusted
accordingly. Pt's urine sediment was consistent w/ ATN showing
muddy brown casts but no acanthocytes indiciative of glomerular
injury. Due to a reported moderately positive ANCA sent from
[**Hospital1 2025**], there was concern for recrudescence of Wegener's
granulomatosis and patient underwent urgent bedside renal biopsy
on [**2158-2-17**]. He was given DDVAP 1 hr prior to biopsy given uremic
platelets as well as 6 units of platelets. Cardiology was
consulted to determine whether patient could safely go off
[**Date Range **]/[**Date Range **] for biopsy but given pt's multiple cardiac risk
factors and severe CAD, he was kept on [**Date Range **]/[**Date Range **], with only SC
heparin being held for the biopsy. Biopsy was consistent with
ATN without evidence of Wegener's or rejection, but final
pathology is pending. Creatinine started to trend down after
peak of 5.4 on [**2-16**] and was 3.7 at discharge. All medications
were renally dosed. He should continue sodium bicarbonate
supplementation. He should continue to have creatinine
monitored as well as tacrolimus trough (weekly) and should
follow-up with renal as an outpatient.
.
# ATRIAL FIBRILLATION: Pt has hx paroxysmal atrial fibrillation.
Prior records show that he was initially anticoagulated on
Coumadin until [**2153**] when it was discontinued due to severe
epistaxis requiring transfusions as well as difficulty
controlling his INR. Pt's rate was initially controlled on home
metoprolol 150mg [**Hospital1 **] but he frequently was tachycardic in atrial
fibrillation and required some additional IV lopressor. On [**2-18**]
he was changed to 100mg metoprolol q6h, which helped somewhat,
and he was also loaded with amiodarone on [**2-22**], with a
significant improvement in his rate control. His cardiologist,
Dr.[**Name (NI) **], was contact[**Name (NI) **] for advice on continuing the
amiodarone and a formal cardiology consult was initated.
Additionally, he was started on a heparin drip for bridge to
coumadin given stroke (see below). He will be discharged on
amiodarone 200 mg daily and metoprolol 100 mg q6. He should
follow-up with cardiology as an outpatient.
.
# LMCA INFARCT: On [**2-20**] while examining patient to determine
mental status for potential extubation, it was noted that
patient's affect was abnormal, he did not track past midline and
was not following commands. His right side was noted to be
weaker than the left and he seemed to have some right-sided
neglect but this was difficult to assess given sedation. A STAT
head CT revealed an infarct in the left middle cerebral artery
territory, that was likely several days old per radiology
without mass effect, midline shift or hemorrhage. Neurology was
consulted who felt the patient's exam was out of proportion to
the size of the infarct and that his mental status changes could
be secondary to toxic/metabolic encephalopathy. Neurology also
recommended repeat TTE w/ bubble study which showed no LV or
atrial thrombus and no clear PFO although this was a limited
study. Neurology felt that the source of the infarct was likely
embolic and he was started on a heparin gtt/coumadin. PT/OT
worked with patient and he will be discharged to rehab facility.
He will be discharged on coumadin with INR goal 2.0 - 3.0 and
should continue to have coag panel monitored
.
# DIARRHEA: Mr. [**Known lastname 5850**] suffered from significant diarrhea
while hospitalized. He had several negative stool cultures and
Cdiff tests. It was felt that this diarrhea was attributable to
his immunosuppressant, Mycophenolate. He has had this issue in
the past and was successfully switched to a different formula,
however this formulation was not available in a form that could
be given while he was intubated. A flexiseal was placed to help
protect his skin from breakdown given his volume of stool. After
passing the speech and swallow evaluation, the diet was advanced
and his normal formulation of mycophenolate was restarted. The
rectal tube was removed. He should follow-up with the renal
team as an outpatient
.
#Abdominal Wall Hematoma: On transfer from the unit to the
medical floor, it was observed that the patient complained of
significant pain on palpation of his RLQ (location of renal
graft). A KUB was unremarkable. Renal US was performed and was
initially read as a renal hematoma w/ concern for ?renal
aneursym. Transplant surgery recommended a CT scan which
revealed that the hematoma was actually an abdominal wall
hematoma with concern for active bleeding from R inferior
epigastric artery. Due to a drop in Hct, the patient was taken
for IR embolization on [**2158-2-28**]. He tolerated the procedure well
without complication. He was transfused PRBC and his Hcts
remained stable. His heparin gtt/coumadin was held for the
procedure and was restarted 4 hours after the procedure per IR
recs.
.
# CHRONIC SINUS CONGESTION: Mr [**Known lastname 18118**] main concern on
admission was his chronic debilitating sinus congestion which
has been evaluated extensively as an outpatient. He underwent CT
sinus on [**2158-2-13**] revealed sinus air cell tickening. [**Date Range **] was not
consulted in the ICU given patient's multiple pressing issues.
It is recommended that he follow-up with [**Date Range **] as an outpatient.
.
#CAD/CHF: Patient has extensive cardiac history including 5
vessel CABG and multiple PCI as well as a history of CHF.
[**Date Range **] and aspirin were continued throughout his hospital stay.
He received IV lasix for diuresis while in the unit and was
transitioned to his home dose of lasix. Lisinopril was held
given his renal issues described above. Nifedipine was
initially held and was gradually re-introduced at a low dose.
He should be seen by cardiology for further medication
adjustments and consideration of cardiac rehab in the future.
.
# DEPRESSION: His home zoloft was continued. He was evaluated by
psychiatry as an inpatient in the contect of agitation/delirium.
Haldol was started and will be continued at discharge per
recommendatino of the accepting facility. We recommend weaning
it off over the next week as the patient continues to improve.
The patient has an extensive history of depression in the past
and is at risk for post-stroke depression. He should have
follow-up with neurology/social work.
Medications on Admission:
ASPIRIN - 325 MG daily
ATORVASTATIN [LIPITOR] - 10 mg daily
AZELASTINE [ASTELIN] - 137 mcg Aerosol 2 puffs [**Hospital1 **]
CLOPIDOGREL [[**Hospital1 **]] - 75 mg daily
FLUTICASONE - 50 mcg Spray [**12-18**] sprays Qdaily
FUROSEMIDE [LASIX] - 40 mg daily
IPRATROPIUM BROMIDE - (Not Taking as Prescribed) - 21 mcg Spray
[**Hospital1 **]
LISINOPRIL - 40 mg Tablet - 2 Tablet(s) by mouth once a day (??
dose per patient)
METOPROLOL SUCCINATE - 150 mg [**Hospital1 **]
METRONIDAZOLE [METROLOTION] - 0.75 % Lotion [**Hospital1 **]
MYCOPHENOLATE SODIUM [MYFORTIC] - 360 mg Tablet, 2 tabs [**Hospital1 **]
NIFEDIPINE - 90 mg daily
PANTOPRAZOLE [PROTONIX] - 40 mg [**Hospital1 **]
PIOGLITAZONE [ACTOS] - 15 mg [**Hospital1 **]
SERTRALINE - 150mg daily
TACROLIMUS - 1.5 mg [**Hospital1 **]
CHOLECALCIFEROL (VITAMIN D3) - 1,000 unit daily
GENERIX T - Tablet - 1 Tablet(s) by mouth daily
GUAIFENESIN [MUCINEX]
SENNA
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Astelin 137 mcg Aerosol, Spray Sig: Two (2) Nasal twice a
day.
4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. fluticasone 50 mcg/Actuation Spray, Suspension Sig: [**12-18**]
Sprays Nasal [**Hospital1 **] (2 times a day).
6. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
7. ipratropium bromide Nasal
8. metronidazole 0.75 % Lotion Sig: One (1) application Topical
twice a day as needed for as needed .
9. mycophenolate sodium 360 mg Tablet, Delayed Release (E.C.)
Sig: Two (2) Tablet, Delayed Release (E.C.) PO twice a day.
10. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
11. sertraline 50 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
12. cholecalciferol (vitamin D3) 1,000 unit Capsule Sig: One (1)
Capsule PO once a day.
13. generix Sig: One (1) once a day.
14. Mucinex Oral
15. senna Oral
16. nifedipine 30 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO DAILY (Daily).
Disp:*30 Tablet Extended Release(s)* Refills:*2*
17. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at
4 PM: monitor INR weekly and adjust dose accordingly.
Disp:*30 Tablet(s)* Refills:*2*
18. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
19. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours): hold for heart rate < 60 or SBP < 100.
Disp:*240 Tablet(s)* Refills:*2*
20. tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours): renally adjust dose.
Disp:*30 Capsule(s)* Refills:*2*
21. insulin lispro 100 unit/mL Solution Sig: as directed
Subcutaneous ASDIR (AS DIRECTED).
Disp:*30 mL* Refills:*2*
22. haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 weeks.
Disp:*30 Tablet(s)* Refills:*1*
23. sodium bicarbonate 650 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
24. calcium acetate 667 mg Tablet Sig: One (1) Tablet PO three
times a day.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
PRIMARY:
Atrial Fibrillation with RVR
Stroke
acute tubular necrosis
pneumonia, post-infections bacterial
pneumonia, aspiration
SECONDARY:
End stage renal disease s/p transplant
Congestive heart failure
Coronary artery disease s/p cagb and multiple PCI
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you Mr [**Known lastname 5850**]. You were
admitted to the hospital with difficulty breathing which was
likely due to a post-infectious bacterial pneumonia given your
recent bout of influenza. Because it was so difficult to
breathe, you required mechanical ventilation (breathing machine)
and were treated with antibiotics. You also had a stroke while
you were in the hospital and you were started on anticoagulation
medications. Your renal function worsened and you had a renal
biopsy which showed acute tubular necrosis. Your renal function
gradually improved. You were found to have an abdominal wall
hematoma and you underwent an interventional radiology procedure
to stop the bleeding.
The following changes were made to your medications:
-START amiodarone 200 mg once a day
-START warfarin 2.5 mg once a day. This dose may be adjusted
based on your INR. You should have your INR checked weekly
-STOP Metoprolol Succinate.
- START Metoprolol tartrate 100 mg every 6 hours.
-STOP lisinopril
-DECREASE nifedipine to 30 mg once a day
-STOP pioglitazone
-START Insulin according to sliding scale
-DECREASE tacrolimus to 1 mg twice a day
-START Sodium Bicarbonate 650 mg twice a day
-STOP Sevelamer
-START Calcium Acetate 667 mg three times a day
-START Haloperidol 0.5 mg twice a day - the duration of this
medication will be determined by your primary physician.
.
Please continue your other home medications
Followup Instructions:
The following appointments have been made for you:
Department: CARDIAC SERVICES
When: TUESDAY [**2158-3-14**] at 11:40 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4511**], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: NEUROLOGY
When: TUESDAY [**2158-5-2**] at 7:00 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 2574**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
You have been placed on a cancellation list for this
appointment.
Department: WEST [**Hospital 2002**] CLINIC (Nephrology)
When: WEDNESDAY [**2158-3-8**] at 12:00 PM
With: [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**], 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
|
[
"276.8",
"276.2",
"438.11",
"458.1",
"311",
"446.4",
"E933.1",
"427.31",
"428.0",
"496",
"584.5",
"E878.0",
"507.0",
"403.90",
"434.11",
"276.0",
"342.91",
"285.1",
"428.23",
"473.9",
"349.82",
"585.9",
"518.81",
"998.12",
"787.91",
"272.4",
"482.9",
"996.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"88.47",
"96.6",
"55.23",
"33.24",
"44.44"
] |
icd9pcs
|
[
[
[]
]
] |
19921, 19991
|
7816, 16780
|
363, 533
|
20299, 20299
|
5482, 5482
|
21929, 22986
|
3977, 4153
|
17736, 19898
|
20012, 20278
|
16806, 17713
|
20449, 21906
|
6040, 6996
|
5069, 5463
|
304, 325
|
561, 2251
|
7005, 7793
|
5498, 6024
|
20314, 20425
|
2273, 3477
|
3493, 3961
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,329
| 161,994
|
10183+56116
|
Discharge summary
|
report+addendum
|
Admission Date: [**2161-10-13**] Discharge Date: [**2161-10-20**]
Date of Birth: [**2086-10-25**] Sex: M
Service: CARDIOVASCULAR SURGERY
HISTORY OF THE PRESENT ILLNESS: [**Known firstname **] [**Known lastname **] is a 75-year-old
male with a history of GERD, hypertension, coronary artery
disease and left bundle branch block by EKG. She was
evaluated for severe coronary artery disease. The patient
had had, in [**Month (only) 958**] of this year, oblique marginal stent after
having and episode of chest pain and a positive stress test.
He also underwent an atherectomy of the diagonal branch on
[**2161-7-18**] secondary to recurrence of angina, again on
an exercise treadmill testing. He underwent cardiac
catheterization on [**10-6**], which showed restenosis of
the stent in the oblique marginal artery. Subsequent,
additional cardiac history for this patient perioperatively
included an ablation for an atrial fibrillation performed on
[**2161-9-16**] and bicameral pacemaker implant. The
patient was to have three-vessel CABG for the 27th. Risks
and benefits were described and it was elected to go forward
with the procedure. The patient was admitted in the a.m. of
the 27th. He went to the operating room, where he underwent
a three-vessel CABG; LIMA to left anterior descending,
saphenous vein graft to the oblique marginal, and also
saphenous vein graft to the diagonal. The procedure was
relatively uncomplicated. He was discharged to the TSRU.
The following day he was extubated. Pain was managed with
morphine. He was A-V paced. Intrinsically, he had a rate of
70. Atrial wires were also noted to be capturing. He was
started on oral Lasix, Lopressor, and aspirin. Interrogation
of his pacer was set up to be done. At the time of discharge
he was noted to have good urine output. The hematocrit was
24 from a preoperative hematocrit of 35. White count was
10,000 from a preoperative of 5,000. The electrolytes were
just remarkable for a BUN and creatinine of 33 and 1.2 versus
a baseline of 1.3 on admission. The patient's chest x-ray,
preoperatively and postoperatively were normal. He had no
pneumothorax in the immediate postoperative period with chest
tubes in good position. The patient had his chest tube
removed by postoperative day #3. Lopressor was titrated to
effect, to keep the pulse and blood pressure well controlled.
The Foley was discontinued, however, he failed to void at
eight hours and 500 cc post void residual, so, therefore, he
was kept with a Foley times 24 more hours, after which time
it was discontinued and he successfully voided spontaneously.
On postoperative day #1 through #2, he was noted to
sundowning and having mental status changes. He had a normal
white count, which was low, but tolerable. The hematocrit
showed no new change from his postoperative course.
Electrolytes were normal. He was not hypoxic. He was not
having any arrhythmias of any sort. It was, therefore, felt
that the mental status changes were basically acute and
chronic and acute delirium placed in the setting of chronic
dementia. Once the patient was oriented appropriately and he
had excellent lighting, he had Haldol p.r.n. with restraint,
he quickly cleared up. Sitter was only utilized for 24
hours. By postoperative day #7 the patient was 24 hours free
without a sitter. He was alert and oriented times three. He
was pleasant and in no acute distress. Sternum was stable.
There was no exudate or erythema. Right saphenous vein graft
site was clean, dry, and intact with no exudate or erythema
or evidence of wound dehiscence. The extremity was warm and
well perfused with no skin breakdown.
DISCHARGE LABS: Labs were notable for a white count of
9,000, hematocrit of 23, platelet count 250,000, BUN and
creatinine 43 and 1.4, baseline of 1.3. The remainder of his
electrolytes were unremarkable. The patient had his pacer
interrogated. It was shown to be capturing and properly
functioning. He was, therefore, deemed appropriate for
discharge. The patient's condition discharge was stable.
DISCHARGE STATUS: The patient is to go to home.
DIAGNOSES: Status post three vessel CABG for severe coronary
artery disease.
DR.[**Last Name (STitle) **],[**First Name3 (LF) 412**] 02-351
Dictated By:[**Last Name (NamePattern4) 3204**]
MEDQUIST36
D: [**2161-10-20**] 13:17
T: [**2161-10-20**] 14:05
JOB#: [**Job Number 33973**]
Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 5955**]
Admission Date: [**2161-10-13**] Discharge Date: [**2161-10-20**]
Date of Birth: [**2086-10-25**] Sex: M
Service: CA/TH [**Doctor First Name 1379**]
ADDENDUM: The patient was status post three vessel coronary
artery bypass graft for severe coronary artery disease.
DISCHARGE MEDICATIONS: Includes Lasix 20 mg po bid, K-Dur 20
mEq po bid, Colace 100 mg po bid, aspirin 325 mg q day,
Protonix 40 mg po q day, Lipitor 20 mg po q day, amiodarone
200 mg po bid, Lopressor 75 mg po bid, Combivent inhaler two
puffs qid prn, Percocet as needed for pain, and Coumadin 5.0
mg po bid.
FOLLOW UP: The patient will have his PT/INR checked 48 hours
status post discharge, to be sent to his cardiologist for
management (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]).
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 681**]
Dictated By:[**Last Name (NamePattern4) 935**]
MEDQUIST36
D: [**2161-10-20**] 13:22
T: [**2161-10-23**] 09:14
JOB#: [**Job Number 5956**]
|
[
"414.01",
"530.81",
"293.0",
"401.9",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"39.61",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
4885, 5173
|
3699, 4861
|
5185, 5634
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,558
| 198,829
|
23548
|
Discharge summary
|
report
|
Admission Date: [**2121-3-13**] Discharge Date:[**2121-4-3**]
Date of Birth: [**2064-12-4**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: The patient is a 56 year old
gentleman with a history of end stage renal disease on
hemodialysis since [**2120-10-11**], coronary artery disease,
hypertension and diabetes. He had been recently admitted in
[**2121-2-11**] to an outside hospital with an MSSA bacteremia
thought to be caused by an infected PermCath. At that time,
the patient had the PermCath removed, and he was treated with
an antibiotic course of nafcillin and appeared to recover
uneventfully. On [**2121-3-10**], the patient presented at
an outside hospital complaining of shortness of breath, lower
extremity edema, and a "cold foot." During his extensive
workup at the outside hospital, he was started on
antibiotics. The complaint of back pain led to an MRI which
demonstrated no epidural abscess, and he underwent an
echocardiogram which demonstrated a left ventricular ejection
fraction of 60 percent and significant mitral regurgitation.
He also underwent a cardiac catheterization, which
demonstrated a left circumflex artery stenosis of 70 percent.
He was transferred to the [**Hospital1 188**] for consideration of surgery for mitral valve
endocarditis, coronary artery disease, and evaluation for his
cold left leg.
PAST MEDICAL HISTORY:
1. End stage renal disease on hemodialysis since [**Month (only) 359**]
[**2120**].
2. Coronary artery disease status post myocardial infarction.
3. Peripheral vascular disease.
4. Hypertension.
5. Diabetes.
6. MSSA bacteremia, mitral valve endocarditis, severe mitral
regurgitation.
7. Diverticulitis.
8. Congestive heart failure.
9. Malnutrition with serum albumin 1.9.
PAST SURGICAL HISTORY:
1. Eye surgery.
2. PermCath placement.
MEDICATIONS ON ADMISSION: Calcium carbonate 500 mg p.o.
t.i.d.
Fentanyl patch 50 ug over 72 hours.
Colace.
Insulin sliding scale.
Nafcillin.
Gentamicin.
Aspirin 81 mg p.o. daily.
Protonix 40 mg p.o. daily.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient denies tobacco use or EtOH use.
He is an auto mechanic.
Vital signs on admission - temperature was 97.1, heart rate
101, blood pressure 88/58, with a mean of 64. Breathing 10,
100 percent on room air. Preoperative weight is 72 kg.
The patient is in no acute distress. His chest was clear to
auscultation bilaterally. His heart was regular, with a
III/VI holosystolic murmur at the apex. His abdomen was
soft, nontender, nondistended. His left foot was cold and
mottled, with a capillary refill greater than five seconds.
He had two plus carotid pulses, two plus radial pulses, two
plus femoral, and he had triphasic signals on the right
popliteal, dorsalis pedis and posterior tibialis, and he had
a monophasic popliteal on the left, with no signals over his
dorsalis pedis and posterior tibialis. His left foot
strength - his dorsiflexion and extension were [**1-15**] on the
left, and he had no sensation to the mid calf.
On laboratories, his white count was 12.2, hematocrit 27.6,
platelets 213. His sodium was 129, potassium 5.0, chloride
90, bicarbonate 26, BUN 43, creatinine 6.5, glucose 145. The
troponin was 3.52. Albumin 1.9.
On radiographic studies, he had an echocardiogram at the
outside hospital which showed ejection fraction of 60 percent
and [**3-14**] plus mitral regurgitation. Cardiac catheterization
demonstrated a 70 percent lesion at the left circumflex, 36
percent lesion of the LM, and a 35 percent lesion of the RCA.
HOSPITAL COURSE: The patient was admitted to the cardiac
surgery service, and on the day of admission, the patient was
taken to the operating room, where he underwent enbolectomy of
the lower extremity by Dr [**Last Name (STitle) 27226**], followed later in the day by
a mitral
valve replacement with a 29 mm CE porcine valve, a coronary
artery bypass graft x one, with SVG to OM, and a left lower
extremity thrombectomy with patch closure and a lower
extremity angiography. The patient tolerated the procedure
well and was transferred to the cardiac surgery intensive
care unit for his postoperative care.
In the intensive care unit, the patient was weaned to
extubation. His pressor support was weaned appropriately.
He received transfusions for postoperative anemia, and at
this point his hematocrit has remained stable. The
nephrology team has been following him, and began initially
continuous venous hemofiltration and dialysis, and as he
improved and recovered from his surgery, this was replaced
with typical hemodialysis. The transplant team has placed a
new PermCath, and his temporary dialysis line has been
removed at this point.
He was treated initially with a broad spectrum antibiotic
course, and this has been tailored by the infectious disease
team. His cultures have remained negative to date in the
hospital, and his only positive cultures were the MSSA, which
grew out from an outside hospital. All tissue cultures, as
well, have been negative. He underwent a bone scan to
determine if there were any septic emboli, and there were
none demonstrated on the scan. The patient was transferred
to the floor and his recovery continued, and he has received
physical therapy, nutritional consultation, and has been
making good recovery strides. A PICC line was placed for his
five week course of antibiotics recommended to treat his
bacterial endocarditis. All of his other lines and drains
have been removed as appropriate. He does have a permanent
PermCath, which remains.
He is now postoperative day twenty and two, and is ready for
discharge to rehabilitation.
DISCHARGE DIAGNOSES:
1. Bacterial endocarditis status post mitral valve
replacement.
2. Septic embolus to the left lower extremity.
3. MSSA bacteremia.
4. End stage renal disease.
5. Coronary artery disease.
6. Peripheral vascular disease.
7. Hypertension.
8. Diabetes.
9. Congestive heart failure
10. Severe malnutrition.
PROCEDURES PERFORMED:
1. Status post mitral valve replacement with 29 mm porcine
valve.
2. Coronary artery bypass graft, SVG to OM.
3. Left femoral thromboembolectomy with patch angioplasty.
4. Placement of temporary dialysis catheter.
MEDICATIONS ON DISCHARGE: Colace 100 mg p.o. b.i.d.
Zantac 150 mg p.o. daily.
Aspirin 81 mg p.o. daily.
Repaglinide 1 mg p.o. t.i.d.
Nephrocaps 1 p.o. daily.
Lopressor 25 mg p.o. b.i.d.
Oxacillin 2 grams IV q 4 hours x 5 weeks.
INSTRUCTIONS: The patient is to receive liver function tests
once a week after discharge until antibiotics stop, a
creatinine once a week after discharge until antibiotics
stop, CBC once a week after discharge until antibiotics stop.
These should be faxed to the primary medical doctor and the
infectious disease team. He can call the infectious disease
team for followup.
FOLLOW UP: The patient will follow up with Dr. [**Last Name (STitle) **] in two
weeks. He should call for an appointment. The patient will
also follow up with ID and primary medical doctors. Should
call for an appointment.
DISPOSITION: Stable, and will go to rehab for further care.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1714**], [**MD Number(1) 1715**]
Dictated By:[**Last Name (NamePattern1) 8958**]
MEDQUIST36
D: [**2121-4-2**] 21:14:14
T: [**2121-4-2**] 21:41:36
Job#: [**Job Number 60281**]
|
[
"285.1",
"414.01",
"785.51",
"785.52",
"252.00",
"443.9",
"428.0",
"995.92",
"444.22",
"263.8",
"276.2",
"250.40",
"041.11",
"403.91",
"038.11",
"421.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.95",
"88.48",
"35.23",
"88.72",
"99.05",
"39.95",
"36.11",
"38.93",
"39.61",
"93.90",
"38.08",
"99.07",
"39.56",
"38.91",
"89.68",
"99.04",
"89.64"
] |
icd9pcs
|
[
[
[]
]
] |
5676, 6221
|
6248, 6827
|
1856, 2075
|
3580, 5655
|
1788, 1829
|
6839, 7386
|
163, 1365
|
1387, 1765
|
2092, 3562
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,867
| 118,085
|
30586
|
Discharge summary
|
report
|
Admission Date: [**2117-6-22**] Discharge Date: [**2117-7-12**]
Date of Birth: [**2035-12-3**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Recurrent pleural effusions
Major Surgical or Invasive Procedure:
Left Thoracentesis and Pleurodesis
Right Thoracentesis
History of Present Illness:
81 yo female with pmhx sig for COPD, pulm htn, htn, who
initially presented to [**Hospital 1562**] Hospital on [**2117-6-17**] with
increasing SOB and worsening bilateral lower extremity edema.
Pt was initially admitted to the medicine service, then
transferred to ICU for hypotension and hypoxemia. She was found
to have bilateral pleural effusions, underwent thoracentesis x
2. She was started on IV steroids and antibiotics for possible
pneumonia. She was transferred to [**Hospital1 18**] for further work-up
including possible right heart cath to eval for pulm
hypertension and evaluation for possible pleuredisis to prevent
recurrent pleural effusions. On arrival to ICU, pt denie history
of cough, fevers or chills. No hemoptysis, able to ambulate
limited distances before becoming dyspneic, unable to climb
stairs. Denies any recent chest pain or pleuritis.
Past Medical History:
pacemaker, HTN, COPD, colon polyps, question of CHF, spontaneous
pneumothorax, a-fib w/ RVR
Social History:
Lives with husband, no ETOH or illicits, quit smoking 24 years
ago, previous 2ppd history x 36 years. Three children.
Family History:
none significant
Physical Exam:
vitals: 96.9/ hr 78/ bp 98/39/ 95% on 4.0 L NC
GEN: thin, somewhat cachectic elderly female, sitting upright in
bed
HEENT: atraumatic, anicteric, EOMI, dry mucosal membranes
NECK: no JVD, no LAD
CV: RRR, no murmurs or rubs
LUNGS: crackles [**2-20**] way up B/L, L>R. Conversational dyspnea, +
accessory muscle use
ABD: soft, nt, nd, nabs
EXT: trace pitting edema B/L in LE, symmetric to knees. Feet
are cool, faint but palpable DP pulses
NEURO: A/O x3, [**5-22**] muscle strength in UE and LE B/L. No focal
deficits
SKIN: multiple ecchymoses, no obvious signs of skin breakdown
Pertinent Results:
OSH:
CT W/O CONTRAST: emphysematous changes in the apecices. Large
B/L pleural effusions, no LAD
.
ECHO: enlarged RV, PASP about 80, EF 55-60%
.
EKG: paced
.
LENIS: negative for DVT
.
ECHO [**6-23**]: The left atrium is elongated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). The right ventricular cavity is dilated. Right
ventricular systolic function is normal. [Intrinsic right
ventricular systolic function is likely more depressed given the
severity of tricuspid regurgitation.] There is abnormal septal
motion/position consistent with right ventricular
pressure/volume overload. 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 to moderate ([**1-19**]+) mitral regurgitation
is seen. The tricuspid valve leaflets are mildly
thickened. Moderate [2+] tricuspid regurgitation is seen. There
is moderate pulmonary artery systolic hypertension. Significant
pulmonic regurgitation is seen. There is a trivial/physiologic
pericardial effusion.
.
[**2117-6-24**] 03:26PM PLEURAL WBC-150* RBC-1580* Polys-18* Lymphs-54*
Monos-28*
[**2117-6-23**] 03:49PM PLEURAL WBC-270* RBC-7650* Polys-23* Lymphs-62*
Monos-4* Eos-1* Meso-10*
[**2117-6-24**] 03:26PM PLEURAL TotProt-1.7 LD(LDH)-57 Cholest-28
[**2117-6-23**] 03:49PM PLEURAL TotProt-1.5 Creat-2.0 LD(LDH)-133
Cholest-22
.
[**6-23**] Cytology Pleural Fluid: NEGATIVE FOR MALIGNANT CELLS.
.
[**6-24**] CXR: Chest tube is present in the left mid hemithorax. No
pneumothorax. No change in the small left pleural effusion since
the previous film of the same date. There has however been a
reduction in the size of the right pleural effusion. Was this
aspirated ? No pneumothorax. Chamber left-sided pacemaker.
.
[**6-24**] PICC placement under fluoro: Successful placement of dual
lumen PICC via the right basilic vein with termination in the
distal SVC. The line is now ready for use.
.
[**6-24**] CXR: The left pleural catheter is in unchanged position with
slightly decreased amount of pleural effusion. No pneumothorax
is identified. There is decrease in the amount of right pleural
effusion which is still mild to moderate in size which can be at
least partially explained by different position of the patient.
No evidence of pulmonary edema is present. Pacemaker leads
terminate in the right atrium and right ventricle.
.
[**6-24**] Cytology Pleural Fluid: NEGATIVE FOR MALIGNANT CELLS.
Reactive mesothelial cells, histiocytes and lymphocytes.
.
[**6-27**] RUE U/S: No evidence of DVT in the right upper extremity.
.
[**6-27**] CXR PA/LAT: There are small-to-moderate bilateral
effusions, slightly larger than on [**2117-6-24**], with underlying
collapse and/or consolidation. The lungs are otherwise grossly
clear. A right-sided PICC line is present, tip over distal SVC.
Pacemaker again noted. No CHF.
.
[**6-29**] Echo: The left atrium is normal in size. Left ventricular
wall thickness, cavity size, and systolic function are normal
(LVEF 70%). There is no ventricular septal defect. The right
ventricular free wall is hypertrophied. The right ventricular
cavity is dilated. Right ventricular systolic function is
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve appears structurally normal with trivial mitral
regurgitation. Moderate [2+] tricuspid regurgitation is seen.
There is moderate 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 [**2117-6-23**], the findings are
similar.
.
CTA Chest [**6-30**]: 1. No evidence of pulmonary embolism. Prominence
of the main pulmonary artery could be consistent with underlying
pulmonary hypertension. 2. Moderate right pleural effusion and
adjacent compressive atelectasis. Smaller left pleural effusion,
with left apical chest tube in place, and adjacent atelectasis.
3. Heterogeneous left lobe of the thyroid, with foci of
calcification and hypodensity. Thyroid ultrasound is recommended
for further evaluation. 4. Mild-to-moderate apical predominant
panacinar emphysema.
.
R Heart Cath [**7-1**]: 1. Normal filling pressures. 2. Mild
pulmonary hypertension with slight improvement in cardiac index
and pulmonary vascular resistance on 100% O2.
.
[**7-2**] CXR: Right pleural effusion has nearly resolved following
thoracentesis with no evidence of pneumothorax. However, left
pleural effusion has increased in size and is now moderate. Left
chest tube remains in place with no evidence of left
pneumothorax. Right lower lobe atelectasis has resolved, but
left basilar atelectasis has worsened in the setting of
increasing effusion.
.
[**7-2**] Pleural Fluid Cytology: NEGATIVE FOR MALIGNANT CELLS.
Reactive mesothelial cells, histiocytes and lymphocytes.
.
CXR [**7-4**]: Interval increase in small right pleural effusion. A
left pleural effusion is no longer evident. There is interval
development of a small to moderate left pneumothorax
post-thoracentesis.
.
CXR [**7-7**]: Left-sided chest tube remains in place with persistent
small-to-moderate left pneumothorax with both apical and basilar
components. Allowing for slightly lower lung volumes on today's
study, this is not substantially changed. Moderate right pleural
effusion has slightly increased compared to the recent
examination. There is otherwise no substantial change from the
recent study.
.
CXR [**7-8**]: Persistent small left apical pneumothorax, but
slightly smaller, with a new small left-sided effusion.
.
CXR [**7-12**]: Slightly smaller left apical pneumothorax. Enlargement
of right effusion.
Brief Hospital Course:
Ms. [**Known lastname 72572**] is an 81 year old with COPD, hypertension,
transferred for further evaluation and treatment of recurrent
pleural effusions, pulmonary hypertension, SOB; called out of
MICU for further treatment and workup.
.
MICU Course: Ms. [**Known lastname 72572**] was transferred to the [**Hospital1 18**] MICU and
underwent a repeat echocardiogram which demonstrated severe
valvular disease and diastolic dysfunction, which was initially
thought to be the cause of her pulmonary hypertension. Given
her tenuous blood pressure, it was thought that the best
management would be afterload reduction. She was given BI-PAP
intermittently which improved her BP, and an ACE was then
initiated. Her effusions were known to be transudative (from OSH
records). Thoracics was consulted, a left pleurex catheter was
placed and the patient underwent a right thoracentesis with
removal of 1.2 liters, and fluid from both sides consistent with
transudate. Her breathing was significantly improved after
thoracentesis. Her shortness of breath was thought to be
multifactorial from pulmonary hypertension, pleural effusions,
and COPD. No history of leukocytosis, fevers, or productive
cough to suggest infiltrate/ infection. Her COPD medications
were tailored to Spiriva and Advair, with albuterol PRN. Her
antibiotics were discontinued, and her steroids were quickly
tapered and discontinued. Her breathing greatly improved with
both drainage of pleural fluid and BIPAP. She underwent
nocturnal noninvasive ventilation as tolerated. Her oxygen
requirement remained stable at her home dose of 2.5-4L NC. She
was transiently hypotensive to the 70-80's systolically,
asymptomatic. Her blood pressure responded well to IVF and
BI-PAP. It was thought that she was likely hypovolemic from
overdiuresis at the OSH. Her blood pressure stabilized, and she
was restarted on afterload reduction with captopril.
.
She was transferred to the general medicine floor, and her brief
hospital course, by problem, is as follows:
.
#) Recurrent pleural effusions. She appeared fluid overloaded on
transfer to the floor, and she underwent aggressive diuresis. A
repeat echocardiogram performed on [**7-1**] showed mild pulmonary
hypertension. Cardiology and pulmonary were consulted for
possible right heart cath to determine the severity of her
pulmonary hypertension. A right heart cath demonstrated normal
filling pressures and mild pulmonary hypertension (but this was
after aggressive diuresis) and pulm HTN had adequate response to
O2 therapy. She underwent several pleurodeses for treatment of
the recurrent pleural effusions. The prevailing theory is that
the etiology of her effusions is diastolic heart failure,
worsened when fluid overloaded +/- hypoalbuminemia, as there was
no evidence of liver failure, nephrosis, or hypothyroidism,
although her albumin was quite low. Upon discharge, she was
being drained every 2-3 days with the goal of draining pleurex
catheter every 3 days at the rehab facility. The RN from
[**Month/Year (2) 11063**] Pulmonary will set up an appointment for followup
at the [**Hospital 18**] clinic once the patient is at the rehab.
.
#) Atrial fibrillation. Spoke with Dr. [**Last Name (STitle) **], Mrs.[**Location (un) 72573**]
cardiologist in [**Hospital1 1562**], regarding anticoagulation; he has
never documented atrial fibrillation, which is why she is not
anticoagulated; the episode of atrial fibrillation is documented
as transient and having occurred at [**Hospital 1562**] Hospital in the
context of being sick. She was not started on anticoagulation.
.
#) ?Oral thrush. Noted on [**7-7**]. Started Nystatin S&S.
.
#) COPD. Unclear if exacerbation precipitated hospital
admission. Medications were tailored to Spiriva, Advair, and
albuterol nebs PRN.
.
#) Metabolic alkalosis. Developed during aggressive diuresis.
Resolved with IV fluid.
.
#) Hypotension. Resolved. Thought secondary to overdiuresis at
OSH. Continue to monitor as outpatient and add back
antihypertensives as needed to keep BP well-controlled.
.
#) ARF. Developed within 72 hours of right heart cath and then
resolved to normal. Likely secondary to ATN from cath +/-
prerenal etiology from overdiuresis. Creatinine was back to her
baseline of 0.8 upon discharge.
.
#) Nutrition: had poor PO intake but improved after starting
Remeron. She was also on Magace which was stopped.
Medications on Admission:
advair
foradil
fluticasone
solumedrol
evista (on hold)
valsartan
spiriva
aspirin
PPI
levofloxacin- started [**6-19**]
torsemide (on hold)
digoxin (on hold)
levalbuterol
lopressor 25 mg TID
rezerom
lasix
albuterol/atrovent
darven
tylenol
Discharge Medications:
1. 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)
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
[**1-19**] Disk with Devices Inhalation [**Hospital1 **] (2 times a day).
4. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q2-4H (every 2 to 4 hours) as needed.
8. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
9. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
12. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
13. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed for pain.
14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
16. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
17. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
18. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 2 days. Capsule(s)
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] TCU - [**Location (un) 701**]
Discharge Diagnosis:
Primary:
1. Bilateral Pleural Effusion.
2. Left Heart Failure.
3. Malnutrition Moderate
4. Acute Renal Failure.
5. Anemia of Chronic Disease.
Secondary:
1. COPD - Emphysema
2. Atrial Fibrillation.
3. Osteoporosis.
4. Pacemaker
Discharge Condition:
Stable
Discharge Instructions:
Please take all your medications and follow up with all your
appointments. Please call your doctor or come to the ED if you
have any worsening of your symptoms or have any shortness of
breath, diaphoresis, chest pain, cough, palpitations or swelling
of your feet.
.
The pleurex catheter has to be drained every 3 days.
.
The nurse [**First Name (Titles) 767**] [**Last Name (Titles) **] pulmonary department at [**Hospital1 18**] will
call you to make a clinic appointment for evaluation and removal
of the pleurex catheter.
Followup Instructions:
Heterogeneous left lobe of the thyroid, with foci of
calcification and hypodensity - Thyroid Ultrasound Recommended
.
If there is any problem with the pigtail catheter, please call
[**Telephone/Fax (1) 3020**] for the RN/scheduler, and if an urgent issue
arises, contact [**Telephone/Fax (1) 2756**] and ask that pager number #[**Numeric Identifier 72574**] (this is the pager number of the [**Numeric Identifier 11063**] Pulmonary
fellow).
.
She should be seen by [**Hospital1 18**] [**Hospital1 11063**] Pulmonary clinic. The
nurse will call to make an appointment.
Completed by:[**2117-7-12**]
|
[
"496",
"276.4",
"427.31",
"458.29",
"707.07",
"416.8",
"794.5",
"276.52",
"285.29",
"584.5",
"733.00",
"263.0",
"707.05",
"584.9",
"511.9",
"041.11",
"599.0",
"410.71",
"512.1",
"V45.01",
"428.31",
"424.0",
"112.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.92",
"99.21",
"34.09",
"96.6",
"34.91",
"37.21",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
14512, 14588
|
8038, 12430
|
307, 364
|
14860, 14869
|
2168, 8015
|
15442, 16041
|
1533, 1551
|
12718, 14489
|
14609, 14839
|
12456, 12695
|
14893, 15419
|
1566, 2149
|
240, 269
|
392, 1264
|
1286, 1380
|
1396, 1517
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,140
| 140,471
|
35820+58037
|
Discharge summary
|
report+addendum
|
Admission Date: [**2177-1-17**] Discharge Date: [**2177-1-27**]
Date of Birth: [**2098-7-2**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
right innominate artery stenosis
Major Surgical or Invasive Procedure:
s/p right innominate artery stent [**1-20**]
History of Present Illness:
This is a woman who presented with a right hemispheric TIA. She
was noted on imaging studies to have a severe stenosis of the
innominate artery, felt to be causing her symptoms. She was a
candidate for retrograde innominate
artery stent placement through a common carotid cutdown. Of
note, she also had a hematoma of the right groin after an
attempt at primary injection of the pseudoaneurysm.
Past Medical History:
Coronary Artery Disease status post PTCA and stent to the LAD
and
RCA ('[**61**])
Chronic Obstructive Pulmonary Disease
h/o stroke in distant past
Chronic Atrial fibrillation
congestive cardiomyopathy
NID Diabetes Mellitus
Hypertension
Hypothyroidism
peripheral vascular disease
h/o right carotid endarterectomy
mild chronic renal insufficiency (baseline creatinine of 1.4)
mild anemia of chronic disease
Social History:
Lives on her own, in appartment across her daughter's. She has
been using a walker since her recent pelvic fracture.
Family History:
N/C
Physical Exam:
T: 98.9-98.4 P: 74 BP: 143/47 RR: 19 Spo2: 93%
Gen : NAD
Cards: RRR
Lungs: CTAB
Abd: soft, NT, ND
Wound: neck soft without hematoma
JP drain intact.
Pedal pulses dopperable
Pertinent Results:
[**2177-1-24**] 06:55AM BLOOD WBC-8.1 RBC-3.22* Hgb-10.3* Hct-29.8*
MCV-93 MCH-31.8 MCHC-34.4 RDW-18.9* Plt Ct-181
[**2177-1-24**] 06:55AM BLOOD Plt Ct-181
[**2177-1-24**] 10:35AM BLOOD Glucose-86 UreaN-23* Creat-0.9 Na-142
K-3.4 Cl-107 HCO3-28 AnGap-10
[**2177-1-24**] 10:35AM BLOOD CK(CPK)-39
[**2177-1-24**] 10:35AM BLOOD Calcium-8.2* Phos-3.1 Mg-1.9
Brief Hospital Course:
[**2177-1-17**]-Patient admitted to hospital. See HPI for [**Hospital1 2824**] details
on her admission.
[**2177-1-18**]-Neurology was consulted immediately and followed the
patient during her hospital stay. Patient begun on heparin drip
with PTT's performed.
[**2177-1-19**]-Patient transfused for low hematocrit 2 units PRBCs.
Also, given Lasix subsequently. CT chest done with unremarkable
results.
[**2177-1-20**]-Innominate artery stent placement was performed by Dr.
[**Last Name (STitle) **]. Please see operative report for more details.
Subsequently, evacuation of right groin hematoma and repair of
right common femoral artery pseudoaneurysm performed. Please see
operative report for more details.
[**2177-1-21**]-Patient bolused due to low pressue and urine output
problems. [**Name (NI) **] responded well.
[**2177-1-22**]-Patient out of bed to chair. Home diuretics restarted.
Physical therapy consult initiated.
[**2177-1-23**]-JP changed to bulb suction. Foley discontinued. Due to
low back pain, MRI scheduled.
[**2177-1-24**]-MRI performed and patient fitted with [**Doctor Last Name **] brace. Dr.
[**Last Name (STitle) **] from Ortho saw the patient and recommended outpt.
followup. Doppler U/S of upper extremity veins done to rule out
thrombus of neck.
[**2177-1-25**]-Patient begun to be weaned off oxygen. Coumadin begun.
Fluconazole begun for thrush.
[**2177-1-26**]-Warfarin continued. Oxygen fully weaned. Patient
otherwise stable.
[**2177-1-27**]-PT recommends rehab. Patient screened and received bed
offer. Patient agrees and is medically fit for extended care
facility.
Medications on Admission:
Nifedical XL 60', Metformin 750', Januvia 1', glipizide 10'',
simvastatin 40', Coumadin 1', diovan 80/12.5', Levoxyl 50',
Lopressor 12.5', Feosol 325', Actonel
.
Discharge Medications:
1. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q6H (every 6 hours) as needed.
6. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. Sitagliptin 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. 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.
9. Nifedipine 10 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8
hours).
10. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
12. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
13. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
14. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO DAILY (Daily).
15. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
17. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
18. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
19. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed.
20. Insulin sliding scale (Regular)
Breakfast Lunch Dinner Bedtime
Regular
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
0-60 mg/dL [**1-10**] amp D50 61-120 mg/dL 0 Units 0 Units 0
Units 0 Units
121-160 mg/dL 2 Units 2 Units 2 Units 2 Units
161-200 mg/dL 4 Units 4 Units 4 Units 4 Units
201-240 mg/dL 6 Units 6 Units 6 Units 6 Units
241-280 mg/dL 8 Units 8 Units 8 Units 8 Units
281-320 mg/dL 10 Units 10 Units 10 Units 10 Units
321-360 mg/dL 12 Units 12 Units 12 Units 12 Units
> 360 mg/dL Notify M.D.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
critical R inominate artery stenosis (pre-op)
PMH:
CAD
COPD
Chronic Afib
CHF (last LVEF 48%)
NIDDM
Hypertension
Hypothyroidism
PVD
mild anemia of chronic disease
Discharge Condition:
Stable
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Innominate Stent Discharge Instructions
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? Take Plavix (Clopidogrel) 75mg once daily
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
?????? After 1 week, you may resume sexual activity
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate
?????? No driving until you are no longer taking pain medications
?????? You should not have an MRI scan within the first 4 weeks after
carotid stenting
?????? Call and schedule an appointment to be seen in [**3-12**] weeks for
post procedure check and ultrasound
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site)
?????? Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office. If bleeding does not stop, call 911 for
transfer to closest Emergency Room.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2177-1-31**] 10:15
Please also follow up with Dr. [**Last Name (STitle) **], [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], the
orthopedic surgeon who saw you in the hospital. The phone number
for his clinic is ([**Telephone/Fax (1) 2007**].
Completed by:[**2177-1-27**] Name: [**Known lastname 45**],[**Known firstname 11466**] D Unit No: [**Numeric Identifier 13057**]
Admission Date: [**2177-1-17**] Discharge Date: [**2177-1-27**]
Date of Birth: [**2098-7-2**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 270**]
Addendum:
Adjusted discharge information:
Patient's sutures will be taken out at follow up visit.
Wound care instructions contained on Page 1 of discharge
paperwork.
Medications list should include:
Warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
No need for heparinization.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1933**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 272**] MD [**MD Number(1) 273**]
Completed by:[**2177-1-27**]
|
[
"425.4",
"244.9",
"433.10",
"428.30",
"112.0",
"285.29",
"250.00",
"496",
"V45.82",
"285.9",
"585.9",
"V70.7",
"428.0",
"433.80",
"403.90",
"724.5",
"442.3",
"458.29",
"427.31",
"998.12",
"410.72",
"788.5",
"997.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.52",
"00.64",
"00.46",
"00.63",
"00.61",
"00.40"
] |
icd9pcs
|
[
[
[]
]
] |
9725, 9927
|
1997, 3600
|
346, 393
|
6288, 6297
|
1619, 1974
|
8571, 9702
|
1397, 1402
|
3813, 6012
|
6103, 6267
|
3626, 3790
|
6321, 7618
|
7644, 8548
|
1417, 1600
|
274, 308
|
421, 817
|
839, 1246
|
1262, 1381
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,135
| 164,614
|
55085
|
Discharge summary
|
report
|
Admission Date: [**2120-8-26**] Discharge Date: [**2120-9-1**]
Date of Birth: [**2036-12-27**] Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
intraabdominal bleeding and hypotension s/p unwitnessed fall at
home
Major Surgical or Invasive Procedure:
[**2120-8-27**] - angiogram, coiling of inferior pancreatic branch of SMA
History of Present Illness:
83F s/p unwitnessed fall at home three days prior to
presentation. Today she was lightheaded and pale looking per her
family. She went to a referring hospital where she was
hypotensive with an SBP in the 70s. A CT torso there showed
intra-abdominal bleeding with active extravasation that appeared
to be retroperitoneal in nature. She was given 1500cc of IVF, 1
unit of pRBC, and 1 unit of FFP and then transferred to [**Hospital1 18**]
for further management. Upon arrival she had a BP of 113/65
which then dropped to the high 80s, which was responsive to IVF.
Hgb
on presentation at OSH was 11.7 and then 8.7 on recheck.
Past Medical History:
PMH: hypertension, depression, hyperlipidemia, BRCA
PSH: none
Social History:
Pt lives alone, but gets a lot of support from her children and
some community organizations, has had multiple falls in the past
year, no tobacco, no ETOH
Family History:
noncontributory
Physical Exam:
Discharge Exam:
VS: 98.2 58 118/56 18 96RA
Gen:NAD
Heart:RRR
Lungs:CTA
Abd:s/NT/ND
Ext:no edema
Pertinent Results:
[**2120-8-26**] 04:50PM BLOOD WBC-22.6* RBC-4.13* Hgb-12.3 Hct-37.5
MCV-91 MCH-29.6 MCHC-32.7 RDW-14.3 Plt Ct-271
[**2120-8-26**] 09:30PM BLOOD WBC-19.2* RBC-3.31* Hgb-10.0* Hct-30.2*
MCV-91 MCH-30.3 MCHC-33.1 RDW-14.9 Plt Ct-202
[**2120-8-27**] 03:04AM BLOOD WBC-20.5* RBC-3.48* Hgb-10.3* Hct-31.6*
MCV-91 MCH-29.7 MCHC-32.7 RDW-15.3 Plt Ct-168
[**2120-8-27**] 07:23AM BLOOD Hct-24.5*
[**2120-8-27**] 10:47AM BLOOD WBC-20.7* RBC-3.34* Hgb-10.1* Hct-29.7*
MCV-89 MCH-30.2 MCHC-33.9 RDW-15.4 Plt Ct-169
[**2120-8-27**] 07:45PM BLOOD WBC-18.7* RBC-2.89* Hgb-8.6* Hct-26.1*
MCV-90 MCH-29.8 MCHC-33.0 RDW-15.4 Plt Ct-170
[**2120-8-28**] 12:54AM BLOOD WBC-18.6* RBC-2.77* Hgb-8.5* Hct-25.1*
MCV-91 MCH-30.6 MCHC-33.8 RDW-15.3 Plt Ct-176
[**2120-8-28**] 08:22AM BLOOD WBC-14.8* RBC-2.67* Hgb-8.1* Hct-24.5*
MCV-92 MCH-30.3 MCHC-33.0 RDW-15.3 Plt Ct-172
[**2120-8-28**] 04:40PM BLOOD WBC-13.8* RBC-2.62* Hgb-8.0* Hct-24.0*
MCV-92 MCH-30.5 MCHC-33.3 RDW-15.2 Plt Ct-175
[**2120-8-29**] 01:30AM BLOOD WBC-11.6* RBC-2.53* Hgb-7.8* Hct-23.1*
MCV-91 MCH-30.7 MCHC-33.6 RDW-15.1 Plt Ct-157
[**2120-8-29**] 03:45PM BLOOD WBC-11.4* RBC-2.53* Hgb-7.7* Hct-23.4*
MCV-93 MCH-30.3 MCHC-32.7 RDW-15.1 Plt Ct-196
[**2120-8-30**] 04:47AM BLOOD WBC-8.8 RBC-2.44* Hgb-7.4* Hct-22.4*
MCV-92 MCH-30.2 MCHC-32.8 RDW-15.3 Plt Ct-198
[**2120-8-26**] 04:50PM BLOOD Glucose-221* UreaN-24* Creat-1.2* Na-142
K-3.5 Cl-104 HCO3-21* AnGap-21*
[**2120-8-26**] 09:30PM BLOOD Glucose-221* UreaN-24* Creat-1.4* Na-139
K-4.1 Cl-108 HCO3-14* AnGap-21*
[**2120-8-27**] 03:04AM BLOOD Glucose-144* UreaN-26* Creat-1.8* Na-140
K-4.3 Cl-106 HCO3-20* AnGap-18
[**2120-8-28**] 12:54AM BLOOD Glucose-118* UreaN-33* Creat-2.0* Na-141
K-4.5 Cl-108 HCO3-22 AnGap-16
[**2120-8-28**] 04:40PM BLOOD Glucose-102* UreaN-29* Creat-1.6* Na-141
K-3.5 Cl-106 HCO3-26 AnGap-13
[**2120-8-29**] 01:30AM BLOOD Glucose-93 UreaN-28* Creat-1.5* Na-141
K-3.3 Cl-107 HCO3-27 AnGap-10
[**2120-8-29**] 03:45PM BLOOD Glucose-166* UreaN-25* Creat-1.2* Na-140
K-3.5 Cl-106 HCO3-29 AnGap-9
[**2120-8-30**] 04:47AM BLOOD Glucose-97 UreaN-23* Creat-1.0 Na-141
K-3.8 Cl-106 HCO3-28 AnGap-11
[**2120-8-26**] Angiogram
INDICATION: 83-year-old woman with mesenteric and
retroperitoneal bleed and active extravasation on CTA.
ANESTHESIA: Moderate sedation was achieved by providing divided
doses of 25 mcg of fentanyl and 1.5 mg of Versed over the entire
intraprocedure time of 2 hours, during which the patient's
hemodynamic parameters were continuously monitored.
PROCEDURES PERFORMED:
1. SMA and celiac axis arteriograms.
2. Selective coiling of pseudo aneurysm from inferior
pancreatic-duodenal SMA branches.
PROCEDURE DETAILS: Informed consent was obtained from the
[**Hospital 228**]
healthcare proxy after explaining the risks, benefits, and
potential
complications of the procedure. Following this, the patient was
brought to
the angiography suite and placed supine on the imaging table.
The right groin was prepped and draped in the usual sterile
fashion and a pre-procedure timeout performed as per [**Hospital1 18**]
protocol.
After accessing the right common femoral artery with a 19-gauge
needle, [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) 7648**] wire was advanced into the abdominal aorta and the
needle exchanged
for 5 French [**Last Name (un) 2493**]-Tip sheath. A C2 Cobra catheter was changed
in and used to selectively cannulate the celiac trunk. A DSA
celiac trunk run demonstrated normal anatomy of the splenic and
hepatic artery as well as the GDA, specifically without evidence
of active extravasation. A small caliber of the celiac trunk
arteries was seen and was consistent with the patient's
hypotension.
Accordingly, the Cobra catheter was repositioned in the SMA and
an additional SMA DSA run performed. The latter demonstrated
pseudoaneurysm and active extravasation from what appeared to be
an inferior pancreatic branch of the SMA.
A Renegade STC microcatheter and Transcend guidewire were now
advanced over the Cobra catheter to selectively cannulate the
branch identified. Multiple coils were then successfully
positioned both proximal to the site of extravasation, distal to
it in what appeared to be a collateral with the GDA area of
supply, and finally within the area of extravasation itself.
Subsequent selective runs demonstrated no residual hemorrhage.
The same was true for a final selective run performed over the
GDA.
Wires, catheters, and the sheaths were then removed and
hemostasis
successfully achieved by holding pressure for about 20 minutes.
The patient tolerated the procedure well and there were no
immediate complications.
IMPRESSION: Active extravasation and pseudo aneurysm from what
appeared to be an inferior pancreatic branch of the SMA, which
was successfully treated by placement of multiple coils. The
latter were deployed along the bleedingbranch proximal and
distal to the site of extravasation. Following treatment, there
was no evidence of collateral flow to the hemorrhagic focus.
Brief Hospital Course:
Ms. [**Known lastname 88135**] was transferred from an OSH after receiving
1uPRBC, 1uFFP, 1.5L IVF. The patient was initially consented for
an exploratory laparotomy upon evaluation by the ACS service in
the [**Hospital1 18**] ED. After a second review of the available CT scan
images, interventional radiology was contact[**Name (NI) **] to perform an
angiogram and attempt to isolate and treat the source of
bleeding without the need for surgical exploration. The source
of the bleeding appeared to be retroperitoneal on CT. Ms.
[**Known lastname 88135**] was taken to IR, where active extravasation and
pseudoaneurysm were seen from what appeared to be an inferior
pancreatic branch of the SMA, which was successfully treated by
placement of multiple coils. The latter were deployed along the
bleeding branch proximal and distal to the site of
extravasation. Following treatment, there was no evidence of
collateral flow to the hemorrhagic focus.
The patient was admitted to the SICU for close monitoring after
the procedure on [**8-27**]. She received 4L IVF and 2uPRBC during the
periprocedure period and required low dose pressors for a brief
time period. She received albumin 25% for borderline low urine
output overnight after the procedure. She picked up well after
that maintaining 20-30cc/hour without further oliguria. Serial
hematocrits were followed which were overall stable during her
ICU stay in the range of 23-25, and she did not require further
transfusion. Her vital signs were closely monitored for signs of
tachycardia or hypotension, and these remained within normal
limits. She was out of bed to chair with assistance.
On [**8-28**], her hematocrits remained stable, but her WBC rose to 18
without a clear explanation. Her creatinine bumped to 2.0,
thought to be acute renal failure secondary to the contrast load
from the CTA and angiogram. This came down nicely with ongoing
IVF hydration. She tolerated sips without nausea.
On [**8-29**], her WBC count and creatinine trended down and her
hematocrits remained stable. She was restarted on her home
medications, with her diuretics remaining on hold, and she was
advanced to a regular diet. Heparin prophylaxis was started.
PT/OT were consulted to assess home safety after her recent fall
and to determine a need for rehabilitation after discharge. She
was transferred to the surgical floor in stable condition.
On [**8-30**], PT worked with the patient and recommended discharge to
rehab when clinically cleared. The patient had diarrhea and a
cdiff was ordered. The patient's foley was removed. Her
hematocrit was 22.4, still stable having been in the low-mid
20's over the past few days of her admission.
[**9-1**], Patient has had stable Hct's in the low 20s.
Medications on Admission:
sertraline 50mg daily, donepezil 10mg daily, amlodipine 5mg
daily, HCTZ 25mg daily, lasix 10mg daily, atenolol 50mg daily,
simvastatin 10mg daily, Klor-Con 25meq daily
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Atenolol 50 mg PO DAILY
3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
4. Docusate Sodium 100 mg PO BID
5. Donepezil 10 mg PO HS
6. Furosemide 20 mg PO DAILY
7. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB
8. Sertraline 50 mg PO DAILY
9. Simvastatin 5 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1036**] - [**Location (un) 620**]
Discharge Diagnosis:
Fall, Retroperitoneal bleeding with pseudo aneurysm of inferior
pancreatic branch of the SMA
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 Acute Care Surgery service for a
retroperitoneal bleed.
Please call your doctor or go to the emergency department if:
*You experience new chest pain, pressure, squeezing or
tightness.
*You develop new or worsening cough, shortness of breath, or
wheeze.
*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 an unusual discharge.
*Your pain is not improving within 12 hours or is not under
control within 24 hours.
*Your pain worsens or changes location.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*You develop any concerning symptoms.
General Discharge Instructions:
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Please take any
new medications as prescribed.
Please take the prescribed analgesic medications as needed. You
may not drive or heavy machinery while taking narcotic analgesic
medications. You may also take acetaminophen (Tylenol) as
directed, but do not exceed 4000 mg in one day.
Please get plenty of rest, continue to walk several times per
day, and drink adequate amounts of fluids. Avoid strenuous
physical activity and refrain from heavy lifting greater than 20
lbs., until you follow-up with your surgeon, who will instruct
you further regarding activity restrictions. Please also
follow-up with your primary care physician.
Followup Instructions:
Please call and schedule follow-up with your primary care
provider.
Please call [**Telephone/Fax (1) 600**] to schedule follow-up in [**Hospital 2536**] clinic in
[**1-26**] weeks.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
|
[
"787.91",
"311",
"V15.88",
"293.0",
"902.25",
"E888.9",
"401.9",
"V83.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.47",
"39.79"
] |
icd9pcs
|
[
[
[]
]
] |
9807, 9884
|
6521, 9268
|
339, 414
|
10021, 10021
|
1494, 6498
|
11980, 12272
|
1346, 1363
|
9486, 9784
|
9905, 10000
|
9294, 9463
|
10206, 11177
|
1378, 1378
|
1394, 1475
|
11209, 11957
|
231, 301
|
442, 1070
|
10036, 10182
|
1092, 1156
|
1172, 1330
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,796
| 189,385
|
41271
|
Discharge summary
|
report
|
Admission Date: [**2198-7-25**] Discharge Date: [**2198-7-29**]
Date of Birth: [**2125-8-3**] Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 3256**]
Chief Complaint:
Dyspnea.
Major Surgical or Invasive Procedure:
Intubation, self-extubation.
History of Present Illness:
72yo F with a PMHx of severe COPD (on home oxygen, multiple
recent admissions requiring intubation), dCHF, T2DM
(insulin-dependent), OSA on home BiPAP, atrial fibrillation on
coumadin, and CKD who presented to the ED with increased work of
breathing.
Per EMS report, the family noticed that sometime between last
night and today, patient began having shortness of breath and
altered mental status. EMS arrived to find the patient on her
[**Last Name (un) **] BiPAP (family thought that it might help with SOB) sitting
in a chair with her neck flexed forward and tongue exnteded,
awake confused, tachypneic, with shallow respiration. She was
noted to be cool, clammy, with distant lung sounds and fine
rales 3/4 up. She was noted to have an O2 Sat of 88% on RA as
well as hypertensive. Her FSBG at the scene was 219. The patient
was initially give O2 via NR, but then changed to CPAP when she
was noted not to have improvement in her SOB. She was then
transferred via EMS to [**Hospital1 18**].
In the ED, patient was oriented only to self noted to be using
accessory muscle use. Vital signs on arrival: 160/100, 100
(afib), RR 35-45, 98% on CPAP. ABG was significant for pCO2 of
98. Her exam was notable for bilateral rales. She was on a nitro
gtt briefly for The patient as intubated with 20mg etomidate and
120mg succs given IV reportedly with no difficulties. During
intubated, the ETT was noted to have pink and brown mucous. She
was started on antibiotics for treatment of PNA with Vanc and
Zosyn. Patient currently on propofol for sedation. A foley was
placed. The patient had transient episodes of hypotension, which
the ED resident attributed to auto PEEPing (he was able to
express air from her chest while pressing down on the patient's
chest) as well as sedation. Her lung exam was noted to have
worsen with worsening rales than when she presented. She was
given 40mg of IV lasix prior to transfer to the floor. Patient
received a total of 400cc of IVFs since arrival in the ED via
medications. Vent settings prior to transfer: CMV, FiO2 40%,
PEEP 6, RR 14, TV 400mL. Vital signs on transfer: 97.8, 73
(afib), 107/50, 92-98% (vented).
On arrival to the MICU, the patient is intubated and sedated.
Review of systems: Unable to obtain as the patient is intubated
and sedated.
Past Medical History:
- COPD on home oxygen
- Obstructive sleep apnea with BiPAP at night
- Type 2 diabetes mellitus, on insulin
- Atrial fibrillation on coumadin
- Diastolic congestive heart failure
- Diverticulitis s/p colostomy, then s/p reversal
- Obesity
- Anemia of chronic disease
- Hypertension
- Dyslipidemia
- Chronic kidney insufficiency stage III in f/u renal [**Hospital1 18**]
- GERD
Social History:
Used to be school bus driver. Lives in [**Location (un) 538**] with
husband and usually granddaughter, multiple kids in local area,
HHA cleans. Denies tobacco, EtOH, illicit drug use.
Family History:
No history of CKD, lung disease, or malignancies.
Physical Exam:
Upon admission:
General: Patient intubated, sedated in NAD
HEENT: Left PERRL, right pupil irregular, minimally-reactive to
light.. ETT and OGT in mouth.
CV: Irregularly, irregular. No murmurs, rubs, or gallops.
Lungs: Lungs clear to auscultation at the apices bilaterally,
anteriorly. Left anterior lung field with diminished breath
sounds.
Abdomen: Obese. Longitudinal midline scar. BS+ Soft. NT/ND.
Ext: Warm feet, but non-palpable pulses (DP and PTs)
bilaterally), but Dopplerable. 2+ pitting edema of the LE to the
mid-shins bilaterally.
Neuro: Intubated, sedated, unable to follow commands, but
grimaces and tries to withdraw with examination of pupils.
At discharge:
VS 98.4, 136/78, p74, R20, 96% on 2L
GEN: Alert. Cooperative. In no apparent distress. Appears
comfortable
HEENT/NECK: PERRLA. EOMI. Mucous membranes pink/moist. No
scleral icterus or pallor.
LUNGS: Clear to auscultation B/L. Mild bibasilar crackles.
CV: S1, S2. Regular rate and rhythm. No murmurs/gallops/rubs
appreciated. Pulses 2+ throughout. No JVD.
ABDOMEN: BS present. Soft. Nontender. Nondistended. No
organomegaly noted.
EXTREMITIES: No gross deformities, clubbing, or cyanosis. No
pitting edema.
NEURO: CNII-XII intact, motor and sensory grossly normal
SKIN: No rashes, bruises or ulcerations.
Pertinent Results:
Labs:
[**2198-7-25**] 07:34PM BLOOD WBC-9.9# RBC-3.40* Hgb-8.6* Hct-29.2*
MCV-86 MCH-25.3* MCHC-29.5* RDW-15.8* Plt Ct-447*
[**2198-7-25**] 07:34PM BLOOD Neuts-76.0* Lymphs-16.3* Monos-6.0
Eos-1.5 Baso-0.3
[**2198-7-25**] 07:34PM BLOOD PT-23.4* PTT-25.3 INR(PT)-2.2*
[**2198-7-25**] 07:34PM BLOOD Glucose-207* UreaN-47* Creat-2.1* Na-141
K-6.6* Cl-96 HCO3-36* AnGap-16
[**2198-7-25**] 07:34PM BLOOD cTropnT-0.04*
[**2198-7-25**] 07:55PM BLOOD proBNP-2415*
[**2198-7-26**] 02:01AM BLOOD CK-MB-4 cTropnT-0.03*
[**2198-7-26**] 02:01AM BLOOD Calcium-9.5 Phos-3.2 Mg-1.6
[**2198-7-25**] 07:40PM BLOOD Type-[**Last Name (un) **] pO2-57* pCO2-98* pH-7.25*
calTCO2-45* Base XS-11
[**2198-7-26**] 09:46AM BLOOD Type-ART Tidal V-359 PEEP-5 FiO2-40
pO2-120* pCO2-82* pH-7.34* calTCO2-46* Base XS-14 Intubat-NOT
INTUBA
[**2198-7-25**] 07:34PM BLOOD Lactate-1.3
Micro:
[**2198-7-25**] blood cultures pending x2
[**2198-7-25**] urine culture NGTD
Imaging:
[**2198-7-25**] CXR: Cardiomegaly with pulmonary edema.
[**2198-7-26**] CXR: As compared to the previous radiograph, the patient
is still
intubated and a nasogastric tube is in place. There is
unchanged obvious
cardiomegaly with signs of mild pulmonary edema. However,
pre-existing
opacity in the right perihilar areas and at the right lung base
have almost completely cleared. No interval appearance of new
opacities. No larger pleural effusions. No pneumothorax.
DISCHARGE:
[**2198-7-29**] 06:40AM BLOOD WBC-4.7 RBC-3.36* Hgb-8.3* Hct-28.2*
MCV-84 MCH-24.6* MCHC-29.3* RDW-16.0* Plt Ct-390
[**2198-7-29**] 06:40AM BLOOD PT-24.9* PTT-41.9* INR(PT)-2.4*
[**2198-7-29**] 06:40AM BLOOD Glucose-133* UreaN-48* Creat-1.8* Na-146*
K-4.0 Cl-96 HCO3-43* AnGap-11
[**2198-7-29**] 06:40AM BLOOD Calcium-9.4 Phos-4.0 Mg-1.8
Brief Hospital Course:
72 yo female with severe COPD and OHS on home oxygen, OSA on
BiPAP, afib, and chronic diastolic heart failure (EF 75%)
recently admitted [**6-/2198**] for acute hypercarbic respiratory
failure requiring intubation presented to the ED in respiratory
distress found to have an acute on chronic diastolic heart
failure exacerbation in the setting of recent IVF
administration.
# Acute on chronic diastolic heart failure exacerbation: Likely
secondary to IVF administration at an OSH in the setting of
diarrhea. Patient initially had lower extremity edema which
improved after diuresis. She was returned to her home
furosemide dose on day 2 of her admission and responded with
adequate diuresis. In addition carvedilol was added to
benazepril 40 and amlodipine 10 for improved BP control.
# Hypercarbic and hypoxic respiratory failure: Likely baseline
pCO2 around 75 or 80. The patient was diuresed as above, but did
not have signs of COPD flare. She was continued on her her home
COPD inhalers. She needs full PFTs as it is unclear how much of
her chronic hypercarbia is OHS vs COPD. Per PCP, [**Name10 (NameIs) **]
with med compliance, may also have diet compliance issues; BPs
likely not well-controlled. Nutrition consult was obtained for
dietary education.
# Hypertension: Uncontrolled on benazepril 40 and amlodipine 10.
Carvedilol was increased to 25mg [**Hospital1 **] on discharge. The patient
was instructed to followup as an outpatient. Metoprolol was
discontinued.
# Atrial fibrillation: Rate controlled. INR therapeutic on
warfarin.
# Stage 3 CKD: Baseline serum creatinine 1.9-2.1. Patient
currently within baseline.
# Normocytic Anemia: Chronic, at baseline hct.
# DM: last HgbA1c 8.6 in [**5-26**]: cont home lantus and ss
# Glaucoma: Continue latanoprost, apraclonidin, prednisolone.
TRANSITIONAL ISSUES:
# Code Status:
# Living situation: Patient with multiple hospital admissions,
seemingly not doing well at home. Family meeting was held on
[**7-27**] at which point family decided that patient would live with
daughter temporarily. [**Name2 (NI) **] adamantly declined rehab.
However, if patient is readmitted in the near future, would
require long term skilled nursing facility placement. The
patient was discharged home with her daughter.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Amlodipine 10 mg PO DAILY
2. Glargine 8 Units Bedtime
3. linagliptin *NF* 5 mg Oral DAILY
4. benazepril *NF* 40 mg Oral DAILY
5. Famotidine 20 mg PO BID
6. Gemfibrozil 600 mg PO BID
7. Apraclonidine 0.5% 1 DROP BOTH EYES DAILY
8. Albuterol-Ipratropium 1 PUFF IH Q4H:PRN wheezing, shortness
of breath
9. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES DAILY
10. Metoprolol Succinate XL 50 mg PO DAILY
11. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH [**Hospital1 **]
12. Furosemide 20 mg PO DAILY
13. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
14. Docusate Sodium 100 mg PO BID:PRN constipation
15. Warfarin 5 mg PO DAILY16
16. Tiotropium Bromide 1 CAP IH DAILY
17. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Glargine 8 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
3. linagliptin *NF* 5 mg Oral DAILY
4. benazepril *NF* 40 mg Oral DAILY
5. Famotidine 20 mg PO BID
6. Gemfibrozil 600 mg PO BID
7. Apraclonidine 0.5% 1 DROP BOTH EYES DAILY
8. Albuterol-Ipratropium [**1-15**] PUFF IH Q4-6HRS shortness of breath
9. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES DAILY
10. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH [**Hospital1 **]
11. Furosemide 20 mg PO DAILY
12. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
13. Docusate Sodium 100 mg PO BID:PRN constipation
14. Warfarin 5 mg PO DAILY16
15. Tiotropium Bromide 1 CAP IH DAILY
16. Carvedilol 25 mg PO BID
HOLD for SBP < 100, HR < 60
RX *carvedilol 25 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary: Chronic Obstructive Pulmonary Disease, Congestive Heart
Failure
Secondary: Hypertension, Diabetes Mellitus, Atrial Fibrillation,
Chronic Kidney 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 Ms. [**Known lastname 1458**],
It was a pleasure to care for you at [**Hospital1 827**]. You were admitted because you were having
extreme difficulty breathing, probably due to your COPD or your
heart failure. We treated you in the medical ICU with a
breathing tube and a mechanical ventilator while giving you
medications to help you breath better and to remove fluid from
your body. You eventually improved and were able to breath on
your normal level of oxygen without the breathing tube.
.
We also found you to have a very high blood pressure and treated
you with some medications to help control it. You should
followup on control of your blood pressure medications with your
primary care physician.
.
Please note the following changes to your medications:
You should START taking Carvedilol for your blood pressure and
heart.
You should STOP taking metoprolol.
You should continue the rest of your medications as previously
prescribed.
Followup Instructions:
You need to follow up with your Primary Care Physician [**Name Initial (PRE) 176**]
1-2 weeks and your Lung (Pulmonary) Physician [**Name Initial (PRE) 176**] 1-2 weeks.
Please contact their offices to make these appointments as soon
as possible.
Department: MEDICAL SPECIALTIES
When: TUESDAY [**2198-7-31**] at 3:00 PM
With: DR. [**Last Name (STitle) 87631**]/DR. [**Last Name (STitle) 611**] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: WEST [**Hospital 2002**] CLINIC
When: THURSDAY [**2198-8-16**] at 10:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
**We recommend that you contact the following office and change
your appointment to within 1-2 weeks.**
Department: PULMONARY FUNCTION LAB
When: [**Street Address(1) **] [**2198-9-24**] at 9:40 AM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2198-7-29**]
|
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icd9cm
|
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3038, 3223
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,982
| 124,522
|
52849
|
Discharge summary
|
report
|
Admission Date: [**2142-3-11**] Discharge Date: [**2142-3-24**]
Date of Birth: [**2065-4-17**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1185**]
Chief Complaint:
Vomiting, fever, shortness of breath
Major Surgical or Invasive Procedure:
Intubation [**2142-3-11**], Extubation [**2142-3-17**]
History of Present Illness:
76F history of DMII with peripheral neuropathy, PVD with
persistent non-healing ulcer at the lateral and medial malleolus
(recently admitted in [**2141-11-28**] for left foot cellulitis
with ulcer culture growing MDR pseudomonas) who presents to ED
from home for nausea/vomiting, fevers and AMS (AAOx2). Pt had 10
episodes of emesis (small volumes) but no diarrhea and no
abdominal pain.
Pt reports that in [**2141-2-5**] she had cough and sore throat and
was given Flovent by her PCP. [**Name10 (NameIs) **] symptoms then improved. Over
the last 1.5 weeks she has had 3 episodes of emesis but no
diarrhea and no abd pain. Last night she suddenly had nausea and
emesis- 10 episodes. Husband was concerned and brought her to
ED. She had associated chills, no documented fevers. Notes she
had mild SOB after the emesis episodes but not different from
baseline. Also with a chronic cough but not productive and
unchanged from prior. Last bm was yesterday. Patient is also
incontinent of urine and takes detrol. Of note, her fingerstick
glucose has been labile at home with glucose from 55 to 245.
In the ED inital vitals were, T 101 HR 98 BP 120/80 24 O2 94%
3L
On arrival to ED, patient triggered for hypoxia to 84% on RA (no
history of lung disease). Patient also altered, lethargic and
oriented only to place. Lethargic but arousable to name. Tm 103
on arrival to ED. BPs initially low 100 SBP (in a patient with
history of hypertension) but BPs dropped to 80s/40s. She was
also given 1 L NS.
CXR was performed with prelim report suggestive of RLL
pneumonia.
Blood and urine cultures in addition to UA were performed.
She was given vancomycin, zosyn, albuterol, and acetaminophen
1000 mg for fever. VS were T 103 (Tm), 94, 24, 99% 4L NC BPs.
The patient was noted to be lethargic but arousable to voice,
oriented to place and person only. She was tachypneic with
reduced air movement especially at the bases and diffuse
expiratory wheezes. Her LLE heel ulcer was well dressed and
intact.
ECG performed showing sinus tachycardia with old Q waves
antero-lateraly consistent with prior.
Labs showed: CBC with WBC 9.6, Hgb 11.7, Hct 35.5 (recent
baseline 33-37), platelets 273 with Diff showing neutrophilia.
Chemistry panel with Na 145, K 4.8, Cl 98, HCO3 34, BUN 50, Cr
1.7 [Baseline Cr 0.9 - 1.4 in past few months].
Initial lactate was 2.5.
UA showed trace LE, protein 30, WBC 2, moderate bacteria, 0 epi,
2 hyaline cast
Patient was suspected to have sepsis from a urinary source vs
pulmonary source. Given intermittent hypotension responsive to
IVF and mental status, decision was made to admit to MICU.
VS on transfer were 93 20 98%4L NC 107/32 s/p 1L NS
On arrival to the ICU, vital signs were: 97.0 94 118/32 14
97%1L. Patient was comfortable. Family member in room, able to
corroborate history. Pt A+Ox3, denies any current n/v, no cough,
no sob, no urinary symptoms. Notes mild senstion to have loose
bowel movement right now but no diarrhea over the last few days.
Review of systems:
(+) Per HPI
(-) Denies night sweats, recent weight loss or gain. Denies
headache, sinus tenderness. Denies wheezing. Denies chest pain,
chest pressure, palpitations, or weakness. Denies diarrhea,
constipation, abdominal pain, or changes in bowel habits. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
- DMII complicated by DM neuropathy
- PVD s/p L CFA w/balloon angioplasty of SFA and AK [**Doctor Last Name **] artery
w/ persistent non-healing ulcer at the lateral and medial
malleolus, non-healing L pedal ulcer
- Hypertension
- h/o MDR Psuedomonas and MRSA skin infections
- h/o hemorrhagic pancreatitis ([**2090**])
- h/o cholecystitis (still has gallbladder)
Social History:
Lives at home with her husband in [**Name2 (NI) **]. Tobacco: quit [**2105**].
EtOH:
denies. Illicits: denies. 3 children, 3 grandchildren, 3 great
grandchildren.
Family History:
father- lung ca
Physical Exam:
ADMISSION EXAM
Vitals: 97.0 94 118/32 14 97%1L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: crackles in bases bilaterally R>L
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops , no JVP
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley with clear yellow urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis.
Trace edema. Left wound healing nicely.
Neuro: Right eye ptosis
.
DISCHARGE PHYSICAL EXAM
98.1 (tmax), 149/49, 78, 18, 96ra, fs211
General: Alert, oriented x3, no acute distress. Slightly
confused in evenings. At time of discharge, has not had
hallucinations for 2 days.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: distant breath sounds, crackles at bases bilaterally
improved with coughing
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops , no JVP
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis.
Trace edema. Left foot wound healing nicely.
Neuro: Right eye ptosis/exotropia (baseline)
.
Pertinent Results:
Admission Labs:
[**2142-3-11**] 08:45AM BLOOD WBC-9.6 RBC-3.93* Hgb-11.7* Hct-35.5*
MCV-90 MCH-29.7 MCHC-32.9 RDW-13.7 Plt Ct-273
[**2142-3-11**] 08:45AM BLOOD Neuts-89.0* Lymphs-7.6* Monos-2.7 Eos-0.4
Baso-0.3
[**2142-3-12**] 12:29PM BLOOD PT-15.8* PTT-66.6* INR(PT)-1.5*
[**2142-3-11**] 08:45AM BLOOD Glucose-137* UreaN-50* Creat-1.7* Na-145
K-4.8 Cl-98 HCO3-34* AnGap-18
[**2142-3-12**] 04:43AM BLOOD ALT-17 AST-44* CK(CPK)-289* AlkPhos-90
TotBili-0.7
[**2142-3-11**] 08:45AM BLOOD Lipase-71*
[**2142-3-11**] 08:45AM BLOOD CK-MB-3 cTropnT-0.03*
[**2142-3-11**] 08:45AM BLOOD Calcium-9.1 Phos-5.0* Mg-1.8
[**2142-3-11**] 04:30PM BLOOD Type-ART Temp-37.8 Rates-/16 pO2-65*
pCO2-48* pH-7.44 calTCO2-34* Base XS-6 Intubat-NOT INTUBA
[**2142-3-11**] 09:06AM BLOOD Lactate-2.5*
[**2142-3-11**] 04:30PM BLOOD O2 Sat-91
[**2142-3-11**] 08:14PM BLOOD freeCa-1.09*
Pertinent Interval Labs:
[**2142-3-12**] 04:43AM BLOOD WBC-18.4* RBC-3.26* Hgb-9.5* Hct-29.1*
MCV-89 MCH-29.0 MCHC-32.5 RDW-13.9 Plt Ct-288
[**2142-3-13**] 03:48AM BLOOD WBC-10.9 RBC-2.91* Hgb-8.7* Hct-26.2*
MCV-90 MCH-29.8 MCHC-33.1 RDW-14.0 Plt Ct-199
[**2142-3-19**] 12:53AM BLOOD WBC-6.4 RBC-2.88* Hgb-8.2* Hct-25.7*
MCV-89 MCH-28.3 MCHC-31.7 RDW-14.1 Plt Ct-241
[**2142-3-17**] 03:31AM BLOOD PT-12.3 PTT-32.0 INR(PT)-1.1
[**2142-3-13**] 03:48AM BLOOD Glucose-229* UreaN-35* Creat-1.9* Na-141
K-3.7 Cl-104 HCO3-29 AnGap-12
[**2142-3-19**] 12:53AM BLOOD Glucose-114* UreaN-11 Creat-1.1 Na-142
K-3.8 Cl-104 HCO3-31 AnGap-11
[**2142-3-17**] 03:31AM BLOOD ALT-11 AST-23 LD(LDH)-199 AlkPhos-114*
TotBili-0.2
[**2142-3-12**] 12:00AM BLOOD CK-MB-4 cTropnT-0.25*
[**2142-3-12**] 04:43AM BLOOD CK-MB-21* MB Indx-7.3* cTropnT-0.54*
[**2142-3-12**] 12:31PM BLOOD CK-MB-28* MB Indx-7.0* cTropnT-1.35*
[**2142-3-12**] 09:50PM BLOOD CK-MB-10 MB Indx-5.0 cTropnT-1.07*
[**2142-3-13**] 03:48AM BLOOD CK-MB-5 cTropnT-0.92*
[**2142-3-19**] 12:53AM BLOOD Calcium-8.6 Phos-3.1 Mg-2.0
[**2142-3-17**] 03:31AM BLOOD Albumin-2.7* Calcium-8.7 Phos-3.8 Mg-2.1
[**2142-3-13**] 06:35AM BLOOD Cortsol-14.4
[**2142-3-13**] 06:35AM BLOOD Vanco-27.4*
[**2142-3-17**] 07:59PM BLOOD Type-ART PEEP-5 FiO2-50 pO2-110* pCO2-62*
pH-7.34* calTCO2-35* Base XS-5 Intubat-NOT INTUBA Comment-NON
INVASI
[**2142-3-11**] 04:30PM BLOOD Lactate-1.5
[**2142-3-11**] 08:14PM BLOOD Lactate-1.5
[**2142-3-12**] 12:13AM BLOOD Lactate-1.6
[**2142-3-12**] 02:08AM BLOOD Lactate-1.1
[**2142-3-12**] 04:54AM BLOOD Lactate-1.6
[**2142-3-13**] 03:51PM BLOOD Lactate-1.0
[**2142-3-14**] 10:13AM BLOOD Lactate-0.9
[**2142-3-17**] 05:51PM BLOOD freeCa-1.17
URINE:
[**2142-3-11**] 09:40AM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.010
[**2142-3-11**] 09:40AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-TR
[**2142-3-11**] 09:40AM URINE RBC-1 WBC-6* Bacteri-MOD Yeast-NONE Epi-1
[**2142-3-11**] 09:40AM URINE CastHy-2*
MICRO:
Blood cxs ([**3-11**]): no growth
Blood cxs ([**3-13**]): no growth
URINE CULTURE (Final [**2142-3-13**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 4 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
**FINAL REPORT [**2142-3-12**]**
DIRECT INFLUENZA A ANTIGEN TEST (Final [**2142-3-12**]):
Negative for Influenza A.
DIRECT INFLUENZA B ANTIGEN TEST (Final [**2142-3-12**]):
Negative for Influenza B.
**FINAL REPORT [**2142-3-12**]**
Legionella Urinary Antigen (Final [**2142-3-12**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
**FINAL REPORT [**2142-3-17**]**
GRAM STAIN (Final [**2142-3-12**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final [**2142-3-17**]):
RARE GROWTH Commensal Respiratory Flora.
YEAST. SPARSE GROWTH.
ESCHERICHIA COLI. RARE GROWTH.
WORK UP PER DR. [**First Name (STitle) **]([**Numeric Identifier 24340**]) ON [**2142-3-15**] @ 10:30AM.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
GRAM STAIN (Final [**2142-3-15**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2142-3-17**]):
Commensal Respiratory Flora Absent.
YEAST. SPARSE GROWTH.
IMAGES:
EKG ([**3-11**]):
Rate 94, Sinus rhythm. First degree A-V block. Poor R wave
progression. Lateral ST-T wave abnormalities. Compared to the
previous tracing of [**2141-12-19**] occasional Wenckebach pattern is no
longer seen.
EKG ([**3-11**]):
Junctional rhythm alternating with Wenckebach pattern. Poor R
wave
progression. Minor lateral ST-T wave abnormalities. Compared to
tracing #1
Wenckebach pattern is again seen.
CXR ([**3-11**]):
IMPRESSION: Right lung base opacity, compatible with pneumonia,
in the appropriate clinical setting. Findings also suggestive of
mild vascular congestion.
CXR ([**3-11**]):
IMPRESSION: AP chest compared to [**3-11**]:
Tip of the new right internal jugular line projects over the mid
SVC. No
pneumothorax, mediastinal widening or appreciable pleural
effusion. Large
scale consolidation in the lower lungs, right greater than left,
is unchanged. Heart size is normal. Pleural effusion, minimal if
any. No pneumothorax.
ECHO ([**3-12**])
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Right ventricular
chamber size is normal with mild global free wall hypokinesis.
The aortic valve leaflets (?#) appear structurally normal with
good leaflet excursion. There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. The
pulmonary artery systolic pressure could not be determined.
There is an anterior space which most likely represents a
prominent fat pad.
IMPRESSION: Suboptimal image quality. Normal left ventricular
cavity size with preserved global systolic function. Mild right
ventricular free wall hypokinesis.
.
EKG ([**3-12**]): Sinus rhythm. Poor R wave progression. Lateral ST-T
wave abnormalities. Compared to tracing #2 Wenckebach has
resolved.
.
CXR ([**3-12**]):
IMPRESSION:
1) Mild pulmonary edema with bilateral pleural effusions.
2) Multifocal pneumonia in right lung.
.
CXR ([**3-12**]):
IMPRESSION: Worsening pleural effusions and pulmonary edema.
.
CXR ([**3-12**]):
IMPRESSION:
1) OG tube passes into the stomach. ET tube tip 1.5 cm from the
carina;
withdraw 3 cm for more optimal placement.
2) Unchanged pulmonary edema with increased bilateral pleural
effusions.
3) Pneumonia. Presumed right lung consolidations now obscured.
.
ECG ([**3-13**]): Sinus rhythm. Wandering baseline and baseline
artifact. Left atrial abnormality. Prior anteroseptal myocardial
infarction. Occasional atrial ectopy. Compared to the previous
tracing of [**2142-3-12**] no diagnostic interim change.
.
CXR ([**3-13**]):
The ET tube tip is 4.3 cm above the carina. The right internal
jugular line tip is at the level of mid SVC. The NG tube tip is
in the stomach. The patient continues to be in pulmonary edema
that appears to be even progressed since the prior examination,
currently moderate to severe. Bilateral pleural effusions and
bibasal atelectasis are unchanged.
.
CXR ([**3-14**]):
The ET tube tip is 3 cm above the carina. The NG tube tip passes
below the
diaphragm, most likely terminating in the stomach. Right
internal jugular
line tip is at the level of mid SVC. There is interval
improvement in pulmonary edema, still present, moderate,
associated with bibasilar consolidations and bilateral pleural
effusions.
.
ECG ([**3-15**]): Baseline artifact. The rhythm is most likely ectopic
atrial rhythm. Poor R wave progression suggestive of
anteroseptal myocardial infarction of indeterminate age.
Compared to the previous tracing of [**2142-3-13**] there is no
significant diagnostic change.
.
CXR ([**3-16**]):
FINDINGS: Indwelling support and monitoring devices are in
standard position. Cardiomediastinal contours are stable in
appearance. Pulmonary vascular congestion is similar to the
prior study. Bilateral lower lobe areas of consolidation are
again demonstrated and may reflect pulmonary edema with or
without accompanying pneumonia. Small pleural effusions are
unchanged.
.
Subsequent EKGs notable for resolution of ischemic pattern in
lateral distribution and alternating 2nd degree heart block
(Mobitz type 1) with 1st degree heart block.
.
DISCHARGE LABS
[**2142-3-21**] 05:45AM BLOOD WBC-7.4 RBC-3.03* Hgb-8.8* Hct-27.1*
MCV-90 MCH-29.0 MCHC-32.4 RDW-14.3 Plt Ct-303
[**2142-3-21**] 05:45AM BLOOD Glucose-51* UreaN-14 Creat-1.3* Na-144
K-4.0 Cl-105 HCO3-33* AnGap-10
[**2142-3-17**] 03:31AM BLOOD ALT-11 AST-23 LD(LDH)-199 AlkPhos-114*
TotBili-0.2
[**2142-3-21**] 05:45AM BLOOD Mg-1.8
Brief Hospital Course:
76 yo F with DMII, peripheral neuropathy, PVD admitted with
respiratory failure and sepsis attributable to a multifocal PNA
requiring intubation. Subsequent hospital course complicated by
NSTEMI, ICU-related delirium, and hypoglycemia.
.
# Acute Respiratory Failure / Multifocal Pnemonia / Sepsis:
Found to have a pneumonia on admission with hypotension
requiring fluid resuscitation and pressors. Subsequently
developed respiratory failure requiring intubation for almost
one week. Intially started on vanc/zosyn/levaquin but then
narrowed to levaquin and ceftriaxone when sputum showed
pan-sensitive E. coli (8 day antibiotic course complete on
[**3-21**]). Still with 1-2L oxygen requirement at the time of
discharge.
.
# NSTEMI, type II (demand) Myocardial Infarction / CAD:
Started on dopamine due to low blood pressures, at which time
she became nauseous and was found to have diffuse ST
depressions. Dopamine was stopped. Troponin peaked at 1.35. She
was started on heparin drip. ST depressions resolved off
dopamine and she was started on levophed instead. Troponin
trended down and heparin drip was stopped. Started on aspirin
325, atorvastatin 80. Cardiology consult favored demand ischemia
in the setting of sepsis/pressors and underlying stable CAD
(instead of plaque instability). Once her functional status
returns to basline, she will follow-up with cardiology to
determine whether further evaluation is necessary.
.
# ICU-associated Delirium / Toxic-Metabolic Encephalopathy:
Post extubation she became very delirious, particularly at
night. Assumed to be related to a combination of the sedation
used for intubation, as well as prolonged ICU stay. A component
of baseline dementia is likely contributory. Required prn haldol
early on, but improved greatly by the time of discharge.
.
# DMII / Hypoglycemia:
Sugars difficult to control in setting of sepsis. Restarted on
home insulin regimen of NPH 30 AM and 24 PM, and covered with
sliding scale. She had recurrent episodes of hypoglycemia which
ultimately required discontinuation of her long-acting NPH and
coverage with SS humalog alone. She will likely need gradual
addition of long-acting insulin as she recovers and begins to
eat more.
.
# 2nd degree Heart Block Mobitz Type I / sinus bradycardia:
Tracings revealed underlying sinus rhythm, ectopic atrial
rhythm, and junctional escape while she was septic. On the
medical floor, she was persistently in sinus rhythm with
alternating conduction: mostly 1st degree heart block,
occasionally 2nd degree heart block mobitz type I. Her
conduction disease should either be followed either with serial
EKGs or she should be referred to establish care with
cardiology.
Metoprolol dosing was decreased in response to night-time sinus
bradycardia.
.
# Chronic foot ulceration / PVD:
Ulceration appears clean, intact. No overt evidence of
superficial infection as she has had in past. She was followed
by wound care and has an upcoming appointment with podiatry.
.
THE EXPECTED LENGTH OF STAY AT A REHABILITATION FACILITY IS LESS
THAN 30 DAYS
.
Medications on Admission:
- ASA 81mg
- Flovent 100 mcg/Actuation Aersol 2 pufs INH [**Hospital1 **]
- Losartan-Hydrochlorothiazide 100-- 12.5 mg PO qD
- Metoprolol succinate 50 mg PO qD
- Paroxetine 40 mg PO qD
- Detrol 4 mg PO qD
- INSULIN REGULAR HUMAN [HUMULIN R] - (Prescribed by Other
Provider) - 100 unit/mL Solution - 8 twice a day
- NPH INSULIN HUMAN RECOMB [HUMULIN N] - 100 unit/mL Suspension
-
30 U AM and 24 in PM
-zinc sulfate
Discharge Medications:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheeze, dyspnea.
2. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheeze, dyspnea.
3. paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. metoprolol tartrate 25 mg Tablet Sig: 0.25 Tablet PO BID (2
times a day).
5. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. hydrochlorothiazide 12.5 mg Tablet Sig: One (1) Tablet PO
once a day.
8. Flovent Diskus 100 mcg/actuation Disk with Device Sig: One
(1) Inhalation twice a day.
9. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Detrol 2 mg Tablet Sig: One (1) Tablet PO once a day.
11. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): until pt returns to basleine
motility.
12. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. zinc sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
14. insulin lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 25112**] at [**Doctor Last Name **] Ponds
Discharge Diagnosis:
Acute Respiratory Failure / Multifocal Pnemonia / Sepsis
Toxic Metabolic Encephalopathy
NSTEMI, type II (demand) Myocardial Infarction / CAD
2nd degree Heart Block Mobitz Type I
Dibetes Mellitus type 2, complicated, controlled / hypoglycemia
Discharge Condition:
Mental Status: Clear and coherent.
Mental Status: Confused - sometimes in the evening (sundowning).
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname 108994**],
You were admitted the the Medical ICU at [**Hospital1 18**] with acute
respiratory failure from a multifocal pneumonia. This required
intubation for several days. After you were extubated, you
remained confused for several days which is something we see
very frequently in these situations. Physical therapists
determined that you would benefit from rehabilitation, so you
are being discharged to a facility to receive this.
While you were very sick, blood tests and EKGs showed that there
was some damage to your heart. Because of this, you have been
started on several medications to protect your heart. Once you
have regained your strength, you will follow-up with a
cardiologist to discuss whether further treatment or evalaution
is necessary.
Changes have been made to your medications. A full list of the
medications you should be taking has been attached:
- metoprolol has been decreased because of slow heart rate
- aspirin has been increased
- your long acting insulin is being held because of low blood
sugar
- lipitor 80mg daily has been started
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) 11595**] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) 4094**]: INTERNAL MEDICINE
Location: [**Hospital Ward Name 101561**]
Address: [**Doctor First Name **], STE 2F, [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 19196**]
**Please discuss with the staff at the facility the need for a
follow up appointment with your PCP when you are ready for
discharge**
WE HAVE SCHEDULED A VISIT WITH PODIATRY FOR YOU:
Department: PODIATRY
When: WEDNESDAY [**2142-3-28**] at 4:20 PM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM [**Telephone/Fax (1) 543**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
WE HAVE SCHEDULED AN APPOINTMENT WITH CAREDIOLGY FOR YOU:
Department: CARDIAC SERVICES
When: MONDAY [**2142-4-2**] at 11:00 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD [**Doctor Last Name 1189**]
Completed by:[**2142-3-25**]
|
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icd9cm
|
[
[
[]
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[
"96.6",
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|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,956
| 106,688
|
1178
|
Discharge summary
|
report
|
Admission Date: [**2107-3-29**] Discharge Date: [**2107-4-13**]
Date of Birth: [**2025-8-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
81yoM HTN, CHF, Stage III CKD, lung cancer s/p wedge resection,
prostate CA, s/p hormonal tx and XRT presented [**3-29**] with 4 days
RLQ pain, admitted to surgery for ruptured appendix which was
medically managed, transferred to medicine service on night of
transfer after a trigger for tachycardia.
Pt presented [**3-28**] with RLQ abd pain. Per surgery note, pt
reported he was in his usual state of health until 4 days prior
to presentation when he purchased a bottle of wine and drank [**2-5**]
of the bottle, followed by dull pain and tenderness in RLQ
without radiation. Pain persisted over the next four days,
relatively unchanged, until the pt presented to his PCP for an
urgent care visit on [**2107-3-28**]. During this time, he notes
decreased appetite and loose
stools 2-3x/day. He denies fevers, chills. He notes chronic SOB
unchanged recently and denies chest pain.
Pt was admitted to surgery service on [**3-28**], had a CT of abd,
which showed a perforated appendix with possible early abscess
formation. He was started on hep sq, cipro, and flagyl, and
medically managed on surgery service.
Transferred from [**Hospital Ward Name 1950**] 5 at 7pm from surgery service to
medicine service. HR upon transfer 100, sbp ~100, 2l oxygen.
Around 2200, staff noticed pt "not looking good," hr rose to
120-130s, pt diuresed 10mg iv lasix, bp dropped from 110/60 to
96/56 to 92/58, remained on 2L. Also received one albuterol
neb, ipratropium neb, and PO ativan for concern for ethanol
withdrawal. EKG showed rapid rate at 130, likely afib, nl axis.
Past Medical History:
1. COPD
2. HTN
3. CHF EF <35% - inferior scar and LVEF 43% on [**2103**] MIBI
4. PAF
5. Depression
6. Hip Fx
7. Hyperlipidemia
8. Osteoporosis
9. Stage III CKD (baseline Cr 1.3-1.5)
10. Mild Cognitive Impairment
11. Lung Cancer T1 Adenocarcinoma - wedge resection [**2105**]
12. s/p RUL wedge resection [**7-10**] ([**Doctor Last Name 952**]) - unable to perform
complete lobar resection [**3-7**] poor respiratory reserve. c/b
persistent mediastinal lymph node followed by yearly CT
13. Prostate CA - high grade, s/p Lupron tx, XRT - in [**12-11**]
14. s/p left intertrochanteric nail '[**97**]
15. pancreatic head mass -- likely IPMT
Social History:
He lives alone in [**Location (un) **] apartment. He was divorced 25 yrs
ago. (+) tobacco 69 pack yrs quit 3 yrs ago. has been drinking
since his divorce 25 yrs ago 1/2-1 liter wine qd. no hard
liquor. He lost his job at [**University/College **] because
Family History:
noncontributory
Physical Exam:
On Transfer to the [**Hospital Unit Name 153**]
T=98 BP83/61 HR110 (after 10mg iv lopressor) RR 16 99%2l
.
PHYSICAL EXAM
GENERAL: Pleasant, well appearing ..... in NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No
LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**]. JVP=
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. [**2-4**]+ reflexes,
equal BL. Normal coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
ECHO [**3-30**]: prior myocardial infarction without inducible
ischemia to achieved low workload. Blunted heart rate response
to physiologic stress. Moderate regional left ventricular
systolic dysfunction. Moderate mitral regurgitation at rest. At
least moderate pulmonary artery systolic hypertension. EF 35%.
.
CT abd [**3-28**]:
1. Findings are consistent with perforated appendicitis with
surrounding phlegmonous or early abscess collection. Small
locules of extraluminal air are noted within the pelvic cavity
with free fluid and air also noted to track into the right
inguinal ring. Edema of the terminal ileum is presumed to be
reactive.
2. Known underlying emphysema and extensive atherosclerotic
disease.
3. Stable hypoattenuating pancreatic head lesions likely
representing side branch IPMT.
CT abd/pelvis [**2107-4-12**]:
Final Report
INDICATION: Perforated appendicitis being conservatively managed
with
antibiotics, please evaluate for fluid collections or
pseudocyst.
COMPARISON: [**2107-4-2**].
TECHNIQUE: Axial MDCT images were obtained from the lung bases
to the pubic
symphysis with oral contrast only but no intravenous contrast.
Coronal and
sagittal reformatted images are provided.
CONTRAST: Oral contrast only.
CT OF THE ABDOMEN WITHOUT INTRAVENOUS CONTRAST: Large bilateral
pleural
effusions of low density are slightly increased from the CT of
[**4-2**].
There is adjacent atelectasis in the lower lobes bilaterally,
also more
marked. Focal calcifications along the left hemidiaphragm
(2A:11) are
unchanged and could represent sequelae of prior asbestos
exposure. The
aerated portions of the lungs appear unremarkable. Heart and
pericardium
appear unchanged.
Allowing for non-contrast technique, the liver, spleen, adrenal
glands, and
pancreas appear unremarkable, although it is noted that
hypodense pancreatic
lesions were seen on previous contrast examination that are not
evident on
today's study. Bilateral renal calcifications are most likely
vascular in
nature, and there is no evidence of hydronephrosis. Abdominal
aorta is normal
in caliber with mural calcification consistent with atheromatous
disease.
Since the previous examination of [**4-2**], the degree of
distention of the
proximal small bowel has decreased somewhat, and there is now
passage of
contrast into the colon without definite evidence of small bowel
obstruction.
Note is made of a filling defect in the distal esophagus, which
is hyperdense
and most likely represents a pill. Numerous additional similar
structures are
seen in the ascending colon and cecum, also most likely
representing pills.
Again seen is a distended appendix containing contrast and air
at its base
with periappendiceal stranding and inflammation as well as
extraluminal gas,
consistent with the patient's known appendiceal perforation. A
couple of very
small adjacent organized fluid collections are seen, the largest
in the right
lower quadrant measuring 1.8 x 2.3 cm (2A:61), probably
minimally decreased
from the previous examination and no longer containing gas as it
had at the
time of the prior scan. No new developing fluid collections are
identified.
Hyperdense material again seen within the non-distended
gallbladder possibly
representing stones or sludge.
CT OF THE PELVIS WITHOUT INTRAVENOUS CONTRAST: A left-sided fat-
and fluid-
containing inguinal hernia is again noted, slightly larger than
at the time of the previous study. Smaller right-sided fat- and
fluid-containing inguinal hernia is seen with the fluid
component decreased in size and no longer containing gas. A
Foley catheter is in place within the bladder which appears
otherwise unremarkable. Prostate and seminal vesicles, and
hyperdense prosthetic structures possibly representing
brachytherapy seeds, are unchanged. Rectum and sigmoid colon
appear unremarkable. A small collection in the right upper
pelvis is probably slightly decreased as previously described.
There is diffuse stranding throughout the subcutaneous tissues.
Bilateral femoral neck compression screws in unchanged
orientation.
BONE WINDOWS: Degenerative change of the lumbar spine again
noted.
IMPRESSION:
1. Slight decrease in size of small fluid collections adjacent
to the
patient's known perforated appendicitis, without evidence of
drainable
collections or new collections.
2. Decrease in previously present small bowel obstruction with
only mild
residual small bowel dilation, possibly reflecting ileus.
3. Increase in large bilateral pleural effusions and adjacent
bilateral lower lobe atelectasis.
4. CT appearance of pills located in distal esophagus and in the
colon and
cecum.
[**2107-4-10**] RUE U/S:
Final Report
HISTORY: 81-year-old male with asymmetric right extremity
swelling, with PICC
line. Evaluate for DVT.
COMPARISON: None available in the [**Hospital1 18**] PACS.
RIGHT UPPER EXTREMITY ULTRASOUND: The right arm is erythematous
and
edematous, with multiple blisters on the medial aspect several
centimeters
proximal to the elbow. Grayscale, color, and pulse wave Doppler
ultrasound of
the right upper extremity were performed to evaluate for deep
venous
thrombosis.
A right PICC line enters the basilic vein, and courses beyond
the subclavian vein into the superior vena cava. The subclavian
vein demonstrates thrombus on grayscale images, with minimal
flow distally. Except for where instrumented by PICC, the right
basilic and axillary veins are compressible and demonstrate
color flow with appropriate waveforms. No augmentation maneuvers
were performed due to thrombus in the subclavian vein, and the
patient was unable to perform Valsalva maneuvers. However, flow
in the basilic, axillary, internal jugular, and brachial veins
demonstrate respiratory phasicity. Although compression of the
brachial veins was somewhat difficult, they were somewhat
compressible and demonstrated normal flow with appropriate
waveforms and respiratory variation, and likely do not contain
thrombus. The left subclavian vein was evaluated for comparison,
and demonstrate wall-to-wall flow and collapsibility during the
respiratory cycle.
IMPRESSION: Thrombus in the right subclavian vein, with minimal
if any distal flow.
PCXR [**2107-4-13**]:
Final Report
HISTORY: Left PICC line placement.
FINDINGS: In comparison with study of [**4-6**], there has been
placement of a left subclavian PICC line that extends to the
upper portion of the SVC. Persistent prominent bilateral pleural
effusions. The pulmonary vascular congestion appears to have
substantially reduced.
Brief Hospital Course:
81 yo male with PMH of HTN, CHF, Stage III CKD, lung cancer s/p
wedge resection, prostate CA, s/p hormonal tx and XRT presented
[**3-29**] with 4 days RLQ pain, admitted to surgery for ruptured
appendix which was medically managed, transferred to medicine
service on night of transfer after a trigger for tachycardia,
transferred to micu for 5 day course for management of
tachycardia, called out to medical floor with stable vital
signs.
#Atrial Tachcyardia: Patient was initially in 150's-160's with
SBP in 80's though denying light-headedness, SOB, chest pain, or
any other issues. His heart rate was initially controlled with
iv lopressor with uptitration to po lopressor. The rhythm
transitioned from sinus tachycardia with apbs, with some EKGs
which could not rule out atrial fibrillation. Cardiac enzymes
were checked and were not consistent with an ACS. CTA ruled out
PE. Cardiology was consulted (thought tachycardia was sinus
tach with APBS and MAT) and was due to intra-abdominal appendix
rupture and inflammation, recommended watching clinically, with
consideration of digoxin therapy, which was not initiated.
#Anemia, Guiac positive stool: On the day of presentation to the
[**Hospital Unit Name 153**] the patient had guiac positive stools and a Hct drop from
27-24, with no signs of hemodynamic instability; there was no
melena or hematochezia. GI was consulted, thought no indication
for immediate scope and that this could be dangerous given
ruptured appendicitis. Over the following days, patient showed
no signs of bleed and had a stable hematocrit. His aspirin and
heparin sq was held in ICU and upon transfer to medical floor.
#Ruptured appendicitis: The patient was conservatively managed
by surgery with antibiotics and this was continued with
ciprofloxacin and metronidazole, initiating date was [**3-29**], with
continuation until [**4-2**], then changed to vanco/zosyn for broader
coverage until [**4-6**], then transitioned back to cipro/flagyl, with
plan to complete full course of abx until [**4-23**]. Bladder
pressures and lactates were monitored while in ICU, which both
remained normal, in addition to stable abdominal exam. The
patient's abdominal exam improved and the patient was advanced
to a regular diet per surgery on day of discharge.
-Antibitics can likely be changed to oral if he is tolerating
regular diet well (CT scan had demonstarted retained meds in
esophagaus and stomach).
-Patient to have outpatient surgery f/u.
#Renal failure: pt noted to have rising creatinine from 1.0 to
1.4, 1.8, and 1.9 while in [**Hospital Unit Name 153**]. Urine electrolytes suggested
pre-renal physiology, but clinical suspicion for
contrast-induced nephropathy was high, given dye load on [**4-2**].
Pt was not diuresed in this setting (o2 requirements at 4L
thought [**3-7**] chf, copd) and allowed to run positive. The renal
failure was non-oliguric throughout this course and remained
stable with discharge creatinine of 2.1.
#Right Subclavian Vein thrombus: The patient had RUE swelling in
the arm he initially had a PICC line in. RUE U/S revealed a
thrombus in the right subclavian vein, with minimal if any
distal flow. Given recent hct drop in ICU with concern for GI
bleed, the patient was started on a heparin ggt. If patient
continues to tolerate heparin ggt well, can transition to
lovenox and coumadin for a three month course.
Medications on Admission:
1. ALENDRONATE 70 mg weekly
2. ATENOLOL 100 mg daily
3. PRAVASTATIN 40 mg daily
4. TIOTROPIUM BROMIDE 18 mcg Capsule 1 puff inhalation daily
5. TRAZODONE 75 mg qHS
6. ASPIRIN 325 daily
7. CALCIUM CARBONATE 500 mg TID
8. Vit D3 400 U [**Hospital1 **]
9. Daily MVI
Discharge Medications:
1. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QTHUR (every
Thursday).
2. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO Q
8H (Every 8 Hours).
3. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
5. Trazodone 50 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime).
6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
7. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: One (1)
Tablet PO TID (3 times a day).
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO Q 12H (Every 12 Hours).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every six
(6) hours as needed for pain.
11. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) neb Inhalation q2h () as needed for SOB.
12. Heparin, Porcine (PF) 10,000 unit/5 mL Solution Sig: One (1)
dose Intravenous continuos: Heparin ggt per DVT protocol.
13. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
14. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
15. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
Five Hundred (500) mg Intravenous Q8H (every 8 hours) for 10
days.
16. Ciprofloxacin in D5W 400 mg/200 mL Piggyback Sig: Four
Hundred (400) mg Intravenous Q12H (every 12 hours) for 10 days.
17. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Perforated Appendicitis
Ileus/Partial SBO
Anemia from acute GI bleed
Acute Renal Failure
Multi-atrial Tachycardia
Right Subclavian DVT
COPD Exacerbation
Discharge Condition:
Vital Signs Stable
Discharge Instructions:
Return to the ED if you are having very high fevers, severe
abdominal pain, confusion.
You had a perforated appendicitis which was treated
conservatively with antibiotics.
Followup Instructions:
Tuesday. [**4-26**] at 10am [**Hospital1 18**] Surgery clinic with Dr. [**Last Name (STitle) 1924**]
[**Telephone/Fax (1) 7508**]
Provider: [**First Name11 (Name Pattern1) 3210**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2107-6-3**] 1:10
Provider: [**First Name8 (NamePattern2) 20**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2107-6-13**]
2:30
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD,PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 22**]
Date/Time:[**2107-6-23**] 9:30
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 250**] Call to schedule
appointment
|
[
"584.9",
"401.9",
"540.1",
"272.4",
"453.8",
"311",
"578.9",
"285.1",
"491.21",
"427.31",
"733.00",
"585.3",
"V10.11",
"427.0",
"428.0",
"428.22",
"560.9",
"V10.46",
"996.74"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
15753, 15819
|
10345, 13739
|
329, 335
|
16016, 16036
|
3803, 10322
|
16257, 17020
|
2886, 2903
|
14052, 15730
|
15840, 15995
|
13765, 14029
|
16060, 16234
|
2918, 3784
|
275, 291
|
363, 1938
|
1960, 2598
|
2614, 2870
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,581
| 166,591
|
1755
|
Discharge summary
|
report
|
Admission Date: [**2127-1-24**] Discharge Date: [**2127-1-31**]
Date of Birth: [**2048-11-29**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
left sided weakness, lethargy
Major Surgical or Invasive Procedure:
Amiodarone Infusion
History of Present Illness:
Source : history is obtained from the patient's aide, [**Doctor First Name **].
Ms. [**Known lastname 9950**] is a 78 year old with a h/o stroke in [**2125**], afib
on Coumadin, CAD s/p CABG x 2, hypertension, and diabetes, who
presents from home with altered mental status. Patient's aid
saw her this morning at 11:30AM and was normal. She came back
around noon, knocked on the door and there was no response. She
then went to a neighbor to get the spare key. She found her on
the couch saying that she was, "good, fine, I'm okay" in Russian
but the aid theought she was obviously not fine. EMS was called
and she was transported
to [**Hospital1 18**] ED.
Since arrival, she was intially able to mostly cooperate with
the exam, answering questions about her medical history and
following commands. Her heart rate is 89 and SBP 138. She was
94% on room air. Head CT was done, which shows a likely right
MCA infarct. Several hours later, she started desaturating and
is on a nonrebreather with sats in the 90s. She then became
tachycardic to the 140s, wide complex, appearing to be SVT with
abberancy.
She has been started on Amiodarone drip. On exam, she also
became more somnolent.
At baseline, the aid states that she is independent with most of
her ADLs except that she is currently having more memory
troubles. She has some residual left sided weakness from the
old stroke but has recovered well. She ambulates with a walker.
In review of systems, she has been otherwise doing well. In the
ED, she is complaining of some trouble breathing and some chest
pain.
Past Medical History:
CAD s/p CABG x 2
Bioprosthetic Mitral Valve
Stroke in [**2125**] with left sided weakness treated at [**Hospital3 **]
Diabetes
Social History:
Lives independently and has an aid, [**Doctor First Name **], who comes to help her.
Her daughter is in CA.
Family History:
Unknown
Physical Exam:
Vitals on presentation: T 97.9 HR 89 and irregular BP 138/86
94% on RA
Gen: WD/WN, comfortable, NAD.
HEENT: NC/AT. Anicteric. MMM.
Neck: Supple. No masses or LAD. No JVD. No thyromegaly. No
carotid bruits.
Lungs: CTA bilaterally. No R/R/W.
Cardiac: RRR. S1/S2. No M/R/G.
Abd: Soft, NT, ND, +NABS. No rebound or guarding.
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place - [**Hospital3 **], and
date - [**2126**].
Attention: Able to recite DOW backwards.
Language: Speech fluent with good comprehension and repetition.
Has dysarthria. No apraxia, no neglect. Able to follow two step
commands that cross midline.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2 mm
bilaterally.
III, IV, VI: Eyes deviated to the right and do not cross
midline.
She also keeps her eyes closed and will not open them on
command.
Also resists eye opening by examiner.
V, VII: Left lower facial droop.
VIII: Responds to voices in the room.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk bilaterally. Increased tone on the left. Full
strength on the rigth. Some weakness on the left but is
antigravity.
Sensation: Withdraws to pain in all 4 extremities.
Reflexes: B T Br Pa Ac
Right 2 2 2 3 1
Left 2 2 2 3 1
Right toe down, left toe up.
Coordination and gait deferred.
Pertinent Results:
135 99 30 106 AGap=19
----------------
4.6 22 1.8
Ca: 9.4 Mg: 2.2 P: 4.2
estGFR: 27/33 (click for details)
CK: 108 MB: 6 Trop-T: <0.01
8.2 > 12.9 < 247
38.6
N:63.9 L:27.3 M:6.7 E:1.7 Bas:0.3
PT: 20.5 PTT: 28.3 INR: 1.9
IMAGING:
CTA HEAD W&W/O C & RECONS [**2127-1-25**] 9:23 AM
HEAD CT:
Comparison was made to previous study of [**2127-1-24**]. There is now
apparent an acute infarct in the distribution of right middle
cerebral artery involving the insular cortex and the right
frontal lobe. There is also involvement of the right temporal
lobe seen anteriorly. There is no evidence of hemorrhage or mass
effect seen. No midline shift. There is mild-to-moderate brain
atrophy.
CT ANGIOGRAPHY OF THE NECK:
The CT angiography of the neck is slightly limited secondary to
venous contamination. There are markedly tortuous carotid and
vertebral arteries noted. There is no evidence of high-grade
stenosis or occlusion seen in the carotid arteries and in the
right vertebral artery. The left vertebral artery is small in
size but appears patent.
CTA OF THE HEAD:
The CTA of the head demonstrates narrowing and tapering of the
right middle cerebral artery near the bifurcation with
diminished filling of the right sylvian branches. These findings
are consistent with occlusion or high-grade stenosis at this
level. The remaining arteries of the anterior and posterior
circulation are patent without evidence of stenosis, occlusion,
or an aneurysm.
IMPRESSION:
1. Acute right middle cerebral artery infarct which has evolved
since the previous CT of [**2127-1-24**].
2. Tortuous cervical, carotid and vertebral arteries without
evidence of stenosis or occlusion.
3. High-grade stenosis and partial occlusion of the right middle
cerebral artery near the bifurcation. The remaining arteries of
the circle of [**Location (un) 431**] are normal.
4. Patchy opacities at visualized both lung apices, correlation
with chest plain film is recommended.
ECHOCARDIOGRAM:
The left atrium is moderately dilated. No atrial septal defect
is seen by 2D or color Doppler. There is moderate symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Regional left ventricular wall motion is normal. Overall
left ventricular systolic function is normal (LVEF>55%). There
is no ventricular septal defect. The RV is normal size with
borderline normal free wall function. The ascending aorta is
mildly dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Mild (1+) aortic
regurgitation is seen. A bioprosthetic mitral valve prosthesis
is present. The motion of the mitral valve prosthetic leaflets
is not well seen. The transmitral gradient is top normal for
this prosthesis. Torn mitral chordae are present. Mild (1+)
mitral regurgitation is seen. [Due to acoustic shadowing, the
severity of mitral regurgitation may be significantly
UNDERestimated.] The tricuspid valve leaflets are mildly
thickened. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.
Brief Hospital Course:
Ms. [**Known lastname 9950**] is a 78 year old primarily Russian speaking woman
with prior Right MCA infarct in [**2125**], afib on Coumadin, CAD s/p
CABG x 2 with bioprosthetic mitral valve, s/p pacemaker,
hypertension, and diabetes, who presented from home with altered
mental status. She was found to have a new right MCA infarction.
1) Right MCA infarction-
Her examination at presenation revealed worsened left sided
weakness, new left UMN facial droop, right gaze deviation, and
possible eye opening apraxia. A CT confirmed new R MCA territory
infarct. MRI could not be performed due to patient's cardiac
pacemaker. At presentation she was outside the window for IV
TPA. The likely etiology of her stroke was cardioembolic due to
subtherapeutic INR of 1.9 at presentation.
The patient was started on Heparin IV drip at 13units/kg with a
goal PTT of 50-70. Echocardiogram revealed preserved EF with 1+
MR via her bioprosthetic valve. There was no echo evidence for
intracardiac source of emboli. CTA head and neck revealed high
grade right MCA stenosis and partial occlusion. Her carotid and
vertebral arteries were tortuous without evidence for occlusion
or stenosis. Her LDL was 81, and her Hbg A1c 6.1. She was
increased on lipitor to 40mg daily. She was covered on an
insulin sliding scale and will likely require an oral
antiglycemic [**Doctor Last Name 360**] for her evidence of insulin resistance. Given
her stroke was likely due to subtherapeutic INR, her new goal
INR should be 3-3.5. She should follow up with Dr. [**First Name8 (NamePattern2) 2530**] [**Name (STitle) **]
in the Stroke Center at [**Hospital1 18**] in 6 weeks following discharge
from rehab.
2) Rapid Atrial fibrillation with aberrancy-
Patient was started on Amiodarone drip for rate/rhythm control
as she has a marked tachyarrhthmia on presentation with
development of likely secondary pulmonary edema and hypoxia. As
a result she was admitted to the neuro ICU for closer
hemodynamic and neurological monitoring. She did not require
intubation. She was ween from the amiodarone drip in the first
24hrs and changed to PO dosing with excellent rate control. She
reverted to AV pacing. Her oxygen requirement improved and she
was transferred to the neurology step down unit for further
care. She was one room air, AV paced at time of discharge. She
was continued on Amiodarone and Metoprolol at time of discharge.
3) Dysphagia-
Initially kept NPO, then seen by speech and swallow therapists.
Video swallow performed with recommendation for diet of nectar
thick liquids and pureed solids to prevent aspiration.
Re-evaluate at rehab to advance her diet PRN.
Medications on Admission:
Lasix 20mg QD
Amiodarone 200mg QD
Docusate 100mg QAM
Folic acid 1mg QAM
Spironolactone 20mg QAM
Metoprolol 25mg QAM
Lipitor 20mg QHS
Coumadin 2mg QHS
Calcium QHS
NitroDur 0.3 patch Q12
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO DAILY16 (Once
Daily at 16): Please draw daily PT/INR and adjust coumadin for
goal 3-3.5.
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Acute Right Middle Cerebral Artery Infarction
Atrial Fibrillation
Discharge Condition:
Slight left sided neglect. Left Arm > leg weakness. Left Upper
motor neuron facial droop.
Discharge Instructions:
You were admitted for a stroke.
Please take all medications as prescribed.
Call your doctor or 911 if you experience any new weakness,
tingling, numbness, difficulty speaking, chest pain, shortness
of breath or any other concerning symptoms.
Followup Instructions:
Please see Dr. [**First Name8 (NamePattern2) 2530**] [**Name (STitle) **] at the Stroke Neurology Center at
[**Hospital1 18**] in 6 weeks. Call [**Telephone/Fax (1) 2574**] for an appointment.
You will need daily PT/INR checks while at rehab until your are
assured to be at your goal INR of [**3-10**].5 on coumadin. This will
continue once you return home through your primary care doctor
Please see your primary care doctor shortly after being
discharged from rehab.
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
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65,956
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41739
|
Discharge summary
|
report
|
Admission Date: [**2158-11-10**] Discharge Date: [**2158-11-15**]
Date of Birth: [**2109-5-21**] Sex: M
Service: MEDICINE
Allergies:
naproxen / penicillin G
Attending:[**First Name3 (LF) 13256**]
Chief Complaint:
GI Bleed
Major Surgical or Invasive Procedure:
mechanical ventilation
extubation
upper endoscopy (EGD)
History of Present Illness:
49yo male w/ EtOH cirrhosis with h/o multiple prior upper GI
bleeds from esophageal and gastric ulcers transferred from [**Hospital1 **] with hematemesis. Patient has a history of medication
non-compliance and continues to drink EtOH. At about 2:30am he
began vomiting bright red blood. He was found by his roommate
surrounded by blood.
On arrival to [**Hospital3 **], vitals were 92 69/39 18 100% RA.
Started on IV fluids, octreotide and pantoprazole. Intubated for
airway protection. Triple lumen femoral line placed. Cr to 2
from 0.8. Patient taken directly to the endoscopy suite where
EGD showed active, pulsatile arterial bleeding at distal
esophagus. Used argon cautery, epi and 3 clips with hemostasis.
Managed to place 3 clips with hemostasis. Got total 2 units FFP,
5 units PRBC. BP on transfer 124/80, on minimal norepinephrin
(0.05).
On arrival, patient intubated and sedated. Speaking with his
mother, she says that he has been drinking heavily lately
despite knowing that it could kill him.
Past Medical History:
- EtOH and hemochromatosis cirrhosis, c/b varices w/ variceal
bleeds, ascites
- Non-insulin dependent diabetes
- Hypertension
- hyperlipidemia
- Anxiety
- EtOH abuse
- arthritis
Social History:
Per his mother, graduated from [**Name (NI) 90683**] [**Location (un) **], former
financial manager, but is currently unemployed. Lives with a
roommate. Divorced. Has been to rehab before (Garcenold, [**Doctor Last Name **]
Point, [**Hospital1 **])
- Tobacco: No
- Alcohol: Actively drinking heavily. Drinks vodka.
- Illicits: Not to his mother's knowledge
Family History:
Has a maternal uncle who was an alcoholic. Paternal uncles were
also alcoholic.
Physical Exam:
ADMISSION EXAM:
General: Intubated, sedated, though does arouse to follow
commands.
HEENT: Sclera anicteric, PERRL
Neck: supple, no LAD
Lungs: Clear to auscultation anteriorly
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, mildly bulging flanks
with a fluid wave. Palpable liver tip and splenomegaly.
GU: foley in place. Small 1-2mm papules on scrotum
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: moving all extremities spontaneously
DISCHARGE EXAM:
***
Pertinent Results:
ADMISSION LABS:
[**2158-11-10**] 10:49PM BLOOD WBC-10.6 RBC-3.03* Hgb-9.1* Hct-26.5*
MCV-88 MCH-30.1 MCHC-34.4 RDW-16.9* Plt Ct-67*
[**2158-11-10**] 10:49PM BLOOD Neuts-85.3* Bands-0 Lymphs-7.2* Monos-7.1
Eos-0.3 Baso-0.1
[**2158-11-10**] 10:49PM BLOOD PT-18.6* PTT-33.1 INR(PT)-1.7*
[**2158-11-10**] 10:49PM BLOOD Glucose-210* UreaN-32* Creat-1.8* Na-135
K-5.4* Cl-102 HCO3-23 AnGap-15
[**2158-11-10**] 10:49PM BLOOD ALT-55* AST-194* LD(LDH)-383* AlkPhos-72
TotBili-4.3*
[**2158-11-10**] 10:49PM BLOOD Lipase-73*
[**2158-11-10**] 10:49PM BLOOD Albumin-2.9* Calcium-6.9* Phos-4.5
Mg-1.5*
MICROBIOLOGY:
[**2158-11-11**] MRSA screen: negative
STUDIES:
[**2158-11-10**] CXR:
Endotracheal tube with its tip 4.7 cm above the carina in
satisfactory position. Lungs are slightly low in volume with
patchy airspace disease at both bases which may reflect
atelectasis, aspiration, or an early pneumonia. Clinical
correlation is advised. No evidence of pulmonary edema, pleural
effusions or pneumothoraces. No acute bony abnormality. Overall
cardiac and mediastinal contours are within normal limits given
portable technique.
[**2158-11-11**] ABD U/S:
1. Diffuse echogenic liver consistent with fatty deposition;
however, more
advanced liver disease such as cirrhosis and hepatic fibrosis
cannot be
excluded on this study.
2. Perihepatic free fluid as well as mild amount of fluid within
the left
lower quadrant consistent with ascites.
3. Gallbladder wall appears thickened up to 5 mm; however, the
gallbladder
does not appear distended. This suggests third spacing in the
setting of
ascites.
4. Splenomegaly with spleen measuring 17.2 cm.
[**2158-11-13**] 10:00:00 AM - EGD report
3 grade [**1-8**] esophageal varices. Overlying one of the varices was
a linear ulcer with 3 clips distally. No active bleeding. Few
other smaller ulcers at GEJ that looked like peptic injury.
Stomach filled with food and old blood which obscured view. No
active bleeding. There was some evidence of protal HTN
gastropathy in body/fundus. There was a 4mm polyp at junction of
duodenal sweep. No biopsies taken because of recent significant
GI bleed. Impression: 3 grade [**1-8**] esophageal varices. Overlying
one of the varices was a linear ulcer with 3 clips distally. No
active bleeding. Few other smaller ulcers at GEJ that looked
like peptic injury. Stomach filled with food and old blood which
obscured view. No active bleeding. There was some evidence of
protal HTN gastropathy in body/fundus. There was a 4mm polyp at
junction of duodenal sweep. No biopsies taken because of recent
significant GI bleed. Otherwise normal EGD to third part of the
duodenum. Recommendations: Follow closely. Plan per inpatient
liver team. PPI [**Hospital1 **]. Will need repeat EGD to biopsy/remove
duodenal polyp.
DISCHARGE LABS:
***
[**2158-11-15**] 05:20AM BLOOD WBC-4.8 RBC-3.08* Hgb-9.3* Hct-27.6*
MCV-90 MCH-30.2 MCHC-33.7 RDW-16.9* Plt Ct-77*
[**2158-11-15**] 05:20AM BLOOD PT-16.9* PTT-29.3 INR(PT)-1.5*
[**2158-11-15**] 05:20AM BLOOD Glucose-96 UreaN-9 Creat-0.8 Na-135 K-3.7
Cl-101 HCO3-27 AnGap-11
[**2158-11-15**] 05:20AM BLOOD ALT-39 AST-91* AlkPhos-94 TotBili-4.2*
[**2158-11-15**] 05:20AM BLOOD Albumin-3.0* Calcium-8.4 Phos-2.9 Mg-1.7
Brief Hospital Course:
Mr. [**Name13 (STitle) **] is a 49yo male w/ EtOH cirrhosis with h/o multiple
prior upper GI bleeds from esophageal varices and gastric ulcers
transferred from [**Hospital3 **] with hematemesis.
#. Upper GI bleed: Patient with pulsatile arterial bleed at the
distal esophagus per OSH records, hemostasis achieved. He was
transfused 2units pRBCs in the ICU. HCT remained stable. Patient
was treated with octreotide drip for 72 hours and [**Hospital1 **] iv
pantoprazole. Pt was given cipro 500mg [**Hospital1 **], with plan for 1 week
course. Pt had repeat EGD showing 3 grade [**1-8**] esophageal
varices. Overlying one of the varices was a linear ulcer with 3
clips distally. No active bleeding. Few other smaller ulcers at
GEJ that looked like peptic injury. Stomach filled with food and
old blood which obscured view. No active bleeding. There was
some evidence of protal HTN gastropathy in body/fundus. There
was a 4mm polyp at junction of duodenal sweep. No biopsies taken
because of recent significant GI bleed. Otherwise normal EGD to
third part of the duodenum. Pt's diet was advanced to regular.
Pt was discharged with sulcralfate, nadolol, ciprofloxacin, and
increased PPI. Pt will need to have a repeat EGD at some point
in the future to remove his duodenal polyp and will need LFTs to
monitor his recover on pentoxifylline .
#. Acute Alcoholic Hepatitis: Patient with acute alcoholic
hepatitis. Pt was treated with pentoxifylline given discriminant
function of 39. Pt was given pentoxifylline instead of steroids
because of the possible ulcer-related etiology of his bleed. His
liver function tests improved with treatment. Abd u/s shows
echogenic liver c/w fatty infiltration, but cirrhosis cannot be
excluded, small amount of ascites. Pt was repeated counseled on
the importance of abstaining from alcohol and the high
likelihood that further alcoholism will lead to his demise. Pt
did not voice any interest in abstaining.
#. EtOH cirrhosis: Abdominal ultrasound without definitive e/o
cirrhosis, but small amount of ascites was seen. Lasix and
spironolactone were held in the setting of the acute bleed but
restarted without issue after his condition stabilized. Pt
thoroughly counseled about alcoholism (see above).
#) Hypotension: Likely due to blood loss. After 2 units pRBCs
(in addition to 5 units received at the OSH), patient remained
normotensive. Pt became hypertensive up to the 170s after his
lisinopril and metoprolol were held, but was normotensive in
130s after starting and increasing nadolol to 40mg po daily,
which was continued at discharge.
#) Acute renal failure: most likely pre-renal from hypovolemia,
resolved with transfusions and fluids.
#) Alcoholism: Patient given daily thiamine/folate/multivitamin.
Patient monitored on CIWA after extubation. Pt had a baseline
tremor and was also tachycardic to 120s, occasionally to 140s
with exertion, normal sinus. Pt's HR settled at ~100 after
receiving diazepam 5-10mg q4hrs on CIWA scale > 10. Pt was also
tremulous on exam, but has baseline intention tremor. By day of
discharge, Pt's HR was 80s and tremors were greatly reduced. Pt
thoroughly counseled about alcoholism (see above).
TRANSITIONAL ISSUES:
-Pt was discharged w/ 1 month course of pentoxifylline will need
LFTs to assess the degree of recovery.
-Pt's lisinopril and metoprolol were stopped in the setting of
acute GI bleed and nadolol was started instead for varices. His
prior BP meds may need to be restarted if he becomes
hypertensive.
-Pt will need to have a repeat EGD at some point in the future
to remove his duodenal polyp.
Medications on Admission:
- Citalopram 20mg daily
- Metoprolol succinate 100mg daily
- lisinopril 5mg daily
- omeprazole 20mg daily
- sucralfate 1000mg tab QID
- Levaquin 750mg daily x5 days (started [**10-13**])
- Lasix 40mg daily
- spironolactone 50mg [**Hospital1 **]
Discharge Medications:
1. pentoxifylline 400 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO TID (3 times a day).
Disp:*90 Tablet Extended Release(s)* Refills:*0*
2. nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
3. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
4. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
7. spironolactone 50 mg Tablet Sig: One (1) Tablet PO twice a
day.
8. citalopram 20 mg Tablet Sig: One (1) Tablet PO once a day.
9. sucralfate 1 gram Tablet Sig: One (1) Tablet PO four times a
day.
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
bleeding ulcer vs variceal bleed
alcoholic hepatitis
Secondary:
decompensated alcoholic cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Name13 (STitle) **],
You were transferred to [**Hospital1 18**] after you had bloody vomit. You
received blood and had an emergency upper endoscopy at [**Hospital1 **], during which your doctors [**First Name (Titles) **] [**Last Name (Titles) 12681**] a bleeding
ulcer. They were able to control this by placing three clips in
the bottom part of your esophagus, and you were transferred to
[**Hospital1 18**] for further care. You were also started on medications to
help control the bleeding. You did not have any additional
bleeding and did not need any further blood products. You were
started on antibiotics to prevent infections associated with
bleeding in patients with liver disease, which you will need to
continue as an outpatient. You were also treated with
medications for alcoholic hepatitis and acute alcohol
withdrawal. Your symptoms are due to and very much worsened by
your continued alcohol consumption. YOU MUST STOP DRINKING.
We have made the following changes to your medications:
-Start nadolol to prevent bleeding episodes
-Start ciprofloxacin to protect you from infection after the
bleed
-start pentoxyfiline to protect treat your alcoholic hepatitis
and protect your kidneys
-take the omeprazole TWICE daily instead of ONCE daily
-STOP the metoprolol (we have you on Nadolol instead)
-STOP the lisinopril (if you still have high blood pressure,
your PCP may restart this)
Please continue to take your other medications as previously
prescribed.
Followup Instructions:
- You will need a repeat upper endoscopy (EGD) in order to
remove a polyp seen in your duodenum
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] --GI
Address: 100 [**Last Name (un) 49258**] Way, [**Location (un) 10068**],[**Numeric Identifier 39453**]
Phone: [**Telephone/Fax (1) 65146**]
Appt: [**11-20**] at 4:45pm
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 29702**] Care
Address: 100 [**Last Name (un) 49258**] Way, [**Location (un) 10068**],[**Numeric Identifier 10069**]
Phone: [**Telephone/Fax (1) 49260**]
Appt: [**11-27**] at 11:30am
Completed by:[**2158-11-15**]
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] |
10728, 10734
|
5890, 9067
|
296, 354
|
10886, 10886
|
2648, 2648
|
12542, 13272
|
1981, 2062
|
9775, 10705
|
10755, 10865
|
9506, 9752
|
11037, 12019
|
5446, 5867
|
2077, 2608
|
2624, 2629
|
9088, 9480
|
12049, 12519
|
248, 258
|
382, 1390
|
2664, 5430
|
10901, 11013
|
1412, 1591
|
1607, 1965
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,658
| 157,263
|
8150
|
Discharge summary
|
report
|
Admission Date: [**2169-7-19**] Discharge Date: [**2169-7-29**]
Service: NEUROSURGERY
Allergies:
Fosamax / Dilantin / Penicillins
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
L temporal mass
Major Surgical or Invasive Procedure:
L temporal open biopsy
History of Present Illness:
85 yo F seen on [**7-6**] at OSH for dizziness, feeling "spacy";
she was readmitted today w/ confusion. Head CT shows large L
temporal mass, contrast enhancing. Patient received loading dose
of Dilantin and Decadron. Rapid tongue swelling thereafter
prompted her intubation for airway protection. She was
transferred to [**Hospital1 18**] for further treatment.
Past Medical History:
- rheumatic heart disease
- mitral regurg , echo in 03: EF 75%, moderate TR
- PVD, on chronic anticoagulation for graft
- s/p ax-bifem bypass [**2166**]
Physical Exam:
Intubated, ventilated on AC 100% 500x14 peep 5
Not sedated but received vercuronium at time of intubation, then
propofol and versed;
Pupils small, isocore, symteric, reactive 2->1.5; corneal: head
movement in response, bilat.;
Somnolent, not arousable; does not open eyes to pain; does not
follow commands; semi-purposeful movements of L and R UE to
pain;
withdraws R and L LE to pain; DTRs [**Name (NI) **] 1+ bilaterally, Ach trace
bilaterally, [**Last Name (un) **]: no movement bilat.;
Pertinent Results:
MRA Brain [**2169-7-20**]: There is a large lobulated and ill-defined
enhancing mass in the left temporal lobe, which extends along
the fiber tracts and cross the sylvian fissure extending into
the left frontal lobe. The enhancing portion of the mass
measures 4.8 x 3.2 cm, and on T2-weighted images, the mass is
predominantly T2 hypointense, which may reflect
hypercellularity. There is a component of T2 hyperintense signal
swelling the surrounding white matter. This may be edema and/or
tumor. There is flattening of the frontal [**Doctor Last Name 534**] of the left
ventricle, however, no significant midline shift is noted. There
are prominent T2 hyperintense foci in the cerebral white matter,
probably due to underlying chronic small vessel ischemia. Some
of the sequences are limited due to motion artifact.
Head CT [**2169-7-25**]: The patient is status post interval left
temporal craniotomy, with expected postoperative hemorrhage and
pneumocephalus at the biopsy cavity, as well as anterior to the
left frontal lobe. There is linear high density in the left
temporal lobe likely representing hemorrhage along the biopsy
tract, as well as high density tracking along the sulci in this
region consistent with some subarachnoid blood. There is at most
2 mm of rightward shift of the midline structures, unchanged.
Effacement of the left perimesencephalic and widening of the
left ambient cisterns, with mass effect upon the ipsilateral
cerebral peduncle, are also unchanged, and relate to the
extensive vasogenic edema in the left temporal and frontal
lobes. There is also bihemispheric periventricular white matter
hypodensity corresponding to the chronic micro-ischemic change
demonstrated previously . Visualized paranasal sinuses and
mastoid air cells are clear. The soft tissue structures
demonstrate subcutaneous emphysema in the region of the biopsy
as well as skin staples along the left scalp.
MRI Head [**2169-7-26**]: The study is somewhat limited secondary to
patient motion. The patient is status post craniotomy for open
biopsy of a large heterogeneously enhancing tumor in the left
temporal lobe that is unchanged in size today measuring 3.8 x
3.8 cm. Though the study is somewhat limited by motion, the
majority of tumor bulk is still present. Susceptibility imaging
demonstrates minimal-to-moderate amount of postsurgical
hemorrhage at the operative site. Significant vasogenic edema is
unchanged, mass effect and shift of the normally midline
structures is unchanged.
Brief Hospital Course:
Patient admitted to the neurosurgery service and admitted to the
ICU. She was intubated and started on decadron and valproate for
seizure prophylaxis. Her anticoagulation was stopped and
vascular surgery was called regarding her ax-bifem bypass graft.
They recommended anticoagulation as soon as possible
postoperatively. Her INR continued to be elevated up to 4.0
despite coumadin discontinuation. A heme consult was called.
They recommended stopping the patient's subQ heparin which did
correct the patient's abnormal coagulation studies. She was
successfully extubated in the ICU. On HD7 patient was taken to
the operating room for an open temporal biopsy which intial
pathology revealed high grade glioma. Postoperatively her blood
pressure was controlled and she remained stable. She was able to
pass a swallow evaluation at the bedside and was out of bed with
physical therapy.
At the time of discharge, she was mildly confused but awake and
alert. She does not have any gross neurological deficits.
She was discharged to rehab on POD 4.
Medications on Admission:
coumadin
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: One (1) inj
Injection ASDIR (AS DIRECTED).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for T>101.5, headache.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Verapamil 120 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q24H (every 24 hours).
7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) inh Inhalation [**Hospital1 **] (2 times a day).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
10. Valproate Sodium 100 mg/mL Solution Sig: Five (5) ml
Intravenous Q8H (every 8 hours): please follow levels.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 11496**] - [**Location (un) **]
Discharge Diagnosis:
L temporal mass
Discharge Condition:
Stable
Discharge Instructions:
Please come to the emergency room if you have fever >101.4F,
shortness of breath, dizziness, confusion, bleeding/swelling or
persistent redness from your surgical incision.
Please be aware that pain medications may make you drowsy. Take
a stool softener while taking pain medications.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 739**] in [**5-18**] weeks with a CT
scan prior to the appointment. Call his office at [**Telephone/Fax (1) 3571**]
for an appointment.
Please follow up with Dr. [**Last Name (STitle) 724**] in [**Hospital Ward Name 23**] building on [**2169-8-7**] at
10:30 am in Brain tumor clinic.
Staples will be removed at the Brain tumor clinic that day.
Brain tumor clinic phone numner is [**Telephone/Fax (1) 1844**]
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2169-7-29**]
|
[
"795.79",
"518.82",
"286.9",
"443.9",
"496",
"191.8",
"398.90",
"E934.2",
"397.0",
"394.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.14",
"38.93",
"96.6",
"38.91",
"99.07",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
5998, 6069
|
3901, 4946
|
260, 285
|
6129, 6138
|
1378, 3878
|
6472, 7055
|
5005, 5975
|
6090, 6108
|
4972, 4982
|
6162, 6449
|
867, 1359
|
205, 222
|
313, 676
|
698, 852
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,825
| 179,575
|
36639
|
Discharge summary
|
report
|
Admission Date: [**2147-8-1**] Discharge Date: [**2147-8-8**]
Date of Birth: [**2107-7-7**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Aspirin / Chocolate Flavor
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2147-8-1**] - Mitral valve replacement (27mm St. [**Male First Name (un) 923**] Mechanical
Valve)and Tricuspid Valve Repair with MC3 Annuloplasty system.
History of Present Illness:
40 year-old woman, known to our service, who presented to
[**Hospital **] Hospital in [**Month (only) 205**] after waking up with shortness of
breath. She reported that was the first time she has had such an
episode, but in retrospect she probably has had increasing
dyspnea on exertion. A chest CT was done and ruled out PE. An
echocardiogram revealed severe mitral valve regurgitation and
significant pulmonary hypertension. She was referred for
surgical evaluation.
Past Medical History:
severe mitral regurgitation
hypertension
pulmonary hypertension
cardiomegaly
anemia
depression
Social History:
Occupation: on disability Last Dental Exam >1 year
Lives with: children Race:
Tobacco: smoked for 20 years, quit 5 years ago
ETOH: rarely
Family History:
non-contributory
Physical Exam:
Pulse: 96 Resp: 16 O2 sat: 97% RA
BP: 150/90
Height: 5'4" Weight: 115.1 kg
General: WDWN female in no acute distress
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur: SEM III/VI Crisp valve
snap
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: +2 Left: +2
DP Right: +1 Left: +1
PT [**Name (NI) 167**]: +1 Left: +1
Radial Right: +2 Left: +2
Carotid Bruit Right: - Left:-
Pertinent Results:
[**2147-8-1**] ECHO
Pre-bypass:
No mass/thrombus is seen in the left atrium or left atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. There is moderate symmetric left ventricular
hypertrophy. Overall left ventricular systolic function is
mildly depressed (LVEF= 40 %). The right ventricular cavity is
mildly dilated with normal free wall contractility. There are
simple atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve shows characteristic
rheumatic deformity. There is moderate thickening of the mitral
valve chordae. There is mild valvular mitral stenosis (area
1.5-2.0cm2). Moderate to severe (3+) mitral regurgitation is
seen. Moderate to severe [3+] tricuspid regurgitation is seen.
There is a trivial/physiologic pericardial effusion.
Post-bypass:
At the time of post-bypass exam, the patient is receiving
norepinephrine at 0.08 mcg/kg/min. There is a mitral valve
mechanical prothesis well-seated without paravalvular
regurgitation. Both mechanical leaflets are opening
appropriately and there are small regurgitant "washing" jets.The
mean gradient across the mitral valve is 7 mm hg with a heart
rate of 90. The tricuspid valve has a minimal transvalvular
gradient of 4 mm Hg. There is no tricuspid stenosis and mild
tricuspid regurgitation. Ventricular function is similar to
prebypass findings. The aorta is intact post decannulation. All
findings communicated with [**Month/Day/Year 5059**] at time of exam.
[**2147-8-4**] WBC-23.2* RBC-3.70* Hgb-8.6* Hct-28.5* RDW-19.4* Plt
Ct-185
[**2147-8-5**] WBC-21.0* RBC-3.94* Hgb-9.6* Hct-31.2* RDW-19.0* Plt
Ct-227
[**2147-8-6**] WBC-13.5* RBC-3.70* Hgb-8.4* Hct-28.6* RDW-19.6* Plt
Ct-223
[**2147-8-7**] WBC-10.0 RBC-3.69* Hgb-8.8* Hct-29.0* RDW-18.9* Plt
Ct-297
[**2147-8-8**] WBC-9.2 RBC-3.78* Hgb-9.0* Hct-29.6* RDW-18.9* Plt
Ct-346
Warfarin dosing:
[**2147-8-3**]: 5mg
[**2147-8-4**]: 4mg
[**2147-8-5**]: 5mg
[**2147-8-6**]: 5mg
[**2147-8-7**]: 2mg
[**2147-8-8**]: 4mg - discharge dose
PT/INR Results:
[**2147-8-4**] PT-20.9* INR(PT)-1.9*
[**2147-8-5**] PT-23.4* PTT-31.4 INR(PT)-2.2*
[**2147-8-6**] PT-29.0* PTT-48.5* INR(PT)-2.9*
[**2147-8-7**] PT-38.3* PTT-39.3* INR(PT)-4.0*
[**2147-8-8**] PT-38.4* INR(PT)-4.0*
[**2147-8-4**] Glucose-97 UreaN-16 Creat-0.7 Na-135 K-3.7 Cl-102
HCO3-25 AnGap-12
[**2147-8-5**] Glucose-87 UreaN-20 Creat-0.7 Na-139 K-3.6 Cl-105
HCO3-25 AnGap-13
[**2147-8-6**] Glucose-93 UreaN-18 Creat-0.6 Na-136 K-3.5 Cl-105
HCO3-24 AnGap-11
[**2147-8-7**] Glucose-82 UreaN-15 Creat-0.8 Na-138 K-3.9 Cl-105
HCO3-24 AnGap-13
[**2147-8-8**] UreaN-14 Creat-0.8 K-4.2
Brief Hospital Course:
Ms. [**Known lastname 82901**] was admitted to the [**Hospital1 18**] on [**2147-8-1**] for surgical
management of her valvular heart disease. She was taken to the
operating room where she underwent a mitral valve replacement
using a St. [**Male First Name (un) 923**] mechanical valve and a tricuspid valve repair
using a MC3 annuloplasty system. Please see operative note for
details. Postoperatively she was taken to the intensive care
unit for monitoring. On postoperative day one, she awoke
neurologically intact and was extubated. She was weaned from
her pressors. Her chest tubes and epicardial wires were removed
and she was transferred to the step down floor. There she
experienced copious diarrhea and was found to be c.dif positive,
so oral Vancomycin was begun. Coumadin and heparin were
initiated for her mechanical mitral valve. Warfarin was
monitored daily and dosed for a goal INR between 3.0 - 3.5.
Heparin was eventually discontinued once her INR reached above
2.0. The remainder of her postoperative course was uneventful.
Over several days she continued to make clinical improvements
with diuresis and was medically cleared for discharge to home on
postoperative day seven. INR at discharge was 4.0. Prior to
discharge, arrangements were made and confirmed with Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 17466**] for management of Warfarin dosing as an
outpatient.
Medications on Admission:
Zestril 30mg qd
Nifedipine ER 60 qd
Metoprolol XL 50 qd
Ativan prn
Tylenol
Discharge Medications:
1. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO once a day: take
2 tabs(4mg) daily...daily dose may vary according to INR..use as
directed by local MD.
[**Last Name (Titles) **]:*60 Tablet(s)* Refills:*2*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
[**Last Name (Titles) **]:*60 Tablet(s)* Refills:*2*
3. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Last Name (Titles) **]:*30 Tablet(s)* Refills:*2*
4. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
[**Last Name (Titles) **]:*30 Tablet(s)* Refills:*2*
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day
for 7 days: then drop to 1tab(40mg) daily for seven days then
discontinue.
[**Last Name (Titles) **]:*21 Tablet(s)* Refills:*0*
6. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 7
days: then drop to 1 tab(20mEq) daily for seven days then
discontinue.
[**Last Name (Titles) **]:*21 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
7. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO every six
(6) hours for 7 days.
[**Last Name (Titles) **]:*28 Capsule(s)* Refills:*0*
8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every 6-8 hours
as needed for pain.
[**Last Name (Titles) **]:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Mitral and Tricuspid Valve Regurgitation
Possible Rheumatic Valvular Heart Disease
Hypertension
Pulmonary Hypertension
Anemia
C. difficile Colitis
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage or increased pain. Please contact your [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 4044**] with all wound issues.
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) You should wash incision daily with soap and water. No
lotions creams or powders to incision until it has healed. No
bathing or swimming for 6 weeks.
5) No lifting more then 10 pounds for 10 weeks from date of
surgery.
6) No driving for 1 month from date of surgery.
7) Take Warfarin as directed for goal INR between 3.0 - 3.5.
Please check PT/INR on [**8-10**] call results to Dr [**Last Name (STitle) **],[**First Name3 (LF) **] @
[**Telephone/Fax (1) 50485**].
8) Take Lasix and KCl as directed for two weeks then stop
9) Complete one week course of PO Vancomycin as directed
10) Please call with any questions or concerns
Followup Instructions:
[**Hospital 409**] clinic in 2 weeks
Please follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**]
Please follow-up with Dr. [**Last Name (STitle) 17466**] in [**12-27**] weeks. [**Telephone/Fax (1) 50485**]
Please follow-up with Dr. [**Last Name (STitle) 2603**] in 3 weeks.
please call to schedule all appointments
Completed by:[**2147-8-8**]
|
[
"401.9",
"285.9",
"397.0",
"394.2",
"008.45",
"311",
"416.0",
"429.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.24",
"35.14",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
7631, 7706
|
4759, 6174
|
310, 469
|
7897, 7904
|
1999, 4736
|
8885, 9264
|
1280, 1298
|
6300, 7608
|
7727, 7876
|
6200, 6277
|
7928, 8862
|
1313, 1980
|
251, 272
|
497, 968
|
990, 1086
|
1102, 1264
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,295
| 199,475
|
2866
|
Discharge summary
|
report
|
Admission Date: [**2107-12-29**] Discharge Date: [**2108-1-7**]
Date of Birth: [**2038-7-5**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
worsening fatigue with CHF and a positive ETT
Major Surgical or Invasive Procedure:
cabg x3/ LAD endarterectomy (LIMA to LAD, SVG to OM, SVG to
PDA)and placement of Biventricular pacing leads on [**2107-12-29**]
History of Present Illness:
65 yo African-American female with worsening fatigue. Had an
admission in [**Month (only) **]. for CHF and workup revealed a depressed EF and
some wall motion abnormalities. She was referred to [**Hospital1 18**] for
cath and evaulation. She underwent cath in [**Month (only) **]. which showed LAD
100%, 100% Diag 1, CX 100%, 70% OM1, 100% RCA. Referred to Dr.
[**Last Name (STitle) **] for CABG.
Past Medical History:
NIDDM with triopathy
obesity
HTN
CHF
CRI (baseline approx. 1.3)
Asthma as a child.
History of recurrent angioedema secondary to medications
including ACE inhibitor.
Coronary artery disease
inferior MI ( unknown date)
Social History:
divorced, lives alone
has great difficulty [**Location (un) 1131**]
Family History:
sister had MI at age 60
Physical Exam:
5'2" 190 pounds
156/96 HR 69 sat 100% 2L NC RR 16
Pupils equal, constricted and mildly reactive, NCAT,
no thyromegaly or JVD, no carotid bruits
RRR no m/r/g
CTAB
obese abd, soft, NT, ND with positive BS
extrems no c/c/e
pulses 2+ bil carotid /brachial/ radial/PT; 2+ right fem, left
dressing
Pertinent Results:
[**2108-1-3**] 01:44AM BLOOD WBC-15.3* RBC-3.49* Hgb-10.4* Hct-31.2*
MCV-89 MCH-29.7 MCHC-33.3 RDW-14.8 Plt Ct-129*
[**2108-1-3**] 01:44AM BLOOD Plt Ct-129*
[**2108-1-2**] 04:00AM BLOOD PT-14.4* PTT-26.7 INR(PT)-1.4
[**2108-1-3**] 01:44AM BLOOD Glucose-71 UreaN-38* Creat-1.1 Na-139
K-4.3 Cl-106 HCO3-23 AnGap-14
[**2108-1-1**] 11:41AM BLOOD ALT-3 AST-29 LD(LDH)-351* AlkPhos-67
Amylase-35 TotBili-0.3
[**2108-1-1**] 11:41AM BLOOD Lipase-16
[**2108-1-3**] 01:44AM BLOOD Calcium-8.8 Phos-3.1# Mg-2.2
[**2108-1-7**] 04:44AM BLOOD WBC-11.1* RBC-3.05* Hgb-9.5* Hct-27.9*
MCV-91 MCH-31.1 MCHC-34.1 RDW-14.6 Plt Ct-232
[**2108-1-7**] 04:44AM BLOOD Plt Ct-232
[**2108-1-7**] 04:44AM BLOOD Glucose-76 UreaN-41* Creat-1.5* Na-145
K-5.0 Cl-108 HCO3-27 AnGap-15
[**2108-1-1**] 11:41AM BLOOD ALT-3 AST-29 LD(LDH)-351* AlkPhos-67
Amylase-35 TotBili-0.3
[**2108-1-7**] 04:44AM BLOOD Mg-2.1
Brief Hospital Course:
Admitted on [**12-29**] and underwent CABG x3 /LAD endarterectomy /
placement of biventricular leads with Dr. [**Last Name (STitle) **]. Transferred to
the CSRU in stable condition. Required minimal inotropic support
for 72hrs and weaned off successfully. Extubated on POD #1.
Marginal urine output and rising creatinine to maximum 2.3 and
settled over the next few days to baseline levels.Transferred to
the floor on POD #5 and pacing wires were removed. PICC access
needed and obtained. UTI post op and was started on
Ciprofloxacin on day 8. [**Last Name (un) **] consult was obtained for glucose
management. She had continuing peripheral edema and continued on
IV lasix. She needed additional PT/ monitoring and was
transferred to rehab on POD # 9 in good condition.
Medications on Admission:
diovan
aldactone
lipitor
toprol XL
lasix 40 mg daily
norvasc
imdur
metformin
celexa
aspirin
avandia
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) 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. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for SBP>160.
12. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
13. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO BID (2 times a day).
14. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
16. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 7 days.
17. Furosemide 10 mg/mL Solution Sig: Two (2) Injection [**Hospital1 **] (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 11729**] Home - [**Location (un) 686**]
Discharge Diagnosis:
s/p cabg x 3/ LAD endarterectomy/ placement of biventricular
leads
obesity
elev. chol.
HTN
NIDDM
CRI
CHF
PICC line placement
Discharge Condition:
stable
Discharge Instructions:
no lotions, creams or powders on anyh incision
may shower over incisions and pat dry
no lifting greater than 10 pounds for 10 weeks
no driving for one month
Followup Instructions:
follow up with Dr. [**Last Name (STitle) **] in [**1-23**] weeks
follow up with Dr. [**Last Name (STitle) **] in [**2-24**] weeks
See Dr. [**Last Name (STitle) **] for postop surgical visit in 4 weeks [**Telephone/Fax (1) 170**]
Completed by:[**2108-1-19**]
|
[
"414.01",
"585.9",
"272.0",
"250.00",
"401.9",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.52",
"88.72",
"39.61",
"36.15",
"99.04",
"37.74",
"36.12",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
4954, 5037
|
2476, 3247
|
322, 452
|
5206, 5215
|
1576, 2453
|
5420, 5680
|
1219, 1244
|
3397, 4931
|
5058, 5185
|
3273, 3374
|
5239, 5397
|
1259, 1557
|
237, 284
|
480, 878
|
900, 1118
|
1134, 1203
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,492
| 124,897
|
42357
|
Discharge summary
|
report
|
Admission Date: [**2122-11-22**] Discharge Date: [**2122-11-24**]
Date of Birth: [**2048-4-5**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Altered Mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
74F transferred from OSH after having sudden onset of headache
around 630 pm, witnessed by family to have word finding
difficulty and Right sided weakness. Outside hospital CT head
showed large left ICH and acute SDH. Pt was intubated for
airway protection, loaded with Dilantin and transferred to [**Hospital1 18**]
for further evaluation by neurosurgery. Pt takes ASA 81mg
daily.
Past Medical History:
- s/p L mastectomy
- osteoporosis
- glaucoma
Social History:
The patient lives with husband
Occupation: Retired book-keeper.
Mobility: Independent
Smoking: Never
Alcohol: None
Illicits: None.
Family History:
Mother - died [**Name2 (NI) 499**] ca 101
Father - 91 died old age
Sibs - 13 sibs breast cancer in several and in one bilateral
with bilat mastectomy. 3 brothers with ca including lung ca.
Children - well
Physical Exam:
Currently intubated and sedated on propofol
Temp 99.6 HR 87 BP 128/67 Intubated CMV 203 x 500 Sat 100%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: pinpoint
Neck: Supple.
Lungs: decreased bilaterally at bases
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.
Neuro: withdraws left side briskly to noxious. No withdrawal of
right side.
Patient expired on [**2122-11-24**] at 5:35 pm
Pertinent Results:
[**2122-11-22**] 09:30PM WBC-9.2 RBC-3.30* HGB-10.7* HCT-30.7* MCV-93
MCH-32.4* MCHC-34.8 RDW-13.7
[**2122-11-22**] 09:30PM PLT COUNT-189
[**2122-11-22**] 09:30PM PT-13.0 PTT-23.4 INR(PT)-1.1
[**2122-11-22**] 09:40PM GLUCOSE-102 LACTATE-2.1* NA+-139 K+-3.8
CL--100 TCO2-25
[**2122-11-22**] 09:30PM UREA N-16 CREAT-0.6
[**2122-11-22**] 09:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-5* bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
[**2122-11-22**] 09:30PM URINE bnzodzpn-POS barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2122-11-22**] 09:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
[**2122-11-22**] 09:30PM URINE COLOR-Straw APPEAR-Hazy SP [**Last Name (un) 155**]-1.006
[**2122-11-22**] CTA head:
-left frontoparietal and occipital subdural hematoma. Measuring
9 mm
superiorly
-Large left parieto-occiptal intraparenchymal hemorrhage
measuring 3.7 cm x 6.9 cm
-Shift of usually midline structures - 8 mm to the right,
progression from previous 5mm shift.
-Mild effacement of the left sided perimesencephalic cisterns
and suprasellar cistern - findings concerning for impending
transtentorial herniation.
Brief Hospital Course:
Mrs. [**Last Name (STitle) 91745**] was admitted to the Neurocritical care unit for
ventilator management, close neurological observation, systolic
blood pressure control less than 160 and critical care. She was
given one dose of 100g Mannitol for cerebral edema and then
started on a standing dose of 25g Q6hrs. Serum Na and Osm were
closely followed.
CTA head was performed and showed no evidence of large clot or
vascular malformation.
The patient's neurological exam remained poor and discussion was
held with the family about her poor prognosis for a functional
recovery given the devastating tissue injury and her age. On
[**2122-11-23**], family decided on comfort measures only.
Patient was extubated on the morning of [**11-24**] and passed at 5:35
pm.
Medications on Admission:
- Evista 60 mg PO daily
- Travatan Z 0.0004% one drop both eyes qHS
- Brimonidine 0.2% one drop both eyes [**Hospital1 **]
- Systane ultra one drop both eyes twice daily
- ASA 81 mg qd
- Calcium 600 mg 2 tab daily
- MVI
- Vit D 50,000 U q month
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Left Hemorrhagic stroke with Intraparenchymal hemorrhage
Left Subdural hematoma
Respiratory failure
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
Completed by:[**2122-11-24**]
|
[
"V10.3",
"432.1",
"V66.7",
"348.5",
"V45.71",
"365.9",
"733.00",
"431",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
3956, 3965
|
2861, 3630
|
329, 336
|
4109, 4119
|
1644, 2838
|
4172, 4209
|
984, 1191
|
3927, 3933
|
3986, 4088
|
3656, 3904
|
4143, 4149
|
1206, 1625
|
268, 291
|
364, 750
|
772, 819
|
835, 968
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,787
| 112,190
|
2528
|
Discharge summary
|
report
|
Admission Date: [**2124-10-24**] Discharge Date: [**2124-10-30**]
Date of Birth: [**2044-1-3**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]
.
cc: fatigue and SOB
Major Surgical or Invasive Procedure:
right IJ central line
History of Present Illness:
History obtained from patient, wife and family.
.
80 yo male w/ recent hospitalizfation for diverticular bleed,
h/o stroke, h/o CAD and MI, CRI who p/w few days of malaise and
SOB. Pt was feeling reasonably well since his last admission
when his wife brought him to [**Name (NI) 2025**] for increasing SOB over last
few days. Per pt and family, he has been having progressive
fatigue over last months with decrreased interest in activity.
He has been feeling lethargic and wife reports increased
somnolence. He reports an increase in his thirst but denies
polyuria or polydypsia and has no h/o diabetes. He has been
feeling light headed and his appetite as been low over past few
days. Pt endorses some increase in LE swelling, +orthopnea and
occasional PND. He denies chest pain or palipations. He denies
any fevers or chills, weight loss or weight gain, abdominal
pain, dysuria or hematuria. He has chronic black stools and is
on iron but denies any BRBPR. He uses a walker to get around
[**1-21**] residual right-sided weakness after sroke. Pt is not on
home oxygen and has 25-30 pack year smoking hx, quit 20 years
ago. He takes tiotropium daily but denies h/o asthma or COPD.
Pt had nml Echo [**2122**] w/ EF >55%. He denies any changes in his
medications and denies any new weakness. Wife does report
increase in slurred speech over past few weeks.
.
Pt was transferred from [**Hospital1 2025**] ED where he was noted to be in
a-flutter. He received lasix 20mg IV, Metop 25mg PO, atrovent
nebs. Head Ct was ordered but results not reported.
Past Medical History:
- h/o GI bleed, diverticulitis and recent hospitalization
- C. Diff colitis
- h/o stroke 12 years ago w/ right-sided weakness
- h/o nephrolithiasis w/ stent and nephrostomy tube
- CAD s/p MI
- sleep apnea
- h/o supplemental oxygen
- thrombocytopenia
- h/o klebsiella urosepsis
- CRI BL Cr 1.2-1.7, 2.5 last admission w/ GI bleed
- sleep apnea
- depression
.
MEDS:
metoprolol 25mg [**Hospital1 **]
Iron 325mg TID
Tiotropium 18mcg daily
Social History:
Lives with wife [**Name (NI) **], h/o smoking [**12-21**] PPD for 50 years, quit
20 years ago, does not drink alcohol, no drugs.
Family History:
non-contributory
Physical Exam:
VS: 96.3 112/68 68 24 97% on 2L
Gen'l: obese, sleepy, NAD
HEENT: NC/AT, EOMI, MMM, OP clear
NECK: IJ in place, site c/d/i, unable to assess JVD
CVS: NR/RR, +s1/s2 but distant heart sounds, no murmur
appreciated
PUL: ([**Last Name (un) **]) ronchorous breathing, difficult to assess, pt too
lethargic to sit up
[**Last Name (un) **]: obese, +BS, soft, NT/ND, no masses
Extrems: no c/c/e
Pulses: 2+ radial, 2+ DP
Neuro/Psyche: oriented to name, place, year, season, current
events; unable to recite days of week backwards
Pertinent Results:
12:45pm: Trop-T: 0.04
CK: 33 MB: Notdone
.
u/a:
mod leuks, large bld, neg nit, tr prot, neg glu, neg ket, >50
RBCs, 21-50 WBC, mod bacteria
.
03:55am
.
140 106 113
--------------< 110
4.6 18 4.3
.
CK: 36 MB: Notdone Trop-T: 0.05
.
ALT: 34 AP: 194 Tbili: 0.4
AST: 20 LDH: 182
[**Doctor First Name **]: 59
proBNP: 9866
.
T4: 7.5
.
Lactate:1.0
.
9.0 > 29.5 < 330 D
N:85.3 Band:0 L:11.8 M:1.7 E:0.9 Bas:0.2
.
PT: 15.1 PTT: 28.3 INR: 1.4
.
RENAL U/S:
The study is limited by body habitus. The kidneys demonstrate a
homogenous echotexture, although are slightly hyperechoic to the
liver which may indicate underlying medical renal disease. There
is no evidence of hydronephrosis, mass or stone. No definite
stent is seen. IMPRESSION: No evidence of hydronephrosis.
.
CXR:
IMPRESSION: Right IJ terminates at the cavoatrial junction. No
acute cardiopulmonary disease is identified. Stable
cardiomegaly, suggestive of possible cardiomyopathy.
.
EKG: 4:1<-->2:1 flutter; EKG#2 4:1 flutter w/ LAD and LAFB, no
ST segment changes; flutter not noted on prior EKGs
.
ECHO [**2123-6-16**]
The left atrium is mildly dilated. The left ventricular cavity
size is normal. Due to suboptimal technical quality, a focal
wall motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is normal (LVEF>55%). The right
ventricle may be mildly dilated. Right ventricular systolic
function is 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. The tricuspid valve leaflets are mildly thickened.
There is no pericardial effusion. Compared with the prior study
(images reviewed) of [**2122-3-24**], estimated pulmonary artery
systolic pressure is now higher.
.
p-mibi [**2121**] negative
Brief Hospital Course:
80 yo male w/ h/o diastolic CHF, CAD s/p MI, chronic renal
insufficiency (Cr 1.3-1.7), h/o lower GI bleed, diverticulosis,
CVA, C.diff, urosepsis who presents to the ED at [**Hospital1 18**] with
several days of shortness of breath, gradually worseing fatigue,
acute on chronic renal failure and newly diagnosed atrial
flutter.
.
1. Dyspnea
The most likely etiology was CHF exacerbation secondary to new
atrial flutter. BNP was elevated to 9866 on admission. Chest
x-ray on admission showed possible pleural effusion on left side
and stable cardiomegaly. EKG showed new atrial flutter with no
evidence of acute myocardial ischemia. Cardiac enzymes x 3 were
negative. The patient received Lasix 20 mg IV x 2. He had good
urine output and denied any dyspnea during his hospital stay. He
was on oxygen 2L nc which was d/c'd on HOD3.
.
2. Fatigue
His fatigue had started 1-2 months PTA and was most likely
secondary to his CHF and recent lower GI bleed/anemia. Other
contributing causes were uremia (BUN 113) and atrial flutter.
His Hct on admission was 29.3. His Hct in the past have been
between 26-35. His guaiac tests were all negative. Another
contributing was an UTI and bacteremia. His urine culture and
blood culture were positive for E.coli.
On HOD3 he felt much better and was not exhausted any mor.
.
3. Atrial flutter
Possible etilogy was the UTI and bacteremia and CHF
exacerbation. Thyrotoxicosis was unlikely as T4 was normal.
Electrophysiology was consulted and did not change his
metoprolol. He was started on aspirin but no anticoagulation due
to his risk for GI bleed. He got an ECHO which showed LVEF >
55%, and minor changes from last ECHO.
.
4. Acute renal failure
The patient's Cr was 4.3 on admission with baseline Cr 1.3-1.7.
The most likely cause was pre-renal, cardiogenic acute renal
failure resulting from hypoperfusion of kidneys secondary to CHF
and decreased stroke volume. Post-renal cause was unlikely since
renal US was negative for any hydronephrosis. Renal cause was
unlikely since there are no urine casts, no RBC, no protein.
His Cr improved daily and he had good urine output.
.
5. UTI
Patient had positive UA with urine cx E.coli, sensitive to
ceftriaxone and ciprofloxacin. He had no c/o dysuria, hematuria
while in the hospital. He was treated with Ceftriaxone 1 grm IV
q24h while in the hospital and he will be discharged on cipro to
complete a 14 day course.
.
6. Bacteremia
Blood culture was positive for E.coli, sensitive to ceftriaxone
and ciprofloxacin. He had no signs of sepsis. No tachycardia, no
fever or hypothermia. WBC decreasing. He was treated with
Ceftriaxone 1 grm IV q24h while in the hospital and he will be
discharged on cipro to complete a 14 day course.
.
7. Hyperkalemia
The patient's potassium increased to 5.2 on [**10-26**]. This was most
likely related to acute renal insufficiency. EKG showed no
peaked T waves. He received Kayexalate and his potssium
decreased to 4.7. He was placed on a renal/low K diet.
.
8. Gastrointestinal bleed:
Patient has history of recurrent bleeds in the past. During
this admission, he was noted to have several large bloody bowel
movements with blood clots. He was monitored in the intensive
care unit where his bleeding resolved and his hematocrit
remained stable. He denied any abdominal pain, chest pain, new
dyspnea, fevers, chills, night sweats, lightheadedness. GI was
consulted while the patient was in the ICU and colonoscopy was
not performed during this admission as his bleeding had resolved
and his bleed was thought most likely secondary to
diverticulosis. He was recommended to follow-up with GI . . .
.
Of note, he was recently admitted to [**Hospital1 18**] at the end of [**Month (only) 359**]
for a GI bleed. He was not scoped during that admission b/c the
bleed stopped on its own and his hct was stable. He was
scheduled to follow up with GI as an outpatient.
This was likely related to his severe diverticulosis, though AVM
or other etiology cannot be excluded. He appeared stable and
asymptomatic at that time.
Medications on Admission:
Metoprolol 25mg PO BID
Iron 325mg TID
Tiotropium 18mcg daily
Discharge Medications:
1. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
2. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
4. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 8 days: Take 1 pill TWICE a day till finished. .
Disp:*16 Tablet(s)* Refills:*0*
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 12874**] [**Hospital **] Nursing Home
Discharge Diagnosis:
Primary Diagnoses:
- E. coli bacteremia with sepsis
- Urinary tract infection
- Gastrointestinal bleeding
- Atrial flutter
- Acute renal failure
- Congestive heart failure exacerbation
.
Secondary Diagnoses:
- history of gastrointestinal bleed, diverticulitis
- history of stroke 12 years ago with right-sided weakness
- history of nephrolithiasis with stent and nephrostomy tube
- coronary artery disease
- sleep apnea
- chronic renal insufficiency
Discharge Condition:
Stable. Ambulating, talking, returned to baseline.
Discharge Instructions:
You were admitted with a change in your mental status and
shortness of breath and were found to have bacteria (E. coli) in
your urine and your blood. You were started on intravenous
antibiotics and improved. You also had acute renal failure
likely secondary to this infection, in addition to your chronic
kidney disease, and were seen by the Kidney Consult service.
Your kidney function improved over your stay. You will need to
follow-up with the Kidney service.
.
You will finish a 14-day total course of antibiotics on [**11-5**].
Please take as directed.
.
You also had a newly diagnosed abnormal heart rhythm called
atrial flutter. No medications were started and you will
continue to take metoprolol. You will need to follow-up with
the electrophysiology clinic to monitor your rhythm. This
rhythm may have been caused by your infection.
.
You had transient increases in your potassium levels and were
treated with a bowel medicine and your potassium normalized.
You will need to have your blood drawn to monitor this.
.
You were started on an aspirin daily for the heart and brain
protective-effect. You do have a recent history of bleeding
from your gastrointestinal tract.
.
You had gastrointestinal bleeding and you were transferred to
the Intensive care unit for close monitoring. You received IV
fluids and your hematocrit was stable.
.
You need to drink a lot of fluids in the next couple days.
.
If you develop any concerning symptoms such as frequent or
prolonged palpitations, chest pain, swelling in your legs,
shortness of breath, fevers, dizzyness or notice large blood in
your stool, or other concerning symptoms, please call your
primary care physician or proceed to the emergency room.
Followup Instructions:
Renal appointment: Dr. [**Last Name (STitle) 4883**], Monday, [**11-13**], at 3PM. If
you have questions, please call [**Telephone/Fax (1) 60**].
Primay care physician: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], Wednesday, [**11-8**],
at 11:50AM. If you have any questions, please call [**Telephone/Fax (1) 1579**].
Electrophysiology: Dr. [**Last Name (STitle) 73**], Monday, [**11-28**], at
11:20AM. If you have questions, please call [**Telephone/Fax (1) 902**].
.
Provider [**Name9 (PRE) 1576**],[**First Name8 (NamePattern2) 2352**] [**Doctor Last Name 4694**] APG (SB)
Phone:[**Telephone/Fax (1) 1579**] Date/Time:[**2125-1-15**] 1:30
.
Please also follow-up with Dr. [**First Name (STitle) **] [**Name (STitle) 9890**] on
Friday [**12-8**] at 11am. Her office is located in the [**Hospital Unit Name 1824**] [**Location (un) **]. If you need to reschedule, please call her
office at [**Telephone/Fax (1) 463**].
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2124-10-30**]
|
[
"599.0",
"041.4",
"412",
"414.01",
"585.9",
"428.30",
"584.9",
"995.92",
"562.12",
"038.42",
"427.32",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9903, 9979
|
5063, 9100
|
401, 424
|
10475, 10528
|
3207, 5040
|
12292, 13356
|
2632, 2650
|
9211, 9880
|
10001, 10188
|
9126, 9188
|
10553, 12269
|
2665, 3188
|
10209, 10453
|
276, 363
|
452, 2012
|
2034, 2470
|
2486, 2616
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,865
| 182,677
|
32497
|
Discharge summary
|
report
|
Admission Date: [**2119-11-3**] Discharge Date: [**2119-11-7**]
Date of Birth: [**2058-6-16**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
DOE, LE Edema
Major Surgical or Invasive Procedure:
CABG x2 (LIMA - LAD // SVG - DIAG) on [**11-3**]
History of Present Illness:
61 yo M with recent DOE and LE edema, with abnormal ETT,
referred for cath which showed 3 VD. Referred for CABG.
Past Medical History:
Hlipid, DM2, prior MVA, Gout, malignant colon polyp removed,
buttock surgery '[**71**]
Social History:
retired from federal government
[**11-29**] cigars per day
6 drinks/week
Family History:
NC
Physical Exam:
HR 68 RR BP 142/50
NAD, flat after cath
Lungs with decreased breath sounds throughout.
Heart distant S1S2.
Abdomen obese, Soft, NT
Extrem warm, 1+ pitting edema, stasis changes LLE
1+ dp/pt pulses
No carotid bruits, no varicosities
Pertinent Results:
[**2119-11-7**] 09:40AM BLOOD WBC-8.3 RBC-3.88*# Hgb-12.0*# Hct-36.8*#
MCV-95 MCH-31.0 MCHC-32.6 RDW-14.1 Plt Ct-296#
[**2119-11-7**] 09:40AM BLOOD Plt Ct-296#
[**2119-11-5**] 03:07AM BLOOD PT-15.1* PTT-28.8 INR(PT)-1.3*
[**2119-11-7**] 09:40AM BLOOD Glucose-154* UreaN-45* Creat-1.3* Na-136
K-5.4* Cl-98 HCO3-29 AnGap-14
CHEST (PORTABLE AP) [**2119-11-6**] 12:33 PM
CHEST (PORTABLE AP)
Reason: s/p ct d/c, r/o ptx
[**Hospital 93**] MEDICAL CONDITION:
61 year old man with
REASON FOR THIS EXAMINATION:
s/p ct d/c, r/o ptx
HISTORY: 61-year-old male, status post chest tube removal,
evaluate for pneumothorax.
COMPARISON: [**2119-11-4**].
PORTABLE UPRIGHT CHEST, ONE VIEW: The cardiomediastinal
silhouette is unchanged. Despite the stomach not being
over-inflated, lung volumes are low with increased atelectasis
at both lung bases compared to prior study. No pneumothorax is
identified.
IMPRESSION:
1. Low lung volumes with increased bibasilar atelectasis.
2. No evidence of pneumothorax.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 24690**], [**Known firstname 177**] [**Hospital1 18**] [**Numeric Identifier 75815**] (Complete)
Done [**2119-11-3**] at 10:04:56 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
Division of Cardiothoracic [**Doctor First Name **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2058-6-16**]
Age (years): 61 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: CABG in diabetic patient.
ICD-9 Codes: 786.05, 786.51, 799.02, 440.0
Test Information
Date/Time: [**2119-11-3**] at 10:04 Interpret MD: [**Known firstname **] [**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 #: 2007AW-1: Machine: [**Pager number **]
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Inferolateral Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.0 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 55% to 60% >= 55%
[**Pager number **] - Ascending: 3.0 cm <= 3.4 cm
[**Pager number **] - Descending Thoracic: 2.2 cm <= 2.5 cm
Aortic Valve - Valve Area: *2.2 cm2 >= 3.0 cm2
Mitral Valve - Mean Gradient: 1 mm Hg
Mitral Valve - MVA (P [**11-29**] T): 3.1 cm2
Findings
LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Mild symmetric LVH. Overall normal LVEF
(>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
[**Month/Day (2) **]: Normal ascending [**Month/Day (2) 5236**] diameter. Simple atheroma in
descending [**Month/Day (2) 5236**].
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. 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. There is mild symmetric left ventricular hypertrophy.
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the descending thoracic [**Month/Day (2) 5236**]. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no pericardial effusion.
Post-CPB: Normal biventricular systolic fxn. No AI, no MR. [**First Name (Titles) **] [**Last Name (Titles) 18350**]t. Other parameters as pre-bypass.
Brief Hospital Course:
He was taken to the operating room on [**2119-11-3**] where he
underwent a CABG x 2. He was transferred to the ICU in stable
condition on nitro and propofol. He awoke and was extubated
later that same day. He was transfused 2 units for HCT 23. He
was monitored closely for increased creatinine, low urine output
and HCT all of which improved. His wires and chest tubes were
dc'd without incident. He was ready for transfer to the floor on
POD #2. He did well postoperatively and was ready for discharge
home on POD #4.
Medications on Admission:
Plavix 75', Coreg CR 10', HCTZ 25', Lisinopril 5', ASA 325',
MVI', Glyburide/Metformin [**3-/2062**] two tabs [**Hospital1 **], Lipitor 10', Actos
45'
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
7. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*0*
8. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
9. Pioglitazone 15 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours) for 14 days.
Disp:*28 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
11. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 14
days.
Disp:*28 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
CAD now s/p CABG
Hlipid, DM2, prior MVA, Gout, malignant colon polyp removed,
buttock surgery '[**71**]
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds or driving until follow up with
surgeon.
Followup Instructions:
Dr. [**Last Name (STitle) **] 4 weeks
Dr. [**Last Name (STitle) **] 2 weeks
Dr. [**Last Name (STitle) **] 2 weeks
Completed by:[**2119-11-7**]
|
[
"V10.05",
"272.4",
"250.00",
"414.01",
"518.0",
"411.1",
"274.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.15",
"99.04",
"36.11",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
7507, 7568
|
5427, 5947
|
335, 386
|
7716, 7724
|
1016, 1436
|
8023, 8168
|
744, 748
|
6148, 7484
|
1473, 1494
|
7589, 7695
|
5973, 6125
|
7748, 8000
|
763, 997
|
282, 297
|
1523, 5404
|
414, 528
|
550, 638
|
654, 728
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,352
| 153,476
|
37095
|
Discharge summary
|
report
|
Admission Date: [**2170-10-24**] Discharge Date: [**2170-10-26**]
Date of Birth: [**2095-12-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7055**]
Chief Complaint:
Lightheadedness, shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Known firstname **] [**Known lastname **] is a 74 yo male with Factor V leiden, asbestosis,
hyperlipidemia who s/p right Total Knee Replacement
approximately 2 weeks ago who presented to ED with LH, shortness
of breath. He reports feeling progressively more short of
breath for the past week at rehab. He has intermittently
required 2L O2 for the past few days at rehab to keep O2
sats>90. He denies chest pain, pressure, pleuritic symtpoms,
cough, fever or chills. He felt lightheaded and almost fainted
earlier today. He denies history of syncope. He notes that the
lightheadeness is worse with activity. He reports right calf
swelling and pain since his knee surgery. He reports that he
has intermittently been off the coumadin for procedures over the
past few months, but he was generally bridged with lovenox.
.
In the ED, initial vitals were 97 48 114/62 20 100% 2L. His
initial EKG showed a junctional rhythm to the 40s. He since
converted to sinus bradycardia. Seen by EP in ED and they did
not feel he needed a pacemaker. CTA chest showed subsegmental PE
in the RUL. LENI were negative for DVTs. He was given
vancomycin and zosyn for a question HAP b/c upper lobe opacities
on CXR. No PNA on CT chest. He recieved 1.5 L IVF for
hypotension. His current VS are 58 145/96 12 100% 4L.
.
.
On review of systems: Postive for knee pain (currently 0/10) and
nausea & consitpation associated with the oxycodone that he is
taking.
He denies any prior history of stroke, TIA, 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,
paroxysmal nocturnal dyspnea, orthopnea, palpitations, or
syncope.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia
2. CARDIAC HISTORY:
-CABG: n/a
-PERCUTANEOUS CORONARY INTERVENTIONS: n/a
-PACING/ICD: n/a
3. OTHER PAST MEDICAL HISTORY:
# Hypothyroidism
# Factor V Leiden
# Hepatic vein thrombosis - on lifelong Coumadin
# s/p R TKR one week prior
# History of cataract surgery [**5-24**]
# Asbestosis
# GERD
# BPH
# H/o carpal tunnel s/p bilat repair
Social History:
He is a retired elctrician. He lives alone. He has 2 adult
children.
-Tobacco history: never
-ETOH: none
-Illicit drugs: none
Family History:
Father with DVT/?PE at age 42.
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
GENERAL: WDWN 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 8 cm.
CARDIAC: PMI located in 5th ICS, midclavicular line. regular
rhythm, slow rate normal S1, S2. No m/r/g. No thrills, lifts. No
S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. dry crackles at base
bilat, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits. right knee incision
healing well.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
Pertinent Results:
===================
ADMISSION LABS
===================
[**2170-10-24**]
WBC-8.0 RBC-4.32* Hgb-13.0* Hct-39.3* MCV-91 MCH-30.1 MCHC-33.1
RDW-14.1 Plt Ct-232
Neuts-79.8* Lymphs-8.8* Monos-5.2 Eos-5.7* Baso-0.4
PT-32.7* PTT-33.6 INR(PT)-3.3*
Plt Ct-232
Glucose-92 UreaN-20 Creat-0.7 Na-139 K-4.1 Cl-107 HCO3-23
AnGap-13
Calcium-8.6 Phos-3.5 Mg-1.7
Lactate-1.1
==================
DISCHARGE LABS
==================
WBC-5.9 RBC-4.31* Hgb-12.8* Hct-39.6* MCV-92 MCH-29.7 MCHC-32.3
RDW-14.0 Plt Ct-189
PT-30.3* PTT-32.4 INR(PT)-3.0*
Glucose-87 UreaN-16 Creat-0.8 Na-144 K-3.9 Cl-108 HCO3-25
AnGap-15
Calcium-8.6 Phos-3.0 Mg-1.8
=============
RADIOLOGY
=============
CT CHEST ([**2170-10-24**])
IMPRESSION:
1. Right upper lobe and lingular subsegmental filling defects
compatible with acute pulmonary emboli.
Discussed with ED and medicine team house-staff at 4:25 pm
[**2170-10-24**].
2. Pleural calcified plaques compatible with prior asbestos
exposure. While mild reticular and ground glass opacities at
bilateral posterior lung bases most likely represent dependent
atelectasis, it can also be seen in early asbestosis. In case of
clinical concern for asbestosis, an HRCT with prone imaging can
be obtained on a non-emergent basis as an outpatient following
treatment for the acute PE.
3. Borderline mediastinal lymphadenopathy of uncertain clinical
Significance.
4. Splenomegaly.
5. Questionable hypodense lesion in the inferior aspect of the
right lobe of the liver is incompletely characterized. An
ultrasound can be obtained for further evaluation if clinically
warranted.
Brief Hospital Course:
[**Known firstname **] [**Known lastname **] is a 74 yo male with a recent right TKA who
presents with worsening dyspnea for the past week and found to
have bradycardia and PE.
# Dyspnea/Pulmonary embolus: 2 predisposing factors for PE
(factor V leiden and post-op). Patient with small bilat
subsegmental PEs on CTA of the chest despite being therapeutic
on coumadin, although it is not clear that this was not present
prior to anticoagulation. He had no evidence of LE DVT. He was
short of breath but without O2 requirement. Despite the PE he
was supratherapeutic on admission with INR of 3.3. Change in
INR goal or IVC filter placement was thought not to be necessary
given h/o intermittent discontinuation of anticoagulation for
various procedures. This was discussed with his outpt
hematologist who will continue to follow.
# BRADYCARDIA: Patient was previously in junctional escape
rhythm and converted to sinus bradycardia. Patient's
lightheadedness was most likely a consequence of bradycardia
made worse with atenolol. He did not present in renal failure.
Atenolol was started peri-op and likely at too high of a dose.
It was discontinued. Pt continued to be bradycardic, dropping to
high 30s while sleeping but he was not symptomatic.
# Hypotension: Patient reports low blood pressures at baseline
SBPs in 90s. If atenolol was cause of bradycardia is is also
likely the cause of his hypotension to the SBP of 80s. He was
given a bolus of IVF. Atenolol was discontinued. Terazosin was
changed to flomax due to orthostatic symptoms.
# Hypothyroidism: Pt was noted to have TSH mildly elevated at
4.4. In setting of post-op recovery no change was made to
synthroid dose. TSH should be followed as outpt.
# TKR repair/pain: Pain was controlled with tylenol and
tramadol. He was discharged to rehab for continued physical
therapy.
Medications on Admission:
Atenolol 25mg daily - given today and last 3 days at rehab
Prilosec 20mg [**Hospital1 **]
Ditropan 2.5mg daily
Terazosin 4mg daily
MVI 1 tab daily
Proscar 5mg daily
Synthroid 50mcg daily
Oxycodone 10 q6h prn pain
Zocor 20mg daily
Discharge Medications:
1. Senna 8.6 mg Capsule Sig: 1-2 Tablets PO BID (2 times a day)
as needed for Constipation.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
4. Oxybutynin Chloride 5 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
9. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
10. Celebrex 100 mg Capsule Sig: One (1) Capsule PO twice a day.
11. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
12. Warfarin 2 mg Tablet Sig: Four (4) Tablet PO Once Daily at 4
PM.
13. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO every
eight (8) hours.
14. Lidoderm 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) patch Topical once a day: use for 12 hours per day.
15. Outpatient Lab Work
Please check INR daily until stable
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Pulmonary Embolus
Factor 5 Leiden
Dyslipidemia
Benign Prostatic Hypertrophy
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Lethargic but arousable
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
You had a low heart rate and blood pressure because of Atenolol.
This medicine was stoppped and although your heart rate was
still low, your blood pressure is stable. You also had some
trouble breathing and 2 small pulmonary embolus were seen on a
cat scan. We discussed this with your hematologist, Dr.
[**Last Name (STitle) 83595**], and decided against a groin filter but you should
continue with coumadin with goal INR (coumadin level) 2-3.0. You
will need to go to rehabiliation to continue with your recovery
from knee replacement. You should have another CAT scan in about
3 months to check the status of the blood clots in your lungs.
Medication changes:
1.Stop taking Atenolol
2. Stop taking Terazosin, take Tamulosin instead as this may
cause less dizziness.
3. Stop taking Oxycodone, take tylenol and Celebrex with
Tramadol before therapy.
Followup Instructions:
Hematology:
Dr. [**Last Name (STitle) 83596**] Phone: [**Telephone/Fax (1) 67065**] Date/time: The office will call
you with an appt in 6 weeks.
Primary Care:
[**Last Name (LF) **],[**First Name3 (LF) **] Phone: [**Telephone/Fax (1) 83597**] Date/Time: Please make an appt
to see Dr. [**Last Name (STitle) **] after you get out of rehabilitation.
Completed by:[**2170-10-27**]
|
[
"V58.61",
"272.4",
"427.89",
"415.19",
"V43.65",
"530.81",
"289.81",
"501",
"600.00",
"244.9",
"E942.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8728, 8798
|
5356, 7212
|
355, 362
|
8918, 8918
|
3748, 5333
|
9972, 10351
|
2819, 2965
|
7492, 8705
|
8819, 8897
|
7238, 7469
|
9097, 9740
|
2980, 3729
|
2337, 2410
|
1723, 2257
|
9760, 9949
|
279, 317
|
390, 1704
|
8932, 9073
|
2441, 2657
|
2279, 2317
|
2673, 2803
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,430
| 172,620
|
42748
|
Discharge summary
|
report
|
Admission Date: [**2140-2-10**] Discharge Date: [**2140-2-23**]
Date of Birth: [**2103-6-10**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Known firstname 30**]
Chief Complaint:
Dyspnea on exertion.
Major Surgical or Invasive Procedure:
Right heart catherization [**2140-2-22**]
History of Present Illness:
36 yo obese male with no past medical history who presents with
2 months of dyspnea on exertion. He reports normal SOB with
exertion which has worsened since [**Month (only) 1096**]. He had a viral URI
that he treated with OTC meds but which did not resolve. He has
had an intermittent productive cough since then. He has not
received any antibiotics during this time period. He did not
recieve an influenza vaccine this year. His SOB never happens
at rest. His DOE now occurs when he walks short distances,
even up one flight of stairs. He notes chronic 3 pillow
orthopnea, and weight gain in his legs. He denies chest pain,
dizziness, LH or syncope. He denies recent sick contacts or
travel. He presented to [**Hospital **] hosp yesterday and was found to
be hypoxic (86% on RA, 98% on 6L NC. D-dimer was 981, Hct 47.7
and WBC was 10.9. Trop was negative x 1. He was too large for
their CT scanner so he was transferred to [**Hospital1 18**] for further
management.
.
In the ED, initial vital signs were T- 98.4, HR- 87, BP-
191/129, RR- 22, SaO2- 95% on 6L NC. He received a full dose ASA
given EKG changes (diffuse TWI) and underwent CTA which showed
no PE but a RUL PNA and signs consistent with PAH. He is being
admitted for further management of his dyspnea.
.
On arrival to the floor, vital signs were T- 98.3, BP- 150/80,
HR- 99, RR- 20, SaO2- 93% on 5L. He denies any shortness of
breath at rest, chest pain, dizziness, LH or syncope.
.
REVIEW OF SYSTEMS:
+queasy stomach recently
-fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, chest pain, abdominal pain,
nausea, vomiting, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
Past Medical History:
- Obesity
- Status-post hernia repair, [**2130**]
- Borderline hypertension at recent physician [**Name Initial (PRE) **]
Social History:
Lives with mother and brother, works for the mayor of [**Name (NI) 86**].
Non-smoker. Drinks very sporadically (3 times since [**Holiday **]).
No IV drug use. Functional at baseline, is busy at work.
Graduated from [**University/College 5130**] [**Location (un) **].
Family History:
Father with history of CAD with MI at age 57, tobacco use, and
obesity. No known family history of diabetes mellitus,
rheumatologic disease, or malignancy. Grandmother had COPD and
wore BiPAP.
Physical Exam:
Exam upon admission:
V/S: T 97 HR 88 BP 158/126 SPO2 93% NC 6L 418lbs
General appearance: Obese male resting in bed, in no apparent
distress, pleasant, comfortable
HEENT: NC/AT, moist mucous membranes, Mallampati grade II, no
lesions. No scleral icterus or conjunctival pallor.
Neck: supple, JVP to angle of the jaw, no LAD
Lungs: crackles diffusely, also in right upper lung field
Cardiac: RRR, prominent S2, no apparent murmurs, gallops or rubs
Abdomen: Obese, soft, non-tender, non-distended, bowel sounds
present
Extremities: 2+ LE edema to knees bilaterally, right greater
than left, some chronic venous stasis changes in right leg,
mildly erythematous. No clubbing/cyanosis.
Neuro: awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**4-23**] throughout, sensation grossly intact throughout, gait intact
Exam at Discharge:
V/S: T 98.1 HR 93 BP 125/82 SPO2 95% NC 4L 348lbs
General appearance: Obese male sitting on edge of bed in NAD
HEENT: NC/AT, moist mucous membranes, Mallampati grade II, no
lesions. No scleral icterus or conjunctival pallor.
Neck: supple, JVP to mid neck, no LAD.
Lungs: Clear bilaterally, no wheezing, rhonchi, rales
Cardiac: Regular, prominent S2, no apparent murmurs, gallops or
rubs
Abdomen: Obese, soft, non-tender, non-distended, bowel sounds
present
Extremities: 1+ Pitting edema to knees bilaterally. No
clubbing/cyanosis.
Neuro: Awake, alert.
Psych: Pleasant, appropriate
Pertinent Results:
Labs upon admission:
[**2140-2-11**] 06:34AM BLOOD WBC-7.2 RBC-6.09 Hgb-14.5 Hct-45.8
MCV-75* MCH-23.8* MCHC-31.7 RDW-15.1 Plt Ct-130*
[**2140-2-13**] 06:50AM BLOOD Hypochr-3+ Anisocy-NORMAL
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-3+ Polychr-1+
Ovalocy-OCCASIONAL
[**2140-2-11**] 06:34AM BLOOD Plt Ct-130*
[**2140-2-11**] 06:34AM BLOOD Glucose-103* UreaN-13 Creat-0.7 Na-141
K-3.9 Cl-97 HCO3-36* AnGap-12
[**2140-2-12**] 07:30AM BLOOD ALT-10 AST-17 AlkPhos-60 TotBili-0.9
[**2140-2-10**] 11:15PM BLOOD CK(CPK)-38*
[**2140-2-11**] 06:34AM BLOOD CK(CPK)-34*
[**2140-2-11**] 10:40AM BLOOD proBNP-1098*
[**2140-2-10**] 11:15PM BLOOD CK-MB-2 cTropnT-<0.01
[**2140-2-11**] 06:34AM BLOOD CK-MB-2 cTropnT-<0.01
[**2140-2-11**] 06:34AM BLOOD Calcium-8.8 Phos-4.8* Mg-1.9
[**2140-2-12**] 07:30AM BLOOD TSH-2.9
[**2140-2-11**] 06:34AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2140-2-12**] 07:30AM BLOOD HIV Ab-NEGATIVE
[**2140-2-11**] 11:18AM BLOOD Type-[**Last Name (un) **] pO2-192* pCO2-81* pH-7.28*
calTCO2-40* Base XS-8
[**2140-2-11**] 11:57PM BLOOD Lactate-0.8
Labs prior to discharge:
[**2140-2-12**] 07:30AM BLOOD WBC-8.6 RBC-6.05 Hgb-14.2 Hct-46.1
MCV-76* MCH-23.5* MCHC-30.9* RDW-15.1 Plt Ct-123*
[**2140-2-12**] 07:30AM BLOOD Plt Ct-123*
[**2140-2-12**] 07:30AM BLOOD Glucose-91 UreaN-11 Creat-0.6 Na-141
K-4.1 Cl-96 HCO3-37* AnGap-12
[**2140-2-12**] 07:30AM BLOOD ALT-10 AST-17 AlkPhos-60 TotBili-0.9
[**2140-2-13**] 06:50AM BLOOD WBC-6.9 RBC-6.09 Hgb-14.5 Hct-46.3
MCV-76* MCH-23.8* MCHC-31.3 RDW-14.8 Plt Ct-130*
[**2140-2-13**] 06:50AM BLOOD Plt Ct-130*
[**2140-2-14**] 03:10AM BLOOD Glucose-91 UreaN-8 Creat-0.6 Na-138 K-3.4
Cl-91* HCO3-39* AnGap-11
[**2140-2-15**] 07:00AM BLOOD WBC-7.3 RBC-6.56* Hgb-15.2 Hct-49.0
MCV-75* MCH-23.2* MCHC-31.1 RDW-14.9 Plt Ct-125*
[**2140-2-16**] 07:00AM BLOOD WBC-6.3 RBC-6.64* Hgb-15.4 Hct-49.4
MCV-74* MCH-23.1* MCHC-31.1 RDW-15.0 Plt Ct-111*
[**2140-2-17**] 06:30AM BLOOD WBC-6.8 RBC-6.53* Hgb-15.0 Hct-48.5
MCV-74* MCH-22.9* MCHC-30.9* RDW-14.9 Plt Ct-128*
[**2140-2-23**] 05:50AM BLOOD WBC-5.8 RBC-6.37* Hgb-14.8 Hct-45.9
MCV-72* MCH-23.2* MCHC-32.2 RDW-14.2 Plt Ct-116*
[**2140-2-13**] 06:50AM BLOOD Plt Ct-130*
[**2140-2-14**] 03:10AM BLOOD Plt Ct-116*
[**2140-2-15**] 07:00AM BLOOD Plt Ct-125*
[**2140-2-17**] 06:30AM BLOOD PT-13.0* PTT-31.8 INR(PT)-1.2*
[**2140-2-22**] 06:20AM BLOOD PT-13.3* PTT-31.3 INR(PT)-1.2*
[**2140-2-23**] 05:50AM BLOOD Plt Ct-116*
[**2140-2-15**] 07:00AM BLOOD Glucose-90 UreaN-13 Creat-0.7 Na-138
K-4.0 Cl-95* HCO3-37* AnGap-10
[**2140-2-16**] 07:00AM BLOOD UreaN-18 Creat-0.8 Na-140 K-4.1 Cl-98
HCO3-36* AnGap-10
[**2140-2-17**] 06:30AM BLOOD Glucose-92 UreaN-19 Creat-0.8 Na-138
K-4.0 Cl-95* HCO3-35* AnGap-12
[**2140-2-18**] 06:45AM BLOOD Glucose-80 UreaN-20 Creat-0.8 Na-134
K-7.0* Cl-96 HCO3-24 AnGap-21*
[**2140-2-18**] 09:20AM BLOOD UreaN-18 Creat-0.6 Na-139 K-3.9 Cl-95*
HCO3-35* AnGap-13
[**2140-2-19**] 07:40AM BLOOD Glucose-91 UreaN-19 Creat-0.6 Na-137
K-3.8 Cl-96 HCO3-37* AnGap-8
[**2140-2-20**] 06:45AM BLOOD Glucose-93 UreaN-17 Creat-0.5 Na-139
K-3.9 Cl-95* HCO3-38* AnGap-10
[**2140-2-21**] 05:50AM BLOOD Glucose-90 UreaN-19 Creat-0.6 Na-138
K-3.8 Cl-94* HCO3-36* AnGap-12
[**2140-2-22**] 06:20AM BLOOD Glucose-92 UreaN-18 Creat-0.6 Na-138
K-3.9 Cl-92* HCO3-40* AnGap-10
[**2140-2-23**] 05:50AM BLOOD Glucose-92 UreaN-14 Creat-0.6 Na-140
K-4.0 Cl-94* HCO3-39* AnGap-11
[**2140-2-16**] 07:00AM BLOOD ALT-31 AST-37 AlkPhos-58 TotBili-0.9
[**2140-2-23**] 05:50AM BLOOD WBC-5.8 RBC-6.37* Hgb-14.8 Hct-45.9
MCV-72* MCH-23.2* MCHC-32.2 RDW-14.2 Plt Ct-116*
[**2140-2-22**] 06:20AM BLOOD PT-13.3* PTT-31.3 INR(PT)-1.2*
[**2140-2-12**] 07:30AM BLOOD TSH-2.9
[**2140-2-11**] 06:34AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2140-2-12**] 07:30AM BLOOD HIV Ab-NEGATIVE
[**2140-2-11**] 11:18AM BLOOD Type-[**Last Name (un) **] pO2-192* pCO2-81* pH-7.28*
calTCO2-40* Base XS-8
[**2140-2-11**] 09:03PM BLOOD Type-ART pO2-45* pCO2-67* pH-7.45
calTCO2-48* Base XS-18
[**2140-2-11**] 11:57PM BLOOD Type-ART pO2-88 pCO2-73* pH-7.37
calTCO2-44* Base XS-12
[**2140-2-16**] 02:41AM BLOOD Type-ART pO2-88 pCO2-78* pH-7.29*
calTCO2-39* Base XS-7
[**2140-2-13**] Hgb Electrophoresis:
RED BLOOD CELL COUNT 5.99 H 4.20-5.80
Million/uL
HEMOGLOBIN 14.1 13.2-17.1 g/dL
HEMATOCRIT 46.0 38.5-50.0 %
MCV 76.8 L 80.0-100.0 fL
MCH 23.6 L 27.0-33.0 pg
RDW 16.2 H 11.0-15.0 %
HEMOGLOBIN A 95.6 L >96.0 %
HEMOGLOBIN F <1.0 <2.0 %
HEMOGLOBIN A2 ([**Doctor Last Name **]) 3.4 1.8-3.5 %
HEMOGLOBIN S DNR %
HEMOGLOBIN C DNR %
HEMOGLOBIN E DNR %
OTHER HEMOGLOBIN 1 DNR
OTHER HEMOGLOBIN 2 DNR
INTERPRETATION Possible beta thalassemia trait
Micro:
[**2140-2-11**] 12:00 am BLOOD CULTURE (Final [**2140-2-17**]): NO GROWTH.
[**2140-2-11**] 12:15 am BLOOD CULTURE Final [**2140-2-17**]): NO GROWTH.
[**2140-2-11**] 1:30 pm Legionella Urinary Antigen (Final [**2140-2-12**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
[**2140-2-11**] 5:08 pm SPUTUM GRAM STAIN (Final [**2140-2-11**]): >25 PMNs
and >10 epithelial cells/100X field.
[**2140-2-13**] 10:00 pm MRSA SCREEN (Final [**2140-2-16**]): No MRSA
isolated.
Imaging:
[**2140-2-10**] CTA CHEST WITH AND WITHOUT CONTRAST The aorta is normal
in caliber throughout without acute pathology. Allowing for
significant limitation by body habitus, the pulmonary arterial
tree is opacified to the subsegmental level without definite
filling defect to suggest pulmonary embolism. The main pulmonary
artery is dilated to 4.5 cm, suggestive of pulmonary arterial
hypertension. The heart is mildly enlarged without pericardial
effusion. There is ill-defined opacity in the right upper lobe
(2, 28), suggestive of infection. Remainder of the lungs appear
reasonably aerated. There is no pleural effusion. Limited
subdiaphragmatic evaluation demonstrates no definite visceral
abnormality, although evaluation is highly limited. BONE WINDOW:
No definite concerning lesion. There is mild multilevel thoracic
spondylosis and disc space narrowing, consistent with mild
degenerative change. IMPRESSION: 1. No evidence of pulmonary
embolism. 2. Right upper lobe pneumonia. 3. Pulmonary arterial
hypertension as evidenced by main pulmonary artery dilated to
4.5 cm.
[**2140-2-11**] ECHO: The left atrium is moderately dilated. There is
mild symmetric left ventricular hypertrophy with normal cavity
size. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is low normal (LVEF 50-55%). There is no
ventricular septal defect. The right ventricular cavity is
moderately dilated with severe global free wall hypokinesis. The
number of aortic valve leaflets cannot be determined. There is
no aortic valve stenosis. Trace aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion. IMPRESSION: Mild
symmetric left ventricular hypertrophy with low-normal LV
systolic function. Moderate to severe right ventricular
dilatation with global moderate to severe hypokinesis. Moderate
to severe pulmonary hypertension. No ASD/PFO seen but cannot
exclude on the basis of this study.
[**2140-2-13**] RUQ US: 1. Enlarged, coarsened liver echotexture,
possibly secondary to fat deposition, although more advanced
disease such as cirrhosis and/or fibrosis cannot be excluded. 2.
Splenomegaly. 3. No ascites.
[**2140-2-16**] spirometry: Mechanics: The FVC is moderately reduced.
The reduction in FEV1 is moderately severe. The FEV1/FVC ratio
is within normal limits. Flow-Volume Loop: Moderate restrictive
pattern with mildly reduced flows overall. Lung Volumes: The
TLC is mildly to moderately reduced. The FRC is moderately
reduced. The RV is normal. The RV/TLC ratio is elevated. DLCO:
The Diffusing Capacity corrected for hemoglobin is within normal
limits. Impression: Mild to moderate restrictive ventilatory
defect. An obstructive component cannot be excluded. The
preserved DLCO suggests an extraparenchymal process. There are
no prior studies available for comparison.
[**2140-2-16**] CHEST XRAY: Mild to moderate pulmonary edema, lower lung
volumes and radiographic evidence of pulmonary hypertension.
[**2140-2-19**] Echo: The left atrium is dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF 70%). The right ventricular free wall is hypertrophied.
The right ventricular cavity is markedly dilated with severe
global free wall hypokinesis. There is abnormal septal
motion/position consistent with right ventricular
pressure/volume overload. 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 no mitral valve prolapse. Trivial
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. The supporting structures of the tricuspid
valve are thickened/fibrotic. There is severe pulmonary artery
systolic hypertension. There is no pericardial effusion.
[**2140-2-22**] Cardiac cath: 1. Limited resting hemodynamics revealed
high normal left-sided filling pressures with PCWP of 12mmHg.
There was pulmonary arterial hypertension with a PASP of 62mmHg.
The pulmonary vascular resistance was 419 dynes-sec/cm5. The
cardiac index was normal at 2.3 L/min/m2. There was no evidence
of left to right or right to left shunting. 2. Treatment with
100% FiO2 demonstrated no significant change in the PVR or PCWP
(15mmHg). PASP remained elevated at 54mmHg (mean 41mmHg.) 3.
Similarly treatment with iNO demonstrated no change in the PVR
or PCWP (13mmHg). PASP remained elevated at 62mmHg (mean
45mmHg). FINAL DIAGNOSIS: 1. Severe primary pulmonary
hypertension with high-normal left-sided filling pressures
consistent with pulmonary hypertension independent of LV
failure. 2. No significant response to inhaled vasodilator.
[**2140-2-22**] CT CHEST W/O CONTRAST: Mediastinal, axillary and hilar
lymph nodes do not meet CT size criteria for pathology. The main
pulmonary artery is dilated to 4.5 cm, suggestive of pulmonary
arterial hypertension. There is no evidence of pericardial
effusion. There is mild cardiomegaly. The aorta is normal in
caliber. Previously noted ground-glass opacity within the right
upper lobe is no longer visualized. No focal areas of
consolidation are identified. There is no evidence of pleural
effusion. IMPRESSION:
1. Main pulmonary artery is dilated to 4.5 cm consistent with
history of
pulmonary arterial hypertension. 2. Resolution of previously
noted ground-glass opacity. No new focus of consolidation or
evidence of interstitial lung disease.
Brief Hospital Course:
36 year old male with history of morbid obesity who presented
with dyspnea and cough found to be hypoxemic with obesity
hypoventilation syndrome, obstructive sleep apnea, hypertension
and severe pulmonary artery hypertension complicated by right
heart failure.
# Pulmonary hypertension with right heart failure: Likely
secondary to longstanding and severe OSA and obestity
hypoventilation syndrome with subsequent severe pulmonary
hypertension complicated by right heart failure. He was
initially treated for CAP with ceftriaxone and azithro given a
RML infiltrate seen on CT chest. CT chest also demonstrated a
pulmonary artery of 4.5cm. Echo revealed an extremely high TR
gradient of 56 and right heart dilatation. He was profoundly
volume overloaded on initial presentation. Aggressive diuresis
was started with furosemide 20mg IV TID with a large response.
Acetazolamide was added to counteract an increasing contraction
alkalosis with good effect. This was stopped without issue
after a few days as it caused his pCO2 to rise. Then his
furosemide was uptitrated to 40mg IV TID and spironolactone 25
mg PO daily was added. He walked the halls multiple times per
day and wrapped his legs tightly with ACE wraps. His weight
upon admission was 418 pounds, and his weight prior to cardiac
catheterization was 348lbs. His creatinine was stable at
0.8-1.0 during this time. Repeat echo revealed a higher TR
gradient of 70, unchanged right heart dilatation, with abnormal
septal wall motion and position. He went for right heart cath
on [**2140-2-22**] which revealed severe pulmonary hypertension with a
PASP of 54, a normal wedge of 12, and a failed vasodilator
study. [**Doctor First Name **], HIV, and TSH were all negative. He was followed
closely by cardiology and will follow up with Dr. [**Last Name (STitle) 911**] as an
outpatient. He will participate in cardiopulmonary rehab as an
outpatient.
# OHS/OSA: CPAP was initiated on the floor on the second night
of his hospital stay but he desaturated to the 50's with this
mask on. This is felt secondary to severe OHS despite CPAP
being able to stent open his airway. He had initiated on BiPAP
in the MICU with continued desaturations. He was transferred
back to the floor the next morning. His Bipap settings were
titrated to 22/12 with a back up autoset rate of 12. His
desatturations improved with this I:E of 10. He takes
approximately 10 breaths per minute for an overall rate of
approximately 22. He was followed closely by the
sleep/pulmonary consult and will follow up with Dr. [**First Name (STitle) 1833**] as an
outpatient. He was set up for home Bipap, oxygen, and O2
monitoring.
# Hypertension: Initially presented with diastolic hypertensive
urgency with DBP's in the 120's. He was short of breath and
agitated. His blood pressures quickly improved with afterload
reduction including amlodipine, lisinopril, diuresis, and BiPap.
# Thrombocytopenia: Thought secondary to sequestration with
splenomegaly evident on CT. RUQ u/s confirmed splenomegaly and
a liver with a coarse heterogenous echotexture. Needs liver
follow up to rule out and/or treat cirrhosis.
# TRANSITIONAL ISSUES:
-Outpatient sleep study with MD
-Outpatient liver evaluation with potential biopsy
-Repeat Echo 8-12 weeks to evaluate improvement and consider
potential repeat cardiac cath to retrial vasodilators
-Code status: Full
-Contacts: mother, brother
Medications on Admission:
- Furosemide 20 mg IV TID
- Azithromycin 250 mg PO/NG Q24H
- Amlodipine 5 mg PO/NG DAILY
- Heparin 5000 UNIT SC TID
- CeftriaXONE 1 gm IV Q24H
- Captopril 100 mg PO/NG TID
- AcetaZOLamide 250 mg PO/NG Q12H
- Lisinopril 40 mg PO/NG DAILY
Discharge Medications:
1. Bipap: Bipap 20/10 with a backup rate of 12, with 10L
supplemental oxygen, with heated humidification. Dx obesity
hypoventilation and pulmonary hypertension.
2. oxygen: 4-6 liters continuous oxygen. Please evaluate for
pulse dose system. Dx obesity hypoventilation and pulmonary
hypertension.
3. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
6. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. Outpatient Lab Work: Check electrolytes (chem 7) on Thursday,
[**2-25**] and have the results faxed to Dr. [**Last Name (STitle) 18323**] at
[**Telephone/Fax (1) 18324**].
8. Outpatient Physical Therapy: Outpatient physical therapy for
cardiopulmonary rehab
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Pulmonary Hypertension, Hypertension,
Obstructive sleep apnea, Obesity Hypoventilation Syndrome,
Thrombocytopenia, Splenomegaly
Secondary Diagnosis: Obesity
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of while you were here at [**Hospital1 18**].
Your were admitted to the hosiptal for shortness of breath. You
were diagnosed with pulmonary hypertension, right sided heart
failure with fluid overload. You were then started on diuretics
to help you urinate more and decrease the amount of fluid that
had built up in your body. You were also given a sleeping mask
to help improve your oxygen levels while sleeping. Your
shortness of breath and your oxygen levels at night during sleep
improved with these interventions.
Changes to medications while hospitalized:
START Amlodipine 10 mg PO DAILY
START Furosemide 80 mg PO BID
START Lisinopril 20 mg PO DAILY
START Spironolactone 25 mg PO DAILY
Followup Instructions:
Please attend the following appointments that were amde for you:
Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Address: [**Street Address(2) 4472**],[**Apartment Address(1) 24519**], [**Hospital1 **],[**Numeric Identifier 9331**]
Phone: [**Telephone/Fax (1) 18325**]
Appointment: Tuesday [**2140-3-1**] 2:30pm
Department: CARDIAC SERVICES
When: WEDNESDAY [**2140-3-9**] at 3:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PULMONARY FUNCTION LAB
When: MONDAY [**2140-5-2**] at 3:40 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: MONDAY [**2140-5-2**] at 4:00 PM
With: DR. [**First Name (STitle) **] / DR. [**Last Name (STitle) 611**] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
*You have been placed on a cancellation list. The office will
contact you at home if a sooner appointment becomes available.
If you have any questions or concerns please call the office at
the above number.
|
[
"287.5",
"429.3",
"416.0",
"278.03",
"327.23",
"459.81",
"278.01",
"428.33",
"401.9",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.23",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
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|
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|
322, 366
|
20394, 20394
|
4212, 4219
|
21291, 22743
|
2559, 2756
|
19188, 20071
|
20194, 20194
|
18926, 19165
|
14487, 15449
|
20544, 21268
|
2771, 2778
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20089, 20144
|
3610, 4193
|
1872, 2110
|
262, 284
|
394, 1853
|
20363, 20373
|
20213, 20342
|
4233, 14470
|
20409, 20520
|
18655, 18900
|
2132, 2256
|
2272, 2543
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,172
| 185,205
|
49076+59140
|
Discharge summary
|
report+addendum
|
Admission Date: [**2109-3-9**] Discharge Date: [**2109-3-21**]
Date of Birth: [**2055-11-20**] Sex: M
Service: MEDICINE
Allergies:
Heparin Agents / Penicillins / Aspirin / Ibuprofen /
Ciprofloxacin
Attending:[**First Name3 (LF) 949**]
Chief Complaint:
EKG changes
Major Surgical or Invasive Procedure:
temporary pacer placed
History of Present Illness:
53yoM with h/o EtOH cirrhosis, colon cancer s/p colectomy, HTN,
Hypercholesterolemia who was transferred from [**Location (un) 745**]-Wellesly ED
for further evaluation of EKG changes. He initially presented to
N-W ED this afternoon with complaints of lower abdominal
distension and discomfort and inability to urinate despite
feeling like he had to go. He denied N/V. No fevers/chills. No
dysuria/hematuria, but +inability to void x1 day. In the ED
there, a foley catheter was placed with 1600cc UOP and complete
resolution of his discomfort. An EKG performed there, however,
revealed new TWIs from old EKG and because he gets most of his
medical care here at [**Hospital1 18**], he was transferred to our ED for
further evaluation. He denies CP/palpitations. He has mild SOB
which he notes with "fluid builds up in his belly". No
lightheadedness/dizziness/diaphoresis.
.
Of note, he was admitted from [**Date range (1) 102991**] to [**Hospital1 18**] at which
time he was treated for bacterial and candidal peritonitis,
diagnosed with HRS transiently on CVVH and discharged to rehab
on midodrine/octreotide/daily albumin. He was seen in outpatient
f/u in liver clinic on [**2109-3-1**] at which time albumin was
discontinued, but octreotide and midodrine were continued.
.
In our ED, he was noted to have a UTI and was started on
ceftriaxone (was chronically on cipro for SBP ppx). He was
admitted to medicine team for ROMI. The next morning, he was
noted on telemetry to episode of torsades noted in the setting
of a potassium of 3.6 and magnesium of 1.5. The episode lasted
for 30seconds and patient was asymptomatic with stable BP per
report. Review of the EKGs from [**Location (un) 20026**] Hospital showed
QTc of 600. EKGs from after episode this morning show QTc back
to 550 range.
.
He was transferred to the CCU and the EP fellow and attending
placed a temporary pacing wire.
Past Medical History:
-ETOH cirrhosis - has h/o ascites,pleural effusions, multiple
prior taps, had been on prophylactic ofloxacin
-colon cancer s/p colectomy last month
-C. diff infection (still on po vanc)
-HTN
-hypercholesterolemia
-esophageal varices
-cervical stenosis - s/p several vertebral fracture after a fall
Social History:
Lives with wife and daughter in [**Name2 (NI) **], denies ETOH for past 4
years, Tobacco: [**Date range (1) 61126**] PPD x 30 years, denies h/o IVDA; not
currently working as disabled, used to work as construction
worker.
Family History:
Denies fhx of early MI, stroke, cancer
Physical Exam:
VS: T 97.3, BP 111/68, HR 79, RR 14, O2 94% on RA
Gen: WDWN middle aged male in NAD, resp or otherwise. Oriented
x3.
HEENT: NCAT. PERRL, EOMI.
Neck: Supple with JVP of 12 cm.
CV: RR, normal S1, S2. No murmurs or rubs
Chest: CTA anteriorly and laterally
Abd: distended with positive fluid wave, mild tenderness to deep
palpation throughout
Ext: No c/c/e. 2+ DP pulses bilaterally.
Neuro: A&O x3. CN 3-12 intact grossly. Light touch sensation
intact in feet bilaterally.
No asterixis
Brief Hospital Course:
53 yo M with ETOH cirrhosis, HTN and history of SBP on cipro ppx
who presents with urinary retention and now torsades/VT presumed
[**12-29**] quinolone use.
.
# Rhythm: Patient presented with QTc of 600. Old EKGs had normal
QTc. He was on cipro ppx for SBP and recently started on
midodrine and octreotide, and octreotide can cause a prolonged
QT. He also had low normal potassium and magnesium. In this
setting patient had a thirty second episode of torsades but was
asymptomatic. It is likely that the prolonged QT is from the
medications and exacerbated from electrolytes being suboptimal.
The patient was transfered to the CCU for further monitoring,
where a temporary pacer was placed to increase HR and shorten
QT. In addition, with repletion of K to 4.5 and Mg to 2.5,
along with cessation of QT prolonging agents, the patient's QT
interval trended back to his baseline. After monitoring for 24
hours, the patients temporary pacer was removed. The patient
was then transfered to the floor. He remained in normal sinus
rhythm with a normal QT on serial EKGs. He has been without
chest pain, palpitations, or shortness of breath. He was
discharged on Magnesium supplements.
.
# CAD/Ischemia: Pt has no known ischmic heart disease but had
risk factors of HTN, hypercholesterolemia. Stress ECHO recently
was normal. He initially presented with diffuse TWI from prior
with prolonged QT; however, he ruled out for MI with flat
troponins. TWI resolved after correction of QT abnormalities.
.
# Hypercholesterolemia: Despite history of high cholesterol, he
is not on statin given his liver disease.
.
# UTI: The patient had urine growing enterococcus, but was
afebrile and with normal WBC. He was intially started on
vancomycin, but when cultures returned as VRE, he was switched
to doxycycline then to tetracycline to complete 7 days.
Linezolid was considered, but given thrombyocytopenia, it was
avoided. Urine cultures were negative after starting
tetracycline.
.
# ETOH cirrhosis: Pt has previously been onthe transplant list.
The patient's lactulose, rifaximin, docusate, and senna were
continued. He was begun on keflex for SBP prophylaxis, as his
ciprofloxacin was discontinued due to its QTc prolonging
properties. After call out from CCU, patient transfered to
hepatorenal service. He underwent 2 therapeutic paracenteses,
last one on [**3-19**] with removal of 4.5 L of fluid. He received
albumin with each paracetnesis. He did not have SBP. Given the
improvement in his creatinine, he was started on low dose
furosemide 20 mg and spironolactone 50 mg daily. He will f/u
with Dr. [**Last Name (STitle) 497**].
.
# Hepatorenal syndrome: Pt's creatinine started to trend down.
Once his creatinine reached <1.5, his midodrine was stopped as
well. He was started on low dose diuretics furosemide and
spironolactone.
.
# Depression: Sertraline was held given conduction
abnormalities. He should follow up with his PCP.
.
# FEN: low sodium diet, Ensure Plus supplements 6x/day to meet
>[**2100**] calories/day
.
# Full Code
Medications on Admission:
From home Per OMR d/c summary
Sertraline 100 mg PO DAILY
Folic Acid 1 mg PO DAILY
MVI daily
Trazodone 50 mg PO HS prn
Docusate Sodium 100 mg PO BID
Senna 8.6 mg PO BID prn
Lactulose 30 ML PO TID
Thiamine HCl 100 mg PO DAILY
Rifaximin 400 mg PO TID
Midodrine 15 mg PO TID
Octreotide Acetate 200 mcg Q8H
Pantoprazole 40 mg PO daily
Ciprofloxacin 250 mg PO daily
Discharge Medications:
1. Tetracycline 250 mg Capsule Sig: Two (2) Capsule PO Q12H
(every 12 hours) for 2 days.
2. Cephalexin 250 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
3. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
4. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
10. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
11. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
12. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation four times a day.
13. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Spironolactone 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 169**] Center- [**Hospital1 8218**]
Discharge Diagnosis:
Primary:
Torsade [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]
.
Secondary:
Urinary retention
Alcoholic cirrhosis
Ascites
Hepatorenal syndrome
Urinary tract infection
Discharge Condition:
Stable
Discharge Instructions:
You were transferred to [**Hospital1 18**] for an irregular heart rhythm.
This was likely due to the antibiotics you were receiving for
your urinary tract infection. You are now off of that
antibiotics and your heart rhythm is now normal.
.
You also had concerns of inability to urinate. You have been
started on Tamsulosin for your urinary retention. You will need
to follow up with Urology to remove your Foley.
.
Please take your medications as directed. You will need one
more day of tetracycline for you urinary tract infection. You
will also need to take Keflex instead of ciprofloxacin to
prevent an abdominal infection. Keflex is less likely to give
you an irregular heart rhythm. Your kidney function has
improved, you no longer need to take midodrine and octreotide.
Your sertraline has also been held because it may give you an
irregular heart rhythm. Please follow up with Dr. [**Last Name (STitle) 29994**] as to
if and when you need to restart this.
.
You have also been started on diruetics (medications that make
you urinate) to help prevent the accumulation of fluid in your
abdomen. These diuretics are called Lasix (furosemide) and
Aldactone (spironolactone). You will need to follow up with Dr.
[**Last Name (STitle) 497**] regarding these medications.
.
Please keep your appointments as scheduled.
.
If you develop fever, abdominal pain, nausea/vomiting, bladder
issues, or any other concerning symptoms, please call your
primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 29994**] at [**Telephone/Fax (1) 33431**].
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 497**] of Liver [**Hospital 1326**] Clinic. An
appointment has been made for you for [**2109-3-27**] at 11AM. The
clinic number is ([**Telephone/Fax (1) 3618**].
.
Please also follow up with Dr. [**Last Name (STitle) 261**] in Urology in [**11-28**] weeks.
Please call for an appointment ([**Telephone/Fax (1) 4276**].
.
Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 29994**]
within 4 weeks. The clinic number is [**Telephone/Fax (1) 33431**].
.
Please also keep the following appointments:
Provider: [**Name10 (NameIs) 1382**] [**Name11 (NameIs) 1383**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2109-6-3**] 9:30
Name: [**Known lastname 16638**],[**Known firstname **] Unit No: [**Numeric Identifier 16639**]
Admission Date: [**2109-3-9**] Discharge Date: [**2109-3-21**]
Date of Birth: [**2055-11-20**] Sex: M
Service: MEDICINE
Allergies:
Heparin Agents / Penicillins / Aspirin / Ibuprofen /
Ciprofloxacin
Attending:[**First Name3 (LF) 11616**]
Addendum:
Addendum to Brief Hospital Course:
# Stage I pressure ulcer: This was treated with barrier cream
and duoderm dressing, turning and repositioning, and use of an
air mattress.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 1353**] Center- [**Hospital1 **]
[**Name6 (MD) **] [**Last Name (NamePattern4) **] MD [**MD Number(1) 7895**]
Completed by:[**2109-4-12**]
|
[
"789.59",
"311",
"788.29",
"571.2",
"041.04",
"V10.05",
"E931.3",
"272.0",
"401.9",
"707.05",
"599.0",
"427.1",
"572.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.78"
] |
icd9pcs
|
[
[
[]
]
] |
11400, 11606
|
11237, 11377
|
338, 362
|
8434, 8443
|
10065, 11214
|
2858, 2898
|
6884, 8114
|
8232, 8413
|
6500, 6861
|
8467, 10042
|
2913, 3397
|
287, 300
|
390, 2279
|
2301, 2602
|
2618, 2842
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,745
| 145,211
|
37170
|
Discharge summary
|
report
|
Admission Date: [**2189-4-21**] Discharge Date: [**2189-6-26**]
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Respiratory failure, anuria
Major Surgical or Invasive Procedure:
Foley exchange
Gastric tube exchange
Placement of PICC line
History of Present Illness:
[**Age over 90 **]yo M with h/o anoxic brain injury [**2-11**] cardiac arrest, trach
(on vent at home) and peg, presenting from [**Hospital 8**] Hospital
with bilateral pneumonia found to be hypothermic now s/p Vanc.
His family (wife and 2 daughters) are providing all of his care
at home. He has had issues with tracheobronchomalacia and has
had several trach replacements in the past. The family was
concerned when he started experiencing tremulousness, cough, low
urine output and respiratory distress so they brought him to
[**Hospital 8**] Hospital. This morning they transferred him here to
[**Hospital1 18**].
.
Of note patient, had a similar admission to [**Hospital Unit Name **] [**8-19**] c/b
bactermia, MRSA UTI hypoxemia induced VT, ARF, hyponatremia,
copious secretions, and difficult vent weaning and was
discharged HOME with SERVICES. He is followed here loosely by
pulmonary at [**Hospital1 18**] but it is clear that they do not feel
comfortable having him do vent weaning at home.
.
In the ED, initial vs were 90 143/72 12 100% vent. Pt
transferred from OSH with bil pna, found to be hypothermic temp
92.7 rectal, became bradycardic HR 30s(with suctioning), rec'd
atropine at 0330, rec'ing vanco. Responded to Atropine 0.5. Na+
121 K+ 6 Cr 5.5(1.8-2 [**Hospital1 5348**]). EKG: NSR@71 LAD no change
prior, no peaked TW. pCXR: bilat infiltrates, broadened to
Zosyn, 2 IVF, SCL placed. pH 7.06 pCO2 50 pO2 374 HCO3 15 BaseXS
-16. Labs notable for wbc of 16.9, hct 23.6 Na:124 K:5.3 Cl:96
Glu:245 Lactate:1.4. Vent set FiO2%:100; AADO2:297; Req:55;
Rate:/12; AC. He received Piperacillin-Tazob, Albuterol Inhaler
(ProAir) 8.5 g and Lorazepam 2mg/mL x2. BP dropped in ED to
60/40 turned fluids up at VS 115/41 60 100% on 50% CMV PEEP 5,
Peaks pressures in 40s, TV 500, rate of 16(from 12 before gas).
FULL CODE. Received 3LIVF. Scrotum enlarged, challenging foley
placement, pus came out from penis, got it, made NO urine. Cr
5.5 at OSH. No treatment for hyperkalemia.
.
Upon arrival to the ICU, patient noted to be arousable to
painful stimuli and to have facial twitching intermittantly.
Famiy at bedside communicates recent admission to hospital for
hemorrhoids, Gtube being dislodged and anuria. Reports that he
had hospital eval for anuria and foley was dislodged. They
attribute that foley incident to his decline recently. Per their
report, he has not urinated in 5 days. They feel he is off his
[**Hospital1 5348**] mental status and can sometimes talk to dtr.
.
Review of sytems:
Could not be obtained
Past Medical History:
Paroxysmal Atrial fibrillation
Parkinson's disease
Chronic respiratory failure, trached ventilator dependent (due
to aspiration PNA/cardiac arrest in [**1-17**] at [**Hospital 8**] Hospital)
Anoxic brain injury [**2-11**] cardiac arrest
DMII
CKD
Tracheobronchomalacia
h/o C. Difficile
Chronic foley due to massive inoperable inguinal hernia
Hypothyroidism
VT induced hypoxemia [**8-19**]
Social History:
Family denies any illicits (neg tobacco use, neg alcohol use or
VDU).
Family History:
no history of pulmonary or cardiac disease
Physical Exam:
On admission:
Vitals: 93.3 81 113/96 99 17 100% on CMV 500 RR 16 FiO2 of 100%
Peep 5, CVP 14
General: Pt is lying in bed - opens eyes on verbal and painful
stimulus, withdraws arm to touch, unable to follow commands or
speak.
HEENT: No oral lesions apparent
Neck: trach in place, JVP not elevated, no LAD
Lungs: Rhonchi appreciated bilaterally
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, large R inguinal hernia with
catheter present.
GU: Foley in place with scrotom extremely enlarged
Ext: warm, well perfused, 2+ pulses, no edema, legs contracted
b/l.
Skin:intact
Pertinent Results:
LABORATORY DATA:
[**2189-4-21**] (ADMISSION):
-WBC-16.9* RBC-2.50* Hgb-7.3* Hct-23.6* MCV-94 MCH-29.2
MCHC-31.1 RDW-14.0 Plt Ct-288 Neuts-87* Bands-4 Lymphs-4*
Monos-4 Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0
-PT-13.0 PTT-35.3* INR(PT)-1.1
-Glucose-252* UreaN-156* Creat-5.4* Na-123* K-5.5* Cl-91*
HCO3-12* 0
-ALT-25 AST-28 LDH-227 AlkPhos-170* TotBili-0.1
-Albumin-2.1* Calcium-6.6* Phos-7.1* Mg-1.5*
-Hapto-223* calTIBC-166* Ferritn-1248* TRF-128*
-TSH-1.9
-Cortsol-40.0*
Last set of labs:
[**2189-6-23**]
Na 120, K 5.5 Cl 86 HCO3 16 BUN 258 Cr 8.5 Glu 144
Ca 7.8 Mg 2.4 Phos 9.5
WBC 23.2 Hgb 7.8 Hct 24.3 Plt 279
Neuts-89 Bands-0 Lymphs-3 Monos-6 Eos-2 Nrbc-1
URINE:
[**2189-5-26**] 12:37PM URINE RBC-6* WBC-22* Bacteri-NONE Yeast-MANY
Epi-0
[**2189-5-26**] 12:37PM URINE Blood-SM Nitrite-POS Protein-100
Glucose-150 Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
DISCHARGE:
[**2189-5-31**] 04:11AM BLOOD WBC-10.4 RBC-3.03*# Hgb-9.4*# Hct-27.0*
MCV-89 MCH-31.1 MCHC-34.8 RDW-16.3* Plt Ct-188
[**2189-6-1**] 03:09AM BLOOD Creat-6.8* Na-138 K-3.3 Cl-97
[**2189-5-15**] 03:10AM BLOOD calTIBC-126* Hapto-162 Ferritn-741*
TRF-97*
MICROBIOLOGY:
[**4-21**] Sputum mixed gram neg rods, proteus
[**4-21**] Urine legionella negative
[**4-21**] Urine culture (concerning for ESBL)
URINE CULTURE (Preliminary):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- =>64 R
CEFTAZIDIME----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 128 R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
[**2189-4-29**] 10:34 am SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2189-4-29**]):
[**11-3**] PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): YEAST(S).
STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA. HEAVY
GROWTH.
RESISTANT TO TIMENTIN (>64 MCG/ML).
Intermediate TO CHLORAMPHENICOL (16 MCG/ML).
SUSCEPTIBLE TO MINOCYCLINE sensitivity testing
performed by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in MCG/ML
_______________________________________________________
STENOTROPHOMONAS (XANTHOMONAS)
MALTOPHILIA
| PSEUDOMONAS AERUGINOSA
| |
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- =>16 R 4 S
CIPROFLOXACIN--------- <=0.25 S
GENTAMICIN------------ 8 I
LEVOFLOXACIN---------- <=1 S
MEROPENEM------------- <=0.25 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**2189-5-15**] H. pylori negative
[**2189-5-26**] Urine culture- aerobic culture negative, fungal culture
with [**First Name5 (NamePattern1) 564**] [**Last Name (NamePattern1) 10577**]
[**2189-6-14**] 4:48 pm SPUTUM Site: ENDOTRACHEAL
Source: Endotracheal.
**FINAL REPORT [**2189-6-20**]**
GRAM STAIN (Final [**2189-6-14**]):
[**11-3**] PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final [**2189-6-20**]):
HEAVY GROWTH Commensal Respiratory Flora.
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup will be performed appropriate to the isolates
recovered from
this site.
IDENTIFICATION AND SUSCEPTIBILITY REQUESTED BY DR.[**First Name8 (NamePattern2) 6715**]
[**Doctor Last Name **] ON
[**2189-6-17**].
STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA. HEAVY
GROWTH.
Intermediate TO CHLORAMPHENICOL , MIC= 16 MCG/ML.
RESISTANT TO TIMENTIN , MIC > 64 MCG/ML.
PROTEUS MIRABILIS. HEAVY GROWTH. PRESUMPTIVE
IDENTIFICATION.
Piperacillin/tazobactam sensitivity testing available
on request.
ACINETOBACTER BAUMANNII COMPLEX. 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".
KLEBSIELLA PNEUMONIAE. SPARSE GROWTH.
WARNING! This isolate is an extended-spectrum
beta-lactamase
(ESBL) producer and should be considered resistant to
all
penicillins, cephalosporins, and aztreonam. Consider
Infectious
Disease consultation for serious infections caused by
ESBL-producing species.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STENOTROPHOMONAS (XANTHOMONAS)
MALTOPHILIA
| PROTEUS MIRABILIS
| | ACINETOBACTER
BAUMANNII COM
| | |
KLEBSIELLA PNEUM
| | | |
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I <=2 S =>32 R
CEFAZOLIN------------- 8 S =>64 R
CEFEPIME-------------- <=1 S 8 S R
CEFTAZIDIME----------- =>16 R <=1 S =>64 R =>64 R
CEFTRIAXONE----------- <=1 S R
CIPROFLOXACIN--------- =>4 R =>4 R =>4 R
GENTAMICIN------------ 8 I =>16 R <=1 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- <=1 S =>8 R
MEROPENEM------------- <=0.25 S <=0.25 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ 2 S <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=2 S =>16 R 2 S =>16 R
[**2189-6-17**] 6:52 pm STOOL
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2189-6-18**]):
Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2189-6-18**] @ 7:15
AM.
CLOSTRIDIUM DIFFICILE.
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
(Reference Range-Negative).
A positive result in a recently treated patient is of
uncertain
significance unless the patient is currently
symptomatic
(relapse).
IMAGING:
CT Abd/pelvis [**4-21**]
1. Bibasilar airspace consolidation, findings suggestive of
pneumonia or
aspiration.
2. Large indirect left inguinal hernia, with small and large
bowel along with mesenteric fat identified within the left
hemiscrotum.
3. Normal non-contrast appearance of the kidneys.
4. Extensive atherosclerotic disease.
Renal ultrasound [**4-21**]:
Limited study. No definite hydronephrosis in the right kidney.
Left kidney not seen.
CXR [**4-26**]
Frontal view of the chest demonstrates tracheostomy in midline.
Left-sided
catheter terminates at the brachiocephalic SVC junction. There
are bilateral pleural effusions, left greater than right. There
is bibasilar atelectasis. Heart and mediastinum are stable.
CXR [**5-30**]
As compared to the prior study, tracheostomy is in place, right
PICC line tip is at the level of mid low SVC. Left lower lobe
atelectasis is unchanged. There is no evidence of interval
development of new consolidations. Minimal interstitial
engorgement cannot be excluded. Bilateral pleural effusions are
most likely present.
Liver/gallbladder ultrasound [**6-16**]
The gallbladder wall is mildly thickened however this is likely
related to it being partially collapsed. No pericholecystic
fluid is present. No gallstones are identified. There is no
biliary dilatation. No focal liver abnormality is present. The
common bile duct maximally measures 3.4 mm. No evidence of
gallstones or cholecystitis.
CT abdomen/pelvis [**6-17**]
1. Pulmonary parenchymal collapse, bilateral diffuse infiltrates
and
left-sided free layering pleural effusion. Findings have
progressed when
compared to the chest images from the abdominal CT of [**2189-4-21**].
2. Multiple chronic findings as described above. However, there
is no
finding to suggest an etiology for this patient's liver function
abnormalities
or leukocytosis.
3. Multiple chronic findings include anasarca, atherosclerotic
disease,
bilateral probable nephrolithiasis, adrenal adenomas, and
degenerative disc and degenerative joint disease of the spine.
4. Diffuse permeative appearance of the bony structures. Though
this may be seen in osteopenia, an infiltrative process such as
multiple myeloma can also present with such an appearance, thus
correlate clinically.
CXR [**6-23**]
Moderate-to-large left pleural effusion has increased, obscuring
much of the left lung where there could be either asymmetric
edema or pneumonia, both worsened since the previous
examination. Also increased is mediastinal widening suggesting
elevated central venous pressure or volume. Right lung is
relatively clear. Heart is enlarged, but obscured by left
pleural effusion. Tracheostomy tube in standard placement. No
pneumothorax.
Brief Hospital Course:
HOSPITAL COURSE
[**Age over 90 **]yo M w anoxic brain injury, ventilator-dependent who presented
initially with respiratory failure [**2-11**] bilateral pneumonia,
status post 14-day antibiotics course with respiratory status at
[**Month/Day (2) 5348**], course complicated by renal failure, with decreasing
hematocrit likely secondary to chronic GI bleed and anemia of
chronic disease, funguria status post foley change, with
worsening uremia.
# Acute on Chronic Respiratory Failure: Patient p/w
leukocytosis, CXR demonstrating bilateral pneumonia, cultures
growing pseudomonas. Pt was treated w 14d Zosyn. Of note,
patient also grew multiple GNR bacteria out of later respiratory
cultures, however, elected not to treat this given the fact that
he was afebrile, and that his ventilator requirements and
secretions were stable. Pt was maintained on home ventilatory
settings over the course of the entire hospitalization with
stable oxygenation.
.
# Acute Renal Failure/Electrolyte disturbance: Patient was
admitted with Creatinine of 5.5 ([**Month/Day (2) 5348**] of 1.8) and a
significant acidemia (pH 7.04), thought to be [**2-11**] [**Last Name (un) **] in the
setting of sepsis complicated by ATN. His Cr rose to 8.4. Per
discussion with renal service, patient was not a candidate for
HD given underlying severe medical comorbidities. Dr. [**Last Name (STitle) **]
and other attendings including Drs [**First Name (STitle) **] and [**Name5 (PTitle) **] met with the
family on several occasions to discuss the implications of his
progressive renal failure, including the eventual cardiac
instability that would result from untreated uremia,
hyperkalemia and acidosis. The family wanted to take the patient
home, and agreed that if he was to start hemodialysis, he would
require placement in a long-term care facility, which they did
not want. Electrolyte disturbances were managed medically. Cr
gradually improved, but during [**2189-6-10**] the creatitine started
to worsen from oliguria to anuria. He was started on phosphate
binders and his potassium began to rise slowly. He was also
noted to have worsening uremia and hyponatremia. Despite fluid
restriction, hyponatremia continued to worsen. Telemetry showed
repeated bouts of prolonged pauses and brady-tachy rhythms on
starting [**2189-6-20**], most likely thought to be due to uremia.
# C. difficile: on [**6-12**] the pt's WBC was noted to have started to
increase. Blood, urine and sputum cultures were unrevealing,
except for gram negative rods in the sputum. The pt's PICC line
was removed on [**2189-6-16**], and a peripheral IV was placed. Right
upper quadrant ultrasound on [**2189-6-16**] showed a normal appearing
liver and gallbladder. CT abd/pelvis did not show any
infectious source. His C. diff was found to be positive, and he
was started on po vancomycin and IV flagyl. However, his WBC
persisted as did ongoing issues with diarrhea and loose stools
consistent with severe c. diff.
# Anemia: Pt w several episodes of melenotic stool over the
course of the admission, with slow trending down of Hct,
requiring 10 units PRBC during the course of admission. GI was
consulted and did not recommend a scope. There were never signs
of acute bleeding and he remained hemodynamically stable on IV
Pantoprazole. GI felt a scope was not indicated. IV PPI was
transitioned to PO lansoprazole, however this was stopped due to
concern for AIN with urine eosinophilia. He was put on
famotidine 20 mg daily. Pt was started on Epo. His HCT trended
down gradually over time probably from frequent phlebotomy and
decreased production given worsened renal failure. However,
given transfusion would not reverse his grim prognosis in the
setting of worsening renal failure, no transfusion was given.
# Diabetes Mellitus II: His home glipizide was stopped given
renal failure initially. He was continued on sliding scale
humalog while and inpatient. Glipizide was restarted when renal
failure stabilized by family request at 2.5 mg [**Hospital1 **]. Insulin
sliding scale was continued, but titration was limited as family
requested his BS be in the 200s range. Glipizide was stopped
again at family's request after he developed anuria.
# Atrial fibrillation: Pt had episodes of atrial fibrillation.
Responded well to nifedipine for BP control and rate control.
This was gradually weaned off and per families request, pt put
back on prazosin. Pt had episodes of tachycardia which responded
well to diltiazem which was eventually titrated to 45mg QID.
However, with his worsened renal failure, his rhythm became more
unpredictable. At times, he would have bradycardia down to the
20s-30s with associated hypotension. His diltiazem and prazosin
were discontinued.
# Urinary tract infection: Patient with positive UA on admission
for ESBL sensitive to zosyn, which was being used to treat his
pneumonia as above. Urine cx and UA rechecked on [**5-24**] for
concern for appearance of urine and mild leukocytosis, he was
started on meropenem on [**5-25**] considering a urine cx concerning
for ESBL earlier during admission. Final bacterial urine cx
showed no growth so meropenem was discontinued. Many yeast were
noted on UA, so fluconazole was started at 100 mg Q48H for renal
dosing. Fungal cx grew out [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 10577**] so pt was continued on
fluconazole for 14 day course. Foley was changed by urology team
given significant scrotal edema and difficult foley changes in
the past on [**5-26**]. Foley was exchanged again by nurse on [**2189-6-20**]
at family's request.
# Gastrostomy tube exchange: G tube found to be cracked at the
tip on [**5-25**], GI team was consulted and tube was exchanged
without complication.
# Tracheostomy tube. Noted to have some leakage. However, was
able to be adjusted by respiratory therapy and the leakage
improved. Interventional pulmonary attending aware and did not
recommend exchange of tracheostomy.
# Dispo: After lengthy discussions and arrangements, the plan
was for pt to go home with supportive services including vent
services and visiting nursing in late [**Month (only) 116**]. Family agreed to
this, in addition to a plan for monthly trach review and foley
changes by urology in the ICU given the challenges of these
maintenance care procedures in the setting of the pt requiring
continuous ventilation and the difficulty this would pose in the
clinic and ED setting. However, disposition did not occur as
planned at the end of [**2189-5-10**] because of difficulty setting up
the home ventilator. Over the course of [**Month (only) **], he became
progressively unstable in the setting of severe c. diff and
progressive anuric renal failure. Dr. [**Last Name (STitle) **] met with the family
on a regular basis to discuss the implications of his
progressive instability and the inability to stabilize the
situation without hemodialysis, which the renal team and the
family had declined. It was further explained by multiple
attending physicians, including Drs. [**Last Name (STitle) **], [**Name5 (PTitle) **] and [**Name5 (PTitle) **]
that in the absence of a durable treatment for his renal
insufficiency, aggressive life-sustaining efforts including CPR
and defibrillation were not medically indicated. Between [**6-23**]
and [**6-26**], the patient developed longer pauses, and Dr. [**Last Name (STitle) **]
again explained that he was very likely to pass away from the
combined effects of renal failure and infection. After a
discussion with Dr. [**Last Name (STitle) **] on the evening of [**6-24**], the family
asked for all efforts to be made to allow transition back home
with a focus on comfort; however, progressive clinical
instability prevented a transition out of the ICU. The patient
passed away on [**2189-6-26**] from bradycardia and hypotension with the
family at the bedside.
Medications on Admission:
Levoxyl 25 mcg po qam
Glipizide 5mg po at noon
Combivent 3-4 puffs tid
Insulin (Regular) sliding scale: 180-240 (1 unit), 240-280 (2
units), 280-320 (3 units)
Discharge Medications:
1. levothyroxine 25 mcg Tablet [**Date Range **]: One (1) Tablet PO DAILY
(Daily).
2. Probiotic Oral
3. insulin lispro 100 unit/mL Solution [**Date Range **]: as previously
directed Subcutaneous ASDIR (AS DIRECTED).
4. ipratropium-albuterol 18-103 mcg/Actuation Aerosol [**Date Range **]: Four
(4) Puff Inhalation every six (6) hours as needed for shortness
of breath or wheezing.
5. prazosin 1 mg Capsule [**Date Range **]: One (1) Capsule PO BID (2 times a
day).
Disp:*60 Capsule(s)* Refills:*2*
6. psyllium Packet [**Date Range **]: One (1) Packet PO TID (3 times a
day) as needed for loose stools.
7. diltiazem HCl 30 mg Tablet [**Date Range **]: 1.5 Tablets PO QID (4 times a
day).
Disp:*45 Tablet(s)* Refills:*2*
8. darbepoetin alfa in polysorbat 40 mcg/0.4 mL Syringe [**Date Range **]:
Forty (40) mcg Injection once a week.
Disp:*4 syringes* Refills:*2*
9. glipizide 5 mg Tablet [**Date Range **]: 0.5 Tablet PO BID (2 times a day).
10. hydrocortisone 2.5 % Cream [**Date Range **]: One (1) Appl Rectal [**Hospital1 **] (2
times a day).
11. white petrolatum-mineral oil 56.8-42.5 % Ointment [**Hospital1 **]: One
(1) Appl Ophthalmic PRN (as needed) as needed for dry eyes.
12. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette [**Hospital1 **]: [**1-11**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
13. bisacodyl 10 mg Suppository [**Month/Day (2) **]: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
14. senna 8.6 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
15. famotidine 20 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO Q24H (every
24 hours). Tablet(s)
16. Respiratory
Must have wet humidifier for ventilator circuit. Do not use
HME.
17. Heparin Flush 10 unit/mL Kit [**Month/Day (2) **]: Two (2) mL Intravenous
once a day.
Disp:*3 kits* Refills:*2*
18. lactulose 10 gram/15 mL Solution [**Month/Day (2) **]: Thirty (30) mL PO
every eight (8) hours as needed for constipation.
Disp:*100 mL* Refills:*0*
19. chlorhexidine gluconate 0.12 % Mouthwash [**Month/Day (2) **]: One (1)
Mucous membrane twice a day.
Disp:*100 mL* Refills:*2*
20. Medical Equipment
Oxygen Analyzer
21. Medical Equipment
Pulse Oximeter
22. Mechanical Ventilation
Assist Control
500 x 12
PEEP 5
5 liters per minute O2 bleed
In-line heated humidification support
23. Medical Equipment
Heated in-line humidification support
24. Vent
GE iVent 101
25. potassium chloride 10 mEq Tablet Extended Release [**Month/Day (2) **]: One
(1) Tablet Extended Release PO once a day.
Disp:*30 Tablet Extended Release(s)* Refills:*2*
26. D/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 28334**] Medical Equipment
1. D/C ventilator LTV 1200
2. D/C Low Air loss mattress and semi-electric bed
3. D/C Suction machine and all equipment and supplies associated
with this
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary:
-Acute on chronic renal failure
-Ventilator acquired pneumonia
-Anemia from hemorrhoidal bleeding
-Chronic ventilator dependence
-Urinary tract infection
-Anemia of chronic disease (secondary to renal failure)
Secondary:
-Diabetes Mellitus
-Paroxysmal Atrial fibrillation
-Anoxic brain injury
-Tracheobronchomalacia
-Chronic foley
-Hypothyroidism
Discharge Condition:
Mental Status: Not interactive.
Level of Consciousness: Unable to be aroused, but withdraws to
noxious stimuli.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted to the ICU because of difficulty breathing,
and were found to have a serious pneumonia which was treated
with 14 days of IV antibiotics.
You were also were found to have renal failure. Your kidneys
have started producing urine again, however, your creatinine is
still elevated but has improved during this admission. We also
tested your urine and found that you have a fungal infection of
your urine. For this we treated you with fluconazole for a 14
day course. The urology team also changed your foley catheter
during this admission due to the urinary tract infection.
We also made some changes in your blood pressure medications,
which should also help control your heart rate. During your
admission, your blood pressure and heart rate were well
controlled on prazosin and diltiazem, and these should be
continued as directed below.
In addition, you were found to have anemia (low blood counts).
This was likely due in part to bleeding from hemorrhoids, but
also from your kidney disease. For this we started darbopoetin,
and your hematocrit (blood cell counts) have stabilized.
Medications:
- START taking Prazosin 1 mg twice a day
- START taking Diltiazem 45 mg four times a day
- START taking Famotidine 20 mg daily
- START taking Darbopoietin 40 mcg injected once a week
- START taking hydrocortisone 2.5% rectal cream 1 application
twice a day to hemorrhoids
- START taking lactulose 30 mL up to every 8 hours as needed for
constipation
- START taking probiotic three times a day
- START taking senna up to twice a day as needed for
constipation
- START taking bisacodyl up to every night as needed for
constipation
- START taking potassium chloride 10 mEq daily
- CONTINUE taking levothyroxine 25 mcg daily
- CONTINUE taking glipizide 5 mg daily
- CONTINUE using artificial tears as needed for eye dryness
- CONTINUE using albuterol-ipratroprium inhalers every 6 hours
as needed for shortness of breath or wheezing
- CONTINUE insulin as needed according to sliding scale
Followup Instructions:
Please arrange follow-up with your outpatient physician. [**Name Initial (NameIs) **]'re
primary care doctor is aware of your admission but you will need
to arrange for a follow-up appointment. Your primary care doctor
can consult with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
As discussed and agreed upon, your tracheostomy will be reviewed
and Foley will be changed in [**Hospital Unit Name 153**] once a month. Labs should by
performed every 2 weeks.
Completed by:[**2189-6-30**]
|
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icd9cm
|
[
[
[]
]
] |
[
"97.02",
"96.72",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
24772, 24781
|
13808, 21693
|
268, 330
|
25182, 25182
|
4175, 5456
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3402, 3446
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21902, 24749
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24802, 25161
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21719, 21879
|
25347, 27356
|
3461, 3461
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200, 230
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5491, 13785
|
2863, 2887
|
358, 2845
|
3475, 4156
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25197, 25323
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2909, 3299
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3315, 3386
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,815
| 152,276
|
20315
|
Discharge summary
|
report
|
Admission Date: [**2134-11-21**] Discharge Date: [**2134-11-24**]
Date of Birth: [**2073-8-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5644**]
Chief Complaint:
fatigue x 1 day
Major Surgical or Invasive Procedure:
mesenteric angiography
Upper endoscopy x 2
History of Present Illness:
61 year old male with metastatic colon cancer who presented
to OSH with fatigue and shortness of breath. While there he was
noted to have decreased Hct 24 from 36.6 on [**2134-11-2**] and
transferred to [**Hospital1 18**] for further evalaution. In addition, the
patient reports that he feels his abdomen has increased in size.
Denies fevers, chills. While in ED, the patient vomited 1300cc
red dark blood filled with clots as an OG tube was being placed.
She was admitted to the MICU for hemodynamic monitering and
EGD.
While in the MICU an EGD was done on [**11-21**]: 2 cords of
grade I varices were seen in the lower third of the esophagus.
A large piece of clotted blood was seen in the fundus that could
not be dislodged with lavage via the endosocope. Blood in the
gastroesophageal junction. However, afterwards, noted to have
hematemesis with blood clots. Discussed with GI who recommended
angiography.
Past Medical History:
1. Metastatic colon cancer to the liver, diagnosed [**2132**].
Treated with chemotherapy for many cycles where current regimen
includes oxal and xeloda (last received [**2134-11-2**])
2. s/p right hemicolectomy with end to side anastomosis, s/p
feeding jejunostomy, s/p liver biopsy
3. Diabetes mellitus
Social History:
Lives with wife
[**Name (NI) **] tobacco
Social alcohol
Family History:
Uncle: colon cancer
Sister: Leukemia
Father: sinus cancer
Physical Exam:
V: T98.6 P112 BP 164/79 R16 100% 2LNC
HEENT: PERRL, EOMI, OP clear
Neck: supple
CV: RRR nl s1s2 II/VI SEM
Resp: CTA B
Abd: soft, sl distended, + BS, no rebound/guarding
Ext: no cyanosis, clubbing, edema
Neuro: alert, oriented x 3
Pertinent Results:
[**2134-11-21**]
12:00a
140 105 33 / AGap=14
------------- 154
4.4 25 0.5 \
ALT: 16 AP: 247 Tbili: 0.7 Alb:
AST: 43
91
10.1 \ 7.8 / 334
/ 23.1 \
N:60.7 L:29.9 M:7.0 E:1.9 Bas:0.5
Comments: Notified [**First Name8 (NamePattern2) 1022**] [**Last Name (NamePattern1) 35227**] @ 01:00 Am, [**2134-11-21**]
Hypochr: 1+ Anisocy: 2+ Macrocy: 2+
PT: 13.2 PTT: 27.6 INR: 1.1
EGD [**2134-11-21**]:
Blood in the gastroesophageal junction.
Varices at the lower third of the esophagus.
Blood in the fundus.
Ultrasound 12/19:04:
1. normal venous blood flow, no portal vein thrombosis
2. left lobe biliary ductal dilatation without central or bile
duct dilatation, unchanged
3. small ascites
4. diffuse liver metastatic disease
Mesenteric Angiogram [**2134-11-21**]:
IMPRESSION: SMA and celiac arteriograms demonstrating no
evidence of active GI bleeding. The portal vein was patent
without evidence of obvious varices. No intervention performed.
EGD [**2134-11-22**]:
1. Grade I varices at the lower third of the esophagus.
2. Erythema in the whole stomach.
[**2134-11-24**] 09:10AM BLOOD WBC-10.7 RBC-3.32* Hgb-9.9* Hct-30.5*
MCV-92 MCH-29.8 MCHC-32.5 RDW-18.1* Plt Ct-272
[**2134-11-24**] 12:47AM BLOOD Hct-29.6*
[**2134-11-23**] 04:00PM BLOOD Hct-28.2*
[**2134-11-23**] 02:11AM BLOOD WBC-11.4* Hct-27.9* Plt Ct-252
[**2134-11-21**] 12:00AM BLOOD Neuts-60.7 Lymphs-29.9 Monos-7.0 Eos-1.9
Baso-0.5
[**2134-11-24**] 09:10AM BLOOD Plt Ct-272
[**2134-11-24**] 09:10AM BLOOD Glucose-120* UreaN-15 Creat-0.6 Na-137
K-3.7 Cl-103 HCO3-23 AnGap-15
[**2134-11-24**] 09:10AM BLOOD Calcium-7.8* Phos-2.5* Mg-1.9
Brief Hospital Course:
1. Gastritis/Upper GI bleed: The patient presented with fatigue
and had hematemesis in the ED. He was given 3 units of blood for
a hct of 21, and 2 large bore IV's were put in. He was put on IV
Protonix twice daily. He had an EGD which showed a large blood
clot in stomach and grade I varices in the lower third of the
stomach. He was admitted to the MICU and went to angio on [**11-21**].
Octreotide gtt was started [**11-21**] per GI recommendations but
stopped [**11-22**] after repeat EGD showed no active bleeding.
Mesenteric angiogram was negative for any active bleeding and no
intervention was performed. A repeat EGD [**11-22**] showed grade I
varices, portal gastropathy, and gastritis but no ulcer,
including in fundus of stomach. Abdominal ultrasound was
negative for clot in portal vein and showed no ascites. Serial
hematocrits were stable after the initial presentation, and the
patient required 3 units of blood total. He was transferred to
the floor and was able to tolerate food. Gastroenterology felt
that the bleeding was most likely secondary to his gastritis
rather than the varices, though nadolol was added and maintained
at discharge as well as a 6 week course of PO protonix [**Hospital1 **] and
then daily indefinitely.
2. DM: He was put on sliding scale insulin while NPO and Lantus
at 5 units daily while NPO and adjust as needed. When he was
taking PO, the Lantus was increased to his home dose of 18 units
and his metformin was restarted the day after discharge [**11-24**] as
48 hours post IV contrast dye.
3. Colon cancer metastatic to liver - The patient's chemotherapy
agents were discontinued and he will follow up with Dr. [**First Name (STitle) **]
regarding when to restart his Xeloda (2 weeks on, 1 week off).
4. h/o depression - His Paxil was continued.
Medications on Admission:
Xeloda 1000 mg po BID 14/21 days of 3 week cycle and Oxaliplatin
130 mg/ m2 Q 3 weeks
Ferrous Sulfate
Metformin [**Hospital1 **]
Pepcid [**Hospital1 **]
Paxil 40 mg daily
Lantus 18 Units in am
Stool Softener
Compazine
Discharge Medications:
1. Insulin Glargine 100 unit/mL Solution Sig: Eighteen (18)
units Subcutaneous once a day: or resume previous dose.
2. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Metformin HCl 500 mg Tablet Sig: One (1) Tablet PO twice a
day: Or resume previous dose.
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours):
Take twice daily for next 6 weeks, then once daily indefinitely.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
once a day.
7. Xeloda Oral
8. Oxaliplatin Intravenous
9. Stool Softener Oral
10. Outpatient Lab Work
Please check hematocrit and send results to PCP:
[**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Telephone/Fax (1) 32949**]
11. Compazine 10 mg Tablet Sig: One (1) Tablet PO every [**5-11**]
hours as needed for nausea.
Discharge Disposition:
Home
Discharge Diagnosis:
upper GI bleed likely secondary to gastritis
grade I esophageal varices
gastritis
diabetes mellitus
Secondary:
metastatic colon carcinoma
depression
Discharge Condition:
patient was eating solid food, ambulating without assistance,
and wanted to go home
Discharge Instructions:
Please resume your home medications, except you can discontinue
the pepcid. You have been started on two new medications,
protonix and nadolol. Please take protonix twice daily for 6
weeks, then daily indefinitely.
You should discuss with Dr. [**First Name (STitle) **] regarding restarting your
chemotherapy medications.
If you have recurrent black stools, vomit blood, dizziness, low
blood pressure, or other concerns, return to the ED.
Followup Instructions:
With your primary care physician, [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Telephone/Fax (1) 32949**],
in [**12-4**] weeks. Please call for appointment. You should have your
hematocrit checked before this appointment.
With Dr. [**First Name (STitle) **] as scheduled.
GI follow up is not necessary.
|
[
"250.00",
"276.1",
"V10.05",
"197.7",
"535.51",
"263.9",
"456.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.29",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
6824, 6830
|
3724, 5524
|
332, 376
|
7023, 7108
|
2077, 3701
|
7597, 7909
|
1753, 1812
|
5792, 6801
|
6851, 7002
|
5550, 5769
|
7132, 7574
|
1827, 2058
|
277, 294
|
409, 1336
|
1358, 1664
|
1680, 1737
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,828
| 192,255
|
1328
|
Discharge summary
|
report
|
Admission Date: [**2142-2-21**] Discharge Date: [**2142-3-3**]
Date of Birth: [**2083-7-27**] Sex: M
Service: [**Location (un) 259**]
HISTORY OF PRESENT ILLNESS: This is a 58-year-old gentleman
with history of colon cancer status post resection, history
of personality disorder, who presented with syncope [**Location (un) 8150**]. Emergency medical services were called.
Patient awoke and was brought to the Emergency Room, where he
was found to be tachycardiac with a new right bundle branch
block. CT angiogram showed pulmonary emboli with large clot
burden. An echo by report showed new RV dysfunction.
Patient was hemodynamically stable and transferred to the
Medical Intensive Care Unit for further management. Heparin
drip was started in the Emergency Room.
Patient was admitted 10 days prior to admission for atypical
chest pain. He ruled out for a myocardial infarction by
enzymes but refused to stay in house for stress test and was
discharged home. Patient then went to primary care physician
on day prior to admission with complaints of persistent right
lower extremity pain but no shortness of breath, no chest
pain. Except for a history of colon cancer, no risk factors
for hypercoagulable state.
PAST MEDICAL HISTORY:
1. Depression with paranoid personality disorder versus
paranoia and borderline personality disorder.
2. Chronic abdominal pain, unclear etiology.
3. Irritable bowel syndrome.
4. Hyperlipidemia.
5. Colon cancer status post resection in [**2132**] with good
follow up with colonoscopies and CT scans.
6. Hypertension.
7. Chronic low back pain with left thigh numbness, disc
protrusion on C6 and C7.
8. History of atypical chest pain and stress in [**2140**] with
Persantine MIBI was normal. An ejection fraction of 54%.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Valium 10 mg q. a.m., 20 mg q. p.m.
2. Lactulose p.r.n.
3. Aspirin 81 mg q. day.
4. Risperidone 0.25 mg b.i.d.
5. Desipramine 100 mg q. h.s.
6. Cholestyramine 625 mg b.i.d. with meals.
7. Percocet, one, p.o. q. 6 hours p.r.n.
8. Colace 100 mg p.o. b.i.d.
FAMILY HISTORY: Negative for deep venous thrombosis, no
history of coronary artery disease.
SOCIAL HISTORY: Lives alone at home with one son.
PHYSICAL EXAMINATION: Notable for a temperature of 97.2,
blood pressure 122/92, pulse ranging from 129 to 131,
respiratory rate of 18, sats 97% on 100% non-rebreather. In
general, he is a middle-aged man who appears agitated,
refusing complete examination. Extraocular muscles intact.
Neck: Supple. Jugular venous distention could not be
assessed. Cor is tachycardiac, loud split S2. Lungs with
anterolateral decreased breath sounds at the base
bilaterally. Abdomen is soft, nontender, positive bowel
sounds, slightly distended. Extremities: With right lower
extremity painful calf to palpation. Rectal exam is guaiac
negative.
LABORATORY DATA ON ADMISSION: White count 9.7 with 59% white
blood cells, 33% lymphs, hematocrit 49, platelets of 306, INR
of 1.2, PTT 21, Chem-7 within normal except creatinine of
1.4, which is within his baseline, CK of 97, no MB, troponin
T less than 0.01.
EKG was sinus tachycardiac at 120 beats per minute, new right
axis deviation, and right bundle branch block also new.
CT of the head with no acute hemorrhage, no acute injury.
CT of the chest with multiple pulmonary emboli. Left main
pulmonary artery was occluded, non-occlusive thrombus in the
main right pulmonary artery. Pulmonary emboli in his right
upper lobe, right middle lobe and right lower lobe.
Chest x-ray: No congestive heart failure, no pneumonia.
Echo: Ejection fraction of 55%, RV is dilated, severe global
right ventricular hypokinesis.
Lower extremity Dopplers with right popliteal deep venous
thrombosis.
HOSPITAL COURSE: This was a 58-year-old gentleman with no
significant hypercoagulable risk factors who presented with
bilateral large clot burden pulmonary emboli initially
admitted to the Medical Intensive Care Unit.
1. Bilateral pulmonary emboli with lower extremity deep
venous thromboses with RV dysfunction status post syncope:
Patient was continued on his Heparin drip, made therapeutic
after a bolus in the Emergency Room. Continued on Heparin,
and patient was considered a candidate for lysis if he became
hemodynamically unstable. However, he refused lysis and
eventually was just continued on his Heparin drip and
transitioned to Coumadin and goal INR of 2 to 3.
Initial inpatient hypercoagulable workup including
anticardiolipin, antiphospholipid, and homocystine levels
were negative. Rest of hypercoagulable workup can be done as
an outpatient.
Overall, patient's oxygenation improved and patient was
transferred to the floor, did fairly well, and stayed while
waiting for his INR to become therapeutic to be discharged on
his regimen. Patient had three sets of negative CKs and
troponins and otherwise remained hemodynamically stable.
Two days follow admission patient had resolution of his right
bundle branch block and was otherwise stable and discharged
to the floor with continued INR and PTT monitoring. His
Heparin drip was within therapeutic range, and we are waiting
for his INR to be greater than 2.2 for discharge.
Overall, pulmonary emboli status and deep venous thrombosis
status patient was stable on his regimen of Coumadin, and
patient understood risks and benefits of anticoagulation
therapy and will have rest of his hypercoagulable workup as
an outpatient.
2. Depression/paranoid personality disorder: During the
course of his hospitalization patient refused to take his
psychiatric medicines because of a mistrust of the system.
Patient said he would restart at home, where he trusts his
medicines, and otherwise remained stable throughout course.
3. Chronic renal insufficiency: Per baseline through trends
on the computer system, creatinine runs from 1.2 to 1.6, and
since this was chronic, no further workup was done at this
time. Patient did have previous ultrasounds and CTs with
otherwise normal renal functioning on imaging in [**2140**].
4. Hypertension: He was normotensive and did not require
any further medications for his hypertension. His glaucoma
was stable.
5. Glaucoma: Stable on his Timolol drops.
DISCHARGE CONDITION: Good, patient ambulating without
difficulty, not requiring oxygen.
DISPOSITION: Discharged to home.
DISCHARGE DIAGNOSES:
1. Pulmonary embolus.
2. Deep venous thrombosis.
3. Depression.
4. Personality disorder.
5. Chronic renal insufficiency.
6. Glaucoma.
DISCHARGE MEDICATIONS:
1. Diazepam 10 mg p.o. q. a.m.
2. Diazepam 20 mg p.o. q. p.m.
3. Aspirin 325 mg p.o. q. day.
4. Risperidone 0.25 mg p.o. b.i.d.
5. Desipramine 100 mg p.o. q. h.s.
6. Coumadin 5 mg p.o. q. h.s.
7. Timolol Drops, one drop ophthalmic, b.i.d.
DISCHARGE INSTRUCTIONS:
1. Patient is to follow up with Dr. [**Last Name (STitle) **] on [**2142-3-7**] at
8:50 a.m.
2. Patient will be contact[**Name (NI) **] by the [**Hospital 197**] Clinic on
[**2142-3-20**].
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**]
Dictated By:[**Name8 (MD) 264**]
MEDQUIST36
D: [**2142-3-5**] 10:20
T: [**2142-3-5**] 10:27
JOB#: [**Job Number 8151**]
|
[
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"365.9",
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icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6287, 6390
|
2124, 2201
|
6411, 6552
|
6575, 6822
|
3807, 6265
|
6846, 7264
|
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|
180, 1238
|
2924, 3789
|
1260, 2107
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,797
| 110,326
|
26084
|
Discharge summary
|
report
|
Admission Date: [**2170-3-26**] Discharge Date: [**2170-4-16**]
Date of Birth: [**2101-3-19**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 45556**]
Chief Complaint:
GI bleeding, respiratory distress
Major Surgical or Invasive Procedure:
s/p central line placement
History of Present Illness:
68-year-old male with a history of hypertension and gout who is
being treated on the biologics service with IL-2 for metastatic
melanoma. He began the protocol on Monday and had been
tollerating the TID IL-2 infusions, but had a decline in his
plts from 200 to 56 as well as a 11# weight gain attributed to
capillary leak. He also had significant electrolyte imbalances,
tachycardia, and tachypnea expected from this protocol.
On the day of [**Hospital Unit Name 153**] transfer, patient had some mild epigastric
discomfort and complained to his daughter of heartburn. Of
note, he was on daily indocin while on IL-2 therapy. At 10pm,
he developed some diarrhea and then had an episode of nausea and
vomiting. The covering MD noted 2 very large blood clotts in
the emesis. Noted increased RR of 40s, was 84% on RA and then
improved to 100% on 4L NC. Biologics attending was not
concerned about other parameters, but was worried abt bleeding
as patient may be at risk for bleeding given his plts have
dropped in the past few days.
Brought to [**Hospital Unit Name 153**], GI team asks for FFP, plts. Pt has guiac
positive brown stools, but complains of hemorrhoids and some
rectal irritation that may be contributing. Holding on NG
lavage unless patient becomes unstable. First two hcts are
stable.
Past Medical History:
Onc Hx per OMED notes:
Pt was diagnosed with melanoma in [**4-/2167**] when he was found to
have a mole on his left abdomen. He underwent wide local
excision and sentinel lymph node biopsy at that time which
revealed no residual melanoma and the 3 sentinel nodes were
negative. Two years later in [**4-18**], he developed a red raised
nodule under the scar of the local excision. This was reexcised
and he subsequently did well until [**8-/2169**] when he had another
satellite recurrence and reexcision. He then had a third
satellite recurrence and reexcision in [**10/2169**] and was then
started on interferon therapy that was stopped [**2-15**] side effects.
Recent PET/CT done revealed a left axillary lymphadenopathy as
well as 2 liver lesions.
..
..
PmHx: melanoma, Gout, Htn. Reports recent normal EGD and
colonoscopy
Social History:
Married, 4 kids, quit smoking 35 years ago (prior 7pk yr hx),
rare EtOH use, retired engineer
.
Family History:
Father with lung cancer
Physical Exam:
PE: 98.2 133-152/72-75 HR 132 RR 28 100% 4L NC
Gen: obese, breathing rapidly, no acute distress, comfortable,
alert
HEENT: mm dry, op clear, neck supple with tripple lumen in
place, eomi
CV: distant HS, tachy s1s2 no m/r/g
Lungs: crackles noted bilat, L>R, otherwise clear
Abd: obsese, multiple metastatic nodules palpable on L side of
abdomen, soft, nt/nd, active bs
Ext: 1+ edema bilat
Rectal: brown guiac positive stools
Pertinent Results:
CXR PORTABLE [**3-27**]
IMPRESSION: Minimal patchy basilar opacities likely due to
atelectasis. No evidence of pulmonary edema.
.
[**2170-3-31**] CXR PORTABLE
IMPRESSION: New diffuse bilateral parenchymal opacities
compatible with pulmonary edema.
.
[**2170-3-31**]
CHEST XR: A single AP supine view is compared to previous
examination earlier from the same day. Again seen extensive
bilateral parenchymal opacities suggesting pulmonary edema.
There is more dense consolidation in left lower lobe with air
bronchogram, compatible with pneumonia. There is a new
endotracheal tube with the tip overlying T3.
.
[**2170-4-2**]
BILATERAL LE DOPPLER
IMPRESSION: No evidence of lower extremity DVT.
.
ECHO [**2170-4-2**]: EF>60%
Conclusions:
1. The left atrium is mildly dilated.
2. Left ventricular wall thickness, cavity size, and systolic
function are normal (LVEF>55%). Regional left ventricular wall
motion is normal.
3. The right ventricular cavity is moderately dilated. Right
ventricular systolic function appears depressed.
4. The aortic valve leaflets (3) are mildly thickened. No aortic
regurgitation is seen.
5. The mitral valve leaflets are mildly thickened. Trivial
mitral
regurgitation is seen.
6. There is a trivial pericardial effusion.
.
[**2170-4-4**] RENAL US
IMPRESSION:
1. Multiple left kidney stones, the largest measuring 2.1 cm in
the mid pole. No evidence of hydronephrosis. Multiple parapelvic
cysts.
2. Right kidney stone. No evidence of hydronephrosis.
.
[**2170-4-7**] LIVER/GB ULTRASOUND
IMPRESSION:
1. No evidence of intra- or extrahepatic biliary ductal
dilation. No evidence of cholecystitis. 1.3 cm shadowing
gallstone.
2. Two hypoechoic liver lesions likely corresponding to the
lesions seen on CT. Metastatic disease to the liver is within
the differential.
.
[**2170-4-9**] CXR
IMPRESSION: AP chest compared to [**4-2**] and 24:
Left lower lobe consolidation is clearing, probably resolving
atelectasis. Pulmonary vascular congestion is present but edema
has not returned. Azygous distention indicates volume overload.
Heart size is top normal. No pleural effusion or pneumothorax.
ET tube and right subclavian line are in standard placements and
a nasogastric tube passes through the mid stomach and out of
view.
.
*** CULTURE DATA ***
[**4-11**] urine cx neg
[**4-10**] blood cx X 6 pending
[**4-10**] sputum cx: 2+ GPC in pairs, sparse growth oropharyngeal
flora
[**4-10**] stool: O&P pending
[**4-7**] blood cultures neg
[**4-7**] worm macroscopic pending
[**4-6**] CMV VL not detected
[**4-6**] Crytococcus negative
[**4-5**] Rapid resp viral negative
[**4-5**] BAL: oropharyngeal flora, no PMN, no microorg, neg fungal,
AFB
Brief Hospital Course:
HOSPITAL COURSE: On the day of [**Hospital Unit Name 153**] transfer, [**2170-3-29**], patient
had some mild epigastric discomfort and complained to his
daughter of heartburn. Of note, he was on daily indocin while on
IL-2 therapy. At 10pm, he developed some diarrhea and then had
an episode of nausea and vomiting. The covering MD noted 2 very
large blood clots in the emesis. Noted increased RR of 40s, was
84% on RA and then improved to 100% on 4L NC. Biologics
attending was not concerned about other parameters, but was
worried about bleeding as patient may be at risk for bleeding
given his plts have dropped in the past few days.
.
Brought to [**Hospital Unit Name 153**], GI team requested FFP, plts. Pt has guiac
positive brown stools, and complained of hemorrhoids and some
rectal irritation that may be contributing. He was not scoped
emergently that night, and his vitals were closely followed,
along with Hct. His Hct was noted to be stable, with stable VS,
and no episodes of melena. GI felt no emergent need for EGD.
He is receiving PPI [**Hospital1 **]. On [**4-1**], the pt was intubated for
respiratory distress secondary to pulmonary edema thought to be
secondary to capillary leak syndrome from HD IL-2. He underwent
diuresis and was started on levo/flagyl for ?LLL PNA, started
[**3-31**]. On [**4-3**], levo/flagyl d/c'd as all cx negative, pt
afebrile. Another reason abx d/c'd was b/c pt developed a rash
thought to be a drug hypersensitivity reaction, which improved
post d/c abx. ID was consulted [**4-4**] for continued fevers and
recommended the initiation of broad spectrum abx incl.
Vancomycin, Aztreonam, and Flagyl (stopped [**4-8**]), RUQ US to r/o
cholangitis (b/c pt had elev LFTs), and stated would not give
steroids, and would do bronchoscopy/BAL for most likely pulm
source. Chest CT demonstrated b/l lower lobe infiltrates c/w
pulm edema vs. PNA. Pt underwent Bronch [**4-5**], showing limited
eval of right sided airways, lavage with RLL post segment,
result: no PMN, no microorg, grew OP flora, PCP negative, AFB
negative. Vancomycin was continued for ? line infection, and
b/c the pt had difficult access, his line was continued for 19
days. He has been on Vanco for 8 days. The pt's LFT elevation
was attributed to IL-2 therapy, a known side effect.
.
Also, he was noted to have renal insufficiency, with Cr to 1.6,
and eosinophilia, with presumed AIN. His creatinine continued
to rise to 2.6 (baseline 0.9). He was given prednisone, which
was subsequently d/c'd. Renal was consulted [**2170-4-5**] and
recommended for pt to increase free water intake. They felt he
had a number of reasons to have ARF, including: capillary leak
syndrome, NSAIDs, infection, contrast on [**4-2**], and drug reaction
though no eos or WBC in urine. The pt's creatinine demonstrated
slow improvement, was 1.4 [**4-7**], and on transfer from ICU, his Cr
was 0.9 (baseline).
.
Subjectively on transfer from [**Hospital Unit Name 153**] to the medical floor, the pt
felt well, is laughing and joking with family, and has no pain
complaints. States his breathing if fine. No cough, fever,
chills. No N/V. No abd pain. No diarrhea or constipation. No
dysuria. No chest pain or shortness of breath.
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
________________________________________________________________
Impression: A/P: 69 M with metastatic melanoma s/p IL-2
therapy, last dose at 3 pm [**3-29**], now with fevers, resp failure
[**2-15**] non-cardiogenic pulm edema; now improving, extubated [**4-12**],
and satting well on NC. Resolved ARF. s/p Drug
hypersensitivity reaction with discontinuation of all
antibiotics and improvement.
.
#. Pulmonary status s/p respiratory distress: Mr. [**Known lastname 64730**] was
intubated initially [**3-31**] for resp distress, thought secondary to
non-cardiogenic pulm edema from capillary leak syndrome from
Il-2, with possible contribution from PNA. LLL inbfiltrate on
CXR, fevers, but sputum never grew anything, so unclear if PNA
vs atalectasis. He was intially started on levaquin and flagyl.
Chest CT showed lower lobe infiltrates c/w pulm edema vs PNA.
Lenis were neg, but he did not have a CTA because of renal
failure. He has no h/o CHF, COPD or asthma. No Echo on file. The
pt was then taken off all abx on [**4-11**] because all cx data was
negative and fevers seemed likely due to acute interstitial
nephritis given eosinophilia, ARF, rash versus due to his
melanoma and IL'2 treatment. ID was consulted, recommended
bronchoscopy and labs, empiric sntibiotics for presumed Hospital
acquired PNA vs. line infection, so he was started on
vancomycin. Bronchoscopy from [**4-5**] was negative. He remained on
vancomycin for 8 days until his central line was pulled. We
then discontinued Vancomycin IV.
-now on room air, sats stable
-nebs prn if needed
-chest PT, mobilize secretions
-IS to bedside and encourage pt to use
.
# ARF, resolved: this was thought to be acute interstitial
nephritis given fever, rash and ARF with peripheral
eosinophilia. However, eos negative in urine. Renal consulted
felt to be pre-renal also question contrast induced nephropathy.
This fully resolved with hydration, so finally appeared to be
most likely pre-renal and contrast related. His creatinine
continued to be at his baseline. We ended up restarting his
outpatient ACEI. Will see PCP [**Last Name (NamePattern4) **] 1 week.
.
# Fever: Unclear etiology still, all cultures negative. He has
been hemodynamically stable. ID was consulted in the setting of
contemplating starting steroids. ID recomended to r/o infection
BAL prior to starting empiric antibiotics, multiples serologies
histoplasma antigen, EBV viral load, CMV viral load, cryptococal
antigen, Strongiloides serology. RUQ u/s. All work up
unrevealing to date, and fevers tapered off. Afebrile for 6 days
prior to leaving ICU. Initial empiric a/b regimen with flagyl,
aztreonam and vanco was D/C'd . He has remained afebrile on the
medical floor and has been instructed to report to the ED for
fever, chills.
.
#. Hypernatremia, resolved: Likely due to increase insensible
lossess. Free water boluses and D5w was given with normalization
of sodium.
.
#. ?Line infection: Pt was continuing to spike fevers in the
ICU with a negative panculture workup and no infiltrate. Other
sources excluded, so IV vamco empirically given. His line was
pulled, no drainage and erythema at site. His blood cx are
negative to date. We stopped IV vancomycin on transfer to
medical floor, no evidence to support its use.
.
#. Metastatic Melanoma: Il-2 therapy on hold for now. Plan per
Onc team, attending Dr. [**Last Name (STitle) **] and [**Doctor Last Name **]. His restaging lung
CT, head CT showed only mediastinal nodes largest 1.7 cm, could
not assess for pulm nodules given pulm edema. The pt has follow
up with Dr. [**Last Name (STitle) **].
.
#. GI Bleed: The pt had emesis with large clots on [**3-28**]. No
further bleeding, hct has since remained stable stable. The pt
can continue his PPI. His Hct has remained stable, as well as
his vital signs.
.
#. Elevated LFTs: stable. This is a known side effect of IL-2
therapy. We held his IL-2, and trended his LFTs, which improved
over time.
.
# Confusion/ICU psychosis: Pt had vivid dreams as well as
hallucinations while in the ICU, and would often speak
inappropriately at times or answer questions with responses
unrelated. He was started on low dose haldol. On the medical
floor, the pt was appropriate in conversation, but would
occasionally state things that he was going to "[**Country 4194**] to herd
cattle." On questioning his family, they stated that he has no
plans for a trip. He is otherwise appropriate. He has an
appointment to follow up with his PCP [**Last Name (NamePattern4) **] 1 week. His haldol was
not given while he was on the medical floor.
.
#. Communication: with pt, wife and daughter [**Telephone/Fax (1) 64731**]
.
#. Nutrition:
The pt initially failed his speech and swallow study, however
the study was done a few hours post extubation, when the pt
still had copious secretions. At the time of transfer to the
medical floor, the pt was swallowing and chewing fine. He did
not experience any choking or coughing episodes with eating, and
he is tolerating a po diet well. We did not repeat his swallow
study. He does not appear to be an aspiration risk now.
.
#. Access: RSC multi-lumen [**3-26**] discontinued, now with pIV
.
#. Code: full
.
#. Proph: PPI, pneumoboots, heparin sq tid
.
#. Dispo: Home with physical therapy services. Follow up with
PCP. [**Name10 (NameIs) **] has a CAT scan scheduled for the last week in [**Month (only) 547**],
followed by a Heme/Onc appt on [**5-16**].
Medications on Admission:
hctz, atenelol, lisinopril, allopurinol, MVI
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation every 4-6 hours as needed for shortness of breath or
wheezing.
Disp:*1 MDI* Refills:*2*
2. Atrovent 18 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation every 4-6 hours as needed for shortness of breath or
wheezing.
Disp:*1 MDI* Refills:*2*
3. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
Disp:*30 Capsule(s)* Refills:*2*
6. Atenolol 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Primary Diagnoses:
1. Metastatic melanoma status post High dose IL-2 therapy
2. Capillary Leak Syndrome secondary to High dose IL-2
3. Acute Renal Failure
4. Fever
5. Hypernatremia
6. Elevated liver function tests secondary to high dose IL-2
Secondary Diagnoses:
1. Hypertension
2. Gout
Discharge Condition:
Stable
Discharge Instructions:
Notify Dr.[**Name (NI) 46582**] office for fever, chills, bleeding, shortness
of breath, persistent swelling or inability to take oral fluids.
Please take all of your medications as directed. Please follow
up with your doctors (see information below).
Followup Instructions:
You have a follow up appointment with your Primary care
physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 518**] [**Last Name (NamePattern1) 64732**], for Thursday, [**2170-4-26**]
at 1:30pm. His office number is: [**Telephone/Fax (1) 64733**] if you have any
questions.
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2170-5-9**] 10:15
Provider: [**Known firstname **] [**Last Name (NamePattern4) 9402**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2170-5-16**] 4:30
Provider: [**Name10 (NameIs) 13145**],[**Name11 (NameIs) **] HEMATOLOGY/ONCOLOGY-CC9
Date/Time:[**2170-5-16**] 4:30
Completed by:[**2170-4-16**]
|
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"293.0",
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icd9cm
|
[
[
[]
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] |
[
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icd9pcs
|
[
[
[]
]
] |
15441, 15500
|
5880, 5880
|
350, 379
|
15839, 15848
|
3194, 5857
|
16150, 16833
|
2705, 2730
|
14708, 15418
|
15521, 15769
|
14639, 14685
|
5898, 14613
|
15872, 16127
|
2745, 3175
|
15790, 15818
|
277, 312
|
407, 1720
|
1742, 2576
|
2592, 2689
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,815
| 149,650
|
1984
|
Discharge summary
|
report
|
Admission Date: [**2127-6-13**] Discharge Date: [**2127-6-17**]
Date of Birth: [**2046-3-22**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3016**]
Chief Complaint:
dyspnea, abdominal distension
Major Surgical or Invasive Procedure:
thoracentesis, paracentesis (diagnostic and therapeutic)
History of Present Illness:
81 yo female with h/o breast cancer, newly diagnosed stage IV
ovarian cancer, on taxol/carboplatin started [**2127-6-10**], presenting
with dyspnea, abdominal distension, and total body burning/ache
sensation. The patient developed dyspnea and abdominal
distension in early [**Month (only) 116**], and was found to have pleural
effusions, ascites, and omental caking. She underwent diagnostic
and therapeutic paracentesis and right thoracentesis on [**5-27**] and
[**5-29**], respectively, with some relief of her symptoms. Cytology
showed malignant cells. She started chemotherapy with taxol and
carboplatin on [**6-10**]. Over the last few days, her dyspnea and
abdominal distension worsened. She also notes diffuse
burning/achiness with nausea since yesterday. She has had a
cough for 2 weeks. Last BM 2 days ago.
In the ED, she was tachycardic but otherwise stable. Exam
notable for decreased breath sounds in left lung field, and
abdominal distension. CXR shows large left pleural effusion.
Bedside U/S showed no pericardial effusion. Diagnostic
paracentesis was performed, showing WBC 1175, 0% polys, 75%
other. CTA chest was without PE, but noted ground glass
opacities in the left upper lobe representing early pneumonia or
asymmetric pulmonary edema. The patient was started on
levofloxacin and sent to the [**Hospital Unit Name 153**] tachycardic with sats of 98%
on 3L.
In the MICU, IP performed [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 576**] on her large left pleural
effusion. Antibiotics were discontinued given lack of evidence
of an infection. Her tachycardia was felt to be secondary to
pain and she was started on morphine prn and tylenol. Her most
recent vitals in the MICU are 98.7, 104, 129/68, 24, 95% on 2L.
Past Medical History:
PAST ONCOLOGIC HISTORY:
-Ovarian cancer - Presented in [**2127-5-6**] with increasing
abdominal girth and shortness of breath. CT torso [**2127-5-22**] showed
bilateral pleural effusions and findings concerning for omental
caking and malignant ascites. Pleural and peritoneal fluid
positive for malignant cells, consistent with carcinoma. Given
elevated CA-125, this was felt to be ovarian cancer, stage IV.
Taxol/carboplatin started [**2127-6-10**].
-Breast cancer - Diagnosed [**2123-8-6**], stage I (T1c, N0)
right-sided, mucinous carcinoma, grade 2, ER/PR positive,
HER-2/neu, LVI negative. Treated with right partial mastectomy
with sentinel lymph node biopsy followed by radiation. She has
been on Arimidex 1 mg daily since.
PAST MEDICAL HISTORY:
-hypercholesterolemia
-hypertension
-anxiety
-migraines
-s/p cholecystectomy [**2077**]
-s/p appendectomy at age 11
-s/p tonsillectomy at age 8 or 9
Social History:
Lives with grandson. Worked as nurse's aide.
-Tobacco: none
-EtOH: none
-Drugs: none
Family History:
Her daughter died of breast cancer in her 40s. Her son had
[**Name (NI) 4278**] lymphoma. Mother had cervical cancer. Grandmother had
[**Name2 (NI) 499**] cancer.
Physical Exam:
ADMISSION EXAM:
Vitals: 98.3 94 113/62 19 94% 2L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated
CV: Tachycardic, no m/r/g
Lungs: Decreased breath sounds and dullness to percussion at
left base, otherwise CTAB, [**Female First Name (un) 576**] site mildly tender and c/d/i
Abdomen: +BS, soft, markedly distended, mildly tender, no
rebound or guarding, +fluid wave, paracentesis site in RLQ with
clean dressing
Ext: Warm, well perfused, 2+ pulses, no LE edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation
DISCHARGE EXAM:
Vitals: Tm98.5 102/64 (96-105/60s) 70(70-80s) 20 95% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated
CV: Tachycardic, 2/6 SEM
Lungs: Decreased breath sounds at left base, otherwise CTAB,
[**Female First Name (un) 576**] site mildly tender and c/d/i
Abdomen: +BS, soft, non distended, diffusely tender to light
palpation
Ext: Warm, well perfused, 2+ pulses, no LE edema
Pertinent Results:
ADMISSION LABS:
[**2127-6-13**] 04:10PM BLOOD WBC-7.0 RBC-5.06 Hgb-14.9 Hct-46.1 MCV-91
MCH-29.5 MCHC-32.4 RDW-12.7 Plt Ct-304
[**2127-6-13**] 04:10PM BLOOD Neuts-83.4* Lymphs-13.2* Monos-0.9*
Eos-2.1 Baso-0.4
[**2127-6-13**] 04:10PM BLOOD Glucose-180* UreaN-15 Creat-0.9 Na-139
K-4.3 Cl-102 HCO3-27 AnGap-14
[**2127-6-13**] 04:10PM BLOOD Calcium-9.1 Phos-3.2 Mg-1.6
DISCHARGE LABS:
[**2127-6-17**] 07:20AM BLOOD WBC-4.6 RBC-4.40 Hgb-12.8 Hct-40.1 MCV-91
MCH-29.0 MCHC-31.8 RDW-12.3 Plt Ct-259
[**2127-6-17**] 07:20AM BLOOD Glucose-104* UreaN-11 Creat-0.6 Na-139
K-4.0 Cl-102 HCO3-30 AnGap-11
[**2127-6-17**] 07:20AM BLOOD Calcium-8.7 Phos-2.9 Mg-1.6
PLEURAL FLUID:
[**2127-6-14**] 02:53PM PLEURAL WBC-4250* RBC-6250* Polys-0 Lymphs-3*
Monos-5* Meso-4* Macro-4* Other-84*
[**2127-6-14**] 02:53PM PLEURAL TotProt-3.7 Glucose-48 Creat-0.7
LD(LDH)-326 Amylase-36 Albumin-2.4 Cholest-80 Triglyc-45
ASCITIC FLUID:
[**2127-6-13**] 04:59PM ASCITES WBC-1175* RBC-1900* Polys-0 Lymphs-24*
Monos-1* Other-75*
[**2127-6-13**] 04:59PM ASCITES TotPro-4.2 Glucose-94
MICROBIOLOGY:
[**2127-6-17**] STOOL C. difficile DNA amplification assay-PENDING;
FECAL CULTURE-PENDING; CAMPYLOBACTER CULTURE-PENDING INPATIENT
[**2127-6-14**] PLEURAL FLUID GRAM STAIN-
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE- NO GROWTH; ANAEROBIC CULTURE-PRELIMINARY NO
GROWTH
[**2127-6-13**] PERITONEAL FLUID GRAM STAIN-
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE- NO GROWTH; ANAEROBIC CULTURE-PRELIMINARY NO
GROWTH
[**2127-6-13**] BLOOD CULTURE -PENDING
[**2127-6-13**] BLOOD CULTURE - PENDING
Brief Hospital Course:
81 yo female with h/o breast cancer, newly diagnosed stage IV
ovarian cancer, on Taxol/carboplatin started [**2127-6-10**], presenting
with dyspnea found to have a large left pleural effusion s/p
thoracentesis.
ACTIVE ISSUES:
# Hypoxia with dyspnea: Pt was admitted with hypoxia and
dyspnea, likely related to pleural effusions and ascites. She
underwent a thoracentesis on day of admission with 1.5-2L of
serosanguinous fluid removed. This dramatically improved her
breathing and she was able to be weaned off room air. Cell count
and chemistries revealed and transudative exudate with 84%
"other" cells, concerning for malignancy. Her pleural cultures
were pending at time of discharge, along with cytology.
# Ascites: Pt presented with complaints of abdominal distension.
She has required 1 therapeutic paracentesis in the past, with
cytology positive for malignancy. Her current ascites was
thought to be due to metastatic disease. She underwent a
therapeutic paracentesis during this admission, with ~3 liters
of fluid removed. Hopefully her current chemotherapy regimen
will decrease her need for paracenteses, however she may be a
candidate for a pleurex if she requires recurrent drainage.
# Stage 4 Ovarian Cancer: Likely cause of patient's effusions,
though cytology was still pending at time of discharge. Pt is
currently receiving Taxol/carboplatin. She will discuss port
placement with her outpatient oncologist. She will also discuss
possible pleurex catheter if her ascites/pleural effusions
continue to re accumulate despite chemotherapy treatment.
# Neuropathic pain: Pt complained of total body pain and diffuse
burning, which was new since starting chemotherapy. She was
started on low dose gabapentin, and has room for titration of
this as an outpatient. She was also discharged with a short
prescription for Dilaudid, pending titration of her gabapentin.
CHRONIC ISSUES:
# Hx Breast Cancer: Per patient, she stopped anastrozole a month
ago.
# HTN: Pt was normotensive during her admission so enalapril was
held.
# Hyperlipidemia: Continued simvastatin
TRANSITIONAL ISSUES:
Pt had thoracentesis with pleural cultures and cytology pending
at time of discharge.
Pt will need to arrange port placement with her outpatient
oncologist.
She will need to follow up in pleural clinic for evaluation for
re-accumulation of pleural fluid. She may require a pleurex if
she continues to require [**Female First Name (un) 576**]/paracenteses.
Medications on Admission:
anastrazole 1 mg daily (stopped a month ago)
-enalapril 20 mg daily
-lorazepam 0.5 mg 1-2tabs Q8HRs
-ondansetron 8 mg Q8H PRN nausea
-simvastatin 30 mg daily
-calcium-vitamin D
-chemotherapy with taxol/carboplatin
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
2. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
3. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO every eight (8)
hours as needed for anxiety, insomnia, nausea.
5. ondansetron HCl 8 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours as needed for nausea.
6. Calcium-Vitamin D 600 mg calcium- 400 unit Tablet Sig: One
(1) Tablet PO twice a day.
7. gabapentin 300 mg Capsule Sig: One (1) Capsule PO three times
a day.
Disp:*90 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
PRIMARY:
Ovarian cancer with malignant ascites and pleural effusions
SECONDARY:
hypertension
hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 10916**],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted for shortness of breath and
abdominal distension. You were found to have fluid around the
lungs (pleural effusion) and fluid in the abdomen (ascites).
Both were drained, with improvement in your symptoms. This fluid
accumulation is likely due to your cancer.
Please make the following changes to your medications:
# STOP enalapril. Your blood pressure has been normal during
this hospitalization and you do not need this medicine now.
# START gabapentin 300 mg every 8 hours
# START dilaudid 2 mg every 6 hours as needed for pain
Continue all other medications as prescribed. Please follow up
with your oncologist to discuss possible port placement.
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2127-6-24**] at 10:30 AM
With: [**First Name8 (NamePattern2) 2295**] [**Last Name (NamePattern1) 10917**], RN [**Telephone/Fax (1) 9644**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: WEST PROCEDURAL CENTER
When: MONDAY [**2127-6-30**] at 1:30 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 7769**]
Building: [**Hospital Ward Name 121**] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2127-7-1**] at 9:30 AM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 10280**], PA [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) **] [**Name8 (MD) 831**] MD, [**Doctor First Name 3018**]
Completed by:[**2127-6-25**]
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|
[
[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,120
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39724
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Discharge summary
|
report
|
Admission Date: [**2156-12-14**] Discharge Date: [**2156-12-16**]
Date of Birth: [**2070-4-13**] Sex: M
Service: MEDICINE
Allergies:
Fluoride
Attending:[**Doctor First Name 1402**]
Chief Complaint:
ventricular tachycardia status-post ablation
Major Surgical or Invasive Procedure:
[**2156-12-14**] - Ablation of ventricular tachycardia
History of Present Illness:
86 year-old male with CAD who is s/p CABG x 5 in [**2156**]. He is followed by Dr. [**Last Name (STitle) 7047**] and
underwent a nuclear stress test in [**2155-7-20**]. This revealed a
severe fixed perfusion defect involving the inferior wall with a
mild degree of peri infarction ischemia. There was also a fixed
apical defect consistent with an old apical MI. There was
akinesis of the inferior wall and apex with severe hypokinesis
of the mid to distal anterior wall apex which is consistent with
multi-segmental CAD. The ejection fraction was 27%. He underwent
BiV ICD placement on [**2155-9-9**] for primary prevention of sudden
cardiac death. His course was complicated by a moderate
pneumothorax, he was asymptomatic, and an x-ray the following
day showed improvement of the pneumothorax and he was
discharged.
.
3-4 months ago he was pulling on a garden hose and he became
dizzy and saw "lights". He leaned against a wall and received a
shock from his ICD. He felt fine within a minute. He went to
[**Hospital3 417**] where he stayed there 3 days. He denies any
further testing or medication changes.
.
Two months ago he was driving and felt poorly and noted his
heart was "fluttering" he was able to drive home but had a near
syncopal episode and he felt his ICD fire. EMS was summoned and
he was found to be in VT at a rate of 140 bpm his ICD did not
fire as it was set for 170 bpm. Patient states he knows his ICD
fired prior getting to the hospital. He was externally
cardioverted. His amiodarone was increased to 400mg daily.
.
He denies any further fluttering or ICD shocks. When he is
resting he feels that he can feel his heart beating but denies
any palpitations. He does report his heart rate has been fast
and he has brief intermittent dizziness. His Amiodarone was
discontinued last week ([**2156-12-1**]) by Dr. [**Last Name (STitle) 17918**] as it was
thought to be ineffective.
.
He denies chest pain, and reports some dyspnea with exertion
along with mild dizziness if he gets up too quickly. He loses
his balance frequently from his neuropathy. He has not been able
to drive since his last ICD shock. He was referred for VT
ablation today.
.
During VT ablation, EP was able to induced 6 different VT in
lab, ablate along the scar in the inferior septum at the base on
LV. At the end of study, no longer able to induce any VT.
Bedrest for 6 hrs, continue carvedilol no antiarrythmic. In
procedure, he was 2L positive and got lasix 40 IV.
.
On arrival to CCU, he appears to be comfortable.
.
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: CAD S/P CABG x 5 in [**2156**]
- PERCUTANEOUS CORONARY INTERVENTIONS: none documented
- PACING/ICD: Cardiomyopathy and LBBB s/p [**Company 1543**] Concerto
D274TRK BiV ICD [**2155-9-9**]
3. OTHER PAST MEDICAL HISTORY:
Severe neuropathy
Prostate enlargement
H. Pylori
Colon CA
Peripheral Neuropathy
TIA [**4-26**]
GERD
Hiatal Hernia
Diverticulosis
Actinic Keratosis
Ventral Hernia
Polio age 8
Depression
Weight Loss with negative CT scan
Social History:
He lives with his wife [**Name (NI) **]. [**Name2 (NI) **] has six children. He was an
electrical engineer for the Navy then working in local power
plants. The patient's daughter [**Name (NI) **] [**Name (NI) **] will bring the
patient to the procedure and arrange transportation home.
.
Tobacco: smoked cigars 40-50 years ago
ETOH: rare
Family History:
Brother died of a "heart" problem at the age of 88. He thinks
his mother may also have died of heart problems but he is not
really sure.
Physical Exam:
PHYSICAL EXAMINATION on admission
VS: T= 98 BP=102/41 HR=64 RR=18 O2 sat= 99% 2L
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 8 cm.
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
.
PHYSICAL EXAM ON DISCHARGE
VS: T 97.5, HR 60s, BP 120s/60s, RR 20, O2 sat 98% on RA
GEN: NAD, A&OX3
HEENT: supple, JVP ~ 8cm
HEART: RRR, good S1, S2, no m/r/g
LUNG: CTA BL
ABD: soft, NT/ND, no HSM
EXT: no pitting edema, DP/PT 2+ bilaterally
Pertinent Results:
ADMISSION LABS:
[**2156-12-14**] 07:30AM BLOOD WBC-7.4 RBC-3.50*# Hgb-11.3* Hct-32.3*
MCV-92 MCH-32.3*# MCHC-35.0 RDW-12.6 Plt Ct-159
[**2156-12-14**] 04:54PM BLOOD Neuts-75.8* Lymphs-17.2* Monos-5.7
Eos-0.9 Baso-0.4
[**2156-12-14**] 07:30AM BLOOD PT-11.9 PTT-25.1 INR(PT)-1.1
[**2156-12-14**] 07:30AM BLOOD Glucose-106* UreaN-35* Creat-1.5* Na-137
K-4.7 Cl-105 HCO3-23 AnGap-14
[**2156-12-14**] 04:54PM BLOOD ALT-36 AST-51* LD(LDH)-246 AlkPhos-48
TotBili-0.4
[**2156-12-14**] 04:54PM BLOOD Albumin-3.2* Calcium-7.9* Phos-3.6 Mg-1.9
[**2156-12-14**] 12:54PM BLOOD Type-ART pO2-179* pCO2-32* pH-7.38
calTCO2-20* Base XS--4 Intubat-INTUBATED
[**2156-12-14**] 12:54PM BLOOD Glucose-134* Lactate-0.7 Na-136 K-4.1
Cl-112*
[**2156-12-14**] 12:54PM BLOOD Hgb-9.2* calcHCT-28
.
DISCHARGE LABS:
[**2156-12-16**] 06:55AM BLOOD WBC-7.1 RBC-3.32* Hgb-10.6* Hct-30.1*
MCV-91 MCH-31.9 MCHC-35.1* RDW-13.3 Plt Ct-107*
[**2156-12-16**] 06:55AM BLOOD PT-12.1 PTT-23.9* INR(PT)-1.1
[**2156-12-16**] 06:55AM BLOOD Glucose-98 UreaN-25* Creat-1.2 Na-134
K-4.8 Cl-105 HCO3-23 AnGap-11
[**2156-12-16**] 06:55AM BLOOD Calcium-8.6 Phos-3.3 Mg-2.1
.
URINE:
[**2156-12-16**] 10:24AM URINE Blood-LG Nitrite-NEG Protein-TR
Glucose-150 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR
[**2156-12-16**] 10:24AM URINE RBC-89* WBC-15* Bacteri-FEW Yeast-NONE
Epi-<1
.
MICROBIOLOGIC DATA:
[**2156-12-14**] MRSA screen - pending
[**2156-12-14**] Blood culture - pending
.
CYTOLOGY
[**12-16**] urine - pending
.
IMAGING STUDIES:
[**2156-12-14**] CXR - ReportLeft transvenous pacemaker leads end in the
standard position within the right Preliminary Reportatrium,
right ventricle and through the coronary sinus. There is no
pleural Preliminary Reporteffusion or pneumothorax. Bilateral
lungs are expanded and clear. Ill-defined
Preliminary Reportopacity with lucency in the right lower
paracardiac region is likely a Preliminary Reportherniated bowel
loop. Mildly enlarged heart size, mediastinal and hilar
Preliminary Reportcontours are normal. Aortic arch and
descending thoracic aorta are moderately calcified (Preliminary
Report).
.
[**2156-12-15**] CT ABD & PELVIS W & W/O
IMPRESSION
1. No evidence of retroperitoneal or intra-abdominal bleed.
2. Heterogeneous high-density material within the bladder which
is
nondependent and appears adherent to the bladder wall. Recommend
further
evaluation with contrast-enhanced CT/MRI or ultrasound.
3. Benign-appearing bony lesion in the right ilium is most
consistent with a bone island. Given no history of prostate
cancer, attention on followup
studies is indicated.
4. Large midline abdominal wall hernia containing loops of
unobstructed small bowel without evidence of incarceration or
strangulation.
5. Small left pleural effusion and trace right pleural effusion
with right
pleural thickening.
6. Cholelithiasis.
7. Large hiatal hernia.
.
[**2156-12-15**] 2D-ECHO - The left atrium is mildly dilated. No atrial
septal defect is seen by 2D or color Doppler. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity is moderately dilated. There is moderate regional left
ventricular systolic dysfunction with inferior and
infero-lateral akinesis (LVEF 35%). No masses or thrombi are
seen in the left ventricle. There is no ventricular septal
defect. The right ventricular cavity is mildly dilated with
borderline normal free wall function. There is abnormal septal
motion/position. 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. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
Brief Hospital Course:
This is an 86 year-old with a history of coronary artery disease
who is s/p CABG x 5 in [**2156**] who
presented with a history of ventricular tachycardia and
underwent ablation on [**2156-12-14**] with procedure complicated by
gross hematuria.
.
ACTIVE ISSUES
# GROSS HEMATURIA - The patient underwent his ventricular
tachycardia ablation on [**2156-12-14**] and was noted to have gross
hematuria with clot burden following Foley catheterization; with
evidence of a hemtocrit drop from 32.3% to 23.3%. He was
admitted to the Coronary care unit for closer monitoring and was
transfused 2 units of packed red blood cells. His hematocrit
improved to 27% following transfusion. Urologic surgery was
consulted and placed a three-way irrigating Foley catheter. He
had some residual clot burden, but this was otherwise stable.
Urine cytology was obtained and an outpatient cystoscopy will be
performed. He remained hemodynamically stable otherwise.
Terazosin and Finasteride were continued.
.
# VENTRICULAR TACHYCARDIA, STATUS-POST ABLATION - The patient
has a history of ventricular tachycardia. His EP study was
notable for a mixed cardiomyopathy with inferior scar and global
LV dysfunction. Multiple morphologies of VT were noted, induced
with programmed electrical stimulation; all eminating from the
scar. Two morphologies were successfully ablated after mapping -
along basal, septal and lateral scar margins. The patient had no
further episodes of ventricular tachycardia following the
ablation and remained hemodynamically stable. He received single
doses of Vancomycin and Ceftriaxone following his procedure for
prophylaxis. He was not continued on any anti-arrhythmics.
.
CHRONIC ISSUES
# CORONARY ARTERY DISEASE - The patient has a history of
significant coronary disease and markedly depressed ejection
fracture with nuclear imaging showing irreversible deficits from
prior ischemic events. He presented without chest pain or
concern for active ischemia for his outpatient VT ablation. We
continued his Aspirin, ACEI, Carvedilol, Simvastatin and Imdur,
his home medications.
.
# CONGESTIVE HEART FAILURE - The patient's home heart failure
regimen was continued and he had no evidence of volume overload
or signs of exacerbation of his underlying heart failure. We
aimed for his goal fluid balance to be even and continued his
ACEI, beta-blokcer, Lasix and Spironolactone. His daily weights,
in's and out's and fluid balances were closely monitored.
.
# HYPERTENSION - We continued his Carvedilol, Lisiniopril and
Imdur.
.
# HYPERLIPIDEMIA - We continued Simvastatin at his home dosing.
.
# PERIPHERAL NEUROPATHY - We continued Gabapentin at his home
dosing.
.
TRANSITION OF CARE ISSUES:
# CODE STATUS: Full
# PENDING STUDIES AT DISCHARGE:
- Blood culture [**12-14**] - NGTD
- MRSA screening - pending
- Urine cytology - [**12-15**]
# MEDICATION CHANGES
- START aspirin 81 mg qd
# FOLLOW UP PLAN
- PCP follow up on [**2156-12-24**]
- Urology follow up on [**2156-12-27**] for cystoscopy
- Continue with routine pacemaker followup
Medications on Admission:
CARVEDILOL 12.5 mg Tablet by mouth twice a day
ISOSORBIDE MONONITRATE 60 mg Tablet ER by mouth once a day
SIMVASTATIN 10 mg Tablet by mouth once a day
ASPIRIN 325 mg Tablet by mouth once a day
LISINOPRIL 10 mg Tablet by mouth once a day
FUROSEMIDE 20 mg Tablet by mouth every other day
MEGESTROL 625mg/5 mL Suspension - 1 (One) tsp by mouth every day
NITROGLYCERIN 0.4 mg Tablet SL every 5 minutes X 2 PRN chest
pain
OMEPRAZOLE 20 mg Capsule EC by mouth twice a day
POLYETHYLENE GLYCOL 3350 [MIRALAX] 17 gram PO once a day
Terazosin 1mg QHS
FINASTERIDE 5 mg Tablet by mouth once a day
GABAPENTIN 900 mg Capsule in the morning, 300mg Capsule at night
Discharge Medications:
1. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
3. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. furosemide 20 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
6. Megace ES 625 mg/5 mL Suspension Sig: Five (5) mL PO once a
day.
7. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual every 5-minutes as needed for chest pain: Please do
not use more than 3 times total at one time.
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
9. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily).
10. terazosin 1 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
11. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. gabapentin 300 mg Capsule Sig: Three (3) Capsule PO QAM
(once a day (in the morning)).
13. gabapentin 300 mg Capsule Sig: One (1) Capsule PO QPM (once
a day (in the evening)).
14. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*0*
15. Outpatient Lab Work
Please obtain lab for CBC and sent the result to
Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] at [**Hospital1 **] [**Hospital1 1474**] Tele: [**Telephone/Fax (1) 17919**], Fax:
[**Telephone/Fax (1) 87528**]
Discharge Disposition:
Home With Service
Facility:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Care
Discharge Diagnosis:
Primary Diagnoses:
1. Acute gross hematuria
2. Ventricular tachycardia ablation
.
Secondary Diagnoses:
1. Hypertension
2. Hyperlipidemia
3. Ischemic cardiomyopathy
4. Biventricular ICD placement
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 56636**],
.
You came to our hospital for a procedure for your recurrent
abnormal heart rhythm called ventricular tachycardia. You
underwent successful ablation in the cath lab. However, you
were found to have bleeding in your urine, and was admitted to
the Coronary Care Unit (CCU). Urology was consulted regarding
the management of your bloody urine and an irrigating Foley
catheter was placed. You were transfused 2 units of packed red
blood cells given a drop in your hematocrit. A CT study showed
normal kidneys with some concern for a bladder mass or residual
clot burden. You will follow-up with Urology as an outpatient
and a cystoscopy will be performed.
.
Please call your doctor or go to the emergency department if:
* You experience new chest pain, pressure, squeezing or
tightness.
* You develop new or worsening cough, shortness of breath, or
wheezing.
* You are vomiting and cannot keep down fluids, or your
medications.
* If you are getting dehydrated due to continued vomiting,
diarrhea, or other reasons. Signs of dehydration include: dry
mouth, rapid heartbeat, or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit, or have a
bowel movement.
* You experience burning when you urinate, have blood in your
urine, or experience an unusual discharge.
* Your pain is not improving within 12 hours or is not under
control within 24 hours.
* Your pain worsens or changes location.
* You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
* You develop any other concerning symptoms.
.
CHANGES IN YOUR MEDICATION RECONCILIATION:
- Please STOP taking aspirin 325 mg, instead, please START to
take aspirin 81 mg tablet by mouth once daily
.
* You should continue all of your other home medications as
prescribed, unless otherwise directed above.
.
It has been a pleasure taking care of you here at [**Hospital1 18**]. We
wish you a speedy recovery.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) 4094**]: INTERNAL MEDICINE
Location: [**Hospital1 **] HEALTHCARE - [**Hospital1 **]
Address: ONE PEARL ST, [**Apartment Address(1) 12836**], [**Hospital1 **],[**Numeric Identifier 9647**]
Phone: [**Telephone/Fax (1) 17919**]
Appointment: FRIDAY [**12-25**] AT 11:15AM
Department: SURGICAL SPECIALTIES
When: MONDAY [**2156-12-27**] at 2:10 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4653**], MD [**Telephone/Fax (1) 164**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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"356.9",
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"428.0",
"V45.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.34",
"37.26",
"37.27"
] |
icd9pcs
|
[
[
[]
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] |
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|
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|
317, 373
|
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,025
| 113,878
|
37220
|
Discharge summary
|
report
|
Admission Date: [**2171-8-29**] Discharge Date: [**2171-9-13**]
Date of Birth: [**2125-1-16**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 949**]
Chief Complaint:
GI Bleed
Major Surgical or Invasive Procedure:
Left internal jugular central vein line placement
History of Present Illness:
Mr. [**Known lastname 1024**] is a 46 year old gentleman with a PMH EtOH cirrhosis
c/b multiple prior UGIBs and past possible HRS, continued
alcohol abuse c/b seizures, CKD (had been on HD until [**Month (only) **]
[**2169**]), now being transferred from [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for management of
hypovolemic shock secondary to GI bleed, and possible TIPS
procedure.
History obtained from OMR and OSH records, as well as
conversation with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ICU nurse, as patient is
intubated and sedated.
[**Name (NI) **] girlfriend reported to OSH that patient had filled
four "buckets" of bloody emesis at home, and was then convinced
to go to the ED at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2171-8-27**]. On arrival, patient
was only able to speak in short sentences, but was making little
sense. VS on arrival were BP 91/37 HR 160 RR 20 (temperature and
SaO2 not recorded). He became obtunded, and was intubated
shortly thereafter, with Fentanyl boluses, followed by propofol
drip. Labs were notable for: H/H 2.8/8.2, Plts 64, Cr 3.9, INR
2.6, urine tox positive for oxycodone, EtOH level 238, and UCx
with 100,000 Coag negative staph. OG tube was placed, and this
prouced another container full of bloody emesis. Massive
transfusion protocol was initiated in the ED, and patient was
given 4 units FFP, 2 units of PRBC and 4 Liters of NS. EGD that
evening showed erosive esophagitis, Barrett's esophagus, coffee
grounds in stomach, and a suggestion of duodenal varices.
Gastroenterologists at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] hypothesized that the
patient may have been chronically bleeding from his
esophagitis/varices, as they could find little evidence of
active bleeding. During his admission at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], he
received a total of 10 units PRBCs, 7 units FFP, and two 6-packs
of platelets. He was kept on octreotide drip (began [**8-27**]) and
pantoprazole 40 mg IV BID ([**8-27**]). He was also treated with Zosyn
for possible aspiration pneumonia (starting on [**2171-8-27**]). For
sedation, he was kept on propofol for sedation with lorazepam IV
boluses as needed. Prior to transfer to [**Hospital1 18**] labs H/H [**7-11**], and
plt 25 @ 1200 today. For access, he had a right triple lumen CVL
and a left a-line. He also had an OG tube, and fully matured RUE
AV fistula (not used since [**69**]/[**2169**]). He was transferred to [**Hospital1 18**]
for further management, including possible capsule endoscopy,
balloon enteroscopy and/or TIPS.
On arrival to the MICU, patient was intubated and sedated, but
appeared comfortable.
Past Medical History:
1. Multiple admissions to [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 83800**] for upper and lower GI
bleeds. Most recently at [**Hospital1 18**] UGIB, admitted [**Date range (3) 83801**]:
transfused 9U PRBC, 8U FFP and 10U plts. No noted varices on EGD
[**2171-4-2**]. Thought to be secondary to erosive esophagitis.
2. EtOH cirrhosis: acute EtOH hepatitis in [**8-27**] (was not
started on corticosteroids due to GI bleed, UTI and [**Last Name (un) **]); was
started on pentoxyphyline to prevent HRS with a planned 4 week
course from [**2168-9-26**] (last day [**2168-10-24**]); negative hepatitis A, B
and C serologies. Complicated by GI bleeds as above in the past
(but no varices), and possible history of HRS.
3. CKD: Cr baseline around 3.0. Was HD-dependent via RUE fistula
until [**2170-9-18**]. Diagnosis was multifactorial from ATN +/-
NSAIDs +/- HRS
4. MRSA bacteremia [**2171-10-23**] treated with vancomycin
5. EtOH abuse with h/o seizures in the setting of heavy alcohol
consumption
6. Gastroesophageal Reflux Disease
7. MVA [**3-/2153**]: Right femur fracture with [**Male First Name (un) **] placement, pelvic
fracture
8. Asthma
Social History:
Has never smoked. Drank [**11-22**] Vodka daily until recently, but
denies drinking in the past 4 months (last drink first week of
[**Month (only) 359**]). Never has used IV drugs. Lives with girlfriend, [**Name (NI) 5627**]
[**Name (NI) 83758**] [**Telephone/Fax (1) 83759**]. Has 2 children, daughter 17, son, 16
who live with their mother who the patient is still very close
to. Pt formerly worked at Mass Electric.
Family History:
Mother - Deceased [**12-20**] alcoholic liver disease
Father - Deceased [**12-20**] [**Name2 (NI) 499**] cancer, diagnosed in his 40s. No
other family history of [**Name2 (NI) 499**] cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: T: 97.8 nBP: 100/56 aBP: 136/66 P: 74 R: 18
SaO2: 100% on AC TV 500 RR 12 FiO2 50% PEEP 5
General: Intubated/sedated, appears comfortable
HEENT: Scleral icterus, PERRL, no head trauma.
Neck: Unable to assess JVP due to habitus. Right IJ in place
without surrounding hematoma or erythema.
CV: Regular rate and rhythm, normal S1/S2, II/VI systolic murmur
loudest at the LLSB.
Lungs: Upper airway sounds of ventilation transmitted
throughout. Breath sounds throughout anterior lungfields.
Abdomen: Distended with tense subcutaneous edema worse on flanks
bilaterally. Unclear whether distention is primarily from
anasarca vs. underlying ascites. Unable to assess for
hepatosplenomegaly due to distention. Slight erythema on lower
abdomen. Minimal scrotal edema and erythema.
GU: + Foley
Ext: Onchonychia. 2+ distal pulses. 2+ pitting edema in UE
bilaterally. RUE with prominent fistula, +thrill. Lower
extremities with 4+ pitting edema to halfway up thighs.
Neuro: Opens eyes to voice. Opens and closes eyes on command,
but does not squeeze hands. Withdraws to pain.
DISCHARGE EXAM
VS: 99.8 98.8 89 130/60 20 92% RA
GENERAL: NAD.
HEENT: NCAT. Icteric sclera. MMM.
CARDS: RRR no MRG
PULM: CTAB. Decreased breath sounds right base.
ABD: NABS. Soft NT/ND.
EXT: 2+ edema BL to knees
Pertinent Results:
ADMISSION LABS
[**2171-8-29**] 07:49PM BLOOD WBC-5.4# RBC-2.90* Hgb-9.1* Hct-27.1*
MCV-93 MCH-31.4 MCHC-33.7 RDW-16.7* Plt Ct-36*
[**2171-8-29**] 07:49PM BLOOD Neuts-87.6* Lymphs-6.9* Monos-5.4 Eos-0.1
Baso-0
[**2171-8-29**] 07:49PM BLOOD PT-14.8* PTT-30.9 INR(PT)-1.4*
[**2171-9-1**] 03:11AM BLOOD Fibrino-173*
[**2171-8-29**] 07:49PM BLOOD Glucose-184* UreaN-93* Creat-4.2* Na-139
K-4.3 Cl-107 HCO3-21* AnGap-15
[**2171-8-29**] 07:49PM BLOOD ALT-60* AST-97* LD(LDH)-171 CK(CPK)-159
AlkPhos-90 Amylase-207* TotBili-6.2*
[**2171-8-29**] 07:49PM BLOOD CK-MB-4 cTropnT-0.15*
[**2171-8-30**] 02:15AM BLOOD CK-MB-4 cTropnT-0.14*
[**2171-8-29**] 07:49PM BLOOD Albumin-3.1* Calcium-7.9* Phos-5.8*#
Mg-2.1 UricAcd-12.6* Cholest-94
[**2171-8-29**] 07:49PM BLOOD Triglyc-134 HDL-31 CHOL/HD-3.0 LDLcalc-36
LDLmeas-<50
[**2171-8-29**] 07:49PM BLOOD Osmolal-330*
[**2171-8-29**] 07:49PM BLOOD TSH-0.76
[**2171-8-29**] 08:09PM BLOOD Type-ART Temp-36.7 Tidal V-500 PEEP-5
FiO2-50 pO2-104 pCO2-38 pH-7.36 calTCO2-22 Base XS--3
-ASSIST/CON Intubat-INTUBATED
[**2171-8-29**] 08:09PM BLOOD Lactate-1.1
IMAGES AND PROCEDURES:
CXR [**8-29**]
FINDINGS: Portable semi-upright chest radiograph was obtained.
Endotracheal tube terminates at the level of the carina and
should be withdrawn 2-3 cm. Orogastric tube courses into the
stomach and out of view. Right IJ catheter likely terminates in
the right atrium and can be withdrawn 4 cm for more optimal
positioning. Consider repeat radiograph after repositioning.
Bilateral pleural effusions and dense retrocardiac opacity are
noted, with low lung volumes and possible mild pulmonary edema.
Moderate cardiomegaly noted.
CXR [**9-10**]
FINDINGS: In comparison with study of [**8-31**], the degree of
pulmonary vascular congestion has somewhat decreased, though
part of this may be due to the upright position. Substantial
enlargement of the cardiac silhouette persists with large right
pleural effusion with atelectasis involving the right middle and
lower lobes. Blunting of the left costophrenic angle is seen but
the left chest is otherwise clear.
ECHO [**8-31**]
The left atrium is moderately dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). There is an abnormal systolic flow contour
at rest, but no left ventricular outflow obstruction. The right
ventricular cavity is mildly dilated with mild global free wall
hypokinesis. The ascending aorta is mildly dilated. 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. Physiologic mitral
regurgitation is seen (within normal limits). There is moderate
pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion. IMPRESSION: Mild
symmetric left ventricular hypertrophy with near hyperdynamic
left ventricular systolic function. Dilated and hypokinetic
right ventricle with mild tricuspid regurgitation and mild to
moderate pulmonary hypertension. Compared with the prior study
(images reviewed) of [**2170-1-3**], the right ventricle appears
dilated and hypokinetic with elevated pulmonary pressures.
Colonoscopy [**8-30**]
Normal colonic mucosa from rectum up to the cecum. No signs of
active bleeding. One small diverticula seen in the ascending
[**Month/Year (2) 499**]. Retroflexed view revealed small internal hemorrhoids
Otherwise normal colonoscopy to cecum
EGD [**8-30**]
Severe esophagitis in lower esophagus with what appeared 2
tongues of salmon colored mucosa left undisturbed.Moderate to
severe diffuse portal gastropathy without signs of active
bleeding. Normal duodenum bulb, second portion and normal small
bowel mucosa up to proximal jejunum Otherwise normal EGD to
second part of the duodenum
CXR [**8-31**]
A radiograph centered at the thoracoabdominal junction was
obtained to assess for placement of an orogastric tube, which
terminates within the stomach. Within the chest, endotracheal
tube and central venous catheter are unchanged in position, and
there remains marked enlargement of the cardiac silhouette, now
accompanied by mild pulmonary vascular congestion. Worsening
homogeneous opacity in the right mid and lower lung region
likely represents a combination of a large right pleural
effusion and atelectasis involving the right middle and right
lower lobes.
Portable CXR [**9-10**]
Small left pleural effusion has minimally increased. Moderate
right pleural effusion is probably unchanged allowing the
difference in positioning of the patient, decreased though from
[**8-31**]. There is no evident pneumothorax. Cardiomegaly is
obscured by the pleural effusions. Right lower lobe and right
middle lobe atelectases have improved. There are increasing
atelectases in the left lower lobe.
PA and Lateral CXR [**9-11**]
FINDINGS: PA and lateral views of the chest are obtained.
Since the prior study, there is interval improvement of right
pleural effusion. There is also evidence of right middle lobe
atelectasis with associated volume loss. The previously seen
left lower lobe atelectasis is improved since the prior study.
There is no pneumothorax. Cardiac size is unchanged.
CONCLUSION: Improved right pleural effusion and left lower lobe
atelectasis with persistent right middle lobe atelectasis and
volume loss. No pneumothorax.
KEY LAB STUDIES:
Pleural fluid ([**9-11**])
ANALYSIS WBC RBC Polys Lymphs Monos Meso Macro Other
[**2171-9-11**] 17:51 1000* [**Numeric Identifier 22065**]* 2* 48* 0 1* 49*1 02
PLEURAL CHEMISTRY TotProt Glucose LD(LDH) Albumin Cholest
[**2171-9-11**] 17:51 1.5 89 172 < 1.0 24
GRAM STAIN (Final [**2171-9-11**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
Urine Cultures Negative
Blood Cultures Negative
DISCHARGE LABS:
[**2171-9-12**] 06:15AM BLOOD WBC-2.9* RBC-2.87* Hgb-9.2* Hct-27.0*
MCV-94 MCH-31.9 MCHC-33.9 RDW-17.1* Plt Ct-85*
[**2171-9-12**] 06:15AM BLOOD PT-14.3* PTT-38.5* INR(PT)-1.3*
[**2171-9-12**] 06:15AM BLOOD Glucose-86 UreaN-22* Creat-4.2*# Na-134
K-3.6 Cl-97 HCO3-34* AnGap-7*
[**2171-9-12**] 06:15AM BLOOD ALT-14 AST-27 LD(LDH)-165 AlkPhos-122
TotBili-3.2*
[**2171-9-12**] 06:15AM BLOOD TotProt-5.3* Albumin-2.9* Globuln-2.4
Calcium-8.1* Phos-2.5* Mg-1.9
Brief Hospital Course:
Mr. [**Known lastname 1024**] is a 46 year old gentleman with a PMH EtOH cirrhosis
c/b multiple GI bleeds, CKD with baseline and ongoing alcohol
abuse, transferred to [**Hospital1 18**] for further evaluation of GI bleed.
# GI bleed: Unclear source, as EGD revealed no prominent active
bleed; most likely sources include erosive esophagitis and
duodenal varices, although these may not account for the amount
of blood loss evidenced by blood counts at OSH. Hematemesis,
melena, brisk tempo of bleeds and precipitous in counts would
also be more consistent with upper GI source. He was transferred
for further exploration with possible EGD/[**Last Name (un) **] vs. capsule
study, with consideration of TIPS, based on findings. Patient
was hemodynamically stable (normal HR and BP) on admission to
MICU, with H/H increased to [**8-15**] after massive blood product
repletion at OSH. On [**2171-8-30**] EGD showed no sign of active
bleeding, severe esophagitis, moderate gastropaty and
colonoscopy was unremarkable. This raised the possibility of a
portal gastropathy. His CVL from OSH was removed and new line
placed in LIJ. Octreotide and pantoprazole now since [**2171-8-27**],
octreotide discontinued on [**2171-9-2**]. He was started on Zosyn for
the possibility of an aspiration PNA (see below) which also
doubled as SBP prophylaxis and he completed a 7 day course on
[**2171-9-3**]. Capsule endoscopy on floor did not function properly,
perhaps secondary to body habitus. Patient thereafter monitored,
with stable hematocrit for nearly 2 weeks thereafter as patient
awaited placement in rehab. Ultimately, his blood losses were
thought to be secondary to gastropathy.
# Cirrhosis: MELD 27 on discharge(mortality over 3 months =
20%). Secondary to alcholic liver diseases, with prior
decompensations from GI bleeds and possible HRS. No known
hepatic encephalopathy, ascites or variceal bleeds. Patient was
removed from transplant list in [**2169**] for failure to keep
appointments and relapse with alcohol use. Octreotide,
pantoprazole and Zosyn were continued as above. After completion
of his EGD/colonoscopy and following his extubation on [**2171-9-1**],
he was started on lactulose and rifaximin for prevention of
hepatic encephalopathy. These medications were continued on
discharge.
# Pleural effusion: Patient found to have pleural effusion on
CXR. Per prior reports and notes, has been longstanding and
likely [**12-20**] volume overload and was previously characterized as
hepatic hydrothorax following pleural effusion analysis several
months prior to admission. Patient offered thoracentesis, but
was initially very against the idea and declined, preferring
instead to allow dialysis to take off fluid. Patient ultimately
agreed to the procedure, and it was performed on [**2171-9-11**].
Extended light's criteria suggested transudative effusion.
Post-procedure portable XR raised concern of trapped lung, but
repeat PA and lateral XR was unremarkable. He may require
periodic thoracentesis if fluid reaccumulates and he develops
dyspnea or coughing.
# Acute on chronic kidney disease: Creatinine elevated on
admission to 4.2 from baseline in the low 3 range, with urine
electrolytes consistent with prerenal azotemia. There was
concern for developing HRS, especially in setting of GI bleed,
but the patient was still making urine so it was considered less
likely. Clincially, he was total body volume overloaded with
extensive peripheral edema. Patient was briefly trialed on
furosemide drip, but experienced worsening creatinine and after
discussion with renal it was decided to move forward with
ultrafiltration in order to remove his excess fluid (5L off on
[**8-31**]). Thereafter, patient was initiated on hemodialysis and
will continue a MWF course via his RUE AVF. A small
pseudoaneurysm was appreciated- he was evaluated by transplant
surgery who will follow him as an outpatient.
# Urinary tract infection: On [**9-12**], patient developed low grade
fevers. Continued to cough, but cough was slightly improved s/p
thoracentesis mentioned above. Patient also with chills, some
sweats. UA suggestive of urinary tract infection, so patient was
started on levaquin with dosing to also cover a potential
pulmonary source as well. Will complete roughly 5d of treatment.
# Aspiration Pneumonia: Based on retrocardiac opacity on CXR, as
well as concern for aspiration reported from OSH. Treated with
Zosyn as mentioned previously, remained afebrile without
leukocytosis while in ICU.
# Alcohol abuse: Continued through current admission, with EtOH
level 238 on admission. Initially patient was on midazolam drip
as well. Because of history of seizures during alcohol
intoxication, and patient was closely monitored. Patient did
well and did not show evidence of withdrawal. Received
counseling and SW consultation with a focus on rela
# UTI: Noted at OSH, treated with total 7 days of Zosyn. Was
coag negative staph. Repeat cultures were negative.
# Supraventricular Tachycardia: he developed a narrow-complex
tachycardia during dialysis session on [**9-6**] with pulse
instantaneously rising to 130 from 80. Was asymptomatic. EKG
appeared consistent with AVNRT. Failed vagal maneuvers. Broke
with IV metoprolol and he maintained sinus rhythm for the
remainder of the hospitalization after we re-initiated his
home-dose metoprolol tartrate [**Hospital1 **].
TRANSITIONAL ISSUES:
- patient to continue levaquin with a dose of 500 mg on [**9-15**]
and [**9-17**] (500 mg q48hr) to complete ~5 day course for UTI
- patient to continue hemodialysis once discharged from hospital
- patient may need repeat thoracentesis for hepatic hydrothorax.
Please evaluate with CXR if he has increased coughing or
shortness of breath.
- followup/workup of microhematuria seen repeatedly on UA
- watch phos level (decreased sevelamer from 1600TID to 800TID
b/c phos on low side)
- watch potassium level (patient has required replacement)
- f/u in liver clinic
FOLLOW UP:
- patient will need PCP followup after [**Name Initial (PRE) **]/c from rehab
- outpatient nephrology f/u
- transplant surgery f/u for AVF pseudoaneurysm
- aggressive social work support for alcohol relapse prevention
PENDING STUDIES:
- Pleural fluid culture (NGTD)
- Pleural fluid cytology
- Urine culture (NGTD)
- Blood culture (NGTD)
MEDICATION REGIMEN:
- CONTINUE metoprolol as previously
- START NEW MEDS lactulose, rifaximin, pantoprazole, sucralfate,
nephrocaps, sevelamer, miconazole powder, multivitamins,
thiamine, folic acid
- DISCONTINUE spironolactone
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Tartrate 25 mg PO BID
2. Spironolactone 25 mg PO DAILY
Discharge Medications:
1. Metoprolol Tartrate 25 mg PO BID
RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*2
2. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth DAILY Disp #*30 Tablet
Refills:*3
3. Multivitamins 1 TAB PO DAILY
RX *multivitamin [Daily Multi-Vitamin] 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*2
4. Thiamine 100 mg PO DAILY
RX *thiamine HCl [Vitamin B-1] 100 mg 1 tablet(s) by mouth DAILY
Disp #*30 Tablet Refills:*2
5. Lactulose 30 mL PO TID
please titrate to [**1-20**] bowel movements a day
RX *lactulose 10 gram/15 mL 30 cc by mouth three times a day
Disp #*3 Liter Refills:*1
6. Miconazole Powder 2% 1 Appl TP TID
RX *miconazole nitrate [Lotrimin AF Powder] 2 % rash [**Hospital1 **]:PRN
Disp #*1 Container Refills:*3
7. Nephrocaps 1 CAP PO DAILY
RX *B complex-vitamin C-folic acid [Nephrocaps] 1 mg 1
capsule(s) by mouth DAILY Disp #*30 Capsule Refills:*2
8. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*2
9. Rifaximin 550 mg PO BID
RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*2
10. sevelamer CARBONATE 1600 mg PO TID W/MEALS
RX *sevelamer carbonate [Renvela] 800 mg 2 tablet(s) by mouth
three times a day Disp #*180 Tablet Refills:*2
11. Sucralfate 1 gm PO QID
RX *sucralfate 1 gram 1 tablet(s) by mouth four times a day Disp
#*120 Tablet Refills:*2
12. Levofloxacin 500 mg PO 2X Duration: 1 Doses
dose on [**9-15**] and [**9-17**] after dialysis
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 8957**]
Discharge Diagnosis:
GI Bleed
Alcholic cirrhosis
Aspiration pneumonia
Acute Tubular Necrosis secondary to hypovolemic shock
Volume overload
Urinary tract infection
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 1024**],
It was a pleasure being involved in your care. You were admitted
first to the ICU at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospital for for concern of
severe bleeding into your GI tract and then transferred here. It
was reported that you had vomited several buckets of blood. When
your blood counts were done, they were found to be EXTREMELY
low. The bloody vomit is certainly related to alcohol abuse. An
endoscopy and a colonoscopy were done to look for a site of
bleeding. When we did not find one, we did a capsule endoscopy
(you swallowed a pill with a camera) to look for bleeding in
your small intestine. This was also unrevealing. The bleed
likely originated from gastric (stomach) inflammation which was
seen on the scope study.
During this episode you were noted to be very confused. This can
happen with severe liver disease. We gave you lactulose and
rifaximin to make you have bowel movements. Your mental status
eventually cleared on these medicines.
There was a high suspicion that you had inhaled stomach contents
while you were confused because you were not clearing your
airway properly. We treated you with an 8 day course of the
powerful IV antibiotic Zosyn.
Also since you had low blood pressures, the ICU had to give you
many liters of fluid to keep your blood pressure high enough.
Unfortunately, this caused your tissues to swell up. After your
episodes of low blood pressure resolved, the nephrologists
(kidney doctors) took 10 liters of fluid out of your body with
ultrafiltration and then gave you dialysis on [**9-4**] to support
your kidney function, which remains extremely poor. You will be
continuing hemodialysis on an outpatient basis.
Prior to discharge, on [**9-12**], you were found to have a low grade
fever. We looked at your urine, which suggested a urinary tract
infection. We are treating you with antibiotics.
It is important that you take the medicines we prescribe after
discharge EXACTLY AS PRESCRIBED. Please see them attached.
Briefly:
- please CONTINUE metoprolol as previously
- please START NEW MEDS levofloxacin, lactulose, rifaximin,
pantoprazole, sucralfate, nephrocaps, sevelamer, miconazole
powder, multivitamins, thiamine, folic acid
- please DISCONTINUE spironolactone
Followup Instructions:
Please follow up with your PCP after discharge from rehab:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] P.
Location: [**Hospital 46644**] MEDICAL ASSOCIATES
Address: [**Location (un) 32946**], [**Location (un) **],[**Numeric Identifier 32948**]
Phone: [**Telephone/Fax (1) 32949**]
Fax: [**Telephone/Fax (1) 64198**]
Department: LIVER CENTER
When: THURSDAY [**2171-9-19**] at 9:20 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Name: [**Last Name (LF) 7674**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital 46644**] MEDICAL ASSOCIATES
Address: [**Location (un) 32946**], [**Location (un) **],[**Numeric Identifier 12023**]
Phone: [**Telephone/Fax (1) 32949**]
Appointment Thursday [**2171-9-26**] 3:10pm
Department: TRANSPLANT CENTER
When: MONDAY [**2171-9-30**] at 10:45 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 14955**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2171-9-13**]
|
[
"511.89",
"285.1",
"427.89",
"537.89",
"456.8",
"571.2",
"V12.04",
"698.9",
"599.0",
"455.0",
"572.2",
"276.2",
"553.20",
"585.4",
"562.10",
"276.69",
"507.0",
"530.19",
"785.59",
"578.9",
"303.90",
"493.90",
"287.5",
"V16.0",
"518.81",
"584.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97",
"34.91",
"45.23",
"96.71",
"39.95",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
21019, 21093
|
12727, 18124
|
312, 363
|
21280, 21280
|
6332, 12231
|
23784, 25130
|
4788, 4981
|
19467, 20996
|
21114, 21259
|
19314, 19444
|
21463, 23761
|
12247, 12704
|
4996, 6313
|
18720, 19288
|
18145, 18709
|
264, 274
|
391, 3149
|
21295, 21439
|
3171, 4335
|
4351, 4772
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,181
| 129,110
|
12038
|
Discharge summary
|
report
|
Admission Date: [**2176-3-16**] Discharge Date: [**2176-4-6**]
Date of Birth: [**2152-3-29**] Sex: M
Service: MEDICINE
Allergies:
Benzocaine / Zosyn / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
OSH Transfer for Aspiration Pneumonia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 23 yo M with [**First Name3 (LF) **]'s Syndrome who initially
presented to an OSH ([**2176-3-11**]) with aspiration PNA requiring
intubation. The patiet was at his group home facility ([**Location (un) 32944**]
Village) when he was found to have a blood sugar of 30. He was
given a can of Ensure orally which he aspirated resulting in
hypoxia. He was given IM glucagon. Paramedics attempted to
intubate the patienet but were unsuccessful. He was brought to
an OSH ER where his O2 sats were 45%, HR 45. He was successfully
intubated. He was admitted to the OSH MICU. Sputum cultures
grew MRSA and the patient was started on vancomycin and
clindamycin to cover for aspiration and mrsa pneumonia. He was
extubated after 2 days, continued on positive pressure
ventilation for another 24 hours and then maintained on
supplemental O2. He has been continued on his home BiPAP 17/5
at night. He has been oxygenating well since extubation with
oxygen supplementation. His initial xray was not remarkable,
but a repeat chest x-ray showed development of bilateral
infiltrates.
During his hospital course the patient had episodes of sinus
tachycardia and was started on a cardizem drip. He was also
seen by neurology for questionable seizure activity during they
attributed to hypoxia after his aspiration event. They
recommended continued antiepileptic medication.
The family requested transfer to [**Hospital1 18**] where he has had the
majority of his care. On the day of transfer the patient
received KCL 40mg PO x 3.
Currently denies chest pain, abdominal pain, nausea, or
vomiting. He reports thirst.
Past Medical History:
- [**Hospital1 **]'s syndrome (DIDMOAD)
- recurrent Aspiration pneumonia (MRSA/Pseudomonas/VRE)
- Central hypoventilation (ventilator dependent at night); sleep
apnea
- History of hypoglycemic seizures.
- Bladder Disorder --> being worked up by Dr. [**Last Name (STitle) 1454**] at
[**Hospital1 1926**]. Was being straigth cath'd daily.
- Hypothyroidism secondary to Hashimoto thyroiditis.
- Anxiety disorder.
- Depression.
- Questionable history of epilepsy.
- History of supraventricular tachycardia (AVNRT) s/p ablation
- History of pilonidal cyst.
- Diabetes insipidus/sodium imbalance.
- Diabetes mellitus.
- Status post PEG
- Status post tracheostomy now decannulated
- Status post laparoscopic Nissen fundoplication [**12-31**]
Social History:
Lives in a Nursing Facility. His mother is his HCP. His
[**Name2 (NI) **] are divorced but both are involved in his care. He
graduated from [**Doctor Last Name 32496**] School for the blind. He works out with
a "personal trainer" everyday at his nursing home facility.
Family History:
No other member of his family with symptoms of Wolframs
syndrome.
Physical Exam:
Temp on admission 102 BP 136/75 HR 130 RR 23 Sat 92%
Gen: young male lying in bed, appears comfortable, answering
questions appropriately
HENNT: dry mucous membranes, anicteric, PERRL, horizontal
nystagmus; + conjuntivitis (R>L)
Neck: no LAD, no JVD
CV: RRR, nl S1S2, No M/R/G
Lungs: decreased breath sounds at right lung base; diffuse
rhonchous breath sounds
Abd: soft, NT/ND, +BS, No HSM
Ext: edema, strong DP/PT pulses bilaterally
Neuro: A&Ox3
Skin: no rash
Pertinent Results:
Labs: OSH
WBC 9.8-->16.0 (31% bands)-->12.5-->10.3
HCT stable at 44
Na 135-->149-->152-->150
UA 100 glucose, negative bili/ketone/LE/Nit, trace bacteria, WBC
[**11-29**]
[**2176-3-12**] Sputum - MRSA (sensitive to vanco).
Studies:
CXR at OSH: per report bilateral pulmonary infiltrates
[**2176-3-14**] ECHO - normal LV fxn (60-65%), normal wall motion,
normal chamber size, mild MR, trace AI, mild TR, decreased LV
compliance.
[**2176-3-16**] CXR - The tip of the endotracheal tube is identified at
the thoracic inlet. There is worsening of bilateral multifocal
opacities indicating aspiration pneumonia. There is continued
small bilateral pleural effusion. The heart is normal in size.
No pneumothorax is identified. There is dilatation of the
stomach.
[**2176-3-17**] CXR - The tip of endotracheal tube is identified at the
thoracic inlet. The nasogastric tube terminates in the gastric
body. No apparent pneumothorax is seen, also both apices are not
included in the radiograph.
There is slight improvement of the extensive aspiration
pneumonia. There is continued small bilateral pleural effusion.
The heart is normal in size.
[**2176-3-18**] ECHO - The left atrium is normal in size. No atrial
septal defect is seen by 2D or color Doppler. Left ventricular
wall thickness, cavity size, and systolic function are normal
(LVEF>55%). Regional left ventricular wall motion is normal.
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The estimated
pulmonary artery systolic pressure is normal. There is a
trivial/physiologic pericardial effusion. Compared with the
report of the prior study (images unavailable for review) of
[**2173-9-9**], the findings are similar. Based on [**2166**] AHA
endocarditis prophylaxis recommendations, the echo findings
indicate a low risk (prophylaxis not recommended).
[**2176-3-19**] Abdominal U/S - No evidence of acute cholecystitis.
[**2176-3-19**] CXR - Slight interval worsening of bilateral diffuse
airspace consolidations. Slight overdistention of the cuff of
the ET tube
[**2176-3-20**] CXR - The apices are not imaged on this study. Tip of
the endotracheal tube again seen approximately 4 cm above the
carina. Tip of orogastric tube seen overlying the stomach.
Otherwise, no significant change from prior study, with
bilateral multifocal opacities consistent with aspiration
pneumonia and bilateral pleural effusions again seen.
[**2176-3-21**] CT Abdomen/Pelvis - 1. Multifocal pneumonia. Small
moderate-sized bilateral pleural effusions. Multiple enlarged
mediastinal and right axillary lymph nodes. This may be
secondary to the patient's current multifocal pneumonia. 2. Mild
amount of ascites and pelvic free fluid.
3. Mildly distended gallbladder with no other evidence of acute
cholecystitis.
Brief Hospital Course:
The patient is a 23 yo M with [**Month/Day/Year **]'s Syndrome who initially
presented to an OSH with aspiration PNA requiring intubation.
Aspiration PNA - The patient arrived from the OSH with bilateral
aspiration and mrsa pneumonia extubated (s/p 2 days on the
ventilator). The patient was oxygenating well on 40% FM on
admission. That evening, he became acutely agitated asking for
water. He dropped his sats to the upper 70's and required
intubation. He was initally treated with vanco/clindamycin for
aspiration and MRSA pneumonia. He was switched to
vancomycin/cefepime/flagyl to broaden coverage. He continued to
be difficult to oxygenate and was switched to pressure control
ventilation. On hospital day #3, the patient's respiratory rate
was elevated and was unable to maintain O2 sats >88%. We
paralyzed him with cisatracurium to decrease his respiratory
rate and increase his oxygenation. He continued to spike fevers
to 104 and became acutely hypotensive. He was started on
levophed to maintain a MAP >65 and his antibiotics were changed
to vanco/meropenem. Because he had a history of meropenem
resistent organisms, he was switched back to
vanco/cefepime/flagyl. He was quickly weaned off the levophed.
Sputum samples grew staph aureus and pseudomonas. We performed
a CT scan of his torso and sinuses to look for further sources
of infection given his ongoing fevers; he was found to have
multifocal pneumonia. Over the course of the week, he
progressed to ARDS and developed fibrosis of his lungs. After
multiple unsuccessful attempts to wean off the ventilator, his
family made the decision to provide comfort measures only. He
was extubated on [**2176-4-6**] with his family members present, and he
expired within the next 2 hours. The attending was notified,
and the family agreed to a post-mortem examination.
Diabetes Mellitus - The patient was maintained on an insulin
drip during his ICU course.
Conjunctivitis - The patient was admitted with bilateral
conjunctivitis with purulent drainage (R>L). He was treated
with vanco and erythromycin topical ointment (7 day course). He
was seen by opthalmology who felt his eyes were irriated from
drying. His eyes were taped shut while paralyzed/sedated.
Diabetes Insipidus - The patient was continued on desmopressin
[**Hospital1 **] (per home regimen). On the evening of admission his Na rose
to 152 and he was started on increasing free water boluses q4
hrs with his tube feeds. This was altered to maintain a Na
within normal limits.
Hypothyroidism - He was switched to an IV equivalent dose of
levothyroxine (from PO) on admission.
Anxiety/Depression - Continued Seroquel.
?Epilepsy - It was unclear if the patient had been on dilantin
at the time of admission. He had been on it at some point in
the past. Given that his seizures seemed to occur in the
settings of hypoxia (previous pneumonias) and hypoglycemia, we
felt we should start dilantin given his predisposition to those
conditions in his current state. He was bolused and started on
a standing dose. Levels were checked.
FEN - The patient was started on tube feeds while intubated.
They were stopped when the patient was paralyzed and he was
started on TPN on [**2176-3-21**].
PPX - SC heparin, PPI
Medications on Admission:
Home Meds: Per OSH report (awaiting confirmation from mother in
AM)
- bacitracin zinc ointment as needed
- Seroquel 200 mg qhs
- Seroquel 50 mg q3 hrs as needed
- Tylenol as needed
- Synthroid 200 mcg once daily
- phenytoin 200 mg twice daily
- Nystatin as needed
- calcium carbonate as needed
- albuterol inhaler as needed
- Colace as needed
- lansoprazole 60 mg once daily
- Mucomyst nebulizer treatments as needed
- insulin NPH 18 units qam and 10 units qpm
- desmopressin 0.5 mcg injection qam and 1 mcg injection qpm
- Roxicet 5/325 mg/5 cc elixir take 5 cc to 10 cc p.o. q.4-6h
prn
Transfer Meds:
- Protonix 40 po daily
- NPH 18 U qAM, 4 U qPM
- Heparin SC
- Colace 100 [**Hospital1 **]
- Flomax 0.5 mg qAM
- Synthroid 225 mcg daily
- DDAV 2 mcg SC bid
- Albuterol INH
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
Completed by:[**2176-5-11**]
|
[
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icd9cm
|
[
[
[]
]
] |
[
"96.04",
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icd9pcs
|
[
[
[]
]
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10800, 10809
|
6675, 9941
|
339, 345
|
10860, 10869
|
3650, 6652
|
10925, 10963
|
3071, 3139
|
10768, 10777
|
10830, 10839
|
9967, 10745
|
10893, 10902
|
3154, 3631
|
262, 301
|
373, 2004
|
2026, 2764
|
2780, 3055
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,425
| 148,075
|
28273+57589
|
Discharge summary
|
report+addendum
|
Admission Date: [**2158-9-7**] Discharge Date: [**2158-10-2**]
Date of Birth: [**2109-1-23**] Sex: F
Service: MEDICINE
Allergies:
Shellfish / Flexeril / Tricyclic Compounds
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
shortness of breath and leg swelling
Major Surgical or Invasive Procedure:
removal of hardware from right hip
History of Present Illness:
Ms. [**Known lastname 68459**] is a 49yo woman with h/o HCV cirrhosis s/p TIPS who
was directly admitted from clinic on [**9-7**] with shortness of
breath and LE edema. Prior to presentation, her home lasix had
been stopped due to hyponatremia. She also notes that her
dyspnea has increased since her aldactone was stopped in
mid-[**Month (only) **] because of hyperkalemia. She was therefore
initially felt to be fluid overloaded and given lasix and then
albumin/lasix [**Hospital1 **] for diuresis.
.
The team obtained LE ultrasound and CTA chest, which were
negative for DVT or PE. Because of concern for possible
pneumonia on her CXR, she started treatment with vancomycin and
ceftriaxone on [**9-13**] (switched to vanc/ceftazidime [**9-14**]).
.
She has had a complicated hospital course, and has been followed
by ID, Orhopedics, and Psychiatry. The team obtained plain films
of her knee and hips because of a known h/o hip infection and
persistent leukocytosis. [**Month/Day (4) 1957**] was consulted and MRIs obtained,
concerning for right hip infection (where she has hardware from
an arthroplasty). She was found to have E coli from her right
hip aspirate, and zosyn was started on [**9-15**]. Because of
difficulties with hypoglycemia, she was started on stress dose
steroids given concern for adrenal insufficiency.
.
The night prior to transfer, Ms. [**Known lastname 68459**] was triggered for acute
hypoxia. She was found to be blue with pulse ox in the 50s in
RA. She improved with lasix and oxygen. Per report, she had an
episode of scant hemoptysis (not witnessed by MD). However, she
continued to have an increasing oxygen requirement through the
day and was transferred to the MICU for further care.
.
Upon arrival to the ICU, she continued to feel somewhat out of
breath.
Past Medical History:
1.HCV Cirrhosis s/p TIPS [**11-9**] for ascites. Complicated by
encephalopathy, thrombocyotpenia, ascites, and hydrothorax.
Currently on [**Month/Year (2) **] list.
2.Hyponatremia baseline 128-133
3.Secondary adrenal insufficiency
4.asthma
5.DM
6.GERD
7.Anxiety
8.h/o UTI's
9.Hip fx and L4 compression Fx on [**2157-11-6**] s/p ORIF of hip fx.
10.Prolactinoma
Social History:
The patient is single with one child, she was living in a
chronic care facility, [**Hospital1 **] [**Hospital1 3894**] Nursing Facility in [**Location (un) 29158**] prior to admission. She is currently on disability,
formerly a waitress.
Illicits: Past IV drug use with needle sharing, last use 7 years
ago. Past drug-snorting.
Alcohol: Past alcohol use, last drink at age 46.
Tobacco: Past smoker with 10 pack-year history
Family History:
Mother w/ DM2, HTN, and hyperlipidemia.
Father w/ COPD and EtOH cirrhosis
Physical Exam:
VS - 97.8 104 126/69 27 95% 6L
GENERAL - frail-appearing woman who appears anxious, she is
mildly tachypneic and has some distress when speaking.
HEENT - Pupils equal, EOMI, sclerae anicteric, MMM, OP clear,
+spider angiomata
NECK - supple, +JVD to angle of jaw when sitting at 45 degrees
LUNGS - crackles throughout lung fields b/l
HEART - Regular tachycardia with systolic murmur
ABDOMEN - +BS, soft/NT, no rebound/guarding
EXTREMITIES - warm with 2-3+ pitting BLE edema to above knees
R hip is tender to palpation and with movement at hip joint (leg
roll)
SKIN - spider angiomata
NEURO - awake, appropriate, A&Ox3, slight asterixis present
Pertinent Results:
[**2158-9-11**] MRI hip
1) Very limited study for reasons stated above.
2) Small residual or recurrent fluid collection within the soft
tissues
lateral and superior to the proximal aspect of the right hip
prosthesis
contiguous with the prosthesis, though intra-articular extent
cannot be
established on this study. Susceptibility artifact from the
prosthesis limits
evaluation for a hip joint effusion, though no large effusion is
directly
visualized.
3) Severe diffuse subcutaneous edema/anasarca as well as deep
interfascial and
muscular edema throughout the right thigh. No deep abscess/focal
fluid
collection.
[**9-8**]
bilateral hip xray
Since the prior study, interval continued periostitis and
erosion of the
lateral aspect of the proximal femur. This is worrisome for
continuing
infection
Brief Hospital Course:
Pt is a 49-yo woman w/ HCV cirrhosis s/p TIPS, c/b ascites,
encephalopathy, thrombocytopenia, and hepatic hydrothorax,
currently on [**Month/Day (4) **] list w/ MELD 15, directly admitted from
clinic w/ worsening BLE edema and SOB in setting of being off
diuretics due to hyperkalemia and hyponatremia. Transferred to
MICU [**2158-9-16**] for progressively worsening hypoxia and dyspnea
(See MICU course below)
.
#. SOB and BLE edema - Likely [**1-7**] fluid overload in setting of
being off diuretics. CXR does not reveal pulm edema or pleural
effusions as expected. Improved significantly w/ diuresis and
addition of albumin. She improved for several days w/ diuresis
but then her platelet count dropped and she developed
hemoptysis, after which her O2 sats dropped, CXR demonstrated
alveolar and interstitial opacities and she was transferred to
the ICU for further management of her hypoxia. She was intubated
in the ICU and diuresed for several days after her sugery, her
oxygenation slowly improved and she was extubated and
transferred to the floor. By the time she was transferred back
to the floor her edema was significantly improved.
.
#. Septic arthritis: Pt. had been on bactrim suppression for
CONS infxn of hardware, but got increasing hip pain and low
grade temps. Hip was tapped and grew E. coli resistant to
everything except pip/tazo and amikacin. Dr. [**Last Name (STitle) 497**] held long
family meeting w/ pt. and discussed her poor prognosis w/ her
and code status. She decided to go ahead w/ all interventions
and to be full code. She recieved a right hip explant of all
hardware w/ placement of an abx spacer and continued on
vancomycin and meropenem per ID for a total 6-week course.
.
#. Hyponatremia - Hypoalbuminemia vs. adrenal insufficiency. She
was given albumin along w/ hydrocortisone for combination of
persistent hypoglycemia and hyponatremia.
.
#. Headache - Pt. complained of pain and locking of her jaw
while chewing. She was seen by dentistry who suggested that it
might be TMJ and that she should avoid chewy foods and possibly
get a night guard for her mouth.
.
#. Anemia - Appears anemia of liver disease, Hct trended slowly
downward and on day of transfer to MICU was 21.1. An NG tube was
placed in the ICU and she hemorrhaged from her nose and required
multiple transfusions before it stopped.
.
#. HCV cirrhosis - Pt w/ HCV cirrhosis s/p TIPS, c/b
encephalopathy, thrombocytopenia, ascites, and hepatic
hydrothorax. Currently on [**Last Name (STitle) **] list, will need to complete
antibiotic treatment and have hip replaced before she can get a
[**Last Name (STitle) **].
.
#. Pain: Oxycontin with oxycodone for breathrough was continued.
Lidoderm patches were also continued.
.
#. Asthma - was continued on her montelukast and advair along w/
albuterol and ipratropium nebs.
.
#. Diabetes: Glargine dose was cut from 40U on admission to 20 U
QD because the pt. presented w/ persistent hypoglycemia. She
will be discharged on 25 units at bedtime and a humalog sliding
scale.
.
#. Secondary adrenal insufficiency - continued home prednisone,
started stress dose hydrocortisone for persistent
hypoglycemia/hyponatremia which was tapered back to home dose
after 2 doses of stress dose.
.
#. GERD - home PPI was continued.
.
#. Depression / anxiety - continue home Effexor psych was
consulted per [**Last Name (STitle) **] coordinators request.
.
#. Osteopenia - continue home Vitamin D and Calcium carbonate
.
#. FEN - diabetic low-protein diet, albumin tonight then resume
diuresis, electrolyte repletion
.
MICU Course
Patient transferred to MICU on [**9-16**] for progressively worsening
hypoxic respiratory failure requiring intubation [**9-16**]. Chest CT
and CXR c/w diffuse airspace consolidation which was thought to
be multifactorial secondary to ARDS/[**Doctor Last Name **], pulmonary edema +/-
infection. BAL [**9-18**] was negative for infection. She was
intermittently diuresed on Lasix gtt and with Lasix IV prn and
was continued on antibiotics (Vanc/[**Last Name (un) **] for hip infection). She
was continued on standing and prn ALbuterol and Atrovent MDIs
while intubated with improvement in respiratory exam but
persistent R pleural effusion which will be tapped by IP
[**2158-9-27**] prior to transfer. Pt extubated on [**2158-9-23**] and is
currently satting in high 90s on 2L nasal cannula, continued on
home inhalers and Advair.
On [**2158-9-16**] she developed severe epistaxis when placement of NGT
was attempted with drop of HCT to 17 requiring 5 units PRBC to
maintain stable HCT. She was seen by ENT who performed anterior
nasal packing which was removed after 5 days. She was transfused
to keep patelets >[**Numeric Identifier 1871**] due to h/o bleed. There were no further
episodes of bleeding.
Meropenem and Vancomycin were continued for hip infection and
had removal of hardware with explant and replacement with
antibiotic spacer on [**2158-9-19**]. She will need total 6 week
course of ABx after procedure. Intraop cx grew Enterococcus
sensitive to Vanc and Coag neg staph. She was afebrile during
MICU course. Periprocedure was given stress dose steroids which
were tapered to home PO prednisone. PLanned removal of stitches
after 3 weeks and was restarted on home PO pain medication
regimen after extubation.
She was started on Captopril for HTN. She was tolerating PO diet
at time of transfer with clear mental status. RIJ which was
placed [**9-20**] was DC'd [**9-27**]. PICC placed [**9-17**].
ID, [**Month/Year (2) 1957**], and Hepatology continued to follow.
Medications on Admission:
Albuterol nebs q6hrs PRN
Ergocalciferol 50,000units PO QMWF
Fluticasone-Salmeterol 250mcg-50mcg [**Hospital1 **]
Insulin: glargine 40units QAM, lispro SS
Lidoderm patch daily
Singulair 10mg daily - Holding
MVI daily
Omeprazole 20mg daily
OxyContin 15mg QAM, 10mg QPM - MODIFIED
Oxycodone 5mg PO Q6hrs PRN - Holding
Prednisone 5mg PO daily
Rifaximin 400mg PO TID
Bactrim DS 800mg-160mg PO TID - Holding
Venlafaxine 75mg PO daily
Calcium carbonate 1000mg PO TID
Folic acid 1mg PO daily
Off her diuretics (spironolactone and lasix [**1-7**] hyponatremia)
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] rehab
Discharge Diagnosis:
primary: septic arthritis, hepatitis C cirrhosis
secondary: asthma, diabetes mellitus, GERD
Discharge Condition:
stable
Discharge Instructions:
You were admitted for shortness of breath and lower extremity
edema. You were found to have an infection in your hip joint.
The hardware was removed. You will require 6 weeks of IV
antibiotics for treatment at which point you will return for
replacement of your hip joint. At that time, you can be relisted
on the tranplant list.
.
Please return to hospital for fevers/chills or other concerning
signs or symptoms of infection.
Followup Instructions:
Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2158-10-19**] 10:50
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2158-10-27**] 10:00
Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2158-10-18**] 2:20
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
Completed by:[**2158-10-3**] Name: [**Known lastname 11763**],[**Known firstname 511**] M Unit No: [**Numeric Identifier 11764**]
Admission Date: [**2158-9-7**] Discharge Date: [**2158-10-2**]
Date of Birth: [**2109-1-23**] Sex: F
Service: MEDICINE
Allergies:
Shellfish / Flexeril / Tricyclic Compounds
Attending:[**First Name3 (LF) 4091**]
Addendum:
Mrs.[**Known lastname 11776**] fluid overload was secondary to low serum albumin
which was secondary to hepatitis C cirrhosis.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] rehab
[**First Name8 (NamePattern2) 1558**] [**Last Name (NamePattern1) **] MD [**MD Number(1) 2301**]
Completed by:[**2158-10-19**]
|
[
"789.59",
"V15.82",
"996.66",
"286.7",
"E878.2",
"518.81",
"041.4",
"572.8",
"786.3",
"287.4",
"733.00",
"571.5",
"733.49",
"285.29",
"578.1",
"493.90",
"724.5",
"416.8",
"227.3",
"458.9",
"276.1",
"070.44",
"250.80",
"V58.67",
"719.46",
"255.41",
"V43.64"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"99.05",
"96.04",
"38.91",
"96.6",
"99.07",
"33.24",
"81.91",
"96.72",
"80.05",
"38.93",
"84.56",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
12515, 12719
|
4619, 10172
|
339, 376
|
10960, 10969
|
3795, 4596
|
11446, 12492
|
3041, 3116
|
10844, 10939
|
10198, 10752
|
10993, 11423
|
3131, 3776
|
263, 301
|
404, 2199
|
2221, 2583
|
2599, 3025
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,173
| 145,083
|
37523
|
Discharge summary
|
report
|
Admission Date: [**2155-1-16**] Discharge Date: [**2155-1-23**]
Date of Birth: [**2086-3-21**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Iodine / Statins-Hmg-Coa Reductase Inhibitors
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
chest discomfort, jaw pain
Major Surgical or Invasive Procedure:
cardiac catheterization
CABG
Off pump Coronary Artery Bypass Graft x 2 with LIMA --> LAD,
Reverse saphenous vein graft --> Obtuse marginal
History of Present Illness:
68 year old female with known Coronary Artery disease and
carotid artery disease was admitted to [**Hospital6 84260**] on [**2155-1-14**] with chest discomfort and jaw pain.
She reports discomfort presented during exertion and was not
relieved by rest. Sublingual nitroglycerin helped with resolving
the pain. She had several episodes the following day. She noted
dyspnea and radiation to the jaw. She denies nausea, vomiting or
diaphoresis. The pain again progressed the day of admission when
she presented to the emergency department. Her EKG showed NSR
with anterolateral ST segement depression more accentuated than
baseline EKG per OSH reports. She was admitted for further
treatment. While she was in the hospital she ruled in for NSTEMI
with a troponin peak of 5.1. She was catheterized which showed
severe 2 vessel disease LVEF reportedly normal. She had post
cath chest pain which resolved with NTG and morphine. She was
transferred to [**Hospital1 18**] for evaluation and cardiac surgery was
consulted for coronary artery revascularization.
Past Medical History:
PAST MEDICAL HISTORY:
1. CAD RISK FACTORS: Know CAD, carotid artery disease,
hyperlipidemia, hypertension, prior cigarette use
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: cardiac catheterizations
in [**2128**] and [**4-/2152**] which showed diffuse triple vessel disease
with calcified coronary arteries per OSH records.
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
- tobacco history
- CAD treated medically
- ? PVD - pt denies but in records
- s/p left carotid endarterectomy
- hyperlipidemia
- hypertension
Social History:
-Tobacco history: quit 6 years ago, 49 pack year history
-ETOH: social alcohol
-Illicit drugs: none
Family History:
Father died with throat cancer, mother diet of old age, sister
died at 57, brother alive with history of MI, she has 4
children.
Physical Exam:
VS: T= 98.2 BP= 109/53 HR= 74 RR= 18 O2 sat= 96% 2LNC
GENERAL: elderly female in NAD, oriented x3, mood and affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, OP without lesions. No xanthalesma.
NECK: Supple, no JVD appreciated.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. II/VI systolic murmur best heart at
apex, no rubs or gallops. No S3 or S4 appreciated.
LUNGS: CTAB without crackles, wheezes or rhonchi, good air
movement bilateral.
ABDOMEN: Soft, NT/ND. Abd aorta not enlarged by palpation. No
abdominial bruits appreciated.
EXTREMITIES: No c/c/e. No femoral bruits. R hip cath site
clean/dry and intact.
PULSES:
Right: Femoral 2+ DP 1+ PT 1+
Left: Femoral 2+ DP 1+ PT 1+
Pertinent Results:
[**2155-1-16**] 09:46PM CK(CPK)-156*
[**2155-1-16**] 09:46PM CK-MB-9 cTropnT-0.69*
[**2155-1-16**] 05:25PM GLUCOSE-98 UREA N-18 CREAT-0.8 SODIUM-144
POTASSIUM-3.9 CHLORIDE-108 TOTAL CO2-25 ANION GAP-15
[**2155-1-16**] 05:25PM CALCIUM-8.9 PHOSPHATE-3.0 MAGNESIUM-2.1
CHOLEST-207*
[**2155-1-16**] 05:25PM TRIGLYCER-116 HDL CHOL-66 CHOL/HDL-3.1
LDL(CALC)-118
[**2155-1-16**] 05:25PM WBC-14.2* RBC-4.34 HGB-12.8 HCT-36.9 MCV-85
MCH-29.4 MCHC-34.6 RDW-13.7
[**2155-1-16**] 05:25PM NEUTS-62.7 LYMPHS-31.1 MONOS-3.9 EOS-1.3
BASOS-1.0
[**2155-1-16**] 05:25PM PT-11.8 PTT-27.1 INR(PT)-1.0
ECHO [**2155-1-17**]:
Off-Pump CABG:
1. The left atrium is normal in size. No spontaneous echo
contrast is seen in the left atrial appendage. No thrombus is
seen in the left atrial appendage.
2. No atrial septal defect is seen by 2D or color Doppler.
3. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%).
4. Right ventricular chamber size and free wall motion are
normal.
5. There are simple atheroma in the aortic root. There are
complex (>4mm) atheroma in the aortic arch. There are complex
(>4mm) atheroma in the descending thoracic aorta.
6. There are three aortic valve leaflets. The aortic valve
leaflets are moderately thickened. There is no aortic valve
stenosis. Trace aortic regurgitation is seen.
7. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen.
8. There is a small pericardial effusion.
[**2155-1-22**] 05:10AM BLOOD WBC-11.2* RBC-3.52* Hgb-10.3* Hct-31.7*
MCV-90 MCH-29.4 MCHC-32.6 RDW-16.1* Plt Ct-305
[**2155-1-22**] 05:10AM BLOOD Glucose-120* UreaN-20 Creat-0.8 Na-141
K-3.8 Cl-103 HCO3-28 AnGap-14
**FINAL REPORT [**2155-1-21**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2155-1-21**]):
Feces negative for C.difficile toxin A & B by EIA.
Brief Hospital Course:
This 68-year-old patient, who presented with unstable angina
with non-ST elevation
myocardial infarction, subsequently had a coronary angiogram
which showed 2-vessel disease involving the left anterior
descending artery and a small obtuse marginal artery. Initial
angiogram showed the obtuse marginal to be quite small so the
plan was to possibly stent this artery and do endoscopic LIMA to
LAD graft. Subsequent angiogram the next day, when she developed
further pain, showed the OM to be bigger than initially thought
of and hence she was taken to the OR for an off pump sternotomy
and 2-vessel bypass grafting on [**2155-1-17**]. Preoperative CT scan
showed severe calcification of the ascending arch and descending
aorta and hence the plan was to proceed with off-pump coronary
artery bypass grafting. See operative note for details.
The patient was hemodynamically stable on transfer to the CVICU.
She was weaned off neosynephrine with stable cardiac
index/output. Ms. [**Known lastname 38707**] [**Last Name (Titles) 5058**] neurologically intact and was
extubated on post operative day 1 morning without incidence.
Postoperatively she transiently had an episode of atrial
fibrillation, was treated with amiodarone and converted to sinus
rhythm. Chest tubes and pacing wires were removed per cardiac
surgery protocol. She was transferred to the step down unit in
stable condition. Physical therapy continued to work with her
to increase strength and endurance. On post operative day #4,
she did have a large amount of loose stools. She was negative
for Clostridium difficile and her bowel regimen was adjusted
with resolution of her diarrhea. She remained afebrile, in
sinus rhythm and her incisions were healing well. It was felt
that she was safe for transfer to rehab on post operative day #
6. All follow up appointments were advised.
Medications on Admission:
Verapamil, Aspirin, Centrum Cardio, Metamucil, Fish Oil
Discharge Medications:
1. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 5 days.
2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 5 days.
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever/pain.
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 3 months.
7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
9. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO DAILY
(Daily).
10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. Psyllium Packet Sig: One (1) Packet PO TID (3 times a
day) as needed for diarrhea.
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Coronary Artery Disease
Dyslipidemia
Hypertension
Peripheral vascular disease
s/p Left carotid endarectomy
s/p Left carotid endarectomy
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 [**First Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Primary Care Dr [**First Name8 (NamePattern2) 29069**] [**Name (STitle) 29070**] in [**2-15**] weeks [**Telephone/Fax (1) 37284**]
Cardiologist in [**2-15**] 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:[**2155-1-23**]
|
[
"518.5",
"427.31",
"285.9",
"410.71",
"997.1",
"300.4",
"E878.2",
"443.9",
"272.4",
"401.9",
"V45.02",
"414.01",
"V15.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"36.11",
"88.56",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
8214, 8261
|
5146, 7004
|
338, 479
|
8442, 8538
|
3176, 5123
|
9163, 9678
|
2253, 2383
|
7110, 8191
|
8282, 8421
|
7030, 7087
|
8562, 9140
|
2398, 3157
|
1730, 1943
|
272, 300
|
507, 1561
|
1974, 2119
|
1605, 1710
|
2135, 2237
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,751
| 186,107
|
27418
|
Discharge summary
|
report
|
Admission Date: Discharge Date:
Date of Birth: [**2132-9-22**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5868**]
Chief Complaint:
unresponsive
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 67118**] is a 66 year old man
who was previously healthy except for a recent episode of
zoster,
until his wife found him unresponsive in their bed this morning.
Per his wife he had been awake and speaking to her when she got
out of bed. Twenty minutes later she called upstairs to him
before leaving the house, but when he didn't answer she went
back
upstairs, and found him still lying in bed but completely
unresponsive. She called 911 and per EMS he was moving his left
leg and arm but not the right side. He had a GCS of 4. He was
intubated for airway protection (it was a difficult intubation
requiring 3 attempts), and received fentanyl, versed, and
succinylcholine for this. His blood glucose was 148, blood
pressure was 160/palp and ekg revealed sinus brady in 50's to
60's. He was brought to [**Hospital3 36606**] Hospital where he was
noted to resist suctioning of his ETT, but was otherwise
unresponsive. He was moving his left arm only at that point,
but
not purposefully. His blood pressure there was 156/65. No
seizure activity was observed. He had a head CT which revealed
a
large left frontal intraparenchymal hemorrhage, with blood in
all
the ventricles, including the fourth. Per the nurses' order
sheets he was loaded with 1000 mg fosphenytoin, received 10 mg
decadron, and 35g mannitol. There was also an order for 32 mg
of
ativan at 7:15 a.m.(this was probably an erroneous
transcription), as it was not transmitted to nursing here that
he
received that much ativan. He was then transferred to [**Hospital1 18**] for
further management. Since his arrival he had a repeat CT which
reveals the aforementioned hemorrhage. Neurosurgery consulted
and per Dr. [**Last Name (STitle) 548**], the neurosurgery attending, the patient's
prognosis is so poor that surgical intervention is not
warranted.
Per Mr. [**Known lastname 67119**] wife he has always been active and has been
in excellent health. He does not take any anticoagulant
medications. His blood pressure has been low to normal, and he
has had no difficulties with cardiac disease, respiratory
disease, or diabetes. He has no past history of stroke or
seizure. He has not had any cognitive difficulties of late.
Review of systems: Had zoster recently, s/p course of
acyclovir.
Had a mild headache earlier this morning. He had otherwise been
feeling quite well, without chest pain, palpitations, shortness
of breath, fever, cough, weakness, numbness, or paresthesias.
Past Medical History:
recent zoster, s/p acyclovir
Social History:
Lives with his wife. Retired biology teacher. Has three adult
children.
Family History:
Daughter with meningioma
Physical Exam:
Examination:
Afebrile HR 60 BP 159/76 - 170/80 Pulse Ox 100%
Vent: AC TV 550 Rate 16 PEEP 5 100% FiO2
Gen: 66 year old man, intubated, in NAD
Resp: scattered rhonchi bilaterally
CV: rr, nl s1/s2, no mrg
Abd: s/nt/nd
Neuro:
MS: Intubated but not sedated (last sedating medication at
least
2-3 hours previously)
No response to sternal rub, no spontaneous eye opening
PERRL, 4>2. No blink to threat. + corneal reflexes b/l.
Minimal OCR present. +gag with ETT.
Tone normal. Decerebrate posturing bilaterally with any
stimulation (touch, pinch) to all four extremities. Triple
flexes both legs in response to proximal pinch. No purposeful
movements, no withdrawal to pain.
Deep tendon reflexes 2+ and symmetric. Plantar responses
extensor bilaterally.
Pertinent Results:
Phenytoin: 16.3
pH 7.38 pCO2 46 pO2 523 HCO3 28 BaseXS 1
Type:Art; Intubated; FiO2%:100; AADO2:149; Req:35; Rate:/16;
TV:550; PEEP:5; Mode:Assist/Control
O2Sat: 99
Na:142 K:4.3 Cl:104 TCO2:28 Glu:138 Lactate:2.0
[**Doctor First Name **]: 62 Lip:
Serum ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc Negative
Urine Benzos, Barbs, Opiates, Cocaine, Amphet, Mthdne Negative
MCV 104
9.1 >13.1< 235
38.7
PT: 12.4 PTT: 21.5 INR: 1.1
Fibrinogen: 238
UA negative
At [**Hospital3 36606**]:
136 103 16
3.8 28 0.9 <160
Ca 8.3
Tbili 0.7 Tprot 6.7 Alb 3.4 Alt 33 AST 2-
* * *
HEAD CT
FINDINGS: There is a massive intraparenchymal hemorrhage
involving the left frontal lobe with intraventricular extension.
There is associated mass effect with roughly 1 cm rightward
subfalcine herniation. Blood is seen extending
into the third and fourth ventricles and temporal horns. The
basal cisterns are not effaced. The fourth ventricle is
moderately distended with blood, without frank hydrocephalus
elsewhere. There is no evidence of transtentorial
herniation at this time. Bone algorithm windows demonstrate no
fractures or areas of osseous destruction. There are small
fluid
levels in the sphenoid sinus. Surrounding extracranial soft
tissues are unremarkable.
IMPRESSION: Huge left frontal lobe hemorrhage with
intraventricular extension, rightward subfalcine herniation and
moderately distended fourth ventricle. Urgent neurosurgical
consult needed. Comparison with prior outside hospital study is
needed to assess for change in the size of hemorrhage/mass
effect.
CHEST X-RAY
FINDINGS: ET tube is located at the level of the clavicles 5 cm
above the carina in standard placement. NG tube is in the
stomach. The lungs are clear. There are no effusions or
pneumothoraces. The cardiac and mediastinal silhouettes are
within normal limits.
IMPRESSION: Standard ET tube placement.
Brief Hospital Course:
Impression:
66 year old male without significant past medical history who
became unresponsive acutely this morning following a mild
headache, and was found to have a large left frontal hemorrhage
extending throughout the ventricular system. Due to his
extremely poor prognosis for meaningful recovery no
neurosurgical
intervention will be performed. This was explained to the
patient's family in detail by the attending neurosurgeon, Dr.
[**Last Name (STitle) 548**]. Initially he was made DNR, but otherwise full care was
pursued. This included:
NEURO: Continue mannitol 25g q6h
Continue dilantin 100 mg IV q8h
Follow exam q1h
Will hyperventilate to paCO2 < 40
FEN:
NS at 50 cc/hr
Recheck lytes this evening
Measure osm/Na q6h, hold for osm >320 or Na >150
NPO
Goal fluid status is negative
RESP:
Not overbreathing vent at present. Continue to follow abg's,
adjust vent as necessary.
CV:
Goal SBP <160, hydralazine prn
HEME:
Heparin SC for DVT prohylaxis, pneumoboots to prevent DVT
ENDO:
RISS
GI:
pantoprazole
* * *
During the course of his admission Mr. [**Known lastname 67119**] exam did not
improve. Dr [**Last Name (STitle) **] and Dr [**Last Name (STitle) 548**] individually met with the family
to discuss prognosis. His family decided that, given his poor
prognosis for meaningful recovery, they preferred to withdraw
care, as they noted the patient "would not want this". On
Friday [**6-7**] he was extubated and comfort measures were
instituted. He expired that evening. The family declined an
autopsy, including neuropathology.
Medications on Admission:
Aspirin
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Intracerebral hemorrhage
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
|
[
"431",
"348.1",
"518.81",
"331.4",
"288.8",
"780.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
7407, 7416
|
5736, 7319
|
304, 310
|
7484, 7493
|
3812, 5713
|
7546, 7553
|
2987, 3014
|
7378, 7384
|
7437, 7463
|
7345, 7355
|
7517, 7523
|
3029, 3793
|
2587, 2826
|
252, 266
|
338, 2567
|
2848, 2879
|
2895, 2971
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,685
| 105,211
|
3258
|
Discharge summary
|
report
|
Admission Date: [**2174-3-3**] Discharge Date: [**2174-3-5**]
Date of Birth: [**2102-12-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
AICD firing
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname **] is a 71 y.o male with history of [**Known lastname 15196**] disease
s/p aortic valve replacement, non-ischemic cardiomyopathy with
EF of 30% whose icd fired last night multiple times. Patient
reports that around 2 am he was using a urinal and felt a
"thump" when his ICD fired. He was assymptomatic and did not
have any chest pain, lightheadedness, or shortness of breath.
He was sent to [**Hospital **] Hospital where EKG/strip captured fast VT
(>200 bpm; K+ 4.1, Troponin-I 0.08). Mr. [**Known lastname **] had similar
episode in [**Month (only) 404**] and was started on amio in that setting. He
was sent to [**Hospital1 18**] for further evaluation.
.
In the [**Hospital1 18**] ED initial VS were HR 75, BP 94/72, RR 14, 99% 2L
NC. He was given a 500 cc NS bolus. He was seen by EP who
recommended lidocaine gtt at 4mg/min.
.
On arrival to the floor, the patient was comfortable and
assymptomatic. Interrogation of his ICD revealed he had been
shocked 6 times between [**3-2**] 21:58 and [**3-3**] 05:37. He had been
shocked out of afib into sinus rhythm.
.
On further review, the patient reports being admitted to [**Hospital **]
Hospital within the past month, discharged to [**Hospital1 **] for rehab
on [**2-4**] where he was started on albuterol and his blood pressure
medications were uptitrated for hypertension. He was then
transfered to [**Location (un) 169**] in [**Location (un) 1411**] for further rehab. On
review of systems he reports worsening vision with difficulty
[**Location (un) 1131**] small print for the past couple of weeks and
intermittant lightheadedness on sitting up that resolved about 5
days ago. Also positive for constipation with last bowel
movement 3 days ago. He denied any increased orthopnea, PND,
chest pain, shortness of breath, cough, fevers, chills, recent
flu-like illnesses or rashes. No nausea, vomiting, abdominal
pain, BRBPR, melena, or diarrhea. All other review of systems
were negative.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes - none, + Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
-Non-ischemic cardiomyopathy s/p BiV-ICD [**2167**], c/b pocket
hematoma
-Mechanical AVR for [**Year (4 digits) 15196**] disease
-Hx of atrial arrythmias, failed dofetalide and amiodarone,
recent failed cardioversion [**2173-12-23**]
-s/p AV junctional ablation and Pulm vein isolation
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD:
[**Company 1543**] BiV ICD, Concerto C154DWK
Atrial fibrillation
Aortic valve replacement
3. OTHER PAST MEDICAL HISTORY:
OSA compliant with BiPap
hypertension
hyperlipidemia
reactive airway disease
osteoarthritis
BPH
h/o chronic UTIs
h/o torn right quadriceps s/p surgical repair
Social History:
-Tobacco history: none, never
-ETOH: none
-Illicit drugs: none
Retired software engineer. Is married. Wife is currently at
[**Location (un) 169**] in [**Location (un) 1411**] with him recovering from pneumonia.
Patient has been undergoing rehab and has been confined to bed
and wheelchair - not yet walking again.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death. History of hypertension and stroke on
mother's side of the family. Father had "lung problems".
Physical Exam:
VS: T= 96.5 BP= 81/61 HR= 84 RR=22 O2 sat= 100% 3L NC
GENERAL: Morbidly obese 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, no lymphadenopathy. JVP difficult to assess due
to habitus.
CARDIAC: RRR, normal S1, mechanical S2. No m/r/g. No thrills,
lifts. No S3 or S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, obese, NT. No HSM or tenderness. No abdominial
bruits.
GU: Foley catheter in place
EXTREMITIES: No c/c/e. DP pulses 2+ bilaterally
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
Admission Labs:
[**2174-3-3**] 06:40AM BLOOD WBC-4.6# RBC-3.84* Hgb-11.6* Hct-33.1*
MCV-86 MCH-30.3 MCHC-35.1* RDW-14.4 Plt Ct-289
[**2174-3-3**] 06:40AM BLOOD Neuts-51.7 Lymphs-36.3 Monos-9.7 Eos-1.9
Baso-0.3
[**2174-3-3**] 06:40AM BLOOD PT-16.5* PTT-23.8 INR(PT)-1.5*
[**2174-3-3**] 06:40AM BLOOD Glucose-133* UreaN-20 Creat-1.5* Na-130*
K-4.6 Cl-95* HCO3-23 AnGap-17
[**2174-3-3**] 06:40AM BLOOD Calcium-9.3 Phos-4.3 Mg-1.7
[**2174-3-3**] 01:50PM BLOOD TSH-2.8
[**2174-3-3**] 01:50PM BLOOD Free T4-1.7
[**2174-3-3**] 06:40AM BLOOD CK-MB-4 cTropnT-0.04*
[**2174-3-3**] 06:40AM BLOOD CK(CPK)-115
[**2174-3-3**] 01:50PM BLOOD CK-MB-4 cTropnT-0.03*
[**2174-3-3**] 01:50PM BLOOD CK(CPK)-106
[**2174-3-3**] 07:56PM BLOOD CK-MB-4 cTropnT-0.03*
[**2174-3-4**] 04:29AM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2174-3-4**] 04:29AM BLOOD CK(CPK)-88
[**2174-3-3**] ECG: Baseline artifact. A-V paced rhythm with A-V
conduction delay and ventricular premature beats. Since the
previous tracing of [**2174-1-22**] there is probably no significant
change but baseline artifact on both tracings makes comparison
difficult.
[**2174-3-3**] AP CXR - IMPRESSION: No definite acute intrathoracic
abnormality. Limited study due to lack of imaging of the
costophrenic angles. Repeat imaging can be obtained if
clinically warranted.
[**2174-3-4**] Transthoracic Echo - The left atrium is markedly
dilated. The right atrium is markedly dilated. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity is moderately dilated. There is severe global left
ventricular hypokinesis (LVEF= 20%). No masses or thrombi are
seen in the left ventricle. The aortic root is mildly dilated at
the sinus level. A bileaflet aortic valve prosthesis is present.
The aortic valve prosthesis appears well seated, with normal
leaflet/disc motion and transvalvular gradients. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Moderate (2+) mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Dilated left ventricle with severe global systolic
dysfunction. Normally-functioning bileaflet aortic prosthesis.
Moderate mitral regurgitation. Moderate pulmonary hypertension.
Compared with the prior study (images reviewed) of [**2173-10-20**], LV
systolic function has further deteriorated. Severity of mitral
regurgitation has increased. Pulmonary pressures are slightly
higher.
Brief Hospital Course:
Mr. [**Known lastname **] is a 71 year old male with non-ischemic
cardiomyopathy and history of atrial tachycardias, s/p failed
cardioversion and dofetelide who presents with multiple episodes
of v-tach/v-fib for which he was shocked with his AICD.
# V-tach/V-fib storm - Etiology of increased frequency of shocks
was unclear. There was no evidence for infection, exacerbation
of pulmonary disease, or worsening heart failure on
presentation. He was ruled out for an MI. The patient was
started on a lidocaine drip in the ED that was continued for 24
hours without further episodes of VT or VF. He was noted to be
difficult to arose the morning after admission that may have
been related to lidocaine toxicity. These symptoms resolved
later in the morning after the drip was stopped. EP also
recommended reloading the patient with amiodarone 400 mg [**Hospital1 **] for
2 weeks followed by 400 mg daily (instead of the previous 300 mg
daily), starting mexilitine 150 mg [**Hospital1 **], and starting magnesium
oxide 400 mg [**Hospital1 **]. He was continued on an aspirin and
beta-blocker.
# Heart failure - The patient's ejection fraction at last echo
was 30%. Repeat ECHO on this admission showed worse EF of 20%
with increased MR and higher pulmonary pressures. He did not
appear clinically volume overloaded and was likely actually
somewhat volume deficient. He was initially continued on lasix
80 mg PO BID, but lasix was discontinued due to worsening
hyponatremia. His beta-blocker was changed from carvedilol to
metoprolol to have decreased blood pressure effect as the
patient's systolic blood pressures were 80-100, and also to have
decreased pulmonary effect given his history of reactive airway
disease. He was started on a lower dose of carvedilol prior to
discharge. Spironolactone and losartan were continued at his
prior doses. He was placed on a 1.5L fluid restriction.
# Anticoagulation for aortic valve - The patient's INR on
presentation was 1.5. Goal INR is 2.5-3.5 given that he has a
mechanical aortic valve. He was not receiving his coumadin at
[**Location (un) 169**] for unclear reasons. He was started on a heparin
gtt and his coumadin was restarted.
# Hypertension/Hypotension: Patient's systolic blood pressure
was in the 80s on presentation. He likely has a low blood
pressure at baseline given his poor EF. He was continued on a
beta-blocker and [**Last Name (un) **] given its beneficial properties in patients
with heart failure.
# Hyponatremia: The patient's serum sodium was 130 on
presentation and dropped to 121 the following day. Urine sodium
was less than 10, indicating that the patient was appropriately
sodium avid. His hyponatremia was likely due to aggressive
diuresis and free water excess from IV medicactions (lidocaine,
heparin).
# Chronic Kidney disease - Creatinine at on presentation was
1.5, at the patient's baseline. Medications were renally dosed.
# Anemia - Normocytic, hematocrit at 33, appears at or above
baseline.
# Hyperlipidemia - Patient was placed on his prior regimen of
atorvastatin 10 mg daily
# Obstructive Sleep apnea - Patient was given BiPAP per his home
regimen.
# Obstructive and reactive airway disease: Patient was continued
on advair, montelucast, flonase, and ipratropium that he was on
at rehab. He was not given albuterol given his tachyarrhythmias
on presentation.
# Back pain - Patient had previously been on a lidocaine patch,
however, per pharmacy, IV lidocaine and mexiletine have similar
effects. This was not an issue for the patient during this
admission.
# BPH - Continued finasteride and flomax
# History of chronic UTIs - Patient was restarted on
nitrofurantoin which he was previously on for chronic
suppression.
# FEN: Low Na, heart healthy diet. 1.5L fluid restriction.
Replete lytes as needed.
# CODE: Full, confirmed with patient
Medications on Admission:
(From OMR with [**Location (un) 169**] changes noted):
amiodarone 300 mg daily
simvastatin 20 mg daily (was atorvastatin 10 mg previously)
carvedilol 25 mg [**Hospital1 **] (was 12.5 [**Hospital1 **] previously)
flomax 0.8 qhs
advair 250/50 [**Hospital1 **]
furosemide 80mg [**Hospital1 **]
losartan 25 mg daily
flonase 1 spray NU [**Hospital1 **]
nitrofurantoin 50mg daily - not receiving at [**Location (un) 169**]
protonix 40 mg [**Hospital1 **] (was omeprazole 20 [**Hospital1 **] previously)
proscar 5mg qd
spironolactone 25mg qd
warfarin 9mg STTS, 8mg MWF - not receiving at [**Location (un) 169**]
aspirin 81mg qd
calcium carbonate 500 mg [**Hospital1 **] - not receiving at [**Location (un) 169**]
multivitamin daily
.
fluid restriction 1L daily
Duonebs QID
singulair 10 mg daily
dulcolax 10 mg supp prn
miralax 17 g daily
colace 100 mg [**Hospital1 **]
tylenol 650 mg PO prn pain
potassium chloride 20 mEQ daily
lidocaine patch 5% daily
xanax 0.25 mg PO TID
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO DAILY (Daily) as
needed for constipation.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
7. Nitrofurantoin Macrocrystal 50 mg Capsule Sig: One (1)
Capsule PO DAILY (Daily).
8. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
12. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
14. Mexiletine 150 mg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
15. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
16. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
18. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
19. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of
breath.
20. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO twice a
day.
21. Losartan 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
22. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) as needed for anxiety.
23. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
24. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 169**] Center - [**Location (un) 1411**]
Discharge Diagnosis:
Primary Diagnoses:
1. Ventricular tachycardia s/p ICD firing
2. Non-ischemic cardiomyopathy
3. Hyponatremia
Secondary Diagnoses:
1. Hypertension
2. Obstructive sleep apnea
3. Hyperlipidemia
4. Reactive airway disease
5. Benign prostatic hypertrophy
6. History of chronic urinary tract infections
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital because your heart went into a
very fast rhythm and your ICD fired multiple times. You were
started on a new medication intravenously and then transitioned
to a pill form called mexiletine. Your amiodarone dose was also
increased. You did not have any more fast heart rates or
shocks.
The following changes were made to your medications:
1. Increase amiodarone to 400 mg twice a day for 2 weeks (until
[**3-18**]) then take 400 mg daily
2. Start taking mexiletine 150 mg twice a day
3. Start taking magnesium oxide 400 mg twice a day
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) 275**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2174-3-10**] 8:40
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2174-3-22**] 11:00
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2174-6-16**]
9:30
|
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"285.9",
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icd9cm
|
[
[
[]
]
] |
[
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] |
icd9pcs
|
[
[
[]
]
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13873, 13952
|
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|
327, 334
|
14293, 14293
|
4370, 4370
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362, 2342
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14308, 14445
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2932, 3093
|
2364, 2437
|
3109, 3426
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,330
| 157,010
|
45560
|
Discharge summary
|
report
|
Admission Date: [**2180-9-27**] Discharge Date: [**2180-10-2**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 82 -year-old
male who experienced new onset angina for the past three or
four weeks. He does have a history of peripheral vascular
disease with a lower extremity percutaneous transluminal
coronary angioplasty and bilateral claudication; however, the
patient denied any orthopnea, paroxysmal nocturnal dyspnea,
asthma, or diabetes. His cardiac risk factors included
hypertension and hypercholesterolemia.
Based on his evidence of new onset angina, he underwent
cardiac catheterization which revealed 80% left circumflex
disease, 40% left anterior descending osteal lesion, and a
mid 50% left anterior descending lesion, 80% left main
disease with a normal ejection fraction of 50%. Based on
these results, the patient was referred to Dr. [**Last Name (STitle) **] for
cardiac surgery and coronary artery bypass grafting.
PAST MEDICAL HISTORY:
1. Peripheral vascular disease.
2. Hypertension.
3. Hypercholesterolemia.
4. No diabetes.
5. History of melanoma.
ADMITTING MEDICATIONS: Include aspirin, Toprol, Vasotec,
triamterene, and Imdur.
ALLERGIES: He has an allergy to penicillin.
SOCIAL HISTORY: He denied any smoking history and just has
social alcohol history with no evidence of any intravenous
drug abuse.
PHYSICAL EXAMINATION: He was afebrile with stable vital
signs. Regular rate and rhythm. Clear to auscultation.
Abdomen was soft and nontender, nondistended. Extremities
were no cyanosis, clubbing or edema.
LABORATORY DATA: Preoperatively his hematocrit was 33.4, his
platelets were 366,000. His potassium was 4.4 and his
creatinine was 1.2.
HOSPITAL COURSE: Thus the patient underwent coronary artery
bypass grafting times two on [**2180-9-27**]. He received a left
internal mammary artery graft to the left anterior descending
and a saphenous vein graft to the diagonal. Interoperatively
a mediastinal lymph node was also biopsied for suspicious
appearance. The patient tolerated the procedure well without
any complications and was transferred to the Intensive Care
Unit in stable condition. He was extubated overnight and
received one unit of packed red blood cells for a low
hematocrit.
On postoperative day one, his hematocrit was noted to be 25
and was off all drips. The patient was then transferred to
the floor and continued to progress well. His physical
therapy status remained somewhat of an issue, since he was
noted to be requiring increased assistance in order to
ambulate. His vital signs remained stable and the patient
continued to diurese and work with Physical Therapy.
His blood pressure was noted to be on the high side, so his
Lopressor medications were slowly increased, finally reaching
a maximum of 100 mg po bid. He was restarted on his
preoperative Vasotec, also noted to assist with blood
pressure control. The patient was thus, on postoperative day
five on [**10-2**], he remained afebrile with stable vital
signs, with his blood pressure being slightly high, ranging
from the 140s-170s/70s-80s. He was noted to be ambulating at
approximately level III, still requiring assistance and thus
is awaiting rehabilitation placement in order to be
discharged.
DISCHARGE CONDITION: Stable.
DISCHARGE DIAGNOSES:
1. Coronary artery disease, status post coronary artery
bypass graft times two.
2. Suspicious lymph node with lymph node biopsy.
3. Peripheral vascular disease.
4. Hypertension.
5. Hypercholesterolemia.
6. History of melanoma.
DISCHARGE MEDICATIONS: Include Lopressor 100 mg po bid,
Vasotec 20 mg po q day, aspirin 81 mg po q day, Lasix 20 mg
po bid times four days, KCL 20 mEq po bid times four days,
then after four days triamterene 37.5/25 mg po q day,
Percocet one to two po q four to six hours prn, Colace 100 mg
po bid.
DISCHARGE INSTRUCTIONS: The patient will follow-up with Dr.
[**Last Name (STitle) **] and with his primary physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 2539**], in
approximately three weeks. Currently the patient will be
informed also to follow-up on lymph node biopsy results, as
the pathology results right now are currently pending. The
patient currently is awaiting rehabilitation placement and
discharge.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Name8 (MD) 3181**]
MEDQUIST36
D: [**2180-10-2**] 07:44
T: [**2180-10-2**] 09:03
JOB#: [**Job Number 45034**]
|
[
"401.9",
"443.9",
"202.80",
"V10.82",
"272.0",
"413.9",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"40.11",
"36.11",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
3287, 3296
|
3317, 3551
|
3575, 3852
|
1726, 3265
|
3877, 4551
|
1382, 1708
|
113, 956
|
978, 1227
|
1244, 1359
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,609
| 120,297
|
15273
|
Discharge summary
|
report
|
Admission Date: [**2130-12-20**] Discharge Date: [**2131-1-11**]
Date of Birth: Sex: M
Service: Thoracic Surgery
DISCHARGE DIAGNOSES:
1. Status post mediastinal debridement with omental flap to
open sternal wound and primary closure for chronic sternal
infection.
2. Status post percutaneous tracheostomy.
3. Chronic obstructive pulmonary disease.
4. Coronary artery disease; status post coronary artery
bypass graft times three.
5. Insulin-dependent diabetes mellitus.
6. Atrial fibrillation.
7. Congestive heart failure.
8. Peripheral vascular disease; status post right carotid
endarterectomy.
9. Hypothyroidism.
10. History of lower extremity bypass surgery.
11. History of stomach ulceration resulting in a
gastrointestinal bleed.
PROCEDURES PERFORMED: (Procedures performed during this
admission included)
1. Sternal debridement and omental flap as described above.
The omental flap was done by the Plastic Surgery Service (Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13797**]).
2. Percutaneous tracheostomy.
3. Bronchoscopy; therapeutic times two.
REASON FOR ADMISSION/HISTORY OF PRESENT ILLNESS: The
patient is a 75-year-old gentleman with non-insulin-dependent
diabetes mellitus, peripheral vascular disease, chronic
obstructive pulmonary disease, and coronary artery disease
(status post coronary artery bypass graft times three with a
left internal mammary artery at [**Hospital6 **] in [**2128-8-1**]). This was complicated by a postoperative sternal
infection requiring debridement and pectoralis muscle
advancements.
He was discharged home following this surgery and did well
until [**2129-5-2**] when he fell at home and had an opening
of the sternal wound.
He was taken back to the operating room in [**2129-11-1**]
where an incision and drainage and removal of the sternal
wires was performed along with closure of the wound. This
ultimately reopened and required another debridement in
[**2130-2-1**].
The patient now presents with two persistent sinus drainage
tracks in the lower sternum.
MEDICATIONS ON ADMISSION:
1. Vitamin C 500 mg by mouth once per day.
2. Imdur 30 mg by mouth once per day.
3. Synthroid 0.5 mg by mouth once per day.
4. Singular 10 mg by mouth once per day.
5. Cardizem-CR 120 mg by mouth once per day.
6. Calcium 500 mg by mouth once per day.
7. Multivitamin one tablet by mouth every day.
8. Plavix 75 mg by mouth once per day.
9. Lisinopril 2.5 mg by mouth once per day.
10. Lasix 80 mg by mouth once per day.
11. Ranitidine 150 mg by mouth once per day.
12. Iron 325 mg by mouth once per day.
13. Lipitor 40 mg by mouth once per day.
14. Zaroxolyn 2.5 mg by mouth once per day.
15. Insulin sliding-scale.
16. He was also on 2 liters to 3 liters of supplemental
oxygen at home.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is married and lives in [**Location 86**]
with his wife. [**Name (NI) **] previously worked as a salesman, but he is
now retired. He has three children. He smoked two packs per
day for 20 years but quit smoking 15 years prior.
FAMILY HISTORY: The patient's mother died at a young age
from asthma. His siblings are healthy.
PHYSICAL EXAMINATION ON PRESENTATION: General physical
examination revealed the patient is an obese elderly
gentleman who presented in a wheelchair since it was
difficult for him to walk long distance required to get into
the clinic. The patient was in no apparent distress on 4
liters of oxygen. The patient's weight was 200.5 pounds and
his height was 65 inches. The patient's blood pressure was
90/58, his heart rate was 81 and irregular, his oxygen
saturation was 92% on 4 liters, and his temperature was 97.5
degrees Fahrenheit. The sclerae were anicteric. The
cervical examination revealed no adenopathy. The lungs were
clear to auscultation bilaterally without wheezes.
Cardiovascular examination revealed irregular heart sounds.
There were no murmurs. Thoracic examination revealed no
lesions on the back or flanks. His midline sternum was
unstable with nonunion. There did appear to be a sternal
bone present on examination. He had a midline vertical
incision extending from the suprasternal notch down to below
the xiphoid. There was a T portion to the lower wound from
reconstructive surgery. From those two areas at the lower
sternum, he had two sinus tracks draining purulent material.
The upper three quarters of his sternum appeared to be free
of sinus tracks, infections, or masses. The abdominal
examination revealed the abdomen was obese with no masses.
He had an umbilical hernia which was reducible. Vascular
examination revealed 2+ carotid pulses without bruits.
Extremity examination revealed no clubbing or edema. Skin
examination revealed no cyanosis, but he clearly had two
fistula tracks on his chest. Neurologic examination was
nonfocal. The patient had an intact and appropriate mental
status.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: The
patient is a 75-year-old gentleman with multiple risk factors
for sternal breakdown, status post median sternotomy. The
patient had a chronic sternal infection that required radical
debridement and omental flap for reconstruction.
The patient was brought into the hospital on [**2130-12-20**] and was taken to the operating room for a combined
procedure between Thoracic Surgery and Plastic Surgery and
underwent opening of his sternal wound and debridement of
some of the remaining sternal bone with removal of all
infectious tissue. Thereafter, Plastic Surgery performed a
omental flap closure of the defect.
The patient tolerated the procedure well after a fairly long
and complicated procedure and was transferred to the
Cardiothoracic Surgery Recovery Unit postoperatively. He was
extubated that evening; however, he required reintubation the
during the night.
Prior discussions with the patient and his family confirmed
the conclusion that if the patient did not tolerate a rapid
extubation status post surgery that we would proceed to early
tracheostomy as the patient had been on a ventilator for
prolonged periods of time after previous surgeries. It was
felt that should the patient not tolerate early extubation he
would likely also require a prolonged intubation, the
decision was made to proceed to early tracheostomy to
facilitate ventilator weaning and pulmonary toilet.
On postoperative day one, the patient underwent percutaneous
tracheostomy and tolerated this well.
1. NEUROLOGIC ISSUES: Neurologically, the patient remained
intact. He had no neurologic events during this prolonged
hospitalization. He pain was controlled with a combination
of empiric and intravenous pain medications. On examination
today the patient was alert, was following commands, and was
appropriate.
2. RESPIRATORY ISSUES: As stated, the patient had to have a
tracheostomy. Despite this, the patient was able to be
weaned off a mild amount of ventilator support and is
currently on a pressure support of 10, a positive
end-expiratory pressure of 8, and an FIO2 of 60%. He has
required aggressive pulmonary toilet via suctioning through
his tracheostomy.
Additionally, at one point the patient's failure in weaning
was felt to due malpositioning of the tracheostomy tube which
had come to rest against the posterior membranous wall of the
trachea. Therefore, he was taken to the Interventional
Pulmonology Service where a new tracheostomy tube was placed
which was then in a more appropriate position.
The patient also had a methicillin-resistant Staphylococcus
aureus in his sputum. He has had a persistent white blood
cell count, and this was the presumed source. He is
currently on vancomycin for this and will be completing
another 1-week course of vancomycin post discharge.
3. CARDIOVASCULAR ISSUES: The patient has a history of
atrial fibrillation and continued to be in atrial
fibrillation postoperatively. At times he was in a rapid
ventricular response which was controlled with both beta
blockers, and at one point an amiodarone bolus plus drip,
which seemed to control the rapid ventricular response. He
did not convert into a sinus rhythm.
The patient was also placed on a diltiazem drip which also
controlled his rate. The patient did, at one point, require
a dose of 20 mg per hour. Once the patient tolerated enteric
feeding, the patient was converted to by mouth diltiazem and
he is now at 120 mg by mouth four times per day.
4. GENITOURINARY ISSUES: The patient has chronic renal
insufficiency with a baseline creatinine of approximately
2.5. Currently, the patient's creatinine is 1.7. The
patient has had no real acute issues with his kidneys. He
has required some intermittent diuresis with intravenous
Lasix.
5. GASTROINTESTINAL ISSUES: The patient has had normal
bowel function. He has had no gastrointestinal
complications. He has been tolerating enteric feedings at a
goal calorie rate. Today, he had a video swallow and the
patient was cleared for puree solids, thin liquids, and to
swallow pills and puree.
6. INFECTIOUS DISEASE ISSUES: As noted, the patient had
methicillin-resistant Staphylococcus aureus from his sputum
and is currently on vancomycin. His white blood cell count
is 16 today, and the patient is afebrile.
7. TUBES/LINES/DRAIN ISSUES: The patient will be sent for a
peripherally inserted central catheter placement for his
remaining one week of vancomycin.
MEDICATIONS ON DISCHARGE: (Discharge medications included)
1. Insulin sliding-scale: He receives NPH 20 units
subcutaneously at breakfast and NPH 40 units subcutaneously
at dinner. Additionally, he receives a sliding-scale for
glucose levels of 121 to 160 use 2 units subcutaneously; for
glucose levels of 161 to 200 to 200 use 4 units
subcutaneously; for glucose levels of 201 to 240 use 6 units
subcutaneously; for glucose levels of 241 to 280 use 8 units
subcutaneously; for glucose levels of 281 to 320 use 10 units
subcutaneously; for glucose levels of 321 to 360 use 12 units
subcutaneously; for glucose levels of 361 to 400 use 14 units
subcutaneously; and notify medical doctor for greater than
400.
2. Vancomycin 500 mg intravenously q.24h. (for another
seven days).
3. Roxicet elixir 5 mL to 10 mL by mouth or per feeding
tube q.4-6h. as needed.
4. Morphine sulfate 2 mg to 4 mg intravenously q.4h. as
needed (for breakthrough pain).
5. Pepcid 20 mg intravenously q.12h.
6. Diltiazem 120 mg by mouth four times per day.
7. Reglan 5 mg intravenously q.6h.
8. Erythromycin ophthalmic ointment 0.5 both eyes four
times per day.
9. Levothyroxine 25 mcg intravenously once per day.
10. Albuterol nebulizers one q.4h.
11. Isosorbide dinitrate 10 mg by mouth three times per day
(while intubated).
12. Isosorbide mononitrate extended release 30 mg once per
day (while extubated).
13. Albuterol and Atrovent 2 puffs inhaled q.4h.
14. Docusate sodium 100 mg twice per day.
15. Metolazone 2.5 mg by mouth every Monday, Wednesday, and
Friday.
16. Simvastatin 40 mg by mouth once per day.
17. Plavix 75 mg by mouth once per day.
18. Singular 10 mg by mouth once per day.
DISCHARGE DIAGNOSES:
1. Status post mediastinal debridement with omental flap to
open sternal wound and primary closure for chronic sternal
infection.
2. Status post percutaneous tracheostomy.
3. Chronic obstructive pulmonary disease.
4. Coronary artery disease; status post coronary artery
bypass graft times three.
5. Insulin-dependent diabetes mellitus.
6. Atrial fibrillation.
7. Congestive heart failure.
8. Peripheral vascular disease; status post right carotid
endarterectomy.
9. Hypothyroidism.
10. History of lower extremity bypass surgery.
11. History of stomach ulceration resulting in a
gastrointestinal bleed.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3351**], M.D. [**MD Number(1) 3352**]
Dictated By:[**Last Name (NamePattern4) 25476**]
MEDQUIST36
D: [**2131-1-11**] 12:38
T: [**2131-1-11**] 12:55
JOB#: [**Job Number 44443**]
|
[
"518.5",
"427.31",
"998.6",
"482.41",
"553.1",
"998.89",
"428.0",
"496",
"998.59"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.74",
"34.79",
"77.61",
"33.21",
"53.49",
"96.6",
"31.1",
"96.72",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
3148, 4990
|
11198, 12100
|
9503, 11176
|
2120, 2871
|
5024, 9476
|
1182, 2093
|
2888, 3131
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,303
| 153,857
|
13733
|
Discharge summary
|
report
|
Admission Date: [**2198-4-10**] Discharge Date: [**2198-4-23**]
Date of Birth: Sex: M
Service: TRAUMA SERVICE
HISTORY OF PRESENT ILLNESS: Mr. [**Name14 (STitle) 41338**] is a 35 year-old
man who fell approximately thirty feet from a tree. He had
reported loss of consciousness at the scene times two
minutes. Once he was awake his GCS was 15. He is
complaining of right chest tenderness and pelvic pain. He
moved all extremities symmetrically.
PAST MEDICAL HISTORY: Significant for colon cancer in [**2197**]
for which he had a colectomy with diverting colostomy. The
colostomy was closed in [**2198-1-2**]. He is currently on
chemotherapy for this malignancy.
MEDICATIONS: Compazine and Ativan as needed.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Vital signs on admission, temperature
99.0, heart rate 85, blood pressure 130/90. 22 breaths per
minute. 99% on room air. He is in obvious discomfort. GCS
was 15. He had recall of the event. Pupils are equal, round
and reactive to light. Extraocular movements intact. No
facial deformities. He had a 3 cm laceration over the left
forehead without any active bleeding. Tympanic membranes
were clear bilaterally. Trachea was midline. Lungs were
clear, but slightly decreased on the right side. He had
tenderness over his right anterior ribs without crepitance.
Heart was regular. Abdomen was soft, nontender, nondistended
without rebound or guarding. He had well healed scars.
Pelvis was stable with significant tenderness. Guaiac was
negative with good tone. Extremities were warm and well
profuse without any deformities. He had multiple abrasions
over his knees and shins. Palpable distal pulses
bilaterally. His TLS was clear without any midline
tenderness. He had significant pain over his sacrum.
LABORATORY STUDIES: Significant for a white count of 8.6,
hematocrit 40.1, coags with an INR of 1.5, chemistries within
normal limits. Amylase 99. Urinalysis showed large blood
and nitrate negative. Protein greater then 300. Chest x-ray
did not show a pneumothorax. Normal mediastinum. No rib
fractures. Pelvis showed bilateral superior and inferior
pelvic rami fractures. SI joints were intact. C spine was
clear to T1. Left wrist films showed a left distal radius
fracture and an ulnar styloid fracture. CT of his head was
negative for intracranial hemorrhage. CT of his abdomen and
pelvis revealed a left grade 3 laceration to the kidney as
well as a large running perinephric hematoma. Pelvis showed
bilateral acetabular fractures, bilateral pubic rami
fractures. TLS spine films showed a question of a T12
fracture.
HOSPITAL COURSE: The patient was admitted to the Intensive
Care Unit for neurological checks and serial hematocrit.
Urology was consulted for the perinephric hematoma. They
recommended serial hematocrits and potential repeating CT.
Orthopedics was consulted for his pelvis fractures. Their
plan was to treat these nonoperatively. His right wrist was
casted and subsequently splinted several days after his
admission. The patient was kept in the Intensive Care Unit
overnight. His hematocrits were stable. Neurosurgery was
consulted for his T12 fracture and they recommended a TLSO
brace as he was neurologically intact. The patient was
transferred to the floor on postoperative day number two. He
was given PCA for analgesia. We attempted to advance his
diet and he found that he was nauseous and unable to tolerate
this. KUBs revealed air filled colon without significant
dilated small bowel loops or air fluid levels.
The patient was maintained on intravenous fluids and slowly
his bowel function returned. His diet was advanced. Late in
his course the patient was noted to be jaundice. Liver
function tests were sent. Transaminases were normal.
Alkaline phosphatase was mildly elevated and total bilirubin
was found to be 7.4 approximately half direct and half
indirect. It was felt that this likely reflected him slowly
reabsorbing his perinephric hematoma. Right upper quadrant
ultrasound showed no ductal dilitation, normal echo
appearance of the liver and no gallstones or gallbladder
pathology. Several days into his hospital course the patient
noted a nontender swelling in the medial aspect of his
scrotum. Urology was following the patient and recommended a
scrotal ultrasound, which revealed a epididymal hematoma.
They recommended conservative therapy of this as it will
slowly resolve. The patient was placed on Lovenox for deep
venous thrombosis prophylaxis as he will be on bed rest for
three months for his orthopedic fractures.
At the time of dictation the patient is tolerating a regular
diet without nausea or vomiting. He slide transfers from bed
to chair wearing TLSO brace. His most recent laboratory
studies on [**2198-4-22**] showed his BUN and creatinine to be
stable at 14 and 0.9. His bilirubin is down to 2.6 with
direct fraction of 1.1 and indirect of 1.5.
MEDICATIONS ON DISCHARGE: Lovenox 30 mg subQ q 12 hours.
Percocet [**5-26**] one to two tabs po q 4 to 6 hours prn,
Ibuprofen 600 mg po q 6 hours, Zantac 150 mg po b.i.d.,
Dulcolax 10 mg pr q.d. prn.
As mentioned the patient is tolerating a regular diet.
Please see the PT page for recommendations for specific
rehabilitation plans, but currently the patient is nonweight
bearing on bilateral lower extremities and left wrist for
which he has a short arm cast.
He showed follow up with the following: 1. Follow up in
General Surgery Trauma Clinic on [**5-3**] at 1:00 p.m. Telephone
number is [**Telephone/Fax (1) 274**]. The clinic is located in the [**Hospital Ward Name 23**]
Building on the [**Location (un) **]. He is to follow up with Dr. [**Last Name (STitle) 41339**]
his oncologist in approximately two weeks time to discuss
resuming his chemotherapy. Telephone number there is
[**Telephone/Fax (1) 41340**]. The patient should follow up with Dr. [**Last Name (STitle) 9694**]
in Orthopedics. Phone number [**Telephone/Fax (1) 4301**] i approximately
two weeks. He should follow up with Dr. [**Last Name (STitle) 6910**] of
Neurosurgery. Telephone number [**Telephone/Fax (1) 3571**] in approximately
four weeks time. He should follow up with Dr. [**Last Name (STitle) 770**] of
Urology. Telephone number [**Telephone/Fax (1) 2906**] in two to three
months time.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], M.D. [**MD Number(1) 2214**]
Dictated By:[**Last Name (NamePattern1) 22884**]
MEDQUIST36
D: [**2198-4-23**] 12:02
T: [**2198-4-23**] 12:12
JOB#: [**Job Number 41341**]
|
[
"560.1",
"805.2",
"153.9",
"813.44",
"808.0",
"866.00",
"E884.9",
"808.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.53"
] |
icd9pcs
|
[
[
[]
]
] |
5010, 6653
|
2689, 4983
|
811, 2671
|
171, 482
|
505, 788
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,585
| 176,005
|
46161
|
Discharge summary
|
report
|
Admission Date: [**2105-12-18**] Discharge Date: [**2105-12-24**]
Date of Birth: [**2032-5-22**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4588**]
Chief Complaint:
pre-syncope
Major Surgical or Invasive Procedure:
Foley Catheter Placement
History of Present Illness:
Patient is admits to forgetfullness, and requests details of
medical history be obtained by HCP. [**Name (NI) **] report, pt is a 73 yo M
w/ CAD, h/o multiple reportedly hemorraghic CVA c/b seizures,
s/p recent suspension microlaryngoscopy with excision of right
vocal fold mass, who presents after an episode of near syncope
at home.
.
Pt had vocal surgery with mass removal by Dr. [**Last Name (STitle) 33748**] on
Monday [**2105-12-14**]. Mass was found during eval for chronic
hoarsenss. Prior to surgery, patient was reported to be in
"very good health" by his HCP. After operation, pt was feeling
"generally unwell" per his HCP. [**Name (NI) **] report, was seen in [**Hospital **]
clinic prior to hospital presentation. Was c/o genearlized
weakness but also on increased pain medication. Symptoms
included increased fatigue, urinary hesistancy/diffuclty
urinating coupled with incontinence (w/o saddle aneshtesias),
genearlized weakness, body aches, stomach soreness. Prior to
presentation, patient on way to the bathroom had to sit down as
he was too fatigued to keep walking. HCP reported period of
unresponsiveness staring off to the wall. HCP attempted
shaking/tapping pt. in face without response. Called paramedics
and came to prior to EMS arrival.
.
In the emergency department VS were afebrile 120 107/84 85% 4L
NC. Patient triggered upon arrival to the ED for hypoxia and
tachycardia to the 120s (noted to be in AF w/ RVR, which
resolved without intervention). Labs sig for Cre of 7.0, K of
3.7, Na 129, Trop-T of 0.07. EKG had ST depressions in V5-V6.
CXR showed no focal consolidation. Guiac was positive. Received
2 L NS, CFTX IV x1 and Azithromycin PO x1 in the ED and 40 mEq
of IV K for K of 3.1. Transferred to ICU
.
In the ICU, patient's VS were 80 130/80 20 100% on NRB. He was
transitioned from NRB to 6 L NC, noted to be consistently
satting 95%. ABG on 6 L NC was 7.46/41/80/30. Patient was alert
and oriented and denied any acute symptoms at that time. RN
noted the patient to briefly in AF w/ RVR with rates up to the
120s, which broke spontaneously. Foleyed with total urination
of 2L. Had complete output of 4.5 L without diuresis. Had TTE
which showed pulm htn. Had RUS with wet read showing no disease
but did show bilateral pulmonary effussions. Spent one night in
ICU with decrased O2 demands post void.
.
On call out, pt's vitals were HR:79 sinus, 141/82 16 98% on 2L
NC.
.
On ROS: Patient currently denies any fevers, cough, chest pain,
shortness of breath, abdominal pain, nausea, vomiting dysuria,
diarrhea, or back pain. Denies any changes in his medication
recently. Endorses constipatiion.
.
Past Medical History:
1. Coronary artery disease status post myocardial infarction
in [**2089**].
2. Strokes in [**2092**] and [**2093**] with left parietal
occipital and right occipital hemorrhages. Also left pontine
infarct.
3. Hypertension.
4. Hypercholesterolemia.
5. History of deep vein thrombosis treated with coumadin x 6
months.
6. History of small bowel obstruction.
7. Seizure disorder x 4-5 years after strokes.
8. Chronic renal insufficiency.
Social History:
lives with caretaker [**Name (NI) 20872**]. [**Name2 (NI) **] is separated from his wife.
Owns several bakeries and restaurants. Several children.
Smoked from age 18-40 (1 pack per week). Denies tobacco use
recently. No heavy EtOH use, IVDU or illicits.
Family History:
Father - stroke and MI
Mother - ?cerebral anneurysm
2 children with IDDM, adult onset
1 sister with metastatic breast ca
Physical Exam:
VS: HR79,BP141/82, RR 16, O2 98% on 2L NC.
GEN: elderly M appears in NAD on NC
HEENT: PERRLA. Anicteric sclera. MMM. B/L cervical LAD 1cm.
No erytema or oral lesions in mouth.
NECK: neck supple. Thyroid nonpalpable.
PULM: Expiratory crackles b/l throughout. No rhonchi or rales.
CARD: RRR S1/S2 NL, [**12-10**] pansystolic murmur auscultated
throughout precordium.
ABD: Protuberant abdomen. Midline scar c/w prior abdominal
surgery. Ventral hernia with intestinal outpouching. NBS.
soft NT no g/rt.
EXT: wwp no edema noted
SKIN: mild chronic venous stasis changes
NEURO: alert and orientedx2 (confused about year). CNII-XII in
intact. Vision 20/70 B/L without corrective lenses. Very
hoarse at baseline. [**4-8**] UE/LE bilaterally. Sensation to gross
touch in tact throughout. MAE. No dysdiachokinesia with
alternating hand movements. Mild past pointing. Gait not
tested.
Pertinent Results:
CBC
[**2105-12-18**] 09:20PM BLOOD WBC-9.0# RBC-4.39* Hgb-13.4* Hct-38.3*
MCV-87 MCH-30.5 MCHC-34.9 RDW-13.1 Plt Ct-129*
[**2105-12-22**] 05:40AM BLOOD WBC-6.2 RBC-4.38* Hgb-13.2* Hct-37.4*
MCV-85 MCH-30.1 MCHC-35.3* RDW-12.8 Plt Ct-200
[**2105-12-18**] 09:20PM BLOOD Neuts-79.4* Lymphs-11.4* Monos-6.4
Eos-2.2 Baso-0.6
CMP
[**2105-12-18**] 09:20PM BLOOD Glucose-182* UreaN-71* Creat-7.0*#
Na-129* K-3.7 Cl-86* HCO3-29 AnGap-18
[**2105-12-24**] 05:40AM BLOOD Glucose-112* UreaN-22* Creat-1.4* Na-138
K-4.0 Cl-106 HCO3-19* AnGap-17
[**2105-12-19**] 01:39AM BLOOD Calcium-8.3* Phos-3.7 Mg-2.8*
[**2105-12-24**] 05:40AM BLOOD Calcium-9.3 Phos-2.6* Mg-1.7
COAGS
[**2105-12-20**] 07:30AM BLOOD PT-14.1* INR(PT)-1.2*
CARDIAC ENZYMES
[**2105-12-18**] 09:20PM BLOOD cTropnT-0.07*
[**2105-12-19**] 01:39AM BLOOD CK-MB-4 cTropnT-0.05* proBNP-7830*
[**2105-12-19**] 09:35AM BLOOD CK-MB-4 cTropnT-0.05*
DIGOXIN LEVEL
[**2105-12-22**] 05:40AM BLOOD Digoxin-0.7*
URINALYSIS
[**2105-12-18**] 09:20PM URINE Blood-LG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-MOD
MICROBIOLOGY
BCX: NEGATIVE
UCX: NEGATIVE
IMAGING:
CXR [**2105-12-18**]
FINDINGS: Single frontal view of the chest was obtained. There
is mild
elevation of the left hemidiaphragm with overlying atelectasis.
Slight
decrease in volume of the left lung as compared to the right.
Prominence of
the hila is unchanged. The cardiac and mediastinal silhouettes
are stable.
The cardiac and mediastinal silhouettes are unchanged. No
pleural effusion or
pneumothorax is seen.
IMPRESSION: Mild elevation of the left hemidiaphragm with
overlying
atelectasis. No definite focal consolidation or pleural
effusion.
ECHO [**2105-12-19**]
The left atrium is elongated. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). Right ventricular chamber size and free wall motion
are normal. The aortic root is mildly dilated at the sinus
level. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve appears structurally normal with trivial mitral
regurgitation. Mild to moderate ([**12-6**]+) mitral regurgitation is
seen. Moderate [2+] tricuspid regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Moderate pulmonary artery hypertension.
Mild-moderate mitral regurgitation. Moderate tricuspid
regurgitation. Preserved global and regional biventricular
systolic function.
Compared with the report of the prior study (images unavailable
for review) of [**2103-5-2**], the severity of tricuspid
regurgitation and the estimated pulmonary artery systolic
pressure are slightly increased.
V/Q SCAN [**2105-12-19**]
IMPRESSION: Low likelihood ratio for acute pulmonary embolism.
RENAL US [**2105-12-19**]
RENAL ULTRASOUND: The right kidney measures 11.7 cm. The left
kidney
measures 12.5 cm. The previously documented left interpolar
subcentimeter
cyst is no longer visualized in the current study. There is no
hydronephrosis, hydroureter, renal mass or calculi. The spleen
measures 12.3
cm. There are small bilateral pleural effusions, left greater
than right.
IMPRESSION: No hydroureteronephrosis, renal mass or calculi.
CT SCANS
CT HEAD [**2105-12-21**]
FINDINGS: There is no acute intracranial hemorrhage, major
vascular territory
infarction, mass effect, or edema. The region of
encephalomalacia in the
right parietal lobe is similar to prior. Left pontine chronic
lacunar infarct
is again noted. There is no abnormal enhancement to suggest
intracranial
mass. The vertebrobasilar system is noted with atherosclerotic
calcification
of the left vertebral artery. No osseous abnormality is
identified. The
visualized paranasal sinuses and mastoid air cells are well
aerated.
IMPRESSION: No abnormal enhancement or significant change from
prior.
CT NECK [**2105-12-21**]
FINDINGS: There is slight asymmetry at the level of the right
vocal cord
(2:70), which may represent the patient's known laryngeal
carcinoma. There is
no abnormal enhancement. There is a slightly prominent level 5
lymph node,
measuring 12.2 by 9.7 mm on the right, (2:72). No other
prominent lymph nodes
are identified elsewhere. Vascular structures are within normal
limits. The
visualized portion of the brain is unremarkable, but better
evaluated on
current CT head. Lung apices are clear. The thyroid gland is
unremarkable.
IMPRESSION: Slight asymmetry at the level of the right vocal
cord may
represent known laryngeal carcinoma. No abnormal enhancement.
CT CHEST/ABDOMEN/PELVIS [**2105-12-21**]
CT OF CHEST WITH INTRAVENOUS CONTRAST: The major airways are
patent to
subsegmental levels bilaterally. Patchy peribronchial opacities
seen in the
right upper lobe, likely represent infectious or inflammatory
etiology. No
suspicious pulmonary nodules or masses are identified. There are
no pleural
or pericardial effusions. No significant axillary, mediastinal
or hilar
lymphadenopathy is detected. This study is not tailored for
evaluation of the
pulmonary arteries. Within the limitations of this study,
filling defects are
seen within the lobar and segmental branches of the left upper
and left lower
lobe. Pulmonary emboli are also seen in the segmental branches
of the right
lower lobe. There is moderate atherosclerotic calcification of
the aortic
arch, coronary arteries and the mitral annulus. A small simple
pericardial
effusion is present.
CT OF THE ABDOMEN WITH ORAL AND INTRAVENOUS CONTRAST: There is a
well-defined
hypoattenuating lesion in the segment VIII of the liver (2F:53)
measuring 3.3
x 2.9 cm, with attenuation values consistent with a simple
hepatic cyst. No
concerning liver lesions or biliary dilatation is present. The
gallbladder is
contracted and unremarkable. The adrenal glands and pancreas are
unremarkable. There is a subcentimeter hypodensity within the
spleen (2F:57),
too small to characterize, may represent hemangioma / cyst. Both
kidneys
enhance and excrete contrast symmetrically, without
hydronephrosis or
concerning renal masses. Subcentimeter hypodensity within the
right kidney,
is too small to characterize.
The stomach, small and large bowel are unremarkable. The
abdominal aorta has
scattered moderate atherosclerotic calcification, without
aneurysmal dilation.
No significant retroperitoneal or mesenteric lymphadenopathy is
detected.
There is no intra-abdominal free fluid or air.
CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The urinary bladder
is nearly
empty with a Foley catheter in place. The distal ureters are
normal. The
sigmoid colon and rectum are unremarkable. No significant pelvic
lymphadenopathy or free fluid is detected. There is evidence of
acute deep
venous thrombosis involving the right common femoral vein and
bilateral
superficial femoral veins. Thrombus is also seen within the
right great
saphenous vein.
BONES AND SOFT TISSUES: No bone lesions suspicious for infection
or
malignancy are detected. Mild degenerative changes of the
thoracolumbar spine
are present, worse at L5 and S1 level.
IMPRESSION:
1. No evidence of metastatic disease in the chest, abdomen and
pelvis.
2. Patchy airspace opacities in the right upper lobe,likely
represent acute
infectious/inflammatory process. Recommended attention on
follow-up studies.
3. Acute pulmonary embolism involving lobar and segmental
branches of the
left upper and lower lobes, and segmental branches of the right
lower lobe.
Small simple pericardial effusion.
4. Acute DVT involving both superficial femoral veins and the
right common
femoral vein.
Brief Hospital Course:
Acute on chronic renal failure in setting of urinary retention:
Concerning for both pre-renal etiology in setting of decreased
PO intake and post-obstructive renal failure in the setting of
post-op urinary retention. Urinalysis was inconclusive for
infection. Foley was placed with 2L output. Patient was
resuscitated with IVF. Cr was trended, initially 7.0, dropped
rapidly to 1.5 post catherization. Medications were renally
dosed and nephrotoxins avoided. Renal ultrasound showed no
hydroureteronephrosis. No renal stone or mass. Urine cultures
were negative. Prostate exam showed significant prostatic
enlargement. Patient was started on finasteride and tamsulosin.
Attempted voiding trials which were unsuccessful. Patient
discharged with foley in place, with urology follow up one week
post discharge.
Squamous cell carcinoma of the larynx: Prior to this
hospitalization, patient was having prolonged hoarsenss and had
vocal cord biopsy of vocal cord growth. On this admission,
pathology reports came back positive for squamous cell
carcionma. Patient had evaluation by oncology, who decided on
in house radiographic examination for assessment of metastatic
disease. Initial imaging showed no evidence of metastasis.
However, incidental pulmonary embolisms and DVTs were seen (per
below)
Hypoxic respiratory distress presumably from pulmonary
embolisms: Patient presented with significant A-a gradient on
ABG, requiring a NRB oxygen demand. Was able to titrate down to
RA over several days with no intervention. No evidence of
pneumonia or volume overload on CXR. Clear CXR was concering for
PE however initial V/Q scan was low probability. Cardiac
enzymes were trended and remained stable. TTE showed Moderate
pulmonary artery hypertension. Mild-moderate mitral
regurgitation. Moderate tricuspid regurgitation. Preserved
global and regional biventricular systolic function. Not a
significant change from prior. On general medical floors,
patient was worked up for possible metastatic disease given
diagnosis of squamous cell carcinoma of the larynx (see below).
CT chest incidentally showed multiple subsegmental pulmonary
embolisms, and pelvic imaging showed lower extremity DVT's.
Patient remained asymptomatic. Discussed risks of placing on
anticoagulation, as has history of stroke with hemorrhagic
conversion. Patient and HCP decided to receive treatment with
enoxaparin injections [**Hospital1 **] for DVT/PE treatment.
*Should follow up any pulmonary symptoms, with reimaging in [**2-7**]
months to assess for dissolution of clots.
Pre-syncope: Likely in setting of renal failure versus
hypovolemia, dehydration as patient appeared volume down on
exam. No evidence of bleeding, Hct stable. Pt was volume
resuscitated and orthostatics subsequently negative. No further
episodes of presyncope in house.
Atrial fibrillation: Patient briefly in AF w/ RVR on the floor
and in the ICU. Perhaps self-limited in the setting of patient's
renal failure and hypokalemia. Continued home labetolol and
digoxin (latter initially renally dosed). Checked daily digoxin
level to avoid toxicity. Continued aspirin in addition to
intiation of enoxaparin per above.
Seizure d/o: Associated with pt's hemorrhagic strokes; Continued
Keppra (renally dosed initially) as well as gabapentin 100 mg
qid. No seizure like activity while hospitalized, although did
have episodes of forgetfullness.
Guiac positive stools: hct stable. Patient without frank BRBPR.
Known Grade I Hemorrhoids, diverticulosis, and cecal polyps on
[**8-/2105**] colonoscopy.
*Follow up hematocrit on future visit to assure stability.
Assure appropriate follow up colonoscopy.
Pending Labs: None
Transitional Issues: Issues with providing patient with
enoxaparin. Post discharge, patient [**Name (NI) 653**] hospital as
enoxaparin cost $1300. Spoke with case management which sent
visiting nurse [**First Name (Titles) **] [**Last Name (Titles) **] in insurance processing for monetary
coverage. Should reassess that patient's LMWH is amply covered
by insurance to allow patient to continue anticoagulation for
PE's and DVTs.
Medications on Admission:
ACETAMINOPHEN-CODEINE - 300 mg-30 mg Tablet - [**12-6**] Tablet(s) by
mouth q 4-6 hours as needed for pain or cough
AMLODIPINE - 5 mg Tablet - one Tablet(s) by mouth daily
ATORVASTATIN - 40 mg Tablet - One Tablet(s) by mouth daily
DIGOXIN - 125 mcg Tablet - 1 Tablet(s) by mouth daily
GABAPENTIN [NEURONTIN] - 100 mg Capsule - one Capsule(s) by
mouth four times a day
HYDROCHLOROTHIAZIDE - 25 mg Tablet - 1 Tablet(s) by mouth daily
LABETALOL - 300 mg Tablet - 2 Tablet(s) by mouth twice a day
LEVETIRACETAM [KEPPRA] - 500 mg Tablet - three Tablet(s) by
mouth twice a day
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 2 Capsule(s)
by mouth daily
RANITIDINE HCL - 300 mg Capsule - 1 Tablet(s) by mouth at
bedtime
Medications - OTC
ACETAMINOPHEN - 500 mg Tablet - 2 Tablet(s) by mouth three times
a day as needed for pain
ASPIRIN - 325 mg Tablet - one Tablet(s) by mouth daily
CALCIUM CARBONATE - 500 mg Tablet, Chewable - 1 (One) Tablet(s)
by mouth twice a day
CHOLECALCIFEROL (VITAMIN D3) - 1,000 unit Capsule - 1 (One)
Capsule(s) by mouth once a day
Discharge Medications:
1. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. labetalol 200 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO TID (3 times a day).
6. levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
7. gabapentin 100 mg Capsule Sig: One (1) Capsule PO QID (4
times a day).
8. ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
9. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*0*
10. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
12. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
13. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours).
Disp:*60 injections* Refills:*0*
14. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary:
Presyncope
Acute on Chronic Renal Failure
Pulmonary Embolisms
Bilateral Deep Vein Thromboses
Benign Prostatic Hyperpertrophy
Urinary Hesitancy
.
Secondary:
Squamous Cell Cancer of the Vocal Cord
Atrial fibrillation
Partial Complex Seizure Disorder
Coronary Artery Disease status post myocardial infarction in
[**2093**]
Hypertenison
Hypercholesterolemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr. [**Known lastname 5903**],
You were admitted to the hospital due to increased weakness,
difficutly urinating, and confusion. You were intitially
admitted to the intensive care unit because you were requiring
high amounts of oxygen on presentation to the hospital and your
kidney function was impaired. You had a foley catheter placed
which allowed you to urinate, and your kidney function returned
to baseline. It seems your symptoms were most likely due to
your acute renal dysfunction, and your symptoms gradually
resolved when your kindey function improved. You will keep the
foley in place until you are seen by your urologists in the
outpatient setting.
.
Additionally, the results of your vocal cord biopsy returned,
and you have been diagnosed with squamous cell cancer of the
vocal cord. You have been seen by the oncology team (cancer
doctors), and will be following up with them next week for
further treatment.
.
Lastly, you were found to have blood clots in the vessels of
your lungs as well as your the veins of your lower extremities.
We discussed placing you on blood thinners to help treat these
clots, and to prevent further blood clots from forming in your
lungs. You understood being placed on anticoagulant therapy
carried a risk of increased bleeding, including bleeding in the
brain as you have had in the past. You and your health care
proxy decided treating these blood clots for the next 3 to 6
months would be in your best interest. You have been placed on
enoxaparin (AKA Lovenox), a drug that is similar to heparin.
You will need to take these enoxaparin injections 2x a day. You
will have a visiting nurse come to your home to [**Known lastname **] you and
show you how to use these injections for the first few days
after your discharge.
.
You have been started on a new medications to help with your
enlarged prostate:
Tamulosin 0.4 mg at night- for urinary hesitancy
Finasteride 5 mg daily- for urinary hesitancy
Enoxaparin 80 mg subcutaneous injections 2x a day- for leg/lung
clots
.
Please continue to take the rest of your medications as
prescribed.
.
It has been a pleasure taking care of you [**Known firstname **]!
Followup Instructions:
You have the following medical appointments:
.
Department: HEMATOLOGY/ONCOLOGY
When: MONDAY [**2105-12-28**] at 2:30 PM
With: [**First Name4 (NamePattern1) 4912**] [**Last Name (NamePattern1) 4913**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: GERONTOLOGY
When: FRIDAY [**2106-1-1**] at 10:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RNC [**Telephone/Fax (1) 719**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
This appointment is with Dr. [**Last Name (STitle) **] nurse practitioner.
.
Department: Urology
When: [**2106-1-7**]:30 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 98174**] NP
Building: [**Location (un) **]/[**Hospital Ward Name 23**] Building Floor 3
Campus: East
.
Department: ENT
When: Tuesday [**1-12**] at 2 PM
With: Dr. [**Last Name (STitle) **],MD [**Telephone/Fax (1) 41**]
Building: LM [**Hospital Unit Name **] [**Location (un) 895**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Department: GERONTOLOGY
When: WEDNESDAY [**2106-3-10**] at 9:00 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 719**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
|
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"161.0",
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] |
icd9cm
|
[
[
[]
]
] |
[
"57.94"
] |
icd9pcs
|
[
[
[]
]
] |
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|
319, 346
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374, 3029
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3503, 3762
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,298
| 134,573
|
47039
|
Discharge summary
|
report
|
Admission Date: [**2119-12-8**] Discharge Date: [**2119-12-12**]
Date of Birth: [**2039-8-6**] Sex: M
Service: MEDICINE
Allergies:
Morphine / Sulfa (Sulfonamides) / Ciprofloxacin
Attending:[**Doctor First Name 1402**]
Chief Complaint:
chest pain, bradycardia
Major Surgical or Invasive Procedure:
Central Line
Pacemaker
History of Present Illness:
Mr. [**Known lastname **] is a 80 year old male with history of CAD s/p CABG
of [**Female First Name (un) 899**]/LAD, vein grafts to the D1, second vein graft to the
right posterolateral and PDA, Diabetes mellitus, Hypertension,
and bladder ca with nephrostomy sent from PCP's office with
bradycardia. He reports that he has not been feeling "himself"
the past two weeks. He initially noted an episode of numbness in
his left hand and on the left side of his face two weeks ago. It
happened a second time a week later. Both episodes lasted
approximately 2 minutes. He reports intermittent "chest
tightness" and some mild shortness of breath, both at rest and
and with exertion. He called his doctor earlier in the week and
was given a prescirption for nitroglycerin.
.
Yesterday he had a poor appetite. He "didn't feel right" and
took nitro SL without feeling better. He could not sleep, so in
the morning he made an appointment with his PCP. [**Name10 (NameIs) **] was found to
have HR of 35 at PCP's office and was sent by ambulence to ED.
.
In the ED, initial vitals were HR 38, BP 139/49, R 18, 97% on
RA. Patient was started on a heparin gtt and received 2 L IVF.
He was monitored on telemetry with HR in the 30s.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, cough, hemoptysis, black stools or red stools.
S/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 paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
-CABG: CAD - s/p CABG in [**2105-5-27**] with a LIMA/LAD, vein grafts
to the D1,second vein graft to the right posterolateral and PDA
-PERCUTANEOUS CORONARY INTERVENTIONS: [**2110-6-27**] and at that
point he was found to have an occluded LAD, patent LIMA/LAD, 60%
circumflex,
70% RCA and occluded PDA but patent vein graft to the PDA and D1
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- CAD
- Hypertension
- Recurrent UTI
- Bladder cancer - total cystectomy w/ileal loop
- Insulin dependent diabetes mellitus
- C4-C7 fusion
- Spinal stenosis
- L shoulder surgery, L hip surgery
- Pelvis fracture after fall
- Chronic renal insufficiency
- Recurrent partial SBOs
Social History:
Former cigar smoker. Rare EtOH. Denies drug use. Former
owner of printing company. Lives with wife.
Family History:
Parents with CAD. Son with congenital tricuspid stenosis.
Physical Exam:
Admission Exam:
VS: T=afebrile BP=137/45 HR=38 RR=18 O2 sat=100% on 2L
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 no elevated JVP.
CARDIAC: Bradycardic, S1, S2, no murmurs/rubs/gallops
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. Lower abdomen with
w/ileal loop, urine drainage system.
EXTREMITIES: No c/c/e. No femoral bruits.
PULSES:
Right: Carotid 2+ DP 2+
Left: Carotid 2+ DP 2+
Pertinent Results:
[**2119-12-8**] 11:00PM CK-MB-3 cTropnT-0.49*
[**2119-12-8**] 11:00PM CK(CPK)-92
Renal U/S:
IMPRESSION: Mild right central renal fullness with no evidence
of frank
hydronephrosis.
Echo:
The left atrium is 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. There is no ventricular septal defect. 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 no aortic valve stenosis. Mild to
moderate ([**1-28**]+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. An eccentric, posteriorly
directed jet of Mild (1+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. The estimated
pulmonary artery systolic pressure is normal.
IMPRESSION: poor technical quality due to patient's body
habitus. Left ventricular function is probably normal, a focal
wall motion abnormality cannot be fully excluded. The right
ventricle is not well seen. Midl aortic and mitral
regurgitation.
Compared with the prior study (images reviewed) of [**2118-8-24**],
image quality is better. Mild to moderate aortic and mild mitral
regurgitation can be seen on the current study.
Brief Hospital Course:
An 80 year-old man with history of CAD, s/p CABG with
intermittent chest tightness admitted for new sinus bradycardia,
elevated troponin, and acute renal failure.
.
# Bradycardia: Patient had bradycardia in 30s with 2nd to 3rd
degree AV block. Improved to 40s after atropine. The etiology
was initialy attributed to decreased atenolol clearance in
setting of rising renal failure. However, as Cr decreased, pt
was still bradycardic. Ischemic etiology was unlikely since
troponin level was stable and echo showed no obvious signs of
ischemia. Pt initially had temporary pacing wire and then had
pacemaker placed. He was given vanco and keflex TID after
procedure and will get 2 more days of keflex TID outpatient
followed by his regular keflex daily routine.
.
# Chest tightness/Coronaries: Patient with history of CAD s/p
CABG and with patent grafts on [**2110**] cath. Patient with
intermittent chest pain and elevated troponin (peaked at 0.58
and trended down to 0.3). Troponin level was stable throughout
hosptialization and was attributed to his renal failure.
Continued ASA, atorvastatin, started metoprolol. He was initialy
put on heparin drip which was discontinued after ruling out
acute ischemic event.
.
# Acute Renal Failure: Patient with creatinine of 2.3, up from
baseline of 1.3-1.6. Renal U/S negative for obstruction. Urine
lytes c/w pre-renal picture possibly [**2-28**] poor forward flow vs
dehydration/poor po intake. After giving pt fluids, his renal
function improved back to baseline. On day of discharge his
Cr=1.5.
.
# Diabetes Mellitus: Patient with history of insulin dependent
type 2 diabetes mellitus. Last HgbA1c was 6.2%. Lantus and ISS
given while in hospital.
.
# Recurrent UTIs: Patient with h/o bladder cancer s/p total
cystectomy with ileal loop. Patient on standing antibiotics
(keflex every day). U/A colinized with fecal flora. Pt was
continued on his daily keflex regimen.
Follow up SPEP and UPEP results outpatient.
Medications on Admission:
Atenolol 50 mg daily
cephalexin 500 mg daily
Lantus 27 units qAM
Humalog sliding scale
Diovan 80 mg daily
Nitro PRN
Discharge Medications:
1. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q24H (every
24 hours): Start [**12-14**].
2. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) as needed for post-pacemaker for 2 days.
Disp:*6 Capsule(s)* Refills:*0*
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*20 Tablet(s)* Refills:*0*
4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
6. hydromorphone 2 mg Tablet Sig: [**1-28**] to 1 tablet Tablet PO Q4H
(every 4 hours) as needed for pain.
Disp:*6 Tablet(s)* Refills:*0*
7. valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. metoprolol succinate 50 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*2*
9. insulin glargine 100 unit/mL Cartridge Sig: Twenty Seven (27)
units Subcutaneous once a day.
10. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual every 5 minutes as needed for chest pain: 1 tab
sublingual, may repeat in 5 minutes if persistent chest pain. .
11. insulin lispro 100 unit/mL Cartridge Sig: Twenty Two (22)
Units Subcutaneous before each meal: Take the amount according
to your regular sliding scale.
Discharge Disposition:
Home
Discharge Diagnosis:
Bradycardia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came to the hospital for having a slow heart rate. We placed
a pacemaker to increase your heart rate. You had no
complications from the procedure. Please continue to limit the
mobility of your arm until you go to device clinic. you can take
the dressing off on Thursday, [**12-14**] and take a shower.
Do not take off the tape strips that cover the pacemaker site.
No lifting more than 5 pounds with your left arm or raising your
left arm over your head for 6 weeks. We thoroughly investigated
the cause for your slow heart rate. There were no signs of a
heart attack which was reassuring. We imaged your heart and
there did not appear to be any signs of ischemia.
Please follow up with Device clinic to have your pacemaker
checked out at the date below. Please also see your primary care
doctor in a couple of days at the date below. Make sure they
check your blood pressure and heart rate.
The following changes were made to your medications:
STOP: Atenolol 50mg daily
START: Metoprolol succinate 100 mg daily
START: Keflex 500mg tablet. Take 1 tablet three times a day for
2 more days (you will take this to protect against infection
after getting your pacemaker). Then resume your usual Keflex
500mg 1 tablet ONCE a day on [**12-14**].
START: atorvastatin 80mg daily to lower your cholesterol
START: Senna for constipation while you are taking pain
medications
START: Dilaudid, take [**1-28**] to 1 pill as needed for pain for next
few days
START: Aspirin 81mg daily to protect your heart
Please follow up with your primary care doctor and the device
clinic at the appointment dates below.
Followup Instructions:
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2119-12-18**]
11:30
DEVICE CLINIC (SB)
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
DEVICE CLINIC (SB)
Dr. [**Last Name (STitle) 172**] appointment: Thursday, [**12-14**], at 10:45AM.
[**Telephone/Fax (1) 133**]
[**Street Address(2) **], [**Location (un) **], MA
|
[
"426.0",
"412",
"403.90",
"414.00",
"585.9",
"V45.4",
"584.9",
"V58.67",
"250.00",
"V13.02",
"V45.81",
"786.09",
"V10.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.69",
"37.72",
"37.83",
"38.97",
"89.45"
] |
icd9pcs
|
[
[
[]
]
] |
8791, 8797
|
5268, 7227
|
333, 357
|
8853, 8853
|
3841, 5245
|
10631, 11011
|
2997, 3056
|
7394, 8768
|
8818, 8832
|
7253, 7371
|
9004, 10608
|
3071, 3822
|
2191, 2553
|
270, 295
|
385, 2081
|
8868, 8980
|
2584, 2863
|
2103, 2171
|
2879, 2981
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,550
| 179,938
|
1631
|
Discharge summary
|
report
|
Admission Date: [**2186-5-10**] Discharge Date: [**2186-5-16**]
Date of Birth: [**2146-2-16**] Sex: M
Service: MEDICINE
Allergies:
Aspirin / Nifedipine
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
fever, malaise, wound infection
Major Surgical or Invasive Procedure:
Patient left AMA
History of Present Illness:
40 yo male paraplegic s/p complications of gun shot wound
injuries including R AKA, L BKA, chronic osteomyelitis, MRSA,
and iron deficiency anemia presents with 1 wk purulent R
infected leg wound drainage. He lives at home, without nursing
services and states his brother helps change his dressings
daily. He has h/o multiple admissions for infection with prior
elopement. He has often required a PICC line. He was febrile in
ED and has Vancomycin hanging on the floor, Unasyn 3mg was
given, as well as total of 3mg IV Dilaudid. In ER T101 HR122
BP123/64 RR18 100%RA at 2:15 AM, when he arrived on med floor
T98.3, BP 95/57, 98, 18. Blood pressure at 8:35A was SBP 82/48.
He is complaining of pain in right wound and deeper in (may
represent [**Last Name (un) 2043**] pain).
In [**2186-3-16**] he had (+) BCx for corynebacterium species. This
has been documented in bone and wound infections in the past.
It was apparently reported after he was discharged from
hospital. Efforts were made at contacting him but were
unsuccessful.
Past Medical History:
(Per OMR):
1. Right AKA and left BKA secondary to osteomyelitis
- biopsy of bone on [**2183-11-19**]--MRSA, corneybacterium,
bacteroides, got two weeks vancomycin/flagyl back in [**11/2183**] and
left AMA
- admitted [**Date range (1) 9425**] and got course of vancomycin/flagyl and left
AMA
- admitted [**Date range (1) 9439**] for the same, pulled out own PICC and left
AMA
- admitted [**Date range (1) 9426**] eloped with picc in place
- admitted [**Date range (1) 9428**]/08 eloped with PICC in place prior to
completing abx course
- admitted [**6-22**] and eloped with PICC
- admitted [**Date range (1) 6960**] received Vanc/Unasyn eloped after PICC
removed
- admitted [**Date range (1) 9440**] received vanc/zosyn, eloped with PICC
line in place
- admitted [**Date range (1) 9438**]/08 decision at this point was for no
further abx, to have ortho eval as last line - pt eloped prior
to eval
- admitted [**2184-10-2**] with fevers and wound pain; not given
antibiotics because of concern for development of resistance and
lack of efficacy of interrupted antibiotic tx, as patient was
not willing to undergo continuous tx. Eloped.
- admitted [**0-0-0**] with fevers and wound drainage
of his leg. He received Vancomycin/Zosyn then switched to
Vanc/Unasyn and discharged to [**Hospital1 **] to complete 6-week course
of antibiotics.
- admitted [**2185-2-4**] - [**2185-2-9**] with fevers and RLE wound drainage.
- admitted [**2186-2-23**] - [**2186-2-24**] with fevers RLE wound drainage, no
antibiotics were given per
Received ertapenem/linezolid while in house but recommended to
start 6 week course of IV antibiotics, which pt declined.
- admitted [**Date range (3) 9448**] with fevers, was treated for 5 weeks
with Vanco and Meropenem and then pulled his PICC and left AMA
on [**2185-4-8**]
- admitted [**2185-4-20**] for fevers and eloped on [**2185-4-21**]
- admitted [**2185-4-25**] and eloped on [**2185-4-29**]
2. Paraplegia secondary to gunshot wound
3. Neurogenic bladder/bowel, suprapubic catheter - h/o of
resistant Pseudomonas UTI [**1-/2186**] (sensitive only to Tobramycin)
4. s/p colostomy [**1-17**] "rectal problem"
5. Sickle Cell Trait
6. Psoriasis
7. History of ESBL Klebsiella UTI
8. History of MRSA
9. History of CVA in [**2172**], right facial droop
10. Hepatitis C positive
11. Hepatitis B exposed (HBsAb pos, HBcAb pos, HBsAg neg)
Social History:
(Per OMR and pt): Patient is s/p a gun shot wound after
completing high school and has had LE paralysis since that time.
He smokes [**12-17**] cigarretes per day. He denies any history of
alcohol intake. He used heroin and cocaine (states that he
snorts it and has not used IV drugs) and cocaine. Most recent
snorted cocaine use 2 weeks prior when relative died. Currently
living with his brother.
Family History:
Pt denies any one in the family with frequent skin infections.
There is no history of premature coronary artery disease, DM,
HTN or cancer
Physical Exam:
Lying in bed, face down, states he's in pain. Doesn't engage in
eye contact, no foul smells, but open, un-dressed cratered R AKA
wound is draining obvious puss.
T98 BP 98/48 --> 82/48, HR 98, RR 18 SPO2 98%
ENT - pt would not permit, states is in pain
JVP flat, no [**Doctor First Name **], neck supple
CHEST - would not permit, states is in pain
LUNG - CTA bilat
BACK - multiple scars\
ABD - no tenderness on flanks
EXT - Large cratered R AKA stump with purulent drainage, L BKA
stumped in gauze dressing w/o drainage. Pt would not allow
inspection of R stump because of pain
NEURO - Alert x 3, coherent speech, moves upper extremities
SKIN - full assessment deferred by patient
PSYCH - calm
Pertinent Results:
[**2186-5-14**] 04:10AM BLOOD WBC-9.4 RBC-3.04* Hgb-6.6* Hct-21.2*
MCV-70* MCH-21.7* MCHC-31.1 RDW-22.1* Plt Ct-716*
[**2186-5-10**] 03:00AM BLOOD WBC-16.5* RBC-3.20* Hgb-6.8* Hct-21.7*
MCV-68* MCH-21.4* MCHC-31.5 RDW-22.5* Plt Ct-903*#
[**2186-5-10**] 03:00AM BLOOD Neuts-83.5* Lymphs-12.3* Monos-2.6
Eos-1.4 Baso-0.3
[**2186-5-11**] 04:10AM BLOOD PT-14.1* PTT-29.4 INR(PT)-1.2*
[**2186-5-11**] 04:10AM BLOOD ESR-90*
[**2186-5-14**] 04:10AM BLOOD UreaN-15 Creat-0.8 Na-138 K-4.3 Cl-102
HCO3-28 AnGap-12
[**2186-5-10**] 03:00AM BLOOD ALT-7 AST-21 AlkPhos-137* TotBili-0.2
[**2186-5-10**] 03:00AM BLOOD Lipase-12
[**2186-5-14**] 04:10AM BLOOD Calcium-8.1* Phos-4.0 Mg-1.4*
[**2186-5-11**] 04:10AM BLOOD Calcium-7.7* Phos-3.2 Mg-1.3*
[**2186-5-11**] 07:57PM BLOOD CRP-64.4*
[**2186-5-11**] 07:57PM BLOOD Tobra-2.5*
[**2186-5-11**] 07:57PM BLOOD Vanco-18.2
[**2186-5-11**] 02:54PM BLOOD Tobra-7.0
[**2186-5-10**] 03:00AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2186-5-10**] 03:09AM BLOOD Lactate-1.0
[**2186-5-14**] 02:31PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.009
[**2186-5-10**] 09:08AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.011
[**2186-5-14**] 02:31PM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG
[**2186-5-10**] 09:08AM URINE Blood-LG Nitrite-POS Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-LG
[**2186-5-14**] 02:31PM URINE RBC-5* WBC-5 Bacteri-FEW Yeast-NONE Epi-2
TransE-1
[**2186-5-10**] 09:08AM URINE RBC-33* WBC-83* Bacteri-MANY Yeast-NONE
Epi-1 TransE-1
[**2186-5-14**] 02:31PM URINE CastHy-1*
[**2186-5-10**] 09:08AM URINE CastHy-3*
[**2186-5-10**] 12:30PM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-POS amphetm-NEG mthdone-POS
[**2186-5-10**] 3:20 am BLOOD CULTURE
Blood Culture, Routine (Preliminary):
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus and [**Female First Name (un) 564**] species.
FINAL SENSITIVITIES.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 4 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
Aerobic Bottle Gram Stain (Final [**2186-5-11**]):
GRAM POSITIVE COCCI IN CLUSTERS.
REPORTED BY PHONE TO [**First Name8 (NamePattern2) 4503**] [**Last Name (NamePattern1) 4504**] #[**Numeric Identifier 9455**] [**2186-5-11**] 12:10PM.
[**2186-5-12**] 12:19 pm SWAB Source: Right stump.
GRAM STAIN (Final [**2186-5-12**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
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..
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
BETA STREPTOCOCCUS GROUP G. RARE GROWTH.
STAPH AUREUS COAG +. RARE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
AMIKACIN-------------- =>64 R
CEFEPIME-------------- =>64 R
CEFTAZIDIME----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM------------- =>16 R
PIPERACILLIN/TAZO----- =>128 R
TOBRAMYCIN------------ 8 I
Brief Hospital Course:
40year old paraplegic c/b neurogenic bladder/SPT, R AKA, L BKA
with h/o recurrent wounds infections and chronic stump
osteomyelitis presented wtih 1 week of purulent discharge from R
AKA. Febrile and hypotensive on arrival. Went to MICU where he
was stabilized with fluids and antibiotics. Was also found to
have a UTI and ID service actually felt this was more likely
urosepsis rather than wound sepsis. His initial UCx was
contaminated but repeat UA was negative. He was initially placed
on Vancomycin and Tobramycin per ID recs. His Blood cx (1 of 2
sets from [**5-10**]) grew MRSA. His wound grew pseudomonas. Again,
since ID did not feel wound was truly infected (colonization),
Tobramycin was d/c'd on [**5-13**] per ID recs. He was kept on Vanc
for the MRSA BSI.
The patient left against medical advice on [**5-16**], despite
recommendations to stay for an echocardiogram. The patient
understood the risks of leaving.
Diagnoses:
1. MRSA Bactremia
2. Septicemia due to Bacterial UTI
3. Probable Stump Infection (Wound)
4. Iron Deficiency Anemia
5. Neurogenic Bladder
Medications on Admission:
None
Discharge Medications:
Left AMA
Discharge Disposition:
Home
Discharge Diagnosis:
Urosepsis
infected stump wound
Discharge Condition:
Patient left AMA
Discharge Instructions:
Patient left AMA
Followup Instructions:
Patient left AMA
|
[
"V49.75",
"070.70",
"707.03",
"596.54",
"305.62",
"707.22",
"599.0",
"038.12",
"280.9",
"E878.5",
"730.15",
"V49.76",
"997.62",
"995.91",
"344.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
10477, 10483
|
9312, 10389
|
313, 331
|
10557, 10575
|
5087, 6923
|
10640, 10659
|
4217, 4357
|
10444, 10454
|
10504, 10536
|
10415, 10421
|
10599, 10617
|
4372, 5068
|
6967, 8404
|
242, 275
|
8439, 9289
|
359, 1397
|
1419, 3785
|
3801, 4201
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
345
| 169,339
|
28463
|
Discharge summary
|
report
|
Admission Date: [**2169-5-21**] Discharge Date: [**2169-5-31**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
aspiration, seizure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient is an 87 yo Spanish Speaking woman with dementia
(requiring [**Hospital 4820**] nursing care), diabetes II, CHF, atrial
fibrillation who presented to the ED yesterday with seizure like
activity in the setting of recent failure to thrive. Her family
noted a gradual decline over the last few weeks with
lethargy/increased confusion, decreased PO intake, diarrhea last
week, no vomiting or fevers. She was also more confused than
normal (baseline does not know where she is, doesn't hold a
coherent conversation), no headaches, no vomiting, no dyspnea,
chest pains. She last spoke around 1430 and then was being fed
dinner and doing poorly when she dropped the fork from her left
hand and began shaking the left arm. EMS was called, upon
arrival EMS noted the patient to have L-sided posturing (and
enroute L arm shaking for a few seconds/posturing to left side,
eyes rolled back) and she was vomiting.
Past Medical History:
FTT, IDDM, CHF, Dementia, HTN, DJD, GERD, Anemia, afib, UTI. OS
s/p BTKA, h/o s/p right thyroidetomy
Social History:
lives at rehab x 7 months, family decided to move her there as
she was unable to walk and she was becoming more
combative/aggressive, no h/o smoking but did use chewing tobacco
'her whole life' until 2 years ago, no etoh or illicit drugs,
from [**Male First Name (un) 1056**], moved to [**Location (un) 86**] area in [**2133**]
Family History:
1 daughter, 2 sons w/DM
Physical Exam:
Admission:
T afebrile BP 120/64 HR 67 RR 16 SaO2 100% CVP 2-5
General: elderly woman, intubated/sedated, moves all extremities
to stimulation
HEENT: NCAT, PERRL, EOMI
CV: irregular rate, no m/r/g appreciable
Pulm: roncerous. No crackles.
Abd: soft, non-distended, non-tender, no organomegaly
Ext: no c/e/c. fingers cold B, B feet warm and well-perfused
with 2+ DP pulses
Neuro:
PERRL. EOMI. Sensation intact V1-V3. Facial movement symmetric.
Motor: Normal bulk bilaterally. Tone normal. No observed
myoclonus or
tremor No pronator drift
Reflexes: +2 and symmetric throughout. Toes downgoing
bilaterally
.
Discharge:
T 96.3 BP 121/58 HR 76 RR 20 SaO2 89-93% RA, SaO2 99% 2L
General: elderly woman, alert, speaking Spanish but not truley
communicating
HEENT: NCAT, PERRL, EOMI, mildly elevated JVP
CV: irregular rate, no m/r/g appreciable
Pulm: CTAB, no labored breathing, occ fine crackles in bases
bilaterally
Abd: soft, non-distended, non-tender, no organomegaly
Ext: no c/e/c.
Neuro: alert, speaking but not communicative, pneumoboots in
place
Skin; no rashes,
Pertinent Results:
ADMISSION LABS
[**2169-5-21**] 04:55PM BLOOD WBC-10.7 RBC-4.90 Hgb-14.3 Hct-46.1
MCV-94 MCH-29.2 MCHC-31.0 RDW-13.6 Plt Ct-341
[**2169-5-21**] 04:55PM BLOOD Neuts-67.1 Lymphs-24.9 Monos-6.2 Eos-1.4
Baso-0.4
[**2169-5-21**] 04:55PM BLOOD Glucose-198* UreaN-19 Creat-0.7 Na-141
K-5.3* Cl-99 HCO3-18* AnGap-29*
[**2169-5-21**] 04:55PM BLOOD ALT-16 AST-36 CK(CPK)-52 AlkPhos-77
TotBili-0.7
[**2169-5-21**] 04:55PM BLOOD cTropnT-<0.01
[**2169-5-22**] 01:45AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2169-5-21**] 04:55PM BLOOD Albumin-4.3 Calcium-9.5 Phos-4.5 Mg-1.7
[**2169-5-21**] 04:55PM BLOOD TSH-5.9*
[**2169-5-22**] 01:45AM BLOOD Free T4-1.2
[**2169-5-25**] 02:44AM BLOOD Phenyto-13.2
[**2169-5-21**] 05:09PM BLOOD Glucose-175* Lactate-10.0* Na-143 K-3.9
Cl-100 calHCO3-19*
[**2169-5-21**] 05:09PM BLOOD Hgb-14.9 calcHCT-45
[**2169-5-21**] 05:09PM BLOOD freeCa-1.12
IMAGING
CT pelvis/abdomen-5/5-1. No definite evidence of intra-abdominal
acute process.
2. Moderate right basilar atelectasis. Please note, aspiration
or early pneumonia is difficult to exclude given this
appearance.
3. Cardiomegaly and coronary artery calcification.
4. Small hiatal hernia.
.
CT head [**5-21**]-No intracranial hemorrhage or evidence of major
vascular territorial infarct. Chronic microvascular disease.
.
MRI head [**5-23**]-
1. No evidence of acute infarction. Multiple FLAIR hyperintense
foci in the cerebral white matter, pons, on both sides, most
likely representing sequela of chronic small vessel occlusive
disease, givent he aptient's age and risk factors.
2. Prominent ventricles and extra-axial CSF spaces most likely
due to age- appropriate parenchymal volume loss. However,
superimposed Alzheimer's dementia cannot be excluded, given the
mild dilation of the temporal horns and small hippocampi.
3. Small linear focus of enhancement in the left occipital lobe,
seen only on the MPRAGE sequences, could represent a small
developmental venous anomaly. However, dedicated mr angiogram
was not performed on the present study. This can be considered
based on clinical discretion.
.
EEG [**5-22**]-Abnormal portable EEG due to the slow and disorganized
background and bursts of generalized slowing. These findings
indicate a
widespread encephalopathic condition affecting both cortical and
subcortical structures. Medications, metabolic disturbances, and
infection are among the most common causes. There were no areas
of
prominent focal slowing, and there were no epileptiform features
.
Echo-[**5-23**]-Possible small mitral valve vegetation. Normal global
and regional biventricular systolic function. Moderate aortic
regurgitation. Moderate mitral regurgitation. Moderate tricuspid
regurgitation. Moderate pulmonary hypertension.
Compared with the prior study (images reviewed) of [**2167-10-8**],
severity of valvular regurgitation has increased slightly.
Pulmonary pressures are higher. The other findings are similar.
A transesophageal study may better be able to assess the mitral
valve morphology.
.
CXR's
[**5-21**]:The endotracheal tube terminates approximately 3 cm from the
carina. Patient rotation somewhat limits interpretation. Lung
volumes are low, but pulmonary vasculature does not appear
engorged. There is no evidence of pleural effusion. No focal
parenchymal opacities are seen in the lungs. The cardiac size,
mediastinum and hila cannot be fully evaluated due to patient
rotation.
[**5-23**]:AP single view with patient in semi-erect sitting position
demonstrates patient in semi-oblique position towards the right.
The Dobbhoff line is seen and apparently has not passed the
hiatus. Otherwise, there is no evidence of any new abnormality,
but as before, pulmonary vascular congestion is present and the
lateral pleural sinuses are blunted.
IMPRESSION: Unsuccessful advancement of Dobbhoff line finding
resistance in hiatal area.
[**5-30**]: As compared to the previous radiograph, there is
considerable patient rotation. The endotracheal tube,
nasogastric tube and central venous access line right have been
removed. The lung volumes are slightly smaller than before,
there is unchanged mild-to-moderate bilateral pleural effusions
and signs suggesting mild volume overload. Retrocardiac
atelectasis is unchanged. There is no evidence of newly appeared
parenchymal opacities.
.
MICROBIOLOGY DATA
[**5-21**]-BCx-staph coag negative 2/3 bottles
[**5-22**] Bcx- negative
[**5-26**] Bxc pending
[**5-21**]-urine culture negative
[**5-22**]-CSF-cryptococcal ag negative, HSV neg, prot 113, glucose 85,
WBC 4
[**5-22**]-sputum cx-1+GNR
Brief Hospital Course:
89 yo woman with dementia, DM, atrial fibrillation, CHF who
presented with lethargy/altered mental status, witnessed to have
a possible seizure, and admitted to the ICU after intubation.
.
# Altered mental status/seizure: EEG showed widespread
encephalopathy, CT was negative for acute pathology. Per pt's
family, pt has a history of seizure in setting of urosepsis. A
full infections work up was performed. She was initially on
Ceftriaxone/Ampicillin and Acyclovir for concern for meningitis.
Ceftriaxone/ Ampicillin/Acyclovir were discontinued. An LP was
not suggestive of bacterial or viral infection, HSV negative.
Blood cultures were negative, only [**2-19**] coag nesg staph (positive
from the same set) that was likely contaminant. Prior to
speciation, she was on Vancomycin for possible gram positive
bacteremia. She also received a TTE which did not show any over
vegetations - see below. UA and Ucx were negative. Given her
vomiting, it was thought that she may have an aspiration PNA.
Although she had no leukocytosis, no fever and no infiltrate on
CXR, she did grow 2+ GNR in her sputum. For this she was on
Unasyn and Vancomycin for possible aspiration PNA. An EKG showed
no new arrythmia and cardiac enzymes were negative making a
primary cardiac event with hypoxia unlikely. A metabolic cause
was also thought to be unlikely as electrolytes were normal.
Head CT was negative for bleeding. MRI showed no new pathology.
She was followed by neurology. Per their discussion, her seizure
may have been a manifestation of underly neurodegenerative
disease. She was intially given dilantin and then switched to
Keppra. She was on Keppra 500 [**Hospital1 **] at discharge. She should be
titrated up to Keppra 1,000mg [**Hospital1 **] on [**2169-5-30**]. She had no further
seizures but was maintanted on seizure precautions.
.
# Intubation: Pt was intubated for airway protection and is
required minimal ventilator support. She was easily extubated.
.
# Possible bacteremia: Pt was reported to have [**2-19**] bcxs with
GPCs, prompting concern for endocarditis with septic emboli to
brain (neg on MRI). An echo showed no overt vegetations but a
questionable hyper-echo area on the aortic valve where
vegetation could not be ruled out. However, upon clarification
with the lab, pt has only [**1-20**] bcxs positive with coag neg staph
which was likely contaminant. Given that further blood cultures
were negative and that the coag neg staph was likely a
contaminant, no further endocardidtis work up was pursued. She
did receive 7 days of Vancomycin. Her TTE was discussed with
cardiology who noted that the patient has aortic and mitral
valve abnormalities and that if the clinical suspicion for
endocarditis is low that these possible vegetations may just be
fibrin strands. Please draw routine blood cultures on Monday
[**2169-6-5**] and with any fever. If blood cultures are positive,
please readmit patient to [**Hospital1 18**].
.
# Possible Aspiration PNA: Given the witnessed aspiration event,
there was a concern of Aspriation PNA. She did not have a fever,
leukocytosis or infiltrated but did have 2+ GNR on sputum. She
was treated with Unasyn and Vancomycin for 7 days, day 1 was
[**2169-5-23**]. She received a speech and swallow evaluation which she
passed w/o evidence of impaired swallowing. It was ultimately
decided that she did not have an aspiration PNA w/o fever,
leukocytosis or infiltrated and her abx was stopped at 7 days
rather than the planned 14 day course.
.
# Acute on Chronic Systolic Congestive Heart Failure: The
patient has a known EF of 40% but was not admitted on any heart
failure regimen. She received 6+L in the ED and on day 1 in the
MICU. She had subsequent volume overload and was diuresed.
Several days later, she was found to have hypoxia 86% RA,
crackles and elevated JVP. a CXR showed pulmonary edema. She was
once again diuresed with lasix 10 IV for two days - put out
1.5-2L daily. She was started on low dose lisinopril and every
other day lasix without adverse effect, stable creatinine. She
did have slightly low K with diuresis which required repletion.
She will need Chem 7 every other day to monitor sodium,
potassium and creatinine.
.
# Hypotension/bradycardia: Pt had a brief episode in ED with the
rest of VS being stable. This may have been drug effect after
intubation or a vagal episode. This has not recurred.
.
# Atrial fibrillation: Currently rate-controlled but has had
some episodes of RVR. She was maintained on Metoprolol and ASA
325mg.
.
# Diabetes: Her home metformin was held and she was on a humalog
sliding scale. Metformin was restarted at discharge.
Medications on Admission:
Metformin 500 [**Hospital1 **]
Vicodin prn
Flovent 110 [**Hospital1 **]
Albuterol prn
Tylenol prn
Robitussin prn
Prozac 20 daily
ASA 325 daily
Seroquel 50mg QAM
Lopressor 25 [**Hospital1 **]
Discharge Medications:
1. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 4 days.
4. Keppra 1,000 mg Tablet Sig: One (1) Tablet PO twice a day:
Start after 4 days of Keppra 500mg [**Hospital1 **].
5. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
6. Flovent HFA 110 mcg/Actuation Aerosol Sig: One (1) puff
Inhalation twice a day.
7. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
[**1-18**] nebs Inhalation Q6H (every 6 hours) as needed for wheezing.
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
9. Lopressor 50 mg Tablet Sig: [**1-18**] Tablet PO twice a day.
10. Seroquel 50 mg Tablet Sig: One (1) Tablet PO once a day.
11. Vicodin 5-500 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
12. Lasix 20 mg Tablet Sig: [**1-18**] Tablet PO QOD.
13. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare-[**Location (un) 86**]
Discharge Diagnosis:
Seizure
Acute on Chronic Systolic Congestive Heart Failure
Discharge Condition:
improved
Discharge Instructions:
You were admitted for a seizure. You did not have a brain
infection or head bleeding. You seizure was most likely due to
underlying dementia. You were started on anti-seizure
medications. You were started on a low dose and your medications
will need to be titrated up.
.
You were found to have an aspiration pneumonia due to vomiting
and received antibiotics.
.
If you have another seizure, fevers, chill or respiratory
distress, you should return to the emergency room.
Followup Instructions:
Please call your primary care provider to arrange for an
appointment in the next two weeks.
.
This patient has been started on lisinopril and lasix for heart
failure. She will need every day Chem 7 to monitor her sodium,
potassium and creatinine.
.
Please draw routine surveillance blood cultures on Monday
[**2169-6-5**].
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
|
[
"290.3",
"276.2",
"428.0",
"530.81",
"250.02",
"427.31",
"V49.75",
"428.23",
"780.39",
"348.30"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"03.31",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
13342, 13418
|
7406, 12038
|
281, 287
|
13521, 13532
|
2835, 7383
|
14052, 14508
|
1710, 1735
|
12279, 13319
|
13439, 13500
|
12064, 12256
|
13556, 14029
|
1750, 2816
|
222, 243
|
315, 1225
|
1247, 1349
|
1365, 1694
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,726
| 156,498
|
41063
|
Discharge summary
|
report
|
Admission Date: [**2121-4-6**] Discharge Date: [**2121-4-13**]
Date of Birth: [**2045-6-19**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2121-4-8**] - Mitral Valve Repair (28mm Annuloplasty Ring)
[**2121-4-7**] - Cardiac Catheterizatin
History of Present Illness:
75yo woman with past medical history of cardiomyopathy and know
mitral regurgitation admiited for heparinization bridge for
history of Afib. Pre-op MVR
Past Medical History:
Past Medical History:
Atrial Fibrillation s/p AV node ablation
Breast CA s/p bilat mastectomy
Cardiomyopathy (EF 40-50%)
Hypertension
Mitral Regurgitation
Sarcoid - negative myocardial biopsy [**2116**]
Past Surgical History:
PPM [**2117-11-16**] ([**First Name8 (NamePattern2) **] [**Male First Name (un) 923**])
Social History:
Last Dental Exam: 1 wk ago
Lives with:very involved daughters
Occupation: retired
Tobacco: Quit 45pack year history
ETOH:
Family History:
non contributory
Physical Exam:
Pulse: 75 VP Resp: 16 O2 sat: 100%-RA
B/P Right: 128/76 Left:
Height: 5'0" Weight: 64.2
General:NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI []
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur 3/6 SEM
Abdomen: Soft [x] non-distended [x] non-tender [x] +BS [x]
Extremities: Warm [x], well-perfused [x] Edema: trace bilateral
lower extremity edema/ chronic left upper extremity lymphedema
Varicosities: None [x]
Neuro: Grossly intact- nonfocal exam
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit no
Pertinent Results:
[**2121-4-7**] Cardiac Catheterization
1. Selective coronary angiography of this right-dominant system
demonstrated no angiographically apparent flow-limiting coronary
artery
disease. The LMCA, LAD, LCx, and RCA all had no
angiographically
apparent flow-limiting disease.
2. Resting hemodynamics revealed normal left- and right-sided
filling
pressures with an LVEDP of 17 mmHg and an RVEDP of 4 mmHg.
Pulmonary
arterial pressures were normal at 35/15 mmHg. Mean PCWP was
normal at
15 mmHg. Cardiac output was decreased at 3.65 L/min with an
index of
2.09 L/min/m2.
3. Left ventriculography demonstrated [**1-30**]+ moderately severe
mitral
regurgitation. Ventricular function was decreased at 33-45%.
There was
severe anteroapical and inferoapical hypokinesis.
FINAL DIAGNOSIS:
1. No angiographically apparent coronary disease.
2. Moderately severe mitral regurgitation.
3. Left ventricular dysfuction with EF 33-45% and severe
anterioapical
and inferoapical hypokinesis.
4. Normal left- and right-sided filling pressures.
[**2121-4-8**] ECHO
Pre Bypass: The left atrium is moderately dilated. No atrial
septal defect is seen by 2D or color Doppler. There is mild
global left ventricular hypokinesis (LVEF = 45 %). Right
ventricular chamber size and free wall motion are normal. There
are three aortic valve leaflets. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is partial posterior mitral
leaflet flail at P3 with severe prolapse at P1 as well..
Moderate to severe (3+) mitral regurgitation is seen. Due to the
eccentric nature of the regurgitant jet, its severity may be
significantly underestimated (Coanda effect). The tricuspid
valve leaflets are mildly thickened. Wires can be seen entering
the RV and Coronary Sinus consistent with BiV pacer. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] is
seen passing through the atrium and ventricle into the pulmonary
artery.
Post Bypass: The patient is AV paced on epinepherine and
phenylepherine infusions. Left ventricular function remains
unchanged, except prominent septal dyskinesis consistent with
epicardial V pacing. Initial RV dysfunction seen post bypass
improved to baseline over time (suspect coronary air). Tricuspid
regurgitation is severe initially post bypasss, is mild to
moderte by chest closure with improved RV function. The RV wire
and PA catheter are seen as pre bypass. The coronary sinus wire
can not be identified in the sinus. There is an additional thin
structure with a small lucent mass on the end seen just above
the tricuspid valve. It may be associated with the pre-existing
coronary sinus wire (consider migration of the wire into the
RA), but association with the tricuspid valve can not be
excluded. Aortic contours intact. Remaining exam is unchanged.
All findings discussed with surgeons at the time of the exam.
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2121-4-7**] for cardiac
catheterization and surgical management of her mitral valve
disease. Her cardiac catheterization revealed clean coronaries.
She was worked-up in the usual preoperative manner. Heparin was
started as a bridge to surgery as she had previously been on
coumadin for atrial fibrillation. On [**2121-4-8**], she was taken to
the operating room where she underwent a mitral valve repair.
Please see operative note for surgical details. Postoperatively
she was taken to the intensive care unit for monitoring. Over
the next several hours, she awoke neurologically intact and was
extubated without difficulty. She weaned off pressors and was
started on Beta-blocker/Statin/Aspirin, and diuresis. She was
transferred to the floor on POD #1 to begin increasing her
activity level. Physical Therapy was consulted for evaluation of
strength and mobility. Home physical therapy was recommended on
discharge. Many of her preoperative medications were resumed.
She continued to progress and on [**2121-4-13**] she was cleared for
discharge to home with VNA. All follow up appointments were
advised.
Dr. [**Last Name (STitle) 1683**] will resume coumadin management as an outpatient. She
will take 1mg on [**2121-4-14**] and have her blood checked [**2121-4-15**].
Medications on Admission:
Actonel 35 QWk
ASA 81 QD
Calcium 600 qd
Coreg 3.125 [**Hospital1 **]
Coumadin 1mg QMon and Fri/2mg rest of week- LAST DOSE [**2121-4-2**]
Digoxin .125 qd
Fish Oil 1000 qd
Lasix 40 QD
Lisinopril 5 QD
MAg Oxide 400 qd
MVI
Potassium Chloride 10mEq qd
Proteinex 40
Zocor 10 QD
Discharge Medications:
1. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Coumadin 1 mg Tablet Sig: As instructed by Dr. [**Last Name (STitle) 31149**] for a
goal INR of 2.0-2.5 Tablets PO once a day: Please [**Last Name (un) **] as
instructed by Dr. [**Last Name (STitle) 1683**]. .
Disp:*30 Tablet(s)* Refills:*2*
8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Fish Oil 1,000 (120-180) mg Capsule Sig: One (1) Capsule PO
once a day.
10. digitek Sig: One (1) 0.125mg (125mcg) once a day.
Disp:*30 Tablets* Refills:*2*
11. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
12. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
13. potassium chloride 10 mEq Tablet Extended Release Sig: One
(1) Tablet Extended Release PO once a day.
Disp:*30 Tablet Extended Release(s)* Refills:*2*
14. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO once a
day.
15. Actonel 35 mg Tablet Sig: One (1) Tablet PO once a month.
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Hospital Homecare
Discharge Diagnosis:
Atrial Fibrillation s/p AV node ablation
Breast CA s/p bilat mastectomy
Cardiomyopathy (EF 40-50%)
Hypertension
Mitral Regurgitation s/p MV repair
Sarcoid - negative myocardial biopsy [**2116**]
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
1+ edema
Discharge Instructions:
1) 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.
2) Please NO lotions, cream, powder, or ointments to incisions.
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided.
4) No driving for approximately one month and while taking
narcotics. Driving will be discussed at follow up appointment
with surgeon when you will likely be cleared to drive.
5) No lifting more than 10 pounds for 10 weeks
6) Coumadin dosing per Dr. [**Last Name (STitle) 1683**]. Take 1mg on Monday [**4-14**] and
then as instructed by Dr. [**Last Name (STitle) 1683**].
7) You may resume your at home fish oil, multivitamins, Actonel
and magnesium oxide.
8) Please call with any questions or concerns [**Telephone/Fax (1) 170**]
*Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] on Thursday [**2121-5-1**] 1:30PM
Cardiologist:Dr. [**Last Name (STitle) 83788**] in 3 weeks. Please call [**Telephone/Fax (1) 8226**]
to schedule appointment.
Wound check appointment [**2121-4-17**] at 11:00AM [**Hospital **] Medical
Buliding [**Hospital Unit Name **]
Please call to schedule appointments with your
Primary Care Dr.[**Last Name (STitle) 1683**] in [**4-1**] weeks [**Telephone/Fax (1) 35326**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication A Fib
Goal INR 2.0-2.5
First draw day after discharge Tuesday [**2121-4-15**]. This may be done
at Dr.[**Name (NI) 10122**] lab or by visiting nurse. You will then be
instructed on what dose to take. You may take 1mg on [**2121-4-14**].
Results to phone [**Telephone/Fax (1) 35326**], Dr. [**Last Name (STitle) 1683**] will continue to
follow- confirmed with [**Doctor First Name 717**]
Completed by:[**2121-4-13**]
|
[
"V58.61",
"V13.01",
"401.9",
"V10.3",
"424.0",
"427.31",
"425.4",
"V15.81",
"V45.71",
"135"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"35.12",
"39.61",
"37.23",
"88.56",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8231, 8295
|
4786, 6130
|
329, 433
|
8534, 8708
|
1854, 2624
|
9916, 11042
|
1109, 1128
|
6453, 8208
|
8316, 8513
|
6156, 6430
|
2641, 4763
|
8732, 9893
|
863, 953
|
1143, 1835
|
270, 291
|
461, 615
|
659, 840
|
969, 1093
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,694
| 182,719
|
45634
|
Discharge summary
|
report
|
Admission Date: [**2147-8-10**] Discharge Date: [**2147-8-12**]
Service: UROLOGY
Allergies:
Penicillins / Darvon / Iodine; Iodine Containing
Attending:[**First Name3 (LF) 5272**]
Chief Complaint:
Gross hematuria
Major Surgical or Invasive Procedure:
cystoscopy/clot evacuation
History of Present Illness:
HPI: 82 y/o female who presents with a HX. of persistent gross
hematuria over the past 1.5 weeks. She is a patient of Dr. [**First Name8 (NamePattern2) 1158**]
[**Last Name (NamePattern1) **] who is s/p TURBT 1.5 weeks ago. She started to bleed
1
day after her surgery. She commented that she has been bleeding
ever since then. She called Dr. [**Last Name (STitle) 770**] yesterday and she went
into his office today and was referred to this ER. She was
alert
and oriented x3 with no major complaints. There was a foley
catcher present attached to a leg bag filled with dark red
fluid.
Past Medical History:
Bladder Cancer
CAD
HTN
Hyperlipidemia
PVD
AFib/Aflutter
Social History:
Married. Lives with her husband who is blind
Family History:
unknown
Pertinent Results:
[**2147-8-10**] 11:30PM GLUCOSE-165* UREA N-56* CREAT-1.4* SODIUM-141
POTASSIUM-4.0 CHLORIDE-107 TOTAL CO2-26 ANION GAP-12
[**2147-8-10**] 11:30PM CK(CPK)-214*
[**2147-8-10**] 11:30PM CK-MB-11* MB INDX-5.1 cTropnT-0.02*
[**2147-8-10**] 11:30PM CALCIUM-7.8* PHOSPHATE-3.9 MAGNESIUM-2.7*
[**2147-8-10**] 11:30PM WBC-9.7 RBC-2.88*# HGB-8.6*# HCT-25.0* MCV-87
MCH-29.9 MCHC-34.5 RDW-16.4*
[**2147-8-10**] 11:30PM PLT COUNT-231
[**2147-8-10**] 11:30PM PT-14.4* PTT-21.5* INR(PT)-1.3*
[**2147-8-10**] 07:10PM HCT-25.8*#
[**2147-8-10**] 12:15PM GLUCOSE-135* UREA N-70* CREAT-1.7* SODIUM-138
POTASSIUM-5.1 CHLORIDE-103 TOTAL CO2-26 ANION GAP-14
[**2147-8-10**] 12:15PM CK(CPK)-154*
[**2147-8-10**] 12:15PM CK-MB-10 MB INDX-6.5* cTropnT-0.03*
[**2147-8-10**] 12:15PM WBC-10.1# RBC-1.98*# HGB-6.1*# HCT-18.3*#
MCV-93 MCH-30.7 MCHC-33.2 RDW-15.6*
[**2147-8-10**] 12:15PM NEUTS-77.3* BANDS-0 LYMPHS-18.0 MONOS-4.1
EOS-0.1 BASOS-0.4
[**2147-8-10**] 12:15PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-NORMAL
MACROCYT-1+ MICROCYT-1+ POLYCHROM-NORMAL STIPPLED-OCCASIONAL
[**2147-8-10**] 12:15PM PLT SMR-NORMAL PLT COUNT-303
[**2147-8-10**] 12:15PM PT-15.3* PTT-21.5* INR(PT)-1.4*
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2147-8-10**] 12:51 PM
CHEST (PORTABLE AP)
Reason: eval for infiltrate, CHF
[**Hospital 93**] MEDICAL CONDITION:
82 year old woman with SOB, anemia, bleeding bladder
REASON FOR THIS EXAMINATION:
eval for infiltrate, CHF
AP CHEST 12:51 P.M. [**8-10**]
HISTORY: Shortness of breath and anemia. CHF.
IMPRESSION: AP chest compared to [**2145-6-16**]:
Heart size is top normal, unchanged. Lungs are clear.
Cardiomediastinal contours are essentially unchanged since [**3-31**], [**2144**]. No pleural abnormality seen.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Approved: SAT [**2147-8-12**] 10:28 AM
Brief Hospital Course:
Patient was admitted through the ED and had a very low
hematocrit. She was transferred by ambulance to the [**Hospital Ward Name **]
for clot evacuation. A very large clot was evacuated from the
bladder and hemostatis was achieved. She recieved several units
of blood to increase her hematocrit. She went to the [**Hospital Unit Name 153**] and
had an uneventful course overnight. She passed her void trail
and was due for discharge yesterday, but had some issues about
being unsteady on her feet. She left the ICU and spent the
night on 11 [**Hospital Ward Name 1827**]. She is due for discharge today.
Medications on Admission:
ATENOLOL 25 MG--Take one tablet every day
BENADRYL 25MG--Take 1-2 tablets at bedtime as needed
COLACE 100MG--Take one tablet twice a day as needed
NIFEDIPINE EXT RELEASE 30 MG--One tablet by mouth every day --
hold sbp<100, hr<60
NITROGLYCERIN 400 MCG (1/150 GR)--One tablet under the tongue as
needed for chest pain every 5 minutes, times 3; if no
improvement, come to hospital
PRILOSEC 20MG--Take one tablet twice a day
ROXICET 5 MG/325 MG--Take 1-2 tablets every 4-6 hours as needed
SENOKOT 187MG--Take 1-2 tablets three times a day as needed
VITAMIN E 400U--Take one tablet every day
WARFARIN 2 MG--Take one tablet every day
Discharge Medications:
1. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 1 days.
Disp:*2 Tablet(s)* Refills:*0*
2. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
In addition to admission medications.
Discharge Disposition:
Home
Discharge Diagnosis:
hemorrage into bladder/major clot
Discharge Condition:
good
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:
Followup Instructions:
Call Dr.[**Name (NI) 825**] office for an appointment.
Call you primary care doctor to make an appiontment to figure
out when to restart your warfarin.
Completed by:[**2147-8-12**]
|
[
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"272.0",
"V10.51",
"427.31",
"998.11",
"V45.81",
"E878.8",
"585.9",
"443.9",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"57.0"
] |
icd9pcs
|
[
[
[]
]
] |
4638, 4644
|
3039, 3651
|
271, 300
|
4722, 4729
|
1109, 2428
|
4896, 5080
|
1080, 1090
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4330, 4615
|
2465, 2518
|
4665, 4701
|
3677, 4307
|
4753, 4873
|
216, 233
|
2547, 3016
|
328, 922
|
944, 1001
|
1017, 1064
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,636
| 186,911
|
19611+19612
|
Discharge summary
|
report+report
|
Admission Date: [**2178-8-10**] Discharge Date: [**2178-8-16**]
Date of Birth: [**2116-7-7**] Sex: M
Service: [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: This is a 62-year-old male
status post Whipple procedure for duodenal cancer in [**2178-1-11**] presenting with a likely case of typhlitis. The
patient has had four days of diarrhea and dark stools with
nausea, vomiting, and abdominal pain following a recent cycle
of chemotherapy that finished two weeks ago. The patient
also complains of fevers and chills in addition to nausea and
vomiting and right lower quadrant abdominal pain. The
patient does not complain of any jaundice.
PAST MEDICAL HISTORY: The patient's history is remarkable
for T4 N1 M0 adenocarcinoma status post Whipple procedure
with positive pancreatic margins in [**Month (only) 956**] or [**2177**]. A
history of diabetes mellitus, hypertension, peptic ulcer
disease, in addition to coronary artery disease.
MEDICATIONS ON ADMISSION: The patient comes in taking
[**Last Name (LF) 6196**], [**First Name3 (LF) **], and a multivitamin daily.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs revealed a
temperature of 98.9 degrees Fahrenheit, pulse was 104, blood
pressure was 127/87, respiratory rate was 20, and breathing
98 percent on room air. On examination, this was a
chronically ill-appearing male in no apparent distress. The
extraocular movements were intact. The conjunctivae were
without juandice. Heart was in a regular rate and rhythm.
There were no murmurs, rubs, or gallops. The lungs were
clear to auscultation bilaterally. The abdomen revealed a
well-healed incision with focal right lower quadrant
tenderness with guarding. No rebound, no rigidity, and no
diffuse tenderness. Rectal examination was heme-negative.
The prostate was slightly enlarged on examination.
SUMMARY OF HOSPITAL COURSE: Thus, the plan at this time was
to admit this 62-year-old patient with a likely case of
typhlitis, status post Whipple procedure, to give the patient
pain control, to place the patient nothing by mouth, and to
perform serial examinations at this point. The patient was
then placed on ampicillin, Levaquin, and Flagyl. He was
placed on intravenous hydration. A Foley catheter was placed
at this time as well. The plan was to place a nasogastric
tube if necessary if the patient vomited or started to have
worsening abdominal symptoms.
At this point, the patient was formerly admitted to the
Medicine Service. It is important to note that the patient
had been given Unasyn at an outside facility prior to his
arrival at [**Hospital1 69**].
On hospital day - [**2178-8-10**] - the patient was noted to
be significantly more tender in the right lower quadrant with
increased guarding. The plan at this time was to obtain a
computerized axial tomography scan and reevaluate the
patient. The patient's lactate at this time was noted to be
1.1. The computerized axial tomography scan ended up showing
no perforation, contrast going all the way through the small
and large intestines, with no air in the bowel wall, some
stranding in the right lower quadrant, and a small amount of
fluid.
The patient was transferred to the Surgical Intensive Care
Unit at this time given the changes in his abdominal
examination.
NOTE: Dictation to be continued.
[**Name6 (MD) **] [**Last Name (NamePattern4) 7542**], [**MD Number(1) 7543**]
Dictated By:[**Last Name (NamePattern1) 15912**]
MEDQUIST36
D: [**2178-8-25**] 13:17:11
T: [**2178-8-25**] 13:36:37
Job#: [**Job Number 53157**]
Admission Date: [**2178-8-10**] Discharge Date: [**2178-8-16**]
Date of Birth: [**2116-7-7**] Sex: M
Service: [**Last Name (un) **]
HOSPITAL COURSE: On [**2178-8-10**], the patient was
evaluated by the MICU staff who agreed to continue with Zosyn
at this time, to continue serial abdominal exams, and for the
patient to also continue nothing by mouth. They also
suggested that the patient would likely not require the level
of monitoring typical of the Intensive Care Unit and that the
patient could be transferred to the floor.
The Colorectal Service was also consulted at this point who
agreed with the current management being practiced and would
follow the clinical picture during this patient's stay.
Infectious Disease was also consulted during this time who
recommended that Zosyn be continued along with Fluconazole
and that Flagyl be added to the regimen, 500 mg IV q.8 hours,
which was done, until C-difficile was proven to be negative,
which subsequently was.
On [**2178-8-13**], the patient was able to be transferred
to the floor from the Surgical Intensive Care Unit and
continued to improve and had no new events during this time.
Neupogen was stopped at this time. Flagyl was also stopped.
The patient was taken off Lopressor and telemetry, and the
patient was placed on all oral medications and was taking
clear liquid at this point and ambulating without difficulty.
Infectious Disease then suggested that Vancomycin could be
stopped due to continued negative blood cultures and that
Flagyl could be stopped, C-difficile had come back negative a
total of three times.
The patient was also seen by Oncology during his stay on
[**2178-8-14**], who suggested holding off on cycles of
chemotherapy until the patient had resolved medically and
diarrhea had slowed and that the patient would follow-up with
Oncology as an outpatient.
The patient was started on Ciprofloxacin at this time, and
white blood cell count was noted to be dropping during this
time, and on the day of discharge, [**2178-8-16**], was
down to 18 from its most recent value of 22. The patient was
on day 2 of Cipro at this time and will be taken for one
week. The patient is to follow-up with Dr. [**Last Name (STitle) 468**] in two
weeks. The patient was receiving a full diet during this
time.
Physical examination was within normal limits. Vital signs
revealed a temperature maximum of 98.4 over the last 24 hours
with the rest of his vital signs within normal limits.
DISCHARGE INSTRUCTIONS: The patient is to follow-up with Dr.
[**Last Name (STitle) 468**] in [**12-12**] weeks, and he is to follow-up with Oncology in
[**12-12**] weeks. He is to call his physician if he has increased
abdominal pain, fevers, chills, nausea, vomiting, or with any
other questions or concerns.
DISCHARGE DIAGNOSIS: _______________________ status post
Whipple procedure in [**2178-1-11**].
DISCHARGE MEDICATIONS: Ciprofloxacin 500 mg p.o. b.i.d. to
be taken for 5 more days, Pantoprazole 40 mg p.o. q.12 hours.
DISPOSITION: The patient will be discharged to home without
services.
[**Name6 (MD) **] [**Last Name (NamePattern4) 7542**], [**MD Number(1) 7543**]
Dictated By:[**Last Name (NamePattern1) 15912**]
MEDQUIST36
D: [**2178-8-25**] 15:54:08
T: [**2178-8-25**] 16:20:22
Job#: [**Job Number 53158**]
|
[
"250.00",
"197.8",
"V10.09",
"V58.69",
"540.0",
"401.9",
"787.91",
"288.0",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.07"
] |
icd9pcs
|
[
[
[]
]
] |
6514, 6942
|
6415, 6490
|
995, 1123
|
3758, 6080
|
6105, 6393
|
1880, 3740
|
182, 667
|
1138, 1851
|
690, 968
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,404
| 110,630
|
39325
|
Discharge summary
|
report
|
Admission Date: [**2110-9-21**] Discharge Date: [**2110-10-25**]
Date of Birth: [**2080-11-6**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
fevers, tachycardia, infected spinal stimulator hardware
Major Surgical or Invasive Procedure:
-[**9-22**]: Explantation of spinal cord stimulator and drainage of
lumbar wound hematoma
-[**10-2**]: Drainage of hematoma at past surgical site
History of Present Illness:
Mr. [**Known lastname **] is 29 yo M w/ h/o complex regional pain syndrome s/p
phase II spinal cord stimulator implant on [**2110-9-10**] (POD 12) who
presented with with a four day history of worsening back pain.
.
The pt went to [**Hospital3 **] Hospital on [**9-21**] with 4D of worsening
low back pain at the site of his spinal stimulator. There, he
had a temp to 100.1 w/ chills , WBC 16.2 and he recieved
vancomycin IV prior to transfer to [**Hospital1 18**].
.
In the ED, the patient was noted to have erythema around the
site with a sm amt yellow serosanguinous/purulent drainage.
Neuro exam was WNL. CT L Spine outlined a 5.7 x 3.4 cm
subcutaneous hematoma with a small amount of gas. Given that the
patient had temp to 100.1 in ED, and was tachy to 120-140s,
patent was taken to the OR for drainage and removal of his
hardware. While in the ED, the pt was given dilaudid IV 6mg,
tylenol 500mg PO, diazepam 5mg IV, zosyn IV.
.
In the OR, the patient was noted to have extension of the
hematoma to the fascia and all of his hardware was removed.
Patient had a JP drain placed. He recvied Vancomycin and
Clindamycin at 1am in the PACU and started on a dilaudid PCA for
pain control.
.
On transfer to the floor, patient's VS were 98.6, 130/84, 115
(100-120), 16, 100%3L NC.
.
Review of systems:
(+) Per HPI (fever, chills)
(-) Denies night sweats, recent weight loss or gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denied
cough, shortness of breath. Denied chest pain or tightness,
palpitations. Denied nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denied arthralgias or myalgias.
.
Past Medical History:
Past Medical History:
Cervical DDD s/p C3-4 fusion
complex regional pain syndrome left knee
s/p appendectomy
spinal cord stimulator placement [**2110-9-10**]
.
Social History:
Patient lives at home with his wife and two young
children, he denies any tobacco abuse or recreational drug use.
Has 1 drink of etoh every few weeks.
Family History:
Non contributory
Physical Exam:
Admission exam:
Tc: 96.6, BP:108/78 HR:103 RR:18 SaO2:98% RA
General: pleasant, nad
HEENT: op clear, mmm, no lesions; no cervical LAD
Neck: supple, no LAD, no thyromegaly
Cardiovascular: RRR, no MRG
Respiratory: CTA bilat w/o wheezes/rhonchi/rales
Back: + TTP over L-spine at surgical site
Gastrointestinal: +bs, soft, non-tender, non-distended
Musculoskeletal: moving all extremities
Lymph: no cervical, axillary or inguinal LAD
Skin: surgical dressing in place with JP drain with
serosanguinous drainage
Neurological: aaox3, cn 2-12 intact
.
.
DISCHARGE EXAM:
VS: 96.8 (tmax was 98.6 in the last 24 hours), 99/80, 89, 18,
97% on RA
GEN: pleasant, appears comfortable in NAD
HEENT: MMM, sclera non-icteric, intact EOM, PERRLA
RESP: CTAB bil, no increase in WOB
CV: RRR, S1 and S2 wnl, no m/r/g
ABD: Soft, +b/s, non distended, mildly tender on right LQ around
inc site (overall improving), no masses or hepatosplenomegaly.
Large mid line scar well approximated, healing well, no
drainage.
Back: mildly tender on lower back on area of hematoma, with
small bulge (improving) no drainage noted
EXT: no c/c/e, pain to palpation of entire left knee
(unchanged), +2 pulses. Ambulating without assist. Sl decrease
in ROM of LLE due to L knee discomfort
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout, mild
decrease in sensation on R anterior thigh area
Pertinent Results:
Admission labs:
[**2110-9-21**] 05:10PM NEUTS-76.0* LYMPHS-18.9 MONOS-3.5 EOS-1.1
BASOS-0.6
[**2110-9-21**] 05:10PM WBC-13.9* RBC-4.11* HGB-12.5* HCT-36.4*
MCV-89 MCH-30.4 MCHC-34.4 RDW-14.5
[**2110-9-21**] 05:24PM LACTATE-1.3
ESR/CRP:
[**2110-9-23**] 07:00AM BLOOD ESR-65*
[**2110-10-18**] 05:13PM BLOOD ESR-30*
[**2110-9-23**] 07:00AM BLOOD CRP-150.8*
[**2110-10-18**] 05:13PM BLOOD CRP-17.0*
.
MICROBIOLOGY:
.
#[**2110-10-22**] 7:00 am BLOOD CULTURE 1 OF 2.
Blood Culture, Routine (Pending):
.
# [**2110-10-21**] 1:17 am CATHETER TIP-IV Source: PICC line.
**FINAL REPORT [**2110-10-23**]**
WOUND CULTURE (Final [**2110-10-23**]): No significant growth.
# [**2110-10-20**] 6:02 am BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Pending):
# [**2110-10-19**] 11:20 am BLOOD CULTURE
**FINAL REPORT [**2110-10-25**]**
Blood Culture, Routine (Final [**2110-10-25**]): NO GROWTH.
# [**2110-10-18**] 2:00 pm BLOOD CULTURE Source: Line-PICC.
Blood Culture, Routine (Preliminary):
[**Female First Name (un) **] ALBICANS, PRESUMPTIVE IDENTIFICATION.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus and [**Female First Name (un) 564**] species.
Aerobic Bottle Gram Stain (Final [**2110-10-20**]):
REPORTED BY PHONE TO [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] @ 2034 ON [**10-20**] - FA9A.
[**Month/Year (2) **](S).
# [**2110-10-19**] 9:34 am BLOOD CULTURE Source: Line-PICC.
Blood Culture, Routine (Preliminary):
MORGANELLA MORGANII. FINAL SENSITIVITIES.
sensitivity testing performed by Microscan.
MORGANELLA MORGANII. SECOND MORPHOLOGY. FINAL
SENSITIVITIES.
sensitivity testing performed by Microscan.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
MORGANELLA MORGANII
| MORGANELLA MORGANII
| |
CEFEPIME-------------- 8 S 8 S
CEFTAZIDIME----------- =>32 R =>32 R
CEFTRIAXONE----------- =>64 R =>64 R
CIPROFLOXACIN--------- <=0.5 S <=0.5 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM------------- S S
PIPERACILLIN/TAZO----- =>128 R <=8 S
TOBRAMYCIN------------ <=1 S <=1 S
Anaerobic Bottle Gram Stain (Final [**2110-10-21**]):
REPORTED BY PHONE TO DR. [**First Name4 (NamePattern1) 3750**] [**Last Name (NamePattern1) 86954**] PAGER# [**Serial Number 86955**] @
0425 ON
[**2110-10-21**].
GRAM NEGATIVE ROD(S).
#[**2110-10-14**] 9:17 am CSF;SPINAL FLUID
Source: spinal fluid collection.
**FINAL REPORT [**2110-10-20**]**
GRAM STAIN (Final [**2110-10-14**]):
3+ (5-10 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 [**2110-10-20**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2110-10-20**]): NO GROWTH.
# [**2110-10-12**] 7:25 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT [**2110-10-13**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2110-10-13**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
# [**2110-10-4**] 11:51 am BLOOD CULTURE
**FINAL REPORT [**2110-10-7**]**
Blood Culture, Routine (Final [**2110-10-7**]):
KLEBSIELLA PNEUMONIAE.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 86956**],
[**2110-10-5**].
MORGANELLA MORGANII.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 86956**],
[**2110-10-5**].
Anaerobic Bottle Gram Stain (Final [**2110-10-5**]): GRAM
NEGATIVE RODS.
Aerobic Bottle Gram Stain (Final [**2110-10-5**]): GRAM NEGATIVE
RODS.
.
#[**2110-10-2**] 1:03 pm FLUID,OTHER LOWER BACK FLUID COLLECTION.
**FINAL REPORT [**2110-10-13**]**
GRAM STAIN (Final [**2110-10-2**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2110-10-13**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from broth media only, INDICATING VERY LOW
NUMBERS OF
ORGANISMS.
DR. [**First Name4 (NamePattern1) 674**] [**Last Name (NamePattern1) 86957**] 9-0841 [**2110-10-7**] WANTS VANCOMYCIN
SENSITIVITY.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance Oxacillin RESISTANT Staphylococci MUST be
reported as
also RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
VANCOMYCIN Sensitivity testing performed by Sensititre.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ 2 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ 2 S
ANAEROBIC CULTURE (Final [**2110-10-7**]): NO ANAEROBES ISOLATED.
# [**2110-10-2**] 2:45 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT [**2110-10-3**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2110-10-3**]):
REPORTED BY PHONE TO [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**2110-10-3**] 11:21AM.
CLOSTRIDIUM DIFFICILE.
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
(Reference Range-Negative).
A positive result in a recently treated patient is of
uncertain
significance unless the patient is currently
symptomatic
(relapse).
#[**2110-9-22**] 7:15 am SWAB GENERATOR POCKET.
**FINAL REPORT [**2110-9-26**]**
GRAM STAIN (Final [**2110-9-22**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2110-9-25**]):
ENTEROCOCCUS SP.. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
PENICILLIN G---------- 8 S
VANCOMYCIN------------ 1 S
ANAEROBIC CULTURE (Final [**2110-9-26**]): NO ANAEROBES ISOLATED.
# [**2110-9-22**] 7:15 am SWAB LUMBAR WOUND.
**FINAL REPORT [**2110-9-26**]**
GRAM STAIN (Final [**2110-9-22**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
SMEAR REVIEWED; RESULTS CONFIRMED.
WOUND CULTURE (Final [**2110-9-24**]):
ENTEROCOCCUS SP.. MODERATE GROWTH.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
PENICILLIN G---------- 4 S
VANCOMYCIN------------ 1 S
ANAEROBIC CULTURE (Final [**2110-9-26**]): NO ANAEROBES ISOLATED.
DISCHARGE LABS:
[**2110-10-24**] 07:40AM BLOOD WBC-14.4* RBC-3.96* Hgb-11.4* Hct-34.2*
MCV-86 MCH-28.7 MCHC-33.3 RDW-14.8 Plt Ct-716*
[**2110-10-24**] 07:40AM BLOOD Neuts-65.0 Lymphs-26.5 Monos-4.5 Eos-2.7
Baso-1.4
[**2110-10-21**] 07:10AM BLOOD Hypochr-3+ Anisocy-NORMAL
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
Burr-OCCASIONAL
[**2110-10-22**] 07:00AM BLOOD Glucose-109* UreaN-6 Creat-0.9 Na-141
K-3.9 Cl-100 HCO3-30 AnGap-15
[**2110-10-23**] 06:40AM BLOOD ALT-37 AST-23 AlkPhos-130 TotBili-0.6
[**2110-10-23**] 06:40AM BLOOD Calcium-9.5 Phos-4.5 Mg-1.9
[**2110-10-5**] 11:13PM BLOOD HCV Ab-NEGATIVE
RBC MCH MCHC RDW Ct
[**2110-10-25**] 07:00
WBC 11.1/ Hgb 10.6* / Hct 30.9*/MCV 87/ Plt 609*
DIFFERENTIAL: Neuts 61/ Bands 0/ Lymphs 25/ Monos 10/Eos 3/Baso
1/Atyps 0
IMAGING:
ECHO ON [**2110-10-23**]:
=================
Conclusions
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF 65%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. No masses or
vegetations are seen on the aortic valve. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. No mass or vegetation is seen
on the mitral valve. The estimated pulmonary artery systolic
pressure is normal. No vegetation/mass is seen on the pulmonic
valve. There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2110-10-6**], findings are similar.
IMPRESSION: normal study; no vegetations seen
MRI LUMBAR SPINE ON [**2110-10-19**]:
===============================
FINDINGS:
Numbering used is shown on Vertebral body height and sagittal
alignment are maintained. There remains diffusely low although
somewhat heterogeneous marrow signal on T1-weighted images,
unchanged.
Compared to the prior study the fluid collection in the
posterior soft tissues has decreased in size, now measuring at
this point 1.7 TV x 1.2 AP x 3.4 CC cm in widest dimensions.
There remains a thick rind of enhancing soft tissue surrounding
collection, and there are foci of low signal both within and
around the fluid which may represent small foci of air or
residual metallic fragments from hardware removal. There is
unchanged paraspinal muscular abnormal stir signal, left greater
than right.
The enhancement abuts the spinous processes of L2 and 3, but
there is no
abnormal signal within the spinous processes or the osseous
structures
elsewhere. There is no abnormal intrathecal enhancement, or
abnormal
enhancement within the epidural space.
The conus terminates at L1. There is normal signal within the
conus
medullaris and the cauda equina. There is mild clumping of some
of the nerve roots along the periphery of the thecal sac within
the lower lumbosacral spine which is unchanged from the prior
study. There is no abnormal enhancement within the nerve roots.
The visualizedretroperitoneal structures are unremarkable.
Mild facet degenerative changes are possibly noted at L4/5 and
l5/S1 levels. Small Schmorl's nodes are noted at T11-T12 level
indenting the adjacent endplates.
IMPRESSION:
1. Decrease in the size of the peripherally enhancing fluid
collection in the posterior lumbar soft tissues, which now
measures 1.7x1.2x3.4cm. No evidence of osteomyelitis.
2. Stable minimal clumping of the nerve roots in the inferior
spinal canal
could reflect a component of arachnoiditis, which could be
postprocedural,
although post infectious/inflammatory etiologies cannot be
excluded. No abnormal intrathecal enhancement.
3. Distended blader- correlate clinically.
CXRAY ON [**2110-10-19**]:
REASON FOR EXAMINATION: Rigors and sepsis.
Portable AP chest radiograph was compared to [**2110-10-15**].
Cardiomediastinal silhouette is stable. Bibasal linear
atelectasis is
redemonstrated, but no focal consolidation definitely
demonstrating infectious process is seen. Further evaluation
with lateral view would be beneficial to exclude the possibility
of posterior basal infection hidden on the AP projection.
CT ABD/PELVIS ON [**2110-10-19**]:
TECHNIQUE: Multiple axial images of the abdomen and pelvis from
lung bases
through the pubic symphysis were obtained following the
uneventful administration of oral and 130 cc Optiray IV
contrast. Coronal and sagittal images were reformatted and
reviewed.
FINDINGS:
There is minor, dependent atelectasis. No pleural or pericardial
fluid.
The liver, spleen, adrenal glands, and pancreas are normal in
appearance.
There is a hypodensity in the mid pole of right kidney which is
too small to adequately characterize and unchanged from prior.
There is no hydronephrosis. The ureters are normal caliber.
Bowel loops are normal caliber. The colon demonstrates no
evidence of wall thickening with stool present throughout the
colon. There are surgical clips in the right lower quadrant. No
right lower quadrant inflammatory change. The gallbladder is
fluid filled. There is minor stranding and inflammation in the
midline of the anterior abdominal wall likely related to prior
incision. There is no abdominal ascites. No pneumoperitoneum. No
pneumatosis.
CT PELVIS: The bladder is relatively well distended and
unremarkable. There is no pelvic lymphadenopathy.
There is no upper abdominal adenopathy, retroperitoneal or
mesenteric.
There is a residual, small fluid collection posterior to the
L3/L4 vertebral bodies which has been seen on prior examinations
and previously sampled. The fluid component appears slightly
smaller than on prior study and there is no associated gas
within this collection or the surrounding soft tissues.
There is sclerosis in the left femoral head and a defect along
the weight
bearing surface that may be related to chronic AVN.
IMPRESSION:
1. No evidence of acute intra-abdominal pathology or focal
abdominal fluid
collection on today's examination.
2. Subcutaneous fluid collection posterior to L3/L4 vertebral
bodies as seen
on prior examinations.
3. Question chronic AVN left femoral head.
Cardiology Report ECG Study Date of [**2110-10-19**] 2:55:20 PM
EKGS ON [**2110-10-19**]:
Sinus tachycardia. Otherwise, probably normal tracing. Since the
previous
tracing of [**2110-10-18**] tachycardic rate is slower and delayed R
wave progression pattern is now absent.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
120 142 88 318/423 22 8 18
Brief Hospital Course:
Mr [**Known lastname **] has had a long and protracted hospitalization between
[**2110-9-21**] to date. He's had multiple transfers between the floor
and intensive care requiring multiple practioners in his
management. To summarize his course: in the ED he presented
with an infection around his TENS stimulator and went to the OR
for hardware removal. He grew out enterococcus and coag
negative staph from the wound and was started on antibiotics
accordingly. He was started on a dilaudid PCA initially for
pain control and then needed a ketamine drip for escalating pain
requirements. Repeat drainage of L3, L4 was then required,
drained by IR. He then developed gram negative bacteremia, had
C diff in his stool, and devloped peritoneal signs that required
an ex-lap. This revealed no perforation. He was intubated
peri-procedure and then in the MICU was transiently extubated
and then again re-intubated for increased work of breathing and
CXR findings suggestive of ARDS. He ultimately had 6/6 bottles
of positive BCx for GNR (Klebiella and Morganella). Broad
spectrum antibiotic coverage was initiated for Klebsiella and
Morganella (meropenem) PO vanc and IV flagyl for C difficile
(initially needed tigacycline), and daptomycin for MRSA. His
gram negative sepsis was thought to be secondary to
translocation in the setting of C diff colitis. He had
hypotension on 2 pressors, potential DIC with new coagulopathy,
transaminitis to the 600s, and acute kidney injury with a rising
creatinine to 2.8.
.
He underwent another MRI on [**10-7**] that showed a persistent L2
fluid collection, which was aspirated on [**10-14**]. This aspirate
revealed neutrophils but culture has been negative. The patient
was switched from Meropenem to Zosyn and tigecycline was
discontinued after sensititives were obtained. Dapto was
switched to Vancomycin as well. He was continued on vancomycin
IV and zosyn until [**10-19**] when he developed rigors and
tachycardia
.
His fevers and tachycardia began on [**10-18**]. On [**10-19**], these were
accompanied by a mild hypotension ~ SBP 90's, a fleeting feeling
of pain in the right thigh, a generalized sense of weakness, and
severe chills and rigors that were controlled with meperidine
and tylenol. He received 3L of NS with response in SBP to 120's.
His Tachycardia persists at 120-130. ID recommended switching
antibiotics from vanco and zosyn to Linezolid and Meropenem. He
was continued on oral vanco for C.diff. His HR and BP are now
stable and he returned to the general medicine floor.
He was transferred back to the medicine floor on [**10-20**] and has
been stable and afebrile since his transfer. He has been feeling
much better. His WBC had a sl.increase on [**10-24**] but is now
trending back down. He continues to have pain on L knee and mild
pain on back and abd which are now much better controlled on MS
contin and MSIR, as well as on clonodin and gabapentin.
.
# Enterococcus and Coag negative staph lumbar hematoma
infection: This was patient's initial presentation to [**Hospital1 18**].
Mr [**Known lastname **] had underwent spinal stimulator implantation on
[**2110-9-10**] for complex regional pain syndrome. On [**2110-9-21**], he
had presented to OSH with fevers, chills, and back pain and was
transferred to [**Hospital1 18**] for further evaluation. CT L spine had
shown a large subcutaneous fluid collection, c/w hematoma that
was evacuated in the OR with hardware removal. The patient's
hematoma cx had grown enterococcus and coagulase neg staph and
was to be on a 4 week course of IV Vancomycin given elevated
ESR/CRP. He had repeat MRI on [**9-29**] that showed a 2.3 x 2.5cm
subcutaneous fluid collection. He underwent IR aspiration
yielding 10cc serosanguinous fluid, which grew coagulase
negative staph. In the setting of his sepsis, he underwent
another MRI on [**10-7**] that showed a persistent L2 fluid
collection, which was aspirated on [**10-14**]. This aspirate
revealed neutrophils but culture has been negative. He developed
rigors on [**10-18**] and was transferred to the ICU on [**10-19**] for
concern of sepsis. Since it appeared that he was septic while on
vancomycin IV his antibiotic was changed to Linezolid due to
concern for VRE. His antibiotics were switched and he has been
afebrile and hemodynamically stable. He had repeat MRI that
showed decrease in size of fluid collection.
-He will be following up with ID and chronic pain.
-He is scheduled to have repeat US of lumbar spine on [**2110-11-5**]
for evaluation of size of fluid collection.
-Cont Linezolid for 3-4 weeks ( day 1 was on [**2110-10-14**]). ID will
reassess
.
#. Klebiella and Morganella Sepsis: Likely a result of GI
bacterial translocation in the setting of C Diff. The patient
on [**2110-10-4**] was found to have an acute onset of rigors,
respiratory distress, hypotension, and acute abdomen. Patient
underwent an urgent ex-lap that was unremarkable, however was in
gram negative septic shock (6/6 bottles). The patient's MICU
course was complicated by ARDS, needing pressors, renal failure,
and shock liver. The patient was initially treated with
Daptomycin (for possible MRSA), Vancomycin PO, IV Flagyl,
Meropenem, and Tigecycline. The patient was switched from
Meropenem to Zosyn and tigecycline was discontinued after
sensititives were obtained. Dapto was switch to Vancomycin as
well. He was continued on vancomycin IV and zosyn until [**10-19**]
when he developed rigors and tachycardia. He was transitioned
back to Meropenem and continued on Vancomycin. he was
transfered to the MICU on [**10-19**] and antibiotic coverage was
changed to meropenem and linezolid. Pt has since then grown GNR
that found to be 2 different colonies of Morganella with one
that was resistant to Zosyn, but both were sensitive to Cipro.
So his PICC line was D/c and he as discharge on cipro for a
total of 14 days (last day will be on [**2110-11-4**]). He has been
hemodynamically stable and afebrile
- Cipro for total of 14 days (last day on [**11-4**]). He will need
to have QT intervals checked since Quetiapine may cause
prolonged QT intervals. He has script to have EKG done on [**10-28**]
and I will call the PCP on [**Name9 (PRE) 766**].
- He will f/u with ID on [**11-7**]
.
#. C. diff: The patient developed C Diff ten days into his
hospitalization while he was being treated for pain control and
was treated initially with IV Flagyl. The patient developed an
acute abdomen on [**10-4**], and given concerns of possible bowel
perforation, the patient underwent an urgent exploratory
laparotomy which revealed no significant findings needing
surgical intervention. The patient's treatment was increased to
IV Flagyl and PO Vancomycin, and had briefly been treated with
tigecycline. He no longer has diarrhea and his antibiotic was
changed to PO vanco 125mg. He will need to be on this until he
finishes the Linezolid
- Continue PO vanco for ~ 10 days after stopping the Linezolid
.
#.Fungemia: Currently afebrile, HD stable. He was found to have
[**Last Name (LF) **], [**First Name3 (LF) 564**] Albicans, growing from the blood culture from
PICC line site on [**10-18**]. PICC line tip NGTD. Repeat of MRI
improving in L2 fluid collection, and arachnoiditis. Abd CT was
negative and cxray showed atelactasis. So this is unlikely that
he had other source of infection, besides the PICC.
- Switched from Micafungin to Flucanozole (800mg loading dose
and 400mg daily for total of 14 days (Day 1 was on [**2110-10-22**])
- Ophthalmology evaluated pt on [**10-21**] due to the fungemia- No
ocular involvement was found. He will need to follow-up as out
patient in 2 weeks.
- He also had ECho on [**10-23**] that showed no vegetation and was
normal.
- ID will follow-up in [**2110-11-7**]
.
#. Lumbar Pain/CRPS/Abd pain: The patient was given a diagnosis
of complex regional pain syndrome by the pain service, for which
he had the initial stimulator placed. He was found to have an
infected hematoma that was evacuated and then had fluid
aspiration. The patient had persistent lumbar pain and left knee
pain after the surgery. He was on IV Dilaudid PCA, and weaned to
PO dilaudid which did not control his pain. He was treated with
IV Ketamine and was briefly in MICU for airway monitoring. IV
Ketamine was discontinued. He has then switched to PO pain meds
which have have been better controlled. He required increased
amounts of pain mediction, including ketamine drip and this was
concerning for prior opiate abuse.
.
Now fluid collection size on posterior lumbar soft tissues is
decreasing, measuring 1.7x1.2x3.4cm. No evidence of
osteomyelitis and stable minimal clumping of the nerve roots in
the inferior spinal canal could reflect a component of
arachnoiditis seen on MRI on [**10-19**]. He was cleared by PT for
home. He is currently been followed by chronic pain service and
ID. He will have f/u appoitment with both in 2 wks. Currently
cont to have decrease in sensation of right ant thigh region
which is likely related to inflammation and pain on left knee.
- pain service following appointment on [**11-10**] or sooner if
needed. Pt was sent home with MS contin 45mg [**Hospital1 **]. Initially
dispenced enough medication until follow-up pain appointment as
recommended by the inpatient pain team. I was then called by the
pain fellow, Dr. [**Last Name (STitle) 86958**] who was working with Dr. [**Last Name (STitle) 1625**],
his primary pain attending who recommended that the pain
medication dispenced was decresed to last until the patient's
visit with his PCP. [**Name Initial (NameIs) **] was able to changed the prescription and
the MSIR 15mg # disp was 20 and MS contin 30mg (total # dispense
of 15). I also contact[**Name (NI) **] his PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) **] and explained current
concern for narcotic abuse and the fact that pt may need
additional prescription to tx his post-op pain. Dr. [**First Name (STitle) **] did not
feel comfortable in prescribing Mr. [**Known lastname **] [**Last Name (Titles) 1795**] given that
he only saw him once in [**Month (only) 205**]. Dr. [**First Name (STitle) **] then spoke to Dr.
[**Last Name (STitle) 1625**] on [**10-29**] to formulate a plan. I have also called Mr.
[**Known lastname **] x3 to check on how he was doing and to explain the
changes in his treatment plan and he did not answer the phone.
At one point, the phone was answer and then disconnected.
- on MS Contin 45mg [**Hospital1 **] (disp# 15 and pt has not picked up
prescription from pharmacy as of [**10-30**]) and MS IR 15mg Q4hrs as
needed (Disp # 20- prescription filled [**10-26**])
- Pt was also started on CloniDINE 0.1 mg PO TID and on
Gabapentin 300mg TID which should be continued for L knee pain.
.
.
#. Respiratory failure/ARDS: Resolved. Breathing well on room
air. Patient was intubated on [**10-4**] in the setting of gram
negative sepsis, and was extubated on [**2110-10-12**]. Last Cxray on
[**10-19**] showed atlectasis will encourage pt to use inspirometer.
Lungs clear on exam.
.
#. Acute liver injury: Resolved, likely secondary to shock
liver in the setting of sepsis. Patient had transaminitis to the
600s and bilirubin up to 2.2, now improved to normal range. Of
note, the patient has a history of fulminant hepatitis two years
ago at [**Hospital3 **] with transaminases > 10K of unclear
etiology.
- Follow up with PCP
.
# Prophylaxis - SC heparin while inpatient, bowel regimen
.
# Code status - Full
..
# Dispo - going home
.
Medications on Admission:
Oxycodone SR (OxyconTIN) 20 mg PO Q12H
CefTAZidime 1 g IV Q8H
HYDROmorphone (Dilaudid) 0.5 mg IVPCA Lockout
Vancomycin 1000 mg IV Q 12H
Discharge Medications:
1. Outpatient Lab Work
Please check weekly CBC with Differential, ESR, CRP, LFTs (AST,
ALT, Alk Phos and t.bili), BUN and Creatinine.
Please fax results to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 86959**]
2. quetiapine 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*0*
3. morphine 30 mg Tablet Sustained Release Sig: 1.5 Tablet
Sustained Releases PO Q12H (every 12 hours): You should take one
and half tablet every 12hours. You should not drive or do
anything that requires alertness while taking this medication.
Disp:* 15 Tablet Sustained Release(s)* Refills:*0*
4. morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain: You should not drive or do anything
that may require alertness while taking this medication.
Disp:*20 Tablet(s)* Refills:*0*
5. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
Disp:*90 Capsule(s)* Refills:*0*
6. Ambien 10 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia: You should take this medication when you
are ready to go to sleep. You should not drive or do anything
that may require alertness while using this medication. .
Disp:*30 Tablet(s)* Refills:*0*
7. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO once a day
for 12 days: This should end on [**2110-11-4**].
Disp:*24 Tablet(s)* Refills:*0*
8. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 24 days: This medication is for C.diff infection in
your gut. It is very important that you continue to take as
prescribe. Last dose on [**2110-11-17**].
Disp:*96 Capsule(s)* Refills:*0*
9. linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 20 days: It is very important that you take all the
antibiotic as prescribed.
Disp:*40 Tablet(s)* Refills:*0*
10. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*0*
11. Cipro 500 mg Tablet Sig: One (1) Tablet PO every twelve (12)
hours for 10 days: Last day will be on [**2110-11-4**].
Disp:*20 Tablet(s)* Refills:*0*
12. EKG
Please check an EKG on [**2110-10-28**] and then on [**2110-11-7**] when you go
to the infectious disease appointment to evaluate for QTc
prolongation while on cipro and Quetiapine.
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
Primary
- Gram negative septic shock
- Acute respiratory distress syndrome
- Acute renal failure
- Enterococcus infected subcutaneous lumbar hematoma
- Clostridium Difficile infection
- Acute shock liver
- Fungemia ([**Female First Name (un) **] Albicans)
- Bacterimia with gram negative rods
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear [**Doctor First Name **],
You were hospitalized because you had an infection of the spinal
stimulator placed in your back. You were treated with IV
antibiotics, however your course was complicated by CDiff
infection, acute abdomen requiring surgery, and septic shock
requiring intubation and medications to keep your blood pressure
up. You have also developed bacterial and fungal infection in
your blood. After a prolonged hospitalization, you have made a
full recovery, however you will need to finish a course of
antibiotics and antifungal medication.
We have made the following changes to your medications:
- Linezolid 600mg every 12 hours until [**2110-11-13**]. The length of
treatmetn will be evaluated by infectious diseases
- Flucanozole 400mg once daily for 10 more days (ending on
[**2110-11-4**])
- Vancomycin 125mg for your C.diff until approximately [**2110-11-20**],
but this will further evaluated by infectious diseases when they
see you on [**11-7**]
- Cipro 500mg orally every 12 hours for another 10 days (last
day will be on [**2110-11-4**]
- Clonodine 0.1mg for your the pain
- Gabapentin 300mg every 8 hours for neuropathic pain
- Morphine SR (MS Contin) 45 mg orally every 12 hours for your
pain. You should not drive or do anything that requires
alerteness since this medication may cause drowsiness
- Morphine Sulfate IR 15 mg orally every 4 hours as needed for
pain.
You should not drive or do anything that requires alerteness
since this medication may cause drowsiness
- We have stopped your Duoxetine since this medication can
interact with your antibiotics and you should discuss with your
doctor when to restart this medication once the antibiotics have
finished.
Followup Instructions:
You have an appointment with your primary care provider, [**Last Name (NamePattern4) **].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**10-29**], Wed, at 3:20 PM. At that time you will
also need to have blood work done and this will need to be sent
to the infectious diseases office, as in the prescription.
Location: [**Location (un) **] PRIMARY CARE
Address: [**Last Name (NamePattern4) 30770**], [**Location 30771**],[**Numeric Identifier 30772**]
Phone: [**Telephone/Fax (1) 30773**]
Fax: [**Telephone/Fax (1) 30774**]
Department: INFECTIOUS DISEASE
When: FRIDAY [**2110-11-7**] at 9:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 27625**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: [**Hospital3 1935**] CENTER
When: WEDNESDAY [**2110-11-5**] at 1 PM
With: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], 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
Department: PAIN MANAGEMENT CENTER
When: MONDAY [**2110-11-10**] at 10:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 1652**]
Building: One [**Location (un) **] Place ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Parking on Site
You will need to call Ultrasound to schedule your appointment
time on [**11-5**], for evaluation of your back. [**Telephone/Fax (1) 327**]
You will need to have blood work done weekly while on
antibiotics and the results will need to be faxed to the
Infectious Diseases office. Your primary care doctor will also
need to repeat an EKG (electrocardiogram) while on cipro to
monitor for changes.
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,785
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43008
|
Discharge summary
|
report
|
Admission Date: [**2199-2-8**] Discharge Date: [**2199-3-8**]
Date of Birth: [**2139-12-11**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 465**]
Chief Complaint:
DOE, lethargy
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
59y/o F with severe COPD on home O2 of 4L NC, DM2, Asthma,
Dperession, recently admitted to ICU here at [**Hospital1 18**] and intubated
([**Date range (2) 92815**]), discharged to [**Hospital3 672**] Hospital on 3L
of NC O2, then to [**Hospital3 **]. Now comes back with increased
cough, sputum production, sob and lethargy.
In ED initial ABG was 7.21/118/51, placed on continuous nebs,
ICU team did repeat gas one hour later: 7.26/103/57 patient was
still lethargic and unable to speak. ICU team then place patient
on BIPAP with improvement in mental status.
Past Medical History:
1. COPD (intubated in the past), on home O2 of 4L NC
2. Asthma
3. DM type 2
4. Depression
5. hx of + PPD treated
6. history of MVC
7. h/o MAT on diltiazem
Social History:
h/o of tobacco abuse, 40pyrs, quit this year, no ETOH, lives
alone, has one daughter, was at [**Hospital3 672**] Hospital
Family History:
no heart and lung disease
Mother died of CVA
Physical Exam:
PE:
T:99 HR: 90 BP:113/47 RR:23 Sats:97%
GEN: more alert than on presentation to the ED, prior to BIPAP
was somnolent unarousable to voice commands, would wake up with
physical stimulus, speaks in broken sentences, desats with
talking.
HEENT:NC/AT, EOMI, PERRL, mmdry, o/p clear
CV: RRR with PACs, no m/r/g
PULM: Bibasilar crackles, no wheezes, min-mod air movement,
barrel chested,
ABD: +bs, soft, NT/ND, no rebound or gaurding
Ext: edema present in both lower extremities 1+ up to knees, no
c/c
NEURO: CN II-XII grossly intact, alert and oriented x 3,
strenght: [**5-31**] in upper and lower ext, sensation intact to light
touch,
Pertinent Results:
3.52pm: pH 7.26/103/57/48
2:34p pH 7.21/118/51/50 Lactate:0.6
Trop-*T*: <0.01
136 89 12 146 AGap=7
4.6 45 0.4
CK: 21 MB: Notdone
Ca: 9.1 Mg: 1.8 P: 5.5
ALT: AP: 45 Tbili: 0.1 Alb: 4.4
AST: 23 LDH: Dbili: TProt:
[**Doctor First Name **]: 51 Lip: 17
Serum ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc Negative
Urine Benzos, Barbs, Opiates, Cocaine, Amphet, Mthdne Negative
12.1 9.5 260
31.4
N:88.2 L:9.9 M:1.5 E:0.3 Bas:0.2
PT: 11.6 PTT: 27.5 INR: 0.9
UA: normal.
ECHO [**2-11**]: Conclusions:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
and cavity size are normal. There is mild global left
ventricular hypokinesis. [Intrinsic left ventricular systolic
function is likely more depressed given the severity of valvular
regurgitation.] Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. 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. There is mild pulmonary
artery systolic Hypertension. There is no pericardial effusion.
IMPRESSION: Mild global left ventricular hypokinesis c/w diffuse
process
(tocxin, metabolic, multivessel CAD, etc.). Moderate mitral
regurgiattion. Mild pulmonary artery systolic hypertension. Mild
aortic regurgitation.
CXR: : Left lower lobe opacity possibly representing atelectasis
or
pneumonia, Follow up PA and lateral study would be helpful in
further
evaluating this area.
[**2199-2-22**] CXR: IMPRESSION: Small left effusion. Hyperinflated
lungs. Left lower lobe atelectasis/consolidation.
Brief Hospital Course:
59y/o F with severe COPD on home O2 of 4L NC, DM2, Asthma,
Depression, recently admitted to [**Hospital1 18**] and intubated
([**Date range (2) 92815**]) for COPD exacerbation, discharged to [**Hospital1 1099**] then home, came in with increased sputum production,
cough and SOB.
.
# COPD/hypercarbic respiratory failure: In the ED, she was found
to be in respiratory distress, hypercarbic respiratory failure
with intubation on [**2-10**] in am. Nasal aspirate notable for RSV
positive, neg dfa for other resp viruses. She was given
Azithromycin 500mg x1 then 250mg for 4 days. She was treated for
COPD exacerbation initially, but her ICU course was complicated.
The primary complications included 1) Ventilator-associated PNA
and 2) paroxyms of atrial flutter while intubated. She was
treated with Zosyn/Vanc for the PNA, and was initially
heparinized for A flutter and put on amiodarone instead of
diltiazem. Her long-acting diltiazem was originally converted
to short acting b/c it could be crushed; this was felt to have
precipitated her atrial flutter thus she was put on amiodarone.
She progressively improved and was extubated [**2-21**]; this was in
the setting of many prior failed attempts to wean PS. She
subsequently improved and was able to be extubated. Pt was
transfered to the floor for further managment. The pt continued
to improved on the floor and came back to her baseline O2
requirement of 1-2L, and her prednisone was tapered slowly off.
.
## Tachycardia: Pt has history of MAT and has been on dilt.
During intubation, Dilt CR was changed to qid dosing. The pt
was receiving frequent nebulizers, in addition, she was found to
be auto-peeping. She developed a rapid, regular, narrow complex
tachycardia that was found to have underlying fib waves (atrial
fibrillation). Diltiazem was pushed IV x 2 overnight and an
additional PO dose of 30 was given. Initially, with
tachycardias c/w MAT, BP was stable, however, at a rate of 150,
BP began to decrease such that MAP's were in the 50's. After
de-recruitment with ventilator detachment, the pt's BP returned.
Albuterol was held and the pt was started on Amiodarone instead
of Diltiazem for rate control. On the floor, she subsequently
had one more episode of hypotension with tachycardia in the
context of getting up for the first time. She responded well to
fluids and had no other hypotensive events. Amiodarone was
switched back to dilt over concern for lung toxicity given her
pre-existing lung disease. However, on [**2-26**] she had an episode
of atrial flutter for about 45 minutes and spontaneously
converted back to normal rhythm. An EP consult was requested for
management of her arrhythmia, and they recommended staying off
amiodarone and increasing the dose of dilt. This was deferred
over concern for her low EF seen on echo [**2-12**], however, and a
repeat echo was obtained, which still showed a depressed EF at
30-40%. Given that the etiology of this was unclear, cardiology
recommended a pMIBI which showed mild reversible defects on the
anterior and lateral walls. Because this likely indicates 3VD
given involvement of 2 distributions and the defects are mild,
cardiology did not recommend urgent cath, as this may be
deferred to the outpatient setting if the patient so desires.
The patient should follow up with a cardiologist and has an
appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
.
## Anemia: Low iron with normal TIBC and low normal Ferritin.
Component of anemia of chronic disease and iron deficiency. Iron
supplements as outpatient. However intially had hct drop 5
points from baseline most likely in the context of fluid
resuscitation for hypotension. Subsequently recovered without
transfusion and came back to baseline.
.
## Peripheral fluid overload: The patient was on 20mg PO Lasix
QD at home started during last admission. However, by [**2-24**], she
was autodiuresing and did not require any further Lasix. By day
of discharge, she was maintaining approximately even net fluid
balance on her own with baseline O2 sat in the mid-90s on 1-2L
O2 NC.
.
## DM2: Diabetes, usually controlled with diet, started on
Glyburide 1.25mg [**Hospital1 **] during last admission, last hemoglobin A1c
6.5. On FS QID while on steroids. Covered with ISSC while on
steroids, finger sticks were under control.
.
## Depression, Anxiety: Continue Seroquel, Trazadone, and Zoloft
at out-patient doses. Clonazepam TID increased to 1mg, but she
became intermittently disoriented and agitated so it was tapered
down to 0.5mg [**Hospital1 **] to good effect.
.
## Lower back pain/constipation: no open lesion, focal, no
radiation. Reports prior pain in that region, appears chronic.
Rectal pain likely related to constipation, possible
hemorrhoids, stool in vault on rectal. Pt maintained on Tylenol
1g qid w/ oxycodone 2.5mg q4-6h prn for breakthrough (decreased
from 5 to avoid oversedation) and aggressive bowel regimen as
long as no diarrhea: senna, colace, dulcolax, MOM.
[**3-3**] C. diff (sent for diarrhea) was negative. Diltiazem may have
contributed to constipation, it was d/c'ed as above.
Constipation may have contributed to urinary retention
experienced during her hospitalization but improved w/ treatment
of constipation.
.
## Dispo: to skilled nursing facility, expected length of stay
less than 30 days.
Medications on Admission:
1. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
5. Sertraline 50 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
6. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
8. Beclomethasone Diprop Monohyd 0.042 % Aerosol, Spray Sig: One
(1) Spray Nasal [**Hospital1 **] (2 times a day).
9. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed: do not exceed 4g/d.
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): continue until ambulating > 3x/d.
11. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
12. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-28**] Sprays Nasal
QID (4 times a day) as needed.
13. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 6 days.
14. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
15. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
16. Prednisone 40mg q day
17. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
18. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
19. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
20. Glyburide 1.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
21. Lasix 20 mg Tablet Sig: 0.5 Tablet PO once a day.
22. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
23. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Discharge Medications:
1. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
2. Sertraline 50 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
4. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-28**] Sprays Nasal
QID (4 times a day) as needed.
5. Quetiapine 100 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
6. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
7. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q2H (every 2 hours) as needed. neb
8. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
12. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
13. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
sliding scale Injection ASDIR (AS DIRECTED).
14. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed.
15. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO QID (4
times a day) as needed for pain.
16. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO BID (2 times a day) as needed.
17. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
18. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
20. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as
needed for constipation.
21. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
22. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
23. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
24. Warfarin 3 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] Rehabilitation & Nursing Center - [**Location (un) 538**]
Discharge Diagnosis:
COPD
CHF
chronic back pain
Discharge Condition:
good, stable, O2 sat 94% on RA, ambulating with assistance
Discharge Instructions:
If you have fevers, chills, worsening shortness of breath,
lightheadedness, or chest pain, tell your doctor or seek medical
attention immediately.
Followup Instructions:
You should have your INR checked at rehab in 2 days. The doctor
there will adjust your coumadin dose accordingly to a goal INR
of [**3-1**].
Follow up with your PCP (VALIZADEH, [**Last Name (un) **] [**Telephone/Fax (1) **]) within
1-2 weeks after being discharged from the rehab facility.
It is very important that you follow up with a cardiologist as
an outpatient. You have an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
on [**2199-3-25**] at 4pm on the [**Location (un) 436**] of the [**Hospital Ward Name 23**] building. Call
[**Telephone/Fax (1) 2934**] to register and for more information.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,302
| 144,833
|
30587
|
Discharge summary
|
report
|
Admission Date: [**2189-6-30**] Discharge Date: [**2189-7-4**]
Date of Birth: [**2163-7-25**] Sex: M
Service: MEDICINE
Allergies:
Compazine / Bactrim / Pentamidine Isethionate / Vancomycin Hcl
Attending:[**First Name3 (LF) 11040**]
Chief Complaint:
Shortness of breath, headache
Major Surgical or Invasive Procedure:
none (chest tube placed at OSH)
Intubation, A line placement
History of Present Illness:
25 male with AML s/p BMT in [**2187**], GVHD, recent PTX medically
managed, presented to [**Hospital 8**] Hosp from [**Hospital1 **] [**2189-6-30**] with
SOB, N/V, and an enlarged hydropneumothorax. He was seen at [**Hospital1 112**]
and discharged about one week ago for a left hydropneumothorax
that was medically managed. He noted the onset of shortness of
breath yesterday at rest, was hypoxic, and found to have a
larger pneumothorax. He was taken to [**Hospital1 **] hosptial where he
was given pain control and had a chest tube placed in his left
5th intercostal space. He was symptomatically improved, and was
transferred here for further care. He has not had recent f/c,
though has been vomiting daily. He has not had diarrhea.
.
He also has had shingles on his left leg, and has been on
valtrex for this. His immunosuppression was recently decreased
due to voriconazole.
.
ED course: He was given IV dilaudid in the ED, seen by thoracic
surgery, and admitted to medicine for workup.
.
On the floor, he was noted to have a serum bicarb of 45 and was
somnolent. An ABG was done which was 7.23/112/144. CXR from 1 am
showed increased left pneumothorax. He was brought to the CCU
for further management of his chest tube.
.
Review of Systems: Nausea and vomiting, rash on left leg, poor
appetite, decreased energy.
Past Medical History:
AML s/p transplant [**2187**]
? GVHD
Gtube
Depression
Social History:
Lives at [**Hospital **] Rehab, no tobacco or EtOH. Single.
Family History:
NC
Physical Exam:
Gen- Cachectic, pale, ill appearing male, uncomfortable
Heent- MMdry, blood in mouth and nares, anicteric
Neck- supple, no LAD
Cor- tachy, regular, s1,s2
Chest- breath sounds bilateral, rhonchorous anteriorly; chest
tube draining serosanguinous fluid, no bleeding at site
Abd- soft, tender at g tube site, no g/r. Pos BS.
Ext- no c/c/e
Neuro- AAO 3, drowsy
Skin- Open excoriated lesion on left thigh
Pertinent Results:
Admission labs:
[**2189-6-30**] 05:53PM GLUCOSE-99 UREA N-19 CREAT-0.6 SODIUM-134
POTASSIUM-4.7 CHLORIDE-88* TOTAL CO2-42* ANION GAP-9
[**2189-6-30**] 05:53PM WBC-15.4* RBC-2.89* HGB-9.9* HCT-31.0*
MCV-108* MCH-34.2* MCHC-31.8 RDW-16.9*
[**2189-6-30**] 05:53PM NEUTS-83.2* LYMPHS-9.7* MONOS-6.6 EOS-0.3
BASOS-0.2
[**2189-6-30**] 05:53PM PLT COUNT-289
.
Imaging
CT Head [**2188-6-30**] - FINDINGS: No hemorrhage, mass lesion, shift of
normally midline structures or evidence of major territorial
infarction is apparent. There is no hydrocephalus. The orbits
are grossly normal in appearance. There is opacification of
multiple ethmoid air cells and mild mucosal thickening in
bilateral maxillary sinuses consistent with inflammatory
changes. No abnormalities are noted within the bony structures.
IMPRESSION:
1. No acute intracranial abnormality detected.
2. Opacification of multiple ethmoid air cells and mild mucosal
thickening in bilateral maxillary sinuses consistent with
inflammatory changes.
[**2189-6-30**] - UPRIGHT PORTABLE CHEST RADIOGRAPH.
FINDINGS:
There is a mild-to-moderate left hydropneumothorax with a
left-sided chest tube running along the lateral chest wall in an
apical direction. The sideport was unable to be visualized due
to overlying ribs. Obscuration of the left hemidiaphragm is
noted likely reflective of atelectasis from overlying fluid.
Mild right basilar atelectasis is present. There is no evidence
of focal parenchymal infiltrate or pulmonary edema.
Cardiomediastinal silhouette and hilar contours are within
normal limits.
IMPRESSION: Mild-to-moderate left hydropneumothorax with lateral
apical chest tube in place. Sideport unable to be visualized.
CHEST CT WITHOUT IV CONTRAST [**2189-7-2**]:
TECHNIQUE: MDCT was used to obtain contiguous axial images
through the chest without administration of IV contrast.
Standard and lung algorithm images as well as coronal reformats
were obtained. This study was compared with chest radiograph of
[**7-2**], [**7-1**], and [**2189-6-30**].
The image quality of this study is compromised by respiratory
motion. A moderate left hydropneumothorax is similar in size to
the [**2189-7-2**] chest radiograph. Associated atelectasis is
most pronounced at the left lower lobe; coronal reformats show a
3.7 cm ovoid extrapulmonary fluid collection contiguous with
loculated pleural fluid laterally, probably a fibrin clot.
Vague ground-glass and centrilobular opacities, most pronounced
in the right middle lobe, medial left upper lobe, and in
dependent portions of both lower lobes, along with bronchial
wall thickening, most pronounced in the right upper lobe and
left lower lobe, all reflect endobronchial infection. A small
volume of consolidation in the left lower lobe adjacent to the
extraparenchymal loculated fluid is the only candidate for
active pneumonia, and that could be atelectasis.
The left chest tube enters between the sixth and seventh ribs
anterolaterally, courses to the lung apex; it is not contiguous
with the loculated fluid at the left lung base.
A small, layering, nonhemorrhagic, right pleural effusion is
also present. There is no pericardial effusion.
Right PICC terminates in the cavoatrial junction. No mediastinal
lymph nodes are larger than an 8 mm precarinal node (4:90).
This study was not designed to examine the abdomen, however, no
mass lesions are seen in the imaged portion of the liver,
spleen, adrenals, kidneys, or pancreas. A gastrostomy tube is
only partially imaged.
There are no bone findings suspicious for malignancy or
infection
IMPRESSION:
1. Moderate left hydropneumothorax, including basal fluid
loculations not traversed by pleural drain.
2. Minimal left lower lobe consolidation. Mild, multifocal
bronchitis and bronchiolitis.
3. Small right pleural effusion.
Pleural fluid cytology: neg for malignant cells
EMG [**2189-7-3**]:
FINDINGS: Motor nerve conduction study (NCSs) of the left median
nerve were normal, including F waves.
Motor NCSs of the left ulnar nerve showed normal distal latency,
moderate
reduction of response amplitudes, and normal conduction
velocity; F response minimum latency was normal.
Motor responses of the left peroneal nerve, recording extensor
digitorum
brevis and tibialis anterior, were absent.
Motor NCSs of the left tibial nerve showed normal distal
latency, moderate
reduction of response amplitude, and mild slowing of conduction
velocity.
Slow (3-Hz) repetitive nerve stimulation of the left ulnar
nerve, recording abductor digiti minimi, showed no decremental
response at baseline, immediately after 1 minute of maximal
voluntary contraction, or at 1-minute intervals following
maximal voluntary effort out to 5 minutes.
Slow (3-Hz) repetitive nerve stimulation of the left spinal
accessory nerve, recording trapzeius, showed no decremental
response at baseline, immediately after 1 minute of maximal
voluntary contraction, or at 1-minute intervals following
maximal voluntary out to 4 minutes, though the study was
technically limited by movement.
Concentric needle electromyography (EMG) of the left vastus
lateralis showed motor unit potentials (MUPs) of mildly short
duration, small amplitude and increased polyphasia with early
recruitment. EMG examination of the tibialis anterior and medial
gastrocnemius was normal.
EMG of right vastus lateralis showed MUPs of mildly short
duration, small
amplitude and increased polyphasia with early recruitment.
EMG examination of the left deltoid, biceps, and first dorsal
interosseous was normal.
EMG examination of the right deltoid showed a mixed population
of normal MUPs and MUPs of mildly short duration, small
amplitude and increased polyphasia with early recruitment.
The study was prematurely terminated due to the patient's
increasing
respiratory distress. Further needle EMG of proximal muscles and
single-fiber EMG was not performed.
IMPRESSION:
Abnormal, limited study. There is electrophysiologic evidence
for a mild,
generalized myopathic process without denervating features, as
can be seen in critical illness myopathy. The findings also
suggest the possibility of a mild sensorimotor polyneuropathy
with predominantly axonal features. There is no definite
electrophysiologic evidence for a disorder of neuromuscular
transmission, but the limited nature of the study precludes
exclusion of this diagnostic possibility.
**Microbiology:
AEROBIC BOTTLE (Preliminary): [**2189-6-30**].
ENTEROCOCCUS SP.. PRELIMINARY SENSITIVITY.
FURTHER IDENTIFICATION TO FOLLOW.
SENSITIVITIES: MIC expressed in MCG/ML
ENTEROCOCCUS SP.
|
AMPICILLIN------------ R
LEVOFLOXACIN---------- R
VANCOMYCIN------------ S
ANAEROBIC BOTTLE (Preliminary):
ENTEROCOCCUS SP..
IDENTIFICATION AND SENSITIVITIES PERFORMED FROM AEROBIC
BOTTLE.
PLEURAL FLUID [**2189-7-1**] 10:26 am
GRAM STAIN (Final [**2189-7-2**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2189-7-4**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
Transfer labs:
[**2189-7-4**] 02:45AM BLOOD WBC-12.6* RBC-3.00* Hgb-10.0* Hct-30.7*
MCV-102* MCH-33.3* MCHC-32.6 RDW-17.4* Plt Ct-250
[**2189-7-4**] 02:45AM BLOOD Neuts-70 Bands-0 Lymphs-10* Monos-17*
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-2* NRBC-1*
[**2189-7-4**] 02:45AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-NORMAL
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Stipple-1+
[**2189-7-4**] 02:45AM BLOOD Plt Smr-NORMAL Plt Ct-250
[**2189-7-4**] 02:45AM BLOOD Glucose-126* UreaN-26* Creat-0.8 Na-135
K-4.5 Cl-88* HCO3-43* AnGap-9
[**2189-7-4**] 02:45AM BLOOD ALT-14 AST-36 LD(LDH)-176 AlkPhos-223*
Amylase-28 TotBili-0.4
[**2189-7-4**] 02:45AM BLOOD Albumin-3.1* Calcium-10.4* Phos-4.2
Mg-2.3
[**2189-7-4**] 05:28PM BLOOD Type-ART Temp-36.3 Rates-30/ Tidal V-300
PEEP-5 FiO2-40 pO2-83* pCO2-79* pH-7.33* calTCO2-44* Base XS-11
-ASSIST/CON Intubat-INTUBATED
[**2189-7-4**] 09:12AM BLOOD Type-ART Temp-35.2 Rates-30/ Tidal V-300
PEEP-5 FiO2-40 pO2-88 pCO2-84* pH-7.27* calTCO2-40* Base XS-8
-ASSIST/CON Intubat-INTUBATED
[**2189-7-4**] 06:41AM BLOOD Type-ART Temp-35.7 PEEP-5 pO2-137*
pCO2-110* pH-7.25* calTCO2-51* Base XS-15 Intubat-INTUBATED
[**2189-7-4**] 05:30AM BLOOD Type-ART Temp-35.7 Tidal V-300 PEEP-5
pO2-71* pCO2-122* pH-7.17* calTCO2-47* Base XS-10
Intubat-INTUBATED
Albumin 3.1
TSH 0.48
Brief Hospital Course:
Impression/Plan: 25 male with h/o AML s/p BMT in [**2187**], GVHD, now
with new pneumothorax and hypercarbic respiratory failure.
# Hypercarbic respiratory failure: Though pt has no established
history of lung disease, suspect that his hypercarbia has been a
chronic issue. His pco2 of 112 caused pH of only 7.29, and
serum bicarb of 45, suggesting chronic process. Possible causes
of hypercarbia considered include sedation from meds--pt had
been getting fentanyl, dilaudid and ativan; question of
myopathy/neuromuscular disease (? steroid myopathy or
chemo-induced myopathy); and/or obstructive lung disease. His
pain meds were decreased without much effect on his respiratory
status. He was evaluated by neurology regarding question of
neuro-muscular disease. An EMG was performed which which showed
mild, generalized myopathic process without denervating
features; however, the study was limited. [**Name (NI) 1094**] PTX was treated
w/ chest tube
On [**2189-7-3**], pt noted to be increasingly tachypnic and fatigued.
Gas showed worsening hypercarbia (see results section). CT
chest was performed, which showed persistent hydro-pneumothorax
as well as non-specific ground-glass opacities & tree & [**Male First Name (un) 239**]
structures.
He was tried on bipap w/o improvement in respiratory status.
Thus, in early AM of [**2189-7-4**], he was intubated. [Of note, pt
consented to intubation prior to procedure.] He was started on
AC 300 x 26, with some improvement in his CO2@ to the 80's. He
was maintained on light sedation. An A-line was placed. His
pulonary physiology was consistent with severe obstructive
process (high peak pressures, low plateaus, and auto-PEEP of
~13). Pt does not have h/o reactive airway disease or COPD.
Question of GVHD related lung disease raised. Infectious
process also possible cause (? PCP/viral (partic adeno,
CMV)/fungal).
Pt was started on linezolid and zosyn for coverage of possible
PNA, though no clear infiltrate on CT.
# Pneumothorax: No history of this before. Pt had chest tube
placed at [**Hospital 8**] Hospital and transferred to [**Hospital1 18**] (as [**Hospital1 112**] on
divert). He was admitted to the MICU team. CT surgery
consulted. They adjusted chest tube with initial improvement in
respiratory status & improvement of CXR. Chest Tube placed to
suction. Small air leak noted. Pleural fluid studies sent.
Gram stain negative as were cultures. Fluid bloody. Tube
draining >150cc daily until [**2189-7-4**], day of transfer, when it was
putting out more ~20 cc of bloody fluid. He needs to have chest
tube evaluated by thoracics to see if it needs to be readjusted
or pulled.
.
# AML: He is s/p BMT, apparently in remission. Spoke to his
oncologist, Dr [**Last Name (STitle) 11907**] at [**Company 2860**]. Immunosuppresive medications
were continued as were his prophylactive anti-biotics,
atovaquone & voriconazole. Question of GVHD. LFTs were checked
for ? of GVHD as well (see results). Hematology consulted for
question of GVHD in lung. They felt like this was certainly
possible and recommended Bronchoscopy/VATS to get tissue
diagnosis.
# Pain: Low dose dilaudid and fentanyl patch.
# Leukocytosis: Appears be a chronic issue per [**Hospital **] rehab
notes. He just finished a course of levo/flagyl for unclear
reasons, and no cultures were positive there. Here his bld cx
was positive for enterococcus, sensitive to vancomycin. However,
since he was allergic to this he was started on linezolid. While
on this medication, his counts will need to be monitored. Zosyn
was also started for concern of PNA as an infectious source.
# R. corneal tear: diagnosed prior to admission. Pt continued
on cipro eye gtt.
# Depression: continue celexa and remeron
# Nausea: His tube feed have recently been on hold due to high
residuals. These were slowly restarted day prior to transfer and
he is still below goal. Cont to increase TF's and check
residuals; can use reglan as needed to help w/ motility.
.
# Tachycardia: Has been on metoprolol. Unclear if related to
PTX, pain, hypoxia or a combination.
# FEN: Tube feeds as tolerated; regular diet, reglan
# PPx: SC heparin, tums
# Code: full
# Communication: father
Medications on Admission:
Atovaquone, calcium, cipro eye gtt, citalopram, colace, fentanyl
patch, folate, lasix, neurontin, levoflox, ativan, reglan,
lopressor, mirtazapine, mvi, MMF, prednisone, senna, Tacro,
Zosyn, Urodiol, Valtrex, Vori, Albuterol/Ipratrop, lactulose,
dilaudid
Discharge Medications:
1. Atovaquone 750 mg/5 mL Suspension Sig: Five (5) ml PO BID (2
times a day).
2. Ciprofloxacin 0.3 % Drops Sig: One (1) Drop Ophthalmic DAILY
(Daily).
3. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Voriconazole 50 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours).
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
6. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q4H (every 4 hours) as needed.
7. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Collagenase 250 unit/g Ointment Sig: One (1) Appl Topical
DAILY (Daily).
9. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
10. Fentanyl Citrate (PF) 0.05 mg/mL Solution Sig: 25-100 mcg/hr
Injection INFUSION (continuous infusion).
11. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
13. HYDROmorphone (Dilaudid) 0.5-1 mg IV Q6H:PRN
hold for RR<12, sedation
14. 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.
15. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
16. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
17. Linezolid 600 mg IV Q12H
18. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
19. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
20. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
21. Midazolam 5 mg/mL Solution Sig: 0.5-2mg Injection TITRATE
TO (titrate to desired clinical effect (please specify)).
22. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
23. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO
DAILY (Daily).
24. Mycophenolate Mofetil 200 mg/mL Suspension for
Reconstitution Sig: 500mg PO BID (2 times a day).
25. Ondansetron 4 mg IV Q8H:PRN
26. Piperacillin-Tazobactam Na 4.5 gm IV Q8H
27. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
28. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
29. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day).
30. Valacyclovir 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
31. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
1. hydropneumothorax
2. hypercarbic respiratory failure
Secondary:
1. AML s/p BMT
Discharge Condition:
critical
Discharge Instructions:
Transfer to [**Hospital1 112**] MICU for respiratory failure and care under his
primary hematologist, Dr. [**Last Name (STitle) 11907**].
Followup Instructions:
Please f/u with Dr. [**Last Name (STitle) 11907**] of [**Company 2860**]
|
[
"516.8",
"311",
"518.83",
"511.8",
"V44.1",
"205.01",
"V42.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"00.14",
"96.04",
"99.04",
"96.71",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
18084, 18099
|
11021, 15243
|
353, 417
|
18225, 18236
|
2379, 2379
|
18422, 18497
|
1939, 1943
|
15548, 18061
|
18120, 18204
|
15269, 15525
|
18260, 18399
|
1958, 2360
|
9685, 10998
|
1694, 1768
|
284, 315
|
445, 1675
|
2395, 9601
|
9637, 9652
|
1790, 1845
|
1861, 1923
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,097
| 132,998
|
41485
|
Discharge summary
|
report
|
Admission Date: [**2153-3-26**] Discharge Date: [**2153-4-20**]
Date of Birth: [**2085-4-28**] Sex: M
Service: MEDICINE
Allergies:
Iodine
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Found down
Major Surgical or Invasive Procedure:
Intubation, tracheostomy
History of Present Illness:
67M found down today by police after friends had called for a
well check, last seen two days ago. Friend [**Name (NI) **] had not heard
from him since friday at 1900 and called police for well check
found down mumbling, wearing only a t-shirt. Taken initially to
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5678**] hospital where glucose was critical high. Head/Neck
CT at OSH was negative, they intubated him, gave him vanc/zosyn
and put in femoral line. He got 2L IVF, his BP was initially in
the 90s systolic and then drifted down, got 2L more here and
then started him on norepinephrine. brought to ED where initial
pH was 6.99/26/176. Repeat ABG was 7.03/26/515. Transferred here
from [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5678**]. IDDM w/ BKA. Hxo of lung lobectomy. Getting an
abd CT. 81, 107/88, 20 100% on AC 550 x5, 100% FiO2 and 0.06 of
norepi. Is currently getting insulin drip at 5U/hr.
.
He was unresponsive on presentation to the ICU but his friend
[**Name (NI) **] said that he had been having frequent diarrhea since being
on Abx for his toe and had also injured his ribs after walking
into the couch and was complaining of sharp pain on inspiration
x 4 days.
.
In the ED, initial vs were: T P BP R O2 sat. Patient was
given...
Yest 23:30 Insulin Human Regular 100 Units / mL - 10 mL Vial 100
Yest 23:35 Insulin Human Regular 100 Units / mL - 10 mL Vial
Return 1
Yest 23:36 Midazolam 100mg Premix Bag [class 4] 1
Yest 23:39 Norepinephrine 4mg/4mL Amp 2
.
Review of systems:
Unobtainable
Past Medical History:
DMII x ~20yrs, now insulin dependent
Per his friend [**Name (NI) **], [**First Name3 (LF) **] need medical records from [**Hospital1 5979**] and/or [**Hospital1 2025**] in am
Lung CA s/p resection 3 yrs ago w/o recurrence
L AKA
Aorto-fem bypass first on the L then on the R about 3 yrs ago
-followed by Dr. [**Last Name (STitle) 82271**]
Recent Hx of low BP
Subtotal gastrectomy
diabetic foot ulcers s/p staph aureus osteo
Vitamin D deficiency
anemia
aphthous ulcers
Diabetic retinopathy
MRSA infection
gastroparesis
L sided hearing loss
Lumbar laminectomy
chronic pain syndrome
Phantom limb syndrome
DKA admitted to [**Hospital1 2025**] [**2142**]
Social History:
Lives alone, estranged from his son but his ex-wife and daughter
live in [**State 5111**] and are sometimes in contact. His friend
[**Name (NI) **] is his HCP her phone number is [**Telephone/Fax (1) 90243**].
- Tobacco: 3ppd x many years
- Alcohol: Quit when diagnosed with DM
- Illicits: None
In W/c since amputation, stopped driving in [**2152**]. On disability.
Family History:
DMII
Physical Exam:
Admission Exam:
Vitals: T: 95.5 BP:110/63 P: 95 R: 20 O2: 100% on 40% FiO2
General: Sedated on ventilator, does not respond to painful
stimuli
HEENT: Sclera anicteric, MM dry, oropharynx dry, Pupils pinpoint
bilaterally.
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley
Ext: cool, dopplerable pulses in R foot, L radial pulse>R radial
pulse but R axillary puls 2+, slow capillary refill to fingers
and toes.
.
Discharge Exam:
General: on trach, eyes open and oriented to voice, responding
to simple commands, lethargic
HEENT: trach in place, no signs of active bleeding. Sclera
anicteric, dry MM
Lungs: relatively clear, some bibasilar crackles
CV: Regular rate and rhythm, normal S1 + S2, SEM [**2-18**]
Abdomen: Soft, non-distended, bowel sounds hypoactive, no signs
of pain during palpation
GU: Foley in place, significant scrotal edema improved
Ext: s/p left BKA. Right lower ext warm. Ulcer on R great toe,
old stable, dressed. Lateral right knee wound dressing in place
Pertinent Results:
Admission Labs:
[**2153-3-25**] 11:43PM BLOOD WBC-17.7* RBC-3.23* Hgb-9.8* Hct-34.9*
MCV-108* MCH-30.4 MCHC-28.1* RDW-16.1* Plt Ct-379
[**2153-3-25**] 11:43PM BLOOD PT-13.7* PTT-26.8 INR(PT)-1.2*
[**2153-3-26**] 01:25AM BLOOD Glucose-567*
[**2153-3-26**] 02:43AM BLOOD Glucose-504* UreaN-38* Creat-1.6* Na-141
K-5.0 Cl-104 HCO3-9* AnGap-33*
[**2153-3-25**] 11:43PM BLOOD ALT-40 AST-131* LD(LDH)-359*
CK(CPK)-6680* AlkPhos-165* TotBili-0.3
[**2153-3-25**] 11:43PM BLOOD CK-MB-74* MB Indx-1.1
[**2153-3-25**] 11:43PM BLOOD Albumin-2.8*
[**2153-3-25**] 11:43PM BLOOD Type-[**Last Name (un) **] pO2-176* pCO2-26* pH-6.99*
calTCO2-7* Base XS--24 Comment-GREEN TOP
[**2153-3-25**] 11:43PM BLOOD freeCa-1.20
.
Discharge Labs:
[**2153-4-20**] 04:47AM BLOOD WBC-6.6 RBC-2.92* Hgb-9.0* Hct-26.8*
MCV-92 MCH-30.7 MCHC-33.5 RDW-18.0* Plt Ct-179
[**2153-4-9**] 05:45AM BLOOD Neuts-92* Bands-0 Lymphs-4* Monos-3 Eos-1
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2153-4-19**] 03:55AM BLOOD PT-12.9 PTT-31.2 INR(PT)-1.1
[**2153-4-20**] 04:47AM BLOOD Glucose-131* UreaN-110* Creat-2.8* Na-139
K-3.6 Cl-105 HCO3-28 AnGap-10
[**2153-4-20**] 04:47AM BLOOD Albumin-PND Calcium-8.2* Phos-3.2 Mg-2.1
.
CT ABD & PELVIS W/O CONTRAST Study Date of [**2153-3-26**] 12:22 AM
IMPRESSION:
1. No intra-abdominal source of infection is identified. Within
the limits of a non-contrast study, the bowel and solid
abdominal vessel appear normal.
.
2. Emphysema seen at the lung bases, with left basilar
tree-in-[**Male First Name (un) 239**] opacities, which could reflect infection or
aspiration.
.
3. Left groin line in standard position. Air is seen deep to the
insertion site within the left adductor musculature likely
reflects placement. Clinical correlation to exclude cellulitis
is recommended.
.
4. Status post aortobifemoral graft. Graft patency is not
assessed without intravenous contrast. Additional extensive
atherosclerotic disease noted as above.
.
EEG [**2153-4-11**]
ROUTINE SAMPLING: The background is still low voltage and slow
reaching up to a maximum of 7 Hz with reactivity, which is a
mild improvement compared to the previous day's recording.
SPIKE DETECTION PROGRAMS: There were no entries in these files.
SEIZURE DETECTION PROGRAMS: There was one entry in these files
due to muscle artifact.
PUSHBUTTON ACTIVATIONS: There were no entries in these files.
SLEEP: No normal sleep architecture was noted.
CARDIAC MONITOR: Showed a generally regular rhythm.
IMPRESSION: This video EEG telemetry captured no pushbutton
activations and no electrographic seizures. The background
showed reactivity, but was again slow and disorganized reaching
up to a maximum of 7 Hz, which is a mild improvement compared to
the previous day's recording. Overall, the EEG is still
consistent with a mild encephalopathy
.
Abdominal plain film [**2153-4-19**]
FINDINGS: Based on evaluation of the recent CT from [**2153-4-13**], this
patient is status post partial gastrectomy with a
gastrojejunostomy. The
Dobbhoff tube was removed and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2174**]-[**Doctor First Name 1557**] catheter was
inserted and
advanced through the gastrojejunostomy and into the proximal
jejunum. The
catheter was left in a looped position, but peristalsis should
eventually lead to uncoiling of the catheter. Injection of 50 mL
of Optiray was used, both to help position and confirm the
location of the catheter within the jejunum. Surgical clips are
seen overlying the spine at the level of the diaphragm
Brief Hospital Course:
67 yo M with IDDM presenting with hyperglycemia, acidosis, and
hypotension after a prolonged diarrheal illness, intubated for
hypoxia, who developed toxic metabolic encephalopathy
.
# Repiratory Failure: Patient was intubated, after being found
down, for inability to protect airway. Initially there was
suspicion for aspiration PNA in the setting of being found down
and bilateral patchy opacities on CXR. He was extubated [**2153-3-30**]
and reintubated a few hours later due to desaturation. He had a
tracheostomy done [**2153-4-5**] and his course was defined as below in
"hypotension." He was initially treated with vancomycin and
cefepime for healthcare acquired pneumonia and descalated to
bactrim for stenotrophomonas and klebsiella isolated from
sputum; however, those was discontinued 2 days thereafter
because they were thought to be colonizers. On HD13, CXR showed
new RUL infiltrate and he as started on an 8 day course of
Vancomycin and Cefepime for hospital acquired pneumonia.
Throughout the remainder of hospital stay, he tolerated [**6-24**]
hours off of the ventilator on tracheostomy mask; however, he
would either desaturate or appear uncomfortable prompting
resumption of ventilation. We believe that he may have a
component of neuromuscular weakening, for which he tires easily.
At the time of discharge, he was able to tolerate being off the
vent for >24 hours. He should be assessed frequently at his next
facility to ensure he is tolerating his trach collar.
.
# Hypotension: On admission, the patient was hypotensive in the
setting of a recent diarrheal illness and hyperglycemia,
suggesting hypovolemia. He initially required pressors, which
were weaned off on [**3-31**]. After tracheostomy he had three
episodes of hypoxia while on the trach collar, followed by
non-responsivness and hypotension. Each time levophed was needed
transiently and he improved after being placed back on the
ventilator. There was no evidence to support an underlying
infection or sepsis physiology. A random cortisol was drawn and
appropriately elevated, ruling out adrenal insufficiency. This
hypotension ultimately resolved.
.
# Encephalopathy: While intubated the patient had periods of
non-responsiveness and staring spells concerning for seizure.
Neurology was consulted and 48 hour EEG showed encephalopathy
without epileptiform activity. Repeat 24 hour continuous EEG
confirmed no seizure activity and MRI head was declined by
[**Hospital 228**] Health Care Proxy. [**Name (NI) **] had waxing and waining mental
status in the setting of the above hypotensive/hypoxic events.
His encephalopathy is likely multifactorial in nature, relating
to hypotension and toxic metabolic insult from DKA, hypercarbia,
acidosis, and renal failure. His mental status improved, but he
continues to be intermittently confused as well as lethargic. He
may benefit from a stimulant in the future.
.
# Acute Kidney injury: Creatinine rose during admission to 5.1
thought to be secondary to ATN from hypotension and
rhabdomyolysis. Renal ultrasound was negative for hydronephrosis
or stones. Renal consult recommended albumin 25 g daily x 3 days
which did not improve creatinine. Gradually the patient's
creatinine trended down, and continued to trend down with
diuresis with a Lasix gtt. He had about 4L removed. His Cr at
time of discharge was 2.8 and trending [**Last Name (un) 19262**]. Though expected to
resolve without intervention, he may benefit from additional
diuresis, which should be assessed at his next facility and PO
Lasix started if necessary.
.
# Anemia: Patient's hematocrit gradually trended down after
admission 27->21. Stool was GUAIAC positive suggesting possible
GI source. He was transfused 1 unit with appropriate HCT
increase. Hematocrit again decreased gradually and on HD9, he
was transfused 2 units of PRBCs with adequate response. Because
of his poor vascularity, transfusion goal was kept at >25. At
the time of discharge, his Hematocrit had been stable > 5 days.
He was continued on a twice daily PPI.
.
# Wounds: Patient has several wounds secondary to pressure and
longstanding diabetes mellitus, including a 10X7 cm unstagable
sacral decubitus ulcer with small area of black eschar (present
on admission) and multiple ulcers on his distal extremities for
which Wound Care was consulted and provided recommendations
regarding positioning and daily dressings. His pain was
controlled with IV morphine.
.
# Thrombocytopenia: Patient's platelets showed greater than 50%
decrease during admission. Likely secondary to medications or
infection. HITT antibody was negative. Platelets remained stable
prior to discharge.
.
# Hyperglycemia: Presented with diabetic ketoacidosis. He was
treated with fluids and insulin drip initially and subsequently
transitioned to subcutaneous insulin. He had episodes of
hypoglycemia in the setting of holding his tube feeds prior to
the OR for tracheostomy. His insulin was adjusted throughout his
stay to optimize his glucose. The likely inciting event was
diarrhea and dehydration.
.
# Acidosis: Resolved. The gap acidosis appears related to DKA.
Then non-gap acidosis may be a combination of his diarrhea and
volume resuscitation with NS. Patient??????s lactate continues to
remain low. His gap is now closed and bicarb normalizing
.
# Demand ischemia: After admission, troponins trended up from
0.11 to a peak of 0.33, CKMB followed a smililar pattern.
Likely secondary to demand ischemia given hypotension and
prolonged down period, no evidence of acute coronary thrombosis
on EKG.
.
# Feeding: patient evaluated by speech and swallow and
determined to be unalbe to protect airway while eating. He was
given nutrition via nasogastric tube however patient pulled the
tube many times due to encephalopathy. Patient is s/p partial
gastrectomy, [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2174**]-[**Doctor First Name 1557**] catheter was inserted and
advanced through the gastrojejunostomy and into the proximal
jejunum. A bridle was looped around the nasal septum to maintain
the nasogastric tube in place. This bridle should remain in
place to prevent him from pulling the nasogastric tube while it
is in place.
.
# Left ear decreased hearing: patient is extremely hard of
hearing in left ear which is a chroinic issue, he is able to
hear well in the right ear.
.
# CODE STATUS: Do not resuscitate or re-intubate (DNR/DNI). Ok
to be on ventilator.
# Communication: friend [**Name (NI) **] is his HCP her phone number is
[**Telephone/Fax (1) 90243**]. [**Doctor First Name **] Weftberry, daughter, [**Telephone/Fax (1) 90244**].
Medications on Admission:
gabapentin 60mg TID
Lantus 35U qam and 25U qpm
metoclopramide 10mg Q6
percocet 5/325mg 1-2tabs Q6
Humalog SSI 1U for BS 250-299, 2U for BS 300-349, 3U for BS
350-399, 4U for BS >400
Oxycontin 60mg PO BID (40+20)
triamcinolone oral
calcium
vitamin D
Iron tablets one daily
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Telephone/Fax (1) **]:
Four (4) Puff Inhalation Q4H (every 4 hours).
2. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler [**Telephone/Fax (1) **]:
Four (4) Puff Inhalation QID (4 times a day).
3. chlorhexidine gluconate 0.12 % Mouthwash [**Telephone/Fax (1) **]: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day).
4. white petrolatum-mineral oil 56.8-42.5 % Ointment [**Hospital1 **]: One
(1) Appl Ophthalmic PRN (as needed) as needed for dry eyes.
5. acetaminophen 650 mg/20.3 mL Solution [**Hospital1 **]: Six [**Age over 90 1230**]y
(650) mg PO Q6H (every 6 hours) as needed for pain or fever:
please do not exceed 2g per day.
6. insulin regular human 100 unit/mL Solution [**Age over 90 **]: as directed
by sliding scale Injection ASDIR (AS DIRECTED): Please check
FSBG levels every 6 hrs and dose insulin by sliding scale.
dispense QAM, QNoon, QPM and QHS according to the following
scale:
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, .
7. heparin (porcine) 5,000 unit/mL Solution [**Age over 90 **]: 5000 (5000)
units Injection TID (3 times a day).
8. heparin, porcine (PF) 10 unit/mL Syringe [**Age over 90 **]: Two (2) ML
Intravenous PRN (as needed) as needed for line flush: PICC line
flush: Flush with 10mL Normal Saline followed by Heparin as
above daily and PRN per lumen. .
9. Morphine Sulfate 2-4 mg IV Q4H:PRN pain
hold for sedation
10. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**]
Discharge Diagnosis:
Diabetic ketoacidosis
.
Respiratory failure
Hypotension
Toxic metabolic encephalopathy
Acute renal failure
Anemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Mr. [**Known lastname 90245**],
As you know, you were admitted to the hospital for severely
elevated blood sugar levels and respiratory failure. We treated
you with insulin and your blood sugar came down to normal
levels. We were unable to wean you from the ventilator and
placed a tracheostomy collar to allow long term ventilation, as
needed. You were seen by speech and swallow who recommended that
you receive your nutrition through a nasogastric tube. This may
be further evaluated in the future.
We have made a number of changes to your current medication
regimen. These may change again at your next facility.
Followup Instructions:
Please schedule a follow up with your Primary Care Physician in
the future, as you wish. You will be seen and taken care of by a
doctor at you next facility.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
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"536.3",
"268.9",
"707.03",
"414.8",
"250.13",
"584.5",
"792.1",
"287.5",
"728.88",
"V10.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"31.1",
"96.72",
"33.22"
] |
icd9pcs
|
[
[
[]
]
] |
16372, 16472
|
7769, 14379
|
286, 312
|
16630, 16630
|
4241, 4241
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17412, 17708
|
2967, 2974
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14702, 16349
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16493, 16609
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14405, 14679
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16769, 17389
|
4960, 7746
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2989, 3653
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3669, 4222
|
1876, 1891
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235, 248
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340, 1857
|
4257, 4944
|
16645, 16745
|
1913, 2564
|
2580, 2951
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,760
| 186,619
|
51520
|
Discharge summary
|
report
|
Admission Date: [**2171-5-28**] Discharge Date: [**2171-6-1**]
Date of Birth: [**2088-12-23**] Sex: M
Service: MEDICINE
Allergies:
Methyldopa / Atenolol / Codeine / Norvasc
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
hypercarbic respiratory failure
Major Surgical or Invasive Procedure:
Endotracheal extubation (intubated at rehab facility)
History of Present Illness:
The patient is an 82 yo M with h/o COPD (FEV1 0.56 in [**2168**]) and
recent hospitalization for pneumonia, discharged from here to
[**Hospital **] rehab on [**5-11**]. Today he was noted to be dyspneic. He was
given nebs and an extra dose of steroids and an ABG showed
7.3/79/126/39. He failed bipap and was intubated at [**Hospital1 **] and
transferred here. In the ED, initial vs were: T 100.2 P 103 BP
123/87 R 17 O2 sat 100. Patient was given cefepime, levo, 2L NS,
nebs and propofol.
.
On review of [**Hospital1 **] records, he was achypneic to 24 on routine
vitals today and yesterday. Hypertensive this am to 179/95.
Overall net positive fluid balance over past week >3L.
.
On discussion with RN at [**Hospital1 **], the patient has been
non-compliant with bipap using it for several hours a night at
the most. He was transfered to the more acute floor at [**Hospital1 **]
last night for an acute worsening of dyspnea. An ABG in the
evening of [**5-27**] showed 7.31/79/73/39. He was non-compliant with
bipap. Patient was mildly confused. No cough [**Name8 (MD) **] RN. No
increased sputum. No fevers. Again this morning, he appeared
very short of breath. A series of ABGs showed:
7.3/79/126/39 @0653
7.2/108/135/43 @0849
7.3/76/46/40 @1030
He was encouraged to wear the bipap but he was non-compliant and
in fact was given the option of bipap or intubation and
consented to the intubation. He was then intbutaed and given 5mg
versed and total 10mg diazepam. He was also given 60mg IV
methylpred @1400.
.
On arrival he is sedated and intubated but responds to verbal
stimuli. He complains of pain and points to his lower abdomen.
He confirms that pain is the bladder spasm pain. His family is
present and states that he had been doing well but seemed much
worse last night with labored breathing and audible wheezes and
also lethargic. They are not aware of any precipitating events
and are not aware if was aspirating.
.
Of note, they also states that he had been DNR/DNI but reversed
code status for them.
Past Medical History:
-hypertension
-chronic back pain
-COPD
-hyperlipidemia
-BPH
-gastritis
-DJD
Social History:
Lives alone and is independent with ADLs. He had a recent
mechanical fall with left leg bruising. He quit smoking >40
years ago. He drinks socially. No illicits.
Family History:
Positive for pancreatic cancer in his brother, positive for
diabetes in his mother, positive for CAD in his father, positive
for hypertension in his mother, positive for throat cancer in
his mother, questionable stomach cancer in his sister.
Physical Exam:
On admission:
Gen: intubated, awake, opens eyes to voice, follows commands
HEENT: PERRLA
CV: nl S1/S2, no m/r/g, RRR
Chest: anterior vent sounds with rhonchi and rales
Abd: soft, NT/ND, BS+
Ext: 1+ pitting edema to knees b/l
.
Death exam:
Unresponsive to deep pain and sternal rub
Pupils fixed and unreactive
No ausculated or visible breath sounds
No palpable or ausculated pulses or heart rate x 60 seconds
Cool extremities with no palpable pulses
Pertinent Results:
On admission:
=============
[**2171-5-28**] 01:19PM BLOOD WBC-18.5* RBC-3.40* Hgb-10.5* Hct-33.2*
MCV-98# MCH-30.8 MCHC-31.5 RDW-14.0 Plt Ct-145*
[**2171-5-28**] 01:19PM BLOOD Neuts-94* Bands-2 Lymphs-1* Monos-2 Eos-0
Baso-0 Atyps-1* Metas-0 Myelos-0
[**2171-5-28**] 01:19PM BLOOD Hypochr-1+ Anisocy-OCCASIONAL
Poiklo-NORMAL Macrocy-OCCASIONAL Microcy-NORMAL Polychr-NORMAL
[**2171-5-28**] 01:19PM BLOOD PT-11.7 PTT-22.9 INR(PT)-1.0
[**2171-5-28**] 01:19PM BLOOD Glucose-146* UreaN-33* Creat-1.0 Na-146*
K-4.8 Cl-106 HCO3-35* AnGap-10
[**2171-5-28**] 10:35PM BLOOD CK(CPK)-13*
[**2171-5-29**] 05:10AM BLOOD ALT-18 AST-16 CK(CPK)-21* AlkPhos-53
TotBili-0.4
[**2171-5-28**] 01:19PM BLOOD cTropnT-<0.01
[**2171-5-28**] 10:35PM BLOOD CK-MB-2 cTropnT-<0.01
[**2171-5-29**] 05:10AM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-243
[**2171-5-30**] 03:14AM BLOOD CK-MB-3 cTropnT-<0.01
[**2171-5-28**] 10:35PM BLOOD Calcium-8.7 Phos-2.5*# Mg-1.5*
[**2171-5-28**] 09:18PM BLOOD D-Dimer-1487*
[**2171-5-29**] 05:10AM BLOOD calTIBC-159* Ferritn-245 TRF-122*
[**2171-5-28**] 08:05PM BLOOD Type-ART Rates-16/ Tidal V-500 PEEP-10
FiO2-50 pO2-107* pCO2-57* pH-7.43 calTCO2-39* Base XS-11
-ASSIST/CON Intubat-INTUBATED
[**2171-5-28**] 01:33PM BLOOD Lactate-1.6
.
On discharge:
=============
[**2171-5-31**] 02:46AM BLOOD WBC-9.3 RBC-3.25* Hgb-9.9* Hct-30.3*
MCV-93 MCH-30.5 MCHC-32.7 RDW-13.7 Plt Ct-110*
[**2171-5-31**] 02:49PM BLOOD Glucose-98 UreaN-49* Creat-1.1 Na-139
K-4.6 Cl-96 HCO3-40* AnGap-8
[**2171-5-31**] 02:46AM BLOOD Calcium-9.3 Phos-2.6* Mg-1.9
[**2171-5-30**] 10:50AM BLOOD Type-ART Temp-35.9 Rates-/30 Tidal V-700
PEEP-5 FiO2-40 pO2-74* pCO2-70* pH-7.38 calTCO2-43* Base XS-12
Intubat-INTUBATED
[**2171-5-30**] 04:43PM BLOOD Type-ART Temp-36.6 Rates-/29 Tidal V-845
PEEP-5 FiO2-50 pO2-118* pCO2-68* pH-7.40 calTCO2-44* Base XS-14
Intubat-INTUBATED Vent-SPONTANEOU
[**2171-5-31**] 02:56AM BLOOD Type-ART Temp-36.1 pO2-96 pCO2-75*
pH-7.36 calTCO2-44* Base XS-13 Intubat-INTUBATED
[**2171-5-31**] 02:59PM BLOOD Type-ART Temp-36.8 pO2-81* pCO2-74*
pH-7.35 calTCO2-43* Base XS-10 Intubat-NOT INTUBA
.
Imaging:
========
CXR [**5-28**]: The NG tube tip is in the stomach. The ET tube tip is
approximately 7 cm above the carina. There is no change in
severe upper lung emphysema and multifocal bilateral
consolidations. Consolidation is better delineated on the CT
chest obtained on [**2171-5-28**] .
.
CTA [**5-28**]:
1. No evidence of pulmonary embolism.
2. Multifocal pneumonia.
3. Moderately severe centrilobular emphysema.
.
ECHO [**5-29**]:
The left atrium is normal in size. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast at rest. There is mild symmetric left ventricular
hypertrophy with normal cavity size. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic function is normal
(LVEF>55%). The right ventricular free wall is hypertrophied.
Right ventricular chamber size is normal. with normal free wall
contractility. 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 or regurgitation.
There is moderate pulmonary artery systolic hypertension. There
is an anterior space which most likely represents a prominent
fat pad.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved ejection fraction. Right
ventricular hypertrophy with preserved systolic function. At
least moderate pulmonary hypertension. No intracardiac shunt by
bubble study (only done at rest).
.
CXR [**5-31**]: The ET tube tip is 3 cm above the carina. The PICC
line tip is at the level of low SVC. Cardiomediastinal
silhouette is stable. Bibasal consolidations are unchanged as
well as upper lung emphysema. Overall no significant change
since the most recent prior radiograph is noted. As compared to
more remote radiographs from [**2171-5-28**] the appearance is
unchanged as well.
.
Brief Hospital Course:
82yo M with COPD p/w hypercarbic respiratory failure and
pneumonia who had a progressively declining clinical course and
eventually expired after transitioning care to comfort measures
only.
.
# Hypercarbic respiratory failure ?????? patient was admitted
intubated from rehab though previously DNI, his code status was
reversed after he was found hypoxic at his facility. He was
ruled out for PE on admission and imaging revealed volume
overload, multifocal pneumonia, and severe underlying emphysema.
No evidence of ACS on admission. Patient was continued on
vancomycin, cefepime, and levofloxacin for HCAP coverage without
improvement in radiographic or clinical status. He was diuresed
with IV lasix and continued on prednisone 35mg daily. Patient
was extremely clear about his desire to remove the tube and was
awake and alert while intubated. Family expressed that patient
has been consistent about these wishes even prior to this
admission. Given patient's prior and current wishes to be
DNR/DNI and overall poor prognosis, family decided to proceed
with extubation. The patient expressed on repeated occasions
that he wanted the tube removed and did not want to be
reintubated under any circumstances. After the extubation,
patient's clinical status deteriorated and after extensive
discussion with the family, his care was transitioned to focus
on comfort. He was started on a morphine gtt and all other
measures were discontinued. Patient expired later that same day,
please see event notes below regarding the circumstances of his
death.
.
Attending ICU death/event note:
Prior to extubation patient expressed clear wish to be extubated
and did not want to be reintubated even if it meant he would
die. Family understood his wishes and agreed to respect them.
Patient extubated at midday with family present. Initially did
well but became progressively uncomfortable with labored
breathing and obvious distress. Morphine infusion begun to
control breathlessness. Other medications discontinued as
family agreed to respect patient's wish to be comfortable. This
evening BP and oxygen saturation progressively declined with BP
by arterial line < 60 systolic for several hours. Oxygen
discontinued along with other measures not aimed at comfort. I
was called at approx 1:30 because family was upset and
questioning management. Lengthy discussion with family
regarding focus on comfort. Emphasized that we had agreed that
morphine would be used for comfort and that other measures would
not be continued unless directed at his comfort. Physicians and
nurses all agreed Mr. [**Known lastname 106803**] was unresponsive and feeling no
pain. Family remained upset, angry, questioning all care
although they understood he was dying and his wishes were being
respected. During this conversation Mr. [**Known lastname 106803**] died and they
were informed of his passing at 2:18. Code Purple called as
family became increasingly angry and belligerent.
.
Resident ICU death/event note:
Patient was extubated this AM and subsequently confirmed DNR/DNI
with family and patient. Patient was very clear about not
wanting the tube replaced even if his respiratory status
worsened. Post-extubation, patient became tachypneic to RR in
the 40s and O2 sats dropped to high 80's on 5L nasal cannula. We
discussed extensively with the family his goals of care and they
decided to make him CMO. He was started on a morphine drip and
ativan prn for comfort of breathing and antibiotic therapy was
discontinued. Patient was very comfortable and in no distress
throughout the day on the morphine drip, his O2 sats drifted
down to the 50-60s on nasal cannula and BP persisted at SBP
40-50s for several hours. At 2:16am patient expired with family
present at bedside. Several family members were extremely upset
at time of death given concern for the nasal cannula being
weaned down despite dropping O2 sats throughout the evening.
They had expressed similar concerns throughout the day about his
rehab facility, stating that "they were just going to let him
die if we didn't undo his DNI." Attending and nurse manager were
called to mediate, but the family became more argumentative and
combative, threatening to "[**Doctor Last Name **] for killing [our] father", and a
code purple was called to control the situation. Situation
deescalated and family ultimately declined autopsy. Patient was
examined at bedside and pronounced at 2:16am. His PCP was
notified by phone and email. Case was not reported to the
medical examiner.
.
Medications on Admission:
nystatin swish/swallow 5cc q6
carbamaide peroxide drops 5 drops q12 r ear
diphenhydramine 25 po daily (last dose 5/23)
docusate sodium 100 q 12
ensure 1 can daily
finasteride 5mg daily
Advair Diskus 250 mcg-50 mcg twice a day
HCTZ 12.5 mg daily
combinebs q6h
lip balm qid
lisinopril 20 daily
loperamide 4mg q4h prn (last given [**5-26**])
loratidine 10mg daily
melatonin 5mg hs
multivit with min daily
pantoprazole 40 q24
saccharomyces 250 po tid
saline nasal spray q8h
senna/docusate 1 [**Hospital1 **]
simvastatin 10
tamsulosin 0.4 hs
triamcinolone orabase qid prn inner lip
verapamil 240 SR
prednisone taper. now on 5mg
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2171-6-1**]
|
[
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"338.29",
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"401.9",
"V16.2",
"276.3",
"272.4",
"V15.82",
"486",
"600.00",
"276.0",
"491.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.71",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
12792, 12801
|
7565, 12086
|
342, 397
|
12852, 12861
|
3473, 3473
|
12917, 13090
|
2746, 2989
|
12760, 12769
|
12822, 12831
|
12112, 12737
|
12885, 12894
|
3004, 3004
|
4723, 7542
|
270, 304
|
425, 2447
|
3487, 4709
|
2469, 2546
|
2562, 2730
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,190
| 103,127
|
9364+9365+56028
|
Discharge summary
|
report+report+addendum
|
Admission Date: [**2115-3-8**] Discharge Date: [**2088-4-12**]
Date of Birth: [**2046-10-19**] Sex: M
Service:
ADMISSION DIAGNOSIS:
1. Myocardial infarction.
2. Ventricular tachycardia.
HISTORY OF THE PRESENT ILLNESS: The patient is a 68-year-old
male who was taking his garbage out to the curb when he had
the sudden onset of severe chest pain associated with
diaphoresis and shortness of breath. It was described as
similar to chest pain he had during a CHF exacerbation at
[**Hospital1 18**] in [**2112-7-14**]. The patient contact[**Name (NI) **] the EMS System
who found him in ventricular tachycardia and he was
cardioverted in the field to sinus and brought in and
referred to an outside hospital. There, he was given
aspirin, Lopresor, and transferred to [**Hospital1 18**].
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post MI in his 30s.
2. Status post cardiac catheterization with LAD stenting in
[**2112**].
3. Ejection fraction 23%.
ALLERGIES: The patient has no known drug allergies.
ADMISSION MEDICATIONS:
1. Aspirin q.d.
2. Toprol XL 50 mg q.d.
3. Zantac 150 mg b.i.d.
4. Cozaar 25 mg q.d.
5. Lasix 20 mg q.d.
6. Coenzyme Q.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Heart rate
69, blood pressure 110/62, respirations 14, saturations 96%.
General: The patient was in no acute distress. HEENT:
EOMI. PERRL, anicteric. The throat was clear. Chest:
There were coarse breath sounds bilaterally with right
greater than left. Cardiovascular: Regular rate and rhythm
without murmurs, rubs, or gallops. Abdomen: Soft,
nontender, nondistended, without masses or organomegaly.
Extremities: Warm, noncyanotic, nonedematous times four.
Neurological: Grossly intact.
ADMISSION LABORATORY DATA: CBC 7.8/42.5/111. Chemistries:
136/4.0/97/28/12/1.2/288. CKs 154 with an MB of 14.9 and
troponin of 9.4.
The chest x-ray showed only mild atelectasis at the right
lower lobe, no acute CHF picture.
HOSPITAL COURSE: The patient was initially on a lidocaine
drip for his ventricular tachycardia. He was admitted to the
ICU for close monitoring. On hospital day number two, the
patient was transferred down to the floor. At that time, he
was stabilized in preparation for cardiac catheterization and
possible ablation. The patient did rule in for an MI,
although there were no ST elevations detected on the EKG.
The Electrophysiology Service was consulted in regards to his
episode of ventricular tachycardia. VT ablation versus ICD
were discussed and both were possibilities. Catheterization
was performed on [**2115-3-11**] which revealed an ejection fraction
of 20%, as well as diffuse disease of a right dominant
system. It was felt that the patient would benefit from
revascularization. It was also noted that the patient had a
very large abdominal aortic aneurysm greater than 7 cm at
this time. The patient was recommended further delineation
of CT angiography for sizing of the aorta as well as possible
endostenting.
The patient went for VT ablation later that day. The patient
continued, however, to have an episode of ventricular
tachycardia postprocedure. It was asymptomatic and identical
to the episode described three days prior.
Cardiothoracic Surgery was consulted for the patient's three
vessel disease. Vascular Surgery was also consulted for his
large AAA. The patient underwent CABG times three on
[**2115-3-13**] with LIMA to diagonal artery, saphenous vein graft
to LAD and acute marginal.
Postoperatively, the patient was taken to CRSU for closer
monitoring. It was complicated only by having to reopen to
remove a lap pad. The patient was extubated on the evening
of postoperative day number zero and tolerated this well. He
continued to have recurrent ventricular tachycardia status
post ablation and the patient remained A-paced using
temporary pacing wires. The patient also had multiple
episodes of NSVT and Amiodarone bolus was given as well as
Amiodarone drip.
The patient had recurrent prolonged runs of NSVT on
postoperative day number two and the EP Service continued to
follow. It was felt with the patient's multiple arrhythmias
the patient would most likely benefit from implantation of an
AICD. The patient was transitioned to p.o. Amiodarone which
did not seem to be as effective as a drip. He was restarted
on the Amiodarone drip.
On postoperative day number three, the patient's chest tubes
were removed and the insulin drip was weaned to off.
Physical Therapy began seeing the patient. The patient did
begin ambulating some. The patient's Cordis was changed over
a wire to a lumen CVL on postoperative day number five.
By postoperative day number five, the patient was seen to be
stable overnight and the patient was transferred to the
floor. On the floor, the patient had a largely unremarkable
course and was preopped appropriately for the Vascular
Service.
The rest of this dictation summary will be completed either
by Vascular Surgery or the other subsequent services to have
this patient.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 5745**]
MEDQUIST36
D: [**2115-3-26**] 05:49
T: [**2115-3-26**] 18:04
JOB#: [**Job Number 31997**]
Admission Date: [**2115-3-8**] Discharge Date: [**2115-3-28**]
Date of Birth: [**2046-10-19**] Sex: M
Service: C-MEDICINE
This dictation covers the patient's hospitalization from
[**2115-3-26**], to [**2115-3-28**], while on the C-Medicine service.
Hospital course from admission through [**2115-3-26**], [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] of Vascular Surgery.
HOSPITAL COURSE: The patient was transferred from Vascular
Surgery to the C-Medicine Service following ICD placement.
1. Cardiac - ICD was placed without complication. The
patient was monitored on telemetry without any events of
ventricular tachycardia though occasional premature
ventricular contractions were noted on telemetry. He was
continued on Amiodarone at 200 mg p.o. once daily. His
Lopressor was continued at the same dose of 50 mg twice a
day.
2. Congestive heart failure - The patient's Captopril was
titrated from 6.25 mg up to 12.5 mg p.o. three times a day.
He appeared total body volume overloaded and was diuresed
with Lasix, initially intravenous and then changed to 40 mg
p.o. twice a day, with good effect.
3. Ischemia - He was continued on his Aspirin.
4. Pulmonary - At the time of transfer, the patient had a
significant oxygen requirement of six liters to maintain an
oxygen saturation of greater than 90%. Chest x-ray was
repeated which revealed persistent left lower lobe effusion
likely residual from his bypass surgery, as well as
persistent bibasilar atelectasis and prominent pulmonary
vasculature suggesting mild congestive heart failure. He was
given incentive spirometer and encouraged to use it
frequently which he did. In addition, he was diuresed with
Lasix as above with good effect. Physical therapy evaluated
the patient and on ambulation found that his oxygen
saturation dropped to 78% in room air while ambulating on
[**2115-3-26**]. At the time of discharge, the patient has been at
88 to 90% on two liters of oxygen via nasal cannula. He was
discharged with home oxygen with visiting nurses to assess
his oxygen requirement and wean as tolerated with Lasix at 40
mg p.o. twice a day to be taken for one week and then down to
once daily.
5. Infectious disease - At the time of transfer, the patient
was on Levofloxacin which had been started prior to the
abdominal aortic aneurysm repair. This was discontinued
after completion of a seven day course. His interval urinary
tract infection appears to have cleared as a culture drawn on
[**2115-3-25**], had no growth at the time of this dictation. He
was given periprocedural antibiotics for his ICD placement,
initially Cefazolin intravenously, however, the patient lost
peripheral access and was changed to Keflex p.o. which he
will continue to take four days following discharge.
6. Endocrine - The patient's blood sugar has been running a
bit high and the patient was on insulin sliding scale. The
patient did not have a history of diabetes mellitus and at
the time of transfer, his blood sugar was well within the
normal range. It is likely his blood sugar was running on
the high side due to a stress response from the multitude of
procedures that the patient had undergone. His insulin
sliding scale was discontinued and his blood sugar remained
normal.
MEDICATIONS ON DISCHARGE:
1. Amiodarone 200 mg p.o. once daily.
2. Lopressor 50 mg p.o. twice a day.
3. Captopril 12.5 mg p.o. three times a day.
4. Keflex 500 mg p.o. q6hours to end on [**2115-3-31**].
5. Aspirin 325 mg p.o. once daily.
6. Lasix 40 mg p.o. twice a day for one week and then once
daily thereafter.
7. Colace 100 mg p.o. twice a day.
8. Dulcolax 10 mg p.o. q.h.s. p.r.n. constipation.
9. Lactulose 30 ccs three times a day p.r.n. constipation.
FOLLOW-UP: The patient has a follow-up appointment to see
Dr. [**Last Name (STitle) **] in Device Clinic on [**2115-4-3**], at 2:30 p.m. He
is to call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 31998**] to make an appointment
to be seen in two weeks in follow-up. Finally, he is to call
Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 28544**], to make an appointment to be
seen four weeks following discharge.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSES:
1. Ventricular tachycardia, status post ablation and ICD
placement.
2. Coronary artery disease, status post myocardial
infarction and three vessel coronary artery bypass graft.
3. Abdominal aortic aneurysm, status post endovascular
repair.
4. Urinary tract infection.
[**Name6 (MD) 251**] [**Last Name (NamePattern4) 677**], M.D. [**MD Number(1) 25755**]
Dictated By:[**Name8 (MD) 3491**]
MEDQUIST36
D: [**2115-3-28**] 09:54
T: [**2115-3-30**] 11:13
JOB#: [**Job Number 31999**]
Name: [**Known lastname 5565**], [**Known firstname 63**] Unit No: [**Numeric Identifier 5566**]
Admission Date: [**2115-3-8**] Discharge Date: [**2115-3-28**]
Date of Birth: [**2046-10-19**] Sex: M
Service:
ADDENDUM: Hospital course starting when Vascular Surgery got
involved.
The Vascular Surgery Team was consulted on this patient on
[**2115-3-12**] secondary to an incidental finding of
abdominal aortic aneurysm upon cardiac catheterization. The
patient had been admitted to the [**Hospital3 **] on the
Cardiology Service secondary to chest pain and ventricular
tachycardia. A CTA was performed showing a 9 cm AAA.
The patient was taken to the OR by the Cardiac Surgery
Service on [**2115-3-13**] and had a coronary artery bypass
graft times three performed. With the risk of rupture of a 9
cm AAA, it was felt that repair of the AAA should be
performed as soon as possible after the CABG since an open
AAA following a CABG has a very high morbidity. It was
decided by Dr. [**Last Name (STitle) **] and the patient to perform an
endovascular stent graft.
The patient was taken to the OR on [**2115-3-21**], where an
endovascular AAA repair was performed by Dr. [**Last Name (STitle) **] under
general anesthesia with an estimated blood loss of 500 cc.
No complications. The patient was taken to the PACU in
stable condition. Intraoperatively, the patient received 4.5
units of LR, 2 units of packed red blood cells and had a
urine output of 2,000 cc. He was kept intubated and was
transferred to the SICU on propofol and nitroglycerin drip.
Postoperatively, the patient had persistent hypoxemia
requiring FI02 of 100%. The patient was on SIMV with
pressure support of 5, PEEP 12.5, and 100% 02. Blood gas of
7.46, 35, 67, 26, 1, and 95%. The chest x-ray only revealed
mild atelectasis at the bases bilaterally.
The patient was extubated on postoperative day number one
without events. On postoperative day number two, the
hematocrit came back at 26.8 and the patient was transfused 1
unit of packed red blood cells with a Lasix chaser. The
patient had a clear diet on postoperative day number two and
advanced to a full diet by postoperative day number three.
The patient's 02 saturations on postoperative day number
three were 94-95% on 6 liters nasal cannula. Vancomycin and
levofloxacin were started perioperatively and were continued
postoperatively. The levofloxacin was started because of a
U/A that had positive nitrite and micro had many bacteria.
The vancomycin was started when his urine culture grew
Enterococcus.
The patient was transferred to the VICU on postoperative day
number three. The patient continued to do well with the 02
saturations still in the mid 90s on 6 liters nasal cannula.
The patient was receiving Lasix for diuresis as the patient
was positive many liters after his AAA repair. The patient
was stable at this point from the vascular point of view and
Cardiology suggested the placement of an ICD.
The patient was transferred to the Cardiology Service after
the ICD was placed on [**2115-3-26**]. The Cardiology Service will
be dictating the hospital stay from [**2115-3-26**] to discharge.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 273**]
Dictated By:[**Last Name (NamePattern1) 5567**]
MEDQUIST36
D: [**2115-3-28**] 07:37
T: [**2115-3-30**] 21:49
JOB#: [**Job Number 5568**]
|
[
"414.01",
"428.0",
"441.4",
"412",
"427.1",
"V45.82",
"410.71",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"88.55",
"39.71",
"37.34",
"36.15",
"37.94",
"39.61",
"88.53",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
9603, 13589
|
8672, 9548
|
5784, 8646
|
1067, 1215
|
152, 811
|
1230, 1972
|
833, 1044
|
9573, 9582
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,609
| 145,595
|
55008+59644
|
Discharge summary
|
report+addendum
|
Admission Date: [**2129-8-9**] Discharge Date: [**2129-8-14**]
Date of Birth: [**2073-2-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Gastrointestinal bleeding
Major Surgical or Invasive Procedure:
EGD [**2129-8-10**]
History of Present Illness:
Mr. [**Known lastname **] is a 56 year old man with known endocarditis and recent
AVR/MVR/CABG with Dr [**Last Name (STitle) **], now readmitted from rehab with
hematocrit of 22 and fatigue.
Past Medical History:
Hypertension
Endocarditis
Aorto-mitral curtain abscess
Coronary Artery Disease
Hypertension
Sebaceous cysts
hernia umbilical
Past Surgical History:
Right shoulder w/ rotator cuff tear s/p repair 4years ago
AVR/MVR/CABG ([**2129-7-26**])
post-operative afib
Social History:
No alcohol, no tobacco, currently on disability. No recent sick
contacts. [**Name (NI) **] recent travel.
Family History:
Patient claims no cardiac conditions run in family
Physical Exam:
Pulse:108 afib Resp:25 O2 sat:96% on RA
B/P Right:96/64(100s-110s) Left:
Height:6'1" Weight:147.4 kgs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally, decreased L base [x]
Heart: RRR [] Irregular [x] Murmur [] sharp valve sounds______
Abdomen: Soft [x] obese, non-distended [x]non-tender [x]bowel
sounds +[x], rectal exam with melena
Extremities: Warm [x], well-perfused [x] Edema x 2+_____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: Left:
DP Right:1+ Left:1+
PT [**Name (NI) 167**]: Left:
Radial Right: 2+ Left:2+
Discharge Exam:
VS: T: 98.6 HR: 80's SR BP: 110-120/70-80's Sats: 97% RA
WT: 148 kg FSBS 112/114/172/123
General: 56 year-old male in no apparent distress
HEENT: mucus membranes moist
Card: RRR normal S1,S2 no murmur good click
Resp; decrease breaths otherwise clear throughout
GI: obese, benign
Extr: warm 3+ edema
Wound: sternal, & right shoulder well healed. (see wound note
for right gluteal ulcer)
Neuro: awake, alert & oriented. no deficits. ambulates in room.
Pertinent Results:
[**2129-8-13**] WBC-12.5* RBC-3.78* Hgb-11.4* Hct-35.5 Plt Ct-457*
[**2129-8-12**] WBC-12.2* RBC-3.51* Hgb-10.7* Hct-32.8 Plt Ct-411
[**2129-8-11**] WBC-10.5 RBC-3.42* Hgb-10.6* Hct-31.9 Plt Ct-424
[**2129-8-9**] WBC-11.4* RBC-2.50* Hgb-7.3* Hct-22.7 Plt Ct-577*
[**2129-8-9**] Neuts-75.7* Lymphs-16.3* Monos-6.0 Eos-1.6 Baso-0.5
[**2129-8-14**] PT-33.2* INR(PT)-3.2*
[**2129-8-13**] PT-42.7* INR(PT)-4.2*
[**2129-8-12**] PT-53.6* INR(PT)-5.3*
[**2129-8-11**] PT-34.5* INR(PT)-3.4*
[**2129-8-10**] PT-29.0* PTT-38.6* INR(PT)-2.8*
[**2129-8-9**] PT-32.3* PTT-41.8* INR(PT)-3.1*
[**2129-8-9**] PT-63.9* PTT-44.9* INR(PT)-6.4*
[**2129-8-14**] Glucose-112* UreaN-20 Creat-1.4* Na-138 K-4.1 Cl-101
HCO3-29
[**2129-8-13**] Glucose-110* UreaN-21* Creat-1.4* Na-140 K-3.8 Cl-102
HCO3-28
[**2129-8-9**] Glucose-116* UreaN-45* Creat-1.5* Na-139 K-4.4 Cl-108
HCO3-24
[**2129-8-9**] ALT-34 AST-28 AlkPhos-62 Amylase-42 TotBili-0.4
[**2129-8-14**] Mg-2.0
URINE CULTURE (Final [**2129-8-13**]):
KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in MCG/ML
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- I
CEFTAZIDIME----------- 16 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- 1 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 32 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- 2 S
[**2129-8-9**] MRSA SCREEN (Final [**2129-8-12**]): No MRSA isolated.
CXR: [**2129-8-12**]:
Moderate-to-large left pleural effusion is unchanged allowing
the difference in position of the patient. Small right pleural
effusion is also unchanged. Mild-to-moderate vascular
congestion is stable. Enlarged cardiomediastinal silhouette
shows improvement in the mediastinal widening. Left PICC tip is
in the mid SVC. There is no evident pneumothorax.
[**2129-8-10**]: CCT
FINDINGS: There is a large left and moderate right-sided
pleural effusion
with associated compressive atelectasis and volume loss. A
left-sided PICC is in place with tip in the SVC. No focal
esophageal abnormality is seen. No pathologically enlarged
lymph nodes are identified.
The heart is enlarged with no significant pericardial effusion.
The non-contrast appearance of the liver, gallbladder, spleen,
pancreas,
adrenal glands, and kidneys is grossly unremarkable. No
intra-abdominal fluid collection is identified.
Loops of small and large bowel are normal in size and caliber.
The bladder contains a Foley catheter. The prostate gland is
grossly unremarkable. No free air or lymphadenopathy is seen.
There are scattered atherosclerotic calcifications of the aorta
and iliac
arteries. There has been repair of an anterior abdominal hernia
with mesh in place. There remains a small amount of fat
herniation anterior to the mesh. There are bilateral
fat-containing inguinal hernias. There is diffuse anasarca,
greater dependently.
The patient is status post median sternotomy, and there are
multiple
degenerative changes of the thoracolumbar spine. No concerning
osseous lesion is identified.
IMPRESSION:
1. No intra-abdominal fluid collection. No mass or CT finding
to explain
melena.
2. Large left and moderate right homogeneous pleural effusions.
It would be difficult to exclude evolving hemothorax however
these are most likely simple effusions related to cardiac
disease.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted from rehab with anemia and black tarry
stools. He was transfused with 10 units of PRBC and his INR of
6.4 was actively reversed with 2 units fresh frozen plasma to
INR 3.1. A CT torso revealed no collection of blood. An EGD
showed no bleeding source. As he was hemodynamically stable,
his black stools stopped and his Hematocrit rose appropriately
to transfusions, he was transferred to the step down floor. The
gastrointestinal service felt that if bleeding re-occurs he
should undergo a tagged red blood cell scan. As he has never
had a colonoscopy, they also recommend that he have a
colonoscopy after he completes his Nafcillin on [**2129-9-6**].
Continue Protonix 40 mg [**Hospital1 **].
Anticoagulation: Warfarin 7.5 mg was restarted [**2129-8-11**] 3.4, INR
9/21/5.3 warfarin held, [**2129-8-13**] INR 4.3 given 2 mg, [**2129-8-14**] INR
3.2 7.5 mg ordered.
GOAL INR 3.0-3.5. PLEASE MONITOR INR DAILY and titrate Warfarin
accordingly.
ID: Urine Culture with KLEBSIELLA PNEUMONIAE sensitive to Cipro
day [**11-25**] 500 mg twice daily. Nafcillin 2 gm for septic shoulder
thru [**2129-9-6**].
Renal: renal function normal BUN/CRE 20/1.4 stable with good
urine output. Remains slightly volume overload. Furosemide 40
mg twice daily continues. Wt today 148.4.
Cardiac: remains in sinus rhythm 70-80, hemodynamically stable
110-120's on amiodarone 400 mg daily, Lopressor 100 mg three
times daily.
Endocrine: insulin sliding scale FSBS 112-148.
Wound: He was seen by the wound nurse for a right gluteal
unstageable pressure ulcer
measuring 6 x 4 cm 100% yellow tissue Edges: attached Drainage:
minimial yellow
Odor: none Peri wound: left gluteal with 3 small areas of
epidermal erosion
possible moisture related. Goals: Pressure Redistribution,
Topical therapy
Recommendations: 1. Follow pressure ulcer guidelines 2. Cleanse
wound with commercial wound cleanser. Pat dry 3. Apply DuoDerm
wound gel to assist with autolytic debridement 4. Place Mepilex
Sacrum dressing and change q3d.
5. Apply critic aid clear skin barrier ointment thin layer on
left gluteal daily.
6. Cleanse perineal and scrotum with Aloe Vesta foam cleanser
daily and apply skin barrier ointment daily. 7. Elevate
edematous scrotum on pillow. 8. Float heels pillow
By hospital day 6 his Hematocrit remained stable and his INR was
within therapeutic range for a double mechanical valve and afib.
He was discharged in good condition to [**Hospital1 **] in
[**Location (un) 701**].
Medications on Admission:
Furosemide 40 mg [**Hospital1 **], Potassium Chloride 40 mEq DAILY,
Amiodarone 200 mg DAILY, Aspirin EC 81 mg DAILY, Calcium
Carbonate 500 mg QID:PRN, docusate Sodium 100 mg [**Hospital1 **], Insulin SC
Sliding Scale, Nafcillin 2 g IV Q4H, Oxycodone-Acetaminophen
(5mg-325mg) [**11-22**] TAB PO Q4H:PRN, Pantoprazole 40 mg PO Q12H ,
Senna 2 TAB [**Hospital1 **] , Warfarin 10 mg, Simvastatin 10 mg DAILY,
Metoprolol Tartrate 75 mg TID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Amiodarone 400 mg PO DAILY
3. Bisacodyl 10 mg PR DAILY:PRN constipation
4. Ciprofloxacin HCl 500 mg PO Q12H Duration: 5 Days
through [**8-19**]
5. Docusate Sodium 100 mg PO TID
6. Furosemide 40 mg PO BID
7. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
8. Metoprolol Tartrate 100 mg PO TID
Hold for SBP<100 HR<60
9. Nafcillin 2 g IV Q4H
Through [**9-6**]
10. OxycoDONE (Immediate Release) 5-10 mg PO Q6H:PRN pain
RX *oxycodone 5 mg [**11-22**] tablet(s) by mouth every six (6) hours
Disp #*40 Tablet Refills:*0
11. Pantoprazole 40 mg PO Q12H
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
13. Potassium Chloride 20 mEq PO DAILY
Hold for K > 4.5
14. Senna 2 TAB PO BID
15. Simvastatin 10 mg PO DAILY
16. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
17. Warfarin MD to order daily dose PO DAILY16
18. Warfarin 7.5 mg PO DAILY16
INR GOAL 3.0-3.5
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Gastrointestinal bleeding
History of shoulder septic arthritis c/b MSSA bacteremia
AV and MV endocarditis c/b aorto-mitral curtain abscess s/p
mechanical AVR/MVR [**2129-7-26**]
Coronary Artery Disease s/p 2vCABG (LIMA-LAD, SVG-OM) [**2129-7-26**]
Hypertension
Sebaceous cysts
hernia umbilical
Right shoulder w/ rotator cuff tear s/p repair 4years ago
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Discharge Instructions:
Shower daily: wash incisions with mild soap and water
Daily weights: continue furosemide twice daily
Guaiac all stools: continue PPI's and monitor HCT
Monitor Daily INR: Goal 3.0-3.5. Discharge dose of warfarin 7.5
mg
(of note on amiodarone and 5 day course of Cipro which will
effect INR. please adjust accordingly)
Complete Ciprofloxacin through [**8-19**] and Nafcillin through [**9-6**].
Followup Instructions:
You are scheduled for the following appointments:
Surgeon Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**9-8**] 1PM [**Telephone/Fax (1) 170**] in the [**Hospital **]
Medical Building 2A
Dr. [**Last Name (STitle) **] (orthopedics for shoulder) [**8-23**] 2:45 ([**Telephone/Fax (1) 112313**]
Please call to schedule the following:
Cardiologist: Dr [**Last Name (STitle) **] in 3 weeks Primary Care in [**2-24**] weeks
Infectious Disease: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 456**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2129-8-16**] 10:45 in the [**Hospital **] Medical Building basement
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR
Coumadin for double mechanical valves
Goal INR 3-3.5
First draw day after discharge
Then please do daily INR checks until INR stabilized and then
decrease as directed by rehab
On discharge from rehab, please arrange INR follow-up with
primary care physician or cardiologist
Completed by:[**2129-8-14**] Name: [**Known lastname 5493**],[**Known firstname **] Unit No: [**Numeric Identifier 18434**]
Admission Date: [**2129-8-9**] Discharge Date: [**2129-8-14**]
Date of Birth: [**2073-2-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 135**]
Addendum:
Mr. [**Known lastname 18435**] troponin rise was thought by cardiology to be due to
rhabdomyolysis rather than to be of cardiac origin. During his
admission he was also ruled out for bacterial meningitis. He
was diagnosed with MSSA bacteremia.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 49**] - [**Location (un) 50**]
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 137**] MD [**MD Number(2) 138**]
Completed by:[**2129-8-16**]
|
[
"V58.61",
"401.9",
"711.06",
"578.9",
"041.3",
"599.0",
"707.05",
"E934.2",
"V43.3",
"421.0",
"790.92",
"790.7",
"041.11",
"707.25",
"285.1",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
12658, 12885
|
5747, 8254
|
334, 356
|
10267, 10423
|
2227, 5724
|
10867, 12635
|
997, 1049
|
8739, 9776
|
9892, 10246
|
8280, 8716
|
10447, 10844
|
747, 857
|
1064, 1735
|
1751, 2208
|
269, 296
|
384, 577
|
599, 724
|
873, 981
|
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